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Full text of "International record of medicine"

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New York Medical Journal 



and 



Medical Record 

Philadelphia Medical Journal "' Medical News 



A SEMIMONTHLY REVIEW OF MEDICINE 

AND SURGERY 



EDITED BY 
GREGORY STRAGNELL, M. D. 






VOLUME CXV^l ^ 



^V. P" 




JULY TO DECEMBER, 1922, INCLUSIVE 



NEW YORK 
A. R. ELLlOTr PUBLISHING CO. 

1922 



COPYRIGHT, 1922, BY A. R. ELLIOTT PUBLISHING COMPANY. 



i.-H 



v\ 



LIST OF CONTRIBUTORS TO VOLUME CXVI. 



^ 



Those zi'lwse luimes arc marked zcitli ait asterisk liaTC contributed editorial articles. 



Aaron-, Charles D.. Sc. D.. ^^. D., F. A. 

C. P., Detroit, Mich. 

AiKiNS. W. H. B.. M. D.. L. R. C. P. 
(Lond.). F- A. C. P., Toronto, Canada. 

-\nuers, James M., >r. D., LL. D., Phila- 
delphia, Pa. 

.Xpfel, Harrv. M. D., Brooklvn, N. Y. 

Applegate, J. C, M. D., F. A. C. S., 
Philadelphia. Pa. 

Baird. John- H., M. D. 

♦Bancroft. Frederick, M. D. 

Barker, Creightox. M. D., Kew Haven, 
Conn. 

Barnes. George Edwarfi, M. D., Herki- 
mer, N. Y. 

Bartle, Henry T.. M. D., Philadelphia, 
Pa. 

Basch, Seymour. M. D. 

Bassler. Anthony, M. D., F. A. C. P 

Bavi.v. H. Wansey. M. D., London, 
England. 

Bechet, Paul E., M. D. 

Beiirend, Moses. M. D., F. A. C. S., 
Philadelphia. Pa. 

Benjamin. H.\rry'. M. U. 

Berkeley. William N., M. D. 

BiGCS, Hermann M., M. D., .\Ihanv, 
N. Y. 

Bisher. William, M. D. 

Blauner. Samuel A.. M. D. 

Blumenfeld, Louis. M. D.. Brooklvn, 
N. Y. 

♦Boas. Ernest F., M. D. 

Bonner, Clarence A.. ^L D., Worcester, 
Mass. 

Brandt, Murray L., M. D. 

Breitstei.n, M. L., M. D., Baltimore, Md. 

♦Bkink, Louise, A. B. 

Broeman, C. J.. M. D., Cincinnati, Ohio. 

♦Brown. Mabel W., A. B. 

Bugbee, Henry G., M. D., F. A. C. S. 

BuzBV. B. Franklin, M. D., Philadel- 
phia, Pa. 

Carter, R. Franklin. M. D. 

Cherry. Thomas H.. M. D.. F. A. C. S. 

Clark, L. Pierce. M. D. 

Clock, Ralph Oakley, M. D., Pearl 

River. N, Y. 
♦Clouting, Charles A., M. D., London. 

England. 
Connolly. John M.. M, D. 
Cooke, Edwin S.. M. D., Philadelphia, 

Pa. 
Corning, J. Leonard, >L D., LL. D. 
Cornwall, Edward E., M. D., F. A. C. 

P., Brooklyn. N. Y. 
Craig. Henry K.. M. D., Washington, 

D, C. 

Crance, Albert M., M. D., Geneva, N. Y. 
CuLB^;RTS0N, Walter Leon, M. D.. 

Philadelphia, Pa. 
♦Cumston. Charlks Greene, M. D., 

Geneva. .Switerland. 



D'AciERNO, P. A., M. D., West Hoboken, 

N.J. 
Dannreuther, Walter T.. M. D., F. .'\. 

C. S. s 

Darnall, William Edgar, M. D., F. A. 

C. S., Atlantic City. N, J. 
IJe.mbo. Leon IL, M. D., Lancaster, Pa. 



Denenuolz, Aaron. 'SI. D., Brooklvn 
X. Y. 

Dercum. Francis X., SI. D., Philadel- 
phia. Pa. 

♦Diamond. M., D. D. S. 

♦Donnelly, William H., \l. D.. Brook- 
lyn, N. Y. 

Drosin, L.. M. D. 

Drueck. Ch.\rles L,M. D.. Chicago. III. 

Duke, W. W., M. D., Kansas Citv, Mo. 

DuTTON. W. Forest. M. D.. Tnlsa. Okla. 

Ecgston, Andrew A.. M. D. 

♦Eixhorn. Max. M. D. 

Epstein, J., M. D. 

♦Erdos, -\dolf, ^L D.. Tran.-ivlvania. 

Ronmania. 
Ezickson. Wii.LiA.M J.. A. B., M. D., 

Philadelphia, Pa. 

Fairbanks. B. H., SI. D. 

Fisher. Mulkord K.. M. D., Philadel- 
phia, Pa. 

Fossev. Herbert Leighton, M. D., Phila- 
delphia, Pa. 

♦Foster. Matthias Lancktox. M. D., 
New Rochelle, N. Y. 

Fox, Howard, M. D. 

♦Fridenberg, Percy. M. D. 

Fried. Herman. M. D. 

Friedenwald, Jl^lius. iL D.. Baltimore. 
Md. 

Friedman. E. D., M. D. 

Gerson, H. ^L, M. R. C. S.. L. R. C. P., 

London, England. 
Glassburg, John A., M. D. 
Goldfader. Philip, M. D., Brooklvn, 

N. Y. 
Goldstein. Hyman. M. D. 
Goldstein, Hyman L, M. D., Camden, 

N. J. 
Golob. M.. M. D. 
Goodman. Herman, M. D. 
Gordon, Alfred. M. D.. Philadelpliia, Pa, 
Greenberg, David, M. D. 
Greenw.M-D. Jacob G., M. D., Skilhnan, 

N. J. 

Hader.max. J. Victor, .\. B., M. D., S. 
M. D. (Berlin.) 

Hall. T. Proctor. M. D.. Ph. D., Van- 
couver, Canada. 

Hamilton, James A., Ph. D. 

Hammer, A. Wifse, M. D„ F. A. C. S., 
Philadelphia. Pa. 

Hammond, Frank C. M. D., F. .\. C. S., 
Philadelphia, Pa. 

Heaoey, Francis W.. M. L, F. A. C. P.. 
Omaha, Neb. 

Hem METER. John C, M. D., Baltimore, 
Md. 

HiBBEx. Captain Paxton. F. R. G. S. 

Higiiman, Walter, M. D. 

HiRscii, L Seth. M. D. 

Hornstein. Mark. M. D. 

Howell, J. Morton, M. D.. Cairo, Egypt. 

Hubbard. S. Dana, M. D. 

L'yslop, George H., M. D. 

Jackson, J. .^llen. M. D„ Danville. Pa. 
Jeck. Howard S., M. D.. F. A. C. S. 
Tones, John F. X- M. D., Philadelphia, 
Pa. 



I-Lmdkx, Maxwell H.. M. D. 

Kaiser. Albert D.. M. D.. Rochester. 
N. Y. 

Kear. Leon Vincent. M. D.. Oyster Bav, 
N. Y. 

♦Kerbv, Ernest F.. M. D. 

Keilty. Robert A., AL D., Danville, Pa. 

Keyes, Baldwin L., M. D.. Philadelphia, 
Pa. , 

Kilduffe. Robert A., A. M., M. D.. Pitts- 
burgh, Pa. 

Kinlaw. W. Bernard, M. D., Philadel- 
phia, Pa. 

Kisch, Franz. SI. D., Marionhad, 
Czechoslovakia. 

Kleinberg, S., M. D., F. a. C. S. 

♦Knopf, S. Adolpiius. M. D. 

Koenig. C. J., M. D., Paris, France. 

KouixDjY. P., M. D.. Paris, France. 

Kramer, David W.. M. D., Philadelphia, 
Pa. 

Landsman. Arthur A. M. D. 
Langstroth, Francis Ward, M. D. 
Lee. Edward Wallace, M. D., Randolph, 

X. Y. 
Leof, M. v., M. D., Philadelphia. Pa. 
Levitt. Marcus J., M. D., Brooklyn, 

N. Y. 
Lewis. Nolan D. C. \l. I).. Washington, 

D. C. 
♦LiEB, Charles, M. D., Ph. D. 
Litchfield, Harry R., M. D., Brooklyn, 

N. Y. 
LowSLEY, Oswald Swinney. A. B.. M.D. 

M. D. 
LuDLUM, S. De W.. M. D.. Philadelphia, 

Pa. 
Luttinger. Paul, M. D. 
Lyon, B. B. Vincent, M. I).. Philadel- 
phia, Pa. 

McCafferty, Lawrence K.. M. D. 

Marcus. Joseph. M. D., Atlantic City, 
N.J. 

Martindale, Joseph W .. M. D.. Balti- 
more. Md. 

♦M.\vo. Caswell .A.. Phar. D., Cincin- 
nati, Ohio. 

Melman, Ralph J.. M. D., Philadelphia, 
Pa. 

Mills. H. Brooker. M. D., F. A. C. P., 
Philadelphia, Pa. 

MixSELL. Harold R.. A. B., M. D. 

Moore, William James. L. R. C. S. E., 
F. R. F. P. S.. Glasgow. Scotland. 

Mott. Frederick W.. K. B. E., M. D., F. 
R. S., London. England. 

Myerson, M. C, M. D., Brooklyn, N. Y. 

Naccarati. Sante. AL D.. Ph. 1). 
♦Neuwelt, Louis. M. D. 
Norman, N. Philip. M. D. 

Ogden, J. Bergen, M. D. 

Oliver, James. M. D., F. R. S. (Edin.) 

F. L. S.. London. England. 
Orgel, Samuel Z.. M, D. 

Pfahler, George E., M. D.. Philadel- 
phia, Pa. 

Pfeiffer, J. A. F., Ph. D.. M. D.. Balti- 
more. Md. 

PiPKR. Edmund B., M. D., F. A. C. S., 
Philadelphia, Pa. 



h 



PiSKO. Edwaku. M. D. 

Pope, Cirrax. M. D.. Louisville, Ky. 

QuAiN, E. P., M. D., Bismarck, N. D. 

QUIMBY, A. JUDSOX, M. D. 

Randall, G. M.. U. D.. Daytona, Fla. 

Read, Johx Sturdivaxt. M. D., Brook- 
lyn, N. Y. 

Remer. John, M. D. 

Reuben, Mark S., M. D. 

Reuter, F. a., M. D., Washington, D. C. 

Rhein, John H. W., M. D, Pliiladel- 
phia, Pa. 

Rhodes, Frederick A., il. D., Pittsburgh, 
Pa. 

Riddell, William Renwick, LL.D., 
Toronto. 

*Ro<;ers. James F., M. D., United States 
Public Health Service, Wilton, Conn. 

Rogers, Leon,\rd, Lieutenant Colonel, 
I. M. S., retired. London. 

Roman, Benjamin, M. D., Buffalo, N.Y. 

RoNGV, A. J., M. D., F. A. C. S. 

RosENBERGER, R. C, ^L D.. Philadelphia, 
Pa. 

Rosenbloom, Jacob, ^L D.. Pli. D., Pitts- 
burgh, Pa. 

rottenberg, solomon, jl d. 

*Rovinskv, a., M. D. 

RuBENSTONE, A. L, M. D., Philadelphia, 
Pa, 

*RucKER, William C. M.D., Canal Zone. 



*Sajous, Charles E. de M., M. D., 
LL. D., Sc. D., Philadelphia, Pa. 

*Sajous, Louis T. de M., B. S., M. D., 
Philadelphia, Pa. 

S.\mpson, D. G., M. D., Corozal, Canal 
Zone. 

Satenstein, D. L., M. D. 

S.vtterlee. G. Reese. M. D. 

Sautter. C. M.. M. D. 

Scheppegrell, William, A. M., ^L D., 
New Orleans, La. 

ScHOLz, Thomas, M. D. 

Schwartz. Ellis ^L, M. D. 

Schwartz. George, M. D. 

Schwatt, H., M. D. 

Seilikovitch, S.. M. D., Philadelphia, Pa. 

Smith, Clarence H., M. D., F. .\. C. S. 

Smith J. Morrisset, M. D. 

Spielberg, William, M. D. 

Steel, W. A., M. D.. Phi!adel|iliia. Pa. 

Ste\-ens, a. R.wmond, M. D. 

Ste\-ens, J. Thompson, M. D., Montclair, 
N. J. 

Stew.\rt. Thomas M., M. D., Cincinnati, 
Ohio. 

*Stragnell, Gregory, M. D. 

♦Stracxeli, Sylvi.-\, a. M. 

Strecker, Edward A., M, D., Philadel- 
phia, Pa, 

Such, Miguel Prados, M. D., Madrid, 
Spain. 



Talmev. B. S., M. D. 

Taylor, William J., yi. D.. Philadelphia, 
Pa. 

Thomas, W. Hersf.y. M. D.. Philadel- 
phia, Pa. 

Thorek, M.\x. yi. D.. Cliicago, 111. 

Touart, M. D., M. D. 

TOUSEY. Sl-N'CLAIR. M. D. 

Tracy, Edward. M. D., Boston, Mass, 
Traub, Hugo W., ^L D.. Chicago, 111, 

*Vedin, Augusta, M. D. 
YooRHEES, I. W.. M. D. 

*W.\RBURT0N, Gladys B. 

Weiss, Richard. M. D., Berlin, Germany. 

Wender. Louis, M. D.. Corozal, Canal 
Zone. 

WixsLow, Paul Y.. M. D. 

*W0LBARST, A. L., M. D. 

Woodbury, Frank Thomas. M. D., Fort 
Ringgold, Texas. 

WovscHiN, W. A.. M. D. 

Wright, James Thomas. M. D., Skill- 
man, N. J, 

Wright, Jonathan, M. D., Pleanantville 
N. Y. 

*Wyeth, George A., M. D. 

Yawger, N. S.. M. D.. Philadelphia, Pa. 



INDEX TO VOLUME CXVI. 



\ 



Paoe. 
AARON. CHARLES D. Xonsurgical 
^*- qiiadr.->.nt treatment of internal hem- 
orrhoids and prolapse of the rectum.. 732 

Therapeutic value of duodenal tube 64S 

Abdomen, pain in upper left quadrant of 627 
Abdominal conditions, acute, in children.. 132 
chronic, importance of early recogni- 
tion and treatment of 126 

operations for cancer, mortality of.... 57 

routine examinations preliminary to.. 58 

surgery, spinal anesthesia in 58 

.\lx>rtion, ftbrile, treatment of 60 

stptic 60 

Abscess of prostate 550 

psoas, crude petroleum in 602 

pulmonary 98 

subdiaphragmatic, complicating appendi- 
citis . .'. 129 

Accidents, industrial 722 

Acne vulgaris 375 

X rays in 380 

Adenitis, primary, of 2ona 347 

Adenoidectomy, end results of 142 

Adenoids, cause of 183 

Adenopathy, x ray treatment of 389 

Adhesions, postoperative 611 

Adrenal feeding in hyperthyroidism 362 

glands, relation of, to shock 361 

insufficiency 303 

Adrenalin in Stokes-Adams syndrome.... 242 

in vomiting of pregnancy 603 

injection to reanimate stillborn infant.. 612 

Adrenals, pharmacoendocrinology of 435 

-Ksculapins. temple offerings to 404 

Age. preschool, of children 462 

Aikins, W. H. B. Radium in treatment of 

diseases of women 340 

Air passages, upper, dissemination of bac- 
teria in 242 

Albuminuria in newborn 61 

in pregnancy 484 

Alcohol, eifect of, on gastric digestion.... 65S 

Algias, the sympathetic 721 

Alimentary tract, upper, deficient secre- 
tion in 675 

Allergy, food, cause of irritable bladder. . 505 

in relation to internal medicine 671 

Alopecia, treatment of 369 

Amebism of nerve cells 287 

Aminoacids in cow's milk 244 

Amnesia following traumatism 306 

Amputation stumps, adaptation of 243 

Amyostatic syndrome 687 

Analgesia, posthypnotic, for painless labor 484 

synergistic 364 

Anaphylaxis and epilepsy 64 

Anders. James M. Some deficiencies of 

modern therapeutics 429 

Anemia, aplastic 604 

severe, in childhood 181 

Anesthesia cases of unusual interest 364 

in lumbar puncture 364 

in urologicai surgery 511 

local, gynecological operations under. , . 57 

parasacral, in vaginal operations 1 19 

regional 419 

spinal, in obstetrics, gynecology and ab- 
dominal surgery 58 

-\ncsthetist. cases of interest to 364 

.Vneurysm and aortic dilatation 427 

.'lortic. simulating cyst of lung 122 

arteriovenous 121 

of internal carotid 241 

of thoracic aorta 427 

subclavian, with cervical ribs 427 

Angina pectoris 120 

Animal research, economy of 661 

j-tuna Christie, psychological study of. . . . 264 

Annals of Mcdtcal History 661 

Anoxemia in pneumonia 182 

Aritivivisectirm 167 

Antrum of Highmore. maxillary, inflam- 
matory lesions of 571 

Anus, papilhe of 448 

Aorta, dilatation of, and aneurysm 427 

stenosis of isthmus of 121 

thoracic, aneurysm of 427 

Aortic murmur 121 

Apfcl. H.Trry. Acute intestinal obstruc- 
tion due to appendicitis 163 

Aponeuroses, sarcoma of 470 

Apoplexy, uteroplacental, in accidental 

ht-morrhage 62 

Appendices, cpiploicjc, torsion of 58 

Appcndicilix. acute, pyelitis, and salpin- 
gitis, differential diagnosis of 674 

causes 01 failure in operations for 120 

causing acute intestinal obstruction. , . , 16.'' 

subdiap^raamatic abscess complicating. . 129 



P.«;e. 

.\ppcndicitis, supi>urative, coincident with 

ruptured ectopic gestation 58 

Appendix, chronic inflammation of 674 

fishbone in 670 

Applcgate, J. C. Two complicated de- 
liveries requiring Cesarean section . . 9 

Arm fractures 610 

Arteries, elasticity of 241 

Arteriosclerosis, prophylaxis and treatment 

of ; 427 

Arthritis deformans of hip joint 119 

Arthritism in childhood 165 

Ascites, severe, in myoma of uterus 240 

Astrology and astronomy 344 

Atresia of vagina 57 

Auricular fibrillation, quinidine in 427 

Autotherapy 124 

DACILLUS coli infection of urine 548 

•-* Backs, traumatic, treatment of 117 

Bacteria, dissemination of, in upper air 

passages 242 

Baird, John H. General management of 

acute injuries to the brain 311 

Banti's disease, splenectomy in 482 

Barker, Creighton. Infection with organ- 
ism of Vincent 88 

Barnes, George Edward. New virgin 

vaginal speculum 40 

Bartholinitis 550 

Bartle, Henry J., and Lyon, H. B. Vin- 
cent. Sigmoidoscopy 668 

Bascli, Seymour. Non recurrence of gas- 
tric cancer after operation 636 

Bassler, Anthony. Chronic abdominal 
conditions encountered in adults and 

children 126 

Baths in renal affections 709 

light, action of 383 

Bayly, H. Wansey. Prevention of vene- 
real disease 493 

Hazillosan, experiences with 488 

Bechet, Paul E. Pityriasis rubra pilaris 
associated with dystrophia 3diposo- 

genitalis 372 

Fiehrend, Moses. Acute abdominal condi- 
tions in children 132 

Hi-njamin. Harry. Theory and practice 

of the Steinach operation 203 

Berkeley, William N. Notes on new treat- 
ment for Mongolian idiocy 274 

Miggs, Hermann M. Periodical physical 

examinations 606 

iiile, excretion of dyes in 426 

lest in amebic dysentery 658 

Biliary apparatus, effect of magnesium 

sulphate on 645 

diseases 487 

drainage 645 

through duodenal tube 671 

am of Divorcement, psychological studv 

of 264 

Biological products, selective action of . . 455 

Birth analgesia, posthypnotic 484 

after death 240 

Mirths under hypnosis 484 

Misher. William. Report of case of ac- 
cidental occlusion of male urethra... 498 

Bismuth therapy for syphilis 73(> 

Bladder, cancer of 551 

carcinoma of 401 

formation of iodoform in, from potas- 
sium permanganate 550 

irritable, food allergy cause of 505 

r.idium in cancer of 122 

rupture of 510 

traumatic inflammation of 58 

tubt-rculnsis of 118 

tumors of 491 

Blauner. Samuel A.,* and Orgel. Samuel 
Z. . An analysis of end results of 

tonsillectomy and adenoidectomy. , . . 142 

Blood analysis, rapid method of 585 

diseases, radiotherapy in 42 

fat in diabetes 609 

in breast milk 236 

pressure, high, in uterine fibroids 241 

in cerebral decompression 241 

in diabetes 609 

serum in pathological states 720 

supply of dentate nucleus of cerebellum 302 

fransiusion 733 

Bloodvessels, diseases of 120, 241 

Blum*.*nfcld. Louis. Congenital diaphrag- 
matic hernia 131 

Bodies, foreign, removed from rectum . . . 703 

Body and mind, relation of 660 

Bone graft in Pott's disease 243 

grafting 184 



P.\CE. 

Bone lesions, x ray diagnosis of US 

pegs - 611 

Bones, long, syphilitic inflammation of... 552 
Bonner, Clarence A. Origin and scope of 

the modern state hospital 280 

BOOK REVIEWS: 

Baar, Gustav. Die Indicanamie 729 

Balzac. Les Contes drolatiques HO 

Balzac. Short Stories 417 

Barker, Elsa. Fielding Sargent 666 

Barker, Llewellys F. Clinical Medicine 664 
Barton, William E. The Life of Clara 

E. Barton ' 417 

Bassler. Anthony. Diseases of the Stom- 
ach and Upper Alimentary Tract. 664 
Berkeley, Comyns. Diseases of Women 50 

Better Letters 53 

Bishop. R. W. S. My Moorland Pa- 
tients 355 

Bland Sutton, Sir John. Tumors, In- 
nocent and Malignant 416 

Bourne, Aleck W. Synopsis of Mid- 
wifery 51 

Brainard. Annie M. The Evolution of 

Public Health Nursing 600 

Brierley, Susan S. An Introduction to 

Psychology 539 

Brill. A. A. Fundamental Conceptions 

of Psychoanalvsis 290 

Brill, A. A. Psychoanalysis 290 

Brooks, C. Harry. The Practice of Au- 
tosuggestion bv the Method of 

Emile Coue 291 

Brugsch. Theodor. AUgemeine Prog- 
nostik. oder die Lehre von der 
arztlichen Beurteilung des gesunden 

und kranken Menschen 729 

Buchanan. Estelle D. Bacteriology... 477 

Burroughs. John. My Boyhood 53 

Carnot. Harvier and Mathieu. Les I'l- 

ceres digestifs 476 

Cather, Willa. One of Ours 540 

Chamberlin, Frederick. The Private 

Character of Queen Elizabeth. . . . 478 
Chauffard. A. La Lithiase biliaire... 599 
Cook, William G. H. Insanity and 
^lenial Deficiency in Relation to 

Legal Responsibility 599 

Core. Donald E. Functional Nervous 

Disorders 599 

Core, Zachary. The Early Diagnosis of 

the Acute Abdomen 600 

Cotton, Henry A. The Defective, 

Delinquent and Insane 108 

Cournos, John. Babel 665 

Crookshanks, F. G. Influenza SS^ 

Darrow, Clarence. Crime. Its Cause 

and Treatment 665 

DeLee, Jose[)h B. Obstetrics for Nurses 353 
Descour, L. Pasteur and His Work... 478 

Dick. J. Lawson. Rickets. 539 

Dow, Grove Samuel. Societv and Its 

Problems 110 

Drew, Lillian Curtis. Individual Gym- 
nastics 598 

Dunlap. Knight. Elements of Scientific 

Psychology 539 

Kinhorn. Max. Lectures on Dietetics... 599 
Elliott, Robert Henry. A Treatise on 

Glaucoma 477 

Ellis, Havelock, Little Essays of Love 

and Virtue 172 

Ervine. St. John G. The Ship 110 

Fischer, Louis. Diseases of Infancy 

and Childhood 170 

Flcuron, Svend. Kittens: A Family 

Chronicle 540 

Flugel, 1. C. Psychoanalytical Study 

of the Family 290 

Forsyth, David. Tcchnic of Psycho- 
analvsis 290 

Frank. Waldr). City Block 750 

Frank, Waldo. Rahab 110 

Glaister. John. A Textbook of Medical 

Jurisprudence and Toxicology .... 540 

Goethe's Faust 110 

Gorky, Maxim. Mother 666 

Dc Gourmont, Rcmy. Very Woman 

(Sixtinc) 416 

Greene, Charles Wilson, Kirke's Hand- 
book of Physiology 730 

Groves, Ernest W. Hey. A Synopsis of 

Surgery 598 

Groves. Ernest W. Hev. Modern Meth- 
ods of Treating I'raclurcs 352 

Gnillaumc. A. C. t.es Occlusion aigues 

ct subaigues Ac I'intestin 476 



742 



IXDEX TO VOLUME CXVI. 



Pace. 



Pace. 



Jellil 



BOOK REVIEWS: 

Handley, W. Sampson. Cancer of the 
Breast and Its Treatment......... 

Hare. Hobart Amor.v. A Textbook ot 
Practical Therapeutics ,■•■.•••••••,;/ 

Harrow, Benjamin. Glands m Health 

and Disease j}^ 

Hemon, Louis. Maria Chapdelaine .. . 
Hergesheimer. Joseph. The Bright Shawl 
Holt, L. Emmett. Food, Health anrl 

Growth ■ ■, • ' ™,* • ■ V 'ij' " V 

Howat, R. Douglas. The Threshold of 

Motherhood • w V ' '•■ ' 

Howes, Paul Griswold. Insect Behavior 
Howson. G. Handbook for the Limbless 
Hubbard. S. Dana. Pamphlets on Facts 

About Sex ■ ■ : 

Hjtnan, Libbie H. Lalwratory Manual 
for Comparative Vertebrate Anatomy 
liffe. Smith Ely, and Brink, Louise. 

Psychoanalysis and the Drama 

Johnston. Sir Harry. The Veneerings.. 
Kave-Smith, Sheila. Joanna Godden . . . 
Keible. Robert. Simon Called Peter. .. 
Keable. Robert. The Mother of All 

Keith,' Arfhur.' ' Huniaii Embryology, and 

Morphology • ■ j' Vi ' ' 

King, D. Macdougall. Nerves and Per- 

sonal Power . • • • ••■•,• 

Kleen, Emil A. G. Massage and Med- 
ical Gymnastics .• ■ 

Kirke's Handbook "f Ph>'?'5'9e>- •<,;•,■ 
Kroenig. Barnard and Fr-edrich, Wal- 
ter. Principles of Physics and 

Biology of Radiation Therapy li™ 

Lagerlof. Selma. The Outcast ...... .- 3=4 

LaSrens, Georges. Otorhinolaryngology 

for the Student and Practitioner. ... 730 

Lawrence. D. H. Aaron s Rod. ... ..... -v- 

Lee, Arthur Bolles. The Microtomist s 

Vade-Mecum ■ •. *^^ 

Levy, A. Goodman. Chloroform Anes- ^_^^ 

thesia : --nn 

Lewis, Sinclair. Babbitt .............. • ""» 

Lib-r, Benzion. The Child in the Home 52 
Lu.'s, George. A Textbook on Gonor- 

' r'hea and Its Complications 

MacConnell, Sar.ih Warder One. . . ., . 
MacLeod, J. J. R. Physiology and Bio- 
chemistry in Modern Medicine_ . 

McCoUum. E. V. The Newer Knowl- 
edge of Nutrition .......... 

Madinier, Jean. La thoracoplastie extra- 

Mar^fiou" P. 'Mario.' "Caruso's 'Method 
of Voice Production; the Scientific 

Culture of the Voice . .■ - ■ y[ 

Martinet, Alfred. Clinical Diagnosis. . 4/, 
May, Charles H. Manual of Diseases of 



352 
292 



417 
730 

170 

352 
665 

172 

173 

109 

290 
667 

52 
541 

541 

665 



171 
730 



538 
232 

664 

415 
354 



Zahnheil- 
Psychology of 
The Practical Medi- 
Wiiat to bo in Cases 



353 
109 

232 

598 

353 

600 
291 



730 



172 
232 



the Eye 

Mayo Clinic Papers 

Mayo Foundation Papers. .... ..-. • J"' 

Mellish. Maud H. The Writing of 

Medical Papers . - V Vi " ' 

Metzger, John A. Principles and Prac- 
tice of X Rav Technic for Diagnosis 
Meulencracht. E.' Der clironichc heredi- 

tare hiimolytische Ikterus. . 

IVlisch Julius. Lehrbuch der _Grenzge- 
beitc- der Medizin und 

kunde ■ • ■ 

Mitchell, T. W. Thi 

Medicine . . 

Mix. Charles L. 

cine Series . 

Murrell, William. 

of Poisoning -■••••,••. V 

Myenson, Abraham. Foundations ot 

Personality ■ • - - . . . ■ • - .- ■ ■ - . 

c iberndorfer, Siegfried. Pathol.igische- 
anatomische .Situsbilder der Bauch- 

hohle 

Paris. John. Kimono. . . ■ ■ ■ . ... 

Partridge, William. Aids to Bacteri- 

Pill.sliury. \V. B. The Fundamentals of 

Psychology ,• ' ' ; 

Pitfield. Rohirt L. Compend. of 

teriohig) *,;■■;■ 

Pliminer, N'iolet G. and R. H. A. 

mines and the Choice of Food. . 
Polak, John Oshorn. Manual of 

stetrics .•,■„:*. .-•, ' * 

Polano, Oscar. Geburtshilflich-gynako- 

logischc Propadcutik u;,: • ; • ; ^ 

Pottenger, Francis Marion. Clinical 

Tuberculosis •, 

Pottenger, Francis Marion. Symptoms 

of Visceral Diseases ;;; ' ' 

Potter, Irving W. The Place of Ver- 

sion in Obstetrics ••••■. i '" 

Poullon. E. P. Taylor's Practice of 

Medicine ;; ■,' ' ; 

Practical Medicine Series, Vol. 1 ..... . 

Rinchart. Mary Rolierts. The Breaking 

Point • , j 

Russell, William. The Stomach and 
Abdomen from the Physician s View- 
point 



Bac. 

'Vi't'a- 
' ' o'h- 



171 
232 



539 
51 

170 
50 



BOOK REVIEWS: 

Savill. Thomas Dixon. A System of 

Clinical Medicine .- - ■ - 

Schamberg, Jay Frank. Diseases ol the 

Skin and the Eruptive Fevers . 

Scheppegrell, William. Hay Fever and 

Asthma ;■■.•••,■■ y- ■ -.y 

Schmidt, Hans. Zur Biologic der Lipoide 
Schnirer, M. T. Taschenbuch der 

Therapie • 

Schwalbe, J. Diagnostiche und therapeu- 
tische Irrtiimer und deren \ erhu- 

tung 

Scott, Evelyn. Narcissus 

Scott, R. J. E. Hughes Practice of 

Medicine .......;.... 664 

Scott, Thomas Bodley. Endocrine Iher- 

apeutics • • • ■ A,* 1 

Scudder, Charles Locke. The Treatment 

of Fractures '•■•;,•• u V '■' ' ' 

Shuttleworth, G. E. Mentally Deficient 

Children • u- ■ ;.• ■ ■ 

Simpson. Frank Edward. Radium 

Therapy .,*■"■,■* 

Sinclair. May. The New Idealism. ... - o- 
Sollraann, Torald. .\ Manual of Phar- 
macology and Its Applications to ^ 

Therapeutics and Toxicology ■ ' 

Somerville, H. Practical Psychoanalysis 
South Dakota Board of Health Pamphlet 

on Health and Disease. . .• -31 

Stein, Conrad. Diagnostik und Therapie 

der Ohrenkrankheiten 4/7 

Stekel, William. Bisexual Love....... 291 

Stevens, A. A. The Practice of Medicine 

Stillman, Paul R., and McCall Johii 

Oppie. A Textbook of Clinical 

Periodontia ;' "-A' : " ' 

Strauss, H. Nachkrankeiten der Ruhr.. 
Strihiing, T. S. Birthright............ 

Sutton. Richard L. Diseases of the Skin 
Svedberg. The. The Formation of Col- 

Tannenbau'm,"Frank, Wall Shadows.. 

Tarkington. Booth. Gentle Julia 

Terrian, F. Diagnostic, Traitement et 
Expertise des Sequelles Oculo- 

orbitaires ^.■,- ' " " tV ' ' ' 

Tilney, Frederick, and Riley, Henry 
Alsop. The Form and Functions of 

the Central Nervous Systems 

Tormav. Cecile. The Old Housc^.... 

Underwood, Arthur S. Aids to Dental 
Anatemv and Physiology. ......... 

Van Blarcom, Carolyn Conaiil. Ob.stct- 

rical Nursing ..... -y.:^- ■ ■■i,:- 

Van Vechten, Carl. Peter Whiffle. His 

Life and Works. . .■•■•.•■■•• tH 

Voronofl. Serge. Greffes testiculaires. . 399 
Walker, Norman. An Introduction to 

Dermatology • . ; ■ v' Vi ' ' ' 

Walmsley, Thomas. A Manual of Prac- 
tical An.itomy A ■ ■ ' ■■ 

Walter, Herbert Eugene. Genetics.... 

Weber Frederick Parkes. Aspects ot 

Death and Correlated Aspects of 

Life in Art. Epigram and Poetry.. 

Wells H. G. Secret Places of the Heart 

West, Rebecca. The Judge 

Whitnall, S. Ernest. Anatomy of the 
Human Orbit and Accessory Organs 

of Vision :■,■,■■;■■,*:■ 

V^^lson, R. M. The Clinical Method in 

the Study of Disease 

Witherbee, William D., and Remer, John, 
X Ray Dosage in Treatment and 

Radiography ;„•■;••. a-h: 

Wood, F. C. Laboratory Technic. ..... 4/6 

Woolston. Howard B. Prostitution m 

the United States ..•■ 

Wossidlo, Erich. Kystoskopischer Atlas 
Zumbusch, Leo. Atlas of Syphilis 



664 

231 



108 
476 



415 



291 
600 



600 
728 
231 
109 



28 
172 



416 



171 
599 

354 
414 

476 
355 
601 



170 
354 



665 

51 



liSAREAN section 
indications for .... 
two deliveries requiring 



vj I 

two ucim-iii-.^ 1^,1- o .Q,, 

Calcium salts, absorption of.. 408 



P.IGE. 

. 483 

10 
9 



..44, 
'.'2'7'5', 
■"of 



5311 

520 

118 

6 

57 

704 

551 

122 

340 

55 

57 

57 



nd electrocoagula- 



Calculi causing h>dropyonephrosis 

renal, unusual case of 

urinary •-•••:■■ 

Cancer, inoperable, of uterus, radiiun m. 
mortality of abdominal operations for.. 

nodular, of pancreas 

of bladder 

radium in ■ 

of breast, radium in treatment of .... . 
of cervix, abdominal hysterectomy in. 

advanced, operability in . . 

diagnosis and treatment of :>' 

radium in 

of prostate •,■■•,;; 

of rectum with four plus Wassermann 

of skin 

symposium on . . 
X rays, radium 

tion in 

of stomach : 

nonrecurrence after operation 

of uterus, radium in 6» 

rav treatment of *, ' ' *i j' "i ' * ' ' 

what the family physician should know 

about it 

X rav treatment of : -. • ■ 

Carboh'vdrate excess causing malnutrition 

Carcinoma, effect of radium rays on 

of cervix uteri in nuUiparous women . . 

of kidney 

of prostate, radium in 

of uterus in pregnancy, labor and puer- 

perium : 

radium therapy before operation..... 

radium treatment in =5, 

X rav treatment of ■ 

of vagina and vulva, radium treatment ot 

spinal, X ray diagnosis of 

X rav treatment of 

Cardiospasm, therapy of.. 

Cardiostenosis, therapy of ... 

Carditis, acute, pulse charts m .. ... 

Carotid artery, internal, aneurysm ot 

Carriers, diphtheria bacillus,. • . 

Carter R. Franklin. Preoperative and post- 
operative treatment of colon malignancy 

Case histories for record 

Causalgia 

Celiac disease ; ' Vi' ■ ' 

Cereal and milk mixtures concentrated in 

early infancy • ■ ■ ■. ;.• • ■ 

Cerebellar manifestations of encephalitis. . 
Cerebellum. blood supply of dentate 

nucleus of .......■■■... ■■;■ 

Cerebral decompression, blood pressuie in 
Cerebrospinal fluid, colloidal benzoin re- 



414 



665 
110 



599 
292 
730 



2,n 

232 



352 



232 
291 
538 



of, abdominal hysterec- 



55 
14 
57 
57 



412 

6 
363 

123 



gs in .•••.••■%*■' 

Child welfare, county organization for. 
Childbirth, painless, ten years — ■' 



4in 
311 
425 
604 



230 
230 



664 
730 



666 



108 



Botulism 

Brain, acute injuries to... 

tumors 

in young children 

Brandt, Murray L. Report of case 

pregnancy following menopause . 

Breast, cancer of, radium m treatment of 

carcinoma of .' " * V 

female, fat necrosis of 

milk, blood in...... 

rate of secretion of ■ 

operations, life expectancy in --■■ 

tumors ;■; ■ ■ i-'.' ■ ■ " 

Bieitstein, M. L. Review of hereditary 

syphilis of the ear ,•••.••.•■ 

Broeman, C. J. What family physician 
should know about cancer. 



38 
340 
402 
244 
236 
236 
243 



526 
397 



Bronchopneumonia, follow up recoras in 

cases of 

Bughce, Henry G. Some recent advances 



urological surgery • ^^9 

Burns, hot mineral oil treatment of 418 

treatment of °" 

Bursitis, postural ,••.••■■> 

Buzbv. It. Franklin. Tuberculosis of 

the hip '•^" 



action in ... 
rhinorrhea . . 
Cervix, cancer 

tomy in 

carcinoma of . ■ . 

diagnosis and treatment ot. 

operability in 2^ 

tumors of e'^^ 

Chancre on penis at seventy-one. 3Ji 

syphilitic, of palpebral conjunctiva 5-'4 

Chaulmoogra oil in tuberculosis, . . ^o-t 

Chemicals, manufacture of, in America.. 
Cherry, Thomas H. Uses of radium in 

gynecology ■ 

Chest, thoracoscopj; m surgery ot 

X rav densities in V 'i'.' • ' 'i" i;'„j' 

Chests of children, x ray and clinical find- ^^^ 

!"s^i" -■::-.::::.::-^)i,r:::; 659 

experi- 

58 

Childi-CT, 'defecti've',' endocrine therapy in. U7 

preschool age of -j j 

Chiropractic .qj 

Cholecvstenterostomy ■ ■ • 

Choleli'thiasis differentiated from duo- 

denal ulcer ; • : ■ •,• i 

Circulation, stimulation of. iii lobar pneu- 

Clarkl'ir Pierce. " Study of unconscious 

motivations in suicides 

Clavus j ' ' '■ 

Clitoris, genital nerve corpuscles m. 
Clock, Ralph Oakley. 

Cocaine, 'incre^ased 'effect' of. by a'd'dition of 
glucose solution 

Cold drinks, fatality from. 

Colds, common 

Colitis, amebic 

Colon bacillus pyelitis ^j^^ 

carcinoma of ■ -,j^ 

malignancy, treatment of r'-y ?7, 

pain due to disturbances of muscles of . . 6/3 

pathological conditions of • • . 

sins and sorrows of 'OO' 

Conessine. amehicidal action of 4bo 

Confusional states following traumatism. mi 

Conjunctiva, palpebral, syphilitic chancre of 534 



Hay fever and pol- 



.227. 



480 

254 

375 

63 

193 

428 
166 
360 
426 
95 



620 
673 



INDEX TO VOLUME CXVI. 



743 



Paok. 
Connolly, John M., and Q^tlen. J. Bergen. 
New method for quantitative deter- 
mination of sugar in urine 524 

Convulsions due to genital irritation 605 

Cooke. Edwin S. Clinical results obtained 
by the intravenous injection of hexa- 

methylenamin 542 

Cord, umbilical, study of 59 

Corning, T. Leonard. Alleviation of pain 

in severe and fatal illness 677 

Cornwall, Edward E. Conservative treat- 
ment of pneumonia 5<»3 

CORRESPOXDENCE: 

Balkan letter .^51. 475. 

London letter 4S, 350. 474. 596. 

Craig. Henry K. Selective action of drugs 
and biological products. 

Cramp, writers', reeducation in 

Crance, Albert M. Case of chancre on 
penis at age of seventy-one. appar- 
ently with no history of sexual contact 

Cretinism, sporadic 

Culbertson, Walter Leon. Etiology of 
eclampsia 

Cyst of lung. X ray diagnosis of 

Cystoscopic radium application, improved 

method of 

table 528. 

Cysts, epidermoid 



724 
735 



455 
556 



531 
302 

19 
122 

lis 

544 
486 



D'ACIERNO. P. A. The r61e of trau- 
matic factor in pathogenesis of peri- 
colic bands and membranes 

Dannreutber, Walter T. Brief resume of 
some of the recent advances in gyne- 
cology 

Darnall, William Edgar. Suppurating 

uterine myomata 

Deafness, catarrhal, treatment of . . . .466, 

Death, intrauterine 

under ether 

Debility, arthritic, in childhood 

Defective children, endocrine therapy in.. 
Deformities of viscus in peptic ulcer shown 

by X rays 

DeKruif's articles in Hearst's International 

Delivery, method of. in normal cases 

Dembo. Leon H., and f-itchfield. Harry R. 
Malnutrition in infancy: A considera- 
tion of its various phases in relation to 

treatment 

Dementia nrwcox in relation to syphilis.. 

morbid histology of testes in 

pathological studies in 245. 

Denenholz. Aaron. L'nusual case of renal 

calculi 

Dental pastes, advertising of 

Depression, mental, following traumatism 

Dercum, Francis X. Internal secretions 

in their relations to the neurologist 

and psychiatrist 

Dermatology and the nervous system. . . . 

Dermatoses, precancerous 

D'Espine's and allied signs in childhood. . 

Diabetes, divided meals for 

etiology and treatment of 

hyperthyroidism in 

insipidus in xanthoma tuberosum 

lumbar puncture in 

pituitary extracts in 

niellitus, prognosis in 

modern aspects of 

pregnancy in ^ 

Diarrhea, summer, prevention and treat- 
ment of 

Diathermy in malignant disease 

in surgical practice : 

Diet and nutrition 

as a therapeutic measure 

Dietetics applied in outpatient department 
Digestion, gastric, effect of alcohol on.... 

Digitalis, toleratice of children for 

Diphtheria bacillus carriers 

Diphtheritic infection in newborn twins.. 

Disease, infectious, heart in 

Diseases, industrial, due to poison 

of women, radium in treatment of 

Diuretics, effect of, on fibrinogen 

Diverticulum of jejunum, inflammation of 

Drinks, cold, fatalitj; from 

Drosin, L. Ascertaining the viability of 

the fetus 

Locating fetal heart sounds... 

Drueck, Charles J. Hypertrophied anal 

papillze (papillitis) 

Drug addict 

addicts on Riker's Island 

store, travelling, in Russia 

treatment of goitre 

Drugs, price of^ in Hungary 

selective action of 

Duodenal obstruction, chronic 

stenosis of tuberculous origin 

tube, biliary drainage through 

in biliary diseases 

therapeutic value of '. . . . ,648, 

ulcer differentiated from cholelithiattis . 

Duke, W. W. Fond allergy as cause of 

irritable bladder 



699 



12 

17 
488 

61 
351 
165 
147 

614 

718 

56 



216 
102 
315 
315 

520 
410 
306 



438 
402 
367 
178 
60S 
609 
609 
60S 
428 
609 
609 
608 
56 

174 
419 
734 
596 
672 
177 
658 
181 
183 
61 
121 
351 
340 
357 
486 
166 

20 
200 

448 
223 
715 
593 
361 
351 
455 
651 
23S 
671 
487 
671 
487 

505 



Pack. 
Duttoii. W. Forest. Crude petroleum in 
tuberculous osteomyelitis and psoas 

abscess 602 

Dwarfism, pituglandol for 736 

renal 181 

Dysentery, amebic, bile test in 658 

Dyspepsia, conditions underlying 676 

Dystonia musculorum 329 

Dystrophia adiposogenitalis 372 

EAR canal, furuncles of 135 

hereditary syphilis of 526 

Ecbolics. action of. in first stage of labor 56 

Eclampsia, effect of food on -. . . 484 

etiology of 19 

incidence of 61 

microscopic capillary findings in 61 

treatment of 56 

Ectoplasm 102 

Eczema 125 

X rays in 380 

Edema, fugacious, of mastoid region with 

paroxysmal hemoglobinuria 74 

EDITORL\LS: 

Accidents, industrial 722 

Adenitis, primary, of zona 347 " 

Alcoliol, effect of, on gastric digestion.. 658 

Algias. the sympathetic 721 

Amebism of nerve cells 287 

Animal research, economy of 661 

Annals of medical history 661 

Antivivisection 167 

Aponeuroses, sarcoma of 470 

Anthritism in childhood ' 165 

Astrology and astronomy 344 

Hile test in amebic dysentery 658 

Hlood diseases, radiotherapy in 42 

MIood serum in pathological states 720 

Body and mind, relation of 660 

Botulism 44, 410 

Causalgia 721 

Chancre, svplulitic, of palpebral conjunc- 
tiva 534 

Chemicals, manufacture of, in America. . 412 
Chests of children, x ray and clin ical 

findings in 593 

Child welfare, county organization for. . 659 

Cold drinks, fatality from 166 

Colds, common 227 

Colon, sins and sorrows of 166 

Conjunctiva, palpebral, syphilitic chancre 

of 534 

Debility, arthritic, in childhood 165 

DeKruif's articles in Hearst's f u tenia- 

tional 718 

Dementia pr:ecox and syphilis 102 

Dental pastes, advertising of 410 

Digestion, gastric, effect of alcohol on.. 658 

Drinks, cold, fatality from 166 

Drug store, travelling, in Russia 593 

Dysentery, amebic, bile test in 658 

Ectoplasm 103 

Efficiency of human machine 590 

Encephalitis, accuracy in observing and 

recording eye symptoms in 42 

lethargica, causes of 411 

Endocrine glands and sympathetic nerv- 
ous system 286 

Endothermy 409 

Erythema nodosum, relation of, to tu- 
berculosis 226 

Eye symptoms in encephalitis, accuracy 

in observing and recording 42 

Freedom 532 

Freud and telepathy 284 

Gastric digestion, effect of alcohol on. . . . 658 

Health and wealth 344 

board, international, report of 412 

department practice, municipal report 

of committee on 227 

education, public 411 

public, in the United States 45 

supervision of school children 164 

Heart in scarlet fever 103 

High lights , 284 

Honesty, policy of 410 

Hookworm disease, new treatment for.. 168 

Hope 656 

Hospitals, new private 722 

Human machine, efficiencv of 590 

Hygiene, infant and child 592 

mental, international 470 

Hypertension, intracranial •. 43 

Index Catalogue 661 

Industrial accidents 722 

Infant and child hygiene 592 

Infection, wound, treatment of 719 

Influenza, asthenic manifestations of . . 590 

in Framingham 594 

Instincts. McDougal's theory of 285 

Intestinal stasis, effects of 659 

Intestine, alarm clock 659 

.lournal of Oralogy 348 

Leucocytes, examination of ._. 345 

Life Extension Institute, recent activi- 
ties of _. 471 

Loomis sanatorium, twenty-fifth anni- 
versary of 471 

Medical school and hospital at Peking.. 105 

witness, expert 224 



pAr.F.. 

Medicine, fads in 532 

preventive, iti France 535 

Mental deficiency survey in Wisconsin.. 288 

hygiene, international 470 

hygienist. newspaper as 285 

Mind and body, relation of 660 

Mothers, unmarried 105 

Kerve cells, amebism of 287 

Newspaper as mental hygienist 285 

Oral medicine, new journal of 348 

Phlegmon, perinephritic 532 

Pbthiriasis. acute 408 

Pneumonia, communicability of 591 

Professional secrecy 656 

Psychology, high lights on 284 

Psychopatlmlogy 344 

Psychotherapy in France 661 

Public health problems, opinions on.... 45 

Purification "IS 

Quinine, visual disturbances due to.... 104 

Radiotherapy in diseases of the blood.. 42 

Research, scientific, impularization of. . 345 

Respiratory system in scarlet fever lO."? 

Sanitarians, education of 45 

Sarcoma of aponeuroses 470 

Scarlet fever, heart and respiratory sys- 
tem in ' 103 

School health supervision 164 

Science, popularization of research in . . 345 

Scoliosis 225 

Secrecy, professional 656 

Shock, sodium oleate in 225 

Skin pigmentation, etiology of 408 

Sodium oleate in shock 225 

Statistics, vital, in New York Stale.... 346 

Sympathetic algias 721 

nervous system and endocrine glands. 286 

Syphilis and dementia prarcox 102 

Telepathy, Freud in regard to 284 

Tonsil, reprehensible 164 

Tuberculosis, erythema nodosum in re- 
lation to 226 

Uric acid in fiction 533 

Uterus, misplaced or misshapen 722 

traumatic displacements of 722 

Venereal diseases in colleges. ........ . 534 

Vision, disturbances of, due to quinine 103 

Vitality, index of 468 

Wassennann tests, value of 469 

W^isconsin's mental deficiency survey... 28S 

Witness, expert medical 224 

Wound infection, treatment of 719 

Wounds, tbor.'icic. of modern warfare. 468 
X rav and clinical findings in chests of 

children 593 

in diagnosis 720 

Efficiency, experimental pancreatic 123 

of human machine 590 

Eggston. Anilrew A., and Norman. N. 
Philip. Intestinal infections and 
toxemias and their biological treatment 623 
Einhorn, Max. Action of various sub- 
stances on the liver 188 

Peptic ulcer with deformities of viscus, 
evidenced by x rays, changed for the 

better by treatment 613 

Electric lanii). Tungsten incandescent, in 

therapy 382 

Electricity, static, uses of 419 

Electrocnagulation in skin cancer 553 

Electrotherapy in cancer 388 

Emetine, therapeutics of 670 

Emphysema 62 

Empyema, chronic, treatment of . 734 

Encephalitis, accuracy in observing and 

recording eye symptoms in 42 

acute, treated with specific serum 236 

endemic, followed by attack of tetany.. 301 

epidemic . '. 425, 691 

cerebellar manifestations of 321 

simulating brain tumor 326 

Ictliargica. causes of. 411 

Endocarditis complicating tonsillectomy in 

children 145 

Endocrine aspefrt of feebleminded and 

epileptic child 330 

glands and sympathetic nervous system. . 286 

therapy, combined, in defective children 147 

Endotherny 409 

Entaineba, dvsenteri.T 427 

Enteritis, phlegmonous.. ».- 486 

Enteroantigens in gastrointestinal disorders 619 

Epilepsy and anaphylaxis 64 

following traumatism 307 

heredity in relation to 334 

in relation to eugenics 339 

in woman with sixteen children 334 

luminal in treatment of 336. 356^ 

Epileptic and her sixteen children 334' 

child 330 

Epithelioma of face, basal celled 400 

X rays in 381 

Epstein, J. Prevention and treatment of 

summer diarrhea 1 74 

Ergot preparations, action of 612 

Erysipelas, treatment of. with quartz lamp 485 
Erythema nodosum, relation of, to tuber- 
culosis 226 

Esophagogastroanastomnsis 296 



744 



Page. 

Esophagoscop> , technic of 82 

Ether, death under 3^1 

Eugenics in relation to epilepsj- J39 

Eve symptoms in encephalitis, accuracy in 

observing and recording 4- 

Ezickson, William J. Emergencies in 

urology ^O* 

FACE, epithelioma of ; 400 
Fairbanks, B. H., and Friedman, E. D. 
Tumor of middle fossa with autopsy 

findings • • • -''•' 

Fallopian tubes, bacteriology and pathol- 

ogy of . . °- 

Favus, X rays in • • •?°" 

Feebleminded child, endocrine aspect of. 3J0 

Feeding, artificial, of infants 221 

infant, lactic acid milk in JSU 

modification of cow's milk in....... 1/6 

substitute, of infants, use of honey m . . 1:>3 
Femur, excision of head of, in osteoarth- 
ritis of hip j'' 

fracture of i"" 

osteochondritis of ^°^ 

Fetal heart sounds ■ ^"'^ 

Fetus, ascertaining viability of.......-- -^ , 

Fibroid, uterine, radium treatment of J43 

Fibroids, uterine, high blood pressure m.. 241 

Fibromyomata, uterine, radium therapy in 3 

X rav treatment of 209 

Fibrom'v.xomata of nerve trunks /34 

Fisher. Mulford K. Rontgen ray treat- 
ment of adenopathies SS") 

Folic a deux • • -, ?°? 

Food allergy cause of irritable bladder 503 

effect of, on eclampsia and albuminuria - - 484 

Foot, operations on 119 

Form, human, possibilities in reconstruc- 

tion of ^'■' 

Fossev. L. Herbert. Case of dystonia mus- 
culorum with remarkable familial his- 

tory , ■•■; Is, 

Marked atrophy in early tabes ^o- 

Fox, Howard. Two cases of Oriental sore 

(cutaneous leishmaniosis) 363 

Fracture of. femur 1-0 

of lower end of radius /J-j 

of skull in children 1°1 

Fractures, closed, treatment of 119 

of forearm and leg |10 

of lumbar vertebra 363 

of tibia f " 

spiral, treatment of 1°4 

Freedom ^^" 

Freud and telepathy .■•••.• '^"4 

Fried, Herman. Circulatory stimulation in 

lobar pneumonia • • 480 

Friedenwald, Tulius, and Martindalc. Jo- 
seph \V. Some observations on inci- 
dence of pain in upper left quadrant 

of abdomen %;■■,■/ 

Friedman, E. D.. and Fairbanks, B. H. 

Tumor of middle fossa with autopsy ^__ 

findings • ■ : -' -• 

Furunculosis of ear canal simulating mas- 

toiditis 133 

X rays in 3»u 

GALLBLADDER, carcinoma of 401 

connective tissue changes in 640 

disease 487 

surgery, technic of '°7 

(Gallstones, operations for 184 

r.angrene due to thromboarteritis 394 

Garlic as a heart stimulant 296 

Gasserian ganglion, puncture of 423 

Gastric contents, hydrogen ion concentra- 

tion of I'.J 

iligestion, effect of alcohol on 638 

juice, excretion of dyes in 4_6 

ulcer, medical treatment of 6/- 

treatment of o" 

( lastroentcrostomy - 6'4 

Gastrointestinal infection, pathology and 

treatment of r * Vo 5oo 

Generative organs, x rays in diseases of. .68, 208 
Genital irritation causing convulsions and 

petit mal • • • °^' 

Genitals, female, double malformation of . . 240 

Genitourinary cases 530, 546 

Germs, origin of, in newborn 60 

Gcrson. H. M. Notes and statistics on 

twilight sleep ........ • 54 

Gestation, human, limit of duration of . . . . .:■: 
ruptured ectopic, coincident with acute 

suppurative appendicitis 58 

Glassburg, John A. Furuncles of the ear 

canal 1^^ 

Glossopyrosis ;■■•.•,• 

Goitre, congenital familial, treated with 

drugs 361 

endemic, problem of 4-8 

preoperative and postoperative treat- 
ment of llo 

simple, prevention of 30- 

surgical treatment of : -.• '84 

Goldfader, Philip. Colon bacillus pyelitis 93 
Goldstein. Hyman. Endocrine aspect of 

the feeblcmind.d and epileptic child. 330 



IX'DEX TO VOLUME iXVI. 



P.KGE. 

Goldstein, Hyman I. Primary nodular 

cancer of the pancreas /04 

Golob, M. Cancer of rectum in presence _ 

of a four plus Wassermann /06 

Gonorrhea, complement fixation in 550 

in women from aspect of focal infection 26 

Gonorrheal complications, mirion in 348 

Goodman. Herman. Rhinoscleroma 391 

Gordon, Alfred. Mental disorders follow- 

ing traumatism 303 

Grafting of bone, various methods of.... 184 

Granuloma inguinale -44 

Greenberg, David. Case of pulmonary 

abscess ■ - : • "8 

Grcenwald. .Tacob G. Use of luminal in 

epilepsy .- 33^ 

Growths, benign, x rays in 38i 

Gynecological operations under local anes- 
thesia ■ 5/ 

therapy, new trend in 3/ 

Gynecology, hypnosis in ^6- 

'radium in 1. 6. 3-*0 

recent advances in 1- 

spinal anesthesia in 38 

X rays in 68. 208 

HABERMAN, J. VICTOR. The amyo- 

static syndrome 687 

Hall. T. Proctor. Cause of whooping cough I38 

Hallux valgus, congenital, treatment of.. 363 

Hamilton. James A. Drug addicts on _ 

Riker's Island '15 

The drug addict • • • 223 

Hammer, A. Wiese. Cancer of stomach . . 634 
Hammond, Frank C. Carcinoma of the 

cervix uteri in the nulliparous woman 14 

Hay fever and pollen therapy 193 

causes of failure in treatment of 196 

desensitization by ingestion of pollen 

protein : 99 

immunization therapy in 1^* 

Heagev. Francis W. Cerebellar manifes- 
tations of epidemic encephalitis 321 

Health and wealth 344 

board, international, report of -. 412 

department practice, municipal, report 

of committee, on '- 2-/ 

education, public 411 

public, in the United States _43 

law and the concern of '11 

supervision of school children 164 

Heart disease 120, 241 

in pregnancy 56 

occupation in relation to l^jj 

I'^in in !-» 

pregnancy in - - - -^'^ 

findings in progressive muscular dys- 

trophy . 29/ 

in infectious disease j^i 

in relation to habitus !-•; 

in scarlet fever '03 

sounds, fetal, locating the -00 

stimulant, garlic as a remedy for -96 

stimulation in pneumonia 363 

testing function of -41 

Hematoma in tubal torsion 241 

Hematuria, symptomless .- • - 349 

Hemmeter, John C. Effect of magnesium 

sulphate on liver and biliary apparatus 643 

Hemochromatosis, familial • • • - 60S 

Hemoglobinuria, paroxysmal, with edema 

of mastoid •-•••-,■ ' 

Hemorrhage, accidental, caused by knot in 

umbillical cord 61- 

uteroplacental apoplexy in o- 

mvopathic. treatment of -09 

postpartum, one hundred cases of 34 

Hemorrhagic'disease of newborn. . . 15* 

Hemorrhoids, internal, treatment of /32 

Hernia, diaphragmatic, congenital .... 131 

incarcerated, in a man aged ninety-three 6/0 
operation for. with simultaneous lapar- 
otomy 611 

Herpes zoster : ■ . ■ • •'"' 

Hexamethylenamin, intravenous injec- 

tion of ii;- ■■,■;-• i ' 

Hibben. Captain Paxton. Medical relief 

work in Russia 66- 

Highman, Walter J. Precancerous derma- 
toses • 367 

Hip joint, arthritis deformans of 1 1,9 

tuberculosis of ■ ' '" 

Hirsch, I. Seth. Roentgen treatment of 

diseases of generative organs 68, 208 

Honesty, policy of............ 410 

Honev in substitute infant feeding 13" 

Hookworm disease, new treatment for 168 

Hope ;-;\ i *'* 

Hornstein. Mark. One hundred cases of 

postpartum hemorrhage 34 

Hospital, modern state, origin and scope of -SO 

Hospitals, mental, occupational therapy m 294 

new private .■••:••,-, i.,- 

Howell. J. Morton. Sanitation in Egypt . . /2/ 

Hubbard. S. Dana. Law and concern of _ 

public health .• •.• '\\ 

Professional strain and suicide 1-4 

Human form, possibilities in reconstruc- 

tion of 5'- 

machine, efficiency of 5'" 



P.KGE. 

Hupp. Frank LeMoyne. Acute osteomye- 
litis : 443 

Hvdrogen ion concentration of gastric con- 
tents • 1/9 

Hydronephrosis due to aberrant renal 

artery •. 530 

Hydropyonephrosis due to calculi 330 

Hygiene, infant and child 592 

mental, international 470 

Hvperemesis gravidarum, x rays in .. ^4^ 

Hvperglvceniia in diseases with hypertonia 241 
Hvperpnea. tetany attack during par- 
oxysm of 301 

Hyperidrosis 3/3 

Hypernephroma of kidney 50/ 

Hyperplasia, prostatic lymph node 348 

Hypertension, clinical aspect of 357 

intracranial 43 

salt poor diet in -. 1-- 

Hyperthyroidism. adrenal feeding in. . - . - . 36^ 

Hvpertonia, hyperglycemia in diseases with 241 

H'vpnosis in obstetrics and gynecology 62 

painless births under - 484 

Hypotension, garlic as a remedy for...... 296 

Hyslop. George H. Dermatology and the 

nervous system 40- 

Hvsterectomy, end results in 63 

Hysteria after mastoidectomy simulating 

brain abscess -'9 

diagnosis of 30U 

IDIOCY, endocrine aspect of 331 

Mongolian, new treatment for 2/4 

Illness, fatal, alleviation of pain in 6// 

Immunization therapy in hay fever 198 

Impetigo contagioso 3/3 

Impotence in the male 4^^ 

Index Catalogue o°] 

Industrial accidents 'e- 

diseases due to poison 33 1 

Infant and child hygiene 59^ 

feeding, artificial -jri 

bees' honey in substitute 133 

lactic acid milk in 180 

modification of cow's milk in 1/6 

weaning of 1^^ 

Infants, malnutrition in - • -16 

Infection, diphtheritic, in new born twins 61 

droplet, and sanatoria for tuberculosis.. /36 
hematogenous puerperal, complicated by 

lobar pneumonia 24- 

nontuberculous. of lungs 183 

puerperal, new method of treating oU 

with Vincent's organism 88 

wound, treatment of 'Vi 

Infections, biliary - 48/ 

pelvic, surgical treatment of ^4J 

tonsillar, and endocarditis. . 143 

Inflammation, traumatic, of bladder 5» 

Inflammations, pathology of - 388 

Influenza, asthenic manifestations of 39U 

bacillus, significance of ;|3 

etiology of '"J 

in Framingham '^^ 

in ■ pregnancy ••.■,■■•-■„■••■.••• -.••V' ' ; 
Insanity, interstitial cells m different 

forms of ■ 533 

Instincts, McDougal's theory of ^83 

Insufficiency, adrenal •. •. 303 

Insufflation, transuterme. in sterility 38 

Intellect, human, evolution of 3U0 

Interstitial cells of Leydig. dementia prx- 

cox in relation to -43. 315 

summarv of literature of 3U. 

Intestinal flora, simplification of....... 634 

infections, biological treatment of . .62.^. 6/1 
intoxications in infancy and early child- 

hood ■•:•.■• }'° 

obstruction, acute, due to appendicitis. 163 

spasm in infancy -34 

stasis, effects of :••••,:■. ,,? 

relation of. to amebic colitis 4.i6 

toxemia • ■ - • • • J'; 

biological treatment of 623. 6/1 

Intestine, acute diseases of 486 

alarm clock •.- - ■ 639 

Intoxications, intestinal, in infancy and 

early childhood J"". , " 

Intracranial tension, increased, salt solu- ^ 

. »'0" >" 'Ag 

Intussusception Jan 

Iodine, physiological 6»u 

lACKSOX, T. ALLEN. Occupational 

J therapy in mental hospitals 294 

Jaundice, incipient .-••,•■.■ i" ' 

Jeck. Howard S. Tabetic kidneys diag- 

nosed as tuberculous • 3-9 

Jejunum, inflammation of diverticulum of 486 

Joint lesions, x ray diagnosis of.... US 

Jones. John F. X. Incarcerated hernia 

in a man aged ninety-three 6/u 



KAIDEX. MAXWELL H. Tonsillec- 
trmv in children with endocarditis 
and' frequent tonsillar infections. . . 
Kaiser. Albert D. Hemorrhagic disease 
of the newborn 



145 
156 



IXDEX TO VOLUME CXVI. 



745 



Kear, Leon Vincent. Early effects of 
combined endocrine therapy in defec- 
tive children 147 

Keilty, Robert A. Conquest of typhoid 

fever at Chickamauga Park, Ga 77 

^ Pathology of inflammations 588 

Keratitis punctata, leprous 376 

Keratosis, senile, x rays in 381 

Keyes, Baldwin L.. and Strecker, Edward 
A. Ovarian therapy in involutional 

melancholia 30 

Kidney, carcinoma of 530 

disease, diagnosis and treatment of 518 

hypertensive, prognosis of 122 

mineral waters and baths in 709 

double 546 

hypernephroma of 507 

injuries of 511 

neoplasia of 58 

nontuberculous 54 

tabetic, diagnosed as tuberculous 529 

tuberculosis of 735 

Kildutfe, Robert A. Note upon the inci- 
dence of the urochromogen reaction 
of Weiss in a series of 888 examina- 
tions 523 

Kinlaw, W. Bernard. Two cases of sub- 
diaphragmatic abscess complicating 

appendicitis 129 

Kisch, Franz. Treatment of renal affec- 
tions by mineral waters and baths... 709 
Kleinberg, S. Operative treatment of 

scoliosis 93 

Knee joint, derangement of 736 

reconstruction of 363 

Knopf. S. Adolphus. A physiological ad- 
juvant in rest cure of pulmonary tu- 
berculosis 65 

Koenig. C. J. Fugacious edema of mas- 
toid region with paroxysmal hemo- 
globinuria 74 

Kouindjy, P. Reeducation in writers' 

cramp 556 

Kramer. David W. Report of case of spon- 
taneous gangrene, simulating purpura, 
due to acute thromboarteritis 394 

T ABIA minora, genital nerve corpuscles 

,^. in 63 

Labor, action of ecbolics in first stage of. 56 

carcinoma of uterus in 59 

painless 484 

protection of peritoneum in 61 

Labyrinthine surgery 85, 115 

Lactic acid milk in infant feeding 180 

Lamp, quartz, in erysipelas 485 

Tungsten incandescent, in therapy 382 

Landsman. Arthur A. Removal of sharp 
pointed foreign bodies from the rec- 
tum 703 

Langstroth, Francis Ward. Gonorrhea in 

women from aspect of focal infection 26 
Laparotomy, simultaneous with operation 

for hernia 61 1 

Laryngitis, tuberculous, treatment of 183 

Lee, Edward Wallace. Treatment of burns 607 

Leg fractures 610 

Leishmaniosis. cutaneous 365 

Lenticular striate or dyskinetic disease.. 687 
Leof. AL V. Value of x ray in skin dis- 
eases 379 

Leprosy 485 

Leprous keratitis punctata 376 

Leucemia in childhood 181 

Leucocytes, examination of 345 

Leucoplakia of vulva and vagina, radium 

in 343 

Leucorrhea, effect of radium on 343 

Levitt. Marcus J. Case of leprous kera- 
titis punctata 376 

Lewis, Nolan D. C, and Renter. F. A. 
A contribution to study of connective 

tissue changes in gallbladder 640 

Leydig cells in dementia pr.-ecox 245, 315 

LETTERS TO THE EDITORS: 

Biggs, Herman M. Periodical physical 

examinations 606 

Hubbard, S. Dana. Professional strain 

and suicide 124 

Knoi»f. S. Adolphus. Physiological ad- 
juvant in rest cure of lulierciilosis 239 
Lee, Edward Wallace. Treatment of 

burns 607 

Riddell, Willian Renwick. Derivation 

of the word syphilis 607 

Rogers, Leonard. Soluble derivatives 

of chaulmoogra oil in tuberculosis. 64 

Stewart, Thomas M. Autotherapy 124 

Tracy, Edward A. Anaphylaxis and 

epilepsy 64 

Voorhccs. I. W. Common colds 360 

Wood, William. & Co, An explanation 180 

Life expectancy in breast operations 243 

Life Extension Institute, recent activities 

of 471 

Light, colored, in treatment 383 

JMiom. psychological study of. 264 

Linitis plastica 426 



P.\GE. 

Lij), cancer of 420 

carcinoma of 400 

Litchfield, Harry R.. and Dembo. Leon H. 
Malnutrition in infancy: A consider- 
ation of its various phases in relation 

to treatment 216 

Liver, action of various substances on... 188 

carcinoma of 401 

effect of magnesium sulphate on 645 

Longevity in Bulgaria 351 

in seniitropics, factors of 559 

Loomis Sanatorium, t^venty-fifth anniver- 
sary of 471 

Lowsley. Oswald Swinney. A new cysto- 

scopic table 528 

Lucilia. the paralysis fly 605 

Ludlum, S. De W. Clinical psychiatry.. 459 

Luetin, commercial, value of tests with'. . . 428 

Lumbar puncture in diabetes 428 

prevention of complications in 91 

vertebrs, fractures of 363 

Luminal in epilepsy 3.i6. 356 

Lung, abscess of 98 

indications for operations on 120 

nontuberculous infection of 183 

X ray diagnosis of cyst of 122 

suppurations 183 

Lupus vulgaris, x rays in 381 

Lutein solution in nausea and vomiting 

of pregnancy 61 

Luttinger, Paul. Bees' honey in substi- 
tute infant feeding 153 

Lymph node hyperplasia, prostatic 548 

Lymphopenia following exposures to x rays 

and radium 123 

Lyon, B. B. Vincent, and Bartle, Henry 

J. Sigmoidoscopy 668 

IV/lcCAFFERTY, LAWRENCE K. Alo- 

^'* pecia and its treatment 369 

Magnesium sulphate, effect of, on the liver 

and biliary apparatus 645 

Malaria in paretics, sodium nuclei nate in 

treatment of 296 

Malformation of female genitals 240 

Malignancy, diathermy in 419 

of colon 630 

Malignant disease, x ray treatment of... 117 

Malnutrition due to carbohydrate excess.. 453 

in infancy 216 

Marcus. Joseph H. Medical aspect of 
carious teeth in infancy and child- 
hood 161 

Weaning the infant 101 

Martindale. Joseph W., and Friedenwald, 
Julius. Some observations on inci- 
dence of pain in upper left quadrant 

of abdomen 627 

Mary Rose, psychological study of 263 

Mastitis, chronic, radium treatment of. . 341 

Mastoid, edema of, with hemoglobinuria. 74 

Mastoidectomy, hysteria following 279 

Mastoiditis, acute 139 

and furunculosis of ear canal, differ- 
entiation of 135 

associated with acute nephritis 584 

Maxillary antrum of Highmore, inflamma- 
tion of 571 

Medical missions, British 48 

relief work in Russia 662 

school and hospital at Peking 105 

witness, expert 224 

Medicine among the Arabs 475 

dawn of, and serpent worship 185 

fads in 532 

preventive, in France 535 

Medicolegal phase of mental disorders fol- 
lowing traumatism 310 

.Medicoliterarv notes. .53. 111. 173. 233. 

293. 355, 417, 478, 541, 600, 667. 731 
Melancholia,- involutional, ovarian therapy 

in 30 

Melman, Ralph J. Artificial infant feed- 
ing for tne general practitioner 221 

Meningitis, purulent, in newborn 606 

tul)erculosa discrc-ta, symptom complex 

of 301 

Menopause, pregnancy after 38 

Menorrhagia, radium treatment of '343 

Mental dt-ficiency survey in Wisconsin... 288 

disorders following traumatism 305 

enfeeblt-ment, progressive, following 

traumatism 308 

hospitals, occupational therapy in 294 

hygiene and present day nursing 301 

international 470 

hygicnist, newspaper as 285 

Metabolism, basal, in relation to weight 

curve 237 

of diabetes 608. 609 

of underweight children 182 

Metrorrhagia, radium treatment of 343 

'Milk and cereal mixtures, concentrated in 

early infancy 176 

breast, blood in 236 

rate of secretion of 236 

cow's, aminoacids in 244 

modification of, in infant feeding.... 174 

lactic acid, in infant feeding 180 



P-VCK. 

Mills. H. Brooker. Eczema 125 

Mind and body, relation of 660 

Mineral waters and baths in renal atfec- 

tions 709 

^lirion in gonorrheal complications 548 

Mitral stenosis followed by death 121 

Mixsell, Harold R. Some diagnostic 

points in scarlet fever 159 

Mongolian idiocy 274 

Moore. William James. Treatment of 

syphilis 5i4 

Mortality of abdominal operations for can- 
cer 57 

Mothers, unmarried 105 

Mott, Frederick W. and Such, Miguel 
Prados. Further pathological studies 
in dementia praecox, especially in re- 
lation to the interstitial cells of l-ey- 

dig 243, 3 1 5 

Murmur, aortic 121 

Muscles of colon, pain due to disturbances 

of 673 

Muscular dystrophy, progressive heart 

findings in 297 

Myerson, M. C. Esophagoscopy 82 

Myrjclonias, treatment of 425 

Myoma uteri w^ith severe ascites 240 

Myomata, uterjne, suppurating 17 

Mj'xedema, childhood 302 

MACCARATI, SANTE. A case of 
A^ epidemic encephalitis with papille- 
dema simulating brain tumor 326 

Nausea of pregnancy, lutein solution in 61 

Nematode infection in monkeys 486 

Neoplasia ■ of kidney 58 

Nephritis, acute, in mastoiditis 584 

chromic acid 549 

chronic, febrile stages in 549 

salt restriction in diet in 549 

Nephropexy, transperitoneal 58 

Nerve cells, ■ amebism of 287 

corpuscles, genital, in clitoris and labia 

minora 6Z 

resuture 734 

trunks, fibromyxomata of 734 

Nervous diseases, functional 300 

system in relation to skin diseases. . 402 

syphilis of 425 

Neurology, emergencies in 508 

Neuropsychiatric pilgrimage 298, 358 

Neuroses following traumatism 309 

Neurosyphilis and neutrophic strains... 683 

Nevi, X rays in 381 

Newborn, albuminuria in 61 

calcium content of blood in 176 

hemorrhagic disease of 1 56 

meningitis in 606 

origin of oral and rectal germs in.. 60 

twins, diphtheritic infection in 61 

Newspaper as mental hygienist 285 

Nitrous acid poisoning 488 

Norman, N. Philip. Diagnosis, interpreta- 
tion, and biological treatment of renal 

disease 518 

Norman, N. Philip, and Eggston, Andrew 
A. Intestinal infections and toxemias 

and their biological treatment 623 

Nursing, present day, mental hygiene 

in relation to 301 

Nutrition and diet 596 

OBITUARY: 
Ernst. Harold Clarence, M. D., of 

Boston 536 

Gould, George Milbrv, M. D., of At- 
lantic City, N. J.' 536 

Halsted, William Stewart, M. D.. of 

Baltimore 536 

Smith. Stephen, M. D., of New York 472 

Obstetrical armamentarium, additions to 56 

Obstetrics, hypnosis in 62 

operative 59 

pituitrin in 602 

spinal anesthesia in 58 

undergraduate, teaching of S^i 

X rays in 61 

Obstruction, intestinal, due to appendi- 
citis 163 

ureteral 58 

Occupation in relation to heart disease ....120 
Occupational therapy in mental hospitals. .294 
Ogden, J. Bergen, and Connolly. John M. 
New method for quantitative deter- 
mination of sugar in urine 524 

Oliver, James. Natural limit of the dura- 
tion of human gestation 22 

Oophorotomy, pica for, on all pathological 

ovaries 39 

Operations on foot, commission on stabil- 
izing 119 

plastic 119 

vaginal, parasacral anesthesia in 119 

Orgel, Samuel Z. Malnutrition due to car- 
bohydrate excess 453 

Orgel. Samuel Z,, and Blauner. Samuel A. 
An analysis of end results of tonsil- 
lectomy and adenoidcctomy 142 

( )ricntal sore, two cases of 365 

Osteoarthritis of hip joint, treatment of 119 



746 



IXDEX TO VOLVME CXVI. 



Page. 
. 363 
. 445 
. 363 
602 



Oiuochonjritis of femur 

Osteomyelitis, acute 

chronic ; 

tuberculous, crude petroleum in ...... 

Ovarian therapy in involutional inelan- ^^ 

cholia 

Ovaries, pathological, oophorotomy 
Ovary, surface papilloma of. 

teratomata of ■•.■•■,■■■ j' 'i MO 

tumor of, with twisted pedicle *»" 

Oxygen chamber for pneumonia, construe- ^^^ 
tion of ; • ■ 

in peritoneal cavity 



9 
240 



; papilloma of ''^u 

of ■■•. 'I 



5S 



c rays 
of. in 



disturbances of the 



PA(;ET"S disease. 
Pain, alleviation 

fatal illness . . 

cardiac 

due to muscular 

in upper" left 'quadrant of abdomen 

Pancreas, carcinoma of 

internal secretion of ...■ 

nodular cancer of 

oology ot 



and 



381 

677 
120 

673 
627 
401 
362 
704 
436 



pharmacoendocrinology of ^^° 

X ray stimulation of it. 

Pancreatitis, e.xpenmeiital • °^° 

Papillitis 241 

Papilloma of ovary j^^ 

' ""'"■° '.['.'.'.'.'.'.'. 605 



adjustment 



of renal pelvis 

Paralysis fly 

Paraphimosis 

Parent and offspring, proper 

of relationship between .. ■•.••,••■■ Vi 

Pareiilal responsibility, psychopathological 

disturbances from avoidance of 

Paresis following traumatism 

Paretics, treatment uf malaria in 

Parkinson sympton complex 

syndrome, postencephalitic ■■•■;•■•.•■■, 
Parotid gland, radium treatment of mixed 

tumors of • -- :•"•'•■ 

Pasteau operation in traumatic stricture. 

Pelvic surgery - ■'• 

- of 



ilO 
263 

263 

.307 
296 

425 
735 

117 

■545 

610 

402 



Penis, carcinoma ot ■ ■ - jj 



of skill 
radium and electro- 

and 

■for 



510 
613 

699 
58 
61 

605 

602 



Neurosyphilis 



Cesarean 



Pregnancy effect of. on tuberculosis. 

extrauterine, repeated on same side 

heart disease in 

in diabetes ■ • ■ ■ 

in heart disease, treatm.iit ot 

vomiting of, adrenalin m 

lutein solution in 

Presentation, frontal 

Professional secrecy ...•■■ • • 

Prolapse, uterine, surgical treatment 
Pronation, painful, in young children 
Prostate, absence of 

cancer of 

carcinoma of 

Ivmph nodes in 

radium in carcinoma 



of 



P.AGE. 

24 

58 

56 

56 

. 240 

. 603 

61 

61 

I, 656 

f 63 

. 181 

. 550 

. 550 

. 402 

. 548 

. 123 

544 



Rhinoscleroma ^"> 

Five case histories 



P.\GE. 

485 

381 



aneurysm . . 

350. 

Derivation of 



of 



Prostatectomy with unusual blood picture .^^ 



Proteotherapy -.- . . . 

Pruritis senilis, salicylic acm m 

vulva;, X rays in 

x ravs in : 

Psoas abscess, crude petroleum in 

Psoriasis .•••••;■', ■ 

rontgen irradiation of thymus ni 

X rays in 

Psvchiatry, clinical 

Psychology, high lights in 

Ps'ychopathology .■ 

Psvchosis vulgaris, x rays in 

Psvchotherapy in France . . ; 

Public health problems, opinions on 

Puerperal fever, prevention "* ,.•■■■■. •;;, 

infection, hematogenous, complicated by ^ 

lobar pneumonia - " 

new method of treating 

Puerperium, carcinoma_ ot uterus 
Pulse wave, velocity 

Purification 

Pyelitis 

colon bacillus .".■.■;■• v.ic' '' ' i;'.,! 

salpingitis and appendicitis, differential ^_^ 

diagnosis of j22 

Pyelography 



of transmi.ssion ot. 



4*5 
215 
381 
602 
375 
485 
381 
459 
284 
344 
380 
661 
45 
60 



60 

59 

241 

718 

542 

95 



X rays in 

Rhodes, Frederick A 

for record 

Rib, cervical, in subclavian 

Rickets, etiology of 

Riddell, William Renwick 

the word syphilis 

Ringworm of beard 

of scalp. X rays in . ... . . . . : • ■ ■.■ . • 

Rogers, Leonard. Soluble derivatives 
chaulmoogra oil in tuberculosis . . . . 

Roman, Benjamin. Some points in diag- 
nosis of typhoid fever 

Rongv, A. J. Primary sterility ....... ■ 

Rosenberger, R. C. Bacteriological study 
of cutting oils causing skin lesions . . 

Rosenbloom, .lacob. On some urinary 
methods of value ■ 

Rottenberg, S., and Schwartz, George. 
Plea for oophorotomy on all patno- 
logical ovaries and resection ol 
diseased tissue .'•■.•■■': 

Rubenstone, A. I. Immunization therapy 

in hay fever • '^^ 

Russia, medical relief work 



202 
427 
735 

607 
380 
38U 

64 

575 
439 



696 



39 



662 



c Ajors. 

*J ■ coendocrinology as 



CH--\RLES E. deM. Pharnui- 
foundation for 
rapid progress' in therapeutics .■.■•;. '*3- 
Salpingitis, pyelitis, and appendicitis, dif- 

f erential diagnosis of "' ^ 

Salts, action of on liv-er . . ...... •■■■.■ 

D. G., and Wender. Louis 



Sampson 



Treatment of epilepsy with special ^^^ 



reference to use 

Sanitarians, education of 

Sanitation in Egypt 

Sarcoma, cutaneous, x rays in 

of aponeuroses 

of spleen . . . . 
Salenstein, D. L 



and Remer 



John. 



45 
727 
381 
4/0 
736 



chancre on 

injuries of 

Peptic ulcer, treatment ot . . • ■ •■■■,■■ 

Pericolic bands and membranes, patho- 
genesis of 

Peritoneal cavity, . oxygen . in 

Perineum, protection of, in labor 

Petit mal due to genital irritation ...... 

Petroleum, crude, in tuberculous osteo- 

mvelitis and psoas abscess . . 

PfahleV, George E. Treatment 
cancer by x rays, 

coagulation 

Pfeiffer, J. A. F. . 

neurotrophic strains ;•■••■;.••' 

Pharmacoendocrinology foundation 

rapid progress in therapeutics. 

Phlegmon, perinephritic 

P.hototherapy 

p'hthiriasis acute ■"{■''<'' 606 

Physical examinations, periodical o';„ 

Physiotherapy, congress of 
Piper. Edmund B. Once 

always a Cesarean ;■':"' \ 

Pisko, Edward. Diagnosis and treatment 
of more common diseases of the skin 

Pituglandol for dwarfism 

Pituitary extract in diabetes 

Pituitrin in obstetrics ••• 

Pityriasis rubra pilaris 

I'la'renta. clinical study ot 

Plague, bubonic, at Odessa 

Plastic operations •'• ■ • 

i*neumonia, anoxemia in 

communicahility of ...... . 

conservative treatment ol . 
hvdrogen ion concentration 

' bonate level of blood in 

lobar, circulatory stimulation in ■■■■ 

complicating hematogenous puerperal ^^^ 

■ ' "^^ of--;:;;::::.::::: isi 

for treatment of.... 

Pneiimothorax treatment of tuberculosis 

Poison, industrial diseases due to ^. 

Poisoning, lead, m electrical storage 

tory 

nitrous acid ■•,••,■•••: 

Pollen therapy of hav fever 

Polyuria, experimental . . . . ....■■ 

Poor law relief m Great Britain ■.■:•• 

Pope, Curran. Experimental and clinical 
observations on simplification ot in- 
testinal flora ,' ' ' 'r ' i ' ' ' '.■= 

Postpartum hemorrhage, one hundred cases 

of ■,••.•■••; 

Potter version, analysis ot . ■ . . •. ••• 

indications and contraindications tor 
Pott's disease, bone graft in treatment of 

Pregnancy after menopause 

albuminuria in j ■ • 

carcinoma of uterus in 



Pyelograpny ■• 941 

Pyloroplasty, experunental -^:' 

Pvlorus. congenital stenosis ot 1^^' 

Chronic duodenal ob 



-Roentgen therapy of diseased tonsils 

I >l.„;.. .sAnfV^ _ li^ 



Pylorus, 



congen 
E. P. 



QLAIX 

Vi struction - 

Quartz lamp in erysipelas ......■.■.•■■.■• 

Quimby, aI^ Judson. Physiological iodine 

bumidinein auricular hbrillation 

Quinine, visual disturbances due to 



R 



against 



651 

485 
680 
427 
104 

724 



and their adnexa 
Satterlee, G. Reese. Phases of Sf^^'™'""- 

final infection, pathology and treat- ^^^ 

Sautter, C. iV. Acute mastoiditis asso- 
ciated with acute 



nephritis 584 



159 
103 



ABIES, immunity -s-...-. . ,. 

treatment of, in Budapest "' 

Radiation, rectal injuries after |^- 



..563, 
bicar- 



infection 
serum treatment 



fac- 



553 

683 

432 
532 
382 
408 
606 
49 

10 

374 
736 
609 
602 
372 
62 
475 
119 
182 
591 
672 

182 
480 



042 
242 
351 

724 
488 
193 
428 
596 



Radiology . . . 

congress of 

Radiotherapy ; ; ' " J 

in diseases of the blood . . ■ ■ 

Radium, application of, through cysto- ^^ 

beta^rays oi.' iymp'hopenia following ex- 
posure to jjg 

cystoscopic application ot ^^^ 

in cancer j 32 

of bladder j^q 



49 

742 
'42 

118 



123 



..6, 



Genitourinary 
plus Was- 



34 
56 
62 

243 
38 

484 
59 
62 



complicated by influenza ^° 



ectopic , ^, ,. 

origin of bleeding in 



56 



of breast 
in carcinoma of prostate 

of uterus 

in diseases of women .... 

in gynecology 

in leucorrhea 

in skin cancer 

rays, effect of, on carcinoma 

therapy in gynecology 

treatment of chronic mastitis ■ • ■ ; • 
of menorrhagia and metrorrhagia 
of mixed tumors of parotid gland 

of uterine carcinoma .• • 

Randall. G. M. Factors of longcvit> 

semitropics 

Reaction urochromogen 
Read, .Tohn Sturdivant 

case histories ....... 

Rectum, cancer of, with lour 

sermann •.• ■ . ■ ■ ■ 

injuries of, following radjation 
Rectum, prolapse of ........ ■ • • 

removal of foreign bodies fi.om 
Remer. John, and Satenstem, 
Roentgen therapy of diseased 

and their adnexa • • • ■ • • 

Renal affections, mineral waters and baths 

in treatment of . . . • 

calculi, unusual case of .. .•:;••■ 

disease, diagnosis and treatment of . . 

nelvis, papilloma of / ' " ' 

Research, scientific, popularization of .. 
Respiration, restriction of m tuberculosis 
Respiratory system 111 scarlet fever ... . . . 

Responsibility, parental, avoidance of ,.. 

ReT cure of pulmonary Ituberculo.s.s. 

physiological adjuvant " V ,• ' ' ;: ' ' " 

Reube.,-, Mark S. The pr'school age 

Reuter, F. A. and Lewis. Nolan D. 

A contribution to study of connec 

live tissue changes in gallbladder . . 

Rhein, John H. W. Folic a deux 

Rhinorrhea, cerebrospinal 



123 

55 

340 

55 

343 

553 

123 

1 

341 

343 

117 

242 

559 
523 

530 

706 
942 
732 
703 



Scabies ... - . ^ . 

Scarlet fever, diagnostic points in 

heart and respiratory system in . . . . 

Seheppegrell, William. Successft. treat- 
ment of hay fever and causes ot 

Scholz! Thom-as.' ' :\ ' roentgeiiological con- 
tribution to diagnosis of spinal car- 
cinoma in cases having an unrecog- 
nized primary focus 

School health supervision .■...■• 

Schwartz, Ellis M. Hysteria .aOer mas^ 
toidectomy simulating brain abscess 

Schwartz, George. Intussusception. A 
review of recent literature and a re- 

Schw''am,°Ge"/|e and ' RoM^bf^B, Solo- 
mon. Plea for oophorotomy on all 
pathological ovaries and resection ot ^^ 
diseased tissue • : • 

Schwatt, H. Tuberculosis and pregnancy 

Scialica! chronic, surgical treatment of . . 

Science, popularization of research in .. 

Sclerosis, multiple 

Scoliosis ; V " \' 

idiopathic, operative treatment 



196 



566 
164 



279 



449 



of 



24 
693 
345 
328 
225 
118 

93 



operative, treatment of jgj 

Scurvy, etiology of 



upper 



350, 

alimentary 



656 



D. L. 

tonsils 



relation to neur- 



112 

709 
520 
518 
544 
345 
65 
103 
263 



C. 



462 



640 
269 
279 



Secrecy, professional . 
Secretion, deficient, in 

tract 

internal, of pancreas 
Secretions, internal, in 

ologisis and psychiatrists •■■••.•■■-;," 
Seiliko^^tch, S. Intestinal spasm in in- 
fancy 

Septicemia, meningococcus i '^^[rii^e 

Serpent worship and the dawn m medicine 

Serum, specific, in acute encephalitis 

treatment of lobar pneumonia 

Sexual irritability ■•,••■■,■•■,••■;•■,■■■■ 
Shock, relation of adrenal glands to .. 

sodium oleate in 

surgical, treatment ot 

Sigmoidoscopy 

Skin cancer 

symposium on 

X '^"f'^iSum'and' eiectrlicoaguiation 

diseases, diagnosis and treatment of .. 
nervous system in relation to 

^ ravs in 

lesions from cuting oils 

.if face, epithelioma of ][" 

pigmentation, etiology of ' 

sulure material, new ^" 

Skull, fracture of. in children ^b; 

Sleep, twilight, notes and statistics 

Smith, Clarence H. Acute 



.114. 



675 
362 

438 

234 
426 
185 
236 
182 
724 
361 
225 
734 
668 
486 
420 
420 

553 
374 
402 
379 
377 
400 



54 
mastoiditis. .139 



INDEX TO VOLUME CXVL 



Page. 
Smith. J. Morrisset. Labyrinthine sur- 
gery S5 

SOCIETY PROCEEDINGS: 

American Association of Obstetricians, 
Gynecologists and Abdominal Sur- 
geons 56 

American Pediatric Society ... 177, 236, 604 

American Therapeutic Society 671 

Medical Society of the State of New 

York 116 

New York Academy of Medicine 420 

Section in otology 115 

Section in genitourinary surgery .... 544 

New York Neurological Society ..297, 358 

Sodium nucleinate in malaria of paretics. 296 

.Sodium oleate in shock 225 

Sore, Oriental, two cases of 365 

Spasm, intestinal, in infants 234 

Speculum, new virginal vaginal 40 

Spielberg, William. Diagnosis of sub- 
acute and chr'inic inflammatory lesions 
of the mucosa lining of the maxillary 

antrum of Highmore 571 

Spinal carcinoma, x ray diagnosis of .. 566 

Spleen, sarcoma of 736 

Splenectomy in Banti's disease 482 

Splenopneumonic reactions in tuberculosis 177 

Sprue, treatment of 426 

State hospital, modern, origin and scope 

of 280 

Statistics, vital, in New York State 346 

Steel, W. A. Hot air mineral oil treatment 

of extensive burns 418 

Steinach operation, theory and practice of 203 

Stenocardia, amyl nitrite and atropine in 121 

Stenosis, congenital pyloric 181 

duodenal 235 

mitral, followed by death from cerebral 

embolism 121 

of isthmus of aorta 121 

Sterility in the female 240 

primary 439 

transuterine insufflation in diagnosis of 5S 

Sterilization by x rays 215 

Stevens, A. Raymond. Hypernephroma of 
kidney; removal with perirenal fat 

en masse 507 

.-Stevens. J. Thompson. Ray treatment of 

cancer 386 

Stewart, Thomas M. Autotherapy 124 

Stillborn infant, reanimation of 612 

Stokes-Adams syndrome, adrenalin in . . 242 

Stomach, acute diseases of 486 

cancer of 634 

nonrecurrence after operation 636 

carcinoma of 400 

lavage in treatment of whooping cough 158 

ulcer of ...672, 675 

Stragnell, Gregory. Psychopathological dis- 
turbances from avoidance of parental 

responsibility 263 

Sirecker, Edward A., and Keyes, Bald- 
win L. Ovarian therapy in involu- 
tional melancholia 30 

Stricture of vagina 57 

traumatic, treated by Pasteau operation 545 
Such. Miguel Prados. and Mott. Fred- 
erick W. Further pathological studies 
in dementia praecox, especially in 
relation to the interstitial cells of 

Lcydig 245. 315 

Suction difficulties of young infants .... 182 
Sugar in urine, quantitative determina- 
tion of 524 

Suggestion, hypnotic, and irresponsibility 724 

Suicides among the professions 124 

unconscious motivations in 254 

Suppurations yf lung 183 

Sympathetic algias 721 

nervous system and endocrine glands 286 

Syndrome, amyostatic 687 

postencephalitic, Parkinson 735 

Syphilis, bismuth therajiy in 551, 736 

derivation of word 607 

hereditary, of ear 526 

icebox modification of Wasscrmann test 

in 552 

in grncral practice 551 

in relation to dementia prsecox 102 

intracutaneous reaction in 552 

of nervous system 425 

treatment of 514 

Syphilitic inflammation of long bones .. 552 

TABES, earlv, marked atrophy in .... 282 

Talmcy. B. S, Impotence in the male 499 
Taylor, William J. Surgical, treatment of 

chronic sciatica 693 

Teeth, carioui^, in infancy and childhood 161 

Telepathy, h'rcud in regard to 284 

Tendon implantation 733 

transplantation 120, 243 

Teratomata of ovary 57 

Testes, morbid histology of, in dementia 

prsecox 31 S 

Testicle, injuries of 510 

Tetany attack during paroxysm of hypcr- 

pnea 301 

Therapeutics, modern, deficiencies of . . 429 
Itharmacoendr>crinology foundation for 

rapid progrcis in 432 



P.\».K. 

Thomas, W, Hersey. Choice of anesthetic 

in major urological surgery 511 

Thorascopy in surgery of chest 363 

Thorek, Max. Possibilities in reconstruc- 

tiitn of the human form 572 

Thromboarteritis. gangrene due to 394 

Thymus, rontgen irradiation of. in psori- 
asis 485 

Thvroid body, pharmacoendocrinology of. 433 

diabetes 609 

malignant tumors of 302 

tumors of 361 

Tibia, fractures of 363 

Tinea tonsurans 380 

Tissue changes in gallbladder 640 

culture 736 

Toes, artificial 61 1 

Tongue, cancer of 420 

Tonsil, reprehensible 164 

Tonsillectomy, end results of 142 

in children with endocarditis 145 

indications for 239 

Tonsils, X ray therapy of 112 

Touart. M. D. Hay fever: desensitization 

by ingestion of pollen protein 199 

Tousey, Sinclair. Radium therapy in 

certain gynecological conditions 1 

Toxemias, intestinal, biological treatment 

of 623. 671 

Tracy. Edward A. Anaphylaxis and 

epilepsy 64 

Transfusion 733 

Transplantation, tendon 120. 243 

Traub, Hugo W. Status of lumbar punc- 
ture and prevention of its complica- 
tions 91 

Traumatism, mental disorders following. . 305 

Tube, torsion of, in hematoma 241 

Tubercle bacilli, changes in virulence of.. 118 

Tuberculin, local application of 182 

Tuberculosis, bladdec. treatment of .... 118 

derivatives of chaulmoogra oil in 64 

droplet infection t'lr 736 

etfect of pregnancy on 24 

erythema nodosum in relation to 226 

hilum, X ray diagnosis of 123 

in children, diagnosis of 182 

of hip 150 

of kidneys and urinary system 735 

of skin. X rays in 381 

pneumothorax treatment of 242 

pulmonary, physiological adjuvant in 

rest cure of 65 

splenopneumonic reactions in 177 

sanatoria for 736 

Tuberculous laryngitis 183 

Tubes, fallopian, bacteriology and path- 
ology of 62 

Tumor, malignant, of ovary, radium and 

X ray therapy in 5 

of cervix and uterus. 63 

of middle fossa 275 

ovarian, with twisted pedicle 240 

Tumors, malignant, of thyroid 302 

mixed, of parotid gland, radium treat- 
ment of 117 

of bladder 491 

of brain in young children 604 

of breast 244 

of thyroid 361 

Tungsten incandescent electric lamp in 

therapy 382 

Twilight sleep, notes and statistics on . . 54 
Typhoid fever, conquest of, at Chicka- 

mauga Park 77 

Typhus fever among immigrants 304 

diagnosis of 575 

etiology of 304, 578 

infections leading to immunity 304 

Umbilical cord, knot in, cause of acci- 
dental hemorrhage 612 

study of :■•■•:• 59 

Underweight and basal metabolism in 

children 182 

I'reteral obstruction 58 

Ureters, injuries of 511 

Urethra, male, accidental occlusion of.. 498 

Urethral fever 510 

Uric acid in fiction 533 

ULCER, gastric, treatment of 672. 675 

of duodenem 487 

peptic, treatment of 614 

Urinary calculi 118 

system, tul>erculosis of 735 

Urine, bacillus coli infection of ' 548 

metiiods of examining 696 

quantitative determination of sugar in.. 524 

retention of 509 

suppression of 508 

Urochromogen reaction ......._. 523 

Urological surgery, anesthesia in 51 1 

recent advances in 489 

Uterine prolapse, surgical treatment of. . 'i3 
Uteroplacental apoplexy in accidental 

hemorrhage 62 

Uterus, cancer of, radium treatment of 6, 342 

carcinoma of .• • • ■ "^^^ 

in pregnancy, lal)or and pucrpcrium. 59 

radium in 55, 242 

X rays in 213, 242 



I'.\OF. 

Uterus, fibroids of, blood pressure in. . . 241 

radium, treatment of 343 

misplaced or misshapen 722 

myoma of, with ascites 240 

retrodisplacement of 240 

suppurating myomata of 17 

traumatic displacements of 722 

tumors of 63 

VACCINE treatment 603 

of whooping cough 182 

Vagina, atresia and stricture of 57 

carcinoma of. radium treatment of .... 341 

leucoplakia of 343 

Vagina! operations, parasacral anesthesia 

in 119 

outlet, relaxation of 240 

speculiun, virgin 40 

Vagitus uterinus 61 

Vascular disease, hypertensive, prognosis 

of 122 

Venereal disease, prevention of 49o 

diseases in colleges 534 

Verruca ^75 

X rays in 381 

Version. Potter's analysis of methi>d of . . 56 

indications and contraindications for 62 

Vertebrae, lumbar, fractures of 363 

Vesical outlet, obstruction of 490 

Vincent's organism, infection with .... 88 

Vision, disturbances of, due to quinine.. 103 

Vitality, index of 468 

Vitamine, antiscorbutic 181 

effect of heat and oxidation on .... 244 

fat soluble -. • 1 "*' 

products. proprietary, experimental 

studies with 238 

water soluble B. in cabbage and onion . . 244 

Vomiting of pregnancy, adrenalin in . . 603 

lutein solution in 61 

Voorhees, 1. W. C<imm()n colds 360 

Vulva, leucoplakia of 343 

carcinoma of 40- 

X rays in -^^ 

radium treatment of 341, 343 

WASSERM.VNN. four plus, in cancer 

of rectum J06 

test, icebox modification of 552 

tests, value of 469 

Weaning the infant 10* 

Weight curve in relation to basal meta- _ 

holism .-. •■ 23/ 

Weiss. Richard. Rapid method of blood 

analysis - • 585 

Wender, Louis, and Sampson. D. G. 
Treatment of epilepsy with special 

reference to use of luminal • 336 

Whooping cough, stomach lavage in treat- 
ment of J^^ 

vaccine in 1°- 

Winslow, Paul V. Significant results 

obtained in treating catarrhal deafness 466 

Wisconsin's mental deficiency survey . . 288 

Witness, expert, medical --4 

Woodbury. Frank Thomas. Tungsten in- 
candescent electric lamp used as a 

therapeutic agent 38- 

Wound infection, treatment of 719 

Wounds, thoracic, modern warfare .... 468 

Wovschin. W. A. Typhus fever 578 

Wright. James Thomas. Eugenics versus 

epilcpsv • 339 

Wright. Jonathan. Serpent worship and 

the dawn of medicine 18.^ 

Temple offerings to .Esculapius 404 

Writers' cramp, reeducation in :>^o 

XANTHOMA tuberosum with diabetes 

insipidus 605 

X ray and clinical findings in chests of 

children 593 

densities in chest ; J23 

diagnosis in hilum tuberculosis 123 

Umitations of U^ 

of bone and joint lesions 118 

of cyst of lung 122 

of uterine carcinoma 242 

X rays in acne vulgaris 380 

in cancer _ ., 386 

in diagnosis '20 

in disease of generative organs 68 

in furunculosis 3**^ 

in hypcremesis gravidarum 242 

in obstetrics 61 

in p-^vchosis vulgaris 380 

in ri-'gworm of scalp 380 

in skin cancer 553 

in skin diseases • 379 

showing deformities of viscus in peptic 

tilcer 614 

soft, lymphopenia following exposure to 123 

studies on effects of . ^2^ 

Y -^WGER, N. S. An epileptic and her 

' sixteen children 334 

^ ONA, primary adenitis of 347 



4 



A 



LIST OF ILLUSTRATIONS TO VOLUME CXVI 



Pack 
^Esculapius. temple offerings to. Two Illustra- 
tions 405-406 

Apparatus for treatment of burns 418 

Chancre on penis. One Illustration. 531 

Connective tissue changes in gallbladder. Nine 

Illustrations 641-643 

Cystoscoj)ic table. One Illustration 52S 

Dementia pnecox, pathological studies in. Xine 

Illustrations. 'i 247-249, 317-319 

Encephalitis lethargica. One Illustration M2 

Hay fever, treatment of. Two Illustrations. . . . 197 

Hvdro])vone])hrosis. One Illustration 530 

Involutional melancholia. One Chart 33 

Liver, action of various salts on. Two Charts. . 189 
Lumbar puncture, posture and control of patient 

in. One Illustration 92 

Mastoiditis. One Chart 141 

-Maxillarv antrum of Highmore. inflammation of. 

• Two Illustrations 572 

Medical relief work in Russia. Three Illustra- 
tions 662-663 

Oriental sore. Two Illustrations 366-367 



Page 

Papillitis. Three Illustrations 448-449 

Peptic ulcer. Thirty-eight Illustrations. . . .614—618 
Pericolic bands and membranes. Four Illustra- 
tions 700-701 

Pitvriasis rubra pilaris. Five Illustrations. .373-374 
Pottenger, Francis Marion, M. D. Portrait. . . .231 
Psychiatry, clinical. Four Illustrations . . . .460-461 

Pulmonary abscess. Three Illustrations 99-100 

Radium therapy in gynecology. Xine Illustra- 
tions 1-5 

Reconstruction of human form. Si.x Illustra- 
tions 573-574 

Rhinoscleroma. Xine Illustrations 391-393 

Scoliosis, operative treatment of. Three Illus- 
trations 94 

Serjjent worship. Two Illustrations 185-186 

-Skin cancer. Fourteen Illustrations 554 

.Smith. Stephen, M. D. Portrait 472 

.Speculum, virginal vaginal. Two Illustrations. . 41 

Spinal carcinoma. Five Illustrations 568-569 

Thromlioarteritis. Four Illustrations 395 

Writers" cramp. Four lllustratinns 557 



IXDEX TO PAGES 



lulv 5th .-. 1-64 

lulv l')th 65-124 

August 2nd 125-184 

August 16th 185-244 

Seittember 6ih 245-304 

September 20th 305-364 



October 4th 365-128 

October 18th 429-488 

Xovember 1st 489-552 

Xovember 15th 553-612 

December 6th 613-676 

December 20th 677-736 



New York Medical Journal 



and 



Medical Record 

Philadelphia Medical Journal r^t Medical News 
A Semimonthly Review of Medicine and Surgery, Established 1843. 



\'».. (_'X\r. Xi>. 13 



NEW YORK, WEDNESDAY. JULY 5. WJJ 



Whole Xo. 'I'l'i^i 



Radium Therapy in Certain Gynecological Conditions 



By SINCLAIR TOUSEV. M. D.. 
New York. 



Certain properties and physiological effects of 
radium may be new to some of my readers, though 
an old story to those who have done a great deal of 
work with this wonderful element. 

A tube of radium or of emanation sends out alpha, 
beta and gamma rays which have various interesting 
physical properties but especially connected with the 
subject under discussion is the fact that the alpha 
rays are actual particles and are slightly penetrating 
and that they are arrested by the glass of the tube 
or by a sheet of paper. This absorbability occurs if 
under special circumstances they reach the skin and 
gives them the property of reddening, or inflaming 
or destroying superficial growths by a painless 
escharotic action. Practically speaking the alpha rays 
are not applied by any of the instruments used for 
gynecological radium therapy. The beta rays are 
also actual particles, some of them have very little 
penetration and have therefore a marked rubefacient 
or escharotic effect, while others are more penetrat- 
ing and affect deeper tissues as well as the surface, 
though with an intensity that diminishes as the 
square of the distance from the radium and directly 
in i>roportion ta the absorption iiy the overlying tis- 
sues. The third class of radium rays are gamma 
rays with vibrations much more rapid than the most 
penetrating x rays. The tissues exert so little ab- 
sorption upon the gamma rays that the distance from 
the radium is practically the controlling factor in 
their effect at different depths. 

BEr.\ R.\V THliR.VPV IX GYNECOLOGY. 

Unfiltered or slightly filtered radium rays con- 
tain an overwhelming majority of the less penetrat- 
ing rays and are used for a surface effect. The fol- 
lowing case affords a specific instance : 

Case I. — Mrs. C was referred to me by Dr. James 
S. K. Hall. She was suffering from an ulceration 
of the anterior vaginal wall (Fig. 1 ) presenting 
every aspect of mahgnancy and resisting treatment 
by stiinulating or caustic applications. There was 
imminent danger of the formation of vesicovaginal 
fistula; and the patient was warned of the possibility 
and cautioncfl not to attribute it to the effect of the 



radium, which was going to be applied in such a way 
as, if possible, to prevent, not cause, such a distress- 
ing result. Practically unfiltered rays were applied 
in a dose which upon a cutaneous surface would have 
been followed by redness and eventually desc[uama- 
tion of a layer as thin as paper, leaving a normal 
healed skin below. I have myself taken about forty 
such radium applications for the control or cure of 
X ray keratoses of my hands and face and at first 
1 used to have the exfoliated scabs examined micro- 
scopically. The report was invariably that they con- 
sisted of epithelial cells without visible change due 
to the radium. The rays had killed them, but they 
looked just the same as if they had been removed 
surgically and put under the microscope. The same 
report has been received on epitheliomata which have 
exfoliated. An ulceration of the mucous membrane 
does not undergo destruction so as to come away 
as a scab or slough after such an application of 
radium. The diseased cells are more susceptible to 
the lethal action of the rays, while the healthy cells 
are stimulated by the rays. 

The result of two applications in fourteen davs 
was that the ulcer quickly assumed a healthy appear- 
ance and soon healed. Two years later the patient 
was perfectly well. Dr. Hall was convinced of the 
malignancy of the growth, but no section coidd be 
reinoved for microscopical examination without sub- 
jecting the patient to the dangers of fistula and 
metastases. In fact I think it important not to add 
the risk of general dissemination through the blood 
channels in any case of possible malignant disease 
treated by radium. I would far rather have the pa- 
tient think that I had cured her of something which 
possibly was not malignant than to present proof 
of malignancy with the chance of subsequent dis- 
semination and death. The only thing is that in 
this particular case it presented clinically the appear- 
ance of an epithelioma. (3ther cases are entered on 
the records as clinically fibromyomata or clinically 
sarcomata, or recurrences after operation for car- 
cinoma, the latter verified microscopically. The 
same superficial effect is of the greatest benefit in 



Copyright, 1922, by A. R. Elliott Publishing Company. 



TOUSEV: RADIUM TREATMEXT IX GYXECOLOGY. 



[New York Medical Journal 
AND Medical Record. 



leucorrhea and cervical catarrh, and sometimes by a 
single application a case can be cured which has re- 
sisted chemical applications for months or years. 

Erosions of the cervix are frequently cured by 
a single application of radium of such a nature as 
to produce the surface effect under consideration. 

Fissure of the anus and cases of intolerable pruri- 



3 


k 


M 1 Uf^^^^^^ 


^ 


w 


\ 


iWr 


U^^ 


Mf'ik^'-kX. -^^ta^H^ 


*■ Vii^'yi^^^ m 


^|0^^^ 


/ 


'1 ^B ^B^t^' 


/nxs«wt- 



Fig. 1. — Ulcer 
radium. 



(malignant?) of anterior vaginal wall cured by 



tus with bleeding cracks in the skin can be cured by 
a superficial application so calculated as to cause a 
laver as thin as paper to peel ofif like a scab leaving 
a healed, healthy surface underneath. I have often 
watched the progress of a painful fissure after stich 
an application. There is at first no change in ap- 
pearance but soon tliere is an improvement in sen- 
sation and in the course of a few weeks a scab or 
sometimes two or three successive scabs peel off. 

.Simple pruritus vulvae sometimes calls for a 
radium application to the cervical canal, the prurittis 
being of secondary origin. And all patients require 
a series of external applications of a superficial char- 
acter producing a difTuse effect which need not 
usually be intense enough to produce a dry desquam- 
ation. Sometimes, however, this is necessary and 
wonderfully beneficial. 

The little glistening cysts sometimes seen at the 
external os, looking like wet beads or like part of a 
mulberry, are suitable for treatment by these beta 
rays. In a recent case of an elderly woman with a 
tumor of unknown nature palpable in the posterior 
fornix, the presence of a slight cystic degeneration 
of the cervix (Fig. 2) made me apprehensive of 
malignancy and called for energetic radium treat- 
ment of this surface character. 



Urethral caruncle is best treated by the high fre- 
quency spark followed by an application of beta 
radium rays. 

To use these soft or beta rays the cases so far 
alluded to are treated by surface applications of a 
glass tube containing twenty milligrams of radium 
and covered with the thinnest rubber tissue. The 
latter is simply to protect the tube from contamina- 
tion, not to act upon the rays as a filter. The time 
I if application is usually half an hour to an hour. 

\Vith any surface application, of course, at least 
half of the radiation, that which is directed awav 
from the surface, is entirely wasted. And as a mat- 
ter of fact the effect upon a neoplasm from a cer- 
tain amount of radium is five times as great if the 
radium is imbedded in the tumor. The beta rays 
can be so applied by using very small amounts of 
radium emanation one half to one millicurie in capil- 
lary glass tubes which are inserted into the tumor 
through a cannula and left there permanently. About 
ninety-nine per cent, of the radiation is beta rays. 
One millicurie of emanation has the same effect as 
one milligram, of radium. But whereas the radium 
element is practically unvarying in its intensity los- 
ing half its strength in eighteen hundred years, the 
emanation loses half its strength in about four days. 
One millicurie of emanation left embedded perma- 




FiG. 2. — Cystic degeneration at the cervix (in a case of pelvic 
tumor) treated by radium and deep x ray therapy. 

nenlly, applies a total of about two hundretl milli- 
curie hours and this buried in the tissues is suffi- 
cient to destroy any cancer cells within one centi- 
metre of the tube in every direction. 

Several such emanation tubes mav be inserted into 



July 5, 1922.] 



TOUSEV: RADIUM TREATMENT IX GYKECOLOGY. 



a fungating cancer of the cervix with a resuhing 
shrinkage, and sHght sloughing which produce essen- 
tially an amputation of the vaginal portion of the 
neck of the uterus with eradication of its malig- 
nant character. The effect upon cancer cells is not 
limited to those which actually slough away as is the 
case with surgery by the knife or the cautery. 




Fio. 3. — External application of radium in enormous uterine fibro- 
myoma; 1 marks the first series of applications; 2 the second, and 
3 the final series, as the tumor diminished in size. 

FILTERED RADIUM RAYS. 

There are many gynecological cases where the 
ef?ect desired is not limited to the tissues directly 
in contact with either a surface applicator or an in- 
strument puncturing the tissues. Enveloping the 
radium in metal suppresses the soft rays and trans- 
mits rays which exert some of their effect at deeper 
parts of the tissues instead of being practically all 
absorbed by the most superficial tissues. The gamma 
rays are of this nature and to secure their effect 
we use a glass tube containing radium element or 




size of uterine fibroid under radium treat- 



are suppressed in this way, but secondary soft rays 
originate from the metal, and for many cases these 
rays must be suppressed by a filter of rubber or felt 
which has practically no efifect upon the gamma rays 
except to make their action upon the tissues more 
uniform by holding the radium at a little distance 
from die surface. 

THE EFFECT OF GAMMA R.\DIUM R.-WS. 

Like deep x ray therapy, they have a selective ac- 
tion inhibiting cell life of certain normal tissues, such 
as the spermatogenetic cells of the testis and the 
essential ovarian'cells, and lymphoid tissue wherever 
found. They have a selective action upon prac- 
ticallv all abnormal cells, notably those of a rapidly 
proliferating type. They may be used to cause an 
obliterating endarteritis, 

R.\DIUM THERAPY FOR UTERINE FIBROMYOMA. 

Radium applications which cure this condition 
usually produce amenorrhea and often even the very 




emanation and enclose that in a metal tube, say 
brass, or we may have the radium element in her- 
metically sealed steel needles and place these in brass 
capsules. The soft rays radiating from the radium 



Flc. 5. — Intrauterine application of radium for fibrom.voma. 

next period is prevented, the hemorrhage ceases, and 
after a time the tumor is found to have disappeared 
entirely. It is generally believed that the in- 
hibitory action upon the ovaries is largely to be 
credited for the beneficial effect upon the fibroid ; 
and it is certain that in the cases in which the fibroid 
is not cured there is no amenorrhea. These facts 
have an important bearing and must be considered 
in deciding whether to treat a fibromyoma in a 
woman who might desire to have children. Neither 
the X ray nor radium would promise success with the 
fibroid and still assure normal reproduction. In 
cases which I have treated, normal sexual desire 
and gratification have remained. Regarding the 
question of symptoms consequent upon the induc- 
tion of an artificial menopause, they are somewhat 
the same as those of the natural menopause, but 
much less severe, and it is my opinion that the occur- 



TOUSEV: RADIUM TRE.ITMEXT IX GYX ECOLOGY. 



[Xew York Medical Journal 
AKD Medical Record. 



rence of malignant growths of the uterus and ovaries 
is markedly safeguarded against by this treatment. 
If an operation was performed it would often be 
found that the ovaries were affected and required 
removal and in general few cases of uterine fibroid 
would promise normal menstruation and reproduc- 
tion after a surgical operation. 

Radivim can be successfully applied externally in 
some cases. In one class the patients are thin, with 
a relaxed abdominal wall, so that the radium tube in 
its metal and rubber or 
felt filters can be pressed 
into contact with the 
ovary with only a small 
thickness of skin and 
other tissues interven- 
ing. Heavy doses with 
thick filters are required. 
In another class the pa- 
tient has a very large 
fibroid like a full tern- 
pregnancy (Figs. 3 and 
4 ) with a thin abdominal 
wall, and here no effort is 
made to effect a cure by 
a single treatment direct- 
ed chiefly to the ovaries. 
A fibroid of this size re- 
ceives also intrauterine 
applications producing 
the crossfire effect which 
is wonderfully advan- 
tageous in both X ray 
and radium therapy. 

Such a case shows 
gradual reduction under 
repeated external radium 
applications and in the 
course of a year and a 
half about thirty thou- 
sand milligram hours are 
applied with a reduction 
of fift)' per cent, in size. 
There is at first a tre- 
mendous area to be treat- 
ed, one small area after 
another, and the number 
of milligram hours re- 
quired might be em- 
ployed in treating many 
other cases. The au- 
thor's own impulse in 
such a case would be to 
use a deep x ray therapy 
as in the following case. 

Case II. — Mrs. P. re- 
ferred to me by Dr. 
Royle. The patient was forty-eight years old and 
weighed 160 pounds. She had a fibroid suggesting ad- 
vanced pregnancy. It had undergone carcinomatous 
degeneration and there was a great deal of pain, dis- 
charge and odor. .\n operation had been undertaken 
but on examination under ether the whole pelvis 
was found to be a solid mass of cancer, so just a 
small section was taken from the cervix. Micro- 
scopic examination showed this to be cancer and it 
was thought that she had about six weeks to live. 





Fig. 7. — Diagram from Fig. 
and radium. 



My treatment was by x ray applied partly through 
a celluloid Ferguson speculum which permitted some 
x rays to impinge directly upon the cervix while 
others penetrated the perineum and other tissues at 
the pelvic outlet. Other applications of the x ray 
were over various parts of the abdomen and back. 
At first the patient had to come in a carriage with 
mother, husband, nurse and physician to assist her. 
The sequence of events was the disappearance of 
the pain, then of the odor, then later the discharge. 

There was constant re- 
duction in the size of the 
tumor and in a few 
months she was appar- 
ently a well woman, com- 
ing on a street car all 
alone and generally with 
a package of cake or 
fruit for some sick 
friend. A year later, 
however, she died rather 
suddenly, manifesting 
stomach symptoms which 
we thought were due to 
cancer. 

Radium and the x ray 
go hand in hand in gyne- 
rology and of course one 
or both of these methods 
of treatment must often 
be combined with a sur- 
gical operation. 

A fibroid up to the size 
of a three months' preg- 
nancy in a patient of 
moderate size presents 
an opportunity for sim- 
ple, specific and effective 
treatment. Twelve hun- 
dred milligram hour> in- 
trauterine are commonly 
applied with complete 
cure. As an example, a 
hundred milligrams 
screened so as to apply 
only gamma rays may be 
placed in the uterine 
canal for twelve hours 
(Fig. 5J. A smaller in- 
trauterine dose may be 
supplemented by exter- 
nal radium or .x ray 
treatment. 

What happens when 
the radium dosage is in- 
sufficient, either intrin- 
sically or from the unu- 
sual size of the tumor or of the patient, is shown by 
the following case. 

C.\SE III. — Mrs. D. was referred to me by Dr. T. 
-Spencer Halsey. The patient was thirty-eight years 
of age and was a giantess. She had a fibroid the 
size of a grapefruit, practically filling the pelvis and 
producing some abdominal enlargement. She had 
hemorrhages which the doctor described as being the 
most terrifying thing he had even seen. "Just like 
water running out of a faucet." On some occasions 



Fig. 6. — Pelvic tumor of unknown nature, treated by radium and 
deep X ray therapy. 



6 of pelvic tumor treated by x ray 



July 5. li'22.] 



TOiSEV: RADIUM TREATMEXT IN GYX ECOLOGY. 



she was almost completely exsanguinated, and her 
life had been saved with difficulty by packing as 
hard as a baseball, and the hypodermic administra- 
tion of ergotin and similar drugs. She had been 
treated in a hospital with 677 millicurie hours, in- 




FiG. 8. — Diagram of pericecal tumor, x x x locations of radium 
tube applied externally. 

trauterine. This had no perceptible effect ; she did 
not even miss a single period. .\t a latter date and 
at the same hospital 3,100 millicurie hours were ap- 
plied e.xternally but this also was ineffective owing 
to the patient's weight and the distance of the radium 
from the ovaries. As you know the effect varies in- 
versely as the square of the distance. And as the 
safe surface effect must not be exceeded, cells at too 
great a distance cannot be sufficiently influenced. 

The size of the patient and of the tumor made 
successful treatment by radium practically impos- 
sible and when she was referred to me I proceeded 
at once with x ray treatment. The first x ray applica- 
tion was followed by complete amenorrhea lasting 
one year. On the recurrence of the menstruation 
another x ray application was followed by amenor- 
rhea and entire disappearance of the fibroids. No 
return of tumors or hemorrhage. Hut three years 
later after remarriage there was a return of normal 
menstruation and the patient was in such a state of 
terror that another x ray application was given. 
She missed the very next period and so far has had 
no return of men.struation. 

Case IV. — I have recently given a series of treat- 
ments for a patient of Dr. P. F. Cavanagh. Mrs. C, 
aged seventy-four, weight 152 pounds. She had a 
tumor of unknown nature jtalpablc in the right for- 
ni.x, and in the radiograph ( Figs. 6 and 7) seeming 
to measure eight by ten centimetres. There were 
little shiny cysts at the external os which were 
treated with beta, unfiltered radium rays. No effect 
upon the ovaries was ref|uired in a woman of her 
age and the main reliance was upon deep x ray 
therapy applied through several different areas of the 
skin tnu all converging upon the tumor. It is too 



soon yet for any change to be noted in the tumor 
but there has been a change for the better in the 
condition at the os uteri. 

It may i)e desirable to curette the uterine cavity 
and have a microscopical examination before treat- 
ing a fibromyoma. If this shows malignancy, differ- 
ent treatment would be required. 

R.^DIUM .\XD X R.\Y THER.\PV FOR M.^LIGNANT TUMOR 
ORIGINATING IN THE OVARY. 

Case V. — Mrs. D., aged sixty-six years, 105 
pounds, a patient of Dr. Parke, had a malignant 
tumor including the right ovary removed seven years 
before she was brought to me for x ray diagnosis. 
At this time there was a palpable tumor in the right 
iliac region and almost absolute constipation, she 
being able to take only liquids strained through a 
cambric handkerchief. There was a great deal of 
pain and vomiting and emaciation. My x ray diag- 
nosis was of a tumor not involving the wall of the 
intestine or requiring an operation upon the intes- 
tine ; in other words, a pericecal tinnor, and I 
advised x ray and radium treatment after the opera- 
tion to reduce the probability of recurrence. At 
the operation the tumor proved to be of a gelatinous 
character and was taken out with a spoon. Before 
she was brought to me for radiotherapy, a recur- 
rence of the tumor and all the symptoms had taken 
place. Deep x ray therapy was applied to different 
sections of the abdomen and pelvis front and back. 
Radium was applied over the tumor in a glass tube 
in an aluminiun treatment tube, then lead and finally 
rubber over all. The places were selected two and 
a half inches apart in a triangle (Fig. 8), and at 
each treatment the twenty milligrams of radium 
were left in each of these positions for an hour. To 
bring the radium as close as possible to the cancer- 
ous cells the patient lay upon a couch with one side 
close to the wall and with a heavy bowling ball 
(Fig. 9) resting upon the abdomen and pressing the 
radium applicator deeply into the right iliac fossa. 
Under this treatment the tumor, constipation and 
vomiting disappeared and the patient became able 
to eat everything, regained strength and became 
practically well. On one occasion there was a gen- 



JlSAIflST UALL 




Fic. 9. — Radium applied externally for pericecal tumor. Com- 
pression by bowling ball. 

eral distention of the peritoneal cavity with a similar 
gelatinous substance evacuated through an incision. 
After three years of health and comfort the patient 
died rather suddenly with pain and vomiting. This 
was eleven years after the first operation for :i 
malignant tumor. 



CHERRY: RADIUM IX GYXECOLOGV. 



[New York Medical JouftNAL 
AND Medical Record, 



CANCER OF THE UTERUS. 

I have had a good many patients referred to me 
by Dr. John M. Keyes, Dr. J. Kumpf and others, for 
treatment after hysterectomy. These are the hard- 
est cases we have to treat because of the difficuhy 
of applying sufficient radium dosage to the broad 
ligaments without exceeding the dose which will be 
tolerated by the vesicovaginal or the rectovaginal 
wall, and not tend to produce a fistula. The only 
way seems to be to give a safe dose of radium and 
combine that with deep x ray therapy. In this way 
it is possible to convert every cancer cell in the pel- 
vis into a harmless one. This requires great study 
and even then success is not assured. In every case, 
however, there is such improvement in strength and 
comfort and prolongation of life as to make the 
treatment a desirable one. 

RADIUM THERAPY BEFORE OPERATION FOR CARCINOMA 
OF THE UTERUS. 

In many cases it afifords a chance for a perm^inent 
cure. The radium is applied throughout the uterine 
canal. It is important to reach the ftmdus with the 
first application and give a sufficient dose there. 
This is because the radium applied first to the cervix, 
where twice the funda! dose should be used, tends 
to prevent easy dilatation of the cervical canal. For 
the body of the uterus the radium is in a glass tube, 
with metal and rubber filters and gamma rays are 
applied and the same is true of the cervical canal. 
The vaginal portion of the cervix may require punc- 
ture with steel needles containing ten or twelve and 
a half milligrams of radium. These are half an inch 
aj)art and a full cancer dose is six hours. Or glass 
tubes of one millicurie or less may be permanently 
embedded in the cancerous mass. The exact dose 
depends upon whether deep x ray therapy is going 
to supplement the radium effect and this the author 
considers very desirable. This anteoperative radio- 
therapy should be given about four days before the 
operation. Given at that time it produces no effect 
noticeable at the time of operation and neither facil- 
itates nor interferes with the latter, but it does greatly 
improve the chance for a permanent cure. 

RADIUM THERAPY IN INOPERABLE CANCER OF THE 
UTERUS. 

The internal applications are the same as already 
described for other cases of uterine cancer. They 
must be supplemented by external applications of 
either x rav or radium. The case described in the 



paragraph on hbromyoma with the whole pelvis a 
mass of cancer shows what can be done with deep 
radiotherapy alone. Part of the radium application is 
by a radium bomb, simply a tube of radium inside as 
large a globula filter as practicable held far up in 
the vagina by packing. This aims to secure an etifect 
upon the cervix and broad ligaments while exposing 
the rectal and vaginal wall as little as possible. The 
deep radiotherapy considered by the author an in- 
dispensable adjtmct in these cases means x rays of 
such a quality that a very large percentage will pene- 
trate four inches of water, equivalent to the tissues 
between the cancer cells and the skin. This means 
a high voltage, but, my tests have led me to the same 
conclusion as Wintz and Seitz, that beyond a certain 
viiltage no more rapid vibrations are i)roduced, no 
greater percentage of penetration. There are greater 
quantity and more rapid efifect but this is accom- 
panied by very great danger from the extremely high 
voltage alluded to and of course the proper filtration 
is required because of the flood of soft burning rays 
accompanying the hard ones. Deep radiotherapy, 
in my judgment, is not a matter of high voltage alone, 
but also of the proper filtration and crossfire eiTect 
and the voltage need not be excessively high. 

Of course anyone whose work includes relief of 
advanced cases of cancer has many sad moments, 
but one patient who died while I was on my vacation 
sent word to me by her sister that though she was 
dying she wanted me to know how much the radium 
and X ray had relieved her sufferings and prolonged 
her life. 

In a case in which a radium application of forty 
or fifty minutes' x ray treatment causes the disap- 
pearance of a fibroid, but is repeated three years later 
to allay the patient's fears excited by the return nf 
normal menstruation, I have been asked, "Why not 
operate and have it finished for all time?"' Of course 
we are talking of a case suitable for radium or the 
X ray, but which before the discovery of these agents 
would have been operated upon. The answer is that 
there is no comparison between the work entailed 
for the operator, nurses and family, and if my per- 
sonal experience with an entirely successful ex[)lora- 
tory laparotomy with postoperative pain and pros- 
tration and several months' convalescence is my 
guide, radiotherapy in the proper cases would offer 
very great advantages to the patient even if in some 
cases it had to be repeated in a few years. 

850 Seventh Avenue. 



The Uses of Radium in Gynecology* 

By THOMAS H. CHERRY. M. D.. F. A, C. S.. 
New York. 



During the last ten years the use of radium as a 
therapeutic agent has been of great interest to the 
medical profession. This much advertised clement 
in the hands of enthusiasts has been the means of 
raising false hopes in it as a cureall for that almost 
hopeless condition of carcinoma in all its stages. 

• Presented before the Washington HciKhts Medical Society, April 
18. 1922. 



This has jiroduced great harm and hrouglu discredit 
upon it. In the last few years radium has been used 
in the treatment of cancer by dilferent reliable in- 
stitutions and the results observed by unbiased 
minds. From these observations fairly definite con- 
clusions have been reached regarding its limitations, 
and the standardization of the dosage has been regu- 
lated as applied to the different stages of cancer. 



July 5. 1922.] 



CHERRY: RADIUM IX GYXECOLOGV. 



The main source of radium supply is Paradox 
Valley, Colorado. Uranium, the mother metal, by 
its disintegration gives off radium. Radium at 
present is used in two ways — the emanations and the 
salts. The emanations are the rays extracted from 
radium by a specially constructed machine, and col- 
lected into glass tubes best suited for its adminis- 
tration. These tubes gradually lose their power in 
the course of time and must be renewed. The dose 
by this method is measured in millicuries. This 
method safeguards the original supply — an item well 
worth considering when the price is one hundred and 
twenty dollars a mg. 

Radium bromide is the salt used and it is this 
substance that has been utilized by Dr. George S. 
Willis and myself in the treatment of gynecological 
conditions at the Post-Graduate Hospital during the 
last two and a half years. It is a brownish powder 
that can be encased in a glass capsule ; it can also be 
imbedded in needles in varying quantities for trans- 
fixion of the diseased area. The dose by this method 
is measured in milligram hours. 

Radium rays are divided into the alpha, beta and 
gamma rays. The alpha ray constitutes about ninety 
per cent, of the latent energy and has no therapeu- 
tic value because it does not penetrate tissue. The 
beta ray makes up nine per cent, and its power of 
penetrating tissue is one cm. This ray exerts 
great irritating effects upon tissue and produces a 
slough when used. Therefore, it is applied in super- 
ficial lesions. The gamma ray constitutes one per 
cent, of the entire ray and it is this portion that is 
of value to us in the treatment of gynecological con- 
ditions, as it will penetrate ten cm. of tissue. 

How do we use the gamma ray ? The glass cap- 
sule containing the radium blocks the alpha rays. 
We know that the beta rays will not penetrate one 
and five tenths mm. of brass, gold, silver or plati- 
num, therefore by screening the capsule with one of 
these metals the gamma rays alone come into action. 

ACTION OF THE G.VMMA RAY UPON TISSUE. 

The object of applying radium to a growth is to 
destroy that growth without injury to normal adja- 
cent tissues. Dr. James Ewing has made an ex- 
haustive study of this action upon different tissues 
and I herewith give an extract from his description : 
Upon the application of three hundred mg. hours 
the tissues if examined at the end of five days are 
found to be hyperemic with beginning exudation 
of leucocytes, and a swelling of the cells. During 
the second week the cells are loosened, showing 
their nuclei swollen and a beginning formation of 
fusion giant cells. In the third week the cells are 
greatly reduced in number, some having suffered 
necrosis ; others are invaded and compressed by 
lymphocytes. In the fourth week only nuclear frag- 
ments or an occasional giant cell remains. During 
this time the stroma of the tumor has become active: 
there is an infiltration of leucocytes and a prolifera- 
tion of the capillaries which penetrate and excavate 
the tumor cell nests. The later stages of this reac- 
tion show a gathering of leucocytes, lymphocytes, 
plasma cells and polybla.sls. The site of the tumor 
eventually becomes occupied by this granulation 
tissue. Later, epithelium grows over the surface. 



completing the repair. In large tumors necrosis 
may occur with liquefaction and cyst formation ; in 
other instances the stroma may be replaced by fib- 
rous tissue. 

The gynecological conditions to which radium 
may be applied are: 1, carcinoma, 2, fibrornyoma. 
3, myopathic hemorrhages, 4, endocervicitis, 5, be- 
nign and malignant growths of the vulva, vagina 
and cervix. 

CANCER. 

Under this heading we can arbitrarily divide it 
into cancer of the cervix and cancer of the fundus 
of the uterus. 

In cancer of the cervix we classify — 1, operable, 
2, borderline or doubtfully operative, 3, inoperable 
or hopeless, and 4, recurrences. 

Cancer is operable when the disease is confined to 
the cervix without the formation of metastases. 
This is ascertained by vaginal and rectal examina- 
tions. From clinical observations upon the results 
of the Wertheim operation for a period of ten years, 
it is my opinion that surgery has no place in the 
treatment of this condition. This opinion, however, 
is not shared by other men who either do a hysterec- 
tomy and follow up with radium therapy, or as a 
preliminary treatment apply radium, then operate. 

In the borderline or doubtfid class there is some 
thickening of the broad ligaments, but a freely 
movable uterus. This thickening may be only inflam- 
matory in character, therefore is deemed doubtful. 

Cancer is inoperable when there is definite in- 
volvement of the parametrial structures and the 
lymph nodes of the pelvis. There may also be defi- 
nite metastases in the lumbar lymph nodes or other 
portions of the body. Recurrences may occur at the 
site of the vaginal scar, or in the parametrial tissue, 
or lymphatic pelvic structures. 

TRE.^TMENT. 

A [jreliminary statement should l)e made that all 
cases of uterine carcinoma are not fit subjects for 
radium therapy, any more than they are for surgery. 
When we consider that a large fungating cervical 
cancer with metastases is treated with radium, a 
tremendous atnount of cell destruction takes place 
with the consequent absorption of the products of 
cell disintegration. It is, therefore, necessary to as- 
certain if the organs of elimination can take care of 
this extra strain placed upon them. It also becomes 
necessary — when seeing a prospective candidate for 
radium therapy — to make a thorough physical ex- 
amination and give especial attention to the kidney 
function test, the urinary findings, the blood chem- 
istry, the hemoglobin and red blood cell count. For 
instance, if a patient having an inoperable cancer, 
whose blond shows a hemoglobin of 30 to 40 per 
cent., a 2,000,000 red cell count, and urine having 
marked albumin and casts with a ijhthalein output 
in two hours of 10 to 30 per cent, and a blood chem- 
istry showing carbon dioxide combining power of 
25 to 40 per cent. mg. to 100 cc. and a marked re- 
tention of urea nitrogen and creatinin, that patient is 
not a candidate for radium. Under these circum- 
stances we transfuse with whole or cilrated lilood ; 
then, when an interval of time elapses and improve- 



8 



CHERRY: RADIUM IN GYiXECOLOGY. 



[New York Medical Journal 
AND Medical Record. 



ment of the patient is marked, radium is applied. 
Arbitrarily, a patient showing a hemoglobin less 
than 50 per cent., or a red blood count under 3,000,- 
000 is considered a poor radium risk. Also, when 
the phthalein output in two hours is less than 50 per 
cent., radium is not applied unless medical treatment 
improves tlie condition. 

In applying radium to uterine cervical carcinoma 
it behooves us to consider that the lymphatic vessels 
draining this site are composed of two sets — one 
travels upward in the musculature of the titerus to 
the body that anastomoses with the lymphatics of the 
broad ligaments, and the other outward in the layers 
of the broad ligaments. In order to ray these areas 
we first insert a tube of fifty mg. into the fundus 
for twenty-four hours in order to destroy any cancer 
cells in the fundus. In a week's time another treat- 
ment is instituted in the midportion of the uterine" 
body ; and lastly, we apply radium to the cervical 
canal directly to the growth. At times, if the 
patient's condition allows, two tubes of fifty mg. 
of radium can be placed in the uterine cavity end to 
end. thus raying the whole fundus at one time. 
This treatment is repeated in six weeks and is con- 
tinued over such a period of time as the condition 
of the patient, both locally and generally, warrants. 
The usual total dose considered necessary to eii'ect 
arrest of growth is 7,200 mg. hours. 

Cervical carcinomata that are of the ftmgating, 
sloughing type are often treated in combination 
with the foregoing by the introduction of needles 
containing twelve and a half mg. of radium, six of 
these needles being inserted and left for from six to 
twelve hotirs. 

Fundal carcinomata are considered as good sur- 
gical cases if they have not metastasized, which they 
fortunately do late in the disease. Following opera- 
tion, however, it is deemed advisable to ray them at 
intervals for at least six months. 

RESULTS OF R.\DIUM TREATMEXT OF CERVIC.\L 
CANCER. 

In early operable carcinoma a cure may be accom- 
plished. We have two cases that have remained one 
and a half to two years respectively without recur- 
rence or metastasis, and are in good general health 
at the present time. 

The inoperable cases can be markedly improved 
and their lives prolonged and made useful and com- 
fortable. The bleeding can be stopped ; the foul 
smelling vaginal discharge will cease, and the metas- 
tatic masses in the pelvis will become fibrotic and 
smaller. There may be a great alleviation of pain. 
As far as a cure is concerned, some cases appear 
arrested but later mav have recurrences requiring 
more raying. 

FIBROMVO.MATA. 

Fibromyomata of the uterus are generally consid- 
ered best treated by myomectomy or hysterectomy. 
There are some patients, however, who, owing to car- 
diac or renal involvement, are poor surgical risks. 
In these instances radium is an ideal treatment. The 
method of application is to insert sixty mg. of 
radium into the uterine canal for twelve to twenty- 
four hours and crossfire with an application of fifty 
mg. from the abdominal side. These treatments are 
repeated every six to eight weeks. It is truly re- 



markable how rapidly these large tumors shrink, 
with relief, frequently following the first treatment, 
of the pressure symptoms upon bladder and rectum, 
and immediate cessation of uterine bleeding. 

MYOPATHIC HEMORRHAGES. 

Menorrhagia, especially seen at or near the meno- 
pause, is the most responsive to radium therapy of 
all the gynecological conditions. Here we have an 
overactivity of the internal secretion of the ovary 
manufacttired probably in the graafian follicles. The 
introduction of sixty mg. of radium into the uterine 
cavity for twenty-four hours is sufticient to produce 
a complete cessation of the bleeding, and 
bring abotit an artificial menopatise. Before the ad- 
ministration of radium a curettage should be done 
for diagnostic purposes. 

ENDOCERVICITIS, 

Chronic inflammations of the cervical canal pro- 
during a constant leucorrheal discharge have been 
treated with radium. Curtis of Chicago has re- 
ported excellent results with this therapeutic meas- 
ure. At the Post-Graduate Hospital in the service 
of Dr. H. D. Furniss this was tried out in a series 
of cases ; twenty-five mg. were inserted into the 
canal for three hours at a treatment, which was re- 
peated in a week "or ten days. This treatment, I am 
sorry to say, was most disappointing; omr observa- 
tions being that those cases in which it was of benefit 
could have been helped or cured by the usual 
methods of treatment. 

BENIGN GROWTHS OF VULVA AND VAGINA. 

Benign growths of the vulva and vagina, such as 
condyloma, fibroma and papilloma, respond most 
readily to radium. Similarly do other superficial 
conditions. Needles of seven and one half to twelve 
and one half mg. of radium are inserted to every 
centimetre of tumor tissue. This is supplemented 
by radium tubes — sixty mg. screened with brass and 
rubber — applied for an hour. These treatments are 
repeated if necessary at intervals of five to six 
weeks. 

CONCLUSIONS. 

1. Radium in the early cases of carcinoiua of the 
cervix is considered by some to be the treatment of 
choice rather than surgery. 

2. In the treatment of inoperable cancer and in 
the recurrences, the patient's life may be prolonged 
and made more comfortable by the elimination of 
local symptoms and the lessening of absorption of 
toxic products. 

3. All patients with cancer desiring radium 
should first be tested for the kidney function and 
hemoglobin and red cell count if found low, or if 
the blood chemistry shows high nitrogenous reten- 
tion, radium is contraindicated until their condition 
im])roves. 

4. All patients with uterine hemorrhages at or 
near the menopause, not due to uterine fundal can- 
cer, are readily cured by radium application. 

5. h'ibromyomata in patients whose general con- 
dition contraindicates an operation, can be treated 
by radium and good results expected. 

6. The benign condition of the vulva and vagina 
shows excellent results following radium treatment. 

47 \A'est Fiftieth Street. 



July 5, 1922.] 



APPLEGATE: DELIVERIES REQUIRING CJESAREAX SECTIOX. 



Two Complicated Deliveries Requiring Gaesarean Section* 

By J. C. APPLEGATE. M. D., F. A. C. S.. 
Philadelphia, 

Professor of Obstetrics, Department of Medicine, Temple University, Obstetrician to the Samaritan and Garretson Hospitals. 



The two patients whose condition I shall describe 
were distinctly hospital cases, though in labor in the 
home several hours, with little or no progress, be- 
fore being referred to the hospital. One patient had 
a large uterine fibroid, the nature of the dystocia 
undetermined in the beginning ; the other case was 
a breech presentation in a primipara with a pelvis 
below normal in dimensions and a fetal head over- 
size and greatly out of proportion to the pelvis. 

Both were unusual cases and the course of pro- 
cedure difficult to decide ; in the first case as to 
whether it should be Csesarean section or embry- 
otomy, following an attempt at podalic version, and 
in the second a continuation of the breech delivery 
or section. 

It occurs to me that the indications for section 
might be broadened somewhat, conservatively, for 
humanity's sake, and in effect to counteract a con- 
dition of affairs, statistically reported as follows : 
'"The practice of obstetrics has improved and is im- 
proving in private practice," which is quite natural 
following the campaign on prenatal education, "but 
not so in hospital practice, where matters are grow- 
ing worse, especially in infantile mortality.'' If such 
statistics can be verified, and I have no doubt that 
they can, there can be but one conclusion, viz., that 
the hospital is too often the dumping ground for 
patients beyond the stage of recovery, or else there 
has not been due regard to the necessity for asepsis 
and antisepsis in the manipulations before the pa- 
tients are admitted to the hospitals for treatment. 
In other words, they are infected before they reach 
the hospital. 

The foregoing statements do not apply to the 
Samaritan Hospital. While I have not the data at 
hand, I am sure the mortality there has steadily de- 
creased. The physicians referring cases, as a rule, 
are careful as to cleanliness — asepsis and antisepsis 
— and rarely, can it be said, is the hospital used as a 
dumping grouiid for patients beyond the stage of 
recovery. By far the largest percentage of the few 
infections and deaths — maternal and fetal — occurs 
among those who have received no attention at the 
dispen-sary or elsewhere, or have i)een attended by 
midwives. 

The mortality in elective Caesarean section under 
modern surgical technic is practically nil. The 
operation involves the opening of the abdominal cav- 
ity, however, which is always accompanied by some 
risk.- hence the indications should be positive and 
definite or else the woman is entitled to the benefit 
of the test of labor. What is true of elective sec- 
tion, is also true of emergency section providing due 
regard is paid to cleanliness, asepsis and antisepsis, 
or else the hands off method, when in doubt, until 
convinced that she is not a patient for section. The 
maternal morbidity and infant mortality may be still 

* Read before the Samaritan Hospital Medical Society, Phila- 
delphia. January 9. 1922. 



further reduced by broadening, conservatively, the 
indications in this field. 

For example, the time was when we would hesi- 
tate to do section after the membranes had rup- 
tured ; after the patient had been examined or 
manipulated ; after attempts at forceps delivery or 
podalic version, or after the induction of labor that 
failed, when the presenting part did not engage 
under the influence of contractions, by reason of 
dystocia. The floating head in itself is not an indi- 
cation for section, but the floating head because of 
disproportion or other forms of dystocia is an indi- 
cation. Breech presentation in a primipara with a 
la-ge fetal head, or moderate disproportion, whether 
due to the abnormal head or pelvis or both, demands 
section in the interest of both mother and child. 

The hazard in operating under such circumstance- 
is not underestimated when one is without the full 
knowledge that they have not been previously in- 
fected. The first case that I shall report had a pro- 
truding hand and arm for a time but they were kept 
clean and there was no infection. Our results here, 
in emergency sections have been uniformly good. 
with living children, and in two of the cases which 
I present herewith under any other method the in- 
fants would have been stillborn and mutilated and 
the mothers greatly traumatized. 

C.xsK I. — Mrs. M., aged thirty-two, primipara. 
with negative family and personal history, never ill, 
except for the usual diseases of childhood and her 
previous normal labor and puerperium, eight years 
previously. She was referred to the hospital by a 
hospital doctor, without manipulations in the home, 
who recognized an abnormal condition, also the need 
for hospital treatment. She was admitted March 
28th, after having been in labor two or three hours ; 
the membranes had ruptured before she reached 
the hospital. 

The external examination showed a large pen- 
dulous abdomen with a large mass in the left lower 
quadrant, not unlike a fetal head. The fetus could 
be outlined but no fetal heart sound could be heard. 
The pelvic dimensions were normal. By vaginal ex- 
amination the cervix was found to be fairly well 
dilated and the head presenting at the inlet but 
could not be made to engage. Usually uterine 
fibroids above the inlet would permit of delivery by 
the natural route but this involved the lower uterine 
segment and made impossible sufficient dilation for 
head first extraction or podalic version. 

Version was abandoned after several attempts on 
account of beginning exhaustion of the patient, 
fatigue of the doctor and threatening rupture of the 
uterus. Each time a fetal member could be reached 
it proved to be a hand instead of a foot. A hand 
protruded through the vulval orifice. This was 
cleansed and replaced. There remained the choice 
between embryotomy and CjEsarean section. The 
partial obstruction from the tumor with rigidity of 



10 



PIPER: CESAREAN SECTION. 



[New York Medical Journal 
AND Medical Record. 



the lower uterine segment, together with the possi- 
bility of resuscitating the baby, for there appeared 
to be slight pulsation in the umbilical cord, decided 
the course of procedure in favor of section, which 
was performed two hours later, that is, as soon as 
the patient had recuperated under stimulation. 

The medium high incision was made, under ether 
anesthesia, and after the extraction of the child the 
uterus with tumor was removed by hysterectomy. 
The weight of the baby was slightly under eleven 
pounds (ten pounds and fourteen ounces). The 
tumor weighed a little less than eight pounds (seven 
pounds and fifteen ounces). The incision was closed 
in the usual way, with cigarette drain in the lower 
angle of the incision as a precautionary measure, 
and removed on the second day. The wound healed 
promptly. The patient had no rise in temperature 
and she left the hospital on the fourteenth day. 

One of the noticeable features in connection with 
this patient was the unusually rapid growth of the 
fibroid tumor of the uterus by reason of the free 
blood supply during pregnancy. She had no metror- 
rhagia nor menorrhagia prior to pregnancy nor any- 
thing during gestation to indicate that the tumor 
existed until she was in labor and op>erated upon. 

Case II. — Mrs. H., aged twenty-two, primipara, 
with negative family and personal history. She had 
had the usual diseases of childhood, but otherwise 
had always enjoyed good health. This patient was 
due to have been delivered about November 14. 
1921. She was admitted to the hospital November 
20, 1921, having been in labor about fourteen hours 
and in active labor four hours. The physicians in 
attendance diagnosed the breech presentation with 
a large fetal head and wisely concluded that her 
place was in the hospital and that the method of de- 
livery should be by Caesarean section. During the 
trip from her home to the hospital in the ambulance 
there was some progress. The pains and contrac- 
tions, when we first saw her, occurred every three 
minutes with buttocks presenting at the outlet during 
each contraction. 

Her pelvic dimensions were practically normal : 
interspinous, twenty-six cm.; intercristal, twenty- 
eight cm. ; transverse, thirty-two cm., and external 



conjugate, nineteen and five tenths cm. The fetal 
head was apparently considerably oversize, and sub- 
sequently all of the diameters measured two cm. 
above normal. Undoubtedly this woman couid have 
delivered the body of the child spontaneously or with 
little assistance by the natural route, after her trip 
in the ambulance, but it was clearly evident that the 
aftercoming head could not be extracted without 
a great deal of maternal traumatism and the destruc- 
tion of the life of the child. Section was performed 
under ether anesthesia through the medium high 
incision. The lower extremities and buttocks were 
in the vagina, outside of the uterine cavity, and it 
was necessary to apply forceps to the head in the 
cavity of the uterus for delivery through the in- 
cision. This might be termed reverse forceps deliv- 
ery. The fetal heart sounds were indistinct prior 
to operation, but the child was resuscitated without 
great difficulty, by suspension in midair by the feet, 
a spanking, and a few drops of ether on the chest. 

The head measurements were: Occipitofrontal, 
thirteen and five tenths cm. : occipitomental, fifteen 
and five tenths cm. ; suboccipital bregmatic, eleven 
and five tenths cm. (all two cm. above normal). 
The weight of the child was eight pounds and thir- 
teen and a half ounces. 

The incision was closed by layers, peritoneum, 
muscles, fascia and skin with continuous chromic 
No. 1 catgut sutures. Primary union followed with 
uninterrupted convalescence and the patient left the 
hospital on the sixteenth day after operation. In 
this patient there developed a slight sapremic tem- 
perature between the fourth and seventh days — 
never over 100° — accompanied by a vaginal dis- 
charge with some odor, due to retention of small 
portions of membrane, which had ruptured prema- 
turely, by the way, as in the former case. 

This was my first and only experience in deliv- 
ering a child with forceps through the incision after 
being partly born by the natural route, but knowing 
the carefulness on the part of the doctors in attend- 
ance I concurred in their opinion and feel that the 
results justified the course of procedure. In no 
other wav could this child have been bom alive. 

3540 North Bro.^d Street. 



Once a Caesarean Always a Caesarean^ 

By EDMUND B. PIPER, M. D., F. A. C. S., 
Philadelphia. 



Like most epigrammatic phrases used in writings on 
medical subjects, the heading of this article does not 
cover the question. The pendulum has swung back- 
wards and forwards in regard to the truth or fal- 
lacy of the statement that "Once a Caesarean always 
a Caesarean" so much, that I do not believe at pres- 
ent it would be possible to get any large number of 
obstetricians to agree on the subject. 

The first recorded Cesarean section upon a living 
person was done by Trautmann in Wittenberg in 

* Delivered before the John Morgan Society, Philadelphia, Decern- 
ter 2, 1921. 



1610. The patient lived twenty-five days. How- 
ever, the operation is in all probability a much older 
one. Until quite recently the mortality was so. ex- 
tremely high that the operation was avoided at any 
cost. Hirst believes that the mortality at present, in 
the hands of skillful operators and under favorable 
conditions, should be below one per cent. DeLee 
says one per cent, to two per cent. Edgar thinks that 
in the operation under good surroundings the ma- 
ternal mortality should be almost nil. Cragin gives 
his mortality as 6.66 in 150 cases; in 143 nontoxic 
cases his mortalitv was 2.09. 



July S, 1922.] 



PIPER: CESAREAN SECTION. 



11 



The statistics given above ranging from one per 
cent, to two per cent, refer only to tliat type of case 
which we speak of as elective C»sarean section. 
The mortality in emergency Cesarean section is un- 
questionably a great deal higher. In a series of 
thirty-seven cases, all of which were emergency cases, 
my mortality was ten and eight tenths per cent. 

Until recently the only indication for Csesarean 
section was disproportion between the fetal body 
and the maternal birth canal. We now believe that 
there are many other possible indications, but we do 
not believe in the three indications accredited to one 
obstetrician, that is, 1, the patient must be a woman ; 
2, the patient must be pregnant ; 3, the patient must 
be unable to speak English. 

In spite of the low mortality asserted for the elec- 
tive Cesarean, we do not believe that it ever will be 
anything but a serious major abdominal operation, 
and we believe that it never should be resorted to 
except in those cases in which it gives the mother 
a better chance for life and future health than a 
delivery by the normal vaginal route. There are 
very few absolute indications for Cesarean section. 
Pelvic measurements per se must be only looked on 
as comparative. A woman with a somewhat con- 
tracted pelvis will give birth to a small child as easily 
as one with a normal pelvis will deliver a large baby. 
Every case of placenta prasvia should not neces- 
sarily be delivered by a Caesarean section. A few 
of the indications for Caesarean section may be 
given as follows : 

1. A definite disproportion between the fetal presenting 
part and the maternal pelvis. 

2 Central placenta prsevia with no dilatation or efface- 
ment of the cervix. 

3. Marginal placenta previa where there has been hem- 
orrhage with a not easily dilatable cervix. 

4. Premature separation of a normally placed placenta 
with an undilated and not easily dilatable cervix. 

5. Eclampsia where the convulsions are increasing in 
severity and when elimination has been tried and there is 
no evidence of labor. In other words, where the uterus can 
not be easily evacuated by the vaginal route. 

6. In some cases of the toxemia of late pregnancy, in 
which active treatment seems to be of no value, and a long, 
tedious labor is anticipated, which probably will terminate 
in eclampsia. 

7. In some cases of cardiac decompensation. 

8. In some cases of pulmonary tuberculosis. 

9. In some cases of prolapsed cord. 

10. Face presentation with chin posterior, and in some 
impacted shoulder presentations. 

Every case in which the (|iiesti()n of delivery by 
Cresarean section is considered must be looked upon 
as a law unto itself. I do not believe that we can 
unequivocally say that any case under a given con- 
dition must be Caesareanized. The whole question 
resolves itself into what is best for the individual 
case under consideration. At present it is consid- 
ered safer for the patient, both as to her immediate 
recovery and subsequent health, that she should be 
delivered by Cesarean section rather than the use 
of axis traction forceps upon a high floating head. 
It is unf|uestionably so for the child. The injuries 
to the various jjarts of the birth canal, following a 
high forceps o[)eration, are unquestionably the cause 
of invalidism occurring in the later life of many 
women. 

It must be understood that I am speaking only 
of the clas.->ical Ciesarean sectitni. I am not consid- 



ering the Porro or the various types of socalled 
extraperitoneal section, or the vaginal C;esarean sec- 
tion, which latter is a misnomer and should always 
be termed anterior vaginal hysterotomy. 

The chief contraindication to the promiscuous use 
of Caesarean section is the danger of the rupture of 
the uterine scar in a subsequent labor. Davis, of 
Philadelphia, in his discussioir before the American 
College of Surgeons this year, said it was generally 
conceded that iit four per cent, of cases the uterine 
scar was ruptured in a subsequent labor. Hirst has 
the record of but one case that he knows of, of a rup- 
tured uterine scar in a subsequent labor in approxi- 
mately five hundred cases of Ctesarean section done 
by himself. I have seen two cases within the past 
six months which seem to have a peculiar interest in 
this problem. 

Case I. — I delivered this patient by Caesarean 
section two years ago, the indication being ob- 
structed labor. There was a stormy puerperium 
with signs of local peritonitis. On or about ten days 
after operation, the patient passed from the vagina 
a long mass of tissue, the length of the uterine scar, 
with the deep layer *of continuous catgut stitch un- 
absorbed. The patient made a final recovery and I 
warned her that she was never to allow herself to 
fall in labor as she would undoubtedly rupture her 
uterus. Some months ago she presented herself to 
the outpatient department and was given the usual 
prenatal care and ordered to come to the hospital 
two weeks before term. This she failed to do and 
was admitted sometime later in active labor with 
signs of shock and internal hemorrhage. She was 
operated upon and the uterine scar had ruptured 
completely. Hysterectomy was done and the patient 
eventually recovered. 

Case II. — The patient had been previously deliv- 
ered three years before in Boston. I was asked to 
take charge of her by her family physician, who 
showed me a letter from her doctor in Boston stat- 
ing that in his judgment the woman should be de- 
livered by Ca;sarean section and that the indication 
for the previous Caesarean was toxemia of preg- 
nancy and a faulty pelvic inclination. My examina- 
tion two months before term disclosed no pelvic 
contraction and there were no symptoms of toxemia. 
The patient had a slight goitre. It was determined 
to give this patient a test of labor. Later on the 
doctor in charge of the case, which was in a city at 
some little distance, notified me by telephone that the 
head had not come in the pelvis. Before we could 
arrange for an elective section the patient was in 
labor. With the membranes unruptured she was 
given mor])liinc until I could arrive. Examination 
gave every indication that labor could he success- 
tully terminated by the vaginal route so the patient 
was allowed four hours of sharp labor. At the end 
of that time, as she had made no progress, I became 
fearful of the uterine scar and opened her abdomen. 
We delivered a living child and found the scar of 
the previous Ciesarean had thinned out until it was 
less than a half inch thick. One of the indications 
in this case that decided us to do section was a high 
abdominal incision, which made us suspect that there 
had been a high uterine incision, and this proved 
to be the case. A few more hours of hard labor 



12 



DANNREUTHER: ADVANCES IS GYNECOLOGY. 



[N'ew York Medical Journal 
AXD Medical Record. 



would in all likelihood have caused a rupture of 
the uterus. 

I have seen other cases of rupture of the scar of 
a previous Cassarean operation, but the two case.-^ 
cited are the only ones of which I have an intimate, 
personal knowledge. It would seem that any statis- 
tics on this subject must of necessity be rather inac- 
curate, as in order to give real statistics of rupture 
in a subsequent labor in a hundred cases, we must 
know that each of these patients is delivered by the 
vaginal route if they became pregnant at all, and in 
many cases, similar to Case I, cited above, it would 
unquestionably be the worst kind of obstetrics to 
allow the patient to fall into labor at all. 

The question of repeating a Caesarean section, I 
believe, depends upon two things : namely, the indi- 
cation for the first section and the character of the 
patient's postoperative convalescence, following the 
first operation. Taking a hypwDthetical case for an 
example, if I were called to attend a woman in con- 
finement, and she gave a history of having had two 
children normally, and in her third pregnancy she 
was delivered by section on account of central pla- 
centa prjevia, following which she had an tinevent- 
ful. afebrile convalescence, I should certainly allow 
her a test of labor under careful observation. If, on 
the other hand, a woman were delivered of her first 
child by Cesarean section on account of a definiteh' 
contracted pelvis, I should doubt the advisability of 
allowing her to fall in labor in any other of her sub- 
sequent pregnancies, unless she should accidentally 



fall in labor at least four weeks before term, when 
she might be allowed a moderate test of labor. 

This problem is one which is open to a difference 
of opinion, and one should not be too didactic in the 
matter, but I believe that any woman that has been 
delivered twice by Cesarean section should never be 
delivered in any other way. This statement natur- 
ally brings up the question of how many times this 
operation may be done on any one woman. Davis, 
of Xew York, has delivered one woman six times 
and Hirst, of Philadelphia, has delivered one four 
times by Caesarean section. It would seem that any 
woman that had undergone four abdominal opera- 
tions to give birth to children has done her fair share 
along that line, and that she should be sterilized, if 
she expresses such a wish. 

CONCLUSIONS. 

1. A Cesarean section at all times is a serious 
major operation. 

2. The indications for a first Caesarean section is 
the most important factor in determining whether 
it should be repeated in die next parturition. 

3. A stormy puerperium is a contraindication to a 
normal vaginal delivery at the next confinement. 

4. The advisability of elective Caesarean section 
should always be carefidly considered in any sub- 
sequent pregnancy. 

5. Once a Cassarean. alm()5t always a Caesarean. 
1936 SpRrcE Street. 



A Brief Resume of Some of the Recent Advances in Gynecology 

By WALTER T. DANNREUTHER, M. D., F.A. C. S.. 
New York. 
Associate Professor of Gynecology, New York Post-Graduate Medical School and Hospital. 



That intelligent treatment is predicated upon ex- 
act diagnosis is axiomatic. Yet it is astonishing to 
discover how -many practitioners who essay the 
treatment of gynecological patients have failed, and 
possibly still fail, to determine the real cause of 
symptoms referable to the urinary tract. It is not 
necessary that the gynecologist become a urologist, 
nor do I advocate that the former trespass upon the 
field of the latter, but I do contend that the bladder 
is a pelvic organ and that gv^necology properly em- 
braces the diagnosis and treatment of all diseases of 
the pelvic organs in the female. The cystoscope is a 
diagnostic instrument of precision and no gyne- 
cologist is qualified to practise his specialty until he 
has acquired a working knowledge of cystoscopy. 
There is no longer any excuse for attributing vari- 
ous urinary .symptoms in women to cystitis, wash- 
ing out the bladder, and prescribing urinary antisep- 
tics, when the cause of the symptoms may be any- 
thing from an ordinary trigonitis to a neoj)lasm or 
urogenital tuberculosis. That gynecologists them- 
selves have come more and more to appreciate these 
facts constitutes one of the recent advances in gyne- 
cological practice. 

•Read before the Medico-Surgical Society, May 20, 1922. 



Derangements uf the ductless glands comprise a 
large proportion of the problems confronting the 
gynecologist, and to a certain extent he has parti- 
cipated in the study and development of endocrin- 
ology. I believe that much of the difficulty experi- 
enced by some general practitioners in understand- 
ing this complex subject is due in part to the failure 
on the part of those who publish articles on its 
various phases to discriminate between accepted 
facts and pure theories. Endocrine therapy is still 
in its infancy, but despite the lack of standardi;^a- 
tion of several organoriierapeutic agents, properly 
selected cases have already been materially benefited 
by it. The disturbances in each individual, however, 
must be correctly analyzed, otherwise one cannot 
tell which remedial agents are indicated. Thymus 
and mammary extracts in socalled cases of idio- 
])athic uterine hemorrhage : thyroid extract in hypo- 
ihyroidism ; whole ovarian extract or ovarian resi- 
due in amenorrhea and the menopause ; pituitary 
extract in dystrophia adiposogenitalis : and corpus 
luteum extract in the hyperemesis of pregnancy, 
vicarious menstruation, and habitual abortion, have 
all proved efficient in certain instances. It is par- 
ticularly fortunate that all the gynecologist's i)atients 



July 5, 1922.] 



DAXXREUTHER: ADVANCES IN GYNECOLOGY. 



13 



are women, as the character and behavior of men- 
struation, together with the existence of premen- 
strual phenomena, often serve as the signal system 
of the ductless glands. I have been encouraged by 
past experiences and am enthusiastic as to the future 
of organotherapy, but at the .same time realize its 
present limitations. 

One very definite contribution to our gynecolog- 
ical equipment has been made within the past few 
months by Dr. I. C. Rubin. He has devised a non- 
operative method of determining tine patency of the 
Fallopian tubes, by means of intrauterine inflation 
with carbon dioxide and the production of an artifi- 
citl pneumoperitoneum. A knowledge of the patency 
of the tubes is of the utmost importance in the diag- 
nosis and therapy of sterility in the female, and the 
desirability of such a method whereby this can be 
demonstrated is selfevident. Only small amounts 
of gas are necessary and the details can be carried 
out in the office. The technic is relatively simple, 
and by connecting a manometer to the gas circuit 
and carefully regulating the flow of bubbles, the 
operator has complete control of the situation. In 
the positive patent cases, gas will enter the peri- 
toneal cavity under a pressure of from 40 to 100 
mm. When the pressure reaches 150 mm. or more, 
the closure or stenosis of the lumen of the tubes 
may be presumed. This test is of course contraindi- 
cated in the presence of active pyogenic pelvic in- 
fections. 

Pneumoperitoneum itself, as originally intro- 
duced by Stein and Stewart, has a distinct field of 
usefulness in gynecological diagnosis. By this 
means intraabdominal organs can be visualized on 
X ray plates to an extent heretofore impossible. 

To anyone assuming the responsibility for human 
life, there can be no matter of greater concern than 
the predetermination of the vital resistance, before 
subjecting a patient to anesthesia and operation. 
'J'his implies an estimation of the patient's metabolic 
capabilities and abnormalities, in addition to the ex- 
isting pathological conditions. While we are largely 
indebted to the laboratory worker and internist for 
the several recently developed and available proce- 
dures for making such a preliminary survey, the 
gynecologist has promptly recognized their signifi- 
cance. Renal function tests, studies in blood chem- 
istry, particularly of the urea nitrogen and blood 
sugar, the carbon dioxide combining power of the 
blood, and basal metabolism, are all comparatively 
easily applied methods by which these factors can be 
ascertained, and are now in daily use. 

Notwithstanding the futility of attempting an ex- 
l>osition of the gynecological aspects of the cancer 
problem, some reference must be made to the use of 
radium in the treatment of uterine cancer and 
fibroids. The application of radium needles, which 
may be thrust into the tumor mass or adjacent tis- 
sues, standardized dosage, and improved technic, 
have done much to enhance the efficiency of radium 
applications. Acknowledging that the morbidity of 
cancer has not decreased, that it^ causative factors 
remain obscure, and that no cure for tiiis dread dis- 
ease has been discovered, it must be admitted that 
radium therapy is a valuable addition to our arma- 
mentarium. The misuse of radium has lent false 
encouragement and reflected discredit upon it, but 



those experienced in its use are beginning to appre- 
ciate what may be expected of it and what its limi- 
tations are. We have learned that a preliminary 
study of the patient's metabolic activities and pow- 
ers of elimination is as essential before radium 
treatment as before operation, so that the effect of 
the toxemia and increase in nitrogenous elements 
following the extensive cell destruction may be 
anticipated. The dosage is then regulated accord- 
ingly, and ofttimes preceded by a blood transfusion. 

Statistics are notorious!}- unreliable, and I have 
little confidence in them. What are we to think 
when some maintain that surgery no longer has any 
place in the treatment of cancer of the cervix, and 
rely upon the use of radium alone (Clark, Mayo), 
while others state that "it is absolutely certain that 
radium and cautery cannot cure cancer of the cer- 
vix" (Cobb, Peterson), and each faction compiles 
apparently convincing figures to prove their asser- 
tions? The majority of gynecologists are probably 
not in accord with either of these extreme views, 
and utilize both radium and surgery at various 
times. Most of us believe that patients in whom 
surgery is contemplated are distinctly benefited by 
an anteoperative radium application, as this blocks 
the lymphatics and inhibits the dissemination of can- 
cer cells. We are also fairly well in accord that 
surgery is indicated in cases of fundal carcinoma, 
because metastatic involvement of lymph nodes oc- 
curs late in the disease. Most of the dissension ex- 
ists in regard to early cases of cervical carcinoma. 

When radium is used, it should be applied by 
raying the fundus first, the midportion a week 
later, and the cervix last, unless the patient's general 
condition will tolerate an application to the entire 
cavity at one time, by inserting the radium tubes in 
tandem. Radium bromide is used in tubes of fifty 
mgm., and screened by one and five tenths mm. of 
brass and soft rubber. The more advanced cases 
are nearly all treated with radium, paying due atten- 
tion to the patient's vital resistance. Pronounced 
anemia, impaired renal function, or abnormal reten- 
tion of nitrogenous excrementitious products, are 
contraindications for vigorous radium therapy until 
these derangements have been corrected. To sum 
up the situation. I submit that each one of us should 
exercise his judgment in accordance with the merits 
of each individual case, his own impressions, and 
his past experience, with a due regard for the 
opinions of other workers and the results obtained 
by them. 

Radium therapy is an ideal method of treatment 
for uterine fibroids in patients in whom operative 
measures are contraindicated by cardiac lesions, 
nephritis, or metabolic disturbances. It is also of 
service in cases of fibroids of moderate size, when 
sterilization of the patient is of no consequence. 
Bleeding stops promptly and the tumor diminishes 
rapidly in size. Large tumors, tumors in young 
women, and tumors causing pressure symptoms, 
however, should be operated upon. 

These cursory allusions to some of the current 
gynecological problems are made chiefly to suggest 
topics for discussion, rather than to attemi)t deliber- 
ately to condense a mass of material in a few words. 

2020 Broadway. 



14 



HAMMOND: CARCINOMA OF CERVIX. 



[New Vork MedicaL Journal 
AND Medical Record. 



Carcinoma of the Cervix Uteri in the Nulliparous Woman* 

By FRANK C. HAMMOND, M. D., F. A. C. S., 

Philadelphia. 

Clinical Professor of Gynecology, School of Medicine, Temple University; Assistant Gynecologist, Samaritan Hospital; Visiting 

Gynecologist and Obstetrician, Philadelphia General Hospital. 



The question of carcinoma uteri of the nulliparous 
woman is replete with interest and much of value 
can be learned from the nine cases herewith reported 
for the first time. It still remains true that practi- 
cally nothing is known of the specific cause of 
carcinoma. Of the many theories that have been 
advanced, none has been proved. The following 
statements frequently are seen in the textbooks and 
the literature: Cancer of the cervix is rarely found 
in women who have not been pregnant ; or, upon 
whom some operation upon the cervix has not been 
performed ; lower classes are more susceptible than 
the higher ; more frequent among the white than the 
colored women; the traumatism of coition is a 
factor to be considered ; invariably a history may be 
obtained of a miscarriage, or possibly the expulsion 
of a fibroid tumor. Cases have been cited illustra- 
tive of these etiological factors. 

Of the nine cases herewith reported (five patients 
were seen during the past year), five were married 
(one of whom (Case VI) became pregnant, asso- 
ciated with the malignancy) ; of the unmarried, in 
two the hymen was intact, in another the hymen was 
ruptured and patient admitted coition having taken 
place, while in the other the hymen was ruptured, 
but patient denied coition having taken place. Eight 
are white women and one colored. The ages are 
twenty-nine, thirty-four, thirty-six, thirty-nine, 
forty-nine, fifty (two), fifty-five and sixty. It 
is of interest to note that the first two patients were 
seen within a period of one month ; and four of the 
last five cases during a period of four months. Five 
of the patients coming under observation during the 
past eleven months. 

In none was there obtainable a history of 1, a 
miscarriage ; 2, any operations upon the cervix, ex- 
cept in Case VHI ; 3, nor the expulsion of a fibroid 
tumor. In other words, in five of the cases, the 
only possible source of trauma was coition ; in two 
the hymen was intact, and in no way can trauma 
be considered an etiological factor. 

Dr. Thomas Addis Emmet first observed the rela- 
tively frequent development of cancer upon the 
lacerated cervix, and the aImo.st total absence of it 
from the nulliparous cervix. Howard A. Kelly (1) 
states that he has seen but three cases of cervical 
cancer in nulliparze, and, in one of these, the cervix 
had been forcibly dilated. Kelly refers to the state- 
ment that Emmet told him, that the only case of 
cancer of the cervix he had seen in a nullipara, also 
was one where forcible dilatation had been practised. 
Kelly further stales (1) "In advance of the local 
examination the fact that the patient is a nullipara 
is always strong presumptive proof against cancer 
of the cervix uteri." In regard to this latter state- 
ment, in view of the cases herewith reported, and 
others recorded from time to time, the examiner 
must not be influenced by the age or social status 

•Read before the Samaritan Hospital Medical Society, January 
9. 1922. 



of the woman ; when making a pelvic examination, 
the patient must be approached with the firm deter- 
mination of making a positive diagnosis. It is only 
in this way that the early diagnosis of cancer of the 
uterus more frequently will be made. 

The Middlesex Hospital, England, published a 
series of cases of cancer uteri, showing that six per 
cent, of the cases occurred in sterile women. Pos- 
sibly it would be safe to say that about three to four 
per cent, of the cases of carcinoma uteri occur in 
nulliparous women. 

Report oi" Cases. 

Case I. — F. \\'., white, aged forty-nine, married, 
housewife, first seen on May 28, 1919. Six months 
previously she had consulted her physician, an ex- 
cellent internist, for occasional vaginal bleeding. 
A vaginal examination was made and her physi- 
cian said to her, "You have a small lump on the neck 
of the womb; if you have any further trouble, come 
and see me ; as you have not had any children, I 
do not think it is of such a nature that you need 
feel alarmed." The manner in which the matter 
thus was dismissed completely misled the patient 
and her husband, and accordingly, little or no further 
thought was given to the occasional bleeding through- 
out the following five months. During the sixth 
month, in addition to the occasional blood spotting, 
bleeding was noticed on coition, and the husband 
brought her to my office to ascertain the cause. There 
was found a peculiar socalled pushing out of the 
posterior portion of the cervix, more marked at the 
middle third, which was hard, and the examining 
fingers were blood smeared. The blood came out of 
the cervical canal. There was no erosion of the 
cervix ; uterus freely movable, and no jjalpable in- 
filtration in either broad ligament, or anteriorly or 
posteriorly. A clinical diagnosis was made of 
carcinoma of the cervix and the situation fully ex- 
])lained to the husband. The attending physician 
was duly advised of the findings, and requested an , 
examination by another gynecologist, which was 
made, and diagnosis confirmed. The microscopic 
examination showed adenocarcinoma. Upon con- 
ference, it finally was agreed that a high amputation 
of the cervix be done and radium treatment be given. 
The patient was admitted to the Samaritan Hos- 
pital, June 6, 1919, and a high amputation of the 
cervix was done. As we did not have radium at that 
time, she was referred to another hospital for sub- 
sequent radium treatment, which proved ineffectual, 
death occurring in less than a year. 

Case II. — M. B., white, aged fifty, single, cook, 
referred to me by her physician on June 13, 
1919. For four years before she had had general 
abdominal distress, more marked in lower abd men, 
and during the past several months, had had a con- 
stant vaginal bleeding, as a result of which she was 
unable to continue her occiqiation. An odor at times 
accompanied the expulsion of blood clots. The 



July 5, 192J.] 



HAMMOND: CARCINOMA OF CERVIX. 



15 



hymen was intact, and it was not possible to make a 
vaginal examination. Upon rectoabdominal ex- 
amination, it easily was possible to palpate a cauli- 
flower growth, com])letely filling the vault of the 
vagina; with infiltration filling the pelvis to a greater 
extent. The uterus, obviously, was fixed. A diag- 
nosis of advanced carcinoma of the cervix uteri was 
made, and operation advised and accepted. On [ulv 
26, 1919, the i)atient was admitted to the Samaritan 
Hospital, and submitted to a Percy cautery operation. 
Both ovarian and both internal iliac arteries were 
ligated. In order to introduce the water jacket 
vaginal speculum, it was necessary to incise the pelvic 
floor down to the rectutn. Microscopic examination 
showed squamous cell carcinoma. The patient was 
discharged from the hospital August 13, 1919, with 
the vaginal bleeding controlled and pain ameliorated. 
During the following months, her general conditiijn 
showed no improvement, but rather a gradual ex- 
haustion and she passed out of my observation. 

Much to my surprise, on November 11, 1920, she 
walked into my office. During the previous six 
months, she had been working steadily, but on ac- 
count of increasing hemorrhages, requested further 
treatment. At this time, the cervix was noted com- 
pletely to have disapjjeared. There was no crater. 
The amount of pelvic infiltration appeared to be 
about the same as at previous operation. Upon 
introducing the finger into the uterine canal, necrotic 
tissue easily was broken down, accompanied by 
marked bleeding. There was no odor. Through 
the courtesy of Dr. Wiliner Krusen. the patient was 
admitted to the gynecological ward, November 12, 
1920, and radium inserted. One week subsequently 
there was no bleeding nor vaginal discharge. On 
December 11, 1920, the patient again was admitted 
to the gynecological ward, for a second radium 
treatment. At this time the pelvic mass appreciably 
was smaller, but easily bled on palpation. The pa- 
tient stated that for the previous three weeks she 
had been free from all pain and vaginal discharge. 
f)n January ,S. 1921, the patient still was free of 
pain and vaginal discharge, and had gained twelve 
poimds in weight since her first radium treatment. 
No bleeding was provoked on vaginal examination. 
I have not been able to locate her since that time. 

C.\SE III. — E. R., white, aged fifty, married, 
came to the oflice February 8, 1921, after having 
been married three months, to ascertain the cause 
of bleeding on coition and on using a douche. She 
was menstruating regularly. An eroded area was 
palpated on the left cervix, which bled easily, and 
there was infiltration into the left broad ligament, 
which fixed the uterus. There was no palpable in- 
filtration into the right broad ligaiTient, nor anteriorly 
nor posteriorly. .\ diagnosis of malignancy was 
made, and the husband so informed. Microscopic 
examination showed adenocarcinoma. Three radium 
treatments were given a month apart. The last 
opportunity I had to examine this patient was in 
May. 1921. .\t that time, the ijleeding on coition 
hafi disapjieared, the eroded cervix had entirely 
healed, but there was no palpable difference in the 
infiltration in the left broad ligantent. This patient 
has passed out of observation. However, I recently 
saw her on the street, and her general appearance 
had greatly improved. 



Case IV. — A. W., aged thirty-nine, white, single, 
mill worker. Referred to my oftice, September 1, 
1921. For the previous six months she had been 
under the care of two physicians for continuous 
vagmal bleeding, which had persisted for seven 
months. The first physician did not make a diagno- 
sis, prescribed drugs only, and as no relief was 
obtained after a few months, she consulted a second 
physician. The second physician told her that she 
had an ulcerated womb. and. in addition to prescrib- 
ing drugs, was supposed to have given local treat- 
ment. .\ot obtaining relief, .she consulted a third 
physician, who, after taking her history, referred 
her to me for an opinion. It was not possible to 
introduce the index finger into the vagina, on account 
of an intact hymen. The little finger could be intro- 
duced, and met with an obstruction in the vagina. 
On rectoabdominal examination, a cauliflower mass 
was palpated, easily filling the vault of the vagina. 
It was recommended that she be sent to the hospital, 
and further studied under an anesthetic, carrying 
out at that time the treatment that would be indi- 
cated. Through the courtesy of Dr. Wilrner Krusen, 
she was admitted to the gynecological ward, SejJtem- 
ber 3, 1921. Under anesthesia, the vaginal examina- 
tion was completed, and a cauliflower mass which 
could be rotated was found completely filling the 
vault of the vagina. With difficulty a finger was 
passed over the mass which was found to be at- 
tached by a transverse pedicle to the superior border 
of the anterior lip of the cervix. This is the only 
case in which I have seen a pedunculated cauliflower 
growth of cervix. The mass easily was de- 
tached, but no extension could be palpated in pelvis, 
or anteriorly or posteriorly. Radium was inserted 
into uterus and cervix. Microscopic examination 
sliowed squamous cell carcinoma. On October 2, 
1921, she was readmitted to the ward for a second 
radium treatment. At this time the cervix on pal- 
pation and inspection was that of a normal cervix, 
and the pelvis appeared to be normal in all respects. 
The patient was free of all vaginal discharge and 
bleeding. A normal menstrual period occtirred dur- 
ing the four days previous to second admission. On 
Novemiier 10, 1921, she was readmitted to ward 
for a third radium treatinent. Cervical and pelvic 
findings were apparently normal in all respects. On 
December 17, 1921, the patient was examined again. 
The cervical and pelvic findings to all api)earance 
were nortnal. There has been no further bleeding 
nor menstruation and the patient has returned to her 
occupation. 

C.\.SE V. — L. T., colored, married, aged thirty-four, 
housewife. Consulted her physician on account of 
bleeding on coition and metrorrhagia. The physician 
was suspicious of malignancy and referrecl her for 
diagnosis and treatment on October 19, 1921. There 
was a cauliflower growth of the cervix, completely 
filling the vault of the vagina, which bled freely on 
palpation. There was extension into both broad 
ligaments. .\ diagnosis of advanced carcinoma was 
made anfl radium advised. Through the courtesy of 
Dr. Wilmer Krusen this patient was admitted to the 
gynecological ward and radium inserted October 29, 
1921. Microscopic examination showed squamous 
cell carcinoma. On November 31, 1921, the patient 
was readmitted for a second raditmi treatment. The 



16 



HAMMOND: CARCINOMA OF CERVIX. 



[New York Medical Jol-rxal 
AND Medical Record. 



Uterus was still movable and infiltration in both 
broad ligaments about the same as on previous 
admission. The large cauliflower mass had disap- 
peared, the cervix was still enlarged, edges sharp and 
everted. Since the first radium treatment, there has 
been only an occasional bloody show. This patient 
should have returned the end of December for her 
third radium treatment, but has postponed her return 
for personal reasons. (On the next day after this 
paper was read the patient was readmitted to the 
hospital for her third radium treatment. The cervix 
had appreciably decreased in size and the surface of 
the cervix had, apparently, healed. There was no 
bleeding; the uterus was freely movable and no 
])alpabie infiltration into the broad ligaments was 
determined.) 

Case \l. — B. S., white, aged twenty-nine, mar- 
ried, housewife. Seen with her physician Novem- 
ber 20, 1921. About six months previously the 
patient first consulted her physician on account of 
bleeding on coition, and to ascertain the cause of 
her sterility. She had been married several months 
and was extremely anxious to become pregnant. 
On examination, her physician found an anteflexion 
of the uterus, the tubes and ovaries were negative, 
and an erosion of the cervix at the external os. 
Applications were made of nitrate of silver, appro- 
priate douches ordered and at the end of two months 
the erosion on the anterior lip had entirely healed, 
but the posterior lip only partially. In the interim. 
the patient missed her menstrual period. The local 
treatment was continued, but the posterior lip showed 
no disposition to heal and later her physician noticed 
a thickening of the posterior lip, and becoming sus- 
picious of a possible malignancy, requested me to see 
patient with him. On examination the patient was 
found to be about four and a half months preg- 
nant : there was a pushing out of the posterior lip 
throughout its entire lower portion, which was very 
hard. A clinical diagnosis of cancer of the ceryi.K 
was made. There was no palpable infiltration in 
broad ligaments on either side. As the malignant 
process antedated the pregnancy, this case is in- 
cluded in this series as one of carcinoma of the 
cervix in a nulliparous woman. 

This jjatient presented an unusually interesting 
problem. She was extremely an.xious to have a child 
and was a Catholic. Both she and her husband were 
told of the exact findings.' and the teaching of her 
church were discussed. The question of hysterec- 
tomy versus radium was laid before them. They 
finally agreed to waive the church views, if neces- 
sary, and it was decided to have her admitted to 
the hospital, and, under anesthesia, remove a piece 
of tissue for inunediate microscopic examination, 
make a most thorough examination of the pelvis 
and then decide what course to pursue. However, 
within a few days, through relatives, she consulted 
a Catholic gynecologist, who used radium the latter 
part of November and early part of Decemlier and 
who states 1, that the cervi.x showed marked im- 
provement ; 2, that the patient did not abort, and 
3, that the microscopic report was adenocarinoma. 
This case presented, as you readily can realize, some 
interesting features. It is the second patient I have 
seen with carcinoma of the cervix associated with 
pregnancy. (Since reading this paper. I have been 



advised by the gynecologist herein referred to that 
the patient aborted January 8, 1922 ; there was a 
blighted ovum, and he is of the opinion that 
death of the fetus was attributed directly to the 
radium. 

May I digress for a moment. Cancer complicat- 
ing pregnancy and labor is of such rarity and the 
calamity of such a complication is so grave that it 
excites the deepest interest and attention. De Lee 
(2) states in 19,400 consecutive obstetrical cases at 
the Chicago Lying-in Hospital and Dispensary, only 
one was associated with cancer of the cervix. 
Howard A. Kelly ( 1 ) reports twenty-two cases in 
a series of 41,900 cases of labor from three Euro- 
pean maternities, a percentage of 0.047. After a 
careful review of the literature, one is inclined to 
the belief that the consensus of opinion is, that if 
carcinoma of the cervix uteri associated with preg- 
nancy is discovered before the fourth month of 
pregnancy, a radical operation should be advised, 
after the true state of aft'airs has been made known 
to the patient and her family. If discovered after 
the fourth month, the pregnancy should be permitted 
to continue until viability, then an abdominal or 
vaginal Ca;sarean section done, followed by pan- 
hysterectomy. That the induction of abortion or 
miscarriage as a palliative measure is not permissible. 
Radium has its advocates. Botta and de Bengoa (3) 
report the case of a pregnant woman with cancer 
of the cervix uteri, which was allowed to go to term ; 
they saw her at the fifth month of pregnancy and 
instituted radium treatment. This case, apparently, 
demonstrated that at least after the fifth month of 
pregnancy, the fetus does not sulifer from raditmi 
exposure. A panhysterectomy was done on this pa- 
tient after Csesarean section. These observers advise 
that the rochar method of treatment should be 
followed in such cases ; the term rochar is made up 
from the initials of the procedures applied: radium, 
observation, Csesarean section, hysterectomy, an- 
nexectomy, radiation. 

Case VII. — L. S. C, aged fifty-five, white, clerk. 
This is a patient of Dr. D. J. Donnelly, through 
whose courtesy I have the privilege of making the 
report. I had the opportunity of seeing this patient 
at the time of her radium treatment. This patient 
was first seen by Dr. Donnelly, December 9. 1921. 
and gave the following history. Menopause nine 
3'ears ago. Six months previously first noticed a 
watery, vaginal discharge, which gradually increased 
in quantity and consistency. After about four to 
five months, it became offensive. .About a month 
ago, first noticed spot of blood. The day previous 
to consulting Dr. Donnelly, the patient had a marked 
hemorrhage from the vagina while on the toilet. The 
general appearance of patient was good. Upon ex- 
amination, there was found an excavated, enlarged, 
hardened cervix, with infiltration into both broad 
ligaments, and the uterus fixed. .\ diagnosis was 
made of advanced carcinoma of the cervix uteri. 
The ])atient was admitted to Samaritan Hospital and 
radium treatment given December 15, 1921. Micro- 
scopic examination showed adenocarcinoma. Dr. 
Donnelly again examined this patient January 6, 
1922. The vaginal discharge and bleeding have 
ceased, there was no odor to the vagina, and no 
appreciable difference in the pelvic findings. 



July 5, 1922.] 



DARN ALL: UTERINE MVOMATA. 



U 



Case VIII. — (This patient was seen since this 
paper was read.) — F. G., white, married, aged thirty- 
six. Had never been pregnant. Five years ago had 
a dilatation and curettage for sterihty. At that 
time, the physician who performed the operation 
told her that he had lacerated the cervix. There was 
an inoperable adenocarcinoma of the cervix. This 
patient had been under the care of several physi- 
cians, and radium had been used. The hemorrhage 
continued. The interesting points in this case are : 

1. Would the carcinoma of the cervix have devel- 
oped if the cervix had been repaired immediately? 

2. The rapidity with which malignancy developed 
after the stated time of traumatism. 

Case IX. — (This patient was also seen since this 
paper was read.) — S. \\'., white, single aged sixty. 
admitted to the Samaritan Hospital, February 14, 
1922, service of Dr. W'ilmer Krusen, to whom I 
am indebted for the privilege of reporting the case, 
and with whom I had the opportunity of seeing the 
patient. The object of admission to the hospital was 
for radium treatment, .\bout six months ago vaginal 
bleeding was first noticed, which continued more or 
less profusely. The patient concealed her condition 
until a few weeks ago. She denied coition. There 
was no history of an operation. The hymen was 



ruptured. Diagnosis — adenocarcinoma of cervi.x. 
The cervix had entirely disappeared and there was 
a crater at the vault of the vagina. 

One of the patients here reported was under thirty. 
Peterson (4) in a recent .study of five hundred cases 
of cancer of uterus, found twenty-three or four and 
eight tenths per cent, of his cases under thirty years 
of age. It is not so important how often cancer of 
the uterus can occur under thirty, as it is important 
to know that it does occur. 

In conclusion, the following must be emphasized. 
A careful history should be taken of every case of 
pelvic disease, more especially when bleeding is a 
symptom, and, the physician must not be influenced 
by the age or social status of the woman ; when 
making a pelvic e.xamination, the patient must be 
approached with the firm determination of making 
a positive diagnosis. 

REFERENCES. 

1. Kelly. How.\rd A. : Medical Gynecology. 1908. 

2. De Lee : The Principles and Practice of Obstetrics, 
1915, p. 539. 

3. BoTT.\ and de Benco.a : Annates de la Facutal de 
Medicine, Montevideo, June 10, 1918. 

4. Peterson : Surgery, Gynecology, and Obstetrics. 

3311 North Broad Street. 



Suppurating Uterine Myomata* 

By WILLIAM EDGAR DARNALL, M. D., F. A. C.S., 

.\tlantic City, N. J. 



Suppurating uterine myomata are divisible into 
three classes: 1, subperitoneal; 2, interstitial, and 3, 
submucous. Only those cases in which pus forma- 
tion occurred in myomata situated on the outer sur- 
face of the uterus or located in the nmsculature 
are described. The submucous variety has certain 
characteristics that are totally dilTerent from those 
of the other two classes and are, therefore, not dis- 
cussed in this study. Necrosis of myomata is fairly 
common, much more so than suppuration. It is 
likely to occur in subperitoneal, interstitial or sub- 
mucous tumors but, more especially, in the sub- 
mucous nodules. It is nKjre prone to develop in the 
larger tumors, but has been noted in even small 
myomata. 

The necrotic areas are recognized as dirty grayish 
brown or dark reddish blue patches in the myomata. 
Such areas are clearly outlined, but the contrast be- 
tween the myomatous tissue and the degenerated 
portion is not nearly so cleancut as in the cases 
where hyaline degeneration e.xists. In the necrotic 
areas the muscular striation is usually still visible, 
but the tissue is softer than usual. The necrosis is 
usually in the centre of the tumor but may be noted 
on the surface or near it. It may be limited to one 
area or there may be several foci of degeneration. 
Hyaline degeneration and necrosis are often noted 
side by side in the same tumor. 

While .some authorities class supjjuration among 

•Read at the thirty-fourth Annual Meeting of the American 
Association of Obstetricians, Gynecologists and Abdominal Surgeons, 
St. Louis, Mo., September 20-22. 1921. 



the degenerative changes of uterine fibroids, the 
classification can hardly be said to be accurate, if by 
suppuration is meant the invasion of the tumor by 
])yogenic organisms of sufficient virulence to produce 
the abscess. The contusion of terms may be due 
to the fact that, in many reports, suppuration is 
taken more or less for granted without a histological 
or bacteriological study and, also, to the frequent 
association of gangrenous degeneration and abscess 
formation. 

Infection of a uterine fibroid is most likely to take 
])lace during actual sexual life. -Sometimes years 
elapse before suppuration sets in after the first 
symptoms of tumor formation is apparent. Im- 
paired circulation, which activates the bacteria latent 
in the tumor, causes the infection. Other factors 
leading to infection of a fibroid are pregnancy, 
trauma from a surgical or obstetrical procedure, or, 
in the interstitial variety, by direct extensicjn of in- 
fection from an endometritis, torsion of the pedicle, 
chemical irritation, or mechanical irritation. There 
is no type of organism peculiar to supinirative myo- 
mata. This has been revealed by l)acteriological 
studies. 

The time elapsing between the first signs of fibroid 
and the develojiment of the infection indicates that 
the process is evidently not sudden. There may be 
a rapid increase in the size of the tumor accom- 
jmnied by local tenderness, possibly by a discharge 
of pus from the vagina together with emaciation, 
and signs of a general septicemia. In connection 



18 



DARNALL: UTERINE MYOMATA. 



[New York Medical Journal 
AND Medical Record. 



with these symptoms a high leucocyte count should 
suggest a suppurating tumor since it is well known 
that" leucocytosis is not a feature of the ordinary 
myoma uteri. 

'with the advent of suppuration the symptoms 
may undergo a marked change. Instead of the usual 
dull, dragging pain, there is a sticking or lancinating 
pain in the lower abdomen. The patient may have 
chills and fever at times accompanied with night 
sweats. One of the more important late symptoms 
is the sallow color. This differs entirely from the 
pallor that is so frequently noted where there has 
been great and prolonged loss of blood from sub- 
mucous myomata. The patient grows progressively 
weak if septic absorption has taken place and the 
tumor seems, at times, to diminish in size. Renal 
changes take place and albumin and casts appear 
in the urine. If the suppurating tumor ^opens into 
the uterine cavity there is a profuse foul smelling 
vaginal discharge. 

The prognosis is grave. If the tumor is small, 
nonadherent, and can be removed without danger 
of rupture and the spread of its contents, the prog- 
nosis is much more favorable, although these cases, 
like cases of cancer, are usually in a state of lowered 
vitality from toxemia or toxic absorption. In case 
a pregnane}- is complicated by a myoma, it is impor- 
tant to lay more than usual stress on aseptic pre- 
cautions during pregnancy, parturition and during 
the puerperium, and to remove the fibroid as soon 
after the termination of pregnancy as feasible. 

The cause of suppuration in uterine myomata is 
not always clear. In the majority of cases hyaline 
degeneration is also present, probably due to a dimin- 
ished blood supply. In many cases infection from 
the intestine has been thought to be the cause, espe- 
cially where there have been intimate adhesions to 
the intestine. Kelly and Cullen report two such 
cases in which this was evidently true. 

Infection easily takes place in interstitial myo- 
mata that impinge on the uterine cavity, when there 
is a focal necrosis or hyaline degeneration in those 
portions near the uterine cavity, and an infective 
agent in the uterine mucosa. Suppuration in a 
myoma must not be confused with the cases showing 
the presence of tuboovarian abscesses, and as a 
result secondary and encysted abscesses developed 
in spaces between contiguous myomata. Here the 
suppurative process is confined, almost entirely, to 
the outer surfaces of the tumors and not to their 
interiors. 

Hyaline degeneration in a fibroid often simulates 
abscess formation so closely that it is impossible to 
render an absolute diagnosis without making sec- 
tions. In simple hyaline degeneration no nuclei 
are present. If abscess formation has taken place, 
the characteristic polymorphonuclear leucocytes are 
in evidence. 

Too much emphasis cannot be laid on the impor- 
tance of early surgical interference in the treatment 
of suppurating myomatas, especially before compli- 
cations have a chance to develop. The patient's 
resistance is naturally much reduced from toxemia. 
The pulse, just before operation, may be very rapid 
as is so often the case when pus is present. Supra- 
vaginal hysterectomy should be performed ju.st as 
soon as feasible. The patient does not improve by 



delay, but, on the other hand, grows steadily worse. 
The purulent process in these cases is unusually 
active and the consequent dangers of infection are 
great. 

Suppuration of myomata, as shown by statistics, 
is rare and yet 1 cannot but feel that, if every tumor 
removed in every hospital were cut open and ex- 
amined, we would find it much more common than 
we think. A review of the myomata of the uterus 
operated on at the Woman's Hospital in New York 
for the year 1918, and reported by LeRoy Broun, 
comprising 262 cases, showed but one case of sup- 
puration with pus cells infiltrating the tumor tissue. 
Necrotic changes, however, occurred in seven cases. 
In the wide experience of Deaver in the Lankenau 
Hospital, Philadelphia, in a series of 1,200 cases, only 
one case of suppuration was encountered. In my 
own experience of several hundred hysterectomies 
for myomatous uteri, there have been four cases 
of suppuration. With this evidence of the infre- 
quency of this complication, a report of some of the 
cases may be of interest. 

Ca.se I. — Mrs. J. C. W., aged thirty-four, entered 
the hospital on April 9, 1921, complaining of a 
sharp pain in the lower abdomen. She had noticed 
a mass in the abdomen for the past two years, which 
had increased in size but had not given her any 
serious trouble until about two weeks ago. There 
was a rise in temperature and night sweats several 
days before she applied for relief. Her menstrual 
history was normal. She had an irritating leucor- 
rhea and burning on urination. The patient was 
well nourished and slightly delirious with a hot dry 
skin. There was a nodular movable mass in the 
lower abdomen which did not fluctuate. The cervix 
was normal, but the pelvis was filled with a tender 
hard mass. Urine was negative. The blood count 
revealed a leucocytosis of 21,300. The Wassermann 
test was negative. 

On opening the abdomen a nodtilar mass at the 
fundus of the uterus, about the size of a grape fruit, 
with other smaller tumors to which the omentum 
was adherent, presented itself. The tubes and 
ovaries were normal. .\ subtotal hysterectomv 
was performed. One of the nodules was softer 
than the others and on section showed an 
irregular pocketed pus cavity filled with greenish 
pus. Bacteriological examination showed many pus 
cells a few gram negative and intracellular diplococci. 
The other nodules were of the usual fibroid type and 
showed no degeneration. The walls of the abscess 
cavities were lined with partially necrotic fibrous 
tissue, richly infiltrated with pus cells. The patient 
made an uninterrupted recover}'. 

Case I. — Mrs. A. M., colored female, aged fifty- 
three, weight about 220 pounds, had an umbilical 
hernia and said that her abdomen began to enlarge 
about fourteen years ago. She always had profuse 
menstruation lasting about five days, but had passed 
the nieno]iause five years ago. .She had an un- 
pleasant leucorrliea. She had had no children or 
miscarriages. 

-At operation a large mass of fibroid nodules, 
whicli weighed fifteen pounds, was removed. The 
ovaries were enlarged and the tubes much length- 
ened. There were numerous old adhesions of an 
inflammatory nature. The mass was removed by 



July 5, 1922.] 



CULBERTSON: ECLAMPSIA. 



19 



hysterectomy. One of the large nodules, which did 
not seem as hard as the rest, showed on section many 
ragged cavities filled with pus. These cavities pene- 
trated the tumor mass to distances of from five to 
seven centimetres and burrowed their way irregu- 
larly in all directions. 

Case III. — E. D., well developed colored woman 
of thirt3'-six years of age. weighing 140 pounds. 
There was nothing significant in her history 
except that of menstruation. Her periods were not 
painful, but profuse and lasted six days. On ex- 
amination the whole pelvis was filled with nodular 
masses of all sizes and immovable. When the ab- 
domen was opened, everything was found to be ag- 
glutinated, together with inflammatory adhesions 
due to successive attacks of peritonitis. The appen- 
dix was bound down by sheets of adhesions. A 
subtotal hysterectomy was done with difficulty on 
account of the complications. Two of the masses 
were found, on section, to be suppurating and the 
conditions were similar to the other cases. Both of 
these patients recovered. 

C-\SE W. — A mulatto woman of about fiftv-fivc 



years, very septic, with daily evening rise of temper- 
ature and sweats, entered the hospital. She had a 
large abdominal mass reaching above the umbilicus. 
On opening her abdomen the mass w^as found to be 
adherent to the whole anterior abdominal wall, and 
to practically everything else in the abdominal cav- 
ity. The adhesions were most extensive. The 
omentum was adherent over the tumor mass. Large 
omental bloodves.sels passed from the omentum 
straight into the tumor, giving it an adventitious 
blood supply. Some of these vessels were as large 
as an ordinary lead pencil. Ligation had to be car- 
ried out with great care in order not to tear into the 
friable stnictures and produce severe hemorrhage. 
The mass was finally freed from its innumerable 
adhesions, but anywhere on its surface if the finger 
were pressed against the tinnor it sank into a soft- 
ened mass of tissue which was a perfect honeycomb 
of pus that exuded from everywhere. A hysterec- 
toiny was accomplished with difiiculty. Needless to- 
say the patient, who was very toxic to start with,, 
succumbed from septic infection in about three days. 
1704 Pacific Avenue. 



Etiology of Eclampsia 

By WALTER LEON CULBERTSON, M. D.. 
Philadelphia, 

Obstetrician, Northwestern General Hospital 



It is generally agreed by most of the recent and 
well known authorities on the causes of eclampsia 
tliat it is due to a toxemia. When the causal agent 
in toxemia, whatever it may be, is allowed free 
play, when its pernicious activity is not arrested 
either by treatment or by the efforts of nature, the 
result is eclampsia. The innnediate cause of the 
convulsions does not enter into the question, at least 
not directly. The question to be answered here is, 
what is the cause of this condition which gives rise 
to the convulsions? It assumes that it is a cerT 
tain toxin circulating in the maternal blood that 
causes the symptoms of preeclamptic to.xemia and 
eventually the coma and convulsions. But what is 
this toxin ? This is still a vexed cjuestion. For- 
merly it was thought to be uremia, and the cause 
of uremia was thoiigiit to be a nephritis complicating 
pregnancy. The stud)' of the jiatliology of the dis- 
ease, however, shows that the kidney changes are 
.secondary rather than primary, and that the changes 
in the liver are more marked than those of the kidney. 
This, together with the clinical history of the two 
conditions, has jiroved the theory false. 

The theory of autointoxication was first advanced 
by Bouchard, and according to him, the cause of 
eclampsia was due to inability of the kidneys to 
jjerform their work in the elimination of the excess 
waste matter that must be disposed of during preg- 
nancy. This he sought to prove by showing that 
the urine and blood serum of eclamptics injected 
into animals, were more pf)isonous than normal urine 
and blood serum. Various authors have disproved 
this theory by showing that the toxic properties of 



these fluids are due to their concentraticjii ami that 
when diluted up to the normal standard they have 
no toxic action. The autointoxication theory in one 
form or another has always been popular in France, 
and Fabre and others now hold strongly to the belief 
that the absorption of decomposition products from 
the intestinal tract is the real cause of eclampsia. 
Bacterial infection has been attributed the cause of 
eclampsia, but the offending organism has not yet 
been found. Schmore and Dienst, noting the fre- 
quency of multiple thrombosis in eclampsia, attributed 
their presence to the invasion of the blood current 
by an excess of fibrin ferment. Dienst went further 
and attempted to explain why the fibrin ferment was 
increased. There was, he stated, an anlithrombin 
which should normally neutralize any excess of 
coagulating material. This antithrombin was pro- 
duced in the liver, but during i)regnancy this organ 
may have become unequal to the task. 

The modern biological theories and hypotheses 
have recently been much invoked in efforts to dis- 
cover the cau.se of eclampsia and of these theories 
Veit has been the most prominent exponent. It 
is well known that during pregnancy the blood is 
invaded by certain fetal elements, for exanqile, the 
syncytial elements of the ])laccnta, which but for 
the development of a hypothetical antibody would do 
harm if present in excess and that in eclampsia this 
antibody was not present. Bandler in his latest 
book on endocrines quotes that placental secretion is 
the important factor, and it does not produce this 
annoyance in a large propfirtion of cases because 
some protective substances are secreted or formed 



20 



DROSLW: VIABILITY OF FETUS. 



[New York Medical Journal 
AND Medical Record. 



anew. They come from the ovary corpus luteiini, 
from the thyroid and adrenals, from the hypophysis, 
from the liver and from other structures in the body 
not yet recognized as taking part in this protective 
function. 

Then we have a certain number of cases in which 
this function is not properly carried out with the 
result that placental secretion exerts a decidedly irri- 
tating influence. Placental secretion is a substance 
which follows closely the course of the blood, in all 
the organs of the body producing changes of marked 
character, particularly in certain instances in the liver 
with marked alterations in metabolism. These 
changes are of a necrotic nature and a hemorrhagic 
type, showing the irritating nature of this secretion. 
If the usual protective substances are lacking this 
secretion takes on an irritative destructive nature. 
The changes, microscopic in nature, are produced 
typically in the brain, associated occasionally with 
hemorrhage of graver type and with edema more or 
less diffuse and often quite marked, and associated 
with pressure in the spinal cord, then convulsions 
and coma. Thyroid insufficiency has been held by 
Lange, Nicholson and others to be the cause. It 
is probable that if thyroid extract does good in these 
cases it must be by its well known effect in stimulating 
general metabolism and indirectly oxidation. Zweifel 
has suggested that lactic acid which has been found 
in the blood and cerebrospinal fluid of eclamptics 
may prove to be the cause. Somewhat analogous 
theories have been advanced by Ascoli, Weichardt 
and Hofbauer and contradicted by Frank, Heimann 
and Lichtenstein. It is plain even to the uninitiated 
that these theories rest upon unverified assumptions. 

On the whole it seems plain that the cause must 
be bound up with the presence in utero of the living 
growing fetus. The fetus may die as a result of the 
eclamptic poison or poisons. Seldom or never does 
eclampsia develop in a mother carrying a dead fetus. 

Furthermore it is evident that the fetus must have 
reached an advanced stage of development since 
eclampsia usually occurs in the later months of 
pregnancy. The most encouraging and significant 



studies that have recently been made have been those 
of Zweifel, Williams, Stone, Ewing and others in 
connection with nitrogenous metabolism in preg- 
nancy. The studies have shown conclusively that 
during pregnancy large quantities of nitrogenous 
substances are excreted by the kidneys in a state 
of complete oxidation. It is assumed that this in- 
complete oxidation must be the result of some toxin 
of unknown origin circulating in the maternal blood 
and interfering with the oxidative function in the 
liver or the eliminative work of the kidneys or both. 

\\ hile the main facts expressed above are true 
it does not necessarily follow that we need to 
assimie the existence of some special toxin. Mav 
it not be that suboxidation itself is the real cause, 
or at all events a prominent factor? In pregnancy 
a woman needs oxygen more than at any other time. 
Without this excess supply she cannot hope to meet 
the relatively enortnous demands of fetal and 
placental metabolism. Moreover, in the late- 
months of pregnancy her oxygen supply is limited, 
owing to the diminished abdominal space and con- 
sequently limited excursions of the diaphragm. This 
is especially true in cases of external distention, viz. 
in hydroamnion and twin pregnancy and it has long 
been known that these two conditions predispose to 
eclampsia. The clinical symptoms of toxemia of 
pregnancy come from the subjective dyspnea so com- 
mon in pregnancy. The headache, edema and finally 
the convulsions are strongly suggestive of a lack of 
oxygen. No other hypothesis helps to explain the 
unexplicable but undoubted fact that eclampsia usu- 
ally occurs in robust and vigorous young women. 
These patients have a high oxidative equilibrium and 
are the first to suffer from oxygen deficiency. Well 
being is a sign of the absence of toxins and sub- 
o.xidation and whenever a woman in the later 
months of pregnancy does not feel well pretoxemia 
should be constantly considered and reconsidered, 
until it may be absolutely excluded by a decided 
change for the better in the patient's general con- 
dition. 

2502 North TwENXv-NrNXH Street. 



Ascertaining the Viability of the Fetus 



By L. DROSIN, M. D., 
New York. 



The practice of obstetrics is as old as humanity 
itself ; but the obstetrical practice of today bears little 
relation to that of the cave man and the stone age. 
When we consider that it was but slightly more than 
a century ago, in 1818, that the possibility of auscul- 
tation of the fetal heart was accidentally discovered. 
and many years later before the princi])les of asepsis 
were applied to midwifery, these two introductions 
marking the n)ost important diagnostic and thera- 
peutic advances ever made in this particular branch 
of medical science, it is borne in upon us that obstet- 
rics is still a growing and expanding science, far 
even yet from iierfection and completion. There- 
fore, anv addition, however trivial, which serves 



to advance the knowledge of the art, or to increase 
the skill of those who practice it, should not be per- 
mitted to remain unreported. 

IMP0RT.\NCE OF Dr.\GN0SIS. 

The importance of a reliable method of ascertain- 
ing the viability of the fetus can hardly be overesti- 
mated. To the patient it is often of the utmost 
interest, legally, socially, morally or financially. To 
the obstetrician it is of ixiramount importance as a 
guide for all therapeutic jjrocedure. 

C.'\USE l)K DE.\TH. 

The death of the fetus may be the result of a wide 
variety of causes. These causes may bo attributable 



July 5, 1922.] 



DROSIN: VIABILITY OF FETUS. 



21 



to either paternal or maternal influences, may be 
inherent in the fetus itself, or subsequent to outside 
factors, trauma or other accidents. Fetal death ma\' 
occur at any time during pregnancy, or at term dur- 
ing the period of labor. 

A dead fetus is not a menace to the life or liealth 
of the mother, except that when death occurs after 
rupture of the membranes it will putrefy, causing a 
septicemia or general suppurative peritonitis which 
is often rapidly fatal. When fetal death takes place 
early in the period of gestation there is a cessation 
in the growth of the uterus, the abdomen does not 
increase in size — if pregnancy is far enough ad- 
vanced for abdominal enlargement to be visible — 
and in some cases the secretion of milk will begin. 
Subjective symptoms, such as a feeling of weight 
and discomfort in the pelvis, chilly sensations, de- 
pression of spirits and loss of iippetite may be pres- 
ent. When the fetus dies in the later months we 
have in addition to cessation of the growth of the 
uterus and enlargement of the abdominal circum- 
ference, disappearance of fetal movements and heart 
sounds. Not only does the uterus cease to grow, it 
even becomes smaller. After the fetus has been 
dead for some time, so that maceration has taken 
place, there will be loss of resiliency and crepitation 
of the fetal skull. Changes may usually be detected 
in the maternal urine also, peptonuria, albuminuria 
or acetonuria often appearing. According to 
Cohnstein and Fehling, if the fetus is alive, the tem- 
perature of the uterus should be higher than that of 
the vagina.' 

Where the patient has presented all the objective 
svniptoms of pregnancy, cessation of menses, en- 
largement of abdomen, breast signs, and sensations 
of fetal movement, particularly if these symptoms 
have been observed and corroborated by a competent 
physician who has been able to elicit ballotment and 
fetal heart sounds as additional evidence, if there is 
a gradual or sudden cessation of all these symptoms, 
we often find that the diagnostic methods available 
are very imperfect, and time consuming. For we 
know that it is quite possible for all fetal move- 
ments to be suspended, that subjective sym]>toms 
may disappear, palpation and auscultation reveal 
nothing, urinary changes to be negative or doubtful, 
and the child be still alive. In such a case our only 
resource is repeated palliation and auscultation, ab- 
dominal and uterine measurements. 

Under such conditions I have found iwo proced- 
ures of value in establishing the viability of the 
fetus, and have employed them successfully a great 
many times, both separately or in combination. 

DECREASE OF OXYGEN TO THE FETUS. 

The patient is placed in the recumbent dorsal posi- 
tion, with the legs either flexed or extended. She 
is then directed to exhale and suspend respiration 
for as. long a time as possible. Repeat this maneuvre 
from ten to fifteen times (no exact number can be 
laid down). In order not to exhaust the patient 
she shf)uld occasionally be allowed to take a few 
moderately deep inspirations during the procedure. 

As a result of the interrupted respiration of the 
mother, the oxygen supply to the fetus is disturbed 
and diminished ; the fetus, becoming restless because 
(jf air hunger, will begin to move. Sometimes these 



movements will be very active: at others just barely 
sufficient to assure the existence of life. 

ELICITATION OF SHOULDER MOVEMENT. 

Locate the anterior shoulder of the fetus (this 
sometimes requires a long and diligent search), 
press gradually but firmly upon it with the tips or 
palmar surface of the fingers, exerting the pressure 
in an upward and backward direction, and the fol- 
lowing phenomena will be elicited. 

The shoulder, assuming a vermiform action, will 
turn in a direction successively backward, upward, 
inward and downward ; this movement may possibly 
be repeated several times. The shoulder motion is 
more or less shared by the entire body, these move- 
ments being palpable to the examiner's free hand 
when laid upon the mother's abdomen, being per- 
ceived as a wriggling of the trunk and rapid motions 
of the extremities. If the examiner's fingers are 
placed in the vagina he can usually feel the head 
moving. 

It appears that the tip of the shoulder is sensitive 
for some reason, so that in trying to evade the 
intruding hand it assumes an attitude of exagger- 
ated flexiion (usually lateral), of extension and 
rotation, which is participated in by the entire fetal 
body, the di liferent parts being afifected in rapid 
succession. At times we can elicit only the shoulder 
movement alone, and at others only those of the 
breech and extremities. 1 have often produced this 
phenomenon in sleeping newborn infants by pressing 
upon tip of shoulder, in the manner described. 

These movements may not be brought about at 
the first examination, and in some cases not at all, 
especially if the abdominal walls are thick or much 
fluid is present in the abdominal cavity. In three 
cases where conditions were favorable for the em- 
ployment of this diagnostic procedure I was unable 
to bring about any movements or heart sounds by 
either of the methods here described, altlu)ugh the 
examinations were repeated at two gr three day in- 
tervals over a period of three to four weeks. In 
all three cases the fetus subsequently ])roved to be 
dead, two because of syphilitic infection and the 
third — the mother's previous deliveries having been 
spontaneous and normal — ^being due to a blow upon 
the abdomen. These three patients were each about 
seven months pregnant, and came under my obser- 
vation very shortly after they had ceased to be 
conscious of fetal movements. Eacli was delivered 
of a dead and macerated fetus within a few weeks 
of the time she consulted me. One of these patients 
showed a trace of acetonuria shortly before delivery, 
and another manifested a small amount of albumin 
in the urine during the remainder of her jiregnancy, 
although unfortunately I am not in a position to say 
whether she had it before or not. 

In addition to these three patients, out of fifty- 
four cases where fetal death was suspected which 
have come under my observation in the last two 
and a half years, I was able to bring out fetal move- 
ments at the first or second attempt, in forty-nine, 
using one or both methods. In forty-four cases I 
succeeded in eliciting fetal heart sounds. The re- 
maining ]jatieiits failed to return, so that the cases 
were lost sight of, and could not be followed up. 

1851 Seventh Avenue, 



22 



OLIVER: DURATION OF GESTATION. 



[New York Medical Journal 
AND Medical Record. 



The Natural Limit of the Duration of Human Gestation 

By JAMES OLIVER, M. D., F. R. S. (Edin.), F. L. S., 
London, 

Consulting Gynecologist of the Hospital for Women London, and the Ilford Emergency Hospital, Essex. 



In the English Law Courts on July 20, 1921, in 
the case of Gaskill v. Gaskill, it was decreed that 
what was to all intents and purposes a normal case 
of uterine pregnancy could extend over a period of 
331 days and I would observe and e;niphasize the 
fact that this period of 331 days was reckoned 
neither from the commencement nor from the cessa- 
tion of the last men.struation but from the latest date 
on which insemination by the husband could pos- 
sibly have occurred. 

Such a declaration emanating from an English 
Court is most assuredly to the scientific and medical 
world a matter of no mean importance as quite in- 
advertently it may find its way into textbooks and 
be thus for a greater or less length of time dissemin- 
ated not only as a feasible but as a tenable and uni- 
versally accepted proposition, consequently it be- 
hooves us without undue delay to discuss it and at 
the same time determine whether it is a scientifically 
sound pronouncement. In order that we may be 
in a position to arrive at some definite conclusion 
thereon it is imperative that we should even some- 
what briefly review our known facts concerning 
human pregnancy. 

I would, however, at the outset remark that most 
of the phenomena associated with the reproductive 
process in woman are extremely intricate and some- 
what obscure and for these reasons unfortunately 
they have proved only too favorable to the propaga- 
tion of beliefs which, as we shall presently learn, 
are clearly erroneous and they have become so deep 
rooted in the minds of many that they will not be 
easily eradicated. 

Most of my readers no doubt have either seen it 
stated or have been informed that women who have 
never menstruated and who are incapable of men- 
struating have and may nevertheless become preg- 
nant. Now, because of the number of women 1 have 
seen who have lived many years in wedlock and who 
had never menstruated, I have no hesitation in as- 
serting that such a statement as the foregoing must 
have originated through and must be attributable to 
some error of judgment and carelessness in the in- 
vestigation and interpretation of facts. No one can 
validly challenge the statement that the ability to 
harbor and sustain and develop a fertilized ovum 
is indissolubly connected with the ability and power 
to display the recognized phenomena of menstrua- 
tion. An abundant supply of readily available oxy- 
gen is absolutely necessary for starting and carry- 
ing on in the fertilized ovum those chemical reac- 
tions and changes which are metabolic in character 
and which are concomitants of the phenomena of 
life; and if the generative organs of the woman 
caimot function autogenetically and manifest the 
lihenomena of menstruation then because the blood- 
vessels which should respond to the demands of a 
fertilized ovum have never been and can never be 
autogenetically activated, and because the oxidative 



powers and processes of the generative organs never 
consequently exceed those necessary for maintaining 
the organs merely in a resting state, gestation cannot 
occur. To this very important assertion we shall 
again have to refer to later. 

It will moreover be readily conceded that except 
when menstruation is held in abeyance by lactation 
no woman living a regular marital life is justified 
in entertaining the notion that she has conceived, 
and no medical man is ever suspicious of the exist- 
ence of uterine pregnancy in the case of any woman 
until and unless a menstrual period is missed. Sole- 
ly on this accoimt but aided and guided of course 
by statistics it became and is even still customary 
to reckon the stages of advancement and the proba- 
ble date of parturition in any given case of preg- 
nancy either from the commencement or the cessa- 
tion of the last menstrual discharge. That this 
rough and ready method of reckoning has to a cer- 
tain extent proved satisfactory and successful is 
indisputable and the reason of this we shall presently 
take note of, but it nevertheless must be very evi- 
dent to all medical practitioners that it is not only 
unscientific but inisound. Embryologists. even have 
not escaped the pitfall for they, too, have unfor- 
tunately adopted this same datimi from which to 
reckon the age of any given embryo and assign dates 
to the various stages of embryonic development. 

The modicum of success which has attended 
the aforesaid method of foretelling the proba- 
ble date of parturition is entirely due to the 
fact that a large percentage of women menstruate 
every twenty-four to twenty-eight days and to the 
fact that gestation begins — in the case of every 
woman who has conceived — at a definite and fixed 
time. On account of a misinterpretation of facts 
there has prevailed and even still prevails the be- 
lief that when fertilization takes place it is most 
commonly effected immediately after a menstrual 
period. Today it must to tis seem somewhat re- 
markable that this belief should ever have been seri- 
ously entertained, because it was well known 
throughout the ages that the Jews were a prolific 
people and that the strict Jewess, in bygone days 
anyway, adhered to and observed most religiously 
the Mosaic law which forbade her to have inter- 
course with her husband until she had numbered 
seven clear days from the cessation of her men- 
strual discharge and had had the prescribed bath. 
Over and above this we are in possession of abun- 
dant clinical evidence that fertilization may take 
])lace as a result of a fruitful intercourse occurring 
at any time during the intermenstrual resting period 
seven clear days from the cessation of her men- 
strual discharge of one period to two days prior to 
the date of the next expected menstruation. 

Firmly implanted in most minds there exists the 
further erroneous belief that the beginning of ges- 
tation follows immediately on fertilization. Let us 



July 5, 1922.] 



OLIVER: DURATION OF GESTATION. 



23 



for the moment assume that fertilization and the be- 
ginning of gestation are simultaneous events. Then 
because fertilization may be etTected at any time 
during the intermenstrual period the infant result- 
ing from an ovum fertilized immediately after a 
menstrual period would, according to our present 
method of reckoning the probable date of parturi- 
tion, be born three weeks at least before the infant 
resulting from an ovum fertilized just before an 
expected menstruation, and it clearly would be futile 
for us even to attempt to prognosticate the date of 
the birth of any infant. The aforesaid belief has 
no valid basis for its existence and maintenance and 
if we would view aright the question of the natural 
limit of the duration of human gestation we must 
banish it forthwith from our minds. 

In support of this statement I would adduce at 
the outset our knowledge of what happens in the 
case of the germination of vegetable seeds and the 
incubation of birds' eggs. The egg of the domestic 
hen may be kept for twelve or fiftee^i days and then 
incubated while the seed of some cereals may be kept 
for years and then subjected to the conditions favor- 
able for germination. Here then we are forced to 
accept the dogma that the fertilized cereal seed, al- 
though endowed with the power of life, requires the 
timely cooperation of some favorable extrinsic agent 
or agents to start life in it, and what is true of the 
vegetable seed is likewise true of the fertilized bird's 
egg and the fertilized human ovum. As indisputa- 
ble clinical evidence that gestation begins at a definite 
and fixed time in the case of every woman after n 
fruitful intercourse I would instance the fact that it 
is impossible for even the most experienced medical 
practitioner to detect by physical examination the 
e.xistence of uterine pregnancy in the case of any 
woman earlier than fourteen days after the date 
when the first missed menstrual period was expected 
and for the reason that at this stage the pregnant 
uterus is approximately of the same size and con- 
sistence in every normal case. In a case where fer- 
tilizing was eflfected and gestation begun immediately 
after the cessation of a menstrual period one would 
naturally expect the pregnant uterus fourteen days 
after the first missed period to be larger than in a 
case where fertilization was eflfected and gestation 
begim just before the date when the first missed 
period was expected. In the former case the preg- 
nancy would be nearly three weeks anyhow in ad- 
vance of the latter. As corroborative evidence I 
would instance the fact that morning sickness, which 
is a common symptom associated with the pregnant 
state, is never experienced earlier than the time when 
the first missed period was exi>ected, and this is the 
first symptomatic evidence we have of the presence 
of an actively progressing germ jilasm. It is because 
gestation begins at a definite and fixed time in the 
case of every woman who has conceived that our 
prognostication of the probable date of parturition 
meets with any measure of success at all, and no 
matter when the fruitful intercourse may have oc- 
curred it is because gestation begins at a definite 
and fixed time that we are unable to detect the exist- 
ence of uterine pregnancy earlier than fourteen days 
after the date when the first missed periorl was 
looked for. The latter pronouncement holds good 
also of those cases in which menstruation is wont 



to recur every five or six weeks instead of every 
twenty-four or twenty-eight days. As I have al- 
ready observed, an abundant supply of readily avail- 
able oxygen is necessary to start in the human ovum 
those chemical changes which characterize life, and 
as the generative organs in the resting stage cannot 
furnish this requirement the germ plasm, endowed 
with the power of life but as yet incapable of dis- 
playing the phenomena of life, awaits the activation 
of the generative organs which but for the presence 
of a fertilized ovum would induce menstruation ; for 
menstruation, like the beginning of gestation, requires 
an abundant supply of oxygen. If now we reflect, 
scan carefully and interpret aright our facts, we are 
forced to conclude that gestation in the human fe- 
male begins invariably when the generative organs 
begin to be activated for the occurrence of a men- 
strual period which is inhibited because of the de- 
mands of a fertilized ovum. 

Embryologists, therefore, in reckoning the age of 
any given human embryo and in assigning dates to 
the various depicted stages of our embryonic devel- 
opment will sooner or later be compelled by force of 
circumstances to make their calculations not from 
the date of cessation of the last menstruation nor 
from the alleged date of one insemination but from 
the date on which the first missed period was 
expected. 

Having determined that the time when gestation 
starts corresponds in all cases with the time when 
the first missed period was expected, let us now turn 
our attention to the question of the natural limit 
of this physiological jjrocess, and on this point we 
may glean some important information from the 
happenings in cases of full time extrauterine preg- 
nancy. When gestation occurs outside the utenis 
the fetus in its abnormal location may nevertheless 
attain maturity and be as perfectly nourished and 
developed as if it had been lodged in the uterus. If, 
however, it is not delivered, by an abdominal sec- 
tion of the mother, before the natural limit of the 
duration of gestation is reached, it perishes. For- 
tunately and yet unfortunately it dies without a 
struggle and without the mother being in a position 
to throw any light upon or express any opinion as 
to the time when it probably perished. That it dies 
selfpoisoned through a lack of oxygen there can be 
no doubt. We, however, are not altogether without 
circumstantial evidence as to the probable time when 
it perished. 

I have elsewhere and on many occasions drawn 
attention to the fact that after a normal pregnancy 
and parturition if the mother makes no attempt to 
suckle the child it not infrequently happens that the 
menstrual function reasserts itself about six week.s 
after the confinement, or, roughly speaking, about 
eleven and a half months after the date of the last 
menstruation in the case of a woman who is in the 
habit of menstruating every twenty-four to twenty- 
eight days. Now in some cases of full time extra- 
uterine pregnancy and while the infant is still lo- 
cated in the mother's body we witness this same ten- 
dency for the menstrual function to reassert itself 
about eleven and a half months after the date of 
the last menstruation. This being so we may take 
it that so far as the reestalishment of the menstrual 
function is concerned the normal removal of the 



24 



SCHWATT: TUBERCULOSIS AND PREGNANCY. 



[New York Medical Journal 
AND Medical Record. 



practically mature infant from the uterus is an event 
analogous with the intramaternal death of the full- 
time extrauterine infant. Judging, therefore, from 
what happens in cases of full time extrauterine preg- 
nancy it is quite evident that there is a well defined 
natural limit to the duration of human gestation. If 
we would reckon scientifically and soundly we must 
reckon, however, from the time when gestation 
starts, i. e., from the date on which the first missed 
period was expected. Reckoning from this datum 



.statistical evidence supports the opinion that the limit 
of duration of human gestation is nine lunar months 
or 252 days. For the guidance of those practitioners 
who may continue to rely upon the customary and 
rough and ready methods of reckoning the probable 
date of parturition I would observe that their allow- 
ance of ten lunar months holds good only in cases 
where the menstrual cycle of the woman does not 
exceed that of one lunar month or twenty-eight days. 
123 H."iRLEY Street. 



Tuberculosis and Pregnancy'' 



By H. SCHWATT, M. D., 
New York, 

Attending Physician, Tuberculosis Division, Montefiore Hospital for Chronic Diseases and Bedford Sanatorium. 



The efifect of pregnancy on pulmonary tubercu- 
losis has been the subject of widely conflicting opin- 
ions for the past century and a half. The older 
writers believed that pregnancy has a distinctly 
favorable efifect on a coexisting tuberculous lesion, 
even to the extent that of two women in the same 
stage of the disease and of the same degree of 
severity the one who becomes pregnant will with 
certainty survive the other. Since the middle of the 
last century two diametrically opposed views have 
dominated medical thought. 

On one side it is maintained that in the majority 
of cases, pregnancy has a decidedly unfavorable in- 
flluence on the course and prognosis of active pul- 
monary tuberculosis; that it is responsible for the 
reactivation of latent and inactive disease, and that 
its onset can frequently be traced to a previous or 
existing pregnancy. Another group of observers 
holds that there is no definite evidence for assuming 
that pregnancy as such hastens the progress of 
tuberculosis or shortens the life of a tuberculous 
woman ; that its unfavorable influence is negligible 
and has been overemphasized and overestimated. 

Irreconcilable as these views appear, a close analy- 
sis of the extensive literature of the past two decades 
evidences, if we eliminate extremists, a certain de- 
gree of agreement in so far as the influence of 
pregnancy on certain types and stages of tubercu- 
losis is concerned, and that the majority of clini- 
cians hold that pregnancy must be looked upon as 
a serious complication in a tuberculous woman. 

Theories and experimental work are not lacking 
to sui)port and explain either view. Upward pres- 
sure on the diaphragm by the increase in size of 
the gravid uterus is believed to be the cause of the 
alleged favorable influence of pregnancy by produc- 
ing a decrease in the volume of the lungs, and les- 
sened expansion and respiratory capacity, which fac- 
tors together with the increased work thrown upon 
the heart result in a hypertrophy of the right ventri- 
cle and a hyi)eremia of the lungs. The influence of 
this hyperemia in the lesser circulation may be com- 
pared to that occurring in certain cardiac and par- 
ticularly mitral lesions which are unfavorable to the 

* Read before the New York Physician's Association, Fi-hruary 
94. 1922. 



development ami activity of pulmonary tuberculosis 
and favor a tendency of lesions to become fibrous, 
encapsulated and inactive. 

The high position of the diaphragm and conse- 
quent compression of the lungs in pregnancy is also 
said to act analogously to the efTect of a slowly in- 
creasing artificial pneumothorax. Progression of 
the disease which sets in after parturition is on the 
basis of this hypothesis due largely to a release of 
this pressure and a sudden reexpansion of the lungs. 

Other observers, on the contrary, hold that it is 
the high position of the diaphragm and the resulting 
compression of the lungs, the change in the type of 
respiration and in the pulmonary blood supply which 
are the most important mechanical causes of the pro- 
gression and reactivation of pulmonary tuberculosis. 

Cornet ( 1 ) lays the blame on the severe expulsive 
and the deep inspiratory efforts during parturition 
by which tuberculous secretions are aspirated into 
healthy areas. This according to him explains why 
rapid progression of the disease so frequently sets 
in from a quarter to a half year after parturition. 

Of serobiological changes occurring during preg- 
nancy which are alleged to have a deleterious influ- 
ence on pulmonary tuberculosis may be mentioned 
a decrease in the antitoxic and bactericidal sub- 
stances of the blood and in its fat splitting power 
which normally constitutes one of the defensive 
mechanisms against the tubercle bacillus. Hofbauer 
( 2 ) has shown experimentally that there is an in- 
crease in the lipoids and especially the cholestrin es- 
ters of the blood during pregnancy. These are said 
to furnish a more favorable medium for the growth 
of tubercle bacilli and thus to increase the suscep- 
tibility of the pregnant woman to reactivation and 
])rogression of tuberculous lesions. 

The abstraction of lime from calcified tubercles, 
particularly during the latter part of pregnancy, for 
the needs of the growing fetus is another hypothe- 
sis to account for the reactivation and aggrava- 
tion of the pulmonary disease. 

Sergent (3) seeks to explain the relation between 
pregnancv and tuberculosis by the function of the 
adrenals which according to him is impaired in both 
conditions. Inactive forms of tuberculosis are very 
little influenced by pregnancy because in this type of 



July 5, 1922.] 



SCHWATT: TUBERCULOSIS AND PREGNANCY. 



25 



the disease the function of the adrenals is Httle 
disturbed. 

However, neither these nor other theories or ex- 
perimental work on animals are convincing in prov- 
ing or disproving one or the other view. The deci- 
sion of the question rests on careful clinical ob- 
servation. The diversity of opinion has been said to 
be due largely to differences in the clinical and 
pathological forms of the disease which have come 
under observation. It has been said that clinicians 
who have not observed the deleterious influence of 
pregnancy on tuberculosis have had to deal with in- 
active, mild and favorable types of the disease, and 
those who claim its more or less uniformly unfavor- 
able efifects with cases in which the prognosis was 
bad without regard to the pregnancy. There is. 
however, no definite relation between the type of the 
pulmonary disease and the favorable, indifferent or 
deleterious influence of pregnancy except that as a 
general rule the effects are worse the more active 
and advanced the disease. 

Reactivation or progression of a pulmonary lesion 
as a rule begins to manifest itself during the first 
three months of pregnancy and assimies a serious 
aspect in its latter half. In a minority of cases there 
is a definite tendency to improvement after the 
fourth month. In such cases and in those who do 
not show signs of progression of the disease during 
the entire term it frequently becomes increased after 
parturition and leads to a fatal termination in a large 
proportion of cases during the puer])eriuni. 

Begtrup-Hansen (4) finds the alleged difference 
in the effects of the first and second half of preg- 
nancy to be due to the same causes which underlie 
the effects of the premenstrual and postnienstrual 
periods on pulmonary tuberculosis. The first three 
months of pregnancy and the premenstrual period 
are both characterized by the same type of tempera- 
ture and an aggravation of the disease due to in- 
creased tissue waste. During the latter half of preg- 
nancy and the postnienstrual period the postnien- 
strual type of temperature and a state of hypernutri- 
tion, increase in weight and improvement of the lung 
condition prevail. Although he does not deny that 
other factors may be concerned in lessening or in- 
creasing the resistance to the development and pro- 
gression of tuberculosis he considers the changes 
in the metabolic processes during the two periods 
of pregnancy and the corresi)onding menstrual 
periods as the most important. 

A direct corollary of the injurious effect of preg- 
nancy on active pulmonary tuberculosis is the ques- 
tion of whether the pregnancy should be allowed to 
go to term or whether it should be interrupted. On 
this phase of the subject we also meet with con- 
flicting opinions which in the final analysis hinge 
largely on whether or not the i)rognosis of the pul- 
monary disease is improved by interference. An- 
other point of contention is the period of pregnancy 
during which it is most advisable to terminate it. 

Most clinicians advise early interruption. They 
find that termination of the pregnancy during the 
first three months is most favorable for the pul- 
monary flisease and that after the fourth month arti- 
ficial abortion rarely gives satisfactory results. 
Pankow and Kupferle (5) have reported the most 
extensive study on this question and show that ter- 



mination of the pregnancy during the first three 
months results in improvement and favorable course 
of the lung disease in eighty-seven and nine tenths 
per cent., between the fifth and seventh month in 
thirty-three and three tenths per cent, and between 
the eighth and ninth month in twenty-nine and four 
tenths per cent. Artificial induction of labor be- 
tween the eighth and ninth month gives a mortality 
of forty per' cent, in second and one himdred per 
cent, in third stage cases. The results are worse 
the more advanced the disease. In the third stage 
of tuberculosis no benefit is derived in one hundred 
per cent, of cases. 

Other observers while admitting that ]>regnancy 
may prove a serious and even dangerous complica- 
tion in tuberculosis, do not favor its interruption 
except luider limited indications because they have 
not found it of any favorable influence on the course 
and prognosis of the pulmonary disease. 

My personal observations have placed me firmly 
on the side of those who hold that pregnancy in a 
clinicalh- tubercidous woman must be looked upon 
as a serious complication of decidedly unfavorable 
prognostic import in regard to the pulmonary dis- 
ease. Although no dogmatic attitude on the subject 
should be taken the following summary may be re- 
garded as a working basis for the obstetrician and 
the internist who may be called upon to decide 
whether or not a tuberculous woman may safely 
bear a child or for or against termination of a 
pregnancy. 

SUMMARY. 

1. Pregnancy is not an important etiological fac- 
tor in the development of pulmonary tuberculosis. 
In a considerable niunber of cases, however, the dis- 
ease develops following parturition and during lac- 
tation as a consequence of the debilitating effects of 
these periods. 

2. A diagnosis of active pulmonary tuberculosis 
in a pregnant woman should be made only on posi- 
tive evidence. It should be remembered that preg- 
nant women may normally show temperature varia- 
tions which may lead to the suspicion of incipient 
tuberculosis. 

3. Old tuberculosis of slight extent with ])hysical 
signs of a latent and inactive peribronchial condition 
is rarely reactivated as a result of ])regnancy. La- 
tent and inactive parenchymatous lesions of the same 
extent more frequently become active and progres- 
sive. In early clinically cured cases pregnancy may 
be permitted under favorable social and economic 
conditions. All such patients should, howevci, 
be carefully observed for signs and symptoms of 
reactivation and should be treated as potential cases 
of active tuberculosis. I'riniipara and women with 
pregnancies following rapidly one after the other 
are especially in danger of reactivation during 
I^regnancy. 

4. The majority of cases of active pulmonary 
tuberculosis in all stages and of quiescent or arrested 
disease, especially if advanced, are distinctly unfa- 
vorably influenced by pregnancy. Such patients 
should l)e advised against pregnancy and instructed 
in the safest methods of contraception. The disease 
generally begins to progress during the first three 
months of pregnancy or following parturition. In 
active disease of any extent it is safe to adopt the 



26 



LANGSTROTH: GONORRHEA. 



[New York Medical Jouknal 
AND Medical Record. 



dictum of the French school: "If a girl, no mar- 
riage; if a wife, no pregnancy; if a mother, no 
suckling." 

5. A small number of patients with active disease 
are not deleteriously influenced by pregnancy. The 
improvement in the pulmonary disease occasionally 
observed occurs despite of and not because of preg- 
nancy. The old belief that pregnancy has some 
peculiarly favorable effect on pulmonary tubercu- 
losis has been properly stigmatized as superstition. 

6. There are, however, no positive symptomatic 
criteria by which we can foretell which patients will 
be unfavorably influenced and which will go through 
the pregnancy without serious ill effects. 

7. The probability and the degree of unfavorable 
effect is the greater the more advanced the disease. 

8. As a general rule the prognosis of the pul- 
monary disease is decidedly worse than in similar 
cases without the complication of pregnancy, if there 
is present : a, impaired nutrition and particularly a 
persistent loss of weight ; b, laryngeal tuberculosis ; 
c, a persistently high ptilse even without fever ; d, 
continuous or periodic fever even without extensive 
pulmonary involvement ; e, symptoms and physical 
signs of rapid destruction of pulmonary tissue ; f. 
unfavorable social and economic conditions ; g. 
symptoms on the part of the pregnancy such as 
hyperemesis, nephritis, severe chlorosis and nervous 
and mental manifestations. 

9. No absolutely definite schematic rules as to the 
conditions under which interruption is indicated or 
when it shall be instituted can be laid down. It is 
largely a problem of a diagnostic and prognostic 
nature and hence one of individualization and care- 
ful observation by the obstetrician and the internist. 
We must take into consideration the stage of the 
disease, whether it is unilateral or bilateral, station- 
ary or progressive, and whether it is complicated by 
other tuberculous or nontuberculous conditions. It 
should also be kept in mind that even if the disease 
runs an uneventful course during pregnancy the 
woman still has to face a dangerous period after 
parturition. 



10. Before artificial abortion is resorted to the 
patient should be given the benefits of a thorough 
hygienic dietetic course of treatment and in suitable 
cases of artificial pneumothorax, which has been 
shown to be without deleterious effects on the course 
of pregnane}'. 

11. However, if under favorable conditions of 
treatment the disease remains active and persistently 
progresses or in the presence of the unfavorable 
symptoms I have enumerated interruption of the 
pregnancy is indicated in all stages of the disease 
during the first four months of the term. Laryngeal 
tuberculosis even without extensive disease of the 
lungs is a definite indication for the early termina- 
tion of pregnancy. Early interruption is especially 
indicated in arrested cases which set up acute activ- 
ity in the first few months of pregnancy and in cases 
which give a history of exacerbation and progression 
of the disease during a previous pregnancy. 

12. After the fourth month interruption does not, 
as a rule, improve the prognosis of the pulmonary 
disease. It is permissible early in this period under 
urgent indications in moderately advanced cases 
without serious complications but is definitely con- 
traindicated in prognostically unfavorable advanced 
cases. 

13. Premature induction of labor on account of 
the pulmonary disease is practically always contra- 
indicated. 

14. The operation of choice for emptying the 
uterus prior to the fourth month is vaginal hysterot- 
omy under gas and ether anesthesia. 

15. Sterilization to prevent future pregnancies is 
justifiable only under exceptional circumstances, 
and only in multipara with living children, in women 
with rapidly following pregnancies and in working 
women. 

REFERENCES. 

1. Cornet: Tuhcrculnsis. 1907. 

2. Hofbaver: Dcutsch. nicd. Wchnschr.. No. 50. 1910. 

3. Sercent: Prcssr Medicalr. No. 55, 1913. 

4. Begtrup and H.^nsen ; Beitr. s. Klin. d. Tubcrk., 
vol. xlii, H. 1. 1919. 

1215 M.^nI.soN .\venue. 



Gonorrhea in Women from the Aspect of a Focal Infection 

By FRANCIS WARD LANGSTROTH. M. D., 
New York, 
Consulting Gynecologist to the New Jersey State Hospital; Assistant Surgeon to Outpatients and Gynecologist to Gouvemeur Hospital. 



Despite the endless literature on the subject of 
gonorrhea in women, little advancement had been 
made towards an actual cure of this disease until 
very recently. This fact and some others seem to 
offer a sufficient excuse for an additional contribu- 
tion to this timeworn subject. 

SOCIOLOGY. 

It is impossible to consider gonorrhea as a dis- 
ease confined largely to prostitutes. Present social 
conditions have resulted in its widespread distribu- 
tion. The war. by breaking down moral reserve, 
resulted in a freedom of sexual life hitherto un- 
known. Vast numbers of young women submitted 



to intimacies wliich they never would have allowed 
if their lovers had not been about to leave them for 
the uncertainties of war. Many girls attained a new 
freedom and independence during the war which 
separated them from the restraints of home. The 
moral atmosphere of the whole world has assumed 
an attitude of "Live for today, and let the morrow- 
care for itself." 

Since the enfranchisement of women by the enact- 
ment of the nineteenth amendment to the constitu- 
tion, women have insisted upon the adoption and the 
recognition of the socalled single standard. This 
has removed another restraint, for they no longer 



July 5, 1922.] 



LANGSTROTH: GONORRHEA. 



27 



fear the social ostracism which was formerly their 
lot if they broke the bounds of propriety. And now 
the rapid dissemination of contraceptive methods 
has removed the last barrier of fear as a restraint to 
free sexual life. 

These and other conditions, in addition to the 
present high cost of living, which often precludes 
early marriages, have resulted in social arrangements 
which could not fail to facilitate the spread of 
gonorrhea. 

SYMPTOMS OF GONORRHEA IX WOMEN. 

The subjective symptoms of gonorrhea in women 
are unfortunately in many cases of a mild type and 
cause so little inconvenience and suffering that this 
disease is often overlooked or mistaken for a tem- 
porary cystitis. This is deplorable, because disease 
is dreaded in proportion to the suffering, morbidity 
and death it causes. This disease, so farreaching 
in its effects, not only on the individual but upon so- 
ciety as well, is not dreaded or feared as it should 
be, either by the male or the female. 

In many cases the only subjective symptoms no- 
ticed in the female are a burning pain upon urina- 
tion and some itching or smarting of the external 
genitalia, accompanied by an irritating discharge. 
So many women have leucorrhea, that they are in- 
clined to consider the urinary symptoms separately. 
Often these clear up in so short a time that the con- 
dition is not even treated. It is only in a moderate 
proportion of cases that the infection is so vindent 
that it results in severe pelvic conditions and dis- 
eases of the adnexa. Many of these patients who 
seek medical aid are carelessly examined and treated 
by physicians in the routine of general practice. 
Thus these patients, by the establishment of a per- 
sonal immunity, drift into the symptomatic stage of 
a chronic gonorrhea, and so remain for a long period 
of years a source of danger to any male companion, 
and a source of gonorrheal ophthalmia to any child 
they may produce. 

My observations lead me to believe that these pa- 
tients are at times infectious after a period of ten 
or twelve years, unless the special measures of treat- 
ment here outlined are carried out. 

DIAGNOSIS. 

From the time of infection gonorrhea in women 
presents an entirely different problem from the 
same disease in men. In fact, from the anatomy 
of the parts involved, even prophylactic measures 
in women are practically valueless. 

While the male has only one external opening or 
outlet to his genitourinary organs, the female pre- 
sents at least si.x distinct outlets connected with some 
part of her genitourinary organs. These six outlets, 
namely : the urethral orifice ; the openings of the two 
ducts of Skene's glands ; the openings of the two 
ducts of Bartholin's glands, and the orifices of the 
external os, are all capable of, and are likely to be 
simultaneously infected with gonorrhea, when se.xual 
intercourse with an infected male takes place. Thus 
we can readily see that prophylactic and abortive 
treatments arc [jractically useless in the female, and 
that from the start this disease in women presents 
a complex situation. 

Laboratory aids in the diagnosis of chronic gon- 



orrhea in the female are of even less value than in 
the male. The gonorrheal fixation test is of great 
value when positive. Dr. Hastings, in a personal 
communication to me, has pointed out that the fixa- 
tion tests do not necessarily diagnose a focus of 
infection, but rather demonstrate that absorption of 
toxins into the blood stream is taking place from a 
focus of infection, so that a negative fixation test 
does not prove the absence of a local gonorrhea. 
Attempts at culture of gonococcus are unreliable. 
The examination of slides is only of value when the 
intracellular gram negative characteristic biscuit- 
shaped diplococci are positively found. Negative 
smears do not mean an absence of the disease, be- 
cause the organisms become early imbedded in the 
tissues, and even irritation with silver nitrate, and 
other substances, fails to cause their appearance in 
the pus cells. Therefore the diagnosis must depend 
ultimately upon the history and the clinical pictures 
which the case presents to the examiner's sense of 
touch and vision. 

Practically all women who have had gonorrhea 
will recollect a period of burning and irritation upon 
urination. This is the one classical subjective symp- 
tom of this disease in women. Besides this, they 
notice an increase in the vaginal discharge and a 
change from the mucopurulent character of chronic 
cervical focal infection, due to other bacteria, to a 
thin, creamy, profuse discharge, which is rather 
typical of gonorrhea. 

It might be well to say here tliat I am not going 
to attempt to give all the symptoms and complica- 
tions of the disease, as that would necessitate the 
production of a book of many pages. I merely wish 
to indicate what seem the more salient features and 
some new aspects of its danger and treatment. 

Unless pelvic, joint or cardiac symptoms develop, 
many of these patients have no fever or general 
symptoms. The clinical features of acute gonor- 
rhea in women are well known. In the acute stages, 
laboratory methods are generally positive, so that 
diagnosis is comparatively easy. In its chronic stage, 
however, the disease is difficult to diagnose. 

In order to fulfill the purpose of this article, it is 
necessary to digress at tliis point and call attention 
to one aspect of gonorrhea in women that has been 
in the past almost, if not entirely, overlooked. It 
is this aspect which makes it a disease from the per- 
sonal viewpoint greatly to be dreaded. 

Every wotnan infected with gonorrhea sooner or 
later acquires a focal infection of the cervix re- 
sulting from a secondary infection of the cervical 
endometrium with some of the various forms of 
pathogenic bacteria with all the accompanying dan- 
ger of systemic and mental diseases and disturbances 
which a focal infection of the cervix may produce. 

It is not in the scope of the present paper to deal 
with these focal infections, but the interested reader 
is referred to the articles of Sturmdorf (1), Langs- 
troth (2, 4, 7), Curtis (3, 8), and Rosenow (5, 6). 

The fact, however, that is important to empha- 
size is that in every case of gonorrhea treated by the 
usual meliiods, the cervical endnmctrium becomes 
the site of a permanent focal infection. This infec- 
tion is just as potent a source of systemic and men- 
tal disease as foci in the teeth, tonsils, gallbladder, 
prostate in the male, and other less frequent foci. 



28 



LANGSTROTH: GONORRHEA. 



[New York Medical Journai. 
AND Medical Record. 



which have been so carefully studied by men of such 
prominence as Billings (9), Bell (10), King (11), 
Bryant (12), Cotton (13), Lowsley (14), and many 
others. 

In the study of tlie clinical picture of chronic 
gonorrhea, the possibility of these other infections 
and their systemic results must be borne in mind. 
Let us consider the clinical picture. The urethra 
will most likely appear nearly normal, as it seems 
after a time to recover fully from the effects of 
gonorrheal infection. The orifices, however, of 
Skene's glands remain red and pouting for many 
years after infection. The ability to see these ori- 
fices is very typical of chronic gonorrhea, as ordi- 
narily they are practically invisible. 

The orifices of the ducts of the Bartholin's glands 
are also red and visible. Ordinarily, one or both 
of these glands are found swollen. The cervix will 
present a variety of pictures, according to its condi- 
tion before the infection, and the type of secondary 
infections' which have occurred. It will always 
show, however, signs of chronic infection with some 
socalled erosions . at the external os. The whole 
vaginal surface of the cervix will often show a 
petechial rash of a bright red color, resembling the 
tongue in scarlet fever. When this is present, some 
form of streptococcus can usually be isolated from 
the culture taken from the cervical canal. Often 
there are nvnnerous socalled nabothian follicles, but 
these are likely due to the secondary infections, 
rather than to the gonococci. The character of the 
discharge is different in chronic gonorrhea from 
that in a recent gonorrheal infection. It is, even 
after a long period of time, more like a true pus, 
but it varies a great deal both in character and ap- 
pearance, being modified by the secondary infections 
that take place. As time goes on, it tends more 
and more to become thick and mucoid in character. 
Thus we have a picture differing little from the 
nonspecific chronic endocervicitis, excepting for the 
changes in the discharge, which may be slight, and 
the involvement of Skene's glands and Bartholin's 
glands. 

Laboratory work in a case of gonorrhea of one 
year's duration recently was as follows : Slides to 
the number of ten in two dift'erent laboratories 
showed some pus ; no intracellular gram negative 
diplococci : quite numerous extracellular gram nega- 
tive diplococci ; cultures of colon bacillus and hemo- 
lytic streptococci ; complement fixation test negative 
for gonococci ; Wassermann test negative. Thus 
we see the extreme difficulty of diagnosing chronic 
gonorrhea in the female. 

PROGNOSIS. 

The prognosis is never as hopeful as could be de- 
sired. It depends upon, first, the virulence of the 
infection ; second, the individual resistance of the 
patient; third, the type of secondary infection, and 
fourth, the method of treatment. There are many 
other factors that enter into the prognosis but these 
are certainly the main on^s. 

It is impossible to forecast in what percentage of 
cases severe tubal, joint, heart and systemic condi- 
tions will develop. It is likely that no patient escapes 
some tubal involvement, but many times the patho- 
logical disturbances are in time almost overcome, 



especially if early and active treatment of the cer- 
vical infection is carried out (Curtis) (8). It is sel- 
dom necessary to operate for pelvic conditions in the 
acute stage. There is, witliout a doubt, a permanent 
damage to the fallopian tubes, due either to the 
gonococcus or to some secondary infection in ninety 
per cent, of all women who have been infected with 
gonorrhea, and probably fifty per cent, of these pa- 
tients eventually need operative treatment for pel- 
vic disease. When we consider also the joint in- 
volvements and other systemic conditions which so 
frequently result from this disease, we can begin to 
realize the gravity of this infection in women. 

In considering the prognosis in this disease we 
must also remember that the secondary infections 
which invariably follow gonorrheal infection in 
women, also have their own resultant pelvic as well 
as joint, .systemic and mental involvement ( Lang- 
stroth) (7). 

Thus we see that gonorrhea in women is a dis- 
ease fraught not only with many possibilities of im- 
mediate severe pathological changes in the pelvic 
and urinary organs, with or without accompanying 
arthritis and other complications, but also with grave 
late tubal, ovarian, joint, systemic and mental 
diseases. 

TRE.\TMENT. 

The treatment must be considered from both the 
medical and the surgical points of view, in both 
the acute and the chronic stages of the disease. In 
its early stages it is still a local process, and any 
form of treatment which washes away the discharge 
and tends to destroy the specific organisms is of 
value. The difficulties are that the germs so soon 
become buried in the glandular tissues and spread 
by means of the lymphatics to other parts. There- 
fore local treatment even in the early stages of the 
diesase is not a means of curing it. 

Copious vaginal irrigations with a solution of 
potassium permanganate, using one dram of tlie 
saturated solution to two quarts of water at about 
118^ F. twice a day are useful in the early stages. 
This is practically the old treatment recommended 
by Janet (15) and \'alentine (16) for gonorrheal 
urethritis in the male. In addition, some form of 
colloid silver, or dye solution, should be applied to 
all accessible parts of the genitourinary tract every 
other day. I favor a twenty-five per cent, solution 
of argyrol gradually increased to fifty per cent. A 
bivalve speculum e.xjx^ses the cervi.x and the solu- 
tion carried on an applicator in the early stages 
only, to the external os, but later a fifty per cent, 
solution can be carried up to the internal os, in those 
cervices which are sufficiently patulous. As the 
speculum is withdrawn opened, the same solution 
is applied to all parts of the vaginal canal, Skene's 
glands and the ducts of the Bartholin's glands. The 
ureter should be injected with a five to ten per 
cent, argyrol or other suitable solution. Of course 
there are a vast nmuber of drugs to choose from, and 
it is often well to vary the form of the ap])lication 
used. 

Injections of either autogenous or stock antigon- 
orrheal vaccine should be given. The patient's re- 
sistance should be kept at its best by careful atten- 
tion to diet and hygiene and the proper use of tonics. 



July 5, 1922.] 



LANGSTROTH: GOXORRHEA. 



29 



Intramuscular injections with one of the prepara- 
tions of cacodvlate of iron and strychnine are of 
value. Surgical treatment is confined in the acute 
stages to the relief of abscess of Bartholin's glands, 
pelvic abscess, pyosalpinx, and other complications. 
It is now known that a large proportion of pa- 
tients with tuboovarian and pelvic conditions occur- 
ring in the course of acute gonorrhea will get well 
with rest in bed and the use of the icebag and local 
treatment of the cervix. Thus operations in the 
acute stages of this disease are much less frequent 
than formerly. 

RESULTS OF SECONDARY INFECTIONS. 

Despite this method of treatment, gonorrhea in 
women will, after a period of six months, reach a 
chronic stage in which the symptoms are slight but 
persistent. The treatment demands the greatest pa- 
tience and skill of the gynecologist. It is in the 
chronic stages that, due to the secondary infections 
invariably occurring in the cervix, any of the fol- 
lowing conditions may arise : First, persistent and 
offensive leucorrhea from chronic infection of the 
cervix (and less frequently of Skene's glands) ; sec- 
ond, various menstrual disturbances (as dysmenor- 
rhea, menorrhagia, and amenorrhea), resulting from 
pathological changes in the uterus and the ovaries. 
These changes have been described in the papers 
of Sturmdorf (1), Curtis (3, 8), and Langstroth 
(2. 4), and will not be detailed here. Third, arthri- 
tis, especially of the knee and ankle joints, and less 
frequently of the other joints (Lowsley) (14). 
This may occur either as gonorrheal arthritis, or as 
is more frequent in the chronic stage, as a result of 
the toxins absorbed from the cervix which has be- 
come the site of a focal infection due to the various 
organisms which are found to follow gonorrheal in- 
fection. Fourth, various nervous mental and sys- 
temic conditions may result. These have been de- 
scribed in a previous paper (Langstroth) (7). 

LIMIT.\TIONS OF MEDIC.\L TREATMENT. 

The treatment of chronic gonorrhea in women 
can readily be seen to resolve itself into the applica- 
tion of such measures as will remove the areas of 
chronic foci of infection and restore the parts to as 
nearly normal a condition as possible. The field 
of medical treatment in this stage is certainly limited, 
as far as actual permanent cure is concerned. The 
results of x ray applications, radium and cautery in 
these cases are unrelial)le, uncoiitrtillable and uncer- 
tain in their action. They also necessitate a much 
longer period of morbidity and loss of time than 
surgical measures would involve. The use of radium 
and the x ray in these conditions may be the cause 
of serious consequences if it becomes necessary later 
to operate for pelvic complications. This fact has 
been pointed out by Graves (17) and Langstroth 
(18). Deaver deserves the greatest credit for his 
timely warning against the use of radium and the 
X ray in cancer, as a curative agent. 

SURC;iCAL TKEAT.VIENT. 

Surgery offers the only promi.se of a cure in these 
cases. There is. however, no surgical field in wiiich 
the operative work must be carried out with more 
delicacy and skill, if the functions of the generative 
system are to be preserved. In these chronic cases, 



with their accompanying secondary infections, the 
primary foci from which all the other conditions 
arise is, as has been stated, the endometrium of the 
cervix from the external to the internal os. It is 
here that the serious menace to the future health and 
happiness of the patient exists. Second, Skene's 
glands, and third, the Bartholin's glands. It is to 
these foci primarily, and to the pelvic conditions sec- 
ondarily, that surgical methods must be directed. It 
is poor surgery and wrong to do pelvic operations 
in these cases and not remove these areas of infec- 
tion. 

In fact, as has been previously pointed out by me 
and confirmed by the findings of Curtis (8), the 
tubes and ovaries are capable of marked regenera- 
tive changes, especially in gonorrheal infections, if 
the source of primary infection is removed early. 

To be able to decide when pelvic surgery is or is 
not indicated in these cases demands skill and judg- 
ment, since with the infection removed from the cer- 
vical canal many tubes and ovaries can be saved that 
had formerly to be sacrificed. 

Before surgical work is attempted on gonorrheal 
patients the following conditions should be met 
(these, of course, do not apply to the surgical condi- 
tions that arise during the acute stage) ; Six months 
to one year should have elapsed since the last gonor- 
rheal infection occurred: the typical gram negative 
intracellular diplococci should have disappeared" from 
tlie cervical smears, and an intensive treatment of 
local applications of colloid silver should be carried 
out three times a week for three weeks prior to the 
operation. 

The surgical procedures to be carried out are the 
removal of the involved Bartholin glands: the elim- 
ination by cautery or knife of the diseased Skene's 
glands: the complete removal of the cervical endo- 
metrium from the external to the internal os, with 
careful refining of the cervical canal with a flap 
from the vaginal surface of the cervix : and the re- 
removal of such portions of the adnexa as shall be 
determined to be hopelessly diseased and are acting 
as a secondary foci of infection. 

If such surgical work is carefully carried out, I 
believe that fully ninety-five per cent, of these pa- 
tients are made, not only noninfectious, but that 
tiieir health will be restored, and in a majority the 
jjrocreative function will be preserved. 

CONCLUSIONS. 

Gonorrhea in women is not confined to any one 
strata of society, and is rapidly increasing in 
frequency. 

The gravity of this disease is not appreciated as 
fully as it should be. 

The diagnosis is often difficult, and is frequently 
confused witii chronic nonspecific infections of the 
cervical mucosa. 

Gonorrheal infection of the cervix is always fol- 
lowed by secondary infections, which are often the 
cause of severe systemic and mental disturbances. 

Surgical removal of Skene's glands, Bartholin's 
glands, and the cervical endometrium is tlie only 
way in which the disease can be eradicated in the 
majority of cases. 

17 East Thirty-eighth Street. 

The rcfvrcriccs will appear in the author ■•. reprints. 



30 



STRECKER AND KEVES: INVOLUTIONAL MELANCHOLIA. 



[New York MEDICAt JournaI- 
AND Medical Record. 



Ovarian Therapy in Involutional Melancholia"* 

By EDWARD A. STRECKER, M. D., 

and BALDWIN L. KEYES, M. D., 

Philadelphia, 

Pennsylvania Hospital, Department for Mental and Nervous Diseases. 



INTRODUCTION. 

More interesting and possibly more usual than 
dysfunction of individual units of the endocrine ap- 
paratus are the symptomatic expressions which may 
be the possible result of a disturbance of the balance 
and interdej>endence which exists between the 
various ductless glands. In this connection the 
gonads are particularly important. It has been held 
for some time that the eunuch presents a psycho- 
physical anomaly, due, at least in part, to the sec- 
ondary pituitary activity which follows ablation of 
the gonads. The relationship between the thyroid 
and the gonads rests on a less secure foundation, 
but the hypothesis, at least, is reasonable enough to 
merit clinical investigation. For instance, it i.-^ 
thought that during the postmenstrual period when 
the corpora lutea are being formed, the thyroid is 
relatively inactive. With the approach of the next 
period, the luteal activity is distinctly lessened, and 
with the consequent reduction of inhibitory control, 
the thyroid may become overactive and the physical 
and mental phenomena which are so commonly asso- 
ciated with the immediate premenstrual stage are 
produced. Again, the balance is restored by the 
production of fresh luteal secretion. "However, 
when, through nonactivity of the ovary — at the 
menopause for instance — this is not the case, then 
the persistent thyroid, uncompensated by luteal se- 
cretion, produces many of the symptoms of this state. 
The paresthesia, sleeplessness, nervousness, irritabil- 
ity, cardiac arrhythmia, vasomotor disturbances, and 
profuse sweating of this condition are well known ; 
and are in all probability due largely to thyroidal 
disturbance. The increased blood pressure seen 
frequently at this time is due to the sensitization of 
the neuromuscular synapse to adrenalin by the thy- 
roid activity. If this adrenalin content is deficient, 
then we get intense weakness, asthenia, and collapse. 
The administration of ovary at this time olifsets this 
thyroid activity and often brilliant results follow in 
the alleviation of the annoying conditions produced 
by it. The relation of the thyroid to the gonads is 
also strikingly shown in the increased rapidity of 
sexual development under its influence. In amenor- 
rhea, or in delayed and scanty menstruation, thyroid 
administration is effective" (1). 

Several years ago, while investigating a group of 
late psychoses in women from the angle of catatonia 
(2), one of the writers was somewhat impressed by 
the apparent resemblance of certain elements of the 
psychotic content in socalled involutional melan- 
cholia to the mental state which commonly obtains 
at the climacteric and has been rightly or wrongly 
regarded as physiological. Indeed in given instances 
there seemed to be between the normal menopause 
and the psychosis merely a symptomatic difference 

* Read at the stated meeting of the Philadelphia Psychiatric So- 
ciety, March 10, 1922, at the College of Physicians, Philadelphia. 



in degree, but scarcely in kind. Thus, at times, the 
not unusual concomitants of the climacteric such as 
feelings of jealousy, abrupt emotional oscillations, 
light depressive states, impulsive behavior, pro- 
nounced irritability, restlessness, and numerous sub- 
jective hypochondriacal sensations were seemingly 
replaced in the outspoken attack of mental disease 
by strong delusions of jealousy, a deep depressive 
coloring, frequent outbreaks of angry irritability, 
restless agitation, and somatic delusions. However, 
one is not naive enough to believe that there is neces- 
sarily a direct connection between the psychopathol- 
ogy and metabolic toxicity of the physiological (?) 
climax and involutional depression, nor does one 
have the requisite amount of endocrinological op- 
timism to attribute the varied symptoms of the 
epochal psychosis solely to the effect of unopposed 
thyroid secretion. It is more reasonable to assume 
that the steps which are taken in the genesis and 
development of the psychosis are too immensely 
complicated to admit of such a simple explanation. 
N^evertheless, it is probable that endocrine imbalance 
is a factor of some importance and deserves careful 
consideration. From such a point of view, the fol- 
lowing relatively simple clinical therapeutic experi- 
ment was carried out. 

CONDITIONS OF THE EXPERIMENT. 

This experiment consisted in the intramuscular 
injection of the contents of an ampoule of corpus 
luteum and one ampoule of ovarian substance on 
alternating second days, so that each was repeated 
every fourth day for three months. Fourteen fairly 
typical cases of involutional melancholia were util- 
ized. Careful detailed notes were kept before, dur- 
ing, and after the course of medication. Observa- 
tions of physical conditions were noted as follows : 

Daily : Pulse, temperature, respiration, bowel 
movements, and sleep in hours. Every third day: 
Blood pressure. Weekly : Uranalysis, weight. At 
irregular intervals : Appetite, skin, and menstrual 
changes. At beginning and ending: Complete blood 
count. 

Miscellaneous notes are made when indicated. 
Mental changes were recorded every week as fol- 
lows : Agitation, motor activity, occupational inter- 
est, cooperation, delusional formation, insight, suici- 
dal tendencies, reaction to food, and miscellaneous. 

DESCRIPTION OF PATIENTS PHYSICALLY BEFORE 
EXPERIMENT. 

It seems desirable to make a brief statement of 
the physical status of each of the fourteen patients 
as recorded before any medication was started. 

Case I. — Married, aged sixty-one, moderately 
well nourished. Physical examination negative; 
average pulse 74, temperature 97.4°. respiration 
18; blood ])ressure, systolic 130, diastolic 82; uran- 
alysis negative ; bowels regular ; sleep average six 
hours ; appetite poor ; skin normal ; no menstrua- 



July 5. 1922.] 



STRECKER AND KEYES: INVOLUTIONAL MELANCHOLIA. 



31 



tion; weight 111 pounds; blood count: red blood 
cells 4,800.000, while blood cells 10,250, hemoglobin 
95 per cent., eosinophiles 0.' The general condition 
was otherwise normal and fairly good. 

Case II. — Single, aged sixty-two, fairly well 
nourished, some fibrosis at base of right lung ; slight 
fine tremor of hands ; average pulse 80, temperature 
98.4% respiration 20; blood pressure: systolic 135, 
diastolic 84; uranalysis negative, bowels constipated, 
sleep average six hours, appetite fair, skin moist and 
sallow, no menstruation, weight 125 pounds ; blood 
count : red blood cells 3,700,000, white blood cells 
8,000, hemoglobin 85 per cent., eosinophiles per 
cent. The general condition was good. 

C.\SE III. — Widow, aged fifty-two, poorly nour- 
ished, physical examination negative, pulse 92, tem- 
perature 98.6°, respiration 22; blood pressure: sys- 
tolic 140, diastolic 94 ; uranalysis negative, bow'els 
regular, sleep average seven and a half hours, 
appetite fairly good, skin normal, no menstruation, 
weight 97 pounds ; blood count : hemoglobin 95 per 
cent, red blood cells 5,100,000, white blood cells 12,- 
600, eosinophiles 3 per cent. General condition fair. 

Case IV. — Married, aged sixty- four years, fairly 
well nourished, slight e.xophthalnui.s, scar from thy- 
roidectomy base of neck anteriorly, pulse 68, tem- 
jierature 98.2°, respiration 18; blood pressure: sys- 
tolic 168, diastolic 106, uranalysis negative, bowels 
regular, sleep average five hours, appetite good, 
skin normal, no menstruation, weight ninety-seven 
and three-quarters pounds ; blood count : hemo- 
globin 100 per cent., red blood cells 5,000,000, white 
blood cells 10,000, eosinphiles 1 per cent., general 
condition good. 

C.\SE V. — Single, aged si.xty years, greatly ema- 
ciated, physical examination negative, pulse 82, tem- 
perature 98.2°, respiration 20; blood pressure: sys- 
tolic 160, diastolic 99 ; uranalysis : transient albu- 
minuria, appetite good, skin normal, no menstrua- 
tion, weight sixty-eight and one half poimds ; blood 
count : hemoglobin 95 per cent., red blood cells 
4,200,000, white blood cells 10,500, eosinophiles 
2 per cent., general condition fair. 

C.\SE \T. — Single, aged fifty-three years, poorly 
nourished, physical examination negative, pulse 76, 
temperature 98, respiration 18; blood pressure: sys- 
tolic 120, diastolic 7S; uranalysis: transient albu- 
minuria, bowels regular, sleep average eight hours, 
appetite fair ; skin : sallow and cool, no menstrua- 
tion, weight 109 pounds; blood count: red blood 
cells 4,500,000. white blood cells 7,000, hemoglobin 
85 per cent., eosinophiles per cent., general condi- 
tion fair. 

Case VII. — Married, aged forty-eight years, well 
nourished, scoliosis with deviation to the right, irreg- 
ular heart action, prolapsed and retroverted uterus 
and cystocele, pulse 68, temperature 98.2°, respira- 
tion 18; blood pressure: systolic 99, diastolic 64, 
uranalysis negative, bowels loose, sleep average 
eight hours, appetite fair ; skin : pale, then flushed 
when irritable, menstruation regular, caused agita- 
tion, irritability and other symptoms, weight 106 
pounds ; blood count : hemoglobin 90, red blood cells 
4.370,000, white blood cells 7,600, eosinophiles per 
cent., sjeneral condition fair. 

* Eosinophilta only is recorded as the eosinophiles were the only 
white blood cell constituent which underwent notable change. 



C.xsE VIII. — Widow, aged fifty-three years, well 
nourished, palpable thyroid, slight exophthalmos, 
mild myxedematous skin changes, pulse 74, tem- 
perature 97.6°, respiration 18; bowels regular, sleep 
seven hours, appetite good ; skin : blotched flushing, 
no menstruation, weight 139 pounds; blood count 
hemoglobin 100 per cent., red blood cells 4,380,000, 
white blood cells 10,300, basophiles 4 per cent., 
eosinophiles 3 per cent., general condition good. 

C.'^.se IX. — Widow, aged fifty-one, poorly nour- 
ished, physical examination negative, pulse 78, tem- 
perature 98.2°, respiration 18; blood pressure: sys- 
tolic 14S, diastolic 90; uranalysis: transient albu- 
minuria, low specific gravity, hyaline and granular 
casts, bowels regular, sleep average eight hours; ap- 
petite : forcibly fed with spoon, skin normal, no 
menstruation, weight ninety-nine and three quarter 
pounds ; blood count : hemoglobin 90 per cent., 
red blood cells 3,840,000, white blood cells 8,200, 
eosinophiles 1 per cent., general condition fair. 

Case X. — -Single, aged fifty-one, poorly nourish- 
ed, physical examination negative, pulse 86, temper- 
ature 98.6°, resiration 24; blood pressure: sys- 
tolic 128. diastolic 94, weight 115 pounds, uranalysis 
negative, bowels regular, sleep average eight hours, 
appetite good, skin normal, no menstruation ; blood 
count: hemoglobin 80 per cent., red blood cells 4,- 
800,000, white blood cells 10,000, eosinophiles 5 per 
cent., general condition fair. 

C.\se XI. — Married, aged sixty-three years, poor- 
ly nourished ; exophthalmos, moderate arterioscler- 
osis, pulse weak, irregular, 96, temperature 98.2°, 
respiration 22; blood pressure: systolic 148, diastolic 
95, weight eighty-five pounds ; uranalysis : low spe- 
cific gravity, transient albuminuria, hyaline and 
granular casts, bowels regular, sleep six and one- 
half hours: appetite: tube fed; skin: face flushed, 
no menstruation ; blood count : hemoglobin 100 per 
cent., red blood cells 5,000,000, white blood cells 
8,800, general condition very poor. 

Case XII. — Married, aged fifty-four years, un- 
dernourished, moderate arteriosclerosis, pulse 74, 
temperature 98, respiration 18; blood pressure: sys- 
tolic 150, diastolic 99; uranalysis: transient albumi- 
nuria, bowels constipated, sleep average eight hours, 
appetite fair ; skin : rough and oily, no menstruation, 
weight 111 pounds; blood count: hemoglobin 80 
per cent., red blood cells 4,100,000, white blood cells 
7,600, eosinophiles 2 per cent., general condition 
fair. 

C.ysE XIII. — Single, aged fifty-six years, under- 
nourished, hemorrhoids, irregular tremors of hands, 
rheumatoid arthritis ; blood pressure : systolic 160, 
diastolic 99 ; uranalysis : transient albuminuria, bow- 
els regular, sleep average four hours, appetite fair; 
skin: brown pigmentation, pale about mouth and 
nose, no menstruation, weight 110 pounds; blood 
count: hemoglobin 85 per cent., red blood cells 4,- 
200,000, white blood cells 8,800, eosinophiles 2 per 
cent., general condition fair. 

Case XI\'. — Married, aged fifty years, well 
nourished, physical examination negative, pulse 74, 
temperature 98.4°, respiration 20; blood pressure: 
systolic 128, diastolic 88; uranalysis: trace of albu- 
min and occasional casts, bowels regular, sleep five 
hours; .skin: flushing, no menstruation, weight 131 
pounds; blood count: hemoglobin 85 per cent., red 



32 



STRECKER AND KEYES: INVOLUTIONAL MELANCHOLIA. 



[New York Medical Journal 
AND Medical Record. 



blood cells 4,100,000, white blood cells 8,500, general ried, apprehensive, confused, restless, agitated, re- 
condition good. sistive. 

The blood Wassermann was negative in all four- Case X. — Onset at forty-nine, duration twenty 

teen cases. ' months, worried, depressed, selfaccusatory, irritable, 

.^,^^.^^ „r-^^-^T- .,-TTT. manic traits, depressive delusions, restless, agitated, 

MENTAL CONDITION OF PATIENTS BEFORE THE . . . ' K ■ i ^ j I »■ 

resistive, inipulsivelv violent, destructive. 

EXPERIMENT. „ Vt /-> : ^ • .^ j 

Case XI. — Onset at si.xty-two, duration sixteen 

To give a detailed description of the mental con- months, previous attack at fony-three (one year), 

dition of the fourteen patients who were studied worried, depressed, suicidal, selfaccusatory. appre- 

would add unduly to the length of this presentation, hensive, irritable, confused, depressive delusions. 

It will suffice to enumerate the prominent symptoms paranoid ideas, somatic delusions, restless, agitated, 

which were displayed. resistive. 

Case I. — Onset at fifty-five, duration five years. Case XII. — Onset at fifty-two, duration two years, 

five months, depressed, selfaccusatory, worried, ap- three months, recovery, worried, depressed, self- 

prehensive, irritable, suspicious, ideas of reference, accusatory, hypochondriacal, apprehensive, suspi- 

delusions of persecution, hallucinosis, somatic delu- cious. hallucinated, depressive delusions, somatic de- 

sions, restless, agitated. lusions, confused, restless, agitated, resistive. 

Case II —Onset at sixtv-one. duration six Case XIII.— Onset at fifty-four, duration three 

month'; depressed, suicidal, ' irritable, hvpochon- and a half years, worried, depressed, selfaccusatory, 

driacal somatic delusions, restlessness, agitation, suicidal, irritable, apprehensive, hypochondriacal, 

resistiveness. "Nervous prostration" at forty- restless, agitated, somatic delusions, impulsive, re- 

£.yg ' sistive, violent. 

r~ TTT /--, ^ ^ cc^ 1 ,-« + „ =„,o Case XIV. — Onset at fortv-seven, duration three 

Case III. — Onset at hftv. duration two years, . , ir , j ' ir . • j 

, , J ir' *„ , u^^ ; « and a half vears, depressed, selfaccusatorv. worried, 

two months, depressed, selfaccusatory, apprehensive, • ■ , , rp'stip^ pHtated 

irritable, confused, hvpochondriacal, somatic delu- 'rntabJe, restless, agitated. 

sions, depressive delusions, delusions of poverty, st.^tement of physical results. 

restless, agitation, destructiveness, resistive, violent. Physical changes occurring in each case during 

Case I\\ — Onset at sixty-one, previous attack at the three months of this experiment may be more 

table I 

SUMMATION OF PHYSICAL OBSERVATIONS 

Case number Totals 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 -|- — 

Physical Observations: „,, „ „ „ „ „ „, 

Pulse (daily) +10 0+8 0+6 0—8 3+1— 

Temperature (daily) +1"' +1=° — «,° 2+ 1— 

Respiration (da.ly) 0+4 0+6 --t 02+1— 

Blood pressure (every third day): „ „ -„ 

Systolic —10 —10 —30 —20 —5 —15 —20 +10 —30 —15 —10 —10 1+ 11— 

Diastolic —15 —15 —10 —15 —20 —5 —20 —10 —20 —10 —10 —15 —15 —15 0+ 14— 

Urinalysis (weekly) 00 

Bowels' daiW) !....:::. + + n 0. 2+ 

Sleep (hours' a night) + + + + + +6+0 

Appetite (gauge) + + + + + + 6+0 

Skin changes (note) 0+ 0+ + + +5+0 

Menstrual signs (note) + +2+0 

Weight-pounds (weekly) +2/. +8 +3'A +2 +3 +3Ji +4J4 +11 —5 +3}4 +3J4 10+ 1— 

Blood examination: 

Hb ~~ + — + — — 1+ ^ — 

S B C — — + + — 1+3— 

W B C + + + 3+0 

Eosin.' +4% +2% +2% +4% +4% +4% +7% +1% 8+ 

In columns headed Totals is indicated number of cases showing + or — results. 

forty-nine, duration two years, five months, de- easily understood by referring to the accompanying 

pressed, selfaccusatorv-, apprehensive, irritable, rest- chart which indicates results studied by comparing 

less, a<^itated, episodic violence, destructiveness. averages of first two weeks with those of last two 

Case \'. — Onset at fifty-four, duration four weeks, and taking into consideration any definite 

years, seven months, depressed, selfaccusatory, findings noted throughout course of medication, 

suicidal, irritable, hypochondriacal, somatic delu- (Table I.) 

sions, restlessness, agitation, resistivene.ss. summary of fourteen cases. 

Case VI.— Onset at fifty-one, duration eighteen p^^^^^ rate— A persistent increase was shown in 

months, recovery, worried, depressed, suicicial, ^-^^^^^ ^^^ ^ decrease in one. 

hypochondriacal, somatic delusions, hallucinating Temperature.— .\ rise of 1.2° was maintained in 

( ?), agitated, restless. tvvo and a fall of 5° in one case. 

Case \TI.— Onset at forty-seven, duration one Respiratorx ra/r.— This was increased slightly in 

year, depressed, selfaccusatory, irritable, poverty de- ,^^,q ^.35^5 J^,,•J decreased in one. 

lusions, agitated. Blood pressure. — Diastolic pressure fell in all 

Case VIII. — Onset at fifty-one, duration three fourteen cases from five to twenty mm. of mercury, 

years, worried, depressed, irritable, apprehensive, .systolic fell in eleven cases from five to thirty mm. 

suspicious, ideas of reference, persecutory delusions, of mercury, in two cases there was no change and 

somatic delusions, depressive delusions, visual hal- in one an increase of ten mm. of mercury, 

lucinosis (?), restless. Uraiialysis. — No definite change was shown in 

Case IX. — Onset at forty-eight, duration two urine. Several transient albuminurias were noted, 

years, three months, depressed, selfaccusatory, wor- but all of these had had previous similar findings. 



July 5, 1922.] 



STRECKER AND KEYES: INVOLUTIONAL MELANCHOLIA. 



33 



Boz,.-eh. — Changes were noted in two cases; one 
patient with obstinate constipation gradually re- 
turned to normal daily movements, another with a 
persistent diarrhea also returned to her normal 
routine. 

Sleep. — In six cases a gradual definite improve- 
ment was manifested in quality and quantity of 
sleep. 

Appetite. — This gained steadily in six cases, one 
from tube feedings to a ravenous eater, and another 
from spoon feeding to a gormandizer. 

Skin changes. — Changes in the skin occurred in 
five cases. These were recorded as those patients 
whose skin after being rough and oily, having areas 
of flushing and blanching, etc., returned to a normal 
condition. 

Menstrual changes. — These were noted in two 
cases. In one normal menstruation became estab- 
lished during the last month of therapy after an ab- 
sence of seventeen months. In the other case the 
periods became shorter and less troublesome from 
the viewpoint of irritability, pain, and general dis- 
comfort. All the other patients were past the climac- 
teric. 

Weight. — There was an increase in weight in ten 
cases from two to eleven pounds, while one patient 
lost five pounds and three showed no change. 

Blood e.vaniiiiations. — These examinations were 
inconstant in showing results, except that the hemo- 
globin decreased in four and increased in one ; red 
blood cells decreased in three and increased in one ; 
white blood cells increased in three cases. In the 
diflferential count, it was noticed that in eight cases 
there was an eosinophile increase from one per cent, 
to seven per cent, above their former examinations. 
In three cases the blood picture remained practically 
unchanged. 

Since the most constant change was in the blood 
pressure, a chart (Chart I) is presented, which 
shows the average change which occurred in the sys- 
tolic and diastolic readings. 

.ST.\TEMEXT OF MEXT.^L RESITLTS. 

It is never a simple matter to estimate even with 
approximate accuracy the direct effect of an isolated 
therapeutic agent. The difficulty is greatly increased 
when one is considering improvement or the reverse 
in the mental symptoms. There is a margin of error 
which cannot be eliminated. The most serious error 
to be considered is the natural tendency of a benign 
psychosis to reach a favorable issue. Furthermore, 
as is well recognized, there may be various tem- 
porary shiftings in the position of this or that symp- 
tom which may for an interval alter the complexion 
of the psychosis. With these reservations we may 
attempt to briefly discuss the changes which appeared 
in the rsental aspect of our patients. 

C.\SE I. — In this patient there was definite im- 
provement which amounted to practically a social 
recovery. After a two and a half months' period 
of hospital treatment, she was able to return to her 
home and successfully resume satisfactory relations 
with her family and the active care of her hou.se- 
hold. Motor activity dropped to a normal level: the 
emotional tone and the clelusional formation which 
it colored are not now in evidence ; cooperation in 
the matter of occupation and food was excellent 



when she left the hospital. One cannot be certain 
either that the hallucinosis has entirely disappeared 
or that there is clear insight. 

C.\SE II. — Only received six injections. Consid- 
erable improvement was present before the medica- 
tion was used, the slight restlessness which still re- 
mained soon disappeared and the patient is now 
doing well at home. 

C.\SE III. — There was no improvement. 

C.:s^SE R'.— In this patient, the motor activity is 
at a lower level ; the outbreaks of episodic violence 
are somewhat less frequent. The most important 
gain has been a broadening of interest in the direc- 




CiiAKT 1. --Blood pressure averages, upper tracing systolic, lower 
diastolic. Medication was started on October 27th. 

tion of occupation. The emotional tone is not modi- 
fied to any extent. 

C.\SE V. — There was not enough change to con- 
stitute an improvement. 

C.-vsE \T. — After ten months' hospital treatment, 
this patient was able to return to her home markedly 
improved. Her motor activity was much lessetied ; 
her suicidal tendencies disappeared and she attained 
a fairly satisfactory affect level. 

Case YII. — In this patient there has been con- 
sistent improvement. Depression is .still present, 
but it is more accessible to environmental stimuli and 
lost its irritable ironic aspect. With the broadening 
f)f contact with reality there has appeared increasing 
interest in occupation and occasional initiative. 

Case VHI. — Beyond a moderate lessening of 
motor activity, there has not been any improvement. 



34 



HORXSTELV: POSTPARTUM HEMORRHAGE. 



[New York Medical Journal 
AND Medical Record. 



Case IX. — Here there may be recorded only a 
minor reduction of pathological activity with some- 
what less rigid resistiveness. 

Case X. — This patient is less deeply depressed ; 
she is more in touch with het surroundings and is 
more coopeiative and her range of interests is wider. 

Case XI. — In this rather extreme example of an 
involutional psychosis, the periods of severe appre- 
hensiveness, agitation, and depression have de- 
creased in frequency. Her insight, though still in 
a vague and uncertain state, is beginning to appear. 

Case XII. — The patient was able to return to her 
home after a period of six months. Xow she is 
aparently entirely well with the exception of a ten- 
dency to insomnia and a few subjective sensations. 

Case XIII. — Although this patient cannot be 
listed as a recovery, she did show enough improve- 
ment to justify a trial visit to her home. Both the 
emotional tone and its concomitant motor expression 
gradually became less pronoimced ; the somatic delu- 
sions were favorably modified and partial insight 
was acquired. The period of hospital treatment was 
ten months. 

Case XIV. — This patient will probabl}- soon be 
able to leave the hospital. Tlie depression is dis- 
appearing ; the restlessness is under control ; there 
is more initiative, and particularly, there is the de- 
velopment of insight. 

SUMM.ARV. 

The most important and definite physical changes 
resulting from this experiment may he briefly sum- 
marized as follows : 

All fourteen patients showed a drop in diastolic 
blood pressure and in eleven patients a drop in 
systolic pressure ; ten patients gained in weight, six 
improved markedly in appetite, six showed improve- 
ment in quantity and quality of sleep, one reestab- 
lished menstruation after an absence of seventeen 
months, in one there developed a decided improve- 
ment in troublesome menstrual manifestations, and 
eight showed rise in the percentage of eosinophiles. 



No one patient is any worse than before medication 
started and there is a noticeable improvement in the 
general physical condition of the group as a whole. 

It is somewhat difficult to discover adeqtiate terms 
with which to express comparative degrees of men- 
tal improvement. From the social viewpoint which 
impHes sufficient amelioration of symptoms and the 
resumption of enough contact with reality to make 
family and community life feasible, six of our pa- 
tients may be said to have made a recovery. How- 
ever, since some connection between the experi- 
mental medication and the present status of the 
patients is implied, two of them must be eliminated 
from the statistics. In one instance, the injections 
were given only a few times and in the other we 
must be somewhat skeptical regarding the probable 
endurance of even the qualified recovery. There 
remain four patients who remarkably improved after 
an average hospital treatment of seven and a half 
months. Four additional patients showed definite 
improvement and finally there were four in whom 
only ininor favorable changes or none at all could 
be noted. 

conclusions. 

Although no definite connection between any of 
the symptoms of socalled involutional depression 
and ovarian function has been determined, it seems 
probable that in a limited number of patients the 
injection of ovarian extracts exerts a favorable in- 
fluence on the general physical status and perhaps 
more particularly it lowers and stabilizes tlie blood 
pressure, while possibly in a small group a cor- 
responding helpful influence is exerted on the course 
of the psychosis. 

REFERENXES. 

1. TiMME. Walter: Clinical Endocrinology, Neurologi- 
cal Bulletin, vol. iii, January, 1921, No. 1, p. 27-28. 

2. Strecker. Edw.ard A. : Certain of the Clinical As- 
pects of Late Katatonia, with a Report of Cases, American 
Journal of Insanity, vol. Ixxiv, No. 2, October, 1917. 

4401 Market Street. 



One Hundred Gases of Postpartum Hemorrhage* 

By MARK HORNSTEIN, M. D., 
New York, 

Assistant Attending CTbstetrician, Berwind Maternity Clinic; Adjunct in Obstetrics, Jewish Memorial Hospital. 



Bleeding from the uterus after childbirth being 
almost of constant occurrence, the term postpartum 
hemorrhage is to some extent an arbitrary designa- 
tion. It is difficult, therefore, to estimate the fre- 
quency of this complication with reasonable exact- 
ness. In the present report, definite cases of exces- 
sive bleeding from the uterine cavity have been se- 
lected to the number of one hundred. These are rep- 
resentative of 4,200 consecutive deliveries in the 
service of the Berwind Maternity Clinic and in ])ri- 
vate cases. The ratio of one case of postpartum 
hemorrhage to forty-two labors compares with tlie 
incidence of one in fifty-eight reported by Rice at 
the Manhattan Maternity Hospital. 

•Read at a meeting of the Yorkville Medical Society, May 15. 1922. 



Various observers, notably Ahlfeld, have made 
routine measurements of the amount of blood lost 
after labor and found that from three to five hun- 
dred c. c. represents about the normal loss; that 
much larger quantities may be lost without symp- 
toms ; and that, in exceptional cases, as mucli as four 
litres of blood have been lost without fatal result. 
Since women react to hemorrhage in varying de- 
grees, and since death has frequently followed hem- 
orrhage of one litre, quantitative determinations be- 
come of academic importance, as no wise attendant 
in a case of parturition will permit bleeding amount- 
ing to litres. Moreover, it has happened frequently 
in our series that a threatening hemorrhage which 
impelled radical measures for its arrest eventually 



July 5. 1922.] 



HORNSTEIN: POSTPARTUM HEMORRHAGE. 



amounted to a smaller total loss of blood than a slow 
protracted case in which less heroic methods were at 
first deemed sufficient. 

Among the one hundred cases of hemorrhage 
there were twenty-one primipara; and seventy-nine 
multiparse; this was about the proportion of parity 
in the service. In twenty-two cases there was con- 
comitant retained or adherent placenta. There was 
one death in a case of hemorrhage with adherent 
placenta. In this case, a secundipara who had had 
a protracted but spontaneous labor, shock developed 
following moderate bleeding and when this was 
arrested no attempt was made to remove the pla- 
centa. Fifty-one labors terminated spontaneously, 
while forty-nine required some form of assistance. 
The latter consisted of seventeen cases of podalic 
version, sixteen applications of forceps, four breech 
■extractions, and four cases of assisted twin births. 
Version was performed for the following indica- 
tions : two for prolapsed cord, four for placenta 
prsevia, one for transverse presentation, six for un- 
engaged head in occiput posterior position, and four 
for the termination of induced labor. Induction of 
labor was done in two cases for prolonged gestation, 
in one for chronic nephritis, and iti one for endo- 
carditis with contracted pelvis. Six patients pre- 
sented possible predisposing causes for hemorrhage : 
one had endocarditis, three had nephritis, and two 
experienced hemorrhage after spontaneous prema- 
ture labor. Personal notice of individual predisposi- 
.tion was had in seven patients; of these six had the 
complication with two successive labors, and one 
with three successive labors. The ages of the pa- 
tients in the whole series ranged from fourteen to 
fifty-four, but no conclusions as to predisposition on 
:account of age could be drawn. 

That the duration of labor influences the occur- 
rence of postpartum hemorrhage is known. It has 
not been feasible to tabulate the length of labor in 
the several thousand cases for the purpose of com- 
parison. Beside, the onset of labor in many cases 
being indefinite, the duration of labor cannot always 
be determined. Some conclusion may, however, be 
justified from the observation that although in only 
fifteen per cent, of all cases was interference re- 
quired, this class contributed fifty per cent, of the 
hemorrhages. Since, general speaking, these pa- 
tients had been a longer time in labor, and since 
blee'.ings from lacerations are not here considered, 
these having never been excessive, it may be stated 
that prolongation of labor, f^er sc, did prove an im- 
portant factor in the causation of postpartum 
hemorrhage. In this connection some allowance 
may be required for the etTect of anesthesia, but 
this was generally counteracted by the administra- 
tion of pituitary extract inmiediately prior to or 
soon after the termination of the second stage. 

Essential inertia uteri was given in a number of 
cases as the only etiological factor. The exact num- 
ber could not be dei)ended upon, because this condi- 
tion can only l>e ascertained after exclusion of all 
other abnormalities. .Mthough inertia is attributed 
to various diseases of the mother. un(l(nibted cases 
of primary inertia have been seen in apparently 
healthy women. Inertia is often associated with 
arlherent jilacenta and this combination is not amen- 
able to treatment with i)ituitary or ergot. 



A number of cases of postpartum hemorrhage are 
caused or accentuated by faulty management of the 
last stages of labor, such as rapid extraction of the 
fetus or second twin, by excessive manipulation of 
the fundus uteri before complete separation of the 
placenta, by premature attempts to express the pla- 
centa, by failure to hold down the fundus after its 
expulsion, and last but not least, by abandoning the 
uterus with retained blood clots or placental "rem- 
nants. In regard to retained portions of placenta, 
the most careful inspection failed in several in- 
stances to disclose any missing parts, though these 
became evident subsequently by their spontaneous 
passage or by manual removal in the course of re- 
vision of the uterine cavity in cases of postpartum 
fever. This elusiveness has led to the conviction 
that accessory placentae are more common than is 
usually believed. Six cases of retained placental 
tissue came to notice in the records, bu-t as in manv 
instances they are passed spontaneously without fur- 
ther ado, the actual number was undoubtedly much 
greater. In one of these six cases hemorrhage fol- 
lowed the placenta, in two cases bleeding took place 
when the patient left the bed, two exhibited fever 
without excessive bleeding, and one had an other- 
wise uneventful puerperium. 

That hemorrhage may occur after easy labors is 
borne out by four cases in precipitate labor. Two 
of these were ascribed to delay in arrival of atten- 
dant. 

DEATHS FROM POSTPARTUM HEMORRHAGE IN THE 
UNITED STATES. 

The reports on vital statistics of the United States 
Bureau of the Centsus are worthy of study in esti- 
mating the death rate from hemorrhage following 
childbirth. In the year 1919 there were reported 
from the registration area 14,488 puerperal deaths. 
These included deaths from pregnancy. The rate 
for each thousand living births was 7.4, an increase 
oyer the year 1915 of 1.3 to the thousand living 
births. The largest number of deaths, about one 
third, was ascribed to sepsis ; the next largest toll 
was exacted by the toxemias which caused ,3,592 
deaths: there were 1,175 deaths ascribed to postpar- 
tiim hemorrhage, a rate of 0.6 to the thousand living 
births. There is another group of deaths accounted 
for by the heading Other Accidents of Labor, with 
2,087 deaths. It seemed that the number of deaths 
ascribed to hemorrhage is smaller than the actual 
number, and that the more than two thousand deaths 
given under other accidents of labor are in reality 
in large measure deaths caused l)y hemorrhage. 
Upon inquiry at the bureau as to what con.stitute the 
chief causes of death listed under Other Accidents 
of Labor a list was returned which contained no less 
than fifty certifications, Inrt the four most im|xjr- 
tant causes given were: Childbirth (without further 
qualification), difficult labor, instrumental delivery, 
and Cwsarean section. It is evident that the first 
three conditions given cannot in themselves explain 
so many deaths and that in a large number of these 
cases hemorrhage was the chief contributing factor. 

PROPHYLAXIS. 

The ])reveiition of postpartum hemorrhage de- 
pends in large measure upon the i>roper management 
of labor. In given ca.ses what appears to be the 



36 



HORNSTEIN: POSTPARTUM HEMORRHAGE. 



[New York Medical Journal 
AND Medical Record. 



better management of the labor enhances the chances 
of subsec|uent hemorrhage. In most difficult labors 
one finds it advisable to allow ample time for Nature 
to take its course, to the end that the os become suffi- 
ciently dilated and a maximum degree of moulding 
of the head enable engagement. Premature inter- 
ference is a greater danger to the child than undue 
prolongation of labor, in most cases, and subjects 
the maternal soft parts to greater liability to injury. 
It follows that exercise of conservatism, which is 
exceedingly desirable in these cases, may cause uter- 
ine exhaustion and requires the anticipation of, and 
the preparation for coping with, a postpartum hem- 
orrhage. This complication should, however, be 
responsible for very few, if any. maternal deaths. 
Without assumption it may be stated that from the 
viewpoint of conservation of maternal life postpar- 
tum hemorrhage occupies, potentially, first rank in 
obstetrical prophylaxis. 

A certain number of hemorrhages can be avoided 
by proper management of labor. While time is the 
most efficient factor in obstetrics labor is often al- 
lowed to become unreasonably prolonged through 
the oversight of some minor abnormality. One 
which is not commonly emphasized is abnormality 
of the bag of waters. Absence or scant amount of 
liquor amnii is a condition not infrequently met with, 
especially in primiparx. This condition, aside from 
failing to assist the dilatation of the cervical os, 
hinders the efficiency of the uterine contractions and 
delays descent and moulding of the head. A similar 
negative effect is produced by excessive liquor amnii, 
which tends to keep the presenting part floating, and 
the uterine muscle overdistended. Recognition of 
these minor abnormalities and their proper manage- 
ment will shorten the duration of labor in these cases 
and thus prevent exhaustion of the uterus. Pro- 
vided that the cervix is totally effaced and the os 
dilated to at least two fingers, delayed labor caused 
by excessive liquor amnii may be favorably bene- 
fited by rupturing the amniotic sac. In the case of 
absence of liquor amnii the same procedure may be 
employed or a hydrostatic bag introduced. 

Although the administration of pituitary extract 
before the conclusion of the second stage is being 
discouraged of late and extensive experience with 
this proctuct has revealed its limitations and its capa- 
bility to create unpleasant situations, when given at 
the wrong time or in excessive doses, it is difficult 
to overlook its advantages in well selected cases and 
in moderate doses. While one c. c. is usually given 
after the birth of the child three tenths c. c. should 
be the maximum dose during the second stage. The 
third stage has been found to be shortened when 
])ituitary extract is injected immediately after the 
birth of the child, but this seems to be true only in 
cases of normal third stage, for often it fails en- 
tirely to bring about the separation and expulsion of 
the placenta when the latter is pathologically adher- 
ent or in the presence of true inertia uteri. The 
administration of pituitary extract at the end of the 
second stage of labor is, therefore, in a sense a test 
as to the probaliility of eventual spontaneous birlh 
of the ])lacenta. When the latter fails to come away 
thirty minutes after the injection of one c. c. of 
pituitary extract of proved potency, it is an indica- 
tion that the placenta remains adherent. In such 



event one will guide himself according to the amount 
of bleeding. The fundus titeri should be held gently 
while the placenta is still attached. This is designed 
for the prevention of a large retroplacental hema- 
toma or filling up of the uterine cavity with blood, 
but not to promote contraction of the uterus. Ahl- 
feld and those adhering to his rule do not attempt 
to aid expulsion of the placenta for a period of 
two hours, unless there is hemorrhage. This seems 
an expenditure of time out of proportion to its bene- 
fits, as in many cases Crede expression becomes 
necessary in the end. A reasonable rule is that no 
expression be attempted until there is evidence of 
complete separation. Numerous signs of separation 
are described by various authors, the most depend- 
able being : flattening of the fundus in the antero- 
posterior diameter ; a gush of blood from the uterus ; 
increased mobility with assumption of a globular 
shape by the fundus during the contraction period. 
Subjectively, the patient often complains of slight 
pain across the suprapubic region, and there is ten- 
derness on pressure over the fundus. 

After expulsion of the placenta the fundus is 
held down firmly for from thirty to forty-five min- 
utes, and is then left to its own resources for a pro- 
liationary period of about ten minutes. At the end 
of this period the fundus is compressed in Crede 
fashion and if any clots or an appreciable quantity 
of blood comes out it is a sign that the uterus is 
not yet capable of maintaining its retractibility and 
must be supported for another period of ten to 
twenty minutes, depending upon the quantity of 
blood expressed. It is erronetmsly believed that a 
hard fundus precludes the probability of hemor- 
rhage when as a matter of fact it often denotes free 
blood in the uterine cavity. 

Important as all the precautions for the preven- 
tion of postpartum hemorrhage may appear, the ac- 
cident is liable to complicate labor in spite of strict 
observance of all the established rules of procedure. 
The management of this complication assumes, there- 
fore, paramount importance. 

TREATMENT. 

Whenever there was persistent bleeding in spite 
of adoption of the measures outlined above, and the 
amount of blood lost was considered as approaching 
the threshold of danger, resort was had to tam- 
jjonade of the uterine cavity, cervix and vaginal 
canal. In a number of cases, where there was pro- 
crastination in the belief that packing might be 
avoided, the patients went into alarining shock and 
required considerable effort to bring them around. 
For some reason most descriptions of the treatment 
of postpartum hemorrhage proceed to enumerate a 
series of methods for coping with this accident, and 
advise last of all packing. From the number of 
tentative measures advised it is evident that none of 
them is dependable. But most authorities agree that 
packing is <|uite reliable in arresting bleeding from 
the uterus, and, as the evidence points not only to 
its efticacy but also to the safety of this procedure, 
there is no motive in temiK>rizing with less efficient 
means. Some failures have been reported but the 
technic has not been uniform. Some have made use 
of insufficient gauze, others were content to pack 
only the cervix and vagina, while still others at- 



July 5, 1922.] 



HORNSTEIX: POSTPARTUM HEMORRHAGE. 



37 



tempted to apply tampons against the placental site. 
Those who practiced routine tamponade of the whole 
tract, like Grandin and Jarman, have nothing but 
praise for the procedure. The operation of tampon- 
ing was performed forty-seven times in the present 
series. It has not failed to arrest hemorrhage in 
a single instance, and repacking has never been nec- 
essary. In only one case was packing followed by 
a serious complication, phlegmasia ; this occurred in 
a primipara with uterus unicornu, who had also had 
the placenta removed manually. 

The simplest equipment found suitable and finally 
adopted for the performance of tamponade consisted 
of one glass ttibe twelve inches long, two inches in 
diameter, filled with a ten yard gauze bandage, six 
inches wide; and a tubular uterine packer, one com- 
monly known as rapid packer, half an inch in di- 
ameter, which will allow the passage of gauze of the 
width mentioned. The use of the instrument and 
the width of the gauze present certain advantages 
which are important. The bandage has the advan- 
tage over plain gauze in that it is free from loose 
strands, while its width shortens the time required 
for packing. The diameter of the tube has been 
found sufficient for the passage of six inch bandage 
without causing jamming, provided that each bite 
with the obturator does not consist of more than 
about two inches of bandage. This system is pre- 
ferable to other methods because it renders the 
operation clean by preventing the gauze from com- 
ing in contact with the vagina. It causes the patient 
very little pain, requires no trained assistants and 
can be employed without assistance in an emergency, 
and with the patient either across the bed, in the 
lengthwise position, or on a table. The uterine cav- 
ity and vagina can be thoroughly tamponed in this 
manner in a few minutes, and the employment of a 
single bandage renders unpacking easier. 

The external surfaces must always be kept in 
aseptic condition in anticipation of packing, but no 
part of the gauze need be allowed to touch any part 
of the patient's body if the assistant, holding the 
tube containing the packing on the operator's right, 
keeps this at a suitable distance from the mouth of 
the packer — about six inches. Counterpressure on 
the fundus may be exerted by an assistant or the 
operator does this intermittently after passing two 
yards of gauze. As the uterine cavity fills up with 
gauze the packer recedes gradually when the cervical 
and vaginal canals are filled with the remaining part 
of the packing. As a rule seven to nine yards of this 
width of bandage suffices to pack the whole tract. 
The packing is extracted in from twelve to eighteen 
hours, the fundus uteri being massaged during the 
jjulling out of the gauze and firmly compressed 
afterward, for the purpose of s(|ueezing out any clots 
which may have remained behind the packing. 

For successful packing by this tnethod the precau- 
tion must be taken that the tube is guided into the 
uterine cavity proper before introducing the gauze, 
that each bite of gauze is not longer than two inches, 
and that fairly firm coiuiter])ressure is exerted on 
the fundus, so as to render the gauze tight inside 
the cavity. It is also advisable i)rior to packing to 
.scoop out all clots from the uterus manually, lest 
they cause severe afterpains, which should be re- 
lieved by codeine without disturbing the pack. 



When bleeding occurs while the placenta is still 
in utero, the obstetrician is confronted with a situa- 
tion which demands much nicety of judgment. The 
first thing one does in such cases, assuming that an 
injection of pituitary extract has already been given, 
is attempt to arrest the bleeding by compressing the 
uterus. In many cases this will suffice for a time 
until the placenta becomes completely detached and 
can be expressed. Compression of the aorta, a 
method much advocated of late, inay be of special 
value in arresting hemorrhage in cases of adherent 
placenta. 

When the hemorrhage continues in spite of 
the three measures — pituitrin, compression of the 
aorta, and compression of the uterus — and if the pla- 
centa cannot be expressed by the Crede method, one 
must prepare to remove the placenta manually; and 
this must be performed before there is sufficient loss 
of blood to give rise to symptoms. The hazard in- 
volved in manual separation of the placenta is ac- 
cording to some authorities, not as great as was 
generally believed, but there is still a great differ- 
ence of opinion on the subject. In 1915, Polak, in 
discussing adherent placenta, advised strongly 
against manual removal from below and recom- 
mended hysterotomy and removal of the placenta 
through the abdominal incision. This line of treat- 
ment was favored probably because in a special study 
of two thousand labors Polak encountered adher- 
ent jjlacenta only once. In the same year, at the 
Rotunda, they met with twenty-eight cases in 2,070 
deliveries. Hirst's incidence is one in 1,000 cases; 
Reynolds', three in 1,000; while Rice reported six 
cases to the 1,000 labors at the Manhattan Mater- 
nity. Rice also reported a hundred adherent pla- 
centas removed manually without a fatlity and with 
only three cases of fever above 101°. Rogoff stud- 
ied the records of 52.000 labors at the Moscow 
Maternity which included 1,243 manual reiuovals ; 
and Baumm, who compiled statistics of seventeen 
German clinics comprising 20,418 labors with 24.S 
manual removals both conclude that manual removal 
of the placenta per se does not carry much danger 
of infection, if properly performed. The latter 
ascribes most cases of mortality and morbidity fol- 
lowing manual removal to the poor condition of the 
mother due to loss of blood and counsels against 
bleeding. 

One also finds in the literature an under- 
current of belief that puerperal infection is not en- 
tirely a condition introduced from without and sup- 
port is adduced in favor of this theory by the cita- 
tion of cases of sepsis following spontaneous deliv- 
eries without any vaginal examinations. 

In our series of hemorrhage cases the placenta 
was extracted manually in seventeen cases, resulting 
in one case of plegmasia alba dolens. While there 
is difference of opinion regarding the danger of 
manual removal, practically all agree that there is no 
choice in the matter when the condition is accom- 
panied by hemorrhage. Reference has been made to 
the views on the subject outlined above only in 
support of a plea for less hesitation in removing the 
placenta in cases of blecfling. Aside from the more 
or less theoretical contention that there is less risk 
of infection if there has been less loss of blood, 
there are some substantial considerations why an 



38 



BRANDT: PREGNANCY AFTER MENOPAUSE. 



[New York Medical Journal 
AND Medical Record. 



adherent placenta should be removed early in cases 
of hemorrhage. One of these is that women seem 
to tolerate less loss of blood with the placenta re- 
tained than they do with the placenta out. Whether 
this is due to the psychic factor associated with the 
superstition with which the laity regard retention of 
the placenta is difficult to state. Another considera- 
tion is that thorough removal of an adherent pla- 
centa is a painful and somewhat delicate operation 
and requires putting the patient under anesthesia 
for proper performance. It is preferable, therefore, 
that the patient be in good physical condition when 
manual removal is undertaken. The most important 
point in connection with the technic of manual re- 
moval, outside~of perfect asepsis, is that no particle 
of placenta be left behind. It is advisable, therefore, 
after the placenta has been extracted, to reintroduce 
the hand and palpate systematically the whole sur- 
face of the uterine cavity. It is also advisable, espe- 
cially if the loss of blood has alread}- been appre- 
ciable, to tampon the uterus thereafter, since in many 
cases removal of the placenta is not sufficient to 
arrest the hemorrhage. 

A few of otir patients have sustained losses of 
two quarts of blood without exhibiting symptoms, 
while others commenced to complain after hemor- 
rhage of much smaller proportions. In moderate 
degrees of anemia the foot of the bed is raised about 
eighteen inches, the patient is given fluids in small 



quantity repeatedly, morphine, pituitrin, ergot and 
Murphy drip. The body is kept warm and the win- 
dow open. In severe cases the patient may refuse 
to take fluids by mouth or may vomit. Resort must 
be had then to hypodermoclysis. This should 
always be given when the pulse is over 130 
and fails to improve within a short time after arrest 
of bleeding. Usually a thousand c. c. of saline solu- 
tion will produce considerable improvement in the 
patient's condition, but sometimes this has to be 
repeated in about eight hours. In ten of the cases 
hypodermoclysis was employed. Blood transfusion 
was prepared for in one alarming case, but was dis- 
pensed with as the patient rallied by the time the 
donor had been tested. 

CONCLUSIONS. 

Of all the maternal deaths associated with preg- 
nancy, childbirth, and the ptierperal state postpar- 
tum hemorrhage contributes the third largest num- 
ber. The largest number of maternal deaths amen- 
able to prevention are those caused by postpartum 
hemorrhage. Tamponade of the uterus, cervix, and 
vaginal canal offers the most dependable method for 
arresting postpartum hemorrhage. Adherent pla- 
centa, when accompanied by even moderate bleed- 
ing, is serious and impels manual invasion of the 
uterine cavity for its removal irrespective of the dan- 
gers involved in the operation. 

1425 M.^msoN Avenue. 



Report of a Case of Pregnancy Following the Menopause 



By MURRAY L. BRANDT, M. D., 

New York. 



Although pregnancy occurring late in life is not 
a rare condition, in nearly all of the published 
records of such pregnancies, persistence of menstru- 
ation beyond the usual time of the climacteric was 
noted. Thus there are reported cases of pregnancy 
occurring in women of fifty-five and sixty-five years, 
who up to the date of conception were menstruating 
more or less regularly. To find conception taking 
place after the menopause has been definitely estab- 
lished, is a much rarer event. 

Case. — Mrs. S. S., forty-six years of age, began 
to menstruate at thirteen, was alwa3^s regular every 
twenty-eight days, married at eighteen years and 
since then had eleven pregnancies resulting in twelve 
children. The last labor occurred at thirty-nine 
years of age. Following this labor, the patient men- 
struated regularly for a year, the last period occur- 
ring in June, 1916. 

In March, 1919, she applied for treatment for an 
increasing size of her abdomen, increasing weight 
and intraabdominal movements. Examination 
showed a nnich enlarged pendulous abdomen, fundus 
of uterus above umliilicus, fetal parts not definitely 
distinguished and no fetal heart could be heard. A 
diagnosis of ])regnancy was suggested and on ex- 
amination a month later distinct fetal parts and fetal 
movements were found. 

In May, 1919, the patient was delivered of a male 



child weighing nine pounds. Incidentally this child 
showed all the signs of achondroplasia. Ten months 
after the birth of the child the patient, after weaning 
the baby, began to menstruate and had three normal 
periods. The menses have not returned since then. 

COMMENT. 

Although the patient presented a large uterus, the 
diagnosis of pregnancy at the first examination was 
rather difficult because of the vague history of intra- 
abdominal movements since the cessation of menses 
three years before. A diagnosis of fibroid uterus 
had been made elsewhere and operation was urged. 

The literature discloses only five other authentic 
cases of pregnancy occurring after menopause. 

REFERENCES. 

Priou : Last child at forty-eight ; nursed baby and no 
menses followed. At seventy-two menstruated for six 
hours, then ceased for eight weeks and had a definite two 
months' abortion. Bull, dc la Soc. dc Med. d'Angcrs. 1865. 

Lev.\sseur: Menopause at fifty; pregnancy two years 
later. Ga:. Hebdomadairc, 1873. 

Underbill: Menopause at forty-nine; pregnancy two 
years later. American Journal of Obstetrics, 1879. 

Depasse: Menopause at fifty-nine; pregnancy nine years 
later. Ga::. de Gynecol. 1891. Paris. 

Hann: Pregnancy occurred three years after meno- 
pause. Following birth of child menses returned, .lour- 
nal of Obstetrics and Gynecology of British Empire, 1903 

161 West Eightv-sixtii Street. 



July 5, 1922.] 



ROTTENBERG AND SCHWARTZ: OOPHOROTOMY. 



39 



A Plea for Oophorotomy on All Pathological Ovaries and 
Resection of Diseased Tissue 



By SOLOMON ROTTENBERG, M. D., 
and GEORGE SCHWARTZ. M. D., 

New York. 



This plea for ovarian section in all pathological 
ovaries and resection of diseased tissue, is based 
upon the findings of two cases in which the patients 
were recently operated upon by us in the People's 
Hospital. 

CASE HISTORIES. 

Case I. — Miss C. E., aged nineteen, came to the 
hospital complaining of pain in the right lower 
quadrant, nausea and vomiting. She had never be- 
fore been seriously ill. The family history was nega- 
tive. Her last menstruation was two weeks before, 
accompanied by severe menorrhagia and dysmenor- 
rhea. The pulse was 90; temperature 100.05^. F. ; 
blood count: white blood cells, 12,000; polymorpho- 
nuclears 85 per cent. The urine examination was 
negative. There were no urinary symptoms and her 
other complaints had no bearing upon the diag- 
nosis. 

The physical examination of the patient 
showed heart and lungs normal. The abdomen ; 
slight tenderness and rigidity over McBurney's 
point, otherwise negative. The patient was oper- 
ated upon and an acute catarrhal appendix was 
found and removed ; and following our usual 
routine, her pelvic organs were explored. The left 
ovary and both tubes looked normal, but the right 
ovary looked somewhat larger. This was split by 
cutting with a sharp scalpel through the convex 
outer border of the ovary from one pole to the 
other down to the pedicle. A small incapsulated 
tumor the size of a small grape was found and 
easily shelled out and removed from the central 
stroma. 

Pathological examination showed it to be 
a typical dermoid cyst, containing some hair and 
toothlike bone. The patient made an uneventful 
recovery, and we have lost trace of her since her 
discharge from the hospital. 

Case II.- — Mrs. L. R., aged twenty-nine, married, 
four children. Complained of backache with gener- 
alized lower abdominal pain, which increased at each 
menstrual period. .She also complained of menor- 
rhagia. 

The laboratory findings were normal. The 
general physical examination was negative. Vaginal 
examination showed a second degree retroversion 
of the uterus and bilaterally enlarged ovaries which 
were prolapsed ancl adherent to the pelvic perito- 
neum. 

The operative procedure consisted of sus- 
pending the uterus and splitting the ovaries as in 
the last case. Here in the left ovary a small tumor 
was also shelled out of the medullary portion of the 
ovary, which also yjroved to be a small dermoid cyst. 
The right ovary showed multiple simple cysts which 
were excised and this ovary also sewed up as in the 



last case. The patient made an uneventful recovery, 
and as in the previous case we lost trace of the 
patient since her discharge from the hospital. 

COMMENT. 

These two cases are cited because heretofore it 
has been the custom with us, as well as with many 
other surgeons that we have seen operate, to make 
simple punctures with the needle or scalpel into 
whatever portion of the ovary seemed to be imder 
tension, and feel assured that the patient was bene- 
fited and cured of her clinical symptoms by this 
procedure. This has for a long time appeared to us 
to be inadequate and incomplete, since most ova- 
rian tumors have their origin in the stroma, and they 
do not appear on the surface before the growth is of 
sufficient size, and then only a macroscopic diagnosis 
can be made. 

literature. 

Marchandt (1) and Bonnet found a preponder- 
ance of embryomata in the medullary portion of the 
ovary. These embryonal rests may remain dormant 
for many years and suddenly grow to enormous 
cysts. Pfannenstiel (2) reported that he found ac- 
cidentally small tumors in the medullary portion of 
the ovary in young girls during operations and post- 
mortems. He believed that in time these would 
have grown to large dermoids and other types of 
cysts. His experience practically coincides with our 
two cases which would positively have been over- 
looked by the customary procedure of puncture, 
and could only have been found by oophorotomies. 
Pfannenstiel was one of the earliest writers to advise 
operation for demioid cysts. We are urging a pro- 
cedure that will make it possible for earlier diag- 
nosis of ovarian growths in such ovaries that show 
evidence of pathology. Jones (3) in 1913 asserted 
that the treatment for all suspicious ovaries was 
oophorotomy, for fre(|uently small tumors in the 
medullary portion of the ovary were overlooked 
unless the ovary was split in half. Mayo (4) states 
that seven per cent, of all dermoid cysts of the ovary 
are malignant, and the patients show very few men- 
strual disturbances. Bland (5) states that twenty- 
five per cent, of the cysts of the ovaries are malig- 
nant, although pronounced benign by the pathologist. 

plan of procedure. 

After clamping the ovarian pedicle to control 
hemorrhage, we split the ovary in half by cutting 
the convex free border from pole to pole, down to 
the pedicle, much in the same manner as a kidney is 
split in nephrotomy. We now remove any diseased 
tissue that we may find, and in this manner we are 
sure not to overlook any hidden tumor. We then 
place a mattress suture through the ovary near the 
pedicle, which coiurols all bleeding from the small 



40 



BARNES: SPECULUM. 



[New York Medical Journal 
AND Medical Record. 



capillary branches of the ovarian artery after the 
clamp is removed. The cut margin of the ovary of 
the convex border is whipped together with fine 
continuous catgut lockstitch, and the procedure is 
finished without injury to the function of the ova- 
ries. 

CASES WHERE THIS IS APPLICABLE. 

1. Where the ovary is large and seems cystic. 

2. Where there are symptoms of menorrhagia. 
metrorrhagia and dysmenorrhea of ovarian origin. 

3. In all suspicious looking ovaries. 

Martin and Jung (6) state: "Primary ovarian 
carcinoma develops from the germinal epithelium by 
unlimited proliferation into the deeper tissues, and 
although the ovary is getting larger, the surface re- 
mains smooth and does not become nodular until the 
carcinoma permeates through the capsule, reaches 
the surface and then rapidly gives rise to a general 
peritoneal cancer." They assert that at an early 
stage these ovaries seem normal, except for being 
slightly enlarged, but on splitting the ovary the 
nodules can be easily felt and an early removal of 
the ovary is a lifesaving procedure. This one type 
of case would suffice to warrant the sectioning of all 
suspected ovaries and the two cases cited certainly 
justify our plan of procedure. In conclusion, we 
again wish to state that most ovarian cysts, espe- 
cially dermoids, arise from embryonic rest in the 
medullary portion of the ovary. Simple cysts which 
grow to large proportions, also originate in the 



medullary fxjrtion. The small cysts on the surface of 
the ovary rarely grow large enough to cause any 
disturbance, therefore, the cysts that cause the most 
trouble are those originating in the medullary por- 
tion of the ovary, which would be entirely over- 
looked unless the ovary is split in half. 

CONCLUSIONS. 

1. Splitting of the ovary for examination where 
the appearance is pathological is a harmless proce- 
dure. 

2. In all suspected cases opening the ovary is 
entirely justifiable, as by so doing we can discover 
hidden tumors which we would otherwise miss. 

3. We have twice fovmd dermoids in the sub- 
stance of the ovary, which would have been missed, 
had we simply punctured the ovary. 

4. The plan of procedure is simple and thorough. 

5. It is applicable only in enlarged ovaries and 
those suspected of being in a pathological condition 
by the clinical symptoms. 

REFERENCES. 

1. Bard, J.: Medical Obscrz-citions and Injuries, Lon- 
don, 1864, p. 236. 

2. Pfannenstiel : Handbuch dcr Gynekologie. Wies- 
baden, vol. cxi, 1899. p. 140. 

3. Jones, J. : Surgcrv, Gxnccology, and Obstetrics, Jan- 
uary, 1913. 

4. Mayo, William : Ibid, April, 1918. 

5. Bland: Ibid, November, 1913. 

6. Martin and Jung: Diseases of Women, 1913, p. 126. 

People's Hospital. 



A New Virgin Vaginal Speculum 

Presenting Improvements Over Older Models 

By GEORGE EDWARD BARNES, M. D., 
Herkimer, N. Y. 



The virgin vaginal specula now on the market 
have their fulcrum so far in front of the hymen that 
when their blades are spread apart the hymen is 
stretched, causing pain and even laceration. The 
chief distinctive feature about my speculum is the 
location of the fulcrum on the plane of the hymen. 
The spreading of the blades does not injure the 
hymen or cause pain — most important matters. 
Other practical features are the greater narrowness 
and thinness of the blades, permitting their intro- 
duction through a smaller cleft, and the greater 
length of the blades, permitting the cervix to be 
readily reached even in adult virgins and in married 
women with tender parts. The longer blades increase 
the general utility of the instrument but it would 
sometimes be advantageous to have also another 
speculum with shorter blades. 

I have made drawings instead of photographs of 
my speculum because the instrument makers did not 
make the model of the speculum which I now have 
exactly according to my specifications and because 
I wish to make some improvements over the first 
design. 



DESCRIPTION OF INSTRUMENT. 

The large drawing represents the speculum viewed 
obliquely from the front and from the right of the 
observer, and the small drawing represents the 
speculum proper, chiefly its funnel or expended end, 
from in front. The elevating pin passing through 
the lower wall of the funnel is important. This is 
the fulcrum on which the two halves of the instru- 
ment act and in the drawing it is shown pushed up 
so as to separate the blades vertically. The handles 
of the instrument are an upper male of flat material 
about one and five tenths mm. thick and a lower 
female about five mm. wide and about seven mm. 
high having a slot where the upper male handle has 
to pass through it. On the side of the upper handle, 
quite near to the free end, are many conical holes 
into which fit the conical end of the screw which 
presses through a well adapted hole in the inner 
half of the lower handle. This latter hole should be 
somewhat deepened by having a collar about it pro- 
jecting from the surface of the handle so that the 
screw will not be likely to fall out. The length and 
shape of the handles is indicated sufficiently by the 



July 5, 11122.] 



BARNES: SPECULUM. 



41 



large drawing. The thickness of the upper handle 
should fit well but not tightly in the slot in the lower 
handle so that there will be free play up and down, 
but no side motion. The curve on each end of the 
upper handle should be carefully made so as to allow 
but little movement of the upper handle forward and 
backward in the slot of the lower handle. It is 
obvious that the adaptation of the handles to each 
other allows the blades to be moved on the fulcrum, 
i. e., the elevating pin. and holds the blades from 
deviating from each other laterally. Therefore the 
two handles should be attached to the funnel in the 
same vertical plane. On the lower handle is an arm 
projecting vertically downward having on its inner 
surface closely placed slanting ridges on which may 




Fig. 1. — The G. E, liarnts virgin vaginal speculum. 



be rested the handle of the elevating pin, which 
handle has its outer edge supplied with a projection 
to fit into the notches in the vertical arm. The direc- 
tion of the inner surface of the vertical arm must 
allow the handle of pin to fit against it flatly. The 
vertical arm and the pin handle must not collide 
with the lower projection cif the upper handle when 
the latter is depressed. 

The funnel portion is much more shallow than the 
corresponding part in other specula. It is almost 
flat except where it passes into the blades. That 
portion of the lower part of the funnel where the 
pin passes through must be somewhat thickened in 
order to make the tunnel for the pin. Preferably, 
this tunnel should not be perfectly round but should 
be of some form, e. g. oval, to prevent the pin handle 
from swinging away around into the region of the 
anus. Of course, the pin should be of a correspond- 
ing form and should be of small diameter. The 
upper end of pin should be slightly enlarged to pre- 
vent it from falling out of tunnel. The upper end 
of the tunnel through which the pin jjasses should 
be at the junction of the lower funnel and the lower 
blade. And the end of the pin should come into con- 
tact with a similar point between the upper funnel 
and upper blade. Against this latter point the end 
of the pin acts when the pin is elevated or lowered 
to regulate the vertical distance between the two 
blades. 

f)n each side of each half of the funnel is 
a flange, shown best in the smaller drawing. The 
flanges on each side of the lower funnel are only 
one mm. high. The flanges on each side of the 
upper funnel are higher, about four mm. The upper 
flanges slip behind the lower ones when the blades 
are brought together. The flanges prevent the folds 
of the labia from being pinched when the blades are 
brought together and, furthermore, one flange on the 
ui)per funnel, as its end rests against the f)in. pre- 
vents the upper half of the instrument from slipping 
on the lower half. The handles are attached to the 
funnel at the areas represented dark in the side of 



the small drawing. The opposite side of the funnel 
is made wider in order to keep the labia away from 
the funnel on that side. The open space represented 
in the smaller drawing between the two halves of 
the instrument is a little wider from side to side 
than it should be. 

The total length of the upper funnel and blade is 
eighty-three mm. and the total length of the lower 
funnel and blade'is eighty-seven mm. The narrow- 
est part of the blades, near the funnel, is seventeen 
mm. wide and the widest part is nineteen mm. wide, 
measurement being made by air line across the con- 
cavity from outer edges. The combined height of 
the blades when closed is nine mm. in front and 
twelve mm. toward the free end, measurement being 
made from outside surface (with a pair of com- 
passes). However. I think it would be better to 
have the blades of uniform width, seventeen or 
eighteen mm., and of uniform height, nine or ten 
mm., throughout. 

In the latter part of 1920 I began to correspond 
with manufacturers of surgical instruments trying to 
interest them in my new virgin speculum so that they 
would manufacture it for general sale. After a time 
I discovered that nearly all vaginal specula made 
in this country are made by two firms. One after 
another, all these firms declined to manufacture the 
new instrument either because they do not manu- 
facture any vaginal specula or because the cost of 
the tools required for making my speculum would 
be so great as to make the undertaking a bad busi- 
ness proposition. Apparently, only comparatively 
few virgin specula are sold. Some of the firms 
stated that they would manufacture my speculum if I 
would furnish the money to pay for the required 
tools, the necessary sum being estimated at seven 
hundred and fiftv to a thousand dollars. Since the 




Fig. 2. — The G. E. H.-irnis virgin speculum. 

manufacturers prefer to continue to sell the old pat- 
terns of specula to save the expense of the tools for 
making my new instrument, it is evident that the 
latter will not be manufactured unless the profession 
makes a demand for it. At present, those wishing 
to obtain my speculum must place a special order 
with an instrument maker. 

It is possible that large specula made according 
to the principle of this virgin speculum would pos- 
sess greater utility tlian the larger specula which 
are now in use. 

I have not applied and I trust that no one else 
will apjily for a patent on my speculum. 

]2'^ AIaky Street. 



Editorial Articles 



RADIOTHER-\PY IN DISEASES OF THE 
BLOOD. 

The action of x rays on human blood consists of 
an immediate leucocytosis with abinidant polynu- 
cleosis and slight mononucleosis with a moderate in- 
crease of the red cells; secondly, a consecutive de- 
crease of the white cells, the percentage of polynu- 
clears and mononuclears remaining unchanged, and 
thirdly, an abundant and continuous increase of the 
red cells. 

The principal affections in man to which the x 
rays are directed are the chronic leucemias. In the 
acute types of this process the x rays have remained 
without effect. Lymphatic leucemia presents three 
forms, namely, the purely lymphatic type; the com- 
bined lymph node and splenic hypertrophic type. 
and the purely splenic type. The irradiations should 
be directed on all the lymph node groups as well as 
on the spleen. The treatment is both long and 
minute on account of the multiplicity of the points 
of application of the rays. Hypertrophy of the 
spleen, when it exists, is the first to subside, while 
the adenopatliies occasionally disappear with great 
rapidity — ^after two or three seances with three H 
units through an aluminum filter of three millimetres. 

At other times sedation of the process is slower 
to take place, but the general health is invariably im- 
proved in all cases. From the hemotological view- 
point a return to an almost normal count is the rule, 
while at the same time the appetite and strength re- 
turn. This condition of affairs may last for three 
to five years, but at length a recurrence of the pro- 
cess inevitably ensues which ends in death, although 
the process may take several years to run its course, 
thus giving the illusion of a permanent cure. The 
ma.ximum lease of life so far observed in chronic 
myeloid leucemia has been eight and a half years. 
the average being much less, namely, two years and 
a half. Myeloid leucemia rarely offers but one type, 
namely the splenomegalic, and enlargement of the 
lymph nodes is rarely met with. The general health 
is always more or less involved. 

Generally .speaking, the good results reported re- 
cently have been obtained by filtration through two 
to three millimetres of aluminum and there is a ten- 
dency at present to filter through six millimetres. 
It is quite impossible to treat the entire spleen by 
irradiations at once. Very frequently, in fact, the 
surface to act upon may be as much as thirty centi- 
metres long and the breadth even more. Hence it is 
necessary to divide the splenic region into segments, 
each of which receives about the same dose of radia- 



tion. This socalled checkerboard method gives the 
best results, each area receiving- the dose of three 
H units every fortnight. At the first seance the 
total surface to be irradiated is divided into squares 
of about ten centimetres each and under treatment 
the splenic mass will actually melt away. 

All cases of lymphatic leucemia and chronic mye- 
loid leucemia are amenable to radiotherapy. There 
are no cases which fail to respond, but the splendid 
results obtained are unfortunately only temporary. 
For a number of years the patient may present every 
appearance of health and by treatment the blood 
count tends to become normal, the hyperleucocytosis 
drops, and it is not uncommon to observe a leu- 
ct)pnea. At the same time the number of red cells 
and the hemoglobin become nearly normal, while the 
myelocyte tends to disappear, but this is merely ap- 
parent because it will invariably be foimd. 

For the present, radiotherapy is the treatment of 
choice for the chronic leucemias ; it is superior to 
both radium and benzol, but it is only palliative and 
no permanent cure has yet been recorded. Beside 
the chronic leucemias, radiotherapy has given some 
good results in Vaquez's disease Band's disease, and 
in aleuceniic lymphadenias occurring in certain 
hemolytic states. 



ACCURACY 

In a paper entitled Ocular Symptoms of Epidemic 
Encephalitis, published in the January number of 
the American Journal of Ophth-aluiologv, Dr. Mat- 
thias L. Foster pleads for greater accuracy in the 
observing and recording of the eye symptoms in 
encephalitis. He says that these symptoms are 
sometimes the first to appear and are prone to be 
the most annoying to the patient, yet he has found 
indefinite statements concerning them to abound 
even in otherwise well worked out case reports. He 
says that mention is frequently made of ptosis, dip- 
lopia, strabismus, and mydriasis, with occasionally 
a note concerning the pupillary reactions, and that, 
as a rule, the records are vague, while they might 
easily have been made definite and accurate. 

The point made is a strong one. Take the sj-mp- 
tom of diplopia for example. This is a subjective 
symptom, the patient sees double, almost invariably 
caused by a paralytic condition of one or more of the 
recti, but by no means always of the same ones. It 
is easy for the examiner to have the patient look up, 
down, to the right, to the left, and to note whether 
either eye is arrested in its excursion in any direc- 
tion, whether it stops abruptly at the middle line. 



July 5. 1922.] 



EDITORIAL ARTICLES. 



43 



or crosses this line and then lags behind. Then an 
.accurate statement is possible ; diplopia due to paral- 
ysis or paresis of the muscle which fails to act nor- 
mally in moving the eye. Perhaps, as shown in one 
of Dr. Foster's cases, one muscle may be affected 
in one eye and a different one in the other. 

Take the term strabismus. Ophthalmologists have 
tried to restrict the use of this term to conditions in 
which the deviation of an eye from its correct posi- 
tion is not due to a paralytic condition of any of the 
muscles, but not as yet with much success. It is 
commonly used to denote a deviation of an eye in, 
•out, up or down from its normal position without 
reference to the cause, but as a symptom in such a 
disease as this its value is wholly dependent on 
whether its cause is paralytic or not. The same test 
as in diplopia determines this point and also reveals 
which muscle, if any, is atTected. .Vgain, accuracy 
has been easily attained. 

Mydriasis means dilatation of one or both pupils. 
Some persons have much larger pupils than others, 
so it may happen that a size which is normal in one 
person may represent a fair degree of dilatation in 
another. Or the pupils may be dilated because the 
patient is frightened, a condition which may also im- 
pair the light reflex and so needs lo be always borne 
in mind. Inequality of the pupils is more serious ; in 
the majority of cases it points to some lesion in the 
cerebrospinal system. But, no matter what the con- 
dition of the pupils, nothing can be learned from it 
unless the reflexes to light and convergence are taken 
into account, and it is easy to determine these. Flash 
a bright light into the dilated pupils and see if they 
-contract. Have the patient look far away into the 
•distance, then suddenly have him focus his eyes 
on a finger held a few inches away, and see if the 
pupils contract. In this way definite observations 
have been made which are worth recording in con- 
junction with the mydriasis. 

Does the ptosis aiTect one eye or both ? Does the 
drooping lid merely have its margin at a slightly 
lower level than the other, or is the patient unable 
to open the eye at all? Of course this is only a 
matter of degree, for ptosis noted as a symptom 
in such a disease as this means a paralytic condition 
more or less pronounced of the levator palpebrae, 
but accuracy in the observation and record of the 
degree of ptosis gives an accurate idea of the degree 
of existing paresis. 

There is scarcely a calling in which accuracy is 
not insisted upon to a much higher degree than it 
is in medical records. Go into a newspaper office 
and note the emphasis placed upon it. Other vir- 
tues are commendable there, but accuracy is the one 
placed above all others. Accuracy in observation. 



accuracy in statement. Check up the work of a 
reporter on a daily paper and you will find him ac- 
curate to a remarkable degree. Not that he is 
always right ; he is human like the rest of us, and 
when dealing with a subject of which he knows 
nothing, like medicine, he often makes some amusing 
mistakes, but the great mass of his work is free 
from inaccuracy, or he soon seeks employment in 
another field. Accuracy is an essential for the pur- 
veying of material for an evanescent publication 
which is read today and used tomorrow to kindle 
the fire. Would that the reporters for the medical 
press could have such a training in accuracy. They 
are not working for an ephemeral publication, but 
for one intended to be read and studied, to be an 
aid in the relief of human misery. Far more than 
in the daily press is accuracy of observation and 
statement essential. 



INTRACRANIAL HYPERTENSION AND 
ITS TREATMENT. 

The syndrome of intracranial hypertension com- 
prises four principal symptoms, namely, headache, 
vomiting, edema of the papilla, with disturbances 
of sight which ensue, and marked changes in the 
cerebrospinal fluid. The headache, which is not 
influenced by medical treatment, is often entirely 
relieved by decompression. Vomiting is proljably 
the consequence of a reaction of the hypertension 
on the vestibulum, while the edema of the papilla 
is a fundamental element in the diagnosis of hyper- 
tension. After a time this edema is replaced by 
papillary stasis which in turn results in atrophy of 
the structures of the papilla with cecity. 

The two great factors of intracranial hyperten- 
sion are hydrocephalus and neoplasms. The tumors 
which are easiest to localize are those in the Ro- 
landic area, the occipital region, the hypophysis, 
and at the pontocerebellar angle. Growths in the 
Rolandic area give rise to motor disturbances, Jack- 
sonian epilepsy, paresis, monoplegia and hemiplegia. 
Those of the occipital region give rise to visual 
disturbances — homonymous hemianopsia — while 
growths of the hypophysis are readily diagnosed by 
acromegalia, gigantism, the genital adiposis and 
bitemporal hemianopsia. Finall)-, tumors of tiie 
pontocerebellar angle gives rise to cerebellar dis- 
turbances. 

The operative indications are above all indicated 
by the headache and edema of the papilla, and as 
soon as the latter has been diagnosed o])eration 
should be resorted to, because diminution of the 
visual acuity sometimes ensues very suddenly. 
Lumbar inmcture, which is dangerous in cases of 
intracranial hypertension, ceases to be so after the 



44 



EDITORIAL ARTICLES. 



[New York Medical Journal 
AND Medical Record. 



patient has been trephined, and when the cause of 
the hypertension is unknown it is well to follow 
Cushing's rule and trephine over the subtemporal 
region. Both subtemporal fossje should be opened 
after an interval of a few days. 

At the first operation the skull only is opened 
over the left subtemporal fossa and in not a few 
cases this will be enough to relieve all the symptoms, 
but if after a fortnight the edema of the papilla has 
not entirely disappeared the dura may be incised. 
However, it is usually better to trephine over the 
right subtemporal fossa and incise the dura on this 
side, because the disturbances resulting from cere- 
bral hernia are much less marked than after incision 
of the dura on the left side. Before incising the 
dura lumbar pimcture should invariably be done. 
When the dura has been incised on the right side, 
if a tumor is not found, the dura on the left may 
be incised sometime later if the cutaneous cicatrix 
is perfectly clean, and by proceeding in this wav 
tumors that could not be localized are discovered. 

In cases of hydrocephalus the results of decom- 
pression are not as much good as in hypertension 
from tumors. In hydrocephalus it has been pro- 
posed to drain the ventricles in the subarachnoid 
space or into the subcutaneous cellular tissue, but 
puncture of the ventricle through the opening in 
the skull, done from time to time as symptoms war- , 
rant, will be sufficient. 

When the syndrome of hypertension is due to a 
neoplasm which can be localized an attempt should 
be made to remove the tumor. Certain growths 
arising on the inner aspect of the skull can be de- 
tected by the ,\ rays. The operation should always 
be done with local anesthesia with the patient 
seated, thus avoiding shock. 

The results obtained are occasionally surjirising 
and the majority of patients will derive great bene- 
fit although they are not cured. They finally die 
from the evolution of the process but without suf- 
fering and retaining their sight. 



BOTULISM. 
This is a rather neglected subject, a fact to be 
deplored, because in point of fact the disease is a 
serious one. the mortality varying between thirty 
jier cent, and sixty per cent. It is a disease con- 
tracted by the ingestion of sausages, preserved 
meats, etc., although it is a curious fact that these 
products made at home are more prone to give rise 
to it than manufactured articles. However, a cer- 
tain number of epidemics have been due to commer- 
cial products. On the other hand, it must be ad- 
mitted that the generally accepted opinion that botul- 
ism can only be derived from preserved meats 



should be discarded, because vegetables — olives, 
beets, beans, asparagus, etc. — are not less inoffensive 
than others when they contain Bacillus botulinus. 

This bacillus is an anaerobic organism, noninfec- 
tious, and can rarely be found in the organism after 
death. It acts by its toxin which is endowed with 
a great affinity for the nervous sy.stem. The bacillus 
is destroyed at a temperature of 70° C, but the 
spores possess a far greater resistance. On the 
other hand, an acid medium — lemon juice or vinegar 
or one containing a high degree of salt (ten per 
cent.) — prevents the development of the bacillus. 

The affinity of the botulic toxin for the nervous 
system is made evident by the symptomatology of 
the affection which is almost exclusively neuropatho- 
logical. It is, in fact, to be noted that botulism es- 
sentially differs from other affections due to food 
poisoning by the absence of pyrexia and general 
symptoms, as well as by the frequent absence of 
gastroenteritis, at least one of anv severity. Gastric 
pain is never -very marked and vomiting is in- 
frecjuent. C)n the other hand, constipation is the 
rule, and since it is due to inhibition of the motor 
functions of the digestive tract, it resists every kind 
of medication and is occasionally accompanied by 
distention of the intestines from gas. These few 
digestive symptoms develop after a phase of latency 
averaging from one to three days. 

The first neuroparalytic symptoms to arise are 
ocular disturbances : there is paralysis of accommo- 
dation, mydriasis and often paralysis of the third 
pair. Next the mouth becomes dry, there is paresis 
of the tongue, dysarthria, quite frequently paralysis 
of the muscles of tiie velmn and pharynx, hence very 
distressing dysphagia, and the paralysis frequently 
extends to the laryngeal muscles resulting in more 
or less complete aphonia. 

At the same time there is a decrease of contractil- 
ity of the voluntary muscles — muscular weakness 
with true paralysis — motor incoordination with 
diminished tendon reflexes, absolute anorexia, com- 
plete suppression of the sudoral, lacrymal and milk 
secretions and frequently retention of urine. If 
death is to ensue other bulbar symptoms develop 
reacting on the respiration which becomes accel- 
erated, superficial and dyspneic. Death takes place 
in from four to eight days, according to the inten- 
sity of the poison. 

The prophylaxis of botulism consists of perfect 
sterilization of all preserved meats and vegetables at 
a temperature of not less than 100° C. The brine 
used for pickling should contain at least ten per cent, 
sodium chloride. If vinegar is used the acetic acid 
content should be over two per cent. Foods which 
lend themselves to anaerobic fermentation, such as 



July 3, 1922.] 



EDITORIAL ARTICLES. 



45 



sausages, salted meats and nsh or canned meats, 
should never be eaten raw. 

As to treatment, saline aperients, rectal or subcu- 
taneous injections of physiological salt solution are 
indicated for producing diuresis and to control thirst, 
strychnine in large doses to sustain the nervous sys- 
tem, and pilocarpine to induce the return of the 
sudoral function. An antibotulic serum is at pres- 
ent being studied and has already given good results 
in experimental work on animals. 



OPINIONS ON PUBLIC HEALTH 
QUESTIONS. 

A questionnaire on certain unanswered questions 
arising from the conference, held in Washington. 
D. C, March 14th and 15th, on the future of public 
health in the United States and the education of 
sanitarians, was sent out to those who attended. 
The opinions of the ninety-eight individuals from 
whom responses were received furnish some valua- 
ble data on certain puIMic health problems, some of 
which it will be of interest to simimarize. 

There was a strong preponderance of opinion in 
favor of the Public Health Service sending a repre- 
sentative to the various medical schools and univer- 
sities, which offer courses for the training of sani- 
tarians, for the purpose of conferring with presi- 
dents and deans, and of giving to students, through 
the medium of addresses, information regarding the 
field of public health as a life career. In response 
to the question. What other specific steps may be 
taken by national health agencies to bring before 
university students information regarding the field 
of public health? thirty-five suggested the prepara- 
tion and publication of an attractive panqihlet, to be 
sent not only to medical, but to premedical students 
in the universities, and possibly to some high schools. 
"After the medical school has been entered," said 
Dr. M. von W. Schulte, "it is too late to expect many 
recruits." Several felt that the first step was the 
education of the faculty, who in turn might direct 
the interests of their students. The great value of 
motion pictures, charts, drafts, plates, and [portable 
museum material to stimulate interest was men- 
tioned. 

What specific .steps may be taken by some national 
health agency to get public health work "out of 
politics" — to make the tenure of sanitarians more 
secure and their salaries more nearly adequate? was 
another question. "God only knows !" replied one, 
and another, "Why waste time trying to change the 
unchangeable?" More o[)timistic members of the 
profession agreed generally that eiiucation of the 
public was the step of prime importance. Suggestions 



as to how to do this were varied. Dr. W. H. Welch 
said "through city clubs, chambers of commerce, an;t 
manufacturing associations." "Well prepared papers 
in a magazine that reaches the public, advised Dr. 
W. H. Howell. Dr. W. F. Snow suggested the pub- 
lication of impartial case studies of the wrong use of 
politics in relation to public health. Other suggestions 
were public conferences, the use of local chapters of 
voluntary organizations, the extension of civil service 
to public health offices, and the assistance of the 
United States Public Health Service in establishing 
requirements, holding examinations, and selecting 
candidates. As to the tenure of office by sanitarians, 
there were several suggestions, among them the 
formation of a voluntary committee for the investi- 
gation of all cases in which politics interfered with 
the [Kjsition of a health officer, the findings of this 
committee to be puijlished. 

The agencies best fitted to take the steps recom- 
mended, named in the order of the frequency with 
which they were mentioned, are the United States 
Public Health Service, the American Public Health 
Association, the American Medical Association, the 
National Health Council, the American Red Cross, 
women's organizations, nonofficial organizations, 
local medical associations, the Rockefeller Founda- 
tion, a special committee, the National Child Health 
Council, Life Extension Institute, Bureau of Edu- 
cation. The first four were included many more 
times than the others. 

Opinion was much in favor of another confer- 
ence, to be held within a year, on the training of 
sanitarians under the aus])ices of the Public Health 
Service. The question was asked : At this future 
conference, proportionately what time should be 
given to the education of sanitarians now employed 
and to the education of future sanitarians? Thirty- 
two replied that they would give e<|ual time to each 
problem, twenty-six that they woukl give more time 
to the future sanitarians, and fourteen to the sani- 
tarians now empkjyed. Various suggestions were 
made as to improving the program in this future 
conference, most agreeing, however, that the first 
conference was a great success. 

Opinions varied as to the best way to [jrovide 
for the education of sanitarians. Among those 
given, in the order of their frequency, were: The 
short, intensive postgraduate course, lasting about 
six weeks, in connection with a school of jjublic 
health; the use of summer schools for this purpose; 
the special institute: "Periodical institutes," said Dr. 
Walter H. Hrown. "slKjuld be conducted through 
.state departments of health, and j)romoted by the 
United States Public Health Service"; correspond- 
ence courses, bulletins and periodicals, reading 



46 



NEWS ITEMS. 



[New York Medical Journal. 
AND Medical Record. 



courses, and supplementary instruction and training. 

In response to the question, What conclusions did 
you personally reach, as a result of the recent con- 
ference, regarding the education of future sani- 
tarians and of those now employed? the statement 
of Dr. Allen W. Freeman, "that existing methods 
have been reasonably effective and should be ex- 
tended," represented a consensus of opinion. It 
seemed to be generally felt that the education of 
sanitarians now employed had been sadly neglected, 
and should receive careful attention. 

What distinct specialties in the field of public 
health should now be recognized ? brought most in- 
teresting replies, indicative of an incipient 
and growing realization of the wide extent of the 
public health field. The specialties listed, with the 
number of those mentioning each, follows : Sanitary 
engineering, twenty-three ; administration, eighteen ; 
epidemiology, seventeen ; child hygiene, sixteen ; 
laboratory work, fourteen ; vital statistics, fourteen ; 
industrial hygiene, twelve ; public health education, 
nine ; preventive medicine, six ; mental hygiene, six ; 
research, five; social hygiene, four; nutrition, four; 
school hygiene, three ; rural hygiene, three ; physical 
education, two ; serology, two ; tuberculosis, two ; 
economic and social aspects, one ; business manage- 
ment, one. 

The sending out of the ([uestinnnaire and the 
tabulation of replies received has certainl}- added to 
the valuable work done by the conference itself, 
especially in the way of defining and establishing 
high standards, and of raising and clarifying those 
already in practice. The conference and its results 
will be contributions of the greatest significance to 
the able administration of public health in the 
United States. 



-^^ 



N 



ews 



Items. 



Occupational Diseases Excluded from Opera- 
tion of Oregon Workmen's Compensation Act. — 

The Supreme Court of ( )regon has decided that 
according to the meaning of the workmen's compen- 
sation act of that State, an occupational disease is 
not a "personal injury by accident," and therefore 
is not compensable. The questioned disease in this 
case was lead jioisoning. 

American Surgical Association. — The annual 
meeting of the association was held in Wa.shington, 
D. C. The following officers were elected for the 
ensuing year : Dr. Lewis L. McArthur, of Chicago, 
president ; Dr. Ellsworth Eliot, Jr., of New York, 
and Dr. Donald C. Balfour, of Rochester, Minn., 
vice-presidents ; Dr. I-lobert V>. Greenough, of Bos- 
ton, secretary, and Dr. Charles H. Peck, of New 
York, trea.surer. The next meeting is planned for 
June, 1923, in Rochester, Minn. 



Philadelphia Laryngological Society. — Dr. 
George W. AlacKenzie was elected president at the 
annual meeting of the society on June 6th. Other 
officers were elected as follows: Dr. William A. 
Hitchler, vice-president; Dr. Henry A. Leslie, re- 
elected secretary, and Dr. Arthur J. Wagers, 
treasurer. 

American Otological Society.— Dr. George E. 

Shambaugh, of Chicago, was elected president at the 
annual meeting of the society held in Washington, 
D. C, May 2d and 3d. Other officers were elected 
as follows : Dr. John B. Rae, of New York, vice- 
pre.sident, and Dr. Thomas J. Harris, of New York, 
secretary-treasurer. 

American Society for Clinical Investigation. — 

At the annual meeting of this society held in Wash- 
ington, D. C, im May 1st, Dr. Elliot P. Joslin, of 
Boston, was elected president ; Dr. Charles F. 
Hoover, of Cleveland, vice-president; Dr. James H. 
Means, of Boston, secretary, and Dr. Ralph Pem- 
berton. of Philadelphia, treasurer. 

Columbia University Prize Honors. — Dr. Ed- 
gar Fahs Smith, formerly provost of the University 
of Pennsylvania, was awarded the Chandler gold 
medal at the annual commencement of Columbia 
University. In the School of Medicine the Harold 
Lee Alierhof memorial prize was divided between 
Harold Alexander Abramson, of New York, and 
Samuel Harold Gray, of Brooklyn. 

American Orthopedic Association. — Dr. Ralph 

R. Fitch, (if Rochester, N. Y.. was elected president 
(if the association at its annual meeting held in 
Washington, D. C, May 2d to 4th. Dr. W. S. Baer, 
of Baltimore, was elected president-elect ; Dr. Fred 
H. Albee, of New York, vice-president ; Dr. John L. 
Porter, of Chicago, secretary, and Dr. DeForest P. 
Willard. of Philadelphia, treasurer. 

Personal. — Dr. John L. Heflron, for fifteen years 
dean of the College of Medicine of Syracuse Uni- 
versity, recently resigned his connection with tlie 
college after forty years' service. He will be suc- 
ceeded by Dr. Herman G. Weiskotten, professor of 
pathology in the university. 

Dr. Ross G. Harrison, a member of the medical 
faculty of Yale L^niversity, has been elected an hon- 
orary member of the Royal Academy of Medicine of 
Turin. 

Dr. Nathaniel W. Faxon, of Boston, has been ap- 
pointed director of the Strong Memorial Hospital, 
which is the new School of Medicine and Dentistry 
of the University of Rochester, New York. 

Dr. Henry F. Patton and Dr. Robert C. Austin 
are directors of a new goitre clinic recently estab- 
lished in Dayton, Ohio. 

Dr. Blanche A. Burgner, of Chicago, was elected 
president of the Chicago Medical Women's Club on 
June 14th. 

Dr. Walter B. James, of New York, received the 
honorary degree of doctor of lavvs at the annual com- 
mencement of Harvard University. 

Dr. Lewis C. Taylor, Springfield, who has been 
executive secretary of the state board of medical 
examiners during the past twenty-five years, sent in 
his resignation on June 7th to W. H. H. Miller, head 
of the department of education and registration. 



July 5. 1022.] 



NEWS ITEMS. 



47 



Southern Surgical Association. — The annual 
meeting of this society will be held in Memphis, 
Tenn., December 12 to 14, 1922. under the presi- 
dency of Dr. C. Jeff Miller, of Xew Orleans. 

Brooklyn Maternity Hospital Celebrates Anni- 
versary. — An informal reception was held at the 
Brooklyn ]\Iaternity Hospital on Wednesday, June 
14lh, to celebrate the first anniversary of the open- 
ing of the institution. 

Junior Microanalyst. — The United .States Civil 
Service Commission announces an examination for 
junior microanalyst on August 9, 1922, to fill vacan- 
cies in the Bureau of Chemistry, Department of 
Agriculture, for duty in Washington, D. C, and in 
the field, at $1,400 to 31,800 a year. For further 
particulars write to the Commission in Washington. 

First Aid on the Sea. — According to an amend- 
ment of tlie Navigation (Health) Regulations of 
Australia, passed February 1, 1922, every foreign 
going ship or Australian trade ship traveling 600 
miles or more between consecutive ports of call with 
more than ten persons on board must have, in the 
absence of a ship's doctor, a person certified by an 
approved authority as qualified to render first aid. 
St. John's Ambulance Association. St. Andrew's 
Ambulance Association, St. Patrick's .Ambulance 
Association and the British Red Cross Society are 
among the authorities recognized. 

Michigan State Medical Society. — Dr. W'illiam 
T. Dodge, of Big Rapids, was elected president at 
the fifty-seventh annual meeting of the Michigan 
State Medical Society, in Flint, June 7th to 9th. 
Other ofiiicers were elected as follows : Dr. Joshua 
G. R. Manwaring, of Flint, Dr. William E. Mc- 
Namara, of Lansing, Dr. Theodore F. Heavenrich, 
of Port Huron, and Dr. W'illiam K. West, of 
Houghton, vice-presidents ; Dr. Frederick C. Warn- 
shuis, reelected secretary. The action taken by the 
American Medical Association at St. Louis was 
adopted and approved by the delegation, and the 
body subscribed its support in instituting these con- 
structive measures in the State of Michigan. 

Aeroplane Ambulances. — The .'\ir Service of 
the United States Army lias been using aeroplane 
ambulances since the early part of 1918, shortly 
after the first one was constructed in February of 
that year. .^ little later all flying fields had to con- 
vert a suitable plane into an ambulance for use in 
emergencies, according to instructions from the 
Chief of Air Service in Washington. The French 
Army also is making increasing use of the aeroplane 
ambulance. An extract from the Paris Figaro of 
December 5, 1921, says: "A few weeks ago in 
Morocco the ambulance aeroplane made a remark- 
able record by transporting eighteen wounded men 
eighty kilometres; now we hear that in the Levant 
they have just evacuated forty-four wounded a dis- 
tance of four hundred kilometres over the desert of 
Syria between Deir-ez-Zor, on the Euphrates, at the 
sfiuthern border of our mandate, and Aleppo." It 
is thought that the promptness of first aid, and the 
comfortable trips at great speed which the aeroj)lanc 
makes possible, will lessen much sufTering and at 
times save lives. This method of transporting the 
sick and wounded will in a short time become of 
tremendous importance, many authorities believe. 



American Association for the Study of the Fee- 
bleminded. — The annual meeting of the associa- 
tion was held in St. Louis, May 10th to 20th. Offi- 
cers for the ensuing year were elected as follows: 
Dr. Charles Banks McNairy, superintendent of the 
Caswell Training School, Kinston, N. C, president, 
and Dr. Benjamin W. Baker, superintendent of the 
Xew Hampshire School for the Feebleminded, La- 
conia, X. H., secretary-treasurer. 

Civil Service Examinations. — Among the posi- 
tions for which the Xew York State Ctvil Service 
Commission will hold examination on July 15th are 
the following: Laboratory assistant in bacteriology, 
division of laboratories and research. State Depart- 
ment of Health, $900 to $1,500; laboratory assistant 
in serologv, division of laboratories and research, 
State Department of Health, $1,200 to $1,800: as- 
sistant physician and assistant surgeon, state and 
county institutions, with immediate appointments 
expected at the Rome State School at $2,200 and 
$1,600; assistant in biological chemistry. Psychiatric 
Institute, Ward's Island. $1,700 with an allowance 
for maintenance; medical assistant to director 
(Tuberculosis Department), Grasslands Hospital, 
Westchester County. $3,000 with maintenance. 

Rockefeller Foundation Fellowships. — In a re- 
view of the activities of tlie Rockefeller Foundation, 
President George E. \'incent states that one hundred 
and fifty-secen individuals during 1921 held fellow- 
ships, funds for which were directly or indirectly 
supplied by the Rockefeller Foundation. These fel- 
lowships fell into five groups: 1, fifty-four fellow- 
ships in public health under the International Health 
Board: 2, fifty-two fellowships administered by the 
China Medical Board ; 3, sixteen fellowships in medi- 
cal education; 4, thirty-four research fellowships in 
physics and chemistry supervised by a special com- 
mittee of the Xational Research Council, and 5, one 
member of the International Health Board staff, who 
on what is known as study leave, was engaged in 
special study. The distribution of these fellows by 
countries was : seventy-one .\mcricans, one Belgian, 
seven Brazilians, eleven Canadians, one Singhalese, 
seventeen Chinese, one Colombian, two Costa 
Ricans, nineteen Czechs, seven British, four French, 
one Guatemalan, one Mexican, two Xicaraguans, 
seven Poles, two Salvadoreans, two Syrians and one 
Xorwegian. 

® 



Died. 

Alexander. — In New York, on Thursday, May 18th. Dr. 
Welcome Taylor Alexander, aged seventy- four years. 

Andrews. — In Chicago, on Tuesday, May 30th, Dr. John 
James Andrews, aged forty-two years. 

Aronson. — In New York, on Saturday, June 24th. Dr. 
Edward A. Aronson, aged forty-seven years. 

Beacdry. — In New York, on Monday, May 22nd, Dr. El- 
mer Brownell Beaudry. aged sixty-one years. 

BoGCS. — In Pittsburgh, Pa., on Friday, June 2nd. Dr. 
Russell H. Boggs, aged forty-seven years. 

Hall. — In Kansas City, Mo., on Saturday, June 10th, 
Dr. Crawford Lester Hall, aged seventy-six years. 

Laveran. — In Paris, France, on Thursday, May 18th, D.r. 
A. Laveran, aged .seventy-seven years. 

Miller. — In Brooklyn, on Saturday, June 3rd, Dr. John 
F. Miller, aged seventy-five years. 

Smith. — In Cleveland, on Friday, May 19th, Dr. Daniel 
Ruttrick Smith, aged seventy-one years. 

Tavujr, — In Wcsthampton, Va., on Tuesday, May jOth, 
Dr. Hugh McGuire Taylor, aged sixty-six years. 



Book Reviews 



A HANDBOOK OF OBSTETRICS. 

Manual of Obstetrics. By John Osborx Polak. M. Sc. 
M. D.. F. A. C. S., Professor of Obstetrics and Gyne- 
cology in the Long Island College Hospital ; Professor 
of Obstetrics, Dartmouth Medical School ; Obstetrician 
and Gynecologist to the College Hospital, etc. With 
Three Color Plates and One Hundred and Nineteen Il- 
lustrations in Text. Second Edition, Containing a Spe- 
cial Section on Endocrinology. New York : Physicians 
and Surgeons' Book Company. 1922. Pp. xix-488. 

This is the second edition of a manual of which 
it seems that there are already too many in existence. 
It is really questionable whether such handbooks. 
intended as royal roads to learning for "the student 
and the busy practitioner" serve any useful purpose. 
The author in his preface offers it as a "systematic 
introduction to the more elaborate treatises, to serve 
as a guide in following the didactic and practical 
teaching given in the college course." There may 
possibly be some excuse for a book of this sort for 
a second year medical student, but surely the more 
advanced student and especially the postgraduate 
student and the busy practitioner have need of some- 
thing more than the very elementary treatise here 
presented. Such books have a tendency toward the 
development of slovenly methods of acquiring 
knowledge which may be called half baked. Polak's 
manual is little more than an outline of the subject 
of obstetrics. The arrangement of the titles, sub- 
titles and the use of italics makes reference easy. 
The chapter on reproduction and especially the one 
on organology are quite extensive and very lucid. 
They are also excellently arranged so as to be of 
value in explaining those conditions and diseases 
that have malformations and maldevelopnients as- 
their basic cause. The two special chapters are de- 
voted to the theory of the application of the endo- 
crine products in pregnancy, labor and the puer- 
perium, but specific directions for treatment and 
dosage are omitted. .A bibliography would be a 
valuable addition. 

VERS I ( ).\ 1 .\ ( )BSTETRICS. 

The Place of Version in Obstetrics. By Irving W. Pottf.r, 
M.D., F.A.C.S.. Buffalo. Obstetrician in Chief, Deacon- 
ess Hospital and St Mary's Maternity Hospital ; Attend- 
ing Obstetrician, City Hospital, etc. With Forty-two 
Illustrations. St. Louis : C. V Mosbv Company, 1922. 
Pp. 138. 

This monograph describes a n-iethod of internal 
]X)dahc version developed by the author himself. 
For a long time version has been considered an 
emergency operation on occasions when forceps 
failed or were unavailable, and the generally prac- 
tised technic of version is anything but satisfactory. 
It is the author's aim to popularize this technic and 
to urge its more frequent application. With increas- 
ing practice, the technic became standardized. He 
found that ])rcssure exerted over the fundus of the 
uterus, as often recommended, is not only tmneces- 
sary but also dangerous, as it frequentlv leads to the 
extension of the child's arms over the head dtiring 
delivery and other difficulties. As the indications 
for this procedure were increased, the puerperium 
was found to have a smooth course and the morbid- 



ity and suffering of the mother were decreased. At 
the present time the author uses version in ninety 
per cent, of his cases : the last 938 cases, including 
all kinds of complications, showed no maternal mor- 
tality and a fetal mortality of 2.3 per cent. — a re- 
markable record. With the aid of version the second 
stage of labor is eliminated, together with the usually 
resulting suffering and torn or relaxed perineum ; 
the delivery is completed within an hour and the 
physician is not exhausted. This is the result of the 
author's perseverance in the face of severe criticism 
and even persoiial abuse, for which he deserves 
much credit. 

The first two chapters, comprising almost half of 
the book, review the early history of version includ- 
ing that of the nineteenth century and excerpts are 
quoted from the most prominent authors, showing 
the opinions held at various times of this procedure. 
The present trend of obstetrical teaching is to con- 
sider version as a difficult and dangerous operation 
to be undertaken only in extreme emergencies ; this 
the author deprecates and for it he blames inade- 
(juate teaching in the medical schools. 

Potter still favors the use of chloroform for anes- 
thesia, a procedure which is condemned by many as 
unsafe and capable of producing serious damage to 
the maternal viscera, especially in the hands of the 
inexperienced or careless administrator. Every step 
of the technic is carefully and suitabl}' illustratecl. 
The suliject is presented in a forcible and convincing 
style and proves excellent reading. The practice of 
presenting subjects in monographs patterned after 
the style of this one deserves emulation. 

DISEASES OF WOMEN. 

Diseases of Women. By Ten Teachers. Under the Direc- 
tion of CoMYNS Berkeley, M. A., M. D., M. C. (Can- 
tab.), F. R. C. P. Lon.), Obstetrical and Gynecological 
Surgeon to the Middlesex Hospital, etc. Edited by 
CoMYNs Berkeley. H. Ritssell Andrews, J. S. Fair- 
bairn. Illustrated. Second Edition. New York : Long- 
mans, Green & Co., 1922. Pp. xi-641. 

Conjoint authorship seems to be the latest fad in 
English publications. The ten teachers who were 
the authors of this book are H. Russell Andrews. 
J. D. Barris, Comyns Berkeley, Victor Bonney, 
Harold Chappie, G. F. Darwall Smith, Stanley Dodd, 
J. S. Fairbairn, T. G. Stevens and Clifford White, 
who also wrote its companion book "Midwifery." 
Although the various subjects were originally as- 
signed to ])articular authors, each subject was finally 
reviewed by the whole body, thereby overcoming the 
disadvantages of collective authorship, and the final 
])roduct eventually represented the views of all. 
The reasons for differences of opinion tlu- student is 
left to unravel for himself. 

In regard to therapy, the statements regarding 
dosage are fretiuently vague or entirely lacking, 
especially with reference to the endocrine products. 
In a textbook intended for medical students, instruc- 
tions as to the dosage of drugs should be .specific. 
Patent medicines are occasionally recommended, 
such as antikamnia, a practice that seems to nin 
counter to our own ethical standards. Fretiuently 



July i, 1922.] 



BOOK REVIEWS. 



51 



treatment is referred to the companion book Mid- 
wifcry, which, to say the least, seems unfair. The 
impression is given that ichthyol is a panacea in al- 
most every form of gynecological disease. 

The subject of the venereal diseases is discussed 
with the purpose of emphasizing the preventive as- 
pect of state medicine and many abstracts from the 
report of the Royal Commission on \'enereal Dis- 
eases are cited. The method of treating the subjects 
of gonorrhea, syphilis and chancroid is inadequate, 
as it merely scratches the surface, especially in the 
matter of therapy. Giving an anesthetic for the 
treatment of gonorrhea seems extreme. 

The topic of extrauterine pregnancy is treated 
very satisfactorily and gives the student the proper 
point of view. Urinary and intestinal disorders, re- 
spectively, are treated as separate entities. The sec- 
tion dealing with the psychological fac'tor in its rela- 
tionship to the diseases of women, a subject usually 
not extensively discussed in textbooks on gynecol- 
ogy, should be a great aid in the better imder- 
standing of this important subject, too often neg- 
lected under the name of neurasthenia. 

The surgical technic of gynecological operations 
constitutes a .separate section, an arrangement that is 
not as good as that of adding the operative treatment 
indicated at the end of the description of each dis- 
ease. Instead of describing the surgical technic, 
merely a general description of what should be done 
is given at the end of the chapter. The most recent 
operative technics are not given. 

The book on the whole creates an impression of 
dogmatism, which is probablv a good way of pre- 
senting a subject to students. Bibliographies were 
omitted, although it is now an almost universal prac- 
tice to include them. An air of conservatism per- 
vades the whole work. 

TEXTBOOK OF OBSTETRICAL NURSING. 

Obstetrical Nursing. A Textbook on the Nursing Care of 
the Expectant Mother, the Woman in Labor, the Young 
Mother and Her Baby. By Carolyn Coxaxt van Bl.\r- 
COM, R. N. With Two Hundred Illustrations and Eight 
Charts. New York : The Macmillan Company, 1922. 
Pp. xxiv-5S8. 

This textbook on nursing is of great value. It is 
the most complete book of its kind that has come 
within the province of the reviewer. Great atten- 
tion is bestowed upon minor details, which are of 
major importance. Physicians whose work takes 
them into the field of obstetrics would profit by 
reading this book, for they would then be able to in- 
struct their nurses in a concrete way instead of leav- 
ing general orders. The author has realized the im- 
port of the p.sychic state of the mother during the 
period of gestation, labor and puerperium and also 
the need for a state of harmony and rapport between 
physician, nurse and patient. These, it is proved, 
may best be secured by careful training and imder- 
standing on the part of the nurse, .\merican, Eng- 
lish and Canadian schools of nursing are studied and 
the best these have to ofTer are selected with com- 
monsense and presented in this work. Twenty years 
of active work are embodied in the experience of 
the author. Hospital and home conditions are con- 
sidered, and while general plans of procedure are 
followed, there is enough leeway given to make these 
adaptable to anv complications or circumstances. 



OBSTETRICS FOR MIDWIVES. 

Synopsis of Midwiferx. Bv Aleck W. Bourne, B. A., 
M. B., B. Ch. (Cantab.), F. R. C. S. (Eng.), Obstetric 
Surgeon to In-patients. Queen Charlotte's Hospital ; Ob- 
steric Surgeon to Out-patients, St. Mary's Hospital, Lon- 
don. Second Edition. New York : William Wood & Co., 
1921. 

This handbook fulfills in an admirable way the 
purpose of its author, wh^ch is to provide in a clear, 
concise and compact form the principal points in ob- 
stetrics upon which the student preparing for an 
examination should be informed. No attempt is 
made to supplant the standard textbooks on ob- 
stetrics. The second edition of this work has been 
enlarged by the addition of new matter, particularly 
on the toxemias of pregnancy and the hemorrhages 
of pregnancy and labor. The newer methods of 
treating these conditions have been incorporated, and 
in fact all the sections on treatment have been given 
more in detail in order that the work may prove of 
use to the general practitioner as well as to the stu- 
dent, both of whom will find it valuable in re- 
vising their knowledge of the essentials of obstetrics. 

GYNECOLOGY AND MIDWIFERY. 

Geburtshilflich-gyndkologische Propddeutik. Eine theo- 
retische und praktische Einfiihrung in die Klinik und in 
die Untersuchungskurse. Von Prof. Dr. Osc.\R Polano, 
vorstand der Eynakologischen Universitats-Poliklinik, 
Miinchen. Third and Fourth Editions. Leipzig: Curt 
Kabitzsch, 1922. Pp. 195. 

This work appeared originally in 1914 as a 150 
page volume. It has now expanded to 195 pages 
with 96 illustrations, for the most part colored. As 
its title tells it is an introduction to the double stib- 
ject of midwifery and gy-necology. There are six 
chapters on anatomy and physiology, including the 
anatomy of the pelvis, and one each on the anatomo- 
physiology of gestation, physiology of labor, and 
physiology of the puerperium. The remainder of 
the book is devoted to the obstetrical and gyneco- 
logical examinations, technic, including bacteriology 
and rontgenography. The scope of the book is 
somewhat out of the beaten track. Just what added 
or special values it possesses for teaching must of 
course be left to the test of experience, but the basic 
plan seems wholly along the lines of economic 
efficiency. 

BACTERIOLOGY. 

Compend of Bacteriology. Including Pathogenic Protozoa. 
By Rob?;rt L. Pitfield. M. D.. Pathologist to the Ger- 
mantown Hospital ; Late Demonstrator of Bacteriology 
at the Medico-Chirurgical College, Philadelphia, etc. 
Fourth Edition. With Four Plates and Eighty-two Other 
Illustrations. Philadelphia: P. Blakiston's Son & Co., 
1921. 

This compend is designed to meet the needs of 
the student preparing for examination. The minute 
details of cultures and technic are not given, so 
the book will not be very useful to the laboratory 
worker. But for the practitioner of medicine, the 
nurse, or the student who wishes to become ac- 
quainted with the principal facts of the science of 
bacteriology without the expenditure of mucii 
effort, the author has provided a readable and well 
illustrated little book. This edition contains chap- 
ters on filterable viruses, contributed by Dr. Herbert 
Fox, and new matter has been added throughout 
the book. 



52 



BOOK RETIEJVS. 



LXew York Medical Tournal 
AND Medical Record. 



IDEALISM. 

The Xczv Idealism. By May Sincx.\ir. New York: The 
Macinillan Company. 1922. Pp. xvi-333. 

Here we have to deal with a charming presenta- 
tion of a philosophical egocentric anarch)'. Truth 
there may be of as many colors as there are observ- 
ers, a valid truth for each according to his per- 
ceptions, unmindful of corroboration or contradic- 
tion. According to our ne\v idealism the psychotic is 
sane or insane according to his own diagnosis or he 
has as many sanities as the individual opinions of 
his many observers. This may be a convenient if a 
somewhat confusing philosophy, comforting if not 
correct. Pragmatism, vitalism or any other con- 
structive philosophy is deftly shunted to limbo. The 
idealist, so May Sinclair assures us, has little con- 
cern with how things really are, his main interest 
being in how they appear — to him. This then is a 
philosophy which allows for too much error and too 
much phantasy. If this is to be called philosophy 
we should at least Cjualify and let it be known as 
fictive philosophy. It is a socalled philosophy which 
allows for no growth and does not consider differ- 
ences of experience or knowledge among various 
persons. 

In spite of these drawbacks we are indebted to 
]May Sinclair for a clear, impartial, and convincing 
analysis and critique of realism. Of especial inter- 
est are her presentations of space — time and deity. 
She has also presented the case for idealism with 
brilliancy. Defenders it surely requires. The charm 
of her writing is as evident here as in her fiction. If 
more writers in this arid world of philosophy would 
cultivate the clarity which is found in this book the 
entire subject would be less boresome and more in- 
structive. If Miss Sinclair's next contribution to 
the subject of idealism excels The Xezu Idealism in 
the same degree as this is an improvement over her 
Defence of IdcaUsm it will be well worth considera- 
tion. For the present, however, the reviewer opines 
that there is more sound philosophy in The Life and 
Death of Harriet Frcan than in either of the more 
frankly philosophical contributions. 

JOANNA GODDEN. 

Joamw, Codden. By Sheila Kaye-Smith. New York : 
E. P. Dutton & Co, 1922. Pp. 353. 

Society will not tolerate individualistic suprem- 
acy, except in rare cases in which the individual is 
great enough — or clever enough— to subordinate his 
personal aims to the purposes of society. Dr. Con- 
stance Long, the well known British psychiatrist. 
])uts this thought exceptionally well in a recent paper 
on Psychological Adaptation, in which she writes: 
"The individual person differentiates himself from 
what is customary and average, and is only approved 
when he has given to society in exchange for the 
exemptions, licenses, or heresies through which he 
has established his freedom." 

The novel, Joanna Godden, illustrates the working 
out of this hypothesis in the development of the two 
sisters, Joanna and Ellen. Left orphans, Joanna, the 
elder, assumed the place of mother and lovingly 
tyrannized over Ellen, even to the extent of marrying 
her off after her. return from boarding school to a 
man she did not love — an unhappy match culminat- 



ing in Ellen's going to the continent as the mistress 
of an elderly reprobate. Her subsequent disillu- 
sioned return to the village from this escapade, which 
had been kept a secret, only stimulated the curiosity 
and interest of the villagers, and later Ellen, the 
wary, discreet and artful, seeing little in real values 
if appearances were preserved, attained distinction 
by conforming to collective opinion and gaining col- 
lective approval, finally marrying the "catch" of the 
countryside. Joanna, on the other hand, sincere and 
genuine, absolutely incapable of untruth, witli all the 
beauty of person and wholesomeness of nature that 
should come from good heredity, healthful living 
and outdoor occupation, was considered by her 
neighbors as greatly inferior to her sister. Her 
unpopularity was increased by her steady, inde- 
pendent march to success and prosperity, which 
finally elevated her sheep farm to the proud position 
of the manor of the countryside. For Joanna was 
ambitious, practical, and intelligent, and possessed 
an excellent head for business. Also, upon occa- 
sion, she could be headstrong, domineering and 
scornful. None of the young farmers of the vicin- 
ity wanted to marry a "highflyer who had never been 
praaperly broken in," and the one man who was able 
to appreciate her met a sudden death, so Joanna re- 
mained unloved and unwed. But the story end,'^ 
with at least partial compensation promised for the 
future. 

The mutual sustaining of each other by plot and 
characterization is cleverly worked out by the author. 
The style is simple and direct, so that the story tells 
itself, and the psychology of the characters is based 
on a thorough knowledge of and real sympatliy with 
human nature. The book certainly sustains Miss 
Kaye-Smith's position as one of the foremost of 
British novelists. 

BRINGING UP CHILDREN. 

I'lie Child mid the Home. Essays on the Rational Bring- 
ing Up of Children. By Bexzion Liber. M. D.. Dr. P. H,. 
Editor of Rational Livimi. New York : Rational Living. 
1922. Pp. 256. 

It is difficult for a firm believer in the rational 
bringing up of children to form an impartial opinion 
of this book. The reviewer is fortunate in know- 
ing only that kind of bringing up. Consequently to 
him there is much in the book that seems obvious 
and selfevident. If these essays will undermine the 
foundation of families whose creed is, "What was 
good enough for father is good enough for me !" 
they will have accomplished a great and needed 
work. Countless potential brains have been crushed 
by bourgeois mediocrity that could not conceive of 
the future being better than the past. The families 
who still "bring up" their children will undoubtedly 
need the aid of the skilled medical man to unravel 
their problems. We trust that they may fall into the 
capable hands of some such educator of Dr. Liber, 
either in person or figurative speaking through his 
book. To them his message will appeal and strike 
home. To us who are already coworkers and feel 
that the child brings up the parent more skilfully 
than ever parent could guide child, the book serves 
as an illuminating comment on a firmly rooted con- 
viction. 



July 3, 1922,] 



BOOK REVIEWS. 



0,-) 



Medicoliterary Notes. 

The recently issued annual report for 1921 of the 
Central Indiana Hospital for the Insane at Indian- 
apolis contains an interesting section on the ver\- 
full course in psychopathology being conducted at 
that institution. This course is open without charge 
to practitioners and students of medicine, including 
officers and members of the county medical societies 
of the state. Since 1893. the date of the incum- 
bency of the present superintendent. Dr. George F. 
Edenharter. this institution has strongly advocated 
the principle that every state hospital should have 
two functions: 1, that of an institution for observa- . 
tion, research, care and treatment of mental dis- 
eases ; 2, that of a part of a general scheme of com- 
munity service for the prevention of such disorders 
through public education in mental hygiene, for the 
liolding of mental clinics, and as a teaching hospital. 

^ ^ * 

Better Letters is the suggestive title of a pocket- 
sized volume recently published by the Academy 
Press, Wyoming. N. Y.. giving in ver\' brief, yet 
most practical form, valuable suggestions and in- 
formation about business correspondence. The sec- 
retary or stenographer of every physician should 

have a desk copy. 

* ^ * 

The Forty-fourth Annual Report of the Jefferson 
Hospital. Philadelphia, states that during the past 
■year 8,647 patients were treated at the hospital. 
The out patient department handled 32„i81 per- 
sons, and the emergenc\' ward gave first treatment 
to 16,000. 

^ ^ ^ 

According to the records of thirty-seven insurance 
companies, 1921 was the healthiest year in the his- 
tories of the United States and Canada. This was 
due to a reduction in the number of influenza and 
pneumonia cases. Suicides and homicides, automo- 
bile accidents and recorded deaths from cancer were 
more numerous than in 1920. 

=H ^ ^ 

The recently published annual report of the Collis 
P. Huntington Memorial Hospital for Cancer Re- 
search and of the Laboratories of the Cancer Com- 
mission of Harvard Universitv announces as the 
two most notable features of the year's work the 
perfection of an elaborate new x ray machine by 
William Duane, Ph. D., and the completion of the 
new laboratory building. 

^ "^ ^ 

My Boyhood, by the good gray naturalist, John 
Ijurroughs. with a conclusion by his son Julian Bur- 
roughs, and most attractive illustrations, is a restful 
yet entertaining volume recently published by 
Doubleday. and delightful reading for a Sunday 
afternoon in summer. 

=f^ ^ ^= 

.\t a recent session of the Fcoiiomic Council of 
Poland, the Government definitely guaranteed to 
assume the responsibilitv to feed 400,000 children 
from Tune 1 to October' 1. 1922. and .300.000 chil- 
dren from October 1, 1922. to June 1, 1923. Free 
transportation is being provided to .-Kmerican Relief 



Administration supplies acro.-'S Poland, as well as 
free warehousing of foodstuffs at Danzig. 

^ ^ ^ 

The United States Public Heakh Service is send- 
ing out three times weekly public health messages 
from the Xaval Laboratory Air Craft Station, XOF, 
Anacosta, D. C. ; these messages have been heard as 
far west as Kansas. This method of broadcasting 
marks a distinct step in public health education. It 
is reported that answers have come back to "NOF" 
from thousands of radio operators, including very 
young boys, illiterate persons, railwav magnates and 
bank presidents. 

New Publications Received. 



THE PSVCHOLOliV OF MEDICINE. Bv T. \V. MiTCHELL, 

M.D. New York: Robert M. McBride & Company, 1922. 

THE ouTc.vsT. By Selm.\ L.A.CERLOF. Garden City, New 
York and Toronto : Doubledav. Page & Company, 1922. 
Pp. vi-297. 

TR.\XS.\CTIONS OF THE .VMERIC.AX SURGIC.\L .ASSOCI.^TION. 

Volume XXXIX. Philadelphia: William J. Dornan, 1921. 
Pp. liii-779. 

GENTLE JULI.\. By BooTH T.-\RKIN(.T0N'. Garden City, 
New York and Toronto : Doubledav, Page & Company, 
1922. Pp. 57':'. 

ETUDE DE L'EVOLfTION DES .\DENOP.\THIES HIL.\IRES TU- 

BERCULEUSES. Par Dr. M.\rcel P.mllet. Paris : Jouve & 
Cie. Editeurs. 1922. Pp. 60. 

OUR ELEVEN BILLION DOLLARS. Europe's Debt to the 
United States. Bv Robert Molxtsier. New York: 
Thomas Seltzer, 1922. Pp. 149. 

the newer knowledge of nutrition. By E. V. Mc- 
CoLLUM. Second Edition. New York: The MacMillan 
Company, 1922. Pp. xviii-449. 

A M,\NU.\L or CLINICAL L.XBOR.XTORV METHODS. By 

Clyde Lottridge Cummer. Philadelphia and New York: 
Lea & Febiger, 1922. Pp. xviii-484. 

THE pr.\ctice of .\UT0SUGCESTinN. By the Method of 
Emile Coue. By C. H.\rrv Brooks. New York : Dodd, 
Mead and Company, 1922. Pp. 119. 

INFLUENZ.\ : ESS.WS BV SEVER.\L .\UTHORS. Edited by 
F. G. Crooksh.\nk. M.D. (London), F. R. C. P. London: 
William Heinemann, Ltd., 1922. Pp. 529. 

hvperpiesi.\ .\nd hvperpiesis (hypertension). By 
H. Batty Shaw. Oxford Medical Publications. London : 
Henry Frowde and Hodder & Stoughton, 1922. Pp. x-191. 

THE CLINICAL METHOD IN THE STUDY OF DISEASE. By 

R. M. Wilson. Oxford Medical Publications. London : 
Henry Frowde and Hodder & Stoughton, 1922. Pp. xii-S7. 

MENTALLY DEFICIENT CHILDREN. By G. E. ShUTTLE- 

WORTH and W. A. Potts. Fifth Edition. Philadelphia : 
P. Blakiston's Sons & Co. ; London ; H. K. Lewis & Co., 
Ltd., 1922. 

HANDBLCH DER MIKROBIOLOGISCHEN TECHNIK. HeraUS- 

gegeben von Prof. Dr. Rudolf Kraus und Prof. Dr. Paul 
Uhlenhuth. Berlin and Wein : Urban & Schwarzenberg. 
1922. Pp. 532. 

THE OXFORD INDEX OF THERAPEUTICS. Edited by ViCTOR 

E. Sokapure. Oxford Medical Publications. London : 
Henry Frowde and Hodder & Stoughton. 1922. Pp. xvi- 
1126.' 

THE PRINCIPLES OF ELECTROTHERAPY AND THEIR PRACTICAL 

APPLICATION. By W. J. TuRRELL. Oxford Medical Publi- 
cations. London : Henry Frowde and Hodder & Stoughton. 
1922. Pp. xi-276. 

WIENER ARCHIV FUR INNERE MEDIZIN. Golcitet VOn W. 

Falta und K. F. Wenckenbach. IV. Band. 1 Heft. Mit 
5 .-Vbbildungen und 29 Kurven im Text und 9 Tafcln. Ber- 
lin and Wien : Urban & Schwarzenberg. 1922. Pp. 189. 



Practical T herapeutics 



NOTES AND STATISTICS ON TWILIGHl" 
SLEEP. 

By H. M. Gersox, M. R. C. S., L. R. C. P., 

London. 

The following notes are a resume of my expe- 
riences in seventy-five cases conducted under twi- 
light sleep from May to December, 1920. Records 
were kept of every symptom and sign, dose being 
charted at the time given. Where possible, and 
when patients were seen early enough, pelvimetry 
was carried out and the usual antenatal procedures 
were adopted. No patient was advised against treat- 
ment on medical grounds though many might have 
been considered to hold out contraindications bv 
advanced pulmonary tuberculosis, heart disease, or 
other conditions. The methods of Professors Kro- 
nig and Gauss were used as my basis and additional 
details and variations gleaned from practical expe- 
rience may be worthy of record. 

TECHNIC. 

I was informed at once when labor set in, an ab- 
dominal examination only was made, the patient was 
told that her pains would increase in intensity and 
she was asked to call as soon as they became actually 
uncomfortable. When the patient was of nervous 
temperament I relied upon the regularity and inter- 
vals of pain (seven minutes) rather than dilatation 
of the OS, and commenced treatment without any 
vaginal examination. 

In the case of multipara I commenced treatment 
as soon as labor definitely set in, always making cer- 
tain that the pains were those of labor and never 
relying upon the nurse or patient for such informa- 
tion. Before giving the first injection, viz., one 
one hundred and fiftieth gr. of scopolamine and 
one third gr. of morphine made up in a single am- 
poule, the bedroom was arranged, windows opened, 
but light excluded, all swabs, instruments, dressings 
and other material were removed from the room 
only to be brought in when the patient was nar- 
cotized. Dexterity in giving the first injection was 
an important factor in gaining the confidence essen- 
tial while the patient was in the conscious state, an! 
was followed by a remark to the effect the imly pain- 
ful part of the treatment was now over. 

A second injection of one one hundred and fif- 
tieth gr. scopolamine alone was given in one hour's 
time and true amnesia was not obtained until a fur- 
ther three quarters of an hour had elapsed and in 
certain cases this period was even longer. Further 
doses were as in typical cases described below. 

The true state of amnesia can be recognized by 
means of memory tests such as those generally i>rac- 
tised by the Freiburg school, viz., showing the pn- 
tient familiar objects asking her to recognize tlicni 
later, her inability to do so being a criterion of the 
degree of amnesia. In my experience, however, 
these proved not only unnecessary but disturbing to 
the patient: after treating a certain number of 



patients the recognition of this state became almost 
instinctive. 

As will be gathered from the statistics below the 
percentage of complete amnesia in primiparae is high 
in comparson with multiparas, owing to the fact that 
the latter were seen too late in labor for the action 
of the drug to be elifective. The figures for incom- 
plete amnesia refer to those cases where the patient 
emerged from the narcotic state sufficiently to be 
conscious of her surroundings. This emergence in- 
• dicated the repetition of morphine (quarter gr). 
whereby complete amnesia was reinstated but at 
the sacrifice of a certain amount of intensity of uter- 
ine contraction. This in its turn was regained by 
small doses of pituitary extract. 

On the day after the delivery I confirmed my ob- 
servations by interrogating the patient and her recol- 
lections of trivial incidents were found to coincide 
with the time of incomplete amnesia. Analgesia was 
always complete irrespective of the degree of 
amnesia. 

fSF. OF FORCEPS. 

Forceps have been applied in many cases owing 
to delay late in the second stage. There is no doubt 
that the action of the drug in several cases lessened 
the force of uterine contraction to such a degree as 
10 necessitate the employment of the following 
methods : Stimulation of the uterus by abdominal 
massage and pressure ; putting on a binder ; empty- 
ing the bladder; giving enemata ; making vaginal ex- 
aminations; retracting the perineum manually. If 
these methods failed to intensify uterine contraction 
I gave small doses of pituitary extract (fifteen c. c. 
to one c. c). 

EFFECT OF TRE.«iTMEXT ON THE CHILD. 

One of the main objections to this method of de- 
livery would seem to lie in the condition of the child 
at birth. Oligopnea, in my experience, seems to 
occur more frecjuently than in unaided labor al- 
though in none of my cases of infant mortality can 
I attribute death to this cause. I undoubtedly found 
it advisable in every case to exercise a certain 
amount of vigilance until the child gave a healthy 
prolonged cry. In eight cases I found it necessary 
to resort to artificial respiration, attended in each 
case with successful results. I foimd that oligopnea 
occurred more frecjuently in labors of short duration 
than when delivery took place shortly after an early 
injection. 

Regarding the aftereffect upon the mentality of 
the child I have little to remark except that in fol- 
lowing up my cases I found the mortality in the 
first year nil and the mentality as far as one could 
judge normal. 

HEMORRHAGE. 

In no case did I find any appreciable alteration 
in the amount of hemorrhage. In one case the pa- 
tient volinitarily informed me tliat .she was im- 
pressed with the diminished amount of hemorrhage 
as compared with her former and ordinary confine- 
ment. 



July 5, 1922.] 



PRACTICAL THERAPEUTICS. 



55 



PUERPERIUM. 

In no case was there any complication and every 
patient was allowed to get up on the tenth day with 
no untoward result. Many a patient undertook a 
long journey on the fourteenth to seventeenth day. 

Case I. — Dose recorded in two typical primiparse 
occurring simultaneously. Labor pains commenced 
six hours before first injection. Os in each case 
dilated two fifths: pains regular, five minute in- 
tervals. 

Case 16 Case 17 

Time of Time of 

Injection Injection Injection 

1. 1/3 gr. morphine 1/150 gr. scopolamine 5:00 a.m. 5:30 a.m. 

2. 1/150 gr. scopolamine 6:10 a. m. 6:15 a. ra. 

3. 1/150 gr. scopolamine 8:55 a. m. 8:40 a. m. 

4. 1 /4 gr. nicrphine 1/150 gr. scopolamine 11:55 a.m. 11:15 a.m. 

5. 1/450 gr. scopolamine 12:25 a.m. 12:20 p.m. 

6. 1 '450 gr. scopolamine 1:35 p. m. 1 :30 p. ra. 

7. 1 450 gr. scopolamine 2:45 p.m. 2:40 p.m. 
Birth 3:30 p.m. 3:35 p.m. 

Case II. — Dose recorded in a typical multipara. 
Labor commenced three and a half hours before 
first injection. The os was dilated one fifth, pains 
regular, seven minute intervals. 

Injection Case 56 

1. 1/3 gr. morphine 1/150 gr. scopolamine 3:30 a.m. 

2. 1^4 gr. morphine 1/150 gr. scopolamine 4:15 a.m. 

3. 1 /1 50 gr. scopolamine 

+ 1 c.c. pituitary 7:00 a. m. 

4. 1/150 gr. scopolamine 10:00 a.m. 

5. 1 150 gr. scopolamine 12:55 p. m. 
Birth 2 :40 p. m. 

Case III. — A special case of induction of labor 
under twilight sleep, primipara, aged thirty-three, 
urine one hundred per cent, albumin, general edema, 
labia so swollen as to suggest danger of obstruction. 



1/150 gr. scopolamine 



Injection 

1. 1 '3 gr. morphine 1/150 gr. scopolamine 

2. "* ■ 
3. 
4. 
5. 
6. 
7. 
8. 



3 C.C. pituitary extract 

5 c.c. pituitary extract 
1/450 gr. scopolamine 
Birth 



.METHODS OF INDUCTION. 



7\me 

9:05 p. m. 
10:00 p. m. 
12:00 p. m. 

8:45 a. m. 
10:30 a.m. 
10:40 a. m. 
12:05 p. m. 
12:30 p. m. 

1:30 p. m. 

2:00 p.m. 



12 ]). 111. : The patient was given a whiff of chloro- 
form, the vagina packed with gauze, and a T binder 
put on. 8:45 a. m. : The patient was given another 
whiff of chloroform, and the os was dilated with the 
fingers until it was two fifths. 10:30 a. m. : Another 
whiff of chloroform was given and the de Ribes 
bag inserted. 12:5 p. m. : The bag was reinserted 
owing to leakage ; os then four fifths. 2 p. m. : For- 
ceps were applied, and a female child was delivered, 
stillborn, weighing six pounds, seven ounces. 

The patient made a good recovery, edema sub- 
siding and urine clear again three weeks following 
delivery. 

TABLE I 

Statistics of Seventy-Five Cases Delivered I'nder 
Twilight Sleep 



I 



Multipara: 



Primipartc 

Number of cases 48 27 

Maternal mortality Nil Nil 

Infant mortality 2 1 

Average duration of labor 20 I 2 hours 13 hours 

Average duration of twilight sleep. 11 l/'3 hours 7 1/4 hours 
Average period of labor before first 

injection 9 l/'6 hours 5 3/4 hours 

Average number of injections 2 4.2 

Maximum number of injections.... 12 10 

Minimum number of injections 2 2 

Complete amnesia 45 18 

Incomplete amnesia 3 8 

Amnesia unobtainable in one case. ... 1 

Instrumental delivery 28 2 



Radium in Gynecology. — H. O. Jones (Surgery. 
Gynecology and Obstetrics, October, 1921) reports a series 
of cases treated with radium in the g>-necologica! service 
of St. Luke's Hospital and presents the following sum- 
mary: 1. In selected cases of uterine fibroids in women 
near the menopause radium controls the bleeding and 
causes contraction of the tumor in about ninety per cent, 
of cases. 2. Radium is practically specific in the bleeding 
of the menopause ; idiopathic uterine hemorrhage is con- 
trolled in a majority of cases. 3. In carcinoma radium 
is a palliative agent of the greatest merit; as a curative 
agent it ranks at least the equal of other methods of treat- 
ment. 4. Chronic leucorrhea yields satisfactorily to radium 
treatment. 

Treatment of Cancer of the Cervix. — H. Okabayaski 
(Surgery, Gynecology and Obstetrics, October. 1921) gives 
the following results from the use of his technic for radical 
abdominal hysterectomy in cancer of the cervix : 1. The 
technic which he uses is quite different from other methods 
employed in treating cancer of the uterus. 2. With his 
method any case of cancer of the uterus, whether in a very 
advanced stage or in a primary stage, can be operated upon 
very satisfactorily. The dangers and sources of failure 
which occurred in his earlier operations with the Wert- 
heim method have ahnost disappeared. 3. The control of 
bleeding is the most difficult problem in the radical ab- 
dominal operation, because in the radical operation the 
parametrial tissue is widely extirpated. His method ren- 
ders extirpation easy and bloodless, even though the para- 
metrium is extensively infiltrated with cancer and though 
one excises the tissue near the pelvic floor. 4. With im- 
provement in the operative technic the operability percent- 
age has been raised and primary mortality has decreased. 
5. He hopes to be able to report much better results next 
year, when his cases will have passed the five year period. 
So far the results have been very satisfactory. He feels 
that the method described has not been perfected in all 
particulars, but he believes that it is one of the most perfect 
that has been designed for the treatment of cancer of the 
cervix of the uterus. If good results in the treatment of 
cancer of the cervix are secured with this method, it will 
bring great happiness to women. The honor for perfect- 
ing the technic he says naturally belongs to his teacher. 
Professor Takayama, and it is to give credit to him that 
the operation has been described. 

Radium Treatment in Carcinoma of the Uterus. — 

W. Kohlmann (Surgery, Gynecology and Obstetrics. Sep- 
tember, 1921) concludes as follows: 

1. The uterus together with the tubes and ovaries can 
be clearly shown by pneumoperitoneal rontgenography. 

2. Owing to their distention with gas the tubes are 
rather more clearly demonstrated by the x ray where in- 
flation has been brought about through the transutcrine 
route than where the inflation has been made transperi- 
toneally. 

3. On account of the rapid absorption of carbon dioxide 
gas with equally rapid subsidence of the discomfort pro- 
duced by the inflation, this gas should be used in preference 
to oxygen which is very slowly absorbed. 

4. Irregularities of the uterus, omenta! and bowel ad- 
hesions arc clearly demonstrated by pneumoperitoneal x ray. 

5. In not a few instances the diseased and enlarged 
appendages are more clearly made out by pelvic rontgenog- 
raphy tiian by the most careful and searching bimanual 
examination, even under anesthesia. 

6. With the improved position (knee chest and Tren- 
delenburg) smaller and smaller quantities of gas will be 
necessary for inflation. Thus discomfort will be reduced 
to a minimum. 

7. If the technic of pelvic rontgenography be good, 
retention of bowel coils in the pelvis will be proof of ad- 
hesions. 

8. The pneumoperitoneal x ray is able to demonstrate 
pregnancy at a much earlier period than is possible by the 
examining finger. 

9. With good technic and good judgment in the selec 
tion of cases both transuterinc and transperitoneal gas in- 
flation are free from danger. 

10. Bimanual pelvic examination and pelvic pneumo- 
peritoneal rontgenography are not antagonistic diagnostic 
methods. Each is valuable and their value is enhanced if 
used in conjunction, each acting as a check upon the othc.r. 



Practical Therapeutics 



NOTES AKD STATISTICS OX TWILIGHT 
SLEEP. 

By H. M. Gerson, M. R. C. S., L. R. C. P., 

London. 

The following notes are a resume of my expe- 
riences in seventy-five cases conducted under twi- 
light sleep from May to December, 1920. Records 
were kept of ever\- symptom and sign, dose being 
charted at the time given. Where possible, and 
when patients were seen early enough, pelvimetry 
was carried out and the usual antenatal procedures 
were adopted. No patient was advised against treat- 
inent on medical grounds though many might have 
been considered to hold out contraindications bv 
advanced pulmonarv- tuberculosis, heart disease, or 
other conditions. The methods of Professors Kro- 
nig and Gauss were used as my basis and additional 
details and variations gleaned from practical expe- 
rience may be worthy of record. 

TECHNIC. 

I was informed at once when labor set in. an ab- 
dominal examination onlj- was made, the patient was 
told that her pains would increase in intensity and 
she was asked to call as soon as they became actually 
uncomfortable. When the patient was cf nervous 
temperament I relied upon the regularity and inter- 
vals of pain (seven minutes I rather than dilatation 
of the OS, and commenced treatment without any 
vaginal e.xamination. 

In the case of multiparse I commenced treatment 
as soon as labor definitely set in, always making cer- 
tain that the pains were those of labor and never 
relying upon the nurse or patient for such informa- 
tion. Before giving the first injection, viz., one 
one hundred and fiftieth gr. of scopolamine and 
one third gr. of morphine made up in a single am- 
poule, the bedroom was arranged, windows opened, 
but light excluded, all swabs, instruments, dressings 
and other material were removed from the room 
only to be brought in when the patient was nar- 
cotized. Dexterity in giving the first injection was 
an important factor in gaining the confidence essen- 
tial while the patient was in the conscious state, and 
was followed by a remark to the eflfect the only pain- 
ful part of the treatment was now over. 

A second injection of one one hundred and fif- 
tieth gr. scopolamine alone was given in one hour's 
time and true amnesia was not obtained until a fur- 
ther three quarters of an hour had elapsed and in 
certain cases this period was even longer. Further 
doses were as in typical cases described below. 

The true state of amnesia can be recognized by 
means of memory tests such as those generally prac- 
tised by the Freiburg school, viz., showing the pa- 
tient familiar objects a.sking her to recognize them 
later, her inability to do so being a criterion of the 
degree of amnesia. In my experience, however. 
these proved not only unnecessary but disturbing to 
the patient; after treating a certain number of 



patients the recognition of this state became almost 
instinctive. 

As will be gathered from the statistics below the 
percentage of complete amnesia in primiparse is high 
in comparson with multiparse. owing to the fact that 
the latter were seen too late in labor for the action 
of the drug to be effective. The figures for incom- 
plete amnesia refer to those cases where the patient 
emerged from the narcotic state sufficiently to be 
conscious of her surroundings. This emergence in- 
• dicated the repetition of morphine (quarter gr). 
whereby complete amnesia was reinstated but at 
the sacrifice of a certain amount of intensity of uter- 
ine contraction. This in its turn was regained by 
small doses of pituitary extract. 

On the day after the delivery I confirmed my ob- 
servations by interrogating the patient and her recol- 
lections of trivial incidents were found to coincide 
with the time of incomplete amnesia. Analgesia was 
always complete irrespective of the degree of 
amnesia. 

USE OF FORCEPS. 

Forceps have been applied in many cases owing 
to delay late in the second stage. There is no doubt 
that the action of the drug in several cases lessened 
the force of uterine contraction to such a degree as 
to necessitate the employment of the following 
methods ; Stimulation of the uterus by abdominal 
massage and pressure ; putting on a binder ; empty- 
ing the bladder ; giving enemata ; making vaginal ex- 
aminations ; retracting the perineum manually. If 
these methods failed to intensify uterine contraction 
I gave small doses of pituitary extract (fifteen c. c. 
to one c. c). 

EFFECT OF TRE.\TMEXT ON THE CHILD. 

One of the main objections to this method of de- 
livery would seem to lie in the condition of the child 
at birth. Oligopnea, in my experience, seems to 
occur more frequently than in unaided labor al- 
though in none of my cases of infant mortality can 
I attribute death to this cause. I undoubtedly found 
it advisable in every case to exercise a certain 
amount of vigilance until the child gave a healthy 
prolonged cry. In eight cases I found it necessary 
to resort to artificial respiration, attended in each 
case with successful results. I found that oligopnea 
occurred more frequently in labors of short duration 
than when delivery took place shortly after an early 
injection. 

Regarding the aftereffect upon the mentality of 
the child I have little to remark except that in fol- 
lowing up my cases I found the mortality in the 
first year nil and the mentality as far as one could 
judge normal. 

HEMORRHAGE. 

In no case did I find any appreciable alteration 
in the amount of hemorrhage. In one case the pa- 
tient voluntarily informed me that site was im- 
pressed with the diminished amount of hemorrliage 
as compared with her former and ordinary confine- 
ment. 



July 5. 1022.] 



PRACTICAL THERAPEUTICS. 



55 



PUERPERIUM. 

In no case was there any complication and every 
patient was allowed to get up on the tenth day with 
no untoward result. Many a patient undertook a 
long journej- on the fourteenth to seventeenth day. 

Case I. — Dose recorded in two typical primiparas 
occurring simultaneously. Labor pains commenced 
six hours before first injection. Os in each case 
dilated two fifths: pains regular, five minute in- 
tervals. 

Case 16 Case 17 

Time of Time of 

Injection Injection Injection 

1. 1/3 gr. morphine 1/150 gr. scopolamine 5:00 a.m. 5:30 a.m. 

2. 1/150 gr. scopolamine 6:10 a. m. 6:15 a.m. 

3. 1/150 gr. scopolamine 8:55 a.m. 8:40 a.m. 

4. 1/4 gr. mcrphine l/1 50 gr. scopolamine 11:55 a.m. 11:15a.m. 

5. 1/450 gr. scopolamine 12:25 a.m. 12:20 p.m. 

6. 1/450 gr. scopolamine 1:35 p.m. 1:30 p.m. 

7. 1 /450 gr. scopolamine 2:45 p.m. 2:40 p.m. 
Birth 3 :30 p. m. 3:35 p.m. 

Case II. — Dose recorded in a typical multipara. 
Labor commenced three and a half hours before 
first injection. The os was dilated one fifth, pains 
regular, seven minute intervals. 

Injection Case 56 

1. 1/3 gr. morphine 1/150 gr. scopolamine 3:30 a.m. 

2. 1/4 gr. morphine 1/150 gr. scopolamine 4:15 a. m. 

3. 1 / 1 50 gr. scopolamine 

4- 1 c.c. pituitary 7 :00 a. m. 

4. 1/150 gr. scopolamine 10:00 a.m. 

5. 1/150 gr. scopolamine 12:55 p.m. 
Birth 2 :40 p. m. 

Case III. — A special case of induction of labor 
under twilight sleep, primipara, aged thirty-three, 
urine one hundred per cent, albumin, general edema, 
labia so swollen as to suggest danger of obstruction. 





Injection 






Time 


1. 


13 gr. morphine 1/150 


gr. 


scopolamine 


9:05 p. m 


2. 


1/150 


Rr. 


scopolamine 


10:00 p. m 


i. 








12:00 p. m 


4. 








8:45 a. m 


5. 








10:30 a. m 


b. 


5 c.c. pituitary extract 






10:40 a. m 


■J. 








12:05 p. m 


8. 


5 c.c. pituitary extract 






12:30 p. m 


y. 


1/450 gr. scopolamine 

Birth 






1:30 p. m 
2:00 p.m. 



METHODS OF INDUCTIOX. 

12 p. ni. : The patient was given a whifif of chloro- 
form, the vagina packed with gauze, and a T binder 
put on. 8:45 a. m. : The patient was given another 
whiff of chloroform, and the os was dilated with the 
fingers until it was two fifths. 10:30 a. m. : Another 
whiff of chloroform was given and the de Ribes 
bag inserted. 12:5 p. m. : The bag was reinserted 
owing to leakage; os then four fifths. 2 p. m. : For- 
ceps were applied, and a female child was delivered, 
stillborn, weighing six pounds, seven ounces. 

The patient made a good recovery, edema sub- 
siding and urine clear again three weeks following 
delivery. 

table I 

Statistics of Skvesty-Five Casks Delivered U.nder 
Twilight Sleep 

I Primipara: Multipara" 

Number of cases 48 27 

Maternal mortality Nil Nil 

Infant mortality 2 1 

Average <iur3tion of labor 20 12 hours 13 hours 

Average duration of twilight sleep. 11 1/3 hours 7 1/4 hours 
Average period of labor before first 

injection 9 1/6 hours 5 3/4 hours 

Average number of injections 2 4.2 

Maximum number of injections.... 12 10 

Minimum number of injections 2 2 

Complete amnesia 45 18 

Incomplete amnesia 3 8 

Amnesia unobtainable in one case. ... 1 

Instrumental delivery 28 2 



Radium in Gynecology. — H. O. Jones {Surgery, 
Gynecology and Obstetrics, October, 1921) reports a series 
of cases treated with radium in the gynecological service 
of St. Luke's Hospital and presents the following sum- 
mary: 1. In selected cases of uterine fibroids in women 
near the menopause radium controls the bleeding and 
causes contraction of the tumor in about ninety per cent, 
of cases. 2. Radium is practically specific in the bleeding 
of the menopause ; idiopathic uterine hemorrhage is con- 
trolled in a majority of cases. 3. In carcinoma radium 
is a palliative agent of the greatest merit; as a curative 
agent it ranks at least the equal of other methods of treat- 
ment. 4. Chronic leucorrhea yields satisfactorily to radium 
treatment. 

Treatment of Cancer of the Cervix. — H. Okabayaski 

(Surgery, Gynecology and Obstetrics, October, 1921) gives 
the following results from the use of his technic for radical 
abdominal hysterectomy in cancer of the cervix: 1. The 
technic which he uses is quite different from other methods 
employed in treating cancer of the uterus. 2. With his 
method any case of cancer of the uterus, whether in a very 
advanced stage or in a primary stage, can be operated upon 
very satisfactorily. The dangers and sources of failure 
which occurred in his earlier operations with the Wert- 
heim method have almost disappeared. 3. The control of 
bleeding is the most difficult problein in the radical ab- 
dominal operation, because in the radical operation the 
parametria! tissue is widely extirpated. His method ren- 
ders extirpation easy and bloodless, even though the para- 
metrium is extensively infiltrated with cancer and though 
one excises the tissue near the pelvic floor. 4. With im- 
provement in the operative technic the operability percent- 
age has been raised and primary mortality has decreased. 
5. He hopes to be able to report much better results next 
year, when his cases will have passed the five year period. 
So far the results have been very satisfactory. He feels 
that the method described has not been perfected in all 
particulars, but he believes that it is one of the most perfect 
that has been designed for the treatment of cancer of the 
cervix of the uterus. If good results in the treatment of 
cancer of the cervix are secured with this method, it will 
bring great happiness to women. The honor for perfect- 
ing the technic he says naturally belongs to his teacher. 
Professor Takayama, and it is to give credit to him that 
the operation has been described. 

Radium Treatment in Carcinoma of the Uterus. — 

W. Kohlmann (Surgery, Gynecology and Obstetrics. Sep- 
tember, 1921) concludes as follows: 

1. The uterus together with the tubes and ovaries can 
be clearly shown by pneumoperitoneal rontgenography. 

2. Owing to their distention with gas the tubes are 
rather more clearly demonstrated by the x ray where in- 
flation has been brought about through the transuterine 
route than where the inflation has been made transperi- 
toneally. 

3. On account of the rapid absorption of carbon dioxide 
gas with equally rapid subsidence of the discomfort pro- 
duced by the inflation, this gas should be used in preference 
to oxygen which is very slowly absorbed. 

4. Irregularities of the uterus, omental and bowel ad- 
hesions are clearly demonstrated by pneumoperitoneal x ray. 

5. In not a few instances the diseased and enlarged 
appendages are more clearly made out by pelvic rontgenog- 
raphy than by the most careful and searching bimanual 
examinatiiin, even under ancstliesia. 

6. With the improved position (knee chest and Tren- 
delenburg) smaller and smaller quantities of gas will be 
necessary for inflation. Thus discomfort will be reduced 
to a minimum. 

7. If the technic of pelvic rontgenography be good, 
retention of bowel coils in the pelvis will be proof of ad- 
hesions. 

8. The pneumoperitoneal x ray is able to demonstrate 
pregnancy at a much earlier period than is possible by the 
examining finger. 

9. With good technic and good judgment in the selec 
tion of cases both transuterine and transperitoneal gas in- 
flation are free from danger. 

10. Bimanual pelvic examination and pelvic pneumo- 
peritoneal rontgenography are not antagonistic diagnostic 
methods. Each is valuable and their value is enhanced if 
used in conjunction, each acting as a check upon the othqr. 



Proceedings of Societies 



AMERICAX ASSOCIATION OF OBSTETRICIANS. 

GYNECOLOGISTS AND ABDOMINAL 

SURGEONS. 

Thirty-Fourth Annual Meeting. Held at St. Louis, 

Missouri, September 20. 21 and 22, 192L 

The President. Dr. Henrv Schw.\rz, of St. Louis, in 
the Chair. 

Diabetes and Pregnancy. — Dr. JoHX N. Bell, of De- 
troit, said that a more careful prenatal history should be 
taken of all obsietrical patients. A blood sugar estimation 
should be made in all cases where symptoms of diabetes 
were present, regardless of the presence or absence of 
glycosuria. A fair trial of the newer forms of treatment 
should be instituted before terminating the pregnancy. 

Heart Disease in Pregnancy. — -Dr. William G. Dice. 
of Toledo, Ohio, stated that during pregnancy no cardiac 
murmur or irregularity was of itself an evidence of heart 
disease. Pregnancy lessened the life expectancy of any 
woman with a chronic valvular or muscular lesion. Valve 
lesions of themselves did not constitute a bar to pregnancy 
but the manner in which the heart did its work was all 
important. Every cardiopath was a cripple and her treat- 
ment throughout pregnancy and labor must be such as to 
spare the heart in every way. Caesarean section gave the 
best results in uncompensated cases and in cases where 
heart failure threatened during labor. 

Additions to Our Obstetrical Armamentarium. — Dr. 
Ch.'VRLes Edward Ziegler, of Pittsburgh, presented the 
following: 1. A new metalhc nipple shield: This shield 
is made of pure aluminum, with numerous perforations for 
ventilation in both base and dome. The base is flared to 
conform with the convexity of the breast and is sufficiently 
roomy to protect the nipple from contact. It provides for 
the treatment of the abraded, fissured, inflamed, or sensi- 
tive nipple by affording absolute rest and protection against 
traumatism. 2. An umbilical cord clamp : This is com- 
posed of rubber and noncorrosive metal and has the form 
of a disc. It may be incorporated into the cord dressings 
without discomfort and left in place until_ the stump falls 
off. It minimizes the chances of infection, and greatly 
shortens the time of separation of the stump. 3. An 
identification wristlet for infants : In order to prevent mix- 
ing of babies various devic'es are in use, but none are 
entirely satisfactory. 

Teaching Undergraduate Obstetrics. — Dr. Arthur M. 
Mendenh.\ll. of Indianapolis, said that a greater effort 
should be made to impress upon the. student that obstetrics 
was a major division of his medical course and that few. 
if any, primiparK were ever delivered of full sized infants 
and left in as perfect condition as before. Then when the 
student went into obstetrical practice, he would carry this 
impression with him to the laity and do his part toward 
educating them to the importance of proper obstetrical 
care. More emphasis should be laid upon the proper hand- 
ling of socalled normal cases and not so much of the 
student's time taken in trying to teach him the various kinds 
of Cesarean sections and other obstetrical operations 
which should only be performed by the thoroughly trained 
obstetrician. Socalled outdoor obstetrics at best was of 
little real value to the student and had better be abandoned 
entirely than continued without thorough and continuous 
supervision by the obstetrical teaching staff. Since diagnosis 
in obstetrics, as in all branches of medicine, was the real 
foundation for proper care and treatment, it was well that 
every possible opportunity should be utilized to teach this 
most thoroughly and the student's powers in this line were 
greatly enhanced by prolonged manikin practice, by large 
numbers of antepartum examinations, and by wide clinical 
experience. Teaching by interns, or those w-ho had very 
little more knowledge, was sure to create a wrong impres- 
sion of the importance of the subject and fell very far 
short directly and indirectly of the result desired. One of 
the most important ways in which one could at once obtain 
better results in teaching obstetrics was to impress upon 
the mind of the laity and hospital managers that a larg. 



and well equipped maternity hospital was the best place to 
teach obstetrics and at the same time would contribute 
strongly toward a reduction of fetal and maternal death 
rates in the community in which it was established, as well 
as in the communities where the students went to practice. 

The Action of the Commoner Ecbolics in the First 
Stage of Labor. — Dr. M. Pierce Rucker, of Richmond. 
\'a., said that the patient with a \'oorhees bag in her cervix 
offered an excellent opportunity to observe the action upon 
the uterus of the drugs commonly used in obstetrics. From 
his rather limited observation it would seem that hyoscine 
had a moderate but rather constant ecl»Iic action in the 
first stage of labor. The action of quinine was more vari- 
able. Sometimes it markedly strengthened the normal 
rhythmic contractions, and sometimes it showed no action 
whatever. His observations upon the action of strychnine, 
castor oil, ergotol. and the fluid extract of ergot were too 
limited to warrant even a tentative conclusion. It would 
seem, however, that the possibility of an inert preparation 
i>f ergotol and the fluid extract of ergot was a real one. 
In the three cases in which pituitrin was used, even in 
minute doses, there was a continued contraction of the 
uterus that varied from nine to thirty-five minutes. This 
probably explained the disasters that had followed its use. 

A Method of Delivery in Normal Cases. — Dr. Mag- 
xus A. Tate, of Cincinnati, Ohio, summarized the steps 
of the method as follows : 1. Patient must be in labor with 
an OS dilated to at least the size of half a dollar, and an 
effacement of the cervical canal. 2. Surgical anesthesia. 
3. Bladder catheterization. 4. Complete manual dilatation 
of vagina and cervix. 5. Patient allowed to regain partial 
consciousness. 6. Pituitrin, half ace; repeat once if the 
pains are not efficient in half an hour. 7. Membranes rup- 
tured. 8 Management of delivery as in usual cases. 

An Analysis of the Potter Version. — Dr. Edward 
Speidel, of Louisville, said that having had the pleasure of 
a visit to Dr. Potter, in Buffalo, and from a limited ex- 
perience with the method in private and hospital practice, 
he would like to discuss the version from three distinct 
points of excellence. 1. It was such a decided improve- 
ment over all the old established methods that it should 
supplant all other means of performing podalic version. 
2. The delivery of the child after version had been per- 
formed was such a marked advance over the old methods 
of breech delivery that it should displace those practices 
at once. 3. His effective treatment of the child at birth 
by gentle rational manipulations was so superior to the 
many rough treatments tliat the asphj-xiated baby had been 
subjected to heretofore, that it should surely induce every 
obstetrician to emulate them. 

Treatment of Eclampsia: Then and Nowr. — Dr. J. F. 
MoRAX. of Washington. D. C. stated that the keynote of 
the treatment of eclampsia was individualization with at- 
tention directed particularly to morphinization. venesection, 
elimination, and facilitating delivery, all depending upon 
the state of the cervix and exigencies of the case. Radical- 
ism was prompted largely by fear and expediency. In- 
dividualization and conservatism required courage and ob- 
stetrical judgment. Accouchement force was irrational, 
brutal and indefensible. Immediate delivery by Cssarean 
section was rarely necessary unless indications of dispro- 
portion, rigid cervix, etc., obtained. Intermediate and con- 
servative treatment yielded lower mortality and morbidity 
than was obtained by surgical and forcible intervention. 

A Study of the Origin of Bleeding in E-topic Preg- 
nancy. — Dr. Jon.N OsEORX Poi.ak and Dr. Thurston S. 
W'elto.v, of Brooklyn, said that from their studies they had 
shown that a decidual reaction might be found at several 
points in the tube in ectopic points often far remote from 
the scat of implantation. Coincident with the separation 
or death of the ovum by hemorrhage into the decidua. there 
was bleeding from the uterus and also bleeding from the 
several points of decidual reaction in the tube. Tubal 
peristalsis and the fi.t tt tcrao of the clot in the tube, ex- 
pelled blood from the abdominal ostium into the peritoneum, 
which gravitated into the cul de sac. The same factors 
contributed a portion of the blood, making up the bloody 



July 5, 1922.] 



PROCEEDINGS OF SOCIETIES. 



D/ 



discharge from the uterus, which signified the separation 
or death of the embryo. 

Some Phases in the Evolution o; the Diagnosis and 
Treatment of Cancer of the Cervix. — Dr. Rol.xnp E. 
Skeel. of Lui Angeles, stated that any expectation of an 
increased number of cures of cancer of the cervix by 
surgical methods must be based upon earlier diagnosis. 
Panhysterectomy should be reserved for cases in which a 
positive diagnosis could be made with the microscope only. 
The parametrium being free, so far as digital examination 
could determine, but the case far enough advanced to be 
diagnosed clinically, a high cautery amputation of the cer- 
vix followed by radium treatment offered the greatest hope 
of cure. The advanced, surgically hopeless case should be 
treated by radium rather than with the knife, curette and 
cautery, chemical caustics or Percy cauterization, unless 
profound toxemia or serious infection contraindicated local 
interference of any kind. 

Valuable Methods Used to Extend Operability in 
Advanced Cancer of the Cervix, — Dr. George v.ax Am- 
ber Browx. of Detroit, said that the use of the starvation 
ligature mechanically accomplishe^ instantly in the bloody 
supply w-hat a study of a microscopic specimen of carcinoma 
showed nature was endeavoring to accomplish. The vessels 
should be tied at two points with either kangaroo tendon 
or heavy catgut ligature, as finer catgut might cut the 
vessel wall and precipitate a hemorrhage. Between the 
ties the arteries were crushed to a ribbon. Absorbable 
suture was used to avoid as far as possible the irritation 
factor that would undoubtedly arise from the use of the 
nonabsorbable material. In applying the heat the tempera- 
ture was kept at lOOT. to 140'F., and the abdomen should 
always be opened so that the heating iron could be prop- 
erly guided from the vagina through the cervix to the 
fundus. By so doing not only was the iron properly ad- 
justed but the gloved hand of an assistant placed over the 
fundus w^as an aid in determining the amount of heat being 
used and the danger of injury to the bladder, rectum and 
ureter, with the formation of fistula avoided and sealing 
of the smaller bloodvessels and lymphatics accomplished. 
Should one not care to depend upon the heat and starva- 
tion ligature, and extirpation of the uterus was to follow, 
it should be done as a thermocauterectomy between the 
second and fourth week before the sickened cells had re- 
cuperated and before the deposit of scar tissue was suffi- 
cient to interfere seriously with operative procedures. 
With no other method could the fixed pelvic structures be 
loosened and mobilized as by the heat and ligature. Ade- 
quate X ray and radium treatments caused a decided radia- 
tion sickness from which the patient did not fully recover 
for from one to six weeks, rendering a hysterectomy 
hazardous. Hence in this respect the heat had advantages 
over the x ray or radium. After surgical procedures had 
been completed, x ray or radium or both might be em- 
ployed to advantage, as was done in three of his cases; if 
hysterectomy was not to be done and the growth well within 
the cervix, radium alone was indicated ; if involvement was 
broad, x ray combined with radium w-as used ; if hysterec- 
tomy had been done, then later x ray was used, if doulit 
e.\is;cd as to whether all cancer bearing tissues had been 
removed or if there was a recurrence. Postoperatively to 
pursue a set course without variations was hazardous. While 
X rays and radium were useful postoperative adjuvants they 
should never be used as preoperative measures. 

The Control of the Mortality of Abdominal Opera- 
tions for Cancer. — Dr. George W. Crile, of Cleveland, 
Ohio, stated that clinical and experimental investigations 
into the cause of the high mortality of abdominal opera- 
tions for cancer had resulted in the formulation of plans 
of treatment whereby every case which was anatomically 
operable was given the ma.ximum chance for survival. 
Every case was individualized. The type of operation and 
of postoperative care followed the anatomical and patho- 
logical indication, i. e., procedures followed indications, not 
rules. In resections of the stomach, intestines, or gall- 
bladder the operation was performed in two stages, the 
second major stage being deferred until the nutritional 
balance was w'cll established. Nitrous oxide oxygen anal- 
gesia was used in grave risks, anesthesia being secured 
mainly by local anesthesia. P'car and anxiety were con- 
trolled by management, and. when necessary, morphine. 
.^n ample incision, fcathcredge technic, minimum exposure 



of raw tissue to the air, prevention of loss of blood, con- 
servation of body heat, all helped to secure the utmost 
protection of the patient. Blood transfusion was performed 
before, during, or after operation, and was repeated ac- 
cording to the state of the patient. A dietetic and hy- 
gienic regimen — forced feeding and fresh air in abim- 
dance — was established. By the use of these general meas- 
ures and a technic adapted to the extent of involvement 
in the individual case, the mortality of resections of the 
stomach, the gallbladder, intestines, or of the colon for 
cancer had been progressively decreased and the range 
of operability e.xtended : and the postoperative morbidity 
had been minimized. 

Teratomata of the Ovary; Report of a Case.— Dr. 
Miles F. Porter, of Fort Wayne, Ind., said that no pure 
epiblastic tumors had been reported; therefore, the term 
teratoma was preferred to dermoid. There were two 
classes, solid and cystic. Their origin was not definitely 
known. Teratomata were frequently malignant, even the 
cystic variety showed malignancy often. Careful exam- 
ination was necessary to determine the nature of a cyst 
of the ovary, hense the discrepancy as to frequency of 
teratomata. Teratomata occurred at any age, but was 
most frequent between the ages of thirty and forty. These 
tumors were more prone to torsion of the pedicle and to 
malignant cliange than other ovarian cysts, and less prone 
to rupture, Teratomata were peculiarly offensive to the 
uterus, causing abortion and infection. He reported the 
case of a primipara with a dead baby. Normal de- 
livery took place a few days past terra. The tumor was 
first discovered after delivery and removed five days after 
labor. Her recovery was complicated by paratyphoid in- 
fection. The tumor contained nine quarts of fluid. 

New Trend in Gynecological Therapy. — Dr, George 
Gellhorn, of St. Louis. Mo., stated that just at the time 
when the general surgeons w-ere claiming gynecology for 
their own, there was a marked tendency in gynecology to 
resort to nonoperative methods. The results accomplished 
with radium and x rays in the treatment of cancer and 
certain forms of fibroids in the uterus surpassed the 
achievements of the strictly surgical era. In other gyne- 
cological afTections, notably those of inflammatory ori- 
gin, persistent efforts were being made to supplant surgi- 
cal methods by nonoperative ones. While results were 
not yet conclusive, they held out promise for the future. 
Certain diseases of the external genitals which heretofore 
had been entirely within the domain of gynecological sur- 
vey, were cured more readily by nonsurgical means. Pre- 
ventive obstetrics and its effect upon the surgical aspect of 
gj'necology was discussed. 

Atresia and Stricture of the Vagina, — Dr, J.\mes E. 
King, of Buffalo, N. Y,, said that in the cases of atresia 
resulting from infantile vaginal infections, it was often 
impossible to obtain a history of the vaginal discharge, 
and it might thus be difficult to establish the real cause of 
an atresia discovered in adult life. Undoubtedly bj- far 
the most common cause of an atresia developing during 
childhood was infantile vaginitis. The atresia due to 
stricture seemed to present greater difficulties than the 
atresia due to vaginal adhesions. As a rule, the scar 
of these strictures was deep and its base broad. Before 
proceeding with the operation itself the strictures should 
be thoroughly stretched with dilators and finger, until suf- 
ficient dilatation was obtained to permit one to determine 
the limits of the .^^car. 

Gynecological Observations Under Local Anesthesia. 
— Dr. RoBfRT E.M.MET F.-vRR, of Minneapolis, Minn., stated 
that the most ideal condition which had presented itself 
to him for the performance of surgical operations had 
been brought about by the preliminary use of morphine, 
combined with magnesium sulphate, and the establishment 
of perfect local anesthesia. By this means psychic incom- 
patibility was practically eliminated, although in a large 
jiercentage of cases the psychic element had seemed to him 
to be of minor importance. Mixed anesthesia had many 
points of advantage. His feeling was that local anesthesia 
alone, or combined with gas, or with the judicial use of 
morphine and magnesium sulphate, offered special advan- 
tages over other forms of anesthesia now in use. 

Suppurating Uterine Myomata. — Dr. William Edgar 
Darn.m.i.. iif \tlanlic City, New Jersey, read this paper, 
which appears on page 17 of this issue. 



58 



PROCEEniXGS OF SOCIETIES. 



[New York Medical Journal 
AND Medical Record. 



Ureteral Obstruction. — Dr. K. I. S.\xes, of Pittsburgh, 
called attention to the frequent failures to diagnose uret- 
eral obstruction, giving as reasons the anatomical rela- 
tionships of the ureter and the great variety of obstructive 
factors. Good histories and careful physical examinations 
could be relied upon to give the indications for investiga- 
tion of the urinary tract. If the studies he had suggested 
were conducted in doubtful urological cases, many a pa- 
tient could be saved the trouble of unnecessary treatment or 
operative procedures, and could have their pathology cor- 
rected before it became irreparable. The unfortunate re- 
sults of the neglect of such investigations were seen in 
almost every clinic. .'Vttention of the profession, especially 
the surgical, should be called to it. Such investigations 
required a great deal of effort and were time consuming, 
expensive and required a close cooperation of well organized 
cystoscopic, pathological, and rcintgenological departments. 
These arguments should not be used against diagnostic 
methods of procedure that were intended to save many 
lives and much unnecessary sufTering. 

Neoplasia of the Kidney — With Reports of Five 
Primary Cases: 1. Papillary epithelioma: 2. Hyperneph- 
roma; 3. Malignant teratoma; 4. Squamous celled carci- 
noma; 5. Lymphoblastoma. Dr. J.\mes E. D.wis, of De- 
troit, reported five cases of primary renal tumor. He stated 
that the developmental history of the renal tissues was 
yet incomplete and at many points theoretical. The histo- 
genesis for tumor tissue of the kidney was intricately in- 
volved by existing obscurities in both ontogenetic and 
phylogenetic development. The frequency of renal neo- 
plasia occurrence was again emphasized as selective of 
young and old age periods of life. The diagriostic symp- 
tomatology was frequently exceedingly indefinite. Clinical 
and pathological investigation of renal tumors should be 
carefully made and reported in the literature. 

Oxygen in the Peritoneal Cavity. — Commander Will- 
i.\.\i SiAi\i.\.\ B.M.NiiKiuGE, of Ncw York, said that oxygen 
mechanically held the scarified surfaces apart until new 
cells were formed. It increased the activity of the indi- 
vidual cells, thus hastening a new growth of epithelium 
to replace the destroyed peritoneal cells, the denuded areas 
being thus covered over. The increased peristalsis caused 
by the oxygen was unfavorable to the production of ad- 
hesions. From experiments which had been made one 
might deduct the following: 1. O.xygen was completely ab- 
sorbed in the abdominal cavity. 2. It was a slight respir- 
atory stimulant. 3. It was a slight cardiac stitnulant. 4. 
It had but little effect upon blood pressure when the 
pressure of the gas was moderate. 5. It tended to bring 
an animal quickly from deep anesthesia. 6. It hastened 
the recovery of an animal after discontinuance of the 
anesthesia. 7. A. pressure of more than 1,500 mm. of 
water might cause collapse. 8. O.xygen tended to prevent 
the formation of adhesions. 9. It quickly changed a dark 
blood to scarlet in cases of anoxemia. 10. It stimulated the 
intestinal peristalsis. 11. It was not an irritant to the 
peritoneum or the abdominal viscera. 

A Plea for Routine Examination Upon the Operating 
Table as a Preliminary to Abdominal Operations. — 

Dr. John W. Kkefk, of Providence, R, I., emphasized the 
following points: 1. The value of routine exaininations 
under anesthesia upon the operating table preliininary to 
abdominal operations. 2. The necessity of a period to be 
spent in the general practice of medicine previous to be- 
coming a specialist. 3. The importance of considering the 
human Ixidy as a moving equilibrium, in brief, as a living 
unitary organism. 4. The desirability of the masters in 
medicine becoming peripatetic and lecturing as exchange 
professors in the various universities. 5. Above all, the 
importance of remeinbering that careful work demanded 
time and personal attention to those multifarious details 
which inotlern medicine required. 

Transperitoneal Nephropexy. — Dr. Thomas B. Noble, 
of Indianapolis, Ind., .said that he felt warranted in recom- 
mending this operation because it established regional and 
.general abdominal diagnosis. Through its primary incis- 
ion much additional work could be done on other abdom- 
inal viscera, if necessary. It pcrmitled the operator to put 
the kidney where it should be put and the lapse of time 
since its inauguration had been sullicient U> prove the vir- 
tue of its characters. 



Coincident Ruptured Ectopic Gestation and Acute 
Suppurative Appendicitis. — Dr. Ch.\rles E. Ruth, of 
Des Moines, Iowa, stated that twenty years ago suppur- 
ating appendicitis with diffuse peritonitis resulted in a 
mortality of not far from ninety per cent. Now teii per 
cent, was not expected, other complicating factors, such 
as he had in the case he reported, being absent. The prin- 
cipal factors in reducing the former great mortality were, 
he thought, five, as follows : Shorter time of operation : 
contiinious proctoclysis to supply the needed body fluid 
while the stomach was irritable ; Fowler position to aid 
drainage and prevent infection from gaining contact with 
the open mouthed lymphatics of the upper abdomen; less 
trauma from atmospheric exposure, manual manipulation 
and contact of peritoneal surfaces with dry gauze, and well 
placed, large drains. 

The Indications for and the Dangers in the Use of 
Spinal Anesthesia in Obstetrics, Gynecology and Ab- 
dominal Surgery. — Dr. R. R. Huggins, of Pittsburgh, 
said that the freedom from nausea, abdominal distention, 
postoperative weakness and other disturbances so common 
with other forms of anesthesia recommended it as an im- 
proved method for cases when given under proper super- 
vision and with full knowledge of its danger. He believed 
this method to be worthy of careful consideration on the 
part of every progressive surgeon who was willing to 
spend the time and care which were necessary in order 
to achieve success. Spinal anesthesia was the best anes- 
thetic known today for certain operations in the lower 
abdomen. It should be given only after careful study of 
the patient. If it was not properly employed by one pos- 
sessing sufficient skill, it might have a large mortality. 
There was no form of anesthesia which was altogether 
free from danger either immediate or remote. There were 
well defined contraindications to the use of all anesthetics 
in certain instances, and the operator must exercise judg- 
ment as to which should be employed in a given case. 

Torsion of Appendices Epiploicae. — Dr. Benj.\min 
RusH McClellan, of Xenia, Ohio, stated that in twenty- 
four cases of appendices epiploicne found twisted and in- 
carcerated in hernial sacs, seventeen were in the left in- 
guinal, five were in the right inguinal and two were in 
the left femoral 

Transuterine Insufflation, a Diagnostic Aid in Ster- 
ility. — Dr. A. J. RoNGY, of New York, said that this 
procedure had been used in a sufficiently large number 
of cases by three or more investigators to warrant its 
universal adoption as a routine method in the diagnosis 
of and treatment of sterility. He hesitated to institute 
this examination fearing that untoward complications might 
take place and in that way, not only endanger the lives 
of the patients, but also give rise to legal complications. 
This procedure had been found in his hands to be safe, 
and he used it whene\er he thought it was indicated. 

Ten Years of Experience in Painless Childbirth, — Dr. 

Geoi^ge Ci..\Ri<: MosHER, of Kansas City, Mo., stated that the 
hyoscine, morphine and cactin tablets were discouraging. 
The effect of morphine on the mother and fetus was un- 
satisfactory. He finally adopted pantopon after a trial of 
hyoscine and morphine, scopolamine and morphine. Sahli's 
mi.xture of alkaloids was not depressing. Crile's theory 
was not applicable to charity patients in city hospital serv- 
ice. An individual dose rather than a fixed amount 
for each patient was required. It was unsuitable in cases 
where less than two hours was expected before delivery. 
The advantages over cases in which delivery was made 
without amnesia were shown by a series of cases from 
records where scopolamine was used. There was less 
fatigue and shock, an absence of fear, less exhaustion, and 
a more rapid convalescence. Scopolamine amnesia, in his 
opinion, was the outstanding boon in labor in this decade 

Traumatic Inflammation of the Fundus of the 
Bladder. — Dr. Edgar A. Vander Veer, of Albany, New 
York, reported the case of a girl who fell and struck her- 
self in the pelvic region. Si.x months later a tumor ap- 
peared over the injured organ. Operation was performed, 
which disclosed the fact that the tumor involved the fun- 
dus of the bladder and anterior abdominal wall. The in- 
Hammatory mass included the bladder wall. In the centre 
of it was found a small spicule of bone. 



Abstracts from Current Literature 



OBSTETRICS 

Repeated Extrauterine Pregnancy on the Same Side. 

— W. Sigwart (Zcntralblatt fiir Gyiiiikoloyie, May 6, 1922) 
reports such a case in a girl twenty-three years old, who 
was operated on for a rupture in the isthmus of the right 
tube. The tube was excised between the site of the rup- 
ture and the uterui but peritonealization was omitted be- 
cause of her poor condition at the time. Four months 
later she was again seen in a severe stage of acute anemia. 
The cul de sac of Douglas felt doughy and abdominal as- 
piration revealed fluid blood. At operation the right tubal 
stump was found covered with a coil of intestine, under- 
neath which was the fetus. There was no evidence of a 
tubal lumen or dilatation of the interstitial tubal canal 
and the ovum undoubtedly migrated there. The corpus 
luteum was in the right ovary. The site of the implanted 
ovum showed decidual changes and a few villous remains, 
proving the primary embedding of the ovary. The remark- 
able feature of this case was the rapid succession of the 
two ectopic pregnancies. The migration of the ovura was 
' probably due to patency of the right uterine tubal canal 
so that the spermatozoa directly reached the ova from the 
right ovary. This was probably aided by the intestinal 
peristalsis. This case shows that when removing a tube 
for tubal pregnancy, the remaining tubal stump should be 
made impenetrable if the conditions allow. This is best 
accomplished by a wedge shaped excision from the uterus 
and a double seroserous suture of the wound bed. 

That a repeated pregnancy may occur in a partially re- 
sected tube, even if the tubal end is securely closed, is shown 
by another case, in which the ectopic pregnancy took place 
in the isthmic portion of the tube. .About seven years 
before a woman was operated on for a leftsided tubal 
abortion, the tube being excised at that time. There was 
a history of irregular menses and on examination a mass 
was found to the left of the uterus as large as a duck 
egg, doughy and movable with the uterus, which was be- 
lieved to be of inflammatory nature. At operation a bluish 
red mass, corresponding to the tubal stump, egg shaped 
and as large as a plum with a smooth, markedly vascular 
surface, was found moderately fixed to the uterus. This 
was excised and was found to be a tubal mole. The tubal 
distal pole showed no macroscopically visible opening. 

Carcinoma of the Uterus in Pregnancy, Labor and 
the Puerperium. — Kgon Otniar Gross i. Z,-utralblalt fiir 
iiymikolo/jie. April 15. 1922) found an incidence of 0.055 
per cent, for carcinoma of the cervix in 224,080 labors and 
pregnancies. The pregnancy and carcinoma were positively 
simultaneous in twenty-four out of thirty-four cases seen 
one year postpartum. In twenty-six and seven tenths per 
cent., the carcinoma appeared following abortion or mis- 
carriage, which it probably caused. In si.xteen and seven 
tenths per cent, there were symptoms before the pregnancy. 
which was 'then interrupted. Most of the cases occurred 
between the age of thirty-one and thirty-five years ; in the 
childbearing period most of the inoperable cases occurred 
between forty and forty-five years. The average number 
of previous pregnancies was six and three tenths. During 
pregnancy and the puerperium, the cancer grows more 
rapidly than usual and the metastases occur much sooner. 
The prognosis and the malignancy do not always run ab- 
solutely parallel : though permanent results and prognosis 
are particularly favorable in operable carcinomas radically 
operated upon during pregnancy and especially after preg- 
nancy. Carcinoma of the vaginal portion was five times 
more frequent than that of the cervix ; in nineteen and nine 
tenths per cent, both were afi^ected. Youthful patients, espe- 
cially during pregnancy, notice the carcinomatous symptoms 
earlier than is usual : in complicated cases the diagnosis 
was made accidentally during examination in seven and 
five tenths per cent, of cases. Birth traumatism produced 
symptoms of carcinoma after pregnancy : sixteen and 
seven tenths per cent, were treated during the puerperium 
and eighty-three and three tenths l)cr cent, two or more 
months later. The diagnosis is usually easy but in early 
cases, biop.sy gives certain proof. The operability of cases 
seen during pregnancy is strikingly favorable, but in cases 



seen postpartum, it is not so favorable because of the com- 
plications and metastases. The hyperemia of pregnancy 
allows an easier displacement and separation of the carci- 
noma. The primary mortality of operable cases was nil 
as compared to sixteen and ninety-e.ght hundredths per 
cent, in cervical carcinoma in general. In inoperable com- 
plicated cases treated postpartum, the prognosis w-as more 
unfavorable than generally. Energetic radiation never 
produced permanent cures, as contrasted with ten and 
three tenths per cent, results in general The primary mor- 
tality was fifty per cent, in incomplete radical operations. 
Palliative treatment resulted fatally after an average of 
five months and eight and two tenths months after the first 
symptom of carcinoma was noticed. Only an early radical 
operation gives good results. 

Operative Obstetrics. — J. O. Polak (Surgery. Gyiif- 
cology, and Obstetrics, May, 1922) summarizes that sur- 
gical intervention is being too freely employed to terminate 
labor, and furthermore that the results for mother and 
child from such interference (oftentimes unindicated) with 
the physiological processes of labor do not justify their 
employment. That the adoption of the principle and prac- 
tice of aseptic intelligent expectancy in labor, when the 
factors of lalxir are known to be normal or appro.ximate 
the normal, is still the safest method of delivery not only 
for the mother but for the fetus. That there is a high mor- 
bidity even in the clean Cassarean section, much higher in 
fact than is common in operations for pelvic tumors, such 
as fibromyomata and ovarian cysts. This is due to the pres- 
ence of infective bacteria in the cavity of the puerperal 
uterus, which migrate from the vagina to the interior of 
the uterus, through the open cervi.x. That even in expert 
hands there is a definite maternal risk from Caesarean sec- 
tion, greater than is generally known. Mortality studies 
show that this ranges from two and nine tenths jier cent, 
to fourteen per cent., depending on the time in labor at 
which operation is done, after rupture of the membranes, 
and on the amount of vaginal invasion present. Finally, 
in view of these facts, the author believes that every preg- 
nant woman should have greater prenatal study and care 
than is commonly given her. so that complicating condi- 
tions may be recognized, prevented, or corrected before 
labor, and where this is not possible, the knowledge gained 
from this study will permit the obstetrician to conduct the 
labor in such an intelligent and aseptic manner as to mini- 
mize the dangers from abdominal delivery. 

Umbilical Cord. — J. P. Gardiner (Surgery, Gynecology 
and Obstetrics. February, 1922) in a study of the normal 
length, the length in cord complications, etiology and fre- 
quency of coiling, concludes as follows: 1. For the normal 
length of the umbilical cord we may accept the average 
length of fifty-five cm. (twenty-two inches). 2. .Any cord 
under thirty-two cm, is an absolutely short cord and any 
cord over thirty-two cm. and under the average length is a 
relatively short cord. 3. In a vertex presentation, the pla- 
cental insertion of the cord must not be farther than five 
cm. above the superior strait in order that the fetus may 
be born without traction on the umbilical cord, and the 
cord must be thirty-two cm. in length. 4. In a breech 
presentation, in order that the fetus may be born without 
traction on the umbilical cord, the cord must be fifty-five 
cm. in length, 5, In a vertex presentation with a loop of 
the cord about the neck, in order that the fetus may Ix: 
born without traction of the umbilical cord, the cord must 
be 76.50 cm. in length. 6. In a vertex presentation with a 
coil of the cord about the neck, in order that the fetus 
may be born without traction on the umbilical cord, the 
cord must be 9.150 ctn. in length. 7. In a breech presenta- 
tion with a loop of the cord about tlie neck, the loop be- 
comes a spiral and very little needs to be added to the 
length of the cord. 8. In a breech presentation with a coil 
of the cord about the neck, in order that the fetus may be 
born without traction on the umbilical cord, the cord must 
be 101.50 cm. in length. 9. The etiology of the coiling of 
the cord is not yet known but it is generally accepted that 
excessive liquor amnii, a long cord, a small sized fetus and 
the activity of the fetus are factors which make for coiling 
of the cord. 10. There is a coMed cord in every 5.5 births. 



60 



ABSTRACTS FROM CURRENT LITERATURE. 



LXew York Medical Journal 
AND Medical Record. 



Individualized Treatment of Febrile Abortion. — E 

Mautlmer (IJ'ioicr klinisclic H'ochcnschrift, April 6, 
1922) reports a series of 458 cases of febrile abortion in 
which the uterus was immediately emptied with a smooth 
recovery in eighty-nine and seven tenths per cent., with a 
protracted course in seven per cent, and with a mortality 
of three and three tenths per cent. Adnexal diseases are 
contraindications for immediate emptying of the uterus. 
Eight patients, admitted in very poor condition, recov- 
ered after anterior colpohysterotomy. In the fatal cases the 
patients were all admitted on the eleventh day of disease. 
Cases of bacterial intoxication are rarely dangerous but 
those of bacterial infection are dangerous ; as these con- 
ditions are difficult to differentiate, there should be no 
delay in the treatment. Of thirteen patients, in whom the 
uterus was emptied in two or more sittings, five died and 
therefore this procedure is now abandoned. A systematic 
bacteriological examination is unnecessary and in every 
case of febrile abortion the uterus should be emptied at 
once, provided the infection has not advanced beyond the 
uterus. The treatment must be varied according to the 
nature of the case, depending upon the differences in con- 
sistency of the parametria, local inflammatory pain and 
subjective tenderness and anxiety, strands in the parame- 
tria, etc. The exact technic depends upon the condition of 
the cervix. 1. If the cervix admits a finger or is easily 
dilatable, the ovum is separated by the finger or forceps, 
avoiding rough handling; small residual masses of tissue 
are harmless ; hemorrhage is due to uterine atony and 
should be treated with hot irrigations, with the upper 
part of the body raised, and with ergotin pituitrin injec- 
tions, or if necessary, with loose packing of gauze which 
should be removed in twenty-four hours. 2. If the cervix 
is closed or only slightly open and rigid, the patient should 
be referred to a hospital: if the pregnancy is an early one. 
only an experienced physician should attempt the removal 
of the ovum with a forceps and the dull curette mav be 
used exceptionally to empty the angle of the tube. If the 
cervix is impenetrable or if the pregnancy is advanced, 
emptying of the uterus with the forceps after an anterior 
colpohysterotomy is the operation of choice. If a hospital 
is not available, the spontaneous expulsion of the fetus mav 
be hastened with quinine and the uterus may be emptied 
several days later. The use of the sharp curette should 
be abandoned in febrile abortion and the dull curette may 
be used exceptionally. Perforation of the uterus must be 
guarded against in every instrumental procedure in the 
uterus. 

The Origin of Oral and Rectal Germs in the Newborn. 
—Rudolph Salomon (Zcufralblatt fiir Gyndkologic. April 
15. 1922) found that germs may appear in the rectum of 
the newborn immediately after birth and that the same 
organisms were present in the maternal vagina. During 
the first day gram positive cocci were seen and only a few 
gram positive bacilli, but later on this relationship was 
reversed. After twenty-four hours the roedella III were 
predominant ; the colon bacillus appeared early ; staphylo- 
cocci occurred together with other bacteria only, but disap- 
peared gradually with the growth of enterococci and the 
bifidus. The roedella III became gradually less prominent 
and after forty-eight hours the bifidus bacillus controlled 
the field : this organism is closely related to the Dodcrlein 
vaginal bacillus. The bath water cannot be blamed for the 
contamination of the mouth with germs. Forty-six per 
cent, of the mouths showed bacterial growth: first gram 
positive cocci, then gram positive bacilli, similar to the flora 
of the rectum and maternal vagina. The flora of the ma- 
ternal breast skin also play an important part : a reciprocal 
relationship between the flora of the child's mouth and the 
maternal breast skin ensues. The taking of food and the 
change in the reaction of the oral fluid must also be con- 
sidered : the mouth becomes acid with bacillary growth. 
whereas the original alkaline medium favors the cocci. 
Within twenty-four hours, nineteen cases showed twelve 
different organisms and within ten days there were twenty- 
one different organisms. During the first day the staphylo- 
cocci were particularly prominent, then streptococci, gram 
positive diplococci, colon bacilli and the vaginal bacillus 
followed. In contrast to the rectum, the gram positive 
cocci were more numerous in the subsequent period than 
the gram positive and gram negative bacilli. 

The sources of the oral and rectal germs include the 
maternal vagina, operative intervention, obstetrical pro- 



cedures, as the extraction of the child and Ca;sarean sec- 
tion, the puerperium, the maternal vagina and breast, the 
food and change of the oral reaction, the child's surround- 
ings (air, clothing and attendants) and the rupture of the 
amniotic sac. The rectum shows a fair constancy of 
germs, but this is not so with the moiith. The virulence 
of the oral and rectal germs varies from day to day. 

Experiences in the Prevention of Puerperal Fever, — 

F. Ahlfeld (Zciitralbhtt fiir Gyndkologic. April 15, 1922) 
reports a series of 8.753 labors, in which only one patient 
died (probably as a result of a selfexamination or of an 
existing internal disease). This he accomplished without 
the use of rubber gloves, without rectal examination, with- 
out the limitation of internal examinations, without the 
exclusion of preliminary vaginal irrigations and with the 
uninterrupted use of this material for teaching medical 
students and training midwives. These results are cited to 
show the incorrectness of Doderlein's teaching that the 
body is able to protect itself against infection. Because 
of the impossibility of preventing the introduction of in- 
fection by the woman herself and the surroundings, the 
author believes in the propriety of washing the external 
genitals and a full bath previous to delivery. Even in 
normal births intervention is necessary, and therefore the 
attendant must be trained how to prevent infection by the 
proper methods of examination and prophylactic measures. 

Septic Abortion. — O. A. Cannon {Canadian Medical 
.-issociotioii, March. 1922) suggests the following treat- 
ment : The patient is put to bed in the Fowler position, 
seated upon a sling pillow. She is better in a hospital, 
where she can receive skilled care and be shielded from 
visitors and annoyances. She shoQld be put on a two hour 
pulse temperature chart. Water and nourishing fluid diet 
should be given in abundance. The bowels are opened liy 
enemata and gentle laxatives. An ice bag is placed over 
the lower abdomen. If fluid is not taken freely by mouth, 
glucose or saline solution is given per rectum: or if not 
tolerated there, by subcutaneous injection. Appropriate 
stimulation is given if required. Ergot or pituitrin is used 
to keep the uterus in contraction. This probably blocks the 
lymphatic channels. Quinine is often used to remove re- 
tained products of conception. After the temperature has 
been normal for five full days and the uterus is not empty, 
the contents should be removed. The patient's return to 
health is thus expedited. Should hemorrhage have to be 
reckoned with during the course of septic abortion, the 
following procedure is recommended: With the patient pre- 
pared for operation, with plenty of assistants and if pos- 
sible without anesthetic, pass the largest sized tubular 
cervical speculum that can be got in and through it pack 
weak iodoform gauze with blunt dressing forceps. Then 
about the cervix pack sterile cotton layer upon layer until 
the vagina is full. In twenty-four hours the packing is 
removed and with it is usually found the products of con- 
ception. 

A New Method of Treating Puerperal Infection. — 

J. Hofbauer (Zciitratl'latt fiir Gy>i^ik,-ilogic. April 15. 
1922) recommends the subcutaneous injection of a two p-r 
cent, solution of nucleic acid combined with intravenous 
injections of hypophysis extract in cases of severe genera! 
symptoms (high pulse rate, temperature, etc.). with the 
body showing insufficient immunity reactions. Irreparable 
tissue changes are not affected by the treatment. Su!)- 
cutaneous and especially intramuscular injections of nucleic 
acid are painful for a few hours. The resulting reaction 
is characterized by the production of fever, hyperleucocy- 
tosis and the stimulation to the production of ferment and 
antibodies, thereby increasing the patient's resistance ; it 
al.so stimulates leucocytosis. which is an important factor 
in warding off puerperal infection. The reaction may be 
increased by subcutaneous salt injections. The therapeutic 
effect is further increased by the combination with intra- 
venous injections of hypophysis extract. It produces an 
instantaneous and particularly intensive effect, stimulating 
the sites of immune body formation of the hematopoietic 
system and also producing a lasting contraction of the ute- 
rus. The nucleic acid promote? phagocytosis : a pure 
sodium salt of the nucleic acid should be used in the form 
of a two per cent, .solution in physiological salt solution 
or in distilled water, mostly subcutaneously. A ten per 
cent, solution has been used intramuscularly. 



July 5, 19-'-'.] 



ASSTRACTS FROM CURRENT LITERATURE. 



61 



The Birth Effect and Constitutional Element in the 
Genesis of Albuminuria in the Newborn. — Paul Lindig 
{Zctitralblalt fi'ir Gyndkologie. May 0. 1922) states that 
the cause of the usual permeability of the kidneys to al- 
buminous bodies of the blood plasma in the newborn and 
during the first few days of life is traceable to the effect 
of the birth on the fetus. It is comparable to the lordotic 
albuminuria and results from the overstretching and con- 
striction of the ovoid fetus, which lead to congestive proc- 
esses in the kidney with a resulting excretion of albumin. 
The albuminuria has been known to result from head in- 
juries, marked muscular activity, sudden cooling of the body 
and particularly after the most varying external changes. 
In cases of Cesarean section the excretion of albumin is 
the same as in normal births, as was also the case in 
fetuses that were not subjected to the contraction of the 
uterine muscle, showing that these factors are negligible 
as regard the etiology. The albuminuria of the newborn 
is a constitutional albuminuria, which may affect the pre- 
disposed organ during and after delivery as w-ell as the 
newborn. 

A Rare Case of Diphtheritic Infection in Newborn 
Twins. — E. Weber {Zcntralblatt fur Gymikologic, April 
22, 1922) reports the birth of twins in a twenty-five year 
old primipara. The mother manifested fever a few days 
later, which yielded to treatment. In both twins nasal 
snuffling developed after four to five days and both were 
injected with one thousand units of diphtheria antitoxin. 
The older child showed simultaneously a swelling and red- 
ness of the left labia majora, which gradually spread up- 
ward to the umbilicus without a rise of temperature : death 
followed with the signs of a general infection. On the 
sixth day postpartum, the second twin showed the same 
symptoms. The seropurulent discharge from the vulva of 
this child showed virulent diphtheria bacilli, long strepto- 
cocci, the staphylococcus aureus and colon bacilli. Both 
the mother and this child recovered. 

X Rays in Obstetrical Practice. — Edward W. H. 
Shenton (Lancet, April 29, 1922) asserts that pelvic de- 
formities are easily detected with the use of x rays. In 
roentgenograms of the fetus in utero the quantity of the 
amniotic fluid and the paucity of mineral matter in the 
fetal bones may hamper the interpretation of the plate. 
Fairly good plates are obtainable at the fifth or sixth 
months of pregnancy. It is possible to determine: 1. the 
presence of a pregnancy or an abdominal tumor ; 2. the 
position of the fetus; 3. the relations of the fetal head 
and pelvic canal, and 4. twins. The relative measurements 
of the fetal head and maternal pelvis are more valuable 
than the absolute measurements of either. The x rays 
in no way injure the baby. As to technic, the anteropos- 
terior position for the head and pelvis with the latter tilted 
is suggested; for the abdomen, the lateral position with the 
woman on her side. Stereoscopy is u.seful if practicable. 
Intensifying screens and other aids to rapidity are essential. 

Lutein Solution Hypodermically in the Nausea and 
Vomiting of Pregnancy. — Titian Coffey (American Jour- 
nal of Ubitdncs and Gynccohi<i\. May, 1922) reports 
sixty-two cases treated with a solution of corpus luteum, 
following the suggestions of J. C. Hirst. The total num- 
Ijer of injections given was 410, making an average of 
about six and a half injections for each patient. Fifty- 
five cases, or 88.6 per cent., improv-ed more or less rapidly; 
in only one case was failure absolute. The technic used 
consists in preparing the site of injection, using the dcl- 
trjid preferably, with green soap followed by alcohol, with 
enough friction to redden the skin. The solution is in- 
jected deeply into the muscle and the patient, if ambula- 
tory, directed to return home, remain quiet for twenty-four 
liours, and if there is any soreness, to apply a compress of 
equal parts of alcohol and water. Where the disorder is 
severe, the patient losing all meals and having constant 
nausea, the injections are given daily. Usually they are 
given every other day, using the deltoids alternately. Oc- 
casionally a patient complains of dizziness after the in- 
jection, and some state their nausea is increased in the 
first twenty- four hours, but by the second morning they 
are feeling greatly improved. Usually there is a rapid 
return of appetite after the second injection. Many 
patients state that they feel much less languid. No in- 
stance of anaphylaxis or alarming symptoms occurred 
among the author's patients. 



A Case of Vagitus Uterinus. — H. Krause {Zciitratblatt 
fiir Gyiuikologic. April 22, 1922) reports a rare case of 
a fetal cry in the maternal body. During the process of 
an obstetrical version a protracted, fetal cry followed by 
a gurgling noise was heard, similar to the extrauterine cry 
of the newborn. The delivery w^as then hastened and oil 
extraction of the child it cried at once but the respiratory 
passages were apparently not clear. Some bloody mucus 
was withdrawn with a tracheal catheter. The child died 
on the next day after expelling large amounts of bloody 
mucus from the mouth and nose. The necropsy showed 
partial atalectasis of the lung and petechial hemorrhages 
and emphysema underneath the pleura as signs of spas- 
modic inspiration. The uterine cry was probably made 
possible by the wide soft parts and the rapid expulsion of 
the amniotic fluid. -All of the cases in the literature oc- 
curred only in accouchement force. 

The Significance of Microscopic Capillary Findings 
in Eclampsia. — Hans Nevermann (Zcntralblatt fiir 
Gynakologic, April 22, 1922) comes to the following con- 
clusions as a result of his microscopic capillary experi- 
ments: 1. The same capillary changes occur repeatedly in 
more or less pronounced form in eclampsia and its pre- 
liminary stages. 2. These changes occur in the same or a 
similar manner not only in eclampsia but also in other 
diseases. 3. Venesection improves the circulation in 
eclampsia. 4. The circulatory change depends upon other 
factors, such as spasms of the precapillaries and possibly 
of the postcapillary vessels and respiration. 5. The changes 
visible in the skin capillaries also appear in other capillaries 
of the human body. 

Intrauterine Death. — A. B. Spalding (Surgery, Gyno- 
cology and Obstetrics. June, 1922) asserts that from a 
study of fetal skulls with the x ray in thirty-one cases of 
pregnancy, it has been found that with live babies the fetai 
skulls appear normal except for the effect of labor which 
produces an overlapping of the skull bones. In three cases 
of intrauterine death, the x ray picture showed the marked 
overlapping of the skull bones with distinct signs of shrink- 
age of the skull contents. From these facts the author 
believes it justifiable to state that shrinkage of the skull 
contents with overlapping of the skull twnes can be demon- 
strated with the X ray, which gives a pathognomonic sign 
of intrauterine death. 

Frontal Presentation. — .\lfred Hcrmstein (Zentralblatt 
fiir GynJjIiologie, April 29. 1922) reports a case in which 
version and the forceps failed to deliver the child and 
finally the cranioclast had to be used. The treatment de- 
pends upon the stage of lal>or. In the first place, attempts 
should be made to change the presentation into a more 
favorable one by changes in position and the various 
maneuvres, such as that of Baudelocque, Thorn, Schatz, 
Zangemeister, Hildebrand and Collins, all of which de- 
mand that the head be freely movalile. If these fail, pod- 
alic version may be tried with simultaneous or subsequent 
extraction. If this is impossible the forceps may be tried, 
but cranial injuries must be looked for and if possible 
avoided. Undoubtedly the best procedure is a suprapubic 
extraperitoneal section, which offers a much more favorable 
outlook for both mother and child. 

Protection of the Perineum in the Left Lateral Po- 
sition. — K. Heil (Zentralblatt fiir Gynukologie. .\pril 29, 
1922) asserts that with this maneuvre the expulsion of 
the fetus takes four to five minutes in primipar;e and that 
the children are born in excellent condition. It is very 
important that the woman in lalwr should assume the 
left lateral position only when the head is just coming 
through. To prevent precipitate deliveries the attendant 
should keep the left hand tightly pressed against the fetal 
head and retard it during the process of changing the- 
position. The woihan should be instructed to press down 
during the painless intervals and at the same time the 
head is coaxed down with the posterior perineal maneuvre. 
This position affords a better supervision of the parts. 

Eclampsia and Its Incidence. — R. H. Paramore 
(Lancet. Uccember 3, 1921) suggests that eclampsia is a 
variety of uremia due to physical disturbances which pro- 
duce an aberration of the normal metabolism. His con- 
ception is based on the idea that intraabdominal pressure 
is a vital force related to metabolism. Clinical experience 
has shown that eclampsia occurs with greater frequency in 
cases where intraabdominal pressure is unduly elevated. 



62 



ABSTRACTS FROM CURRENT LITERATURE. 



[New York Medical Journal 
AND Medical Record. 



Uteroplacental Apoplexy in Accidental Hemorrhage. 

— P. W'lllson (Surycry, dynccoluyy and (Jbslt'trics. January, 
1922J — The author presents a study of all cases in the 
hterature of accidental hemorrhage, together with report 
of a case of his own. He bases his discussion on si.xty- 
nine clinical and forty-six pathological case reports. He 
also considers the relation of uteroplacental to accidental 
hemorrhage and to other toxemias of pregnancy. In con- 
clusion he discusses the diagnosis, prognosis and treat- 
ment of the affection. In a discussion of the many etio- 
logical theories advanced he shows that hypotheses based 
on mechanical production are untenable. On the contrary. 
l)Oth the negative and positive evidence point to the cause 
lieing in the nature of a toxemia. Fully ninety per cent, 
of the cases under review showed other evidence of a gen' 
eral toxemia. The author's observations have led him to 
conclude that uteroplacental apoplexy is caused by inunda- 
tion of the uterine wall by a to.xin. This appears to be 
similar in nature to the hcmorrhagins found in snake 
venom. He holds that they are liberated from the placenta 
and, therefore, naturally produce their maximum effect at 
the site of their absorption and greatest concentration, i. e., 
in the wall of the uterus, where they cause thrombosis 
of veins and local passive congestion. Clinically the most 
significant fact is the dainaged state of the uterine wall, 
for this is responsible for the intraabdominal as well as 
the postpartum hemorrhage. With regard to treatment, 
the author thinks it most conservative, with an undilated 
cervix, to perform an abdominal Caesarean section, fol- 
lowed by hysterectomy, if this should appear necessary for 
ensuring certain hemostasis. 

Clinical Study of the Placenta. — J. E. Talbot {Sur- 
qery. Gynecology and Obstetrics. June, 1921) states that 
placental infarcts are the result of hematogenous infec- 
tion of the uterine bloodvessels, resulting in localized 
thrombosis, and as such, they are a clinical record of the 
presence of bacteria in the blood stream of the pregnant 
woman. The injury done to the placental site, when it 
occurs in the early months of pregnancy, may aiTect the 
shape of the placenta and thus account for certain of the 
complications of pregnancy. The obstetrical history of an- 
other case reported represents a clinical entity with chronic 
sepsis in the tonsils as the continuous etiological factor. 
Placental infarcts give more positive evidence than blood 
cultures of the presence of bacteria in the blood stream. 

Hypnosis in Obstetrics and Gynecology. — R. Falk 
(Zcntralblatt fiir Gyniikologie, April 29, 1922), asserts 
that hypnosis proved valuable in six out of seven cases of 
hyperemesis gravidarum. Every dysmenorrheic pain, in- 
cluding that due to stenosis, can be relieved by it : only 
three out of sixteen cases were refractory to it. Every 
case must be treated individually, according to the psyche 
of the patient. Twelve cases were permanently and com- 
pletely cured with an average of ten hypnoses. Secretory, 
vasomotor and exudative processes can be influenced by 
hypnosis. The patient may become red, pale or caused to 
perspire : this is applicable especially in the treatment of 
menorrhagias. One case of sexual frigidity was cured by 
hypnosis. Harmful effects were never noted. 

Influenza, Pregnancy and Emphysema. — J. D. T. 
Keckit [Lancet, April 29, 1922) reports a case in which a 
woman while convalescing from influenza, gave birth to 
a child in the breech presentation. Three days later the 
right eye, face, forehead, neck and chest became markedly 
swollen and urgent orthopnea resulted. On the following 
day the cinphyseina extended to both arms, the hacks of 
the hands, the abdomen and back, with a peculiar crack- 
ling in these swollen areas. During the next few days the 
emphysema slowly receded. During the labor pains and 
the forced expiration air escaped into the posterior medi- 
astinum and so into the neck and other i>arts. 

Indications and Contraindications for Potter Version. 
■ — William J. Harman (Journal of Medical Society of Neiv 
Jersey, May, 1922) gives the indications for Potter version 
as. I, left occipitoposterior ; 2, right occipitoposterior ; 3, 
transverse; 4, arm presentations; .S, i)Iacenta pra;via and 
eclampsia ; 6, dead fetus. The contraindications arc set 
down as, 1, normal delivery, every woman should have the 
test of labor; 2, undilated cervix; 3, contracted pelvis; 4, 
funnelshaped pelvis ; 5, oversized child. No version should 
be performed without some idea of pelvic measurements, 
position and size of the child. 



GYNECOLOGY 

Bacteriology and Pathology of Fallopian Tubes. — 
A. H. Curtis (Surgery. Gynecology and Obstetrics. De- 
cember, 1921) presents the following conclusions: 1. 
From the clinical history, examination of the external 
genitalia, and evidence obtained at operation, together with 
a laboratory study of the tubes in this series of nearly 
three hundred patients, it has been possible to determine 
that gonococcal infection was responsible for the patho- 
logical changes in over seventy per cent, of the cases. Ap- 
proximately ten per cent, more were thought to have been 
primarily infected with the gonococcus, but this could not 
be determined with certainty. 

2. In somewhat more than fifteen per cent, of these 
patients the tubal pathology appears to have been entirely 
due to other pus producing bacteria, notably various types 
of streptococci. 

3. Tuberculous tubes, in the absence of generalized 
tuberculous peritonitis, were encountered in five per cent, 
of the cases. 

4. Bacillus coli is particularly frequent in tuboovarian 
abscesses of large size. As a primary cause of salpingitis 
neither the colon bacillus nor the staphylococcus appears 
to be of notable importance. 

5. It has almost never been possible to obtain gono- 
cocci in cultures from thoroughly ground fallopian tubes 
removed from patients who have been free from fever and 
leucocytosis for a period of more than ten days or two 
weeks. The fallopian tube appears, therefore, not to be 
a focus for chronic gonorrheal infection. Persistently 
active gonorrhea of the tubes is evidently ascribahle either 
to recurrence of infection from without or repeated inva- 
sion of bacteria from the chronically infected genital tract. 

6. Tubal infections with various types of streptococci 
yielded pathological evidence of an active inflammatory 
process long subsequent to the introduction of infection, 
and streptococci were occasionally isolated many months, 
or even years, after the acute process had subsided. 

7. Gonorrheal pelvic infection primarily involves the 
tubes, with resultant thickening, induration, closure of the 
fimbriated ends, and pelvic adhesions which are amenable 
to separation by blunt dissection. Microscopically, the 
folds of the mucosa arc found adherent, pockets of gland 
like colu.mnar epithelium extend deeply into the wall of the 
tube, blood vessels are numerous, and plasma cells are 
characteristic. 

8. If the patient can be early isolated from the source 
of her infection, a single attack of gonorrheal salpingitis 
is usually borne without protracted clinical symptoms or 
severe pathological results. Greatly thickened tubes are 
most often associated with repeated exposures. 

9. Implicit reliance should not be placed upon hemato- 
salpinx as dependable evidence of tubal gestation. Hemor- 
rhage may occur in greatly thickened gonorrheal tubes. 

10. Salpingitis nodosa, although most frequently of 
gonorrhoeal origin, may be due to one of many causes, either 
inflammatory or noninflammatory; the microscope best ex- 
plains the etiology of any doubtful case. 

11. In streptococcus infection tubal involvement is usu- 
ally but a part of the picture. Perisalpingitis is the most 
frequent type of tubal lesion. Even though there is an 
extensive salpingitis, the fimbriated extremities will very 
likely remain open ; the mucous membrane folds, or villi, 
of such tubes show few adhesions. On the other hand, 
with the less common occurrence of occluded fimbriae and 
accumulated fluiil within the tube, adhesions are present 
between the villi and there are nests of columnar cells in 
the tube walls ; dilTerentiation from the gonorrheal tube is 
then difficult. 

12. Tuberculosis is likely to be overlooked if routine 
histological preparations are not made. When limited to 
the pelvic organs it is difficult to establish a diagnosis from 
the gross appearance alone. Unusually resistant adhesions 
suggest tuberculous or streptococcus infection. 

13. Somewhat similar operative measures appear indi- 
cated in streptococcus and in tuberculous salpingitis. In 
Iioth diseases infection is not usually confined to the tubes; 
in both, viable bacteria are often still present in the tissues 
at the time of operation and there is danger of chronic 
postoperative infection of the ovaries. Particularly in 
regard to extirpation of the ovaries, more radical surgery 
appears indicated than in gonorrheal infections of cor- 
responding severity. 



July 5. 1922.] 



ABSTRACTS FROM CVRREXT LITERATURE. 



().^ 



14. The results of this work again direct attention to 
the dangers of uterine instrumentation. Nearly all strep- 
tococcus infections in this series were traceable to instru- 
mental abortion or subsequent intrauterine manipulation ; 
some tubal infections recurred after curettage ; tent dila- 
tation was followed by streptococcic pelvic abscess. It 
would appear that the normal uterus and fallopian tubes 
are comparable with an unopened tube of culture media ; 
passage of instruments through the bacterial barrier of the 
internal os is analogous to removal of the cotton plug, and 
nature is not always able successfully to combat infection 
before serious lesions have resulted. This is particularly 
true if infection which has been previously introduced is 
stirred up through subsequent instrumentation. 

A New Surgical Procedure for the Treatment of Ex- 
tensive Uterine Prolapse. — Diischan Maluschew (Zcn- 
tralblatt f'lr Cyiuikologic. April 29. 1922) proposes the fol- 
lowing technic : The vaginal portion of the cervix is cir- 
cumcised and the vaginal wall is bluntly reflected at the 
most two cm. A posterior colpoceliotomy is then done, 
carrying the incision to the perineum. The posterior sur- 
face of the uterus is then brought forward and the round 
ligaments are drawn down through the broad ligaments 
with Kocher clamps and grasped far from the uterine cornua 
by assistants. The upper end of the celiotomy wound is 
sutured a short distance so as to prevent the cervix from 
slipping into the wound. The uterus is then sunk by 
slowly drawing the Kocher clamps forward : the round 
ligaments approach the side of the portio, are then united 
with a few sutures to each other, fastened to its anterior 
surface and covered by the vaginal flap. The celiotomy 
wound is closed in such a manner that the sacrouterine 
ligaments and the two legs of the levator muscles are in- 
cluded by taking a big bite w'ith a large curved needle. 
If necessary, a perineal plastic and an anterior colporrhaphy 
may he added. If urinary incontinence persists, a later 
pyramidalis fascia plastic operation (Goebell-Stoecker) 
may be done. The greatest advantages of this operation 
are the anteversion of the uterus and a pronounced lifting 
of the portio, and a marked flattening of the deep cul de 
sac of Douglas resulting from the suturing of the sacro- 
uterine ligaments and the levators ; sterility does not neces- 
sarily follow. 

Hysterectomy. — Clark and Norris (Surgery, Gyne- 
cology and Obstetrics, April, 1922) from an analysis of 
the end results in 232 hysterectomies, present the follow- 
ing conclusions : 

1. Hysteromyomectomy is productive of excellent end 
results whether or not ovarian conservation is practised. 
Of all patients in our series, over ninety-nine and five- 
tenths per cent, were cured or improved, and over 
eighty-three per cent, declared that their general health 
was good or improved one year or more after operation. 

2. Better end results and greater comfort to the patient 
can be secured as the result of ovarian conservation. 

3. Everything being equal, better end results follow the 
conservation of both ovaries than the retention of one, but 
one ovary is far better than none. 

4. Conserved ovaries seldom give subsequent trouble. 
Among 171 cases in which ovarian conservation was prac- 
tised, 261 ovaries were conserved, and in none of these 
patients was a second operation for the removal of the 
ovary necessary. This is a strong argument in favor of 
ovarian conservation in this class of cases, for if the con- 
served ovary docs not give trouble, there can be no excuse 
for its removal. 

5. That conserved ovaries may give subsequent trouble 
is conceded, as is also the fact that the series of cases 
quoted may have been unusually fortunate in this respect. 
Successful ovarian conservation depends upon the condition 
of the ovary at the time of operation, the maintenance of 
an adequate blood supply, and the retention of the ovary 
in its normal position. 

6. Undue emphasis has been placed upon the frequency 
of cystic and other forms of degeneration in conserved 
ovaries, and that attention to the points just mentioned will 
largely abrogate such disturbances. 

7. Bearing in mind the fact that good results can be 
secured by performing bilateral oophorectomy, it is often 
better to sacrifice a doubtful ovary than to spare it. This 
is a point, however, on which each case must be judged 
individually. 



8. \\ hen both ovaries are removed, the surgical meno- 
pause is by no means severe in all cases, those patients who 
suffer unduly being in the minority. 

9. The age of the patient is not an unfailing criterion 
as to the severity of the surgical menopause in any given 
case. Young women will sometimes bear the loss of "both 
ovaries well, whereas some of the most severe phenomena 
of the surgical menopause encountered in this series have 
occurred in patients past forty years of age. This does 
not imply that the age is an unimportant factor in consi- 
dering the question of ovarian conservation. Other things 
being equal, there is no doubt that younger women 
suffer more severely as a result of a bilateral oophorec- 
tomy than do those who are older. 

10. A more important guide than the age. however, is 
the temperament of the individual patient. The highly 
strung, neurotic woman is likely to suffer more severely 
than her more phlegmatic, asexual sister. 

11. Each case should be individualized. The tempera- 
ment of the patient should be studied, and a correlation of 
this with history and .the pathological process found at 
operation should determine the type of operation. 

12. Conserved ovaries functionate. 

13. Even in those patients in whom the ovary does not 
functionate permanently, the occurrence of the surgical 
menopause is less abrupt and severe than in those women 
upon whom a bilateral oophorectomy has been performed. 
Among the former class of cases the artificial menopause 
generally resembles the normal menopause more closely 
than does that following the removal of both ovaries. 

Tumors of the Cervix and Uterus.— L. R. Wharton 
(Surgery, Gynecology and Obstetrics, September, 1921) dis- 
cusses rare tumors of the cervix and uterus as follows : 
Condyloma of the cervix is one of the rarest of gyneco- 
logical disorders. Etiologically, pathologically, and' clini- 
cally, there are two distinct types of condyloma of the 
cervix, the gonorrheal and the tuberculous. When compli- 
cations are not present, the symptomatology in these two 
types may be identical, the chief complaint "being the pres- 
ence of a profuse, purulent, vaginal discharge which inay 
be_ occasionally tinged with blood. Both from the view- 
point of the history and the clinical findings, there may be 
no small resemblance between condyloma and malignant 
tumors of the cervix. Gonorrheal condylomata may occur 
singly as isolated pedunculated tumors or in clusters of 
papiUomata which may almost entirely cover the cervix. 
These masses may present varying grades of inflammatory 
reaction. Gonorrheal condyloma of the cervix may be 
accompanied by similar lesions on the vulva and perineum 
and also by salpingitis and its many manifestations, but in 
our experience the endometrium is not usually affected. 
The primary focus of infection appears to be in the cervical 
glands. In the treatment of gonorrheal condyloma, it is 
necessary to clean up the focus of infection and also to 
remove the local growth. Curettage of the uterus is un- 
necessary and should not be performed. Tuberculous 
condyloma of the cervix is almost always accompanied by 
other manifestations of the disease. There is almost al- 
ways a concurrent tuberculous endometritis and salpingitis, 
and very frequently other lesions may be found. For this 
reason the operative treatment of the cervical lesion should 
be undertaken only after a careful study has been made 
and on the basis of sound surgical indication. In gonor- 
rheal condyloma the outlook is uniformly good; in tuber- 
culous the prognosis depends entirely upon the nature of 
the concomitant lesions and the method of treatment in- 
stituted. 

Investigations on the Genital Nerve Corpuscles in 
the Clitoris and the Labia Minora. — Fr. Chr. Geller 
(Zentrall'Uitt fiir GymU'ologie. .April 22, 1922) found that 
the nerve ends in the clitoris and labia minora are of two 
groups : the free nerve endings and the nerve end corpuscles. 
The smallest free nerve endings course closely beneath the 
epithelium, whereas the genital corpuscles are never found 
in this region but exclusively beneath the papillary layer. 
The Bielschowsky method of staining shows the typical 
genital nerve corjjuscles as spiral or coil shaped strands 
of one or more nerve fibre, bandshaped and well circum- 
scribed by lamellous connective tissue fibre. They are 
usually intimately connected with or surrounded by a fine 
capillary. The author assumes that these structures are 
sensory end organs whose undisturbed function is necessary 
for an occurrence of the orgasm. 



64 



LETTERS TO THE EDITORS. 



[N'ew York Medical Journal 
AND Medical Record. 



NEW YORK MEDICAL JOURNAL 

and MEDICAL RECORD 

Philadelphia Medical Journal and the Medical News 

A Semimonthly Review of Medicine and Surgery 

Gregory Stragnell. M. D., Editor 

Address all communications to 
A. R. ELLIOTT PUBLISHING COMPANY. 
Publishers, 53 Park Place, at West Broadway, New York. 



Subscription Price: Under Domestic Postage, $6; Foreign 
Postage, $8; Single copies, SO cents. 



Remittances should be made by New York E.xchange, post office 
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money sent by unregistered mail. Remittances from Foreign Coun- 
tries should be made with International Money Orders. 



Entered at the Post Office at New York and admitted for transpor- 
tation through the mail as second class matter. 



NEW YORK, WEDNESDAY, JULY 5, 1922 



Letters to the Editors. 



ANAPHYLAXIS AND EPILEPSY 

Boston, M.^ss., May 24, i<)22. 
To the Editors: 

Dr. Ward'.s interesting paper on Protein Sensiti- 
zation as a Possible Cause of Epilepsy and Cancer, 
in a recent number of the Journwl, furnished 
the stimulus for this letter, which I trust you will 
do me the favor to publish. 

Anaphylaxis is regarded by investigators as due 
to autonomic irritation. It will be remembered that 
the vegetative nervous system is composed of two 
branches, the autonomic and the sympathetic. Epi- 
lepsy has been showti to be a disease in which the 
sympathetic fibres are .profoundly diseased, begin- 
ning with a hypertonicity and ending in their degen- 
eration. The other branch of the vegetative system, 
the autonomic, is sometimes diseased in epilepsy 
(as shown by the eminent New York epileptologist, 
Echeverria, who found vagal degeneration). It is 
interesting to riote that anaphylaxis at times is pre- 
vented by atropine, an autonomic paralysant, and 
to note likewise that belladonna has been found 
effective in some cases of epilepsy, perhaps in the 
rare cases in which anaphylaxis may play a part, 
and in which vagal (autonomic) fibres are diseased. 

There is no question that fright produces convul- 
sions and epilepsy (most frequently in the predis- 
posed) and this without the introduction of a foreign 
protein; so that anaphylaxis can be ruled out in those 
cases. Furthermore, fright acts through the sympa- 
thetic branch of the vegetative nervous system — 
while anaphylaxis depends on autonomic irritation. 

To explain the phenomena of convulsions in epi- 
lepsy, we need no aid from anaphylaxis. It is 
known that acute anemia as is [jroduced by vasocon- 
striction of the bloodvessels in the brain, results in 



convulsions. The diseased sympathetic fibres in 
epileptics that can be made, by reflex action, to pro- 
duce an intense visible vasoconstriction in the skin 
of the patient, indicates that a similar intense vaso- 
constriction can take place in the epileptic's brain 
with a resulting anemia and outbreak of convulsions. 
A French surgeon, during an operation on the skull, 
witnessed this intense vasoconstriction in the brain 
and convulsions in an epileptic. 

Incipient epilepsy, designated by Echeverria as the 
stage of the disease in which the epileptic attacks 
are solely manifested by sudden pallor, loss of con- 
sciousness, and vertigo, has been found to be asso- 
ciated with a demonstrable hypertonia of sympa- 
thetic fibres. This hypertonia yields to drug treat- 
ntent (the use of colloidal renanthe — a sympathetic 
paralysant), and both signs and symptoms of the 
disease disappear. A paper embodying some of the 
research work resulting in these findings, was read 
at the Boston meeting of the A. M. A. last June, 
and published in the Medical Record for JNIarch 11th 
last. With the facts embodied in that paper before 
us, it would be a serious thing to neglect their lesson, 
and negligently allow cases of incipient epilepsy, 
easily diagnosed and treated, to progress into chronic 
epilepsy, that bete voir of scientific treatment. 

Edward A. Tracy. 



SOLUBLE DERIVATIVES OF CHAULMOO- 
GRA OIL IN TUBERCULOSIS. 

LoxDOX, Iiiiie S, igjj. 
To the Editors: 

From the references in Dr. Beasley"s paper on 
the Treatment of Ttiberculosis with derivatives of 
Chaitlmoogra Oil in your issue of September 21, 
1921 (which has only recently come to my notice), 
to the work of Dr. McDonald (Journal American 
Medical Association, November, 1920) your readers 
might incorrectly infer that the febrile and local re- 
actions produced in leprosy by injections of such 
compounds, and the all important breaking up of the 
lepra bacilli in the human tissues accompanying 
them, had been discovered by Dr. McDonald ; so they 
may be interested to learn that these phenomena were 
first described in my paper in the British Medical 
Journal, October 21, 1916, and were illustrated by 
colored plates in the Indian Journal of Medical Re- 
search, October, 1917. Moreover, in the earlier 
paper referred to, I suggested the itse of such prep- 
arations of chaulmoogra oil "in the case of the other 
human acid fast bacillus, namely that of tuberculous 
disease," promising trials of which in phthisis will 
shortly appear in the British Journal of Tubercu- 
losis, while I have also shown the value of sodium 
morrhuate, made in a similar way from codliver oil, 
in tuberculous disease. (British Medical Journal. 
February 8, 1919, and Indian Journal of Medical 
Research, 1919, p. 236.) The papers of such re- 
search workers as Professor Dean and Walker 
and Sweeney (to the latter of which Dr. Beasley 
refers) have, of course, acknowledged my earlier 
work, a convenient summary of which with its bear- 
ing on the tuberculosis prol)lem appeared in TJie 
Practitioner of August, 1921. 

Leonard Rogers, Lt. Colonel. I. M. S., Ret. 






New York Medical Journal 



and 



Medical Record 



Philadelphia Medical Journal ^he Medical News 

A Semimonthly Review of Medicine and Surgery, Established 1843. 



Vol. CXVI. .\"«i 14 



XKW Y((]{K. WEDNESDAY. JUIA" lil, lltL'li 



Whole Xo. 2237 



A Physiological Adjuvant in the Rest Cure of Pulmonary 

Tuberculosis* 

By .S. .^DOLPHUS KNOPF. M. D., 

New York, 

Attending Specialist U. S. Veterans' Hospital No. 61, Fo.x Hills. 

(Approved for publication by tlic Siiri/run General of the i'. S. Public Health Service.) 



Many attempts have been made by numerous ex- 
perimenters to add local rest for the tuberculous 
lung to the general bodily rest treatment. Denison 
(1) and Sewall (2) suggest mechanical restrictions 
by means of adhesive plaster or belt; Bridge (3) by 
will i5o\ver, and Webb (4) by posture. All report 
good results, but none that can be compared with the 
results obtained by a successful artificial pneumo- 
thora.x where the involved lung is completely col- 
lapsed and, so to speak, put out of commission. Of 
the results of artificial pneumothorax in the various 
stages of the disease so much has been written that 
it would be superfluous to try to give any statistics 
here. We all know there is a vast difTerence of 
opinion concerning the utility of artificial pneumo- 
thorax, particularly in the early cases, and we all 
know that, owing to pleuritic adhesions, the number 
of advanced cases of pulmonary tuberculosis suitable 
for that operation have up to now been limited. 

The operations devised by Jacobseus (5) who, with 
the aid of the thoracoscope and a long cautery pro- 
tected by a cannula, divides the pleuritic adhesions, 
may help to diminish the number of cases which 
have heretofore been considered unsuitable for arti- 
ficial pneumothorax. Thoracoplastic operations may 
perhai)s also more frequently be resorted to hereafter 
for the same purpose as the operation becomes more 
perfected, but these procedures must be considered 
more or less dangerous. In dividing the pleuritic 
bands with the bistoury or even with the electric 
cautery, there will always be some danger of coming 
across very va.scular adhesions, or such extensive 
ones that there may be danger of hemorrhage and 
ru])turing the lung. The thoracopneumoplastic op- 
eration has thus far yielded a rather high mortality 
even at the hands of so .skilful a surgeon as Archi- 
bald ((i) so that it must be restricted to a few cases. 

•Read before the tuberculosis staff of the U. S. Veterani' Hos- 
pital No. 61, Fox Hills, N. Y.. March 16, 1922; and before the 
Clinical Section of the National Tuberculosis Association at its 
mectinR in Washington, May 4, 1922. 

Copyright, 1922, by A. K. E 



-All the procedures just described, however, seem 
to have one sole object in view, namely, to limit or 
to restrict entirely the respiratory movement of the 
invaded lung. Comparative physiology (7) leaches 
us that the slow breathing animals live longer and 
are less susceptible to tuberculosis than the fast 
breathing ones. As an example, we will cite the 
horse with only eight to ten respirations a minute, 
in contrast to the cow which breathes fifteen to thirty 
times a minute. The animal which perhaps lives 
longest is the turtle, whose respirations are so few a 
minute that they are hardly perceptible. Its re- 
sistance to human tuberculosis inspired Friedmann 
to make his serum, which unfortunately up to now 
has not proved what the inventor claimed for it. 

Now if the slowly breathing animal is least sus- 
ceptible to the invasion of tuberculosis, and a lung 
invaded by tuberculosis is benefited by restriction of 
its respiratory movements through outside pressure 
or the complete arrest of function by means of 
an air s])lint (artificial pneumothorax) or bone corn- 
jjression, why should not restricted respiratory move- 
ments and reduction in their number by voluntary 
effort be equally valuable as an adjuvant in tlic cure 
of pulmonary tuberculosis? 

I made the first experiments on myself and have 
been able to reduce my respirations, without dis- 
comfort, to eight, six, and sometimes to five a min- 
ute, restricting respiratory movements to the dia- 
phragm. I recommended this to a few of my [latients 
in the various stages of the disease and was aston- 
ished to find how well they could train themselves 
t(i reduce their respirations from twenty-four to 
thirty a minute to ten, eight and six, and gradually 
do this for half an hour or an hour at a time, and 
do it several times a day. 

As far as I have gone, the patients ha\e not ex- 
perienced any discomfort from these exercises but 
felt belter, their general condition had improved, and 
the physical examination showed less activity locally. 

llioll Publishing Company. 



66 



KNOPF: RESTRICTION OF RESPIRATION IN TUBERCULOSIS. 



[New York \rEDlCAL Journal 
AND Medical Record. 



One patient confessed to me that after following 
my suggestions for some length of time, he exper- 
ienced an intense desire to take a deep breath. Hav- 
ing been instructed not to do so, he imagined him- 
self to feel very uncomfortable. I told him that the 
next time he felt like taking a deep inspiration, he 
should not hesitate to follow his inclination. A few 
days laier he assured me that the thought that he 
could take a deep breath when he wanted to made 
him feel much more comfortable and that he jould 
keep up his restricted breathing for a longer time. 

Although clinical experience has shown that pa- 
tients can live and breathe when there is only about 
one fourth of lung area in condition to attend to the 
oxygenation necessary for life, I did not feel certain 
of the wisdom of my procedure as a therapeutic 
means. I feared that perhaps I might in the long 
run do harm to my patients by allowing an accumu- 
lation of carbon dioxide and a privation of the life 
giving oxygen. According to Weber (8) and his 
followers, it would seem that a moderate accumula- 
tion of carbon dioxide is not by any means to be 
feared but rather to be favored in pulmonary tuber- 
culosis ; nevertheless, to be on the safe side, I con- 
sulted with Dr. Graham Lusk, professor of physi- 
ology at Cornell University Medical College, and 
demonstrated for him this method of breathing. He 
was astonished at my being able to reduce my res- 
pirations to four a minute. He told me that in his 
opinion no possible harm could be done to the pa- 
tient by using superficial respiration or restricting the 
number of respirations a minute. Wishing to have 
something authentic for publication on the subject, 
I asked him to write me his opinion with permis- 
sion to use it, which he most kindly did as follows : 

"Under ordinary conditions the production of 
carbon dioxide in the tissues controls the volume 
of the respiration. If the number of respirations a 
minute be decreased, the volume of air expired and 
inspired in each breath is automatically increased. 
The total gaseous exchange, however, remains aji- 
proximately the same. Under ordinary conditions 
of rest the quantity of oxygen absorbed is almost 
the same whether there be seven or fifteen respira- 
tions a minute." 

I have not only been able to verify Professor Lusk's 
statement by interesting experiments, but to my sur- . 
prise I found that the volume of air inspired and 
expired when the respiration was limited to the 
basal portions of the lungs, that is to say, the volume 
of tidal air, was even materially increased over the 
normal. Through the courtesy of Professor Lu,sk 
and with the valuable cooperation of Dr. D. P. Barr, 
of the Russell Sage Institute of Pathology, I was 
])ermitted to make some spirometric tests during the 
respirations restricted in number and limited to the 
diaphragmatic mode of breathing. Dr. Rarr kindly 
lent himself to the exjieriment. After I had demon- 
strated to him how he could diminish the number 
of respirations to five a minute and limit them to 
the basal portion of the lungs, he was surprised to 
find with what comfort he could do it and thought 
he could do it indefinitely. Dr. Barr has an unusu- 
ally well developed chest, and in ordinary respira- 
tion his tidal volume is 600 c. c. to the respiratic^n. 
We both observed with interest that the volume of 
tidal air increased consideral)ly while he was lying 



in a recumbent position, breathing through the tube 
of the spirometer. We repeated the experiment 
twice, each time lasting for three minutes, and the 
average number of inspirations and expirations did 
not exceed five a minute. Dr. Barr assured me that 
throughout the three periods of experimentation his 
respiration was comfortable and adequate, yet the 
upper portion of his lungs was virtually at rest. 

It is of course possible that, when one limits his 
respiratory function voluntarily, there is an uncon- 
scious effort to take in more air than is actually 
needed. But this experiment proves that no harm 
can possibly be done by restricted respiration, and 
that a more thorough ventilation of the usually non- 
affected basal parts of the lungs in tuberculosis in- 
dividuals can only be beneficial. 

Besides the chemical stimulus to the continuance 
of respiration, there exists also a nervous stimulus 
to which McLeod [9) refers in his article on Some 
Recent Work on the Control of the Respiratory Cen- 
tres. He says : ''There are in general two ways in 
which the activities of the centre might be caused 
to alter. These are by changes in the chemical com- 
position of the blood supplying it and by nerve im- 
pulses derived from other parts of the nervous 
system." In other words, the respiratory move- 
ments can, in no small degree, be controlled by the 
will. In recruiting for the aviation service in France, 
it was found that those who could retain their breath 
from fifty to sixty-five seconds were best fitted to 
be aviators (10). 

The reason for the improvement in those of my 
patients who faithfully carried out my instructions 
concerning restricted breathing, I believe to be the 
relative rest which was given to the lung by this 
process. If one succeeds in reducing his respiration 
from twenty a minute to ten, he has spared his lung 
three thousand movements in five hours. Even if 
it seems difficult for the patient to do this for any 
appreciable time, he will derive considerable benefit 
from limiting his respiration to the basal portion 
of the lung. This part of the procedure, intended to 
obtain local rest for the upper portion of the ])ul- 
monary area, is easier to carry out than the volun- 
tary reduction of the number of respirations a 
minute. 

Of course, when one palpates the anterior portion 
of the chest over the u]i]:)er lobes, one may perceive a 
slight movement, particularly in beginners, but this 
diminishes as the patient becomes more habituated to 
diaphragmatic breathing. 

The difficulty of obtaining sufficient rest by ex- 
ternal restriction of the thorax inspired Webb and 
his coworkers, Forster and Houk (4), to investigate 
the value of simple posture in the treatment of pul- 
monarv tuberculosis. These observers found that 
patients who slept or rested during the day on the 
side of their diseased lung, did a great deal better 
than those who slept on the opposite or well side. 
To add this treatment by posture, particularly during 
sleep, to the respiratory method described in this 
paper, can only be of additional advantage. 

In this communication I shall avoid all statistics 
and only refer to the results olitained in a few cases 
in the advanced stages with cavitation in my service 
at Fox Hills and in private practice. The patients 
had the usual symptoms of toxin absorption. After 



July 19, 1922.] 



KNOPF: RESTRICTION OF RESPIRATION IN TUBERCULOSIS. 



67 



practising the method of restricted breathing for a 
couple of weeks, cough, expectoration, and tempera- 
ture had gradually but perceptibly diminished and 
auscultation revealed a decided tendency to fibrini- 
zation. But a few cases and the observations of one 
man alone in the treatment of tuberculosis cannot 
and should never be considered conclusive. Any one 
having a new remedy for tuberculosis can delude 
his patients, if they don't delude themselves, into 
believing that the new remedy has done them some 
good. The inventor of a remedy often unconsciously 
hypnotizes himself into a belief in the efficacy of 
his discovery. Therefore. I wish simply to give my 
ideas on the subject, describe the modus operandi 
and, since it is perfectly safe, ask my fellow practi- 
tioners to try it on as large a scale as possible in 
early, moderately advanced, and even far advanced 
cases, and after a thorough trial send me their re- 
ports. That the results will be best in the early 
cases must be evident ; that the results must be better 
when the general rest treatment in the open air and 
the proper hygienic, dietetic and symptomatic treat- 
ment are carried out at the same time, is also obvious. 

The intelligent cooperation of the patient can only 
be obtained by explaining to him at length the object 
of the procedure. He may be to'.d that it may take 
some time before he can perceive any improvement, 
but that it can in no wise be injurious to him, and 
that if he feels the slightest discomfort he should 
merely stop it. He must be assured that it cannot 
bring on a hemorrhage although a hemoptysis may 
occur, as it does in all sorts of treatment, but that 
it is more likely to prevent one. When one occurs, 
the quiet and diminished respiratory movements will 
help the coagulation of the blood and arrest the 
hemorrhage because of diminishing the movements 
of the bleeding lung. 

Two patients of mine who had had bloody expec- 
toration, and who stated that it always lasted many 
days, assured me that this quiet and diminished 
breathing shortened the usual duration of their blood 
spitting considerably. Of course, we all know that 
a hemorrhage or bloody expectoration may stop 
without any medication or other therapeutic means. 
General rest alone often suffices : nevertheless, it is 
quite logical to assume that respiratory movements 
being diminished in number, and the respiration 
being restricted to the lower portion of the lungs, 
rarely invaded by tuberculosis, may have a very 
beneficial influence. Except shortly after hemorrhage 
or as long as the patient still has bloody expectora- 
tion, he should be encouraged in the ingestion of 
j)lenty of pure water, at least eight tumblerfuls a 
day, between meals. I noticed that those of my 
patients whf) obeyed this order were better able to 
reduce their respirations, and do it for a longer time, 
than those who were neglectful in this matter. 

MODUS OPERANDI. 

At the beginning of the treatment the patient lies 
on his reclining chair or preferably in bed with his 
head low. Later on, he may be able to resort to the 
method of breathing in a comfortable sitting or even 
occasionally in a standing position. The patient 
should be told to imagine that the respiratory move- 
ment begins in the toes of his right foot, traveling 
gradually upward as far as the diaphragm on the 



right side, then goes over to the left side, stops there 
for a second or two and then gradually descends 
during expiration on the left side. While this breath- 
ing from the toes upward and as far as the abdomen 
is of course merely imaginary, it results in a dia- 
phragmatic breathing, and whatever qualit}" of air 
is inhaled passes mainly through the lower portions 
of the lungs, while the upper portion, where the 
tuberculous lesions are usually located, are put at 
comparative rest. Lastly, the physiological relation 
of five for inspiration and four for expiration is 
maintained. 

In the article mentioned above, Sewall says : 
"When respiratory movement is limited to the dia- 
phragm it is the very bases of the lungs that move 
most widely, the extent of motion rapidly diminish- 
ing upwards. When the upper chest expands, 
respiratory motion involves the upper lobes in pro- 
portion to the excursion of the underlying ribs. 
Now, it is familiar enough that, broadly speaking, 
pulmonary tuberculosis is a disease of the upper 
part of the lungs, its intensity being concentrated be- 
tween the hilum and the extreme apex. Remember- 
ing the data of our argument, the deduction is 
obvious that were we able to inhibit respiratory mo- 
tion in. say, the first four ribs, we could, without 
seriously impairing the vital capacity of the chest, 
so restrict the motion of the principal areas of pul- 
monary disease that distribution of the toxins there- 
from would be greatly reduced." 

The most satisfactory results from this physiolo- 
gical adjuvant to the rest cure in pulmonary tuber- 
culosis can naturally be obtained in a sanatorium or 
hospital where the patients have come, so to speak, 
to occupy themselves with getting well. In a closed 
institution the tuberculous patient very often be- 
comes depressed because of lack of employment and 
wishes he had something to do. With watch in 
hand or clock before him, he can occupy his time and 
help toward tbe cure by limiting his respiratory 
movements, thus giving rest to his lungs that they 
may have a chance to heal. However, satisfactory 
results can also be obtained in private practice. Here 
we must consider the factors of personal equation. 
The family physician, having the absolute confidence 
of his patient and knowing his peculiarities and state 
of mind, can often accomplish a good deal more, 
where psychic and nervous elements are involved, 
than the institution physician. I have had private 
patients who became intensely interested in this pro- 
cedure, and they were rewarded for their efTorts by 
a gradual diminution of distressing cough, fever, 
nightsweats and pain. The more confidence and 
peace of mind, the more quiet and rest of body we 
can give the patient suffering from pulmonarj- tuber- 
culosis, the greater will be our success. 

Every student of tuberculosis knows that if he 
could put every case of early tulierculosis at com- 
plete rest and also limit, as much as possible, the 
movements of the involved area, we would have 
fewer advanced cases. In my early career I taught 
respiratory exercises as a prophylactic measure in 
tuberculosis and I do so still ; but as a curative means, 
I feel more than ever that anything which will put 
the inflamed lung at rest, if even only at comparative 
rest, is the ideal treatment in the majority of cases. 
When, in addition to the restricted respiratory move- 



68 



HIRSCH: X RAYS IX DISEASES OF GENERATIVE ORGAXS. 



[New York Medical Journal 
AND Medical Record. 



ments, the patient trains himself to cough onlj- when 
the accumulation of puhnonary or bronchial secre- 
tions demand it, he will he doubh- benefited. 

It may be asked whether there are any contraindi- 
cations to this type of breathing. If pain is caused 
by the diaphragmatic -breathing or, if present, is 
accentuated thereby, it is a decided contraindication. 
The pain may be due to adhesions between dia- 
phragm and pleura on the affected side or to an 
acute pleurisy elsewhere. A further contraindica- 
tion is that exceedingly rare condition in which the 
primary involvement begins in the lower lobes, or 
where the process has extended to that region in 
the terminal stage. 

As to the psychic effect of this treatment making 
the patient more contented and restful in mind, there 
can be no doubt. Many authorities for whom I 
have demonstrated the exercise thought this feature 
as important as obtaining the local rest of the in- 
vaded lung. Dr. John W. Turner, the consultant in 
tuberculosis of the U. S. \'eterans' Bureau, put it 
very tersely when he wrote me recommending a thor- 
ough tryout of the procedure : "It would seem that 
this method of limiting the ventilation of the upper 
portion of the lungs should secure not only local rest 
to the lung, but also serve as an inspiration and give 
the patient something specific to do during his re- 
pose in bed or on the reclining chair while taking the 
cure.'' 



May I hope that this seemingly most rational treat- 
ment will prove as successful in the hands of many 
as I believe it to have been in mine. 

REFERENCES. 

1. Dexisox, Charles : Traction Plaster for Temporary 
Contracting an Affected Lung. etcTraiisactions Colorado 
State Medical Association, 1898-1899. p. 392. 

2. Sew.\ll and Swezev : The Effects of Limiting the 
Respiratory Excursions of the L'pper Thorax in Refrac- 
tory Cases of Pulmonary Tuberculosis. American Revieii' 
of Tuberculosis. September, 1921. 

3. Bridge, Norm.\x : Should a Tuberculous Lung Be 
Exercised? Reprinted from Medicine, November, 1908. 

4. Webb, Forster, and Houk: Rest of the Individual 
Lung by Posture, Transactions National Tuberculosis As- 
sociation, 1916, p. 182. 

5. J.\coB.\EUS, H. C. : Kliniska Mcddelandcn fran 
Kungl. Serafiner-Lasarettess Med. Klin, II — Cauterization 
of Adhesions, Stockholm, 1921, 

6. Edvv.^rd. Archibald : Note upon the Surgical Treat- 
ment of Certain Cases of Pulmonary Tuberculosis, Trans- 
actions National Tuberculosis Association, 1921, p, 221. 

7. Rostock, Hans Wixtersteix : Handhuch der ver- 
ghichendcn Physiologic. Verlag Gustav Fischer, Jena, 1921. 

8. Weber. Hugo : Das Kohlensaureprinzip in the Be- 
handlung der Lungenschwindsucht, Zeitschr. f. Tub., 1903, 
vol. iv. p. 505. 

9. MacLeod, J. J. R. : Journal of Laboratory and Clini- 
cal Medicine, vol. v, p. 166. 

10. BouRGois. Maurice: Maximum d'Apnee-Voluntaire, 
These pour le doctoral. Paris, 1920. 

If) West Xixetv-fifth Street. 



Roentgen Treatment of Diseases of the Generative Organs 



By L SETH HIRSCH, M. D., 
New York. 



The' use of the x ray as a therapeutic agent in 
diseases of the female generative organs is no longer 
new. Already a vast literature, experimental, bio- 
logical, rontgenological and surgical has accumulated 
on the subject, but among the profession the method 
of application of treatment and its limitations, is not 
generally understood. 

After Albers-Schonberg's discovery in 1902 of 
the sterilization effect of the* rays on the testicles of 
rabbits, and Halberstadter's demonstration of the 
greater sensitiveness of the ovary of the female of 
animals to the agent, it was not long before the 
occurrence of similar changes in human beings was 
proved and not long before a mass of evidence had 
accumulated to prove that the application to the 
pelvic structure of a certain x ray dose caused tem- 
porary or peniianent cessation of menstruation.^ 

It is to this end that the x ray has its greatest 
field of applicability. The gynecologist and the 

* Tile hr.'it to apply the rontgcn ray for the treatment of uterine 
fibroids was Fovtau dc Courvelles (1904). Longfeller (1906) was 
the first to make definite observations upon the menstrual changes 
productd by radiation of the generative organs. Albers-Sch6ni)crg 
(1909) was the first to attempt to apply a definite systematic technic 
to this therapeutic procedure. Kronig and Gauss carried the technic 
a step further by their introduction of filtration with aluminum (the 
use of which was first suggested by Thompson) and the dosage through 
numerous ports of entry. Friedrich, Seitz, and Wintz showed the 
importance of the secondary radiations in the tissues, and indicated 
methods of increasing these by the use of higher voltages, heavier 
filtration and greater focal distances and larger fields. They also 
established a unit of dosage. 



radiologist are both concerned in this application of 
the x ray as a therapeutic agent, and a close coopera- 
tion between the two is essential if effects are to be 
obtained and the treatment is to be properly and 
honestly applied. Without a correct diagnosis, with- 
out proper control by the gynecologist, without a 
proper selection of cases, the radiologist works 
blindly and often to the detriment of his patient. 
In fact, the radiologist is but the assistant of the 
gynecologist in these cases. The knowledge of the 
actual pelvic conditions must come from the gyne- 
cologist and the keener his diagnostic ability, the 
closer his scrutiny of the case, the more effective are 
the results and the higher the percentage of cures. 

In reference to the radiologist, there is this to be 
said — that he must apply the rays with brains and 
talent ; that, althotigh certain fundamentals must be 
adhered to, which will be indicated later, and which 
are the essentials of technic, he must remember that 
he has a living human being to deal with, who re- 
sponds and reacts in manifold ways to the applica- 
tion of this powerful agent. 

What is the function of the gynecologist in this 
cooperative treatment? The answer will define for 
us the limitations of the applicability of this treat- 
ment. The function of the gynecologist is to select 
the cases for treatment. 



July 19, 1922.] 



HIRSCH: X RAYS IN DISEASES OF GENERATIVE ORGANS. 



69 



Of the five great causes of uterine bleeding, preg- 
nancy, infection, displacements and lacerations, neo- 
plasms of the uterus and ovaries, and endocrine dis- 
turbances (which are usually ascribed as the cause 
where no gross pathological change is discernible 
and which are due to dysfunction of ovary, thyroid, 
hypophysis or adrenal) we are concerned with the 
latter two only. The remainder are not within the 
province of the radiotherapist. Of the ovary it may 
be stated that dysfunction of this organ is an over- 
whelmingly important factor in the pathogenesis of 
affections of the generative organs. 

CONDITIONS IN WHICH X RAYS SHOULD BE USED. 

The X ray is applicable to the treatment of the 
following conditions : 

1. Excessive or prolonged hemorrhage: 

a. From a uterus showing no gross pathological 

lesions, at puberty, at the menopause, during 
the whole child bearing period. 

b. From a uterus showing pathological changes. 

2. Benign tumors. 

a. Fibroids of the uterus. 

b. Myofibrosis. 

3. Malignancy. 

a. Carcinoma. 

b. Sarcoma. 

4. Sterilization. 

a. For severe dysmenorrhea with infantile devel- 

opment of the uterus. 

b. After Csesarean section. 

c. For osteomalacia. 

d. For systemic diseases, tuberculosis, carcinoma 

(extrapelvic) and heart disease. 

e. For social indications. 

5. Diseases of the vulva. 

Having selected the cases, the radiologist applies 
a certain dosage of rays to the pelvic organs. In 
order that the rationale of the method be clearly 
understood, it is necessary- to recall certain primary 
considerations. 

1. That the reaction of the cell depends upon the 
absorption of x rays. 2. That the reaction of the 
cell is apparently the same to rays of different wave 
lengths, if the same amount of energy is actually 
absorbed. 3'. That the cells vary in their reaction 
to the same amount of energy absorbed, certain cells 
being destroyed, others stimulated to growth, others 
sliowing no changes. 4. For certain cells, both 
malignant and benign, the amount of radiation of a 
certain wave length which will cause degeneration 
and death has been established. 5. That applying 
the ray as a thera{)eutic procedure both the reaction 
of the organism as a whole to the radiation and the 
local effect on the organ treated must be studied. 
The general effects are due to the entire absorption 
by the portion of the body irradiated, while the local 
effects are the result of the varying amounts of radia- 
tion reaching the various tissue layers. 

If the amount of energy of a certain quality which 
will cause the degeneration and death of the normal 
or aberrant cell is established, we know the dose 
which will give the maximum effect. This is com- 
parable to the effect of the maximum dose of a 
drug. The maximum dosage may be applied in one 
continuous period (massive method), or it may be 



divided into several periods (the fractional method). 
The biological effect of the fractional radiation is 
cumulative. The x ray acts in small doses 
to stimulate, in moderate doses to inhibit, and 
in large doses to destroy. Normal and pathological 
tissues differ as regards their reaction to the radia- 
tion. The lymphocytes and glandular tissue are 
more sensitive than the connective tissue cells : the 
ripe graafian follicle is more sensitive than the sper- 
matoza, skin more sensitive than mucous membrane, 
while muscle fibre and brain tissue are relatively in- 
sensitive. So also, pathological tissues vary in their 
sensitiveness to the ray. 

The sarcoma cell requires only sixty to seventy 
per cent, of the dose of the carcinoma cell for 
its destruction. Tumors of embryonal cell origin 
are relatively susceptible. Ovarian carcinomata of 
embryonal origin are very sensitive to radiations. 
The rodent ulcer or basal cell epithelioma responds 
to a smaller dose than does the squamous cell epithe- 
lioma. The Hodgkin's gland responds to a smaller 
dose than the tuberculous gland. 

The more vascularized a growth the more sus- 
ceptible it is to radiation. In general the greater 
the karyokinetic activity and the shorter the karyo- 
kinetic interval the more sensitive is the cell to radia- 
tion. There is, therefore, no one general standard 
maximum dose. 

TECHNIC. 

Until recently, because of the lack of accurate 
methods of measurement, the technic of the appli- 
cation of the radiation to the treatment of patho- 
logical conditions of deep structures was more or 
less a matter of individual experience and observa- 
tions. Xo precise data based on scientific measure- 
ments were possible. Through the use of instruments 
of relative precision fairly exact data are now ob- 
tainable and the entire technic is being established on 
sound scientific basis. 

THE PHYSICAL DOSE. 

This may be defined as the energy absorbed in a 
volume unit of substance. It is directly propor- 
tional to the surface energy of the radiation and in- 
directly proportional to the hardness. It is estimated 
by subtracting the quantity of energy remaining 
on the under surface of the absorbing media from 
the total energy falling on the upper surface of the 
media. Such a unit of physical do.sage is, however, 
the average dose and it becomes necessary to dis- 
tinguish, a, the surface dose, that is, the dose ab- 
sorbed by a very thin uppermost layer of the irra- 
diated medium from the, b, deep dose, the energy 
absorbed in a very thin lower layer of the absorbing 
media. The surface dose is the intensity of the 
energy falling on a square centimetre of surface in 
a unit of time, whether this is on the upper or lower 
surface. 

If all structures reacted similarly to an equal dose 
of the X ray, the technic of treatment would be sim- 
ple. A single dose to the area in which the involved 
tissue existed would be sufficient. This is not the 
case. We are limited in the application of the ray 
by the .skin, a barrier which must be taken into 
consideration in making our attack. The admin- 
istration of such a single dose as might cause a severe 



70 



HIRSCH: X RAYS l.\ DISEASES OF GEXERATIl'E ORiiAXS. 



[New York Medical Journal 
AND Medical Record. 



skin reaction (superficial or surface dose) might 
have but little effect on the organs located at a 
depth. There are many factors which must be 
taken into consideration in the determination of the 
superficial and the deep dose. Before these can be 
considered, it is necessary to understand certain 
primary conceptions relating to dosage. 

THE ESTIMATION OF AN ERYTHEMA DOSE. 

Since it was found that the amount ,of chemical 
and biological action produced by the x rav is in 
direct proportion to the amount of electrical energy 
applied to the tube, and since with modern apparatus 
it is possible to measure this, and since the method 
is more accurate than the methods previously used 
and more easily applied, the standard erythema dose, 
that is to say the quantity necessary to produce an 
erythema of the skin in a certain number of days 
after exposure, may be measured by estimating the 
voltage or spark gap, the milliamperage, the time and 
the distance. The measurement by chemical, photo- 
graphic and color reactions are in this ctiuntry at 
least abandoned. 

This method is of value only for the estimation of 
the skin effects. It gives no clue whatever to the 
dosage underneath the surface. Estimations by 
these formulas are of value in protecting the skin 
from deleterious effects when the lower voltages 
are used. 

The energy absorbed, therefore, is the deep dose, 
subtracted from the surface dose and divided by 
the volume of the absorbing media. If the thick- 
ness of the irradiated layer is made equal to the 
semireducing layer value of the ray (that height of 
a layer of water which will reduce its intensity to 
half), then the intensity of the energy at the depth 
is half that of the surface energy. If the hardness 
of the radiation is expressed in semireducing laver 
values, the physical dose is inversely proportional to 
this. ^ Now it has been established that the semi- 
reducing layer value is equal to the abscirijtion coeffi- 
cient of the ray for the same absorbing media. 
Therefore, the physical dose may also be expressed 
in terms of surface energy and absorption coefficient 
to both of which factors it is directly proportional. 

THE BIOLOGICAL DOSE. 

The biological dose is the physical dose multiplied 
by the sensibility coefficient of the tissue. If, there- 
fore, the sensibility coefficient of a certain cell is 
known, then the biological dose may be estimated 
from the physical. 

According to Wetterer the ovarian follicle is seven 
times more sensitive to the ray than the skin, ten 
times more than connective tissue, twenty times 
more than muscular tissue. Myoma cells arc much 
more sensitive than normal muscular cells and more 
sensitive than the skin. Since the skin acts as the 
barrier which must be taken into consideration in 
estimating the dose, the biological skin dose has been 
taken as a unit of dosage. Taking the sensibility 
coefficient of the skin as 1, the sensibility coefficients 
of the remaining tissues may be estimated. 

1. For the skin 10 

2. For the ovary 2^5 

3. For the sarcoma cells 1.6—1.4 

4. For the carcinoma cells 1.0 0.8 

5. For the intestines 0.74 



6. For the muscles 0.55 

7. For the tuberculous tis^ue 2.0 

There was, until recently, no practical method of 
measuring the deep biological reaction by physical 
means. It cannot be estimated by mathetnatical for- 
mulas because of the essential role played by the 
secondar\^ radiations (scattering) in producing the 
biological effects below the surface. Recently, how- 
ever, the ionization chamber has been made practical 
for this purpose. 

By this iontoquantimeter. as it is called, estima- 
tions of the number of units of ionization required 
to obtain a skin erythema have been estimated.^ This 
value was then itself taken as a unit. Now, by ap- 
plying the iontoquantimeter to various levels of 
human tissue irradiated, the intensity of the rays 
reaching the depth at various levels, in percentages 
of the intensity necessarv to produce the skin unit 
have been determined. It is thus that the dose in 
terms of surface intensity for various conditions 
was estimated. 

Calling this radiation necessary to produce such a 
reaction as one hundred per cent., Seitz and Wintz 
have with this dose as a basis determined a biological 
dosage which, in spite of its deficiencies, is neverthe- 
less useful. 

T.\BLE 1. 
Doic Per cent. 

1. Skin unit dose 100 

2. Castration dose 35 

3. Sarcoma dose 60-70 

4. Carcinoma dose 90-1 10 

Irritation dose for carcinoma .V'i-40 

5. Intestinal dose 135 

6. Muscle dose 180 

7. Tuberculosis dose 50 

These figures for castration and malignancy doses 
should not by any means be accepted as absolute. 
Depending on the characteristics of the individual 
and the characteristics of the type of malignancy the 
(loses given in the table may need considerable modi- 
fication. There is stirely a certain percentage of 
sarcoma and a greater percentage of carcinoma 
which is not affected by the above dosage. There 
is considerable variation in the sensitiveness of the 
ovary to radiation, even in individuals of the same 
age. 

THE DOSE QUOTIENT. 

The dose quotient is that quotient of surface dose 
over deep dose and gives the ratio between the sur- 
face dose and the deep dose. The aim of the deep 
therapy technic is to keep this quotient as small as 
possible, or, in other words, that the dose at a par- 
ticular depth small approach that which was re- 
ceived by the surface at the time of administration 
as closely as possible. The value of the deep dose 
is expressed in percentage of the value of the sur- 
face dose. The deep dose percentage is the recipro- 
cal of the dose quotient. The aim in modern thera- 
peutic technic is to get as high a deep dose percentage 
as possible. Striving for this has been responsible 
for the striking changes in technic. The value of 
the dose depends on three factors: 1. On the ab- 
sorption of the rays in the overlying tissues. 2. On 
the dispersion of the radiation. 3. On the scattering 
of the radiation. 

' The "skin erythema"' of .Seitz and Wintz which is the basis for 
their measurement is apparently too low. 



July 19, 1922.] 



HIRSCH: X KAYS IX DISEASES OF GEXERATIVE ORGANS. 



71 



1. For the same thickness of absorbing media and 
die same focal distance, the dose quotient will be 
smaller the less the absorption by the media irra- 
diated, that is to say, the more penetrating the pri- 
mary radiation. The characteristics of the primary 
radiation may be changed : a, through increasing the 
penetration ; b, through filtration, attempting to 
attain homogeneity. 

2. P'or the same thickness of absorbing media and 
the same ray quality the dose quotient will be smaller 
the further the source of radiation is from the ab- 
sorbing object. Increasing dispersion, therefore, 
diminishes the difference between the surface and 
the deep dose. 

3. For the same thickness of absorbing media and 
the same focal distance and with the same ray qual- 
ity, the dose quotient will be smaller the greater the 
scattering. The production of secondary radiations 
in the tissues which tests have shown greatly im- 
proves the efifective dosage is increased, a, through 
increasing the focal distance, b, through increasing 
the size of the portal. 

1. THE CHARACTERISTICS OF THE RADIATION*. 

The f>enetrating quality of the rays depends on 
the voltage by which the tube is energized. For 
standardization of technic and for relative accuracy 
in estimating dosage, practical homogeneity is neces- 
sary. A ray which is no further hardened (average 
penetration unchanged) after passing through ten 
cm. of human tissue, a desirable qualitative homo- 
geneity for therapeutics, can only be obtained by 
higher voltages and heavier filtration. Until recently 
the voltages used for the generation of x rays with 
the tubes available varied from eighty to one hun- 
dred thousand volts. Recently, however, trans- 
formers have been developed which generate from 
one hundred and eighty thousand to two hundred 
and eighty thousand volts, with the production of 
rays of very great penetrating power, making it pos- 
sible to deliver a considerable quantity of qualita- 
tively homogeneous radiation in the tissue depth and 
to produce considerable scattered radiation, which 
augments the percentage of radiation absorbed at 
the depth. When qualitative homogeneity is main- 
tained the reaction of the different tissue is then de- 
pendent only on two variables , intensity and time. 

The time necessary to produce a given dose with 
various voltages, other factors being the same, may 
be estimated as follows : 

Gap 20 cm. 35 cm. 30 cm. 35 cm. 40 cm. 

Time 7 1/2min. 5 1/6 min. 3 1/6 min. 2 1/2 min. 1 5/6 min. 

It is thus seen that it takes four times as long to 
get the same dose with an eight inch gap as it does 
with a sixteen inch gap. The translation of spark 
gap equivalents into numerical voltage values is re- 
sponsible for much confusion in thought. The mean 
square voltage has usually been stated in this coun- 
try. Abroarl the jjcak voltage has been given. The 
measuring of air gaps between blunt points has been 
used in this country, while abroad the measurement 
is made between point and disc. Because frequency 
and wave shape have no appreciable effect in vary- 
ing the discharge between sphere gaps, these are now 
being utilized for the measurement of voltages. 
With the i)roper sized spheres, voltages from 10,000 
to 5OO.OOO may lie measured with an accuracy of 



about two per cent. (Kaye). The sphere gaps read 
peak voltage. The values are about as follows : 

Blunt points Needle points Sphere gaps Peak voltages 

10 inches 6.96 1.6 110 K.V. 

12 inches 9.4 2.25 140 

14 inches U.l 2.62 160 

16 inches 13.6 3.50 195 

17 inches 14.0 3.64 200 

15 inches 15.5 4.25 220 
20 inches 17.8 5.32 ' - ' ' , 250 

The X ray spectrometer measurements show a sim- 
ple relationship between the voltage applied to the 
tube and the shortest wave length of the emitted 
radiation, namely, that voltage is equal to 12,400 
divided by the wave length in Augstrom units. - 
By measuring the wave length of the radiation the 
maximum effective voltage applied can be deter- 
mined and vice versa, by knowing the maximum 
voltage the wave length can be determined bv divid- 
ing 12,400 by the voltage. Thus with a 200,000 peak 
voltage there would be a wave length of .062 A°. 
It would perhaps be advisable in the future to speak 
of wave lengths of the radiation. 

ril.TKATKIN. 

To still further increase the absorption at the 
depth, the ray is filtered with the view of cutting out 
the rays of longer wave length. The filtration util- 
ized with the old technic consists of three to five 
millimetres of aluminum. With rays of greater 
penetrating power, heavier filtration is necessary. 
Ten millimetres of aluminum, five tenths millimetres 
of copper or zinc are used. 

To obtain practical homogeneity so that the ray is 
not changed after passing through ten cm. of water 
or bakelite, a five mm. zinc filter is necessary. Such 
filtration is practical only with currents of very high 
voltages, such as are being used in the most modern 
therapeutic methods. 

The socalled deep dose percentages with various 
gaps and filters have been estimated as follows : 

Equivalent spark gap 

30 (12 in.) 35 (.14 in.) 40 (16 in.) 

Filter Percent. Percent. Percent. 

Unfiltered 5.2 

Aluminum — 3 mm. ... . . 12.2 

Zinc— 0.5 mm 18.5 19. 20.5 

Zinc— 1.0 mm 20.5 

Zinc — 2.0 mm . . 22. 

Copper — 1.0 mm 31.4 .. 22.5 

Copper — 2,0 mm 21,3 .. 22.6 

These measurements have been obtained by Seitz and Wintz by 
iontoquantimeter tests. 

I^OCAL DISTANCE. 

The furilier the source of radiation is from the 
absorbing media for the same quality of radiation, 
the smaller the dose quotient, in other words, the 
less the difference between surface and deep dosage. 
With the same radiation through the same portal, 
the absorption at a depth of three centimetres will 
vary with the focal distance as fiillows : 

.4t a depth of 3 At a depth of 5 At a depth of 10 

centimetres centimetres centimetres 

30 cm.— 77% 30 cm.— 70% 30 cm.— 47% 

50 cm.— 86% 50 cm.— 79% 50 cm.— 59% 

100 cm.— 93% 70 cm.— 83% 70 cm.— 65% 

With the increase in focal distance there is a loss 
in intensity which varies inversely with the square 
of the focal distance. To get the same intensity at 
an increased distance, it is necessary to increase the 
time directly as the square of the distance, with cer- 
tain exceptions, which will be noted later. 

* The Aut!strom unit is equivalent to one hundred millionth part 
of a centimetre. 



72 



HIRSCH: X RAYS IN DISEASES OF GENERATIVE ORGANS. 



[New York Medical Journal 
AND Medical Record. 



The appended table of \'oltz gives the intensity of three cm. the increase is about sixty per cent, 
and time factors for various distances, from 23 to Under certain conditions, by increasing the focal dis- 
100 cm., the focal distances usually employed. tance to either eighty or one hundred centimetres. 



F D 


23 


25 
0.85 
1.18 


28 
0.67 
1.48 


30 
0.58 
1.70 


35 
0.43 
2.32 


40 
0.32 
3.02 


45 
0.26 
3.83 


50 


I 


1.00 


0.21 


T 


1.00 


4.73 









Checked by iontoquantimeter measurements, 
\Mntz states increasing the focal distance from 
twenty-three to fifty centimetres, the time is five to 
eight per cent, less than calculated and trebling the 
size of the field under the same conditions the time 
fourteen to eighteen per cent. less. Beyond a focal 
distance of fifty centimetres, the time required to 
obtain a skin dose is about twenty-five per cent, 
longer than calculated. As judged by skin reaction 
and epilation this apparent exception to the law 
above stated cannot be corroborated. Judged by bio- 
logical tests the distance square law may be said to 
be valid with this consideration. With long focal 
distances and small fields the rule does not hold. 
But with long focal distances and large fields it does 
hold. Seitz and Wintz use small fields. The size of 
the focal spot on the anticathode plays an important 
part in these considerations. 

PORTALS. 

The absorption quotient may be improved by in- 
creasing the size of the portal. This also increases 
the width of the cone of rays and a greater extent of 
tissue is radiated with an increase in the scattering. 
This scattering comes not only from the tissue over- 
lying the object treated but from the tissues beneath. 
The shorter the wave length of the primary beam 
the greater the scattering. It has been estimated that 
as much as fifty to one hundred per cent, can be 
added to the dose in this way. 

The extent to which varying the size of the portal 
varies the percentage of absorption at the depth is 
indicated in the accompanying table. 

With a peak voltage of 200,000 and one and a 
half milliamperes of current with a filtration of 1.3 
copper the percentage of absorption at various 
depths for different sized portals for various focal 
distances is as follows : 



Portal 


1 




7 


Depth 
3 


5 


7 


10 






cm. 


30 


cm. 
CM. FOCAL 


cm. 

distance 


cm. 


cm. 


cm. 


5.7 X 
9. X 
18. X 


7.6 
12. 

24. 


90 
90 
95 




80 

80 
90 


70 
75 
80 


60 
65 
70 


50 
55 
60 


40 
45 
50 


6.1 X 
9.7 X 
19.3 X 


8.1 
12.9 
25.7 


91 

92 
95 


40 


CM. FOCAL 

82 
83 
91 


DISTANCE 
75 

80 
85 


65 
70 

75 


55 
60 
67 


45 
50 

55 


10.1 X 
20.1 X 


13.4 
26.S 


93 
95 


50 


CM. FOCAL 

90 
92 


DISTANCE 

80 

88 


72 
80 


65 
72 


55 
60 


10.4 X 
20.7 X 


13.8 
27.6 


95 
97 


60 


CM. FOCAL 
90 

93 


DISTANCE 

80 

90 


70 
80 


65 
74 


55 
63 



By increasing the focal distar.ce either to 80 or 
100 cm. the dose at 3 cm. may be increased from 
ninety to ninety-five per cent. These figures would 
indicate that in order to approximate the hundred 
per cent, deep dosage the more superficial the growth, 
the longer the focal distance and the larger the portal 
necessary, while the deeper the growth the more 
numerous and smaller the portals. 

Increasing the size of the portal of entry from 



55 60 65 70 75 80 85 90 95 100 
0.17 0.15 0.12 0.11 0.09 0.08 0.07 0.065 0.060 0.055 
5.72 6.81 7.99 9.26 10.63 12.10 13.66 15.31 17.09 18.89 



1.5X2 cm. to 10X15 cm. gives nearly four times 
the dose at a deptli of ten cm. while at a lesser depth 
the dose at a depth of three centimetres can be in- 
creased from ninety to ninety-five per cent., which is 
over a maximum sarcoma dose and a minimal carci- 
noma dose. The maximum effects may, therefore, 
be obtained by combining the requisite portal with 
the proper focal distance. 

The general findings of Dessauer regarding this 
latest technic of rontgen therapy is of interest. 1. 
With hard rays and large portals, deeply placed and 
centrally situated points receive more radiation 
through scattering from the direct rays. 2. While 
the direct intensity decreases with the depth, accord- 
ing to niles, the scattered intensity increases with 
the hardness, with the size of the radiated volume, 
with the proximity of the area to the central radia- 
tion with the thickness of the overlying layer. 3. 
Definite intensities due to scattered radiation are 
present lateral to the directly radiated volume. 

LOCALIZATION. 

The ideal method of application is that which ccn- 
centrates the x rays upon the particular organ it is 
desired to affect. Such concentration of energy can 
only be obtained by the most exact orientation re- 
garding the fHDsition of the organ in the particular 
individual. Thus, if it is the ovaries upon which the 
radiation must be concentrated in the treatment of 
uterine hemorrhages, it is advantageous to locate 
the ovaries and to administer the dose directly to 
these organs. 

The treatment as generally administered in prac- 
tice is not so accurately localized and the effect ob- 
tained is through secondary and scattered radiation 
upon the organ attacked. With a view to more 
accurate direction of the radiation, the technic for 
the application to ovaries, includes their localization. 
It becomes necessary then to determine the following' 
facts: 1. The relative position of the ovaries to each 
other and their projection upon the surface of the 
body in relation to certain fixed points. 2. The 
depth of the ovaries from the external abdominal 
wall. 

Hoehne and Lizenmeyer have determined the 
position of the ovaries in relation to the interspinous 
line and the median line. By means of bimanual 
examination in the living, controlled by operative 
findings, measurements have been made indicating 
the position of the ovaries in anteflexion both in the 
nonpregnant and the gravid uterus and in retrover- 
sion of the uterus. 

The average di,stance between the ovaries is about 
nine and a half centimetres. In individuals with 
small transverse measurements of the pelvis, it may 
vary from seven to eight centimetres : in those with 
very large and broad pelves it might be as much as 
thirteen centimetres. The right ovary is usually 
more lateral than the left, five to four and a half 



July 19, 1922.] 



HIRSCH: X RAYS IN DISEASES OF GENERATIVE ORGANS. 



n 



centimetres. The more the uterus is anteverted, the 
greater the displacement of the ovary below the in- 
terspinous line. 

The distance between ovaries in the second and 
third months of pregnancy is the same as in the non- 
pregnant state, nine and a half centimetres. This 
also holds true for relationship of the right and left 
ovaries to the median line. In the second month the 
average is about five centimetres, for the right and 
four and a half centimetres for the left ; the third 
month five and one third centimetres for the right 
and four centimetres for the left. As the uterus en- 
larges the interovarian distance increases ; in the 
fourth month it measures twelve centimetres ; in the 
sixth month eighteen centimetres. The distance be- 
low the interspinous line is relatively great in the 
second month but gets smaller with increasing size 
of the uterus, in spite of greater anteversioflexion 
and at about the fourth month is above the line. 
The interovarian distance grows smaller in the re- 
troverted position of the uterus, and so does the 
distance below the interspinous line. The measure- 
ments hold true only in the absence of a fixation of 
the ovaries by an inflammatory process. 

The measurements given above permit us to state 
that in the average case — a square three centimetres 
in size so drawn that its inner border is three cen- 
timetres from the median line, its upper border at 
the interspinous line, will in ninety per cent, of the 
cases include the position of the ovary. In practice 
this square is used as a centre for a portal six by 
eight centimetres in size. The depth of the ovary 
below the skin was similarly obtained. The distance 
varied from four and a half to seven and a half 
centimetres. On the average it was six and a half 
centimetres on the right side and about six centi- 
metres on the left side. 

Though no marked displacement of the ovaries 
occurs with the myomata of average size, in the 
presence of large myomatous uteri the localization of 
the ovaries is difficult, if not impossible. 

Therefore, in the square outlined, it is necessary 
that the ray be so gauged that the required biolog- 
ical dosage is administered at a depth of six centi- 
metres. 

In the localization of the uterus for carcinoma, the 
maximum depth of the organ is considered to be ten 
centimetres beneath the skin. Taking into consid- 
eration the necessity of reaching the pelvic lymph 
nodes and of applying the ray to the whole pelvis in 
carcinoma, the localization is unnecessary. In the 
localization of the uterus for carcinoma, the maxi- 
mum depth of the organ is considered to be ten cen- 
timetres beneath the skin. Taking into consideration 
the necessity of reaching the pelvic lymph nodes and 
of applying the rav to the whole pelvis in carci- 
noma, accurate localization is unnecessary. But in 
certain tumor formations where localization becomes 
neces.sary, in order that the radiation be directed 
with accuracy, the area to be irradiated must be ac- 
curately mapped out. This is essentia! so that, 
firstly, all ])arts of the tumor may receive the re- 
i|uir(-d radiation and secondly, that no normal tissue 
about the tumor receive an overdose. To this end 
such devices as those of Holfelder (1) or Dessauer 
(2) may be utilized, the latter method, con- 



sisting of carefully constructed charts, giving the 
dosage at various centimetre levels, with various 
types of radiation, through various portals, with 
various filters, based on numerous measurements 
made with photographic emulsion. Its accuracy in 
practical work has not, however, been completely 
verified, though it is extremely useful as a basis for 
dosage. Where crossfiring becomes necessary, the 
various cones of radiation must be transferred to 
the tracing of a cross section of the part of the 
body and the portals so selected as to obtain suffi- 
cient radiation to all parts of those tissues which are 
under treatment without overdosage to the other 
parts which are not under treatment. 

APPLICATION. 

As a rule the skin of the lower abdomen from 
the umbilicus to the pubis is divided into a number 
of areas or portals of entry. The number varies, 
depending on the condition under treatment, and 
the dose desired at a particular depth. With the 
old technic the portals were very small, and the 
whole of the lower abdomen was marked oflf. 
Through each such portal, with the voltage equiva- 
lent of a nine inch gap, was applied five milliamperes 
of current with filtration of four millimetres of 
aluminum at a distance of twenty-five centimetres 
in ten minutes by a method the intent of which was 
to crossfire. Though with this technic, in which 
there was a great aimlessness in crossfiring, castra- 
tion was accomplished with ease, since the thirty- 
four per cent, absorption was thus attained. Never- 
theless the malignancies were practically unaffected. 
The iontoquantimetre measurements indicated the 
necessity for greater, more accurate and more cer- 
tain dosage, for such conditions and a complete re- 
vision of the technic followed. Now the size of 
the field depends upon the condition treated and 
upon the depth of the focus to be reached by the 
particular radiation at hand. The number of por- 
tals depends on the biological dose desired. It may 
be administered through one portal as for castra- 
tion under certain conditions, or through many por- 
tals as in carcinoma of the uterus, with lymphatic 
involvement. 

When the requisite portals have been niapjjed 
out, a quantity of radiation is applied at a certain 
focal distance, through a certain portal and given a 
certain direction in order to reach the tissues under 
treatment. The radiation is administered over such 
a period of time as to obtain the requisite absorption 
and administer the efl'ective dose at the particular 
depth at which the structure to be treated lies lim- 
ited, of course, by the skin reaction. As a rule for 
benign conditions the skin Hmit is a first degree re- 
action but in the treatment of carcinoma it is nec- 
essary to administer such a dose through each area 
as will produce a second degree reaction in the skin, 
even with vesiculation and complete alopecia. The 
regeneration of the epidermis, if the dosage is car- 
ried no further, is coinplete without sequela and 
the skin restitutes to normal. There are at the pres- 
ent time two great methods of dosage : a. By com- 
plete dosage at one session : b, by divided doses 
throu.gh several lesions. 

{To he concluded. ) 



KOENIG: EDEMA OF MASTOID. 



[New York Medical Journal 
AND Medical Record. 



Fugacious Edema of the Mastoid Region with Paroxysmal 

Hemoglobinuria* 



By C. J. KOENIG. M. D., 
Paris, France, 

Ex-Otorhiiiolaryngologist to the American Hospital of Paris. 



The case which occasioned this coinaiunication 
concerns a young boy eight and a half years old 
who had scarlet fever ten months previouly with 
nephritis from which he made a good recovery. 

Case. — On December 22, 1921, he went skating 
at tlie Palais de Glace in Paris, where he contracted 
a cold. The next day I was asked to see him, for 
he had a slight rise in temperature (37.9° C.) and 
complained of pain in his right ear. I found a slight 
hyperemia of the throat and drum and prescribed 
warm moist applications over the ear and mastoid. 
In the evening the temperature rose to iB.7° C, but 
fell the next morning to 37.9° C. and in the evening 
to i7.i° C. On December 25th I was informed 
that the child was not doing well, was still com- 
plaining of his ear and that a large swelling had 
appeared over the mastoid. I expected to find a 
mastoiditis and went prepared to perform paracen- 
tesis of the drum. When I arrived at the house. 
the family physician confirmed what the mother had 
said. After removing the bandage I saw no swelling, 
no edema, the mastoid was not particularly painful 
on pressure, the drum was slightly congested and the 
whispered voice was heard at three yards distance. 
The temperature was iJj" C. The mother and the 
doctor were both greatly surprised and stated em- 
phatically that there had existed a marked swelling 
over the mastoid a few hours previously. I thought 
that they were somewhat inclined to exaggeration 
and 1 decided to postpone the paracentesis. Two 
days later the mother again informed me by phone 
diat the child was in a bad way, that he had had 
delirium since my last visit (the temperature, how- 
ever, had not risen above 37.8° C), that his heart 
was irregular and that his urine contained blood and 
albumin (0.20 cgm.). 

I was asked to see him again in consultation with 
the family doctor and Dr. Gaulier. The latter had 
examined him two days previously and informed me 
that the case was one of paroxysmal hemoglobinuria 
and that, besides the albumin and the hemoglobin 
in large quantities, his urine contained biliary pig- 
ment and an abundance of indol and scatol. 

This is what the consultant found on the 25th: 
the patient had had a chill and the temperature was 
?>7.7° C. The right side of the head presented an 
edema reaching from the suborbital to tlie occipital 
region surrounding the mastoid and parietal regions. 
The heart was arrhythmic, the beat a double regular, 
a silence, then five or six precipitate beats. The 
urine was red. Rapid analysis made that day re- 
vealed a retention of chlorides from seven to four 
grams, but the analysis of the twenty-four hour 
urine made on the following days showed no chloride 
retention. A water diet, rest in bed and a counter- 
irritant over the kidneys were prescribed. 

•Communication made to the Otolaryngoloeical Society of Paris. 
January I,!, 1922. ^ » » / 



Preceding this condition the child had remained 
three days without a movement of the bowels. We 
know the influence of constipation on the produc- 
tion of indol and scatol. 

The condition was then made clear. Under the 
influence of the cold at the ice palace, the indol and 
scatol, showing a marked intestinal putrefaction, 
produced, by absorption into the blood, a hemoclasic 
and colloidoclasic shock with symptoms revealing a 
reaction dependent on an irritation of the organo- 
vegetative system. 

This reaction manifested itself by a chill (accord- 
ing to Montagnini ( 1 ) the attack of hemoglobinuria 
is always accompanied by chills, but without fever), 
by excitation of the vagus (vagotonia), slowness, 
irregularity and intermittence of the pulse, and by 
edema. The edema was the forerunner of the attack 
of paroxysmal hemoglobinuria. 

I saw the patient again on December 28th in the 
evening. His temperature, which was i7° C. in the 
morning, had gone up to 38.4° C. He had suffered 
a good deal from his ear during the afternoon. The 
drum membrane was red and slightly bulged out, the 
whispered voice was heard at a distance of fifty cm. 
I thought of performing a paracentesis the next 
morning, but the temperature fell to ^7° C. the 
pains had completely disappeared, and the drum 
membrane was less red. 

The rise in temperature was certainly due to a 
concomitant infection with localization in the middle 
ear, and not to the paroxysmal hemoglobinuria, the 
latter, according to the authors who have written 
on the subject, producing no fever when there is no 
infection. And experimentally, the shock produced 
by indol and scatol causes the centra! temperature 
to fall one degree centigrade (Le Calve) (2). 

This case was doubly interesting to me, because 
I was giving my attention for some time to the 
study of indol and scatol in edematous affections of 
the mucous membranes (rhinorrhea, spasmodic 
rhinitis, spasmodic cough, asthma, etc.), for in these 
affections I had nearly always found an abundance 
of indol and scatol in the urine. I had written to 
Germany to obtain these substances made synthetic- 
ally with experimental work in view. The present 
case, therefore, offered itself to me as the occasion 
for a preliminary communication on the subject. 

These ideas were in germ when in the Prcssc 
mcdlcalc I saw the analysis of a communication 
made to the j\cademy of Medicine of Paris by Dr. 
J. Le Calve (3), on indol and scatol, hemoclasic 
shock bodies. 

I wrote to our colleague who then kindly for- 
warded me his thesis (4). This work, as well as one 
published later (5), contains the description of in- 
teresting experiments with indol and scatol from a 
physioanatomicopathological viewpoint, but the re- 
sults of which remained unexi)lainable to the author 



July 19, 1922.] 



KOEMG: EDEMA OF MASTOID. 



75 



until the idea struck him that indol and scatol acted 
not as toxines, but as shock bodies {corps de choc). 
This is proved by the fact, apart from the phenomena 
observed, that the intensity of the reaction in ani- 
mals injected was far from proportional to the quan- 
tity of the substance employed; a few milligrams 
at times produced results as demonstrative as those 
observed after ten to fifteen centigrams. And in 
spite of the violence of the disturbances manifested, 
his animals recovered quickly and completely. If the 
injection is renewed after a short interval, or after 
one or two weeks or a month, the manifestations re- 
main identical. These two substances, therefore, do 
not produce the anaphylactic shock, but one more 
similar to the protein shock. 

It is only recently that Le Calve renewed his re- 
searches on a new basis, guided by the discovery of 
hemocolloidoclasis, which allowed him to conclude 
that indol and scatol are shock bodies capable of 
producing the phenomena of hemocolloidoclasis and 
that they possess edematogenic power. 

It is a well known fact today that edematous con- 
ditions are frequent in diseases and syndromes in 
which hemacolloidoclasis has been found. And this 
fact has now received experimental confirmation. 

"Indol and scatol," says Le Calve (2), "possessing 
a real action on the nerve centres, produce in the 
latter congestive and hemorrhagic alterations and 
also edematous infiltrations. In the kidneys, the 
congestion predominates, the edema is not impor- 
tant ; the other organs, liver, lungs, spleen, etc., are 
the seat of intense hyperemia." 

And again: "On a subject in a state of shock by 
indol and scatol, the transudation which chooses 
spontaneously the central parts, may be turned away 
to the periphery when intervenes, in the region where 
one desires to draw it, an excitation of the vaso- 
motor or sensitive nervous system ... an ener- 
getic cooling of the ear by evaporation of ether, 
prolonged friction of that organ, an inflammatory 
focus, etc." 

We may therefore explain in our case the 
albuminuria and the presence of biliary pigments 
in the urine by the congestion of the kidneys and 
of the liver, the delirium by the congestion and 
edema of the nerve centres. And I wonder now 
if the warm applications over the ear and mastoid 
did not act as an edematogenic irritant. The same 
(juestion may be asked concerning the otitis, as an 
inflammatory focus. An affirmative answer is more 
than justifiable, the explanation having been given 
us by the experimental researches of Le Calve. 
This edema could not have been due to chloride 
retention, the analyses of the twenty-four hours' 
urine made daily having shown that there was none, 
and furthermore chloride edema does not possess 
the marked character of fugacity in its appearance 
and disappearance, nor the localization which our 
case presented. If the warm apjilications had been 
made only over the mastoid, instead of over the 
whole side of the head, it is probable that the edema 
would have localized itself there. If then I had 
thought of a mastoiditis requiring an operation, T 
should have made a mistake, pardonable it is true, 
for similar cases must be rare and I readily admit 
that this is the first case of paroxysmal hemoglobinu- 
ria that has fallen under niv observation. 



It is to be remarked in this case that the edema 
appeared twenty-four hours before the hemoglobinu- 
ria. That is the rule according to Montagnini (1) 
who says : "The study of the hemoclasic shock has 
clearly shown us how the vasohematic symptoms de- 
cidedly precede the classic phenomena of the hemo- 
lytic process itself ; it has allowed us to emphasize 
again the independence of the autoanaphylactic and 
autohemolytic shocks in spite of their intimate co- 
ordination, and contrary to the opinion prevalent 
shortly ago which made the one dependent on the 
other as a result of the irruption into the tissue cir- 
culation of destroyed red blood corpuscles." 

Instead of autoanaphylactic, it would perhaps be 
preferable in our case to say autohemoclasic or auto- 
hemocolloidoclasic, although we entertain a strong 
doubt as to the possibility of such a condition being 
due to cold alone, according to the ideas of Widal 
and his pupils (6). 

Murri (7) considers the cold only as an occa- 
sional cause, the real and necessarv one being 
sj'philis, as is proved by the nearly constant positive 
Wassermann reaction. It is probable that the cause 
is to be found in the action of shock bodies such as 
indol and scatol in syphilitic subjects. This may 
perhaps be confirmed by the study of hemolysis by 
these substances in vitro, and if this phenomenon 
takes place in syphilitic blood at a different concen- 
tration than that required in nonsyphilitic blood, it 
may turn out to be a very simple diagnostic means. 
The researches of Hamburger (8) on the issue of 
hemoglobin from red blood corpuscles show for each 
salt a certain concentration for which the red blood 
corpuscles begin to lose their coloring matter. But 
it is possible that indol and scatol destroy in zrivo 
the antihemolysins which Duhamel and Thieulin 
(9) state the liver normally produces. And thera- 
peutically there may possibly be a means to obtain 
by intradennic injections of small doses of indol 
and scatol antihemocolloidoclasic effects. 

.\ccording to Le Calve shock bodies, whether 
indol, scatol or any other body, have a direct action 
on the organovegetative system (sympathetic and 
parasympathetic) for which they seem to be pos- 
sessed with special affinity. 

Numerous authors (Richet (TO), Arthus (11), 
Biedl et Krauss (12), Mattirolo and Tedeschi \u), 
Micheli (14) and others), had observed in all .shocks 
the rapid fall of arterial tension, diminution of the 
white blood corpn.scles (leucopenia) with inversion 
of the leucocytic formula and disturbance of coagu- 
lation of die blood. Other phenomena observed by 
various authors are: lowering of the refractometric 
index of the serum, diminution or complete absence 
of the retractility of the clot, the diminution of hema- 
toblasts (Pagniez and Mouzon) (15) with fibrino- 
lysis more or less -marked, flocculation of the niicelhe 
of the serum (Dold) (16 and 17), eitlier hv hydra- 
tation or by electric discharge (Kopaczewski ) (18) 
and (A. Lumiere) (19 and 20), a more marked rud- 
diness of venous blood, increase of superficial ten- 
sion and diminution of viscosity (Kopaczew.ski) 
(21) and (Muttermilch) (22). 

These phenomena, singly or collectively, show a 
marked disturbance in the physical state of the blood, 
and this disturbance combines its effects with those 
of the direct action of the shock bodies. The pre- 



76 



KOENIG: EDEMA OF MASTOID. 



^Xew York Medical Journal 
AND Medical Record. 



cosity of the vagosyinpatlietic manifestations is 
symptomatic of their central origin (Le Calve). 
The hemolytic and consequently the hemoglobinuric 
phenomena follow, and are due to an unstable con- 
dition of the hemolytic system (amboceptor, sensi- 
bilizing substance and complement), the exact ex- 
planation of which offers a complex problem not 
yet solved. 

Indol and scatol are rendered less toxic, it would 
now be more correct to say less shocking, by the 
sulphoconjugation which is produced in the liver 
and which transforms them into indoxyl and sca- 
toxyl. They are then eliminated in the urine as 
indoxylsulphate of potassium (indican) and sca- 
toxylsulphate of potassium (scatol). 

The liver would therefore possess an indopexic 
function (Gilbert and Weill) (23) and in the hemo- 
colloidoclasic shock due to indol and scatol, there 
must exist a certain insufficiency of that function, 
consequently a partial insufficiency of the liver. 

The opinion prevails that indol and scatol are the 
result of intestinal putrefaction by bacterial decom- 
position of the tryptophan contained in proteid sub- 
stances. It has also been asserted that they may re- 
sult from the metabolic disassociation of the tissues. 
Their origin, as well as their normal quantity in the 
urine of difficult determination, are now of second- 
ary importance to us, since experiment has demon- 
strated them to be shock bodies. The question might 
be asked as to what difiference there is between a 
toxic substance which makes one very ill or kills and 
a shock body which, by the violence of the hemo- 
colloidoclasic shock also makes one very ill or kills. 
And the ptomaines of the intestines, may they not 
act in the same way as indol and scatol? 

Shock bodies may accumulate in the organism, 
either on account of their superabundant produc- 
tion, or by insufficiency of the liver, or again by 
lack of elimination by the emunctory organs. It is 
therefore possible that the scarlatinal nephritis, 
which the little patient had ten months previously, 
may have had something to do with his attack of 
paroxysmal hemoglobinuria, his renal filter having 
perhaps remained a little weak. 

The French consultant in the case. Dr. Gaulier, 
suggested the idea that shock bodies might produce 
the simple hemocolloidoclasic shock in nonsyphilitics 
and the hemocolloidoclasic shock plus hemoglobinu- 
ria in syphilitics. And this might supply an answer 
to the question raised by Montagnini (1), viz., if 
specificity and hemoglobinuria stand together in the 
relationship of cause and etTect, why are there so 
many syphilitics who, even exposed to the most 
inten.se cold, never present this morbid phenomenon? 

Silvagni (24) is of the opinion that there are 
syphilitics who are hemoglobinuric, so to say, in 
vivo and in vitro, others only in vitro, but they must 
be considered as subjects in whom the lability of 
the hemolytic system is latent, although not reveal- 
able, even under the influence of the most intense 
refrigeration. We believe the indolic or scatolic 
shock to be the link between the two phenomena, and 
experimentation will prove or disprove their influ- 
ence in that respect. 

It seems to be admitted today by all the authors 
who have studied this question (Murri) (7), Mich- 
cli) (14), (Silvagni) (24), (Datta, Schiassi) (25). 



(Baginsky. Soltman, Comby, Goeltze, Cima) (26), 
that paroxysmal hemoglobinuria a frigare (Widal, 
Abrami and Brissaud) (6) is syphilitic. 

The Wassermann reaction could not be made in 
our case, the consultant fearing that the taking of 
blood might produce a syncope on account of the 
weakened condition of the patient and the bad state 
of the heart. It will, however, be indispensable to 
determine the reaction of the blood of all his sisters 
and brothers, four in number ; if, however, it proves 
to be negative, it could not invalidate the diagnosis 
of hereditary syphilis which seems to be evident for 
reasons drawn from the anamnesis. 

The patient had a big liver. The mother had two 
miscarriages, one vicious presentation, and a lesion 
of the apex and repeated congestions of the right 
lung, without tubercle bacilli. Her liver is rather 
large and she has chloride retention in the blood 
during her menstrual periods. The latter phenom- 
enon is considered by Dr. Gaulier very characteristic 
of hereditary syphilis. The maternal grandfather 
is epileptic. Leredde (27) has recently called atten- 
tion to the frequency of syphilis in essential epilepsy 
(six certain cases out of fourteen epileptics), thus 
confirming the opinion of Fournier who had recog- 
nized its syphilitic nature "in certain cases." 

REFERENCES. 

1. Montagnini, Marion : Crise hemoclasique et hemo- 
globinurie paroxstique, Presse Med., December 24, 1921. 

2. Le Calve, J. : Choc hemoclasique et oedeme, Gac( tie 
dcs Hop., December 6, 1921. 

3. Idem: Butt, de I'Acad. de Med., November 1, 1921. 

4. Idem: Recherches sur la pathogenie des oedemes. 
Oedeme aigu toxinervopathique de la peau et des mu- 
qiieuscs, Royer, Paris, 1901. 

5. Idem: Contribution a la I'etude de deux toxines intes- 
tinales, Arch. gen. de Med., May, 1902. 

6. Widal, Abrami, et Ed. Brissaud : L'autoanaphylaxie. 
Conception physique, Sem. Med., December 24, 1913. 

7. MuREi, A. : Rivista clinica di Bologna. 1880-1886. 

8. Hamburger: Lancet, v, cci. No. 5125, November 19, 
1921. 

9. DuHAMEL and Thieulin : Ayin. des Lab. Clin., Oc- 
tober-December, 1921. 

10. RicHET, C. : C. R. de la Soc. de Biol.. 1902. 

11. Arthus: Acad, des Sciences, 1909. 

12. BiEDL u. Krauss ; Zeitschr. f. inn. Med. u. exp. 
Therapie. 1910. 

13. Mattirolo et Tedeschi: Riforma med.. 1903. 

14. MiCHELi: Clin. med. itai. 1915. Twentieth Congress 
of Int. Med., 1910. 

15. MouzoN, Jean: Les plaquettes du sang humain: re- 
vue critique et etudes cliniques, Tliese de Paris, 1921. 

16. DoLD, H. : Seroscopie, Deutsch. med. Woch., Jan- 
uary 15, 1920. 

17. Idem: Anaphylaxis u. flocculatiun. Arch. f. II \q.. 
1920, B. 89. ■ 

18. KoPACZEWSKi: Des colloides en therapeutique, 
Presse Med.. May 7 and July 27, 1921. 

19. Lumiicre, a. : Role des colloides chez les etrcs 
vivants, Masson et Cie, Paris, 1921. 

20. Idem: Choc anaphylactique et colloidoclasie, Presse 
Med., December 3, 1921. 

21. KoPACZEWSKi: C. R. de la Soc. de Biol. 1914. 

22. MuTTERMiLCH : Ibid. 

23. Gilbert and Weill: Quoted by E. Lambling, Precis 
de Biochcmie, Masson, Paris, 1911. 

24. Silvagni: Twentieth Congress of Int. Med., 1910. 

25. Datta, Schiassi : Policlinico, Ses. Med., 1920, xi. 

26. Baginsky, Soltman, Comby, Goeltze, Cima: 
Quoted by Nobecourt. Precis des Mai des enfants, Masson, 
Paris. 

27. Lerkdde: Presse Med., November 30, 1921. 
65 Rue df. Miromesnil. 



July 19. 1922.] 



KEILTY: TYPHOID FEFER. 



// 



The Conquest of Typhoid Fever at Ghickamauga Park, Ga.^ 



By ROBERT A. KEILTY. ^f. D., 
Danville. Pa. 



The purpose of this paper is to detail, as a matter 
of history, some of the work of the Medical Depart- 
ment of the United States Army during 1917 at 
Chickamauga Park, Georgia. This includes a study 
of the conditions, the possible sources of contagion, 
the history of the cases, and the methods adopted 
for the control of typhoid fever. 1 was fortunate 
enough to be detailed on two typhoid boards and 
had an opportunity to study each case closely. 

The ignorance of sanitation, the disregard of rec- 
ommendations, and the horrors of the results at 
Chickamauga Park during the Spanish-American 
War are too well known, even to the younger gen- 
eration, to need more than passing mention and then 
to recall them that the contrast of the present record 
may be more forcibly shown. There is a legend 
handed down by the natives of this country that the 
name Chickamauga was bestowed on the section by 
the Indians and meant "The valley of death." For 
this reason it is said to have been shunned by them 
as a camping ground. 

In the spring of 1917, Chickamauga Park was a 
Government battlefield, beautifully situated in a roll- 
ing, hilly country, picturesque in its drives, with tall 
trees, descriptive charts, and atrocious monuments. 
At one end of the park. Fort Oglethorpe was situ- 
ated. This was the permanently constructed home 
of the Eleventh Cavalry with its barracks, hospital 
of forty beds, parade grounds, officers' quarters, 
stables, sewage disposal plant, and deep well water 
supply. It was an adequate and partially safe home 
for one regiment with its peace time quota. In May, 
1917, when extensions began at the camp the 
Eleventh Cavalry had been away for months ; the 
Post had been practically abandoned, occupied by 
about two hundred and fifty German war prisoners 
and the necessary prison guard. A part of the 
cavalry had returned and were camped on the side 
of a near by hill in tents. The surroundings were 
those of peace time character and the hospital con- 
tained about twenty patients, most of whom were 
■sufifering from chronic disease, having been re- 
turned from the border. The sanitary reports had 
been going in to the Surgeon General's Office regu- 
larly from this hospital and religiously every month, 
It was noted that the water supply was .good, the 
sewerage adequate, etc., and the same had been 
copied from month to month for several years past. 

Early in June, 1917, signs of life sprang up all 
over the park. New buildings of the one story can- 
tonment type were constructed in units by the hun- 
flreds with all the necessary pipe lines for water and 
sewerage. The men soon began to arrive for the 
various training units. On June 1, 1917, there were 
about three thousand men, all told, at the post. The 
following figures supplied from the records show the 
daily average census and the rapidity of growth for 

•Presented before the Philadclphi.i P.-itholoRical Society, October 
23, 1919. From the U. S. General Hospital No. 14. Fort Ogle- 
thorpe. Ga., and the Department of Laboratories and Research Medi- 
cine, The George F. Geisingcr Memorial Hospital, Danville, Pa. 



the next fuur months; July. 23.132; August, 28,416; 
September, 27,481; and October, 30,111. The park 
was divided into several different camps and never 
became one division during its entire existence. At 
one time three brigadier generals were in command 
at different headquarters. At one headquarters, at 
one time, a major general was in command while 
at another time a second lieutenant commanded the 
same post. This necessitated much change of organi- 
zation and personnel. No officer ever acted as a 
division surgeon nor was there a single division sani- 
tary inspector. The problems of sanitation re- 
mained the same regardless of who was in author- 
ity or what the personality or ability of the medical 
officer might be. The various commands often over- 
lapped, resulting in considerable friction. It must 
be said that as far as the recommendations of medi- 
cal officers to commanding line officers in regard to 
preventive measures against typhoid fever were con- 
cerned, their cooperation was all that could be de- 
sired. The various generals and colonels were ever 
receptive, sympathetic, in fact eager, left everything 
to the medical department and backed them to the 
limit. z\s one general expressed it, "Give us fighting 
effectuals and we'll carry out every recommendation 
you make." Second lieutenants often were not as 
eager to carry out these orders, but when the atten- 
tion of correcting authority was called to their in- 
difference they always received proper reprimand. 

It would seem that some detail along lines pos- 
sibly aside from the main subject is in order, that 
the result may be more clearly shown. I was as- 
signed to the post hospital laboratory in June, 1917, 
and found an equipment, archaic to say the least. 
Necessity was the mother of invention and soon by 
one makeshift or another real work started. It was 
first found that (he tap water supplied the hospital 
was constantly polluted. Investigation revealed two 
sources of main supply. About a third of the quan- 
tity used came from wells averaging four hundred 
and fifty feet in depth. Examination of these wells 
revealed a heavy contamination with Bacillus coli 
at all times. This supply was being chlorinated, the 
amount of bleach, judged at the discretion of the 
engineer, probably was often underestimated. The 
remaining two thirds of the supply came from the 
Tennessee River after filtration and chlorination and 
was never found to contain Bacillus coli. 

At first thought it would seem a simple matter to 
clear this up, but it took several days and consider- 
able change even to main piping before the water 
was entirely potable. The local source required as 
much as eighteen pounds of bleach to the million gal- 
lons of water on some days before it was free from 
Bacillus coli. During the work the hearty coopera- 
tion of the post engineer, Mr. Mansfield, was of 
great value. The task required many trips of in- 
spection by various officers and considerable labora- 
tory work. This may be said to be the first step ac- 
complishefl. It was finisliecl by the middle of July 



KEILTY: TYPHOID FEVER. 



New York Medical Journal 
AND Medical Record. 



SO that potable water was furnished the entire 
camp. 

I should like to mention at this point three officers 
of the regular service to whom not the entire credit 
but a great part thereof is due for the early cleanup. 
The first, the ranking medical officer. Colonel T. J. 
Kirkpatrick, was a man of fiery temper but of keen 
perception and far vision, a doer of things, appre- 
ciative of tasks well performed, condemnatory of 
others, and, above all, not afraid to ask and demand 
of higher authority necessary equipment and regula- 
tions. Much of the excellent and adequate medical 
supply, most of which arrived at camp long after 
his removal, was due to his insistent demands. The 
second, an admirable assistant, more cjuiet but none 
the less persistent, a digger and stickler for the 
buried and unknown (not always fly larvs in manure 
piles either), Lieutenant Colonel E. F. Geddings. 
His work in cleaning up the milk and ice cream, in 
ferreting out manure piles and larval breeding points, 
in closing springs and pumps openly available to the 
soldiers, and his care of the camp dump stand out 
preeminently. 

The third officer was our beloved Colonel Henr)- 
Page. No tribute which I am able to write could 
recompense this gentleman. When I say that the 
large group of medical officers who attended Camp 
Greenleaf have him to thank for a safe abode, from 
the viewpoint of health, I am sure that they will 
agree with me to a man, no matter how much they 
disliked the picking up of cigarette stumps. When 
we first arrived, the flies were so thick that eating 
became only a matter of necessity and the main issue 
at the meal centred around attempts to beat the flies 
to it. It was necessary to fight them from every 
mouthful that as few of them as possible might be 
eaten. This was of special interest since the latrines, 
that mecca of flies, with one exception, a McCall in- 
cinerator, were only a few yards distant and a creek 
conveying the effluent of a much overchoked septic 
tank not much further. The efforts of Colonel Page 
were rewarded to such an extent that the fly, while 
not exactly a rare specimen, might be said to have 
been exterminated by the end of August. This re- 
sult was brought about by the swatting, killing, 
poisoning, trapping, sticking, screening and clean- 
ing up in general. 1 am sure that if everyone learned 
to hate the fly and to kill it. for one reason, as I did 
at this camp, this family of the Diptera would be- 
long to the past and specimens occupy a niche in our 
museums among the valuable and rare collections. 

There were many other officers whose early intel- 
ligent and conscientious work was highly commend- 
able and to each and every one a proper share of 
the cleanup credit is due. 

The extermination of the adult fly was accom- 
plished as much by trapping as by anything else. A 
special trap devised by Lieutenant Ober, using near 
beer as bait and placing it in the favorite habitat of 
the flies, w-orked wonders. The real work was 
accomplished at the source and that was the ferret- 
ing out and destruction of breeding places. All 
manure was daily carried to a railroad siding and 
hauled away. All garbage was either incinerated 
or carried away. Garbage pails were cleaned out. 
lids kept tight, and surroundings whitewashed. All 



old manure piles or other breeding places were 
hunted up and either buried or removed. There 
was one large dump, everything brought there was 
incinerated, and over the fillin the top was covered 
with a layer of dirt and sowed with hay sweepings. 
As a result green fields sprang up over and behind 
the dump and the fly as well as odor and other filth 
conquered. All dirty stable floors, corrals and picket 
lines w-ere soaked with crude petroleum. This was 
partially worked out by experiment in tin cans in 
the laboratory until the proper amount of oil for 
this soil could be approximated. It was found to be 
an excellent larvicide, penetrating to several inches, 
where even in dilution it remained adequate. This 
constitutes the second step in the cleanup. 

Attention was next directed to miscellaneous 
water supplies. It was found that there were a 
number of pumps tapping surface waters scattered 
throughout the park and in the extra cantonment 
zone several large springs available to the troops. 
Among the latter were two or three springs flowing 
several thousand gallons daily of clear, cool, inno- 
cent looking water. These formed the sole supply 
for the neighboring inhabitants. Many samples 
taken from every available source of this miscel- 
laneous group were found to contain Bacillus coli 
in quantity, with the single exception of several 
springs at Catoosa. In the park the pumps were 
removed and the wells promptly closed. Several 
wells in the immediate vicinity were placarded and 
one, which was notorious, was closed with barbed 
wire. This completed the care of water supply and 
may be said to be the third step. 

In this coimtry there has occurred a peculiar con- 
dition known as sink holes. These are large caveins, 
some of which are a hundred feet in diameter, filled 
with water, and said to be bottomless. The .strata 
are lime formations and there is a common opinion 
that an underground river flows through here con- 
necting all deep wells and springs. This could not 
be proved, but would easily explain the generalized 
pollution of all waters. There was one large sink 
hole behind one of the deep wells used as a local 
supply. About thirty grams of fluorescin was placed 
in this and the well w^atched for days, but no con- 
nection could be traced. 

The fourth step was the milk supply. Conditions 
in this field were abominable. The supph' was from 
two general sources, large dealers from the city of 
Chattanooga and small farmers from the surround- 
ing country. Unsurmountable difficulties were met 
with both from within and from without and this 
supply was never what it should have been, but in 
the course of time was generally improved. At first 
fifty thousand bacteria to the c. c. for milk and one 
million bacteria to the c. c. for ice cream, w^ith small 
(juantities of gas production allowable, but free 
from Bacillus coli on Endo plates, was taken as a 
standard. The milk was not to be w-atered and to 
be free from preservatives. Some milk supplies 
were found to contain several hundred thou.sand 
bacteria to the c. c. and to have a heavy colon 
growth, some was found watered to the limit, and 
some supplies were loaded with formaldehyde. To 
get a sufficient supply clean and safe seemed impos- 
sible. The only clear solution to the problem was 



July 19, 1922.] 



KEILTY: TYPHOID FEVER. 



79 



to establish a central pasteurization plant. This 
was recommended on August 30, 1917, and again 
on September 10, 1917, by a typhoid board, of which 
I was a member, but was never carried out and is to 
be considered as one of the failures. In its place 
many inspections were made. Attempts to clear up 
and educate at the source brought little result, so 
that many of the smaller dealers were closed up 
entirely. One of the larger dealers pasteurized his 
milk faithfully and then- put it through a bottler 
found to contain flies, and into bottles which were 
far from being clean. One dealer supplied a non- 
pasteurized milk throughout the entire encampment, 
which was badly contaminated and at times so much 
watered that he deducted several hundred dollars 
from his month's bill to make up for the water. The 
officer resfwnsible merely commented that that was 
the best supply he could get and he would have to 
have it regardless. This was probably true, but a 
pasteurizing plant at a nominal cost could have 
settled the whole problem. 

Ice cream was obtained mostly from Chattanooga 
with a small amount from Knoxville, Tenn. This 
constantly ran a high count, several million bacteria 
to the c. c. An epidemic of typhoid fever, one hun- 
dred and twenty cases with eleven deaths, or two and 
five tenths to three times that of previous normal 
years, occurred in the city of Chattanooga in August, 
1917, and was traced directly to the ice cream of a 
particular dealer by Dr. Lumsden, of the United 
States Public Health Service. For a time all ice 
cream was shut off from the post. Honest effort 
on the part of the dealers improved this, and while 
not up to the standard the supply was greatly 
improved. Late in September, 1917, the United 
States Public Health Service established an extra 
cantonment zone under the able leadership of Dr. 
C. P. Knight, passed assistant surgeon. The earlier 
work of inspection by the medical department was 
amply enlarged by this officer and his efficient staff 
during the latter months. Much credit is due the 
department for its work with the none too well 
educated civilian population. 

A great part of the camp, but not all, drained its 
sewage into an old septic tank. This soon became 
flooded and necessitated its complete abandonment. 
Raw sewage, for a time, passed down the Chicka- 
mauga creek. A new set of septic tanks was built 
and completed. This part of the work the writer 
had nothing to do with, but is able to state that con- 
siderable was done and the plant eventually proved 
quite adequate and satisfactory. Many types of 
latrines were used at different times. This is an 
excellent means of disposal, when carefully built, 
kept clean with hypochlorite of lime or crude petro- 
leum and filled in before overflowing. Where there 
are large numbers of men too much space is required 
for their continued use. In some instances the ex- 
pansion of camp necessitated building over ground 
which was originally filled with latrines. This might 
possibly become a dangerous source of contagion. 

Attention was next directed to the soft drinks. 
These beverages were put up by many firms, made 
in various ways, and usually bottled. They were 
consumed in huge quantities. Inspection of some of 
the plants brought out many defects which were 



corrected to a certain extent. Laboratory examina- 
tion of samples of these drinks, while not extensive, 
was sufficient to furnish some data. It was found 
that all samples examined were free from gas pro- 
duction and Bacillus coli. They were often not 
sterile, showing a variegated flora and one sample 
contained several water bugs. The soft drinks were 
probably not up to a perfect standard, but they were 
free from Bacillus coli and as such were considered 
safe from a typhoid standpoint. 

In searching out less likely sources of contamina- 
tion, many samples of canned foods, fresh foods, 
artificial ice, syrups, specimens of soil and other 
things were studied. No sensational results were 
obtained and attention was never focused to any 
great extent along these lines. The food handlers 
offered a great problem from the viewpoint of car- 
riers. I did a considerable amount of this work, but 
large numbers of cooks and waiters were examined 
under the control of other officers. As far as is 
known, no positive cases were encountered. This 
phase of the subject in a large gathering of men is 
a most important one and too much emphasis cannot 
be given it. However, the technical difficulties are 
tremendous in a large camp with a continually 
changing population. Where cooks, bakers, waiters, 
and others are few in number and do not change 
rapidly, such examination should always be made. 

In the consideration of the general methods taken' 
to prevent typhoid fever I have left out to this 
point what must be looked upon as the most 
important single measure — antityphoid vaccina- 
tion. It will be taken up here merely as a 
statement of fact and resumed in the final 
discussion. Every man coming under the direct 
supervision of the army was vaccinated against 
typhoid fever by the subcutaneous injection, in three 
doses seven days apart, of a vaccine made from 
killed cultures of Bacillus typhosus prepared at the 
Army Medical School in Washington. This rule 
was strictly adhered to and only by the cleverest 
subterfuges or by gross disobedience of orders was 
anybody, from buck private to general, allowed to 
escape. Later, as it was recognized that Bacillus 
paratyphoid A, and particularly B, were prevalent 
on the other side, these organisms were added as a 
triple vaccine. Probably the majority of the men 
in the service received this form of vaccine. Still 
later the vaccine was prepared by suspension in an 
oily base, the dose increased, and the whole amount 
given at one time. It is not my intention to go into 
detail with regard to the relative merits of the dif- 
ferent forms of vaccine, but to consider vaccina- 
tion as a whole with reference to its prophylactic 
value. 

The* study of the incidence of occurrence and the 
handling of all cases of typhoid fever during 1917 
is an interesting one. The cases were divided into 
two groups ; first, typhoid fever positive where 
clinical symptoms were present. Bacillus typhosus 
isolated in pure culture from the blood, urine, or 
feces, and second, clinical typhoid fever, where 
Bacillus typhosus was never isolated but the clinical 
course was typical. Blood agglutination was not 
carried out routinely because oif the influence of vac- 
cination. A typhoid board was created locally at tiie 



80 



KEILTY: TYPHOID FEVER. 



[New York Medical Journal 
AND Medical Record. 



post hospital and all cases of continued fever not 
otherwise accounted for came under its observation. 
This board consisted of Major George A. Traylor, 
later Major Charles Smith, Captain J. B. Blevins, 
and myself. The clinical members of the board did 
yeoman service and by their careful observations we 
feel sure that every case came under consideration. 
The laboratory work was performed at the Anny 
Medical School, the laboratory of the Southeastern 
Department, Atlanta, Ga., and at our own laboratory. 
In this way the cases had a triple check since the 
same case was worked on from three different labora- 
tories. ]Many cases presented difficulties in diagno- 
sis and while many were excluded, it is felt that not 
a single positive case failed to be recognized. The 
board met daily and made such recommendations as 
were advisable. Where difficulties were encountered 
in having regulations properly carried out, the same 
were put in writing, passed through proper channels, 
and in every instance they were promptly attended 
to. The patients were isolated at first in a small 
ward as fast as they were recognized. Many pa- 
tients reported for sick call and were sent to the 
hospital almost on their first days of illness. This 
made early diagnosis a little delayed but offered an 
excellent and accurate chance for study. Later when 
the epidemic among war prisoners broke out, a larger 
ward was obtained and isolation was more complete. 
' After many changes, necessary to meet local con- 
ditions, the following rather ideal condition pre- 
vailed. All patients were in a separate building. All 
nurses and attendants wore caps and gowns or 
changed their clothing. All food was brought to the 
outside of the building and served in utensils which 
never left the building. The ward was carefully 
screened. An outdoor incinerator and stove to boil 
water in large galvanized iron cans was constructed 
and here fires were kept constantly going and water 
constantly boiling. All linen taken from the building 
was boiled for at least half an hour, hung out to 
dry, and then sent to the laundry. All urine and 
feces were dumped into one galvanized iron can and 
boiled. (It must be remembered that the sewage 
disposal plant draining this unit was otit of com- 
mission.) The solid residue was then consumed in 
the fire. The bed pans and urinals made of agate 
were then boiled for one half hour, washed and re- 
turned to the ward. Chemical sterilization, using 
hypochlorite of lime, was given a thorough tryout 
both as a disinfectant for feces and to sterilize uten- 
sils, but after prolonged contact even in concentrated 
solutions, Bacillus coli could easily be recovered. 
This result, together with the imcertainty of the 
human factor, led to the use of the incinerator, which 
was found entirely adequate after men were trained 
to run it in the proper way. The method worked so 
well that it was adopted by other officers for the 
sterilization of linen from all contagious cases and 
was used throughout the winter after all typhoid had 
subsided. 

The occurrence of typhoid fever among the 
United States troops, was as follows: There were 
in all twenty-one cases of typhoid fever during 1917 
among troops of the United States Army at this 
camp. In five cases there were positive blood find- 
ings, in one case, in an officer's child, there was posi- 



tive blood agglutination to Bacillus typhosus, and in 
fifteen cases there was clinical typhoid fever with- 
out positive laboratory findings. The positive cases 
were all fairly severe, the longest duration ninety 
days, a perforation in which recovery took place fol- 
lowing operation, the average being seventy-two 
days. 

In the five cases which gave positive blood 
findings, the first patient, G. Y., had not com- 
pleted prophylaxis, receiving only two doses by 
June 3, 1917, when a second series was started on 
June 19, 1917. He was first taken ill on June 12, 
1917. The second patient, G. G., completed prophy- 
laxis on July 16, 1917, and was taken ill on July 
20, 1917. The third patient completed prophylaxis 
on May 4, 1917. and was taken ill on July 25, 1917. 
The fourth patient completed prophylaxis on Sep- 
tember 9, 1915, and was taken ill on August 5, 1917. 
In the fifth case, second dose was given only on 
October 2, 1917, and the patient was taken ill on 
September 26, 1917. 

In comparing date of onset, with date of arrival at 
Fort Oglethorpe, it will be seen that the first two 
cases were probably and the last undoubtedly im- 
ported, while the third and fourth were local infec- 
tions. One can only conjecture as to the source of 
infection in these two cases. Ice cream seems to have 
been the probable source, since both patients had par- 
taken of the same dealer's cream at the time it was 
responsible for the Chattanooga outbreak. 

From a study of the clinical cases, it will be noted 
that seven patients out of fifteen were either incom- 
pletely vaccinated or vaccination was completed im- 
mediately before the date of onset. In the remaining 
cases the patients were vaccinated at least a month 
before the onset of the disease. These, added to the 
one positive case, make nine cases of typhoid fever 
all told in successfully vaccinated individtials. These 
figures may be appreciated more thoroughly when 
considered with the constantly changing population, 
a daily averaging census of thirty thousand and 
probably well over one hundred thousand men pass- 
ing through the camp during the time under con- 
sideration. 

While there was not a single death among the 
troops, the disability in number of days on sick list, 
the length of time for complete convalescence after 
discharge from the hospital, the development of 
tuberculosis, the complete loss of the services of two 
men in training for officers, and one or two men 
discharged on S. C. D., will suffice to recall the 
economic importance of these results to the effectual 
units of the army. 

There were twenty-two cases of typhoid fever in 
the form of an epidemic among the war prisoners. 
Thirteen of these gave positive cultures or posi- 
tive agglutination of Bacillus typhosus and nine 
did not. All were typically clinical typhoid and most 
of the cases were severe. There was one death, and 
the autopsy revealed all the typical pathology of the 
disease with a severe grade of toxemia and without 
perforation or hemorrhage. Ten patients had never 
received any prophylaxis, seven had been vaccinated 
in 1915 on ship board off the China coast, and five 
had been vaccinated within a month of the onset of 
the disease. The efficacy of vaccination in this epi- 



July 19, 1922.] 



KEILTV: TYPHOID FEVER. 



81 



demic is again clearly shown. It would seem that 
the immunity does not continue over a period of two 
years and that within a month it is not sufficiently 
developed to establish complete protection. 

On orders from the \\'ar Department a typhoid 
board was created consisting of Colonel Roger 
Brooke, Major George A. Traylor, and myself for 
the purpose of investigating this epidemic. A rather 
comprehensive and complete study was carried out. 
It would seem an easy task to find the source of 
infection when the movements of all members to- 
gether with their food supply could be so definitely 
traced as in a prison camp. Deductions were arrived 
at more from negative results than positive findings. 

The first case occurred on August 20. 1917, with 
the apex around August 24th and eighteen cases 
had occurred b}- September 1st. This would give 
the probable source of infection between August 
10th and 15th. Most of the patients were from one 
barracks using one mess hall. Xo milk or ice cream 
was served. The food was obtained from the quar- 
termaster and was the same served the rest of the 
camp. All cooks and waiters, about ninety, were 
examined for carriers twice and proved negative. 
Utensils, cans, unused and opened foods were nega- 
tive. This narrowed the infection to two probable 
sources. One was a package of homemade cheese 
sent in by a friend and another a box of sweet 
chocolate from a dealer, on whose farms typhoid had 
been known to occur. The men had partaken of 
both of these foods but neither of them had re- 
mained for examination. In view of all negative 
local evidence, the confinement of the epidemic to 
one mess, its origin from one apparent infection, and 
its complete control as soon as this source was gotten 
rid of, the conclusion was drawn that it was due to 
the cheese. Efl^orts to get the local board of health 
in the city from whence the cheese was shipped to 
report on the place failed to bring results, so that 
definite data could not be obtained. 

Chickamauga Park, Georgia, has been made 
famous on several occasions but never more in- 
famous than in connection with its typhoid fever 
outbreak at the time of the Spanish-American War. 
During 1917, troops were again to be concentrated 
at this point, and while considerable reliance was 
placed on antityphoid vaccination, it was not a 
proven procedure peradventure of a doubt. 

Upon earliest investigation of general conditions, 
everything favorable to the propagation and spread 
of the bacillus of typhoid was found operative. The 
water supply was contaminated with Bacillus coli, 
the milk and ice cream were filthy, bacterial laden, 
watered, and preserved with formaldehyde. The 
flies were present by the millions with breeding 
places on every hand. The climate was warm and 
moist and above all, cases of typhoid fever, almost 
epidemic in nature, were present among the neigh- 
boring civilian po]ndafion. Balanced against this 
stale of affairs there was operative a rapidly filling 
camp with men from all over the country and vac- 
cination, which had been tried, found to have won- 
derful possibilities, but still on the mat. With 
this, the first case of typhoid began early and those 
in charge found a problem on their hands. Earnest 
effort resulted in potable water, better, if not the 



best, milk and ice cream, the closing of contaminated 
wells and springs, thorough and frequent inspections 
of cattle, barns, milkhouses, milk plants, water 
sources, sewerage plants and effluent creeks. Above 
all, as thorough vaccination of all men as the rapidly 
changing movements would allow. The fly was 
attacked as conscientiously as the training of sol- 
diers and, I cannot repeat too often, conquered. 
These were the methods used to back up and rein- 
force what was hoped for, that is, complete protec- 
tion from vaccination. 

In spite of all these means a few cases of typhoid 
fever occurred, but they were so scattered and so 
few that they became a negligible factor in the 
impediment to the machine as a whole. When these 
cases did begin, they were isolated and treated so 
that J doubt whether a single infection could have 
gotten away from its confines. An imported epi- 
demic occurred among the war prisoners which was 
promptly controlled and out of the whole number 
only one death resulted. This study constitutes the 
cases which arose during 1917. During 1918, there 
were also a few scattered cases but these were not 
even considered important enough to comment on, 
since by that time protective prophylaxis with other 
cleanup methods were no longer on the mat. but had 
been tried and found to be all that could be desired. 

It is not my intention to discuss all the phases of 
this subject but several points stand out distinctly 
and deserve more profound thought. In the first 
place, at this writing after ever\'thing is over, little 
interest is shown in typhoid fever. It is a true 
philosophy that we soon put aside old truths and take 
for granted conditions that are really remarkable 
with the thought that they were well accomplished 
and, being an every day condition, they must have 
always existed as such. Typhoid fever has been con- 
quered as far as the scientific medical world is con- 
cerned, but has it been eliminated? In 1898, while 
not in complete ignorance, advantage was not taken 
of what knowledge had been gained. In 1907, what a 
different story! The civilian population was some- 
what better posted but not much, depending almost 
entirely upon what protection a chlorinated water 
supply gave them. On the other hand, the Army 
could and did take advantage of the knowledge of 
the disease, its etiological factors, its mode of trans- 
mission, the methods of combat, including direct 
vaccination prophylaxis. What were the results? 
A mobilization of over a hundred thousand men and 
only one true case of typhoid fever in a successfully 
vaccinated individual. This is the monument to 
which I wish to call attention, not only to com- 
memorate those earlier earnest workers of the regu- 
lar medical department of the Army but the medical 
profession as a whole. Typhoid fever alone raging 
in the cantonments during the preparatorv training 
for the World War, as it did in 1898, would have 
rendered the effectuals as inefficient as any number 
of intense gas attacks the Germans might have in- 
vented or any number of transports they might have 
sunk after those men were on the firing line. 

The subject of typhoid fever is one that elicited 
small interest during the war by its absence. It is 
this absence that should be brought home to us at the 
present time. 



82 



MYERSON: ESOPHAGOSCOPY. 



[New York Medical Journal 
AND Medical Record. 



Esophagoscopy* 

By M. C. MYERSON, M. D., 
Brooklyn. 



Esophagoscopy is a much older art than one might 
at first believe. Bozini was the first to attempt the 
illumination of cavities of the human body, and he 
described his apparatus for this purpose in 1795. 
In 1807 he examined the upper end of the esophagus. 
In 1860 Voltolini demonstrated what he believed to 
be the first practical tracheoscope before a medical 
congress in Berlin. In 1868 Kussmaul, using an 
elongated urethroscope, diagnosed carcinoma of the 
esophagus. Other workers, such as Trouve in 1873, 
Mikulicz in 1881, Gottstein, \'on Acker, Kirstein 
and Killian in 1897, and Jackson in 1904, helped 
considerably to place endoscopy on a firmer basis. 

In 1895 Pieniazek is reported to have removed 
a small bone through his tracheal speculum. In the 
same year Kirstein performed a direct laryngoscopy 
and bronchoscopy. He met with success in twenty- 
five per cent, of his cases and partial success in fifty 
per cent. He felt that only a limited number of pa- 
tients were fit subjects, and that entering the trachea 
was a dangerous procedure. Killian followed closely 
upon Kirstein's first work, and in 1897 he removed 
a piece of bone from the right main bronchus of a 
man aged sixty-three years. Killian was convinced 
that the thick, resistant walls of the larger bronchi 
could be entered with comparative ease and safety. 
The bronchi are elastic and yield readily to pressure 
so that the entire tube under inspection can be dis- 
placed, bringing its lumen into a single plane for 
observation. 

With the evolution of the technic has come the 
evolution of a suitable instrumentarium. The first 
instruments of Kirstein and Killian were rather 
crude. Bruning, in 1907, improved upon them con- 
siderably. The first esophageal tubes were of the 
design of Rosenheim. Illumination was developed 
simultaneously with the other phases. In America, 
Jackson published the first comprehensive work in 
1907. Until recent years bronchoscopy and eso- 
phagoscopy have been resorted to for foreign body 
removal almost exclusively. Through the publicity 
that has been given the good work of some of the 
best endoscopists, the internist particularly has 
learned to call upon this branch of our specialty. 
Such diseases as asthma, syphilis, malignancy, ery- 
sipelas, diphtheria, lung abscess, and bronchiectasis, 
stenosis, and unsuspected foreign bodies, have been 
noted in the tracheobronchial tree. In the esophagus 
we have on record the following conditions, studied 
and observed endoscopically : Acute esophagitis, car- 
cinoma, syphilis, typhoid and tuberculous ulceration, 
varicosities, angioneurotic edema, diverticula, car- 
diospasm and hysterical tumor. 

It is hoped that the following series of tube cases 
will be of interest. All of these except two of the 
foreign body crises, were seen in the laryngological 
service at the Kings County Hospital within the past 
year. Unfortunately, rontgenological diagnosis and 

•Read before the Brooklyn Medical Association, February 8, 1922. 
(From the Department of Laryngology, Kings County Hospital.) 



confirmation could not be obtained in some of these 
cases, for the x ray room was closed before the time 
of admission to the hospital. 

Foreign bodies in the esophagus are, as a rule, 
easy of removal ; the facility of removal is decreased 
in proportion to the duration of the sojourn, and the 
amount of manipulation and attempted extraction 
the given case has been subjected to. The larger the 
foreign body which is lodged bronchially or esopha- 
geally, the more likelihood there is of local tissue 
changes. These may be slight and negligible, or ex- 
tensive and severe, and a serious menace to life ac- 
cording to the nature of the intruder, the point and 
the duration of lodgment. Digital etiforts at re- 
moval, imsuccessful attempts which consist usually 
of blind stabs with a curved grasping forceps or the 
use of a probang, bougie, or stomach tube to force 
the intruder down, increase both the local and gen- 
eral morbidity and may well designate the border- 
line between life and death in a given case. 

In one of the cases where the intruder had lodged 
high up in the esophagus, although the child escaped 
serious injury, his posterior laryngopharyngeal wall 
was badly lacerated and presented an unsightly pic- 
ture, due to several unsuccesful attempts at extrac- 
tion before the patient was seen. The administra- 
tion of castor oil is of no value and may prove harm- 
ful. Foreign bodies in the esophagus which are not 
pointed and not so constructed as to be likely to 
be impacted will pass through without serious com- 
plication. OiT the other hand, a tack or screw or 
open safety i)in, in fact any pointed object if it has 
worked its way down to the intestinal tract, will be' 
more prone to impaction and perforation by the in- 
created peristalsis which a cathartic induces. 

Three of the foreign bodies here reported were 
not recovered. Of these one case terminated fatally 
and the other two bodies passed through the gas- 
trointestinal tract. In the fatal case, the patient 
with an open safety pin in the esophagus probably 
died as a result of being carried about too much 
before the time of extraction. Impaction, perfora- 
tion, or laceration, creates a grave situation and is a 
great possibility when the subject is allowed to run 
about or be actively moved about. Therefore, a 
patient suspected of having a sharp foreign body 
should be handled with care and kept in bed. 

Case I. — A. A., male, aged nine years, was seen 
through the courtesy of the surgical service at the 
St. Catharine's Hospital, August, 1920, where the 
boy was under treatment for having swallowed a 
fifty cent piece ten days before. The child com- 
plained of discomfort during the sojourn of the 
foreign body, and could take liquids until twenty- 
four hours or so before seen. He was now ema- 
ciated and had considerable acidosis. The laryiigo- 
])haryngeal wall posteriorly was quite swollen and 
edematous. The coin was hidden by the edematous 
tissue of the esophagus which closed around it. No 
anesthesia was used. The coin was removed with 



July 19, 1922.] 



MVERSON: ESOPHAGOSCOPY. 



83 



the aid of an upper esophageal speculum and uni- 
versal grasping forceps. A tampon saturated with 
argyrol solution was placed in the area of lodgment 
and left there for a few minutes. The boy had no 
untoward symptoms as a result of the long sojourn 
of so large a foreign body. 

Case II. — G. S., male, aged two months, was 
brought into the Kings County Hospital on the 
ambulance. An overall button had been forced down 
his throat by an older baby brother. The foreign 
body was lodged between the vocal cords and slid 
along them with the motion of the child's head. 
Forward motion would cause a corking of the glottis 
and suffocation. No anesthesia was used. The for- 
eign' body dropped into the pharynx upon introduc- 
tion of a laryngeal speculum. The patient was seen 
six hours after the mishap. 

Case III. — H. F., male, aged twenty-three years, 
was showing a little boy the trick of inserting a 
penny into his nose and withdrawing it from the 
mouth. He thrust it too far back and it became 
impacted in the upper esophagus in the plica crico- 
pharyngeus from wdiich it was readily extracted. 
No anesthesia was used. The patient was seen three 
hours after the introduction of the foreign body. 

Case IV. — P. P., male, aged thirty-eight years, 
was referred to the hospital by his family physician. 
He had swallowed a roast pork bone, and it had 
become impacted at the level of the clavicle. The 
patient complained of pain and inability to swallow. 
Cocaine anesthesia was used. Esophagoscopy re- 
vealed an abrasion of the mucous membrane of the 
esophagus just below the cricopharyngeus muscle, 
and a small piece of bone was seen in the stomach. 
It was considered inexpedient and unnecessary to 
remove the intruder because removal would have 
lacerated the esophagus and the bone was not so 
large that it could not be digested and taken care 
of by the gastrointestinal tract. He was seen eight 
hours after the entrance of the foreign body. 

Case V. — E. J. McK., male, aged sixty-one years, 
was eating pork chops the evening before and felt 
something stick in the region of the upper esopha- 
gus. He could not swallow anything. Indirect ex- 
amination with a mirror showed a total occlusion of 
both pyriform sinuses with slight forward pres- 
sure upon the arytenoid cartilages interfering slightly 
with phonation. Respiration was not embarrassed. 
The foreign body was removed with difficulty be- 
cause the decomposed meat allowed the grasping 
forceps to pull right through. The intruder had 
some cartilage, but it consisted mostly of meat. The 
patient was seen fifteen hours after the introduction 
of the foreign body. No anesthesia was used. 

Case VI. — E. L., female, aged seven years, went 
to the store with her sister and in the course of an 
argument as to who should carry the money, swal- 
lowed a twenty-five cent piece. She was seen five 
days after the quarter went down. The coin was 
surrounded with considerable food detritus and con- 
gested esophageal w:all. It was therefore not read- 
ily accessible. It was impacted in the plica crico- 
pharyngeus from where it was removed with the 
aid of tlie esophageal speculum and special grasping 
forceps. No anesthesia was used. 

Case VII. — D. B., female, aged twelve months, 
came into the hospital with a history of having 



snatched an open safety pin from the mother's 
apron and of having swallowed it. She was pre- 
sented for esophagoscopy some eight hours after the 
mishap. A rontgenogram showed the safety pin 
open, point upward, in the upper esophagus. The 
child was kept on the table for twenty minutes ; botli 
esophagus and tracheobronchial tree were explored, 
but the intruder was not found. Later rontgen 
study showed the pin in the stomach. The child died 
the following day of bronchopneumonia. The pin 
was not recovered. Esophagoscopy was first at- 
tempted without anesthesia, but because of the 
child's struggle, ether anesthesia was resorted to. 
It is very probable that the struggle prior to anes- 
thesia and during the stage of excitement was re- 
sponsible for the passage further down of the 
intruder. 

Case VIII. — ]M. D., female, aged eighteen years, 
came to the hospital thirty-six hours after having 
swallowed a pin while picking her teeth with it. At 
first she felt it lodge in the pharynx, where it caused 
pain and coughing. When- first admitted to the hos- 
pital X ray and fluoroscopy showed the pin at the 
level of the arytenoids. The patient was fretful and 
nervous and was allowed to walk around a great 
deal. The result was that just before attempted 
extraction the fluoroscope showed the pin in the 
upper esophagus. An esophagoscopy was performed 
and the pin could not be found. Fluoroscopy did not 
disclose it either. In this case esophagoscopy was 
attempted with no anesthesia, but as the patient 
would not relax and cooperate, ether was used. The 
pin was probably lost during the early stage of anes- 
thesia. Six months later it was reported that the 
patient had had no untoward symptoms and that there 
was no certainty that the pin had passed through. 

Case IX. — S. S., female, aged thirty-nine years, 
came to the hospital complaining of loss of weight 
and inability to swallow anything. She was sure 
of the presence of a tumor which she localized below 
the clavicle. Esophagoscopy demonstrated an un- 
obstructed lumen with apparently normal, healthy 
mucosa throughout. The diagnosis of hysteria was 
thus confirmed. The patient was strongly im- 
pressed by the tube passage and swallowed after 
having been esophagoscoped once. Cocaine anes- 
thesia was used so that the patient received the 
psychic benefit of the procedure. 

LUNG abscess AND BRONCIIOSCGPIC IRRIGATION. 

The following three cases of lung abscess are of 
particular interest. They demonstrate the value of 
bronchoscopic irrigation in this type of case ; two 
of them are cases that immediately followed ton- 
sillectomy with general anesthesia : 

Case X. — F. N., a girl of five years, was referred 
for bronchoscopic examination and irrigation by a 
pediatrist, in June, 1921. Her history was as fol- 
lows: She had been coughing since the age of ten 
months when she had pneumonia, and had been ex- 
pectorating as much as a cui)ful and more of pus 
in twenty-four hours just prior to being sent for 
bronchoscopy. She had pyelitis at about the same 
time as her cough first began. There was no history 
of a foreign body. Physical examination showed 
definite impairment of resonance over the left base 
posteriorly with some impairment of resonance and 



84 



MYERSON: ESOPHAGOSCOPY. 



[New York Medical Journal 
AND Medical Record. 



breath sounds over the entire left chest. Coarse 
rales and tubular breathing could be made out over 
the left base. Several months before a provisional 
diagnosis of unresolved pneumonia had been made. 
Repeated Von Pirquet and intradermic tests were 
negative. The x ray study showed an indefinite 
shadow in the left lower lobe obliterating the border 
of the diaphragm on that side. There was no dis- 
tinct limiting boundary as is usually seen in pictures 
of an abscess. The right lung was slightly expanded 
so that the heart was displaced definitely to the left. 
Bronchoscopic study showed pus coming from the 
left lower lobe bronchus. After the pus was evac- 
uated by suction there was no evidence of a foreign 
body or of a stenosis or a dilatation of the bronchus 
examined. The presence of a stenosed bronchus 
would confirm the diagnosis of bronchiectasis. This 
would be the logical conclusion from the lack of a 
true abscess picture in the rontgenogram. It does 
not seem justifiable to differentiate in this case be- 
tween abscess and bronchiectasis though one might 
be inclined more strongly toward the former, be- 
cause of the later behavior of this case. 

This patient was bronchoscoped and her abscess 
cavity irrigated twice at an interval of a week. After 
the first irrigation she expectorated only occasion- 
ally and much less than before. After the second 
irrigation she did not expectorate any pus and only 
coughed occasionally. At the time of her second 
irrigation the stethoscope showed an almost imme- 
diate aeration of the lower left lobe while the bron- 
choscope was in place. A rontgenogram taken two 
months after the second irrigation showed a clear, 
left, lower lobe, with the heart replaced in its nor- 
mal position and evidence in the involved area of a 
slight fibrosis. The diaphragmatic shadow could be 
plainly discerned. She practically expectorated no 
pus and only coughed occasionally until almost six 
months later, when she began to cough and expec- 
torate as frequently as every few minutes. This 
followed upon a socalled cold according to the story 
of the mother. This recurrence was rather a dis- 
appointment, as she was thought to have obtained a 
true recovery. She was again treated, and when last 
seen was expectorating only six or seven times a 
day, as compared with every five or six minutes be- 
fore. This case strongly demonstrates the advantage 
of bronchoscopic irrigation. These irrigations, have 
helped keep this child in fairly good health and have 
improved her general condition. 

Case XI. — M. H., female, aged thirty years, was 
originally referred by the medical service. She had 
a tonsillectomy performed in one of the larger hos- 
pitals in New "^'ork. During the profound general 
anesthesia her throat was subjected to a good deal 
of manipulation, and, from her history it appeared 
that several hours had elapsed before she had re- 
gained consciousness from the anesthesia. She did 
not feel well immediately after operation and went 
to bed at once upon her return home from the hos- 
pital the day following tonsillectomy. One week 
later she began vomiting, coughing, and expectorat- 
ing pus. At the height of her trouble she expec- 
torated as much as eight ounces a day, and coughed 
and expectorated every few minutes. Her physical 
signs when seen were the following: 

Percussion note was decidedly dull at the right 



base posteriorly. Breath sounds were increased 
throughout the left side. The breath sounds over 
the right lower lobe were almost entirely suppressed. 
The voice sounds were impaired, also fremitus. 
Anteriorly, in the axillary line, there was relative 
dullness with suppression of voice and breath sounds 
on the right side. A diagnosis was made of lung 
abscess involving the right lower lobe. Broncho- 
scopic irrigations have kept her expectorating a 
small amount only a few times a day. She has 
gained weight and feels much better than before the 
bronchoscopic irrigations were instituted. 

Case XII.^G. D., female, aged fourteen years, 
who was referred to the service from the Brooklyn 
Home for Consumptives, was a pathetic and very 
instructive case. She had tonsillectomy performed 
at one of the smaller hospitals in Brooklyn. Ac- 
cording to her own statement, her admission tem- 
perature was 102° F. She was nevertheless operated 
upon, and it appears from her history that several 
hours had elapsed before she regained conscious- 
ness from the anesthesia. A few days later she began 
coughing and expectorating a foul, blood tinged 
sputum. She was examined by physicians who de- 
clared her tuberculous and had her sent to the 
Brooklyn Home for Consumptives. The doctor at 
this institution could not confirm the diagnosis of 
tuberculosis of the lung, and it was decided after a 
careful study that she had two lung abscesses. X 
ray study reveals two abscesses of fair size in the 
right upper lobe. At the time of admission for 
irrigation she was expectorating more than six 
ounces of foul, blood stained fluid in twenty-four 
hours. After her first irrigation her expectoration 
decreased somewhat, and the frequency of every 
three or four minutes was extended to every forty- 
five or fifty minutes. She is feeling much better 
and eats and sleeps well as compared to the tiine 
prior to bronchoscopic treatment. At present she 
expectorates but a few times a day and coughs only 
occasionally. 

The late Dr. Lynah. who did considerable work in 
bronchoscopic irrigation, believed that conservative 
bronchoscopic measures of treatment should be given 
a fair trial before radical surgery, some of which 
was quite deforming, was attempted. 

The accepted treatment of lung abscess is drain- 
age. The structure of the lung parenchymal space 
opening into the bronchial tree is such as to provide 
drainage where an abscess communicates with a 
bronchus. Early, spontaneous evacuation frequently 
means a cure of the abscess. The spontaneous evac- 
uation of such a process is dependent on several 
factors. Principal among these there is the in- 
tegrity of the expulsion apparatus of the chest. 
This consists not only of the tracheobronchial mu- 
cosa and musculature, but also that part of the mus- 
culature of the thorax which can compress the lungs 
and help in the expiratory or expulsive effort. The 
function of this latter factor is enhanced, of course, 
by the patient's good, general, physical condition. 
Now, if the patient is weak and debilitated, and too 
tired to force the abscess content out of the chest, 
the danger of spread, absorption, and interference 
with the function of the healthy surrounding lung is 
increased. Another factor and a very important one 
is the consistency of the abscess exudate. If it is 



July 19, 1922.] 



SMITH: LABYRINTHINE SURGERY. 



85 



very thick and tenacious, there is less likelihood of 
expulsion even though tlie patient has a strong ex- 
pulsive force. If an abscess cavity does not evacu- 
ate and cure spontaneously, as some of the smaller 
ones occasionally do, the patient carries a constant 
menace to the surrounding healthy lung structure. 
This is the explanation of some cases in which there 
is more than one abscess. Hedbom, of the Mayo 
Clinic, states that the mortality in cases treated ex- 
pectantly is seventy to ninety per cent. 

TYPES OF TREATMENT. 

In the treatment of lung abscess there are two 
types, conservative and radical. The conservative 
treatment consists of either the expectant plan with 
no local interference as far as the abscess itself is 
concerned or of bronchoscopic irrigation. Radical 
treatment consists of surgical procedures such as 
the production of a pneumothorax as advocated by 
Tevvksbitry. or lobectomy, which is the removal of 
the diseased lobe in its entirety ; or the use of the 
cautery to eradicate the abscess cavity. 

The employment of the bronchoscope and irriga- 
tion suction apparatus in cases of lung suppuration, 
ofifers considerable definite relief to these sufferers. 
Irrigation thins out and evacuates a secretion in 
some cases that frequently could not be removed by 
the patient's own efforts. The secretion which later 



accumulates is softer and looser and is therefore 
more readily expelled. The expectoration and fre- 
quency of the cough is very markedly decreased as 
a result of irrigation and the spread of the patho- 
logic process is held in check. 

The patients gain weight and feel better as a re- 
sult of this form of treatment. If seen early enough 
we can hope for a recovery in some of these cases. 

Lynah reported several cures in his series. When 
an abscess has lasted a long time and cannot be 
helped by bronchoscopy, the thoracic surgeon should 
be called in. 

I wish to thank Dr. Cameron for permission to 
report such of the cases as occurred in his service. 
I also wish to express my deep sense of grati- 
tude and obligation to Dr. Arrowsmith, who is re- 
sponsible for my special interest in bronchoscopy 
and esophagoscopy, and to thank him for his teach- 
ings, suggestions, and guidance in this work. 

REFERENCES. 

1. Mueller. V.: Journal A. S. T. A., 1916. 

2. Mann : Tracheobronchoscopy. 

3. Jackson : Tracheobronchoscopy. 

4. LvNAH : Medical Record, February, 1920. 

5. Hedbom : Minnesota Medicine. 1919. 

6. Tewksbury: Journal A. M. .-i.. March 10, 1917. 

7. Lynah : Ibid, November 12, 1921. 

184 Clinton Street. 



Labyrinthine Surgery* 

By J. MORRISSET SMITH, M. D., 
New York. 



The problem presented by an infected labyrinth, 
when it should be operated upon and the method of 
election, is still an exceedingly interesting as well 
as a very difficult one. The number of cases re- 
quiring operation is so small that even in the large 
clinics the opportunities for observing and operating 
in them are rare and the statistics very limited. One 
fact that seems well established is that at one period 
in the past there were too many labyrinth opera- 
tions performed, the mortality was entirely too high, 
so that at the present time we are inclined to be 
much more conservative and to view the surgical 
invasion of the labyrinth as a grave undertaking, 
especially where it is indicated in the presence of an 
active infection. In a consideration of the subject, 
the fact must be constantly borne in mind that if 
the infection could be limited to the labyrinth there 
would be little danger and it is not a labyrinthitis but 
a meningitis that is responsible for the mortality. 
The problem then resolves itself into the determina- 
tion as to whether an operation in the individual case 
will limit or prevent an intracranial extension of the 
labyrinthine infection. While the actual space con- 
tained in the labyrinth, consisting of the semicircular 
canals, the vestibule and the cochlea, is very small, 
its intimate relation to the meninges renders any 
bacterial invasion a dangerous one. Removal of the 

•Read before the Otological Section, New York Academy of Medi- 
cine, January, 1922. The discussion appears on page 115 of this 
issue. 



stapes makes an opening directly into the vestibule 
and the perilymph, communicating directly with the 
spinal fluid through the aqueduct of cochlea while 
the opening of the cochlea and the destruction of 
the modiolus lead into the endolymph and into the 
arachnoid space. Considering these facts, it is hard 
to see why any infection in these spaces does not 
immediately lead to a diffuse meningitis, but it has 
been definitely proved that many of them do become 
localized and the meninges are successfully walled 
off. This leaves the difficult problem of deciding 
whether a labyrinth operation will help or whether 
the labyrinth should be let alone. 

There is no question in my mind that of late years 
there has been a material reduction in the mortality 
resulting from labyrinthitis, due in part to the fact 
that in certain cases operation has not been per- 
formed and in part to the method of operating. The 
two factors that stand out as material aids in this 
reduction are the improved knowledge of labyrin- 
thine functions and the analysis of the spinal fluid. 

Thanks to the invaluable work of Robert Barany, 
Isaac H. Jones and others, it is now possible to say 
very definitely whether or not the labyrinth in part 
or as a whole is functionating. This will undoubt- 
edly prevent surgical intervention in cases in which 
in the past operation would have been performed 
with disastrous results. I performed a radical mas- 
toid operation upon a patient in the clinic a short 
time ago. The labyrinth had not been examined but 



86 



SMITH: LABYRINTHINE SURGERY. 



[New York Medical Journal 
AND Medical Record. 



there was a report of a dead labyrinth. The radical 
operation showed no visible labyrinthine necrosis 
and the labyrinth was not disturbed. Subsequent 
examination showed a dead cochlea, but an active 
labyrinth. 

In the general consideration of these cases, it is 
important to know just what part the temperature 
plays. I believe that as long as the infection is con- 
fined to the labyrinth there will be little or no rise 
in temperature, and should there be a sudden rise in 
temperature, it is very likely a warning of the exten- 
sion of the infection beyond the labyrinth, ruling 
out, of course, other systemic causes that may be 
responsible for the temperature elevation. 

Analyzing the spinal fluid furnishes the one best 
method of determining in time to be of some assist- 
ance to the patient whether the infection is confined 
to the labyrinth or whether it has extended to the 
meninges. This is most important. A normal fluid 
will not show increased pressure, is clear, has about 
six to eight lymphocyte cells to the c. mm. reduces 
Fehling's solution, gives a negative globulin reac- 
tion. In a diffuse meningitis, the fluid is cloudy and 
under pressure the cell count runs into the thou- 
sands with a marked increase in the polymorphonu- 
clear cells. It does not reduce Fehling's solution, 
gives a positive globulin test, and shows bacteria in 
the fluid. Now let the infection become localized 
and an increase in the polymorphonuclear cells is 
shown. The cells increase with the spread of the 
infection and decrease in proportion as the localiza- 
tion increases. If the infection is taken care of by 
the resistance, the cells return to normal and the 
patient recovers. If a diffuse meningitis intervenes, 
the fluid becomes purulent with free bacteria and 
the patient dies. Even though the cell count runs 
into the thousands if there are no bacteria present 
it shows still some localization and there is a pos- 
sibility of recovery. My observation is that in spite 
of an occasional report to the contrary, where bac- 
teria appear in the fluid the patients die. 

A case occurring at the New York Eye and Ear 
Infirmary a short time ago serves as a good illus- 
tration. With the operator's permission I present 
the following report : 

Case I. — Male, aged eighteen, had a sudden rise 
in temperature to 104° following an ethmoid opera- 
tion. The patient's neck was stiff, Kernig's sign 
was present, and he was unconscious ; fluid was 
cloudy, cell count 13,000, culture negative. Daily 
lumbar puncture showed a gradual return to nor- 
mal, the patient recovered, and left the hospital. The 
last cell count was 25. Probable diagnosis was 
meningitis, which was successfully localized or 
walled off. 

The literature contains an occasional report of a 
case with a diffuse meningitis and free bacteria in 
the fluid in which the patient recovers, and again a 
localized meningitis within the head large enough 
to cause the death of the patient and at the same 
time have a normal spinal fluid. While both are 
possible, they are not at all probable. A total white 
cell count and differential is of considerable value 
where we are trying to determine the progress of 
a labyrinthine infection. Should the labyrinth alone 
be involved, the white count should be normal. An 



extension of the infection to the meninges causes an 
increase in the total leucocyte count. This goes up 
with the spread of the infection. If there is a high 
temperature, with a high leucocyte and a low poly- 
morphonuclear count, it indicates a good resistance. 
Should the polymorphonuclear count rise very high 
with high temperature and cell count, the prognosis 
is bad. 

In order to facilitate the discussion of the differ- 
ent types of labyrinthine infections and the best 
methods for their relief, we will divide them into 
three classes, as follows : 

Class I : Perilabyrinthine and circumscribed laby- 
rinthine infections. 

Class II: Diffuse purulent latent labyrinthitis. 
■ Class III : Diffuse purulent manifest labyrinthitis. 

The term serous labyrinthitis has been purposely 
omitted here since it is supposed to occur with an 
active labyrinth and would fall under the head of 
class I, although it must be remembered that at any 
time one type may be converted into the other. 

CLASS I. 

Under the head of perilabyrinthine cases are in- 
cluded those in which there is an inflammation 
around the labyrinthine capsule causing some laby- 
rinthine symptoms but no real infection in the laby- 
rinth itself. These cases show an active labyrinth 
and usually clear up at once following removal of 
cause. 

C.vsE II. — Female, aged sixty-two, with a history 
of double otitis media purulenta chronica, accom- 
panied by nausea, vomiting and vertigo, was re- 
ferred to me with a diagnosis of labyrinthitis. The 
left ear was dry and the right showed a hard fibrous 
growth just anterior to the drum membrane, canal 
completely obstructed, labyrinth active. Removal of 
the growth showed a large mass of epithelial cells, 
cerumen, etc., in the middle ear; the removal of this 
was followed by complete recovery. The labyrin- 
thine symptoms were evidently due to pressure. 

The circumscribed infections are usually due to a 
fistula in the horizontal semicircular canal which may 
or may not show a positive fistula list. In any event, 
there is still an active or partially functionating laby- 
rinth. All radical mastoid cases should have the 
labyrinthine function tested before operation and 
should the operation show a fistula of the semicir- 
cular canal and the labyrinth be active, a thorough 
radical operation should be done and the fistula let 
alone. It is now generally agreed that in no case 
of labyrinthitis showing evidence of remaining func- 
tion should operation be performed. 

Case III. — Male, aged forty-two, a plumber, with 
a history of right otitis media purulenta chronica of 
several years' duration, rose suddenly and struck his 
head on a pipe. This was followed immediately by 
nausea, vomiting, ataxia and vertigo. The labyrinth 
was active, the positive fistula test showing fistula in 
semicircular canal. Radical operation was advised 
and refused. The labyrinth symptoms quieted 
down and the patient was in good condition several 
months later. 

Ruttin reports in his book forty-three cases of 
circumscribed labyrinthitis with partial or complete 
function present in which the radical operation alone 
was performed and the patients all recovered. 



July 19, 1922.] 



SMITH: LABYRINTHINE SURGERY. 



87 



CLASS II. 



DIFFUSE PURULENT LATENT 
LABYRINTHITIS. 



In this type there has been labyrinthitis with total 
destruction of function but no active evidence of 
infection ; in other words, there is a dead labyrinth 
with no symptoms. A spinal fluid analysis should be 
done and in the event of a normal fluid one can be 
reasonably certain of the infection being limited to 
the labyrinth, the meninges having been successfully 
walled off by nature. The primary consideration 
here is that we institute no operative procedure 
which will interfere with this barrier. This is most 
important. In the event of a healed middle ear con- 
dition, the labyrinth should be let alone. Where 
there is an infected middle ear and a dead but quiet 
labyrinth, I believe only the most conservative opera- 
tive measure should be considered. Either a care- 
ful radical mastoid operation should be done, allow- 
ing the labyrinth to remain undisturbed, or if a laby- 
rinth operation is decided upon, the method followed 
by Hinsberg seems to be the rational one. The hori- 
zontal should be opened and followed forward to 
its opening into the vestibule. This opening should 
be enlarged and a probe then passed under 
the facial nerve to the vestibule. The promontory 
should then be carefully removed, care being taken 
not to get into the second turn of the cochlea. Then 
the small bridge between the oval and round win- 
dow removed. This drains the labyrinth into the 
radical cavity and takes the least chance of disturb- 
ing the barrier between the labvrinth and meninges. 

I believe that where there is a dead labyrinth with 
a normal fluid and the radical operation shows no 
visible necrosis, the labyrinth should be let alone. 
I am also of the opinion that the Neuman operation 
is never indicated in this type of infection since 
there already is a protective barrier present and the 
route through the posterior fossa into the labyrinth 
ofifers far more chance of destroying than it does of 
protecting it. 

CLASS III. DIFFUSE PURULENT MANIFEST 
LABYRINTHITIS. 

It is in this type of labyrinthine infection that the 
real difficulties are encountered ; here there is an 
active process with the problem of preventing or re- 
lieving an intracranial extension of the infection. It 
is well to remember the fact that not only are the 
meninges involved but there may be a brain abscess 
or thrombosis of the lateral sinus as well following 
an infection in the labyrinth. Either there is a very 
active labyrinthitis from which we fear meningitis 
or there is some definite evidence of meningeal 
involvement. 

The first step should be a spinal puncture and in 
the event of a normal fluid and no temperature, the 
case should be carefully watched and no operation 
attemi^ted. Experience has shown that quite a few 
cases of acute purulent labyrinthitis subside without 
intracranial complications and a normal fluid and 
temperature would indicate satisfactory progress in 
that direction. 

Again it has been proved that operation in the 
acute stage offers less chance than one performed 
where the process has had a chance to become quies- 
cent. In those cases of acute labyrinthitis followed 



immediately by a diffuse menmgitis in which the pa- 
tient almost immediately becomes unconscious with 
a high temperature, double Kernig, stiff neck, fluid 
cloudy and filled witli bacteria, I feel that any opera- 
tive procedure is useless. This leaves then those 
cases in which there is some evidence of meningeal 
involvement either through the symptoms or spinal 
fluid, but it is not diffuse. There is, therefore, a 
chance that an operation will help. When and what 
type of operation shall we perform? An important 
question here is whether or not there are bacteria in 
the fluid, and in case there are not, there is always 
a possibility of recovery as is shown by the ethmoid 
case reported above. 

With bacteria in the fluid, if surgical intervention 
is decided upon, a complete operation is indicated, 
including an opening into the internal auditory mea- 
tus, either by the Richards or the Neuman method 
with dural incision in the posterior fossa, realizing 
at the time that there is little if any hope of re- 
covery. Where there are symptoms of meningitis 
with no bacteria in the fluid, if under observation 
the case is progressive, a labyrinth operation by the 
Richards method seems the rational one, opening 
the second cochleal whorl if the symptoms and find- 
ings indicate it. The dura should be inspected in 
the posterior fossa. The Richards method seems 
preferable here because in removing the petrous 
portion of the temporal bone to get to the internal 
auditory meatus, the dura is adherent and is very 
likely to be torn and if there are no bacteria in the 
fluid, this may in itself cause a diffuse meningitis 
and the loss of the patient. 

Dr. Charles Perkins had a case of acute labyrin- 
thitis at the New York Eye and Ear Infirmary a 
short time ago in which the cell count in the spinal 
fluid went to 8,000 with culture of the spinal fluid 
negative. Still no operation was done and the pa- 
tient recovered. It would seem that operation was 
indicated there but none was done and the patient 
got well. I saw another case in which the cell count 
in the spinal fluid was 1,200. The spinal puncture 
showed 500: operation was deferred, dift'use menin- 
gitis developed suddenly and the patient died. These 
cases demonstrate how difficult it is to decide and 
one may be wrong either way. Generally speaking, 
a good rule woulcl be to operate if the findings show 
progression- of the infection and further observation 
if it shows improvement. 

W'here there is a tendency toward localization of 
the meningitis, repeated spinal punctures should be 
done both for diagnostic and therapeutic purposes. 
The possibility arises here for the puncture allowing 
the infection to extend to the lumbar region follow- 
ing the removal of the spinal fluid. This seems more 
theoretical than practical since those cases in which 
there is a localized infection as a rule show improve- 
ment each time the fluid is withdrawn. Where there 
is an accidental injury to the labyrinth during a mas- 
toid operation, such as injury to the horizontal semi- 
circular canal or removal of the stapes, tlie best 
procedure would seem to be to keep the patient 
under careful observation, performing a secondary 
labyrinth operation if necessary rather than a laby- 
rinth operation at the time of the injury. 

Richards calls attention to the fact that all cases 
of necrosis of the labyrinth are not necessarily due 



88 



BARKER: VINCENT'S ORGANISM. 



[New York Medical Journal 
AND Medical Record. 



to an extension from the mastoid or middle ear but 
may have their primary focus in the labyrinth, proba- 
bly through the blood or lymphatics. This again 
emphasizes the importance of a labyrinthine test and 
spinal fluid analysis, if indicated, prior to operation, 
so that we may be better guided as to what should 
be done where the radical operation shows labyrin- 
thine necrosis. 

CONCLUSIONS. 

Considering the number of ear infections, the 
labyrinth operation is rarely indicated. 

Where there is any labyrinthine function still 
present, a labyrinth operation is contraindicated. 

Where there is a dead labyrinth, no symptoms, 
and a normal spinal fluid, only the most conservative 
operation should be attempted . 

A spinal fluid analysis with a culture furnishes 



the most accurate information as to the progress of 
the infection. 

The prognosis in types one and two is good and 
in type three doubtful. 

The problem presented in type three is at present 
a difficult one and we must bear in mind the possibil- 
ity of a radical operative procedure,, inducing as well 
as preventing a diffuse meningitis. 

BIBLIOGRAPHY. 

Denxh : Diseases of Ear. 

Kerrison : Ibid. 

Perkins: Indications for Labyrinth Operation, Laryngo- 
scope. July, 1916. 

Idem: Leucocytosis of the Spinal Fluid in the Dignosis 
of Meningitis, Ameriean Journal Surgery, September, 1918\ 

Richards. J. D. : Labyrinth, Laryngoscope, October, 
1907. 

RuTTiN : Diseases of the Labyrinth. 

25 West Fifty-first Street. 



Infection with the Organism of Vincent* 

By CREIGHTON BARKER, M. D., 
New Haven, Conn. 



Infection with the organism of Vincent is now 
being subjected to intensive study. Physicians know 
more about the disease than ever before, as a result 
of experience gathered in the army. Nevertheless, 
it appears that its recognition and treatment have 
not yet been generally comprehended in a degree 
commensurate with public needs. It is the purpose 
of this paper to summarize the subject briefly and 
add such personal experience as will be of interest 
or value, laying particular emphasis upon the occur- 
rence of the infection in the throat, the clinical en- 
tity that is known as Vincent's angina. 

The use of Vincent's name to designate the or- 
ganism is, on the basis of priority, improper, for it 
was described in 1893 by Rauchfuss and in 1894 by 
Plaut, while Vincent's original contribution did not 
appear until 1896. To avoid confusion, however, 
the terms Vincent's organism and Vincent's angina 
will be retained throughout this paper. 

The organism appears in two forms, a long, spin- 
dleshaped, slightly curved or straight ' rod and a 
spiral. The early observers, including Plaut and 
Vincent, believed they were dealing with two or- 
ganisms growing in symbiosis. This thought was 
held in 1905 when Weaver and Tunniclif? reported 
their first successful cultivation. In 1913 Krum- 
weide and Pratt published the results of their stud- 
ies and also concluded that the forms were separate 
organisms. More recently, however, it has been ac- 
cepted that the two forms are one and the same 
organism, and lately it has been concluded that the 
organism is a leptothrix which, if it be a fact, would 
explain the pleomorphism. 

The rods are long and slender with pointed or 
occasionally roiinded ends, somewhat thicker in the 
middle. They are frequently slightly bent and some- 
times S forms are seen ; they vary from six to twelve 
microns in length. These rods are usually scattered 

•Read at the 138th semiannual meetinR of the New Haven County 
Medical Association, Waterbury, Conn., October 20, 1921. 



uniformly throughout the smears and present vari- 
ous arrangements, occurring in pairs end to end, 
forming obtuse angles, in irregular clumps, or ar- 
ranged radially about a central point, sometimes in 
groups like the Klebs-Loeffler bacillus. They stain 
fairly well with methylene blue and aniline gentian 
violet, but are most clearly demonstrated with car- 
bol fuchsin. With the less active stains, especially 
in the larger forms, there are frequently areas of 
varying size and shape which stain very faintly. 
They do not stain with Gram's method. The ques- 
tion of motility is much debated; I have not been 
able to demonstrate independent motion. 

The spirillae or spiral forms of the organism are 
long and delicate with pointed ends presenting five 
to eight curves and actively motile. They stain uni- 
formly but much less intensely than the rods and in 
faintly stained specimens may be overlooked. They 
do not stain with Gram's metlied but are easily dem- 
onstrated with dark field illumination. 

Cultivation of this organism, while difficult and 
uncertain, is not impossible. It is an anaerobe and 
in growing produces an offensive odor. Tunniclif? 
has isolated the organism from angina and gingivitis 
on ascites agar using Wright's anaerobic method. I 
have been successful in cultivating the organism in 
a one per cent, peptone broth to which a piece of 
human brain was added and the media overlaid with 
liquid petrolatum to exclude oxygen. On the second 
iir third day of incubation the characteristic odor and 
many active spirilL'e were present. The cultures 
died out rapidly and it was necessary to transplant 
large amounts to get successful subcultures. In 
young cultures forty-eight to sixty hours old, the 
organism is markedly polymorphous, spores are fre- 
quent, long chains of bacilli frequently appear, and 
vacuoles are occasionally seen. In one strain that 
was cultivated for several generations the fusiform 
bacilli alone appeared; on transplanting to sheep's 
blood agar the spirill.-e appeared in great numbers. 



July 19, 1922.] 



BARKER: VINCENT'S ORGANISM. 



89 



Each observer of the cuhural characteristics of this 
organism has something new to note, its habits are 
most bizarre. Some investigators have, after sev- 
eral generations, been able to cultivate the organ- 
ism aerobically. I have not been successful in this 
endeavor. Reckord and Baker in their work at 
Camp Devens were unaljje to grow their strains on 
any media. Larson and Barton in 1913 were suc- 
cessful in isolating the organism from the blood 
stream in a case shortly before death. My attempts 
at blood culture in five cases, including one exten- 
sively infected high explosive wound of the back, 
were all unproductive of results. 

Infection with this organism is frequently encoun- 
tered and although it may be said that the throat is 
the point most commonly attacked it is by no means 
the only site of the disease. Much early knowledge 
of the organism came from study of it in connection 
with the socalled hospital gangrene, a common result 
of infection of military wounds during the Crimean 
and Civil wars. Vincent made his original studies 
on material from such sources while serving with 
the French Army and later pointed out that the or- 
ganism derived from these cases of gangrene was 
identical with the one obtained from certain cases 
of ulcerative angina. 

The glans penis and prepuce are not infreqtiently 
attacked, the socalled balanitis gangrenosa, or fourth 
venereal disease. Recently a case was seen in which 
about half the prepuce had sloughed away and the 
necrosing process had extended well into the corona. 
Noma or gangrenous stomatiti.s, described by Blumer 
and McFarland, is another not unconnnon lesion 
caused by this organism. 

A search of the literature reveals reports of cases 
of pelvic peritonitis following endometritis in which 
this organism was the offender. Two cases of brain 
abscesses and one case of fatal meningitis have also 
been reported. Several cases of industrial wounds 
of the hands have been described. It was occasion- 
ally, but not frequently, seen with the Expeditionary 
Forces, infecting military wounds. Gangrene of the 
vulva and perineum has been reported and Noguchi 
has seen an ulcer of the labia dtie to this organism. 
The infective process has also involved the mucosa 
of the respiratory tract producing the physical signs 
of bronchopneumonia. Recently a case has been de- 
scribed in which there was infection of the external 
auditory canal with extensive destruction of the ex- 
ternal ear and Phillips and Berry have reported a 
case of widespread stomatitis in a dog caused by this 
organism. Such infections as those cited are, how- 
ever, extremely unusual and the physician in general 
is more deeply concerned with the lesion as it occurs 
in the throat. 

The disease to which attention is now directed has 
been described under several names, Vincent's an- 
gina, ulcerative angina, ulceromembranous angina, 
angina diphtheroides, angina chancriform, pseudo- 
membranous angina and others. Of all these ulcero- 
membranous angina suggested by Weaver and Tun- 
nicliff in 1905 seems to be the happiest choice al- 
though Vincent's angina has so lung been used it 
will probably not be supplanted. 

The prevalence of this infection is not well real- 
ized. It is a common disease. The fact that it is not 
made reportable by departments of health, although 



it must be considered a contagious disease, makes it 
impossible to present definite figures as to its occur- 
rence. It is, however, frequently encountered by the 
careful observer. It is mentioned with increasing 
frecjuency since the war. Whether this is due to the 
more intimate knowledge of the condition derived 
from medicomilitary experience, or whether the dis- 
ease is more widely disseminated as a result of our 
mobilization, it is difficult to say, both factors proba- 
bly entering into the increasing amount of considera- 
tion that the disease is now receiving. 

There is little to be said regarding its especial 
geographical distribution ; it seems to be a universal 
disease. The Japanese have studied the subject, it 
is mentioned from India, Central European litera- 
ture contains much concerning it, it receives the 
present day consideration of the foremost Italian 
pediatrists, and a most comprehensive review of the 
clinical aspects of the disease has recently come from 
a Norwegian clinic. 

The majority of cases have been in young adults 
from eighteen to twenty-five years of age, although 
one observer has reported cases in- children from 
twenty-six months to thirteen years. In the series 
of twenty-seven cases here reviewed, which excludes 
an unnumbered group encountered during military 
service and for which data are incomplete, the 
youngest was fourteen years, the eldest thirty-two. 

Males appear to be more frequently affected than 
females, but this may be due to the fact that many of 
the groups studied have been soldiers. In my series 
there were twenty-five males and two females. In 
the group reported by Weaver and Tunnicliff fe- 
males predominated. 

The use of tobacco, trauma of the mucous mem- 
brane — as after tonsillectomy — eruption of wisdom 
teeth, defective teeth or those covered with tartar, 
alveolar abscesses, scorbutic gums, syphilis, and mer- 
curial stomatitis, are said to be predisposing causes 
and it is said to follow infectious diseases such as 
measles, scarlet fever and whooping cough. 

In the cases in the present series there is little to 
be said in regard to predisposing factors. Of the 
twenty-seven patients all but four were tobacco smok- 
ers, none chewed tobacco, twenty-three of the cases 
presented dental toilets that were all that could be 
desired, one had carious teeth, six had had tonsillec- 
tomies. Eleven, including one woman, had been in 
the late war, seven, also including a woman, had 
been overseas. None gave recent histories of acute 
infectious disease, none had stomatitis due to mer- 
curials or other cause and all but two gave negative 
Wassermann reactions ; in these two cases it was not 
practicable to obtain specimens of blood. In regard 
to trauma of the mucosa it may be noted that over 
fifteen hundred tonsillectomies have been observed 
(luring the past two years with no case of \'incent's 
angina as a sequel. 

The pathology of the affection has been divided 
into three stages : the onset, characterized by con- 
gestion and edema ; the formation of the pseudo- 
membrane, and lastly the period of ulceration. It is 
scarcely possible to distinguish these stages in any 
given case. 

The disease is commonly located on the tonsils or 
edges of the gums. In two of these cases it extended 



90 



BARKER: VINCENT'S ORGANISM. 



[New York Medical Journal 
AND Medical Record. 



to the soft palate, in one to the pharyngeal wall, in 
one to the mucosa of the cheek. Some observers re- 
port infection of the tongue and lips but it did not 
appear in this group. The gingivitis and angina may 
appear simultaneously or independently ; five of the 
cases presented gingivitis alone. The lesions on the 
tonsils are usually unilateral, in two cases they were 
bilateral. The lesions are usually rounded and vary 
in size from half a centimetre up to an ulcer involv- 
ing practically the entire tonsil. The pseudomem- 
brane is usually a greyish white, sometimes with a 
yellow tinge and of greasy consistency. This mem- 
brane is easily removed and leaves a bleeding sur- 
face beneath, which again becomes covered with 
exudate in a short time. As the disease progresses 
the ulcer rapidly becomes deeper but there is little 
indication of lateral extension. In two cases in this 
series the process extended very deeply, in one about 
two thirds of the tonsil was destroyed and an annular 
perforation through the anterior pillar appeared. In 
another the rounded tip of the tonsil necrosed away, 
continued treatment seemed to accomplish little, there 
was more or les£ constant oozing of blood and a ton- 
sillectomy was performed. Section of the tonsil 
showed the organism throughout and smears made 
from the tonsillar fossa after operation showed the 
organism there also. The typical pseudomembrane 
appeared in the fossa but ulceration did not become 
extensive. This patient, a former overseas nurse. 
was under constant observation for five months and 
when last seen four months ago the lesion was en- 
tirely healed. 

When the pseudomembrane is removed the ulcer 
appears as a bleeding, granulating area with irregu- 
lar borders. It may be confused with a secondary 
syphilide. The area surrounding the ulcer is usually 
firm and healthy, the surrounding edema and redness 
stated by some authors has not been observed. 

In all of the cases in this group in which the dis- 
ease was located on the tonsils there were varying 
degrees of adenitis. The severity of the glandular 
involvement bore no relation to the extent of the ton- 
sillar lesions. In the case of the nurse quoted above 
there was but little involvement of the lymphatics. 
But one case of adenitis was observed when gingi- 
vitis existed alone. 

One of the outstanding features of this disease 
according to the older writers was the extreme de- 
gree of prostration and malaise displayed by the 
patient. Thus Osier describes the condition as "an 
acute febrile inflammation the general symptoms 
of which are severe." This is not borne out in the 
experience of those who encountered the disease in 
military practice. Record and Baker reporting fifty- 
six cases from Camp Devens found thirty-six pa- 
tients complained of malaise, thirty-three had head- 
ache of moderate degree, and seventeen had back- 
ache. The average tem|)erature was between 99° and 
100°. In the present group seven complained of 
symptoms other than sore throat and dysphagia. Of 
these seven all had slight headache and backache, 
one had a definite chill. Three had temperature of 
100°. One patient, one noted above as having had 
a chill, was definitely sick, with a chill, a temperature 
of 102.5° and was confined to bed for eight days. 
This and one other to be noted later were the only 
cases that were not ambulatory. All of the cases 



presented fetid breaths. The common picture pre- 
sented by these patients is dry, sore throat, discom- 
fort durmg swallowing, fetid breath, coated tongue, 
constipation and a varying degree of lassitude; the 
temperature may or may not be slightly elevated: 
The syndrome is much like that encountered in acute 
tonsillitis. 

Various complications are reported by other ob- 
servers, follicular tonsillitis, peritonsillar abscess, in- 
fluenza, chronic interstitial nephritis, otitis media, 
septicemia, arthritis, pneumonia, pleurisy, polymor- 
phous eruptions and appendicitis have been noted. 
In the cases here presented no complications were 
observed except herpes which was present in four 
cases including both women. 

Contagion in this disease has been discussed by 
various writers, and all agree that it is transmitted 
from one person to another by close contact. Pen- 
cils, pipes, cigarette holders and eating utensils are 
undoubtedly responsible for its spread. Small epi- 
demics in closely associated groups are frequently 
encountered. Five of the patients in this group lived 
in the same fraternity house, two others were broth- 
ers, the army nurse whose severe infection has been 
described was the fiancee of another patient included 
in the series. 

It seems necessary that persons suffering from 
this disease should be forbidden intimate contact 
with others. They offer a difficult problem not un- 
like the diphtheria carrier. These patients are not 
very sick, most of them are ambulatory and strict 
quarantine is scarcely to be advised. The plan fol- 
lowed by the department of university health at 
Yale during the small epidemic of last year was ap- 
parently a satisfactory means for control. The pa- 
tient was told that his disease was contagious, was 
warned against communicating it to others, and re- 
quired to get his meals at the university infirmary 
where all utensils were sterilized. Similar control 
was applied to patients in private practice, and when 
they cooperate intelligently the result is satisfactory. 

The diagnosis of the disease depends upon the 
microscopic examination of the exudate and demon- 
stration of the organism. It will be most frequently 
confused with diphtheria and Itxes. In one of these 
cases, a boy fourteen years of age, the patient had 
received 20,000 units of diphtheria antitoxin and 
three reports negative for the Klebs-Loeffler bacillus 
had been returned from the laboratory before a 
correct diagnosis was made. Had smears been made 
from the material on the swab as well as from the 
incubated cultures the diagnosis could have been 
made at once. The lesion is not unlike a syphilitic 
ulcer and this differentiation must be made by the 
dark field examination. A positive Wassermann 
proves nothing for many observers have noted the 
two diseases existing coincidentally. 

The ])rognosis in this disease is good, proper treat- 
ment bringing about a cure. Fatalities are rare in 
those cases in which angina and gingivitis exist 
alone. Noma is frequently fatal and in the only 
recorded cases of meningitis, brain abscess and peri- 
tonitis caused by this organism diagnosis was made 
at autopsy. The case with the shortest duration in 
this series presented a small patch on one tonsil that 
was healed in four days, the longest case required 
five months and surgical intervention to heal. Ex- 



July 19, 1922.] 



TRAUB: LUMBAR PUNCTURE. 



91 



eluding this case which was unusual in many ways 
the average duration of the remaining twenty-six 
cases was twelve days. 

Many methods for the treatment of this disease 
have been suggested : silver nitrate, chromic acid, 
potassium permanganate, zinc chloride, all have their 
advocates. In the cases treated in the army and 
those included in this report one method has been 
employed that has been eminently satisfactory, in 
fact it might almost be considered a specific. It is 
as follows : The pseudomembrane is removed en- 
tirely with a swab saturated with peroxide of hydro- 
gen, or when available a power spray of peroxide, 
the ordinary hand spray not being sufficiently pow- 
erful. Much of the success of the treatment depends 
upon the thoroughness with which this membrane is 
removed. The bleeding base of the ulcer is now 
thoroughly swabbed with a five per cent, solution of 
salvarsan in glycerine, the swab rotated and the sal- 
varsan rubbed deeply into the ulcerating surface. 
This is done twice each day at the start, later once 
a day is often enough. For practical purposes .6 
gram of salvarsan in one ounce of glycerine makes 
the proper solution ; it should be shaken before using. 
Old salvarsan. neosalvarsan and the recently devel- 
oped silver salvarsan were used but there was no 
evidence of any superiority of one above the others. 

The question as to what might occur if an appre- 
ciable amount of the salvarsan solution was swal- 
lowed gave some concern until some time ago there 
was reported from Berlin the case of a woman who 
for six consecutive days took .3 gram of neosalvar- 
san in a glass of water. For ten minutes after in- 
gestion she had suiifered from slight abdominal pain. 
Three days after the first dose diarrhea set in but 
at the end of six days the stools were normal. The 
patient.. showed no objective pathological symptoms, 



the urine was free from sugar and albumin, and no 
arsenic could be demonstrated in the urine. 

Some clinicians advocate the intravenous admin- 
istration of salvarsan, but in view of the fact that 
this procedure is not entirely devoid of danger, and 
having in mind the satisfactory results obtained with 
the local application of the drug its intravenous use 
in the treatment of the ordinary case of Vincent's 
angina is not recommended. 

Brief mention should be made of the frequent 
occurrence of infection with this organism with 
acute leucemia, several writers having recently noted 
this coincidence. Two such cases have come to my 
attention, both fatal, in which there was widespread 
gingivitis due to this organism. No blood cultures 
were made. One observer has seen twenty-two such 
cases, nine of the patients apparently recovering 
after the intravenous administration of salvarsan. 
The cause of acute leucemia is as yet unknown, and 
whether this organism of Vincent may be an etio- 
logical factor, as some writers seem to believe, or 
whether the frequent occurrence of gingivitis and 
stomatitis is due to lessened resistance dependent 
upon the leucemia has yet to be proved. 

In conclusion, attention should be centred upon 
certain important facts in connection with this dis- 
ease. First, it is an infection that is frequently en- 
countered apd in all cases of membranous sore throat 
smears made directly from the exudate should be 
examined as well as incubated cultures. Second, 
the disease is readily communicated by direct and 
indirect contact and precautions against its spread 
.should be instituted at once after diagnosis is estab- 
lished. Third, the application of salvarsan directly 
to the lesions is a safe and satisfactory method of 
treatment. 

66 Trumbull Street. 



The Status of Lumbar Puncture and the Prevention of 

Its Gomphcations 



By HUGO W. TRAUB, M. D, 
Chicago. 



The extensive use which socalled lumbar punc- 
ture has gained for itself, the manner of its em- 
ployment as well as the attitude toward the same 
through its much widened indications, make it per- 
tinent perhaps to inquire briefly what its status is, 
what, if any, safeguards should proi)erly circum- 
scribe it, and finally, how its attendant ri.sks and 
complications may at least be substantially lessened, 
if they cannot be entirely eliminated. 

Introduced originally by Ouincke as a therapeutic 
measure designed to relieve hydroce[)halus, its devel- 
opment soon entered a prolonged period in which it 
became a diagnostic rather than a therapeutic meas- 
ure, which gradually extended itself beyond the do- 
main of neurological investigations to various other 
fields, such as pediatrics, surgery, internal medicine, 
and particularly to that sizeable one of "obscure 
diagnosis." Not until the introduction of Flexner's 
serum did its therapeutic use really come into its 



own, and the simultaneously developing direct in- 
traspinal therapy of specific cerebrospinal lesions has 
given it a therapeutic field as wide as the diagnostic, 
indeed the puncture of the subarachnoid space has 
become so routine a procedure that, aside from those 
conditions in which its use is imperatively indicated, 
an extended clinical investigation is regarded in- 
complete without it. 

But even among its earliest users it was soon 
discovered that this procedure was not unattended 
by serious risks, and Oppenheim was among the 
first, if not the first, to sound the warning of nil 
nocclc. Neurologists naturally first noted accidents 
and complications of various sorts and we find ac- 
cordingly among Schoenbeck's frequently quoted 
collection of seventy-one deaths, which occurred 
immediately or very .shortly following puncture and 
which were reported between 1895 and 1914, that 
thiny-seven of these terminated cases of intracra- 



92 



TRAUB: LUMBAR PUXCTURE. 



[New York Medical Jodrnai 
AND Medical Record. 



nial tumor. Thus suspected or definiteh' diagnosti- 
cated intracranial tumor fairly early became re- 
garded as a contraindication ; nonfatal accidents and 
sequels received little attention. But relatively just 
as little attention is accorded these latter now well 
known possibilities in two recent monographs on the 
cerebrospinal fluid, although Boyd makes note of a 
"remarkable diversity of opinion concerning the fre- 
quency of untoward aftereffects" and remarks that 
the procedure is not so essentially harmless. Levin- 
son minimizes the danger of death, which probably 
applies more especially to those conditions for which 
puncture is done in children. Quincke himself in 
1914 reviewed his experience, laid down well defined 
indications and particularly advocated a careful tech- 
nic, which included among other things manometric 
control — this latter at that time rarely mentioned in 
the American literature. 

Yet puncture is rather commonly practised, to say 
the least, indifferently ; it is still done in the office 
or the ambulatorium, and 
the patient sent about his 
business or instructed to 
rest at home. One of the 
commonest aftereffects — 
the bitterly complained 
of headache — makes sub- 
sequent punctures more 
difficult to obtain consent 
for. It remained for 
Frazier to give the en- 
tire matter of puncture 
comprehensive treatmen*^ 
and to accord the prob- 
lem of its possible com- 
plications adequate and 
systematic exposition. 
Frazier logically places 
all these complications 
into two groups : those 
due to damage produced 
at the puncture site and, 
secondly, those due to 
the remote effects of 
withdrawal of fluid. 

In so far as the first 
group is concerned, it is ' 

obvious that the degree of local trauma produced 
must depend largely on the manner of introduction 
of the needle. In a careful study of this point, Regan 
called attention to the marked topographical ditfer- 
ences which exist at different ages in the path which 
the needle must pursue ; and that in consequence the 
age of the patient and the amount of flexion of the 
spine possible are moments that should be taken into 
account in determining the manner of puncture. On 
anatomical grounds Regan, moreover, conclusively 
shows the great advantage ordinarily of the median 
route in adults as well as children, other things re- 
maining equal. It offers, as a rule, tlie greatest chance 
of immediately successful entrance and therefore the 
minimum degree of trauma. In any event, no very 
great skill or anatomical knowledge should be neces- 
sary to avoid such an accident as aortic puncture. 
Nevertheless, even under optimal conditions, there 
does, and must in the nature of things, occur a small 
measure of injur}- to the meninges, and perhaps to 




Fig. 1. — Posture and control of patient in lumbar puncture. Spine 
is tlexed and the entire patient held securely in the manner shown. 



The buttocks rest 
working room. 



the nervous parenchyma, which in the light of recent 
investigations may attain under certain circumstances 
very considerable significance. Wegeforth and 
Latham — stimulated doubtless by certain curious 
and heretofore inexplicable experiences in military 
hospitals — have shown that it is possible to produce 
meningeal infection under certain conditions, by 
puncturing an animal in which a septicemia has been 
just previously induced. This has been confirmed 
by Reginald \\'ebster, who worked with monkeys 
and who showed furthermore that the probability 
of meningeal localization taking place varies directly 
with the intensity of the septicemic process. The 
possible existence of a general septicemic process 
should therefore make a contemplated puncture a 
procedure not to be imdertaken without a little cir- 
cumspection, if the first principle underlying any 
diagnostic or therapeutic measure be to do no 
harm. Webster wisely denies to puncture the func- 
tion of a "possible royal road to the diagnosis of an 

obscure condition." 

A secondary condition 
substantially influencing 
the frequency of various 
mishaps pertains to the 
posture of the patient. 
Aside from the imme- 
diate advantage of the 
influence of gravity in 
obtaining fluid, the ver- 
tical position offers many 
disadvantages and has in 
consequence fallen into 
relative disfavor. If the 
alternative horizontal 
posture be employed in 
a uniform mann.er — the 
spine being simultane- 
ously fle.xed and fixed to 
the maximum degree and 
the entire patient effect- 
ively controlled in the 
manner shown — a con- 
siderable part of the ac- 
cidents due to otherwise 
unavoidable but unneces- 
sarv- local trauma can be 
prevented. If the patient is unable suddenly to 
extend the spine, an effective method of physical 
restraint, such as is pictured herewith (Fig. 1), 
makes it almost impossible for him to pinch off the 
steel needle ordinarily employed. In a fairlv large 
number of punctures this posture and method were 
found uniformly satisfactory without any form of 
local anesthesia. It goes without saying, of course, 
that special conditions may reqtiire some modifica- 
tion ; opisthotonus or a pathological degree of irrita- 
bility may even compel some form of anesthesia. 

Frazier's second group of complication.s — those 
due to the remote effects of puncture — are doubtless 
of considerably greater importance. Even if the 
])hysiological conception of the cerebrospinal fluid as 
a simple mechanical water bed could be maintained 
— and scarcely anywhere in physiology can we find 
.so simple a functional interpretation — it would be 
necessary to take into account the fact that with- 
drawal of cerebrospinal fluid from the intact nervous 



the edge of the bed giving convenient 



July 19, 1922.] 



KLEIN BERG: OPERATIVE TREATMENT OF SCOLIOSIS. 



93 



system of an animal produces distinct, abnormal 
circiilator>' changes, namely hyperemia and punctate 
hemorrhages, within the brain and cord (Ossipow). 
Since these are doubtless changes due to more or 
less suddenly altered pressure relations, and since 
the mechanism regulating the normal intraarachnoid 
pressure is not known, it would appear that herein 
lies a factor, too long ignored, and of the very great- 
est importance. It has, moreover, been emphasized 
by Quincke that the reading at the puncture site is 
not the actual pressure throughout the higher levels 
of the subarachnoid space, in which pressure 
changes, owing to the anatomical subdivisions of the 
latter, take place more slowly. It is nevertheless 
reasonable to suppose that the rate of pressure 
change at any level of the canal is directly dependent 
on the rate of fluid withdrawal. To do no harm, 
therefore, will require that the intraarachnoidal pres- 
sure relations during fluid withdrawal be manonie- 
trically controlled and that the fluid volume removed 
be governed by the pressure readings. Quincke, in 
this connection, advises that when puncture is 
done for therapeutic purposes and the initial pres- 
sure is normal, the end pressure shall not be per- 
mitted to fall below 100 mm. £1,0; if increased ini- 
tially, to not less than forty to sixty per cent, of the 
nia.ximum. 

It is obvious that such considerations as these 
perhaps do not apply with equal force to such con- 
ditions — as in meningitis — in which a very great 
increase in pressure owing to increased fluid volume 
exists, as they do in cases of present increase due 
to space encroachment, as, for example, in brain 
tumor ; or again, to conditions in which there is a 
marked disturbance in the interrelationship between 



the intraarachnoidal and the intravascular pressure. 
Quincke does not regard the suspected existence of 
an intracerebral tumor a positive contraindication, 
but insists that puncture be surrounded with the 
necessary safeguards, chief among which is niano- 
metric control. 

It has not been the purpose in the foregoing to 
enumerate the entire formidable list of possible com- 
plications and sequelae of lumbar puncture ; nor has 
it been intended to convey the impression that any- 
one is able with our present facilities and knowledge 
absolute to avoid all of these. It is not possible, for 
example — no matter how skilful the technic — to 
avoid woimding at times the intraspinal venous 
plexus, with its resultant difficulties due to bloody 
fluid and the rapid plugging of the needle with clot. 
Xor is it possible invariably to avoid nerve roots, 
although Regan assures us that the median route 
renders this much more likely. Yet it would appear 
that the total incidence of accidents and certainly by 
far the greatest part of the more serious ones are 
avoidable. 

Accordingly it is submitted that so valuable a 
procedure as lumbar puncture should not be ap- 
proached in a spirit of perfunctoriness; that it con- 
tains the elements of a minor surgical attack when 
properly safeguarded, though one with maximally 
awkward possibilities when indifferently executed; 
anfl finally, that most, if not all, of its dangers may 
be avoided by mannmetric control of the fluid, by the 
e.xercise of circumspection and the use of a certain 
amount of anatomical knowledge, and by the aban- 
donment of its practice in the ambulatory patient 
altogether. 

30 North Michig.\n Avenue. 



The Operative Treatment of Scoliosis'* 

By S. KLEINBERG, M. D., F. A. C. S., 
New York. 



It is, 1 believe, generally known and admitted that 
we are able by means of corrective jackets applied 
over a long period of time, to improve about sixty 
to seventy per cent, of cases of structural scoliosis 
including all types. The treatment which I have 
found most effective is carried out with the spine in 
extension but with certain important modifications 
and details. In brief, the method is as follows: 
The patient is suspended until the feet barely touch 
the floor. The pelvis is fixed, the chest twisted to- 
ward the side of the convexity, lateral traction is 
applied over the most prominent part of the deform- 
ity and countertraction on the shoulder and pelvic 
girdles. It is essentially a fixation of the trunk in 
an attitude opposite to that of the deformity. Dur- 
ing the treatment no chance for even momentary re- 
lapse of the deformity is allowerl. The treatment 
is one of gradual stretching, and at each application 
of a jacket an attempt is made to im[)rove further 

*Rcad at a meetini; of the Alumni of the Hospital for Ruptured 
and Crippled, November 21, 1921. 



the appearance of the back and to reduce the cur- 
vature. With this treatment carried on continuously 
for one to five years we are able in the majority of 
the cases to prevent the deformity from getting 
worse and to obtain a marked degree of improve- 
ment. With appropriate aftercare by means of cor- 
sets, exercises, attention to [Xjsture, clothing, seating, 
etc., we are able to retain the improvement, 

This treatment is, however, not wholly satisfac- 
tory. To be effective it must be prolonged over a 
period of years. It is more or less uncomfortable to 
the patient and frequently interrupts school or busi- 
ness. It requires also an expenditure of a great 
amount of energy on the part of the surgeon. 

There are additional observations which have 
urged us to seek a shorter and perhaps more effective 
treatment. It is a well known' fact that in a certain 
))roportion of the cases the curvature of the spine 
and the deformity of the trunk become exceedingly 
marked so that not only is the deformity conspicuous 
but there is an actual interference with the func- 



94 



KLEIN BERG: OPERATIVE TREATMENT OF SCOLIOSIS. 



[New York Medical Journal 
AND Medical Record. 



tion of the internal organs, especially the lungs and 
gastrointestinal tract. 

All cases are mild at the start, but relatively few- 
remain mild. In a given case of mild scoliosis in a 
child it is impossible to predict the course of the 
scoliosis. The deformity may remain stationary or 




Fic. 1. — Frame used in the preoperative and postoperative treat- 
ment of scoliosis. Traction is applied to the Iiead and to the pelvis. 

may become worse. In certain types, as rachitic, 
paralytic and cervicodorsal curves of all varieties, it 
is almost certain that the condition will grow worse 
and that at leasl some of the patients will develop 
into razor backs. In some cases, even with treat- 
ment, the deformity becomes worse. It has also 
been observed that a scoliotic deformity may remain 
stationary for years and then, even in adult life, 
grow worse. These facts have led to the trial of a 
different system of treatment which may be divided 
into the preoperative and operative stages. 

PREOPERATIVE TREATMENT. 

It has been observed that when the trunk is in 
extension there is a reduction of the prominence of 
the projecting ribs and an improvement in the ap- 
pearance of the back, just as there is an exaggeration 
of the deformity when the trunk is flexed. It was, 
therefore, suggested by Whitman that the patients 
be given a period of treatment in extension or hyper- 
extension on a convex stretcher frame. The frame, 
which is the same as that used for Pott's disease, 
is supported on the ordinary hospital bed and the 
patient is placed upon it. This treatment is con- 
tinuous, and the patient is not permitted to get oflf 
the frame or even to sit up. After a few days, when 
the patient has become accustomed to the frame, trac- 
tion is applied to the head and pelvis, and in some 
cases lateral traction is used over the convexity. 

In those cases which are amenalile to improve- 
ment, that is in all but the severe cases, there is ob- 
served a marked change in the appearance of the 
back in about four to eight weeks. The projection 
of the ribs and the curvature of the spine are re- 
duced. The degree of improvement obtainable, so 
far as mv present experience goes, is about the same 
as that accomplished with jackets after many months 
of treatment. The only difference appears to be 
this, that the reduction of the deformity on the 
frame occurring rapidly tends to disappear almost 
immediately when the patient is stood up. In the 



plaster jacket treatment, however, the improvement 
takes place very slowly and is the result of actual 
change in the bony and soft structures, and hence 
either remains when the jackets are taken off or 
disappears gradually. 

As in the treatment with jackets a maximum de- 
gree of improvement is reached beyond which it 
seems impossible to change the spine. So far I 
have found that the maximum degree of reduction 
of the curvature is obtained in about eight weeks. 

OPERATIVE TRE.\TMENT. 

When the back has been improved as far as pos- 
sible by this method a fusion operation is per- 
formed. As immobilization of the back has given 
good results, internal fixation of the spine by fusion 
and splinting of the vertebrae is believed to offer, 
through more accurate immobilization, opportunity 
of arresting the deformity at whatever stage we see 
it. Fusion of the spine is undertaken in the belief 
that a solid column such as a fused spine will have 
less tendency to bend and become crooked than a 
segmented column made up of a number of vertebrae. 

At first I did the Hibbs fusion operation. I 
found that there resulted a certain degree of stiffen- 
ing of the back, but that complete bony ankylosis did 
not occur except perhaps in the dorsal region. The 
X ray, by the way, was of no help in determining 
the presence of ankylosis. In the dorsal spine, where 
there is normally only a slight amount of motion, 
it is difficult to determine whether there was com- 
plete bony ankylosis after operation. Clinically the 
dorsal spine was more favorably affected by the 




Fig. 2. Fio. 

Fig. 2. — Paralytic left dorsal scoliosis. Picture taken before 
treatment was begun. 

Fig. 3. — Picture of same patient as Fig. 2 taken some time after 
the operation, showing the reduction of the curvature, the graft ex- 
tending from the fourth dorsal to the second lumbar vertebra. 

operation than the lumbar. Flexion of the dorsal 
spine after fusion operation was very markedly re- 
stricted and in some cases apparently entirely elim- 
inated. In the lumbar region the degree of stiffen- 
ing was very mucli less marked. 

As the simple fusion operation did not result ap- 



July 19, 1922.] 



GOLDFADER: PYELITIS. 



95 



parently in solid bony ankylosis, I modified the 
operation by adding to the ordinary Hibbs fusion, 
splinting of a comparatively large number of verte- 
brje by means of a stout beef bone graft. The tech- 
nic is a combination of the methods devised by Albee 
and Hibbs, with the exception that I use a beef bone 
graft to shorten the time of operation. 

The graft is long enough to extend from one end 
to the other of a single curve or of one section, pre- 
ferably the dorsal, of a compound curve, Usually 
the graft is about eight inches long and extends from 
the second or third to the twelfth dorsal vertebrae. 
The typical Hibbs fusion operation is performed on 
the most curved part of the spine. The spinous pro- 
cesses of the two uppermost and the two lowest 
vertebras of the operated section are then split and 
the graft is laid on the laminae and transverse pro- 
cesses on the concave side of the curve, the ends of 
the graft being imbedded in the split spinous pro- 
cesses. The periosteum and muscles are sewed with 
kangaroo tendon, and the subcutaneous tissue and 
skin sewed with catgut. 



POSTOPERATIVE CARE. 

The patient is put back to bed and not on the 
frame. After about a week or ten days the patient 
feels comfortable and can be again placed on the 
frame. Traction is then applied to the head and 
pelvis, and maintained for about eight weeks. Dur- 
ing this time healing becomes very firm and the pa- 
tient receives a supporting brace or plaster jacket 
or corset which is to be retained for about three to 
six months. 

This is a preliminary report and my experience 
has not extended over a sufficient length of time 
to warrant conclusions as to the nature and perma- 
nency of the results. It is hoped, however, that the 
preoperative treatment on the convex stretcher frame 
will yield the same degree of improvement as is 
obtained by the more prolonged treatment in plaster 
jackets, and that the fusion and splinting of the 
spine will retain the improvement and prevent in- 
crease of deformity. 

1 West Eighty-fifth Street. 



Colon Bacillus Pyelitis 

By PHILIP GOLDFADER. M. D., 
Brooklyn, N. Y. 



Pyelitis, strictly considered, is an inflammation of 
the mucous membrane of the pelvis and calices of 
the kidney, in contradistinction to pyelonephritis 
which means an infection of both the pelvis and 
parenchyma of the kidney. Acute colon bacillus 
pyelitis does not exist as a clean cut pathological en- 
tit}-. As a rule, all cases of acute pyelitis are asso- 
ciated with varying degrees of pyelonephritis. In 
the subacute and chronic forms, the involvement of 
the parenchyma subsides and it is then that we have 
an almost true pyelitis. Strictly speaking all infec- 
tions of the kidney, from the mildest to the gravest, 
represent different stages of the same condition. In 
a case of pyelitis with obstruction the advent of other 
bacteria may convert the kidney into a pyonephrotic 
sac. 

The actual exciting cause of pyelonephritis is al- 
ways a bacterium. In one hundred and forty cases 
recorded by Kidd, one hundred and seventeen were 
due to the colon bacillus, nine to the streptococcus, 
twice in conjunction with the colon bacillus ; seven 
cases were due to staphylococcus, once in conjunc- 
tion with the colon bacillus; two to the gonococcus, 
one to the proteus bacillus, one to the paratyphoid 
bacillus, one to the bacillus asiaticus, one to the para- 
malta fever and in nine cases no bacteria were (letcr- 
mined. Predisposing causes according to Kidd may 
be divided into four groups. 

A. Causes which i)romntcd bacterial invasion of 
the blood stream at a primary focus of infection: 1. 
Throat infections — dust stirred up by spring clean- 
ing. 2. Bowel infections — infected food. 3. Family 
infections — carriers of bacteria. 

B. Causes which stirred up bacteria already lying 
dormant in a primary focus: 1. Gunshot wounds, 



especially cases of septic compound fractures. 2. 
Operations in septic fields — stitch abscess after ap- 
pendicitis, and after excision of rectum. 3. Bowel 
infections, ■ such as constipation, diarrhea, colitis, 
gastric ulcer, gallbladder infections, typhoid fever 
and dysentery. 

C. Causes which lowered the general resistance of 
the blood and tissues to bacterial invasion: 1. Physi- 
cal overexertion, mental and emotional overexertion, 
fatigue, chill, etc. 

D. Local mechanical, physical or chemical causes 
which lowei-ed the resistance of the kidney and ren- 
dered it susceptible to infection by bacteria when 
filtering through it: 1. Stone in the kidney or ureter. 
2. Congenital hydronephrosis. 3. Enlarged pros- 
tate. 4. Stricture of the ureter. 5. Vaginal prolapse 
with cystocele. 6. Pregnancy. 7. Splanchnoptosis, 
etc. 

i\Iuch controver.sy has arisen as to the route of 
invasion. The consensus of opinion seems to favor 
the hematogenous route. It is a well established 
fact that organisms may be found circulating in the 
blood of patients suffering from various aihuents 
as well as in individuals in apparently good health. 
The sources of these organisms are innumerable. 
The bacteria may be derived from focal infections 
in various parts of the body, or catarrhal infections 
of the various mucous membranes. The intestine is 
the usual source of the colon bacillus infections, 
while other bacteria are derived from foci of low 
grade infections in the vagina, urethra, tonsils, teeth, 
adenoifls, furuncles, accessory nasal sinuses, appen- 
dicitis, etc. 

One of the most convincing series of experiments, 
bearing immediately upon focal infections and py- 



96 



GOLDFADER: PYELITIS. 



[New York Medical Journal 
AND Medical Record. 



elonephritis, has been completed by Bumpus and 
Meisser of the Mayo Clinic. Their studies were 
based upon a series of cases presenting subacute 
lesions of the urinary tract with dental or tonsillar 
sepsis, and colon bacilli predominating the urine. 
Not only were they able to produce in the majority 
of the animals injected definite renal lesions from 
cultures taken from the teeth or tonsils, but in two 
of their cases, showing marked exacerbation follow- 
ing tooth extraction, they were able to recover strep- 
tococci from the urine, which, when injected into 
animals, produced lesions of the urinary tract, iden- 
tical with those obtained from cultures of the teeth. 
These experiments show conclusively that strepto- 
cocci isolated from infected tonsils and teeth mani- 
fest a striking selective affinity for the urinary tract, 
for of the twenty-six animals injected with primary 
cultures, twenty-four had lesions of the kidney and 
eight showed lesions in both kidney and bladder. 
Further, they were unable in those patients, whose 
urine showed only colon bacilli, to produce in ani- 
mals any definite renal lesions by intravenous injec- 
tion of culture from this source. 

A large number of the organisms are carried to 
the liver, where they are destroyed by the cells and 
endothelium and are excreted in the bile, while bac- 
teria which enter the general blood stream reach the 
kidney and are excreted in the urine. W. Wyssoko- 
mitsch (2) experimented on dogs with the anthrax 
bacillus, streptococcus and staphylococcus, and con- 
cluded that bacteria appeared in the urine only after 
there had been a focus of infection in the kidney. 
Briedl and Kraus (3), by a series of very careful 
experiments, showed that in dogs and rabbits staphy- 
lococci appeared in the urine as early as twelve min- 
utes after being injected into a vein. 'The urine 
which contained them had no albumin and the kid- 
neys on microscopical examination seemed perfectly 
normal. The appearance of typhoid bacilli in the 
urine, without pus or albumin, and the very large 
percentage of positive findings of tubercle bacilli in 
the urine during a case of florid tuberculosis, show 
that there can be but little question of bacteria being 
frequently excreted through healthy kidneys. The 
sole condition of this excretion is the presence of 
bacteria in the blood. A kidney may excrete bacteria 
indefinitely without involving the kidney tissue, but 
if for some definite reason the resistance of the kid- 
ney is lowered, involvement of the kidney tissue may 
follow. This may be caused by the constant irri- 
tation of the excreted bacteria and their toxins. The 
most frequent predisposing cause is obstruction to 
urinary drainage such as that due to a movable kid- 
ney, with kinking narrowing or twisting of ureter, 
calculus, hydronephrosis, stricture of the ureter, 
pressure of a pregnant uterus on the ureter, stric- 
ture or obstruction at or below the vesical neck. But 
the most important predisposing causes of all are 
those which lower the general resistance of the body, 
such as overwork, worry, fatigue, chill and starva- 
tion. 

There are three paths by which bacteria might 
reach the kidney: 1, By ascent of the urethra and 
ureter; 2, by descent from the blood stream, and ,S, 
direct from neighboring tissues, such as the colon. 
Ascending renal infctions, i. e.. from the bladder 
directly through the lumen of the ureter to the renal 



pelvis, was the accepted theory until the work of 
Brewer (4) pointed out its fallacy. Draper and 
Braasch (5) proved conclusively that infection by 
ascension up the ureter is possible, but exceptional, 
occurring" only in cases presenting marked changes 
in the vesical orifices of the ureters due to pro- 
longed cystitis. Embleton and Thiele, experimenting 
on animals, showed that they placed doses of bacteria 
on the mucous membrane just within the urethra 
and proved that the bacteria were thence rapidly 
absorbed into the lymphatics of the urethra and so 
passed along the wall of the bladder and ureter and 
collected beneath the capsule of the kidney. From 
there they did not infect the kidney or enter the 
urine stream, but they passed rapidly through the 
lumbar glands into the thoracic duct and so into the 
blood stream. They also found that after intra- 
peritoneal inoculation, bacteria appeared in the urine 
from ten minutes to half an hour. If the thoracic 
duct was cut they did not reach the kidney or the 
urine at all, which proved that they had reached the 
kidney bv the blood stream.' These facts would 
seem to show that lymphogenous renal infections do 
not occur. It has been supposed that bacteria spread 
to the kidney direct from the colon. The kidney is 
separated from the colon by the perinephric fascia 
and its lymphatics are not related to those of the 
colon. If bacteria infected the kidneys by direct 
spread we should expect to find inflammation and 
abscesses in the perinephric cellular tissue. This 
is just what we do not find, except in the rarest of 
instances. There can be little doubt that bacteria 
in life do not commonly spread directly from the 
bowel to the kidney. 

PATHOLOGY. 

As infections of the kidney are as a rule hema- 
togenous in origin, bacteria enter the kidney through 
the renal arteries, pass to the cortex and escape 
through the glomeruli to the collecting tubules, 
thence to the papilla; and the renal pelvis. Cases of 
long duration exhibit a kidney adherent in more or 
less fibrolipomatous perinephritis. The kidney itself 
may not be materially increased in size, but the pelvis 
and upper ureter are likely to be thickened, dilated 
and surrounded by adherent sclerotic fat._ Petechial 
spots and superficial ulcerations may be seen in the 
mucous membrane of the pelvis. At this point it 
may be noted that bacillus infections usually pro- 
duce lesions of the pelvis and medulla, while coccus 
infections involve the cortex. Abscess formation is 
usually dependent upon mixed infection. 

Cabot and Crabtree (7) divide these cases into 
two main groups: 1. The nonpyogenic type, the pure 
colon bacillus infection, which develops in the kidney 
that has previously been sound. 2. The pyogenic 
or suppurative type, which develops in a kidney 
that has previously been unsound. These are 
usually cases of renal or ureteral calculi, obstruction, 
tumor, or chronic nephritis, and are usually mixed 
infections. 

SYMPTOMS. 

Except in the fulminating and hyperacute cases 
the onset is gradual rather than sudden and is 
marked by prodromal symptoms of a generalized 
blood infection, rather than by any local urinary 
symptoms. 



July 19, 1922.] 



GOLDFADER: PYELITIS. 



97 



The symptoms of pyelitis are not as a rule marked 
and the condition may exist for a long time with- 
out giving rise to the suspicion of its presence. In 
acute cases there is a slight evening rise of tem- 
perature, but in chronic cases there is no rise of 
temperature. These patients, as a rule, come for 
relief from bladder symptoms. Frequency of urina- 
tion is always present and is due to the polyuria 
which exists. Frequency is associated with dysuria 
and tenesmus. The patient may complain of a dull 
pain or heavy feeling in one or both loins and slight 
tenderness on pressure at the angle of the twelfth 
rib. In the severe cases, chills, high fever, nausea, 
vomiting, headache, which are signs of renal insuffi- 
ciency and blood invasion by bacteria, may be ob- 
served. The urine is abundant, of low specific grav- 
ity, and contains pus, epithelium from the pelvis of 
the kidney, blood cells, hyaline and granular casts. 
If one kidney is affected there may be periods when, 
owing to obstruction of the diseased pelvis, the urine 
will be normal. In the chronic stages, red blood, 
cells may be absent. The phenolsulphonephthalein 
test shows the amount of renal impairment. Colon 
bacilli are usually found in pure cultures, especially 
in the chronic cases. At other times the staphylo- 
coccus or streptococcus may be present in addition 
to the colon bacillus. 

DIAGNOSIS. 

In order to diagnose this condition, a complete 
and careful e.xamination is necessary. On palpation 
of the kidney slight tenderness may be noted at the 
angle of the twelfth rib, and Murphy's sign may be 
elicited. In uncomplicated cases the kidney is not 
enlarged. The following technic is employed in all 
kidney cases as a routine procedure at the Brooklyn 
Hospital. The patient is prepared for cystoscopy 
and the .x ray — the intestinal tract being thoroughly 
cleared out. He is advised to drink about a quart 
of water an hour before the examination. The blad- 
der is first examined with the observation telescope, 
first taking a sterile specimen of urine from the 
bladder for examination. On viewing the bladder, 
the ureteral mouth on the affected side is usually 
pouting and prolapsed and may be engorged with 
blood, the stream of urine comes from the ureter 
in steady drops and not in spurts, which is due to 
th^ lack of rhythmic contractions of the pelvis of the 
kidney and ureter. The condition of the mucous 
membrane of the bladder is noted, which may be 
apparently normal or intensely congested and a 
search is made for stones, diverticula, hypertrophied 
prostate, etc. This is followed by catheterization 
of both ureters, using opa<|ue catheters. The urine 
from each kidney is collected for examination, which 
should include a microscopical examination, the esti- 
mation of the urea output, and a cultural study of 
the separate urines to determine the organism pres- 
ent. The functional cai>acity of each kidney is then 
determined bv injecting intramuscularly one c. c. of 
the standard solution of phenolsulphone]5hthalein 
into the muscles of the buttocks and noting the time 
appearance of the dye on each side. In operative 
cases the phenolsulphonephthalein is usually collected 
for two hours and the amount of dye eliminated is 
then estimated. X ray examination of the urinary 
tract with opa(|ue catheters /;; situ is then [)erformed 



and a pyelogram of the pelvis of the kidney sus- 
]5ected of being involved is then made, using a 
twenty-five per cent, solution of sodium bromide. 
In cases in which a stricture of the ureter is sus- 
pected, a pyeloureterogram is made. In cases with 
ptosed kidneys the x rays should be taken with the 
patients in lying and standing positions. Stones in 
kidney or ureter, strictures of the ureter, enlarged 
prostate, ptosed kidney, may be diagnosed by this 
examination. A rectal examination should never be 
omitted, particularly in the male, as by this exam- 
ination inflammatory conditions of the prostate and 
vesicles may be detected. It may also reveal the 
source of infection such as a fissure or fistula. An 
expression smear should be obtained by gently mas- 
saging the prostate and vesicles and the fluid exam- 
ined for pus and bacteria. Examination of the stools 
should be made in cases of colitis, for this lesion may 
be the source of infection. A vaginal examination 
will often reveal prolapse of the anterior vaginal 
wall with cystocele, a definite but not very common 
predisposing cause. Smears and cultures should be 
made from the cervical and urethral secretions. 

TREATMENT. 

Cases belonging to the first group are usually re- 
lieved by conservative methods. In acute pyelitis 
rest in bed. alkalies, urinary antiseptics, free cathar- 
sis, the ingestion of large quantities of water, salt 
free and meatless diet, usually are sufficient to con- 
trol mild cases. The alkali is best given as potassium 
citrate in sixty grain doses every two hours until 
the urine becomes alkaline as tested by litmus paper, 
then every three hours, and finally every four hours. 
As a rule the alkalies should be continued for about 
ten days. The fever usually disappears in twenty- 
four to forty-eight hours. On the tenth day, if the 
temperature has been normal for a few days, dis- 
continue the alkalies and give a mixture containing 
thirty grains of acid sodium phosphate, to be taken 
four times a day. Dissolve in each dose ten grains 
of urotropin. The urotropin and the acid sodium 
phosphate should be continued for a few months. 
The bladder symptoms are ameliorated by daily 
bladder lavages with acriflavine one in four thousand 
or oxycyanide of mercury one in four thousand. 
Infected and thrombotic hemorrhoids, rectal ulcera- 
tions, uterine and urethral disorders must be treated. 

In the majority of the acute cases the patients get 
well under conservative treatment. Those that per- 
sist in spite of these measures are due to the pres- 
ence of an infective focus or defective drainage. It 
is only in cases of pyelitis of pregnancy and in the 
acute cases that do not clear up by natural resolu- 
tion that renal lavage is indicated. If the pus in the 
pelvis is thick, the pelvis should be first irrigated 
with a solution of boric acid. For pelvic lavage any 
of the following solutions may be employed : argyrol, 
twenty-five per cent.; silver nitrate, five tenths to 
two per cent. ; or mercurochrome — 220, five tenths 
to one per cent. The lavage may be repeated within 
tive or six days as indicated. Usually few irriga- 
tions of the pelvis are necessary to obtain a bacteri- 
ological and clinical cure. Autogenous vaccines, in 
addition to other measures, may be of service. 

The treatment as outlined helps to clear up about 
sixty per cent, of the cases of acute pyelitis. 



98 



GREENBERG: PULMOXARY ABSCESS. 



[New York Medical Journal 
AND Medical Record. 



Nephrectomy is indicated in the fulminating cases. 
In the treatment of chronic cases general hygienic 
rules, if observed by the patients, will materially aid 
in obtaining a cure. Since the majority of cases are 
due to bowel infections attention must be directed to 
the daily evacuation of the bowels. The diet should 
be generous. The meals should be regular, well 
masticated, and should consist of fresh food. The 
only things to be avoided are strong meat extracts, 
soups and condiments. Internally, give urotropin, 
ten grains four times a day. If improvement is not 
seen in one or two months then resort must be made 
to renal lavage. 

The treatment of cases belonging to the second 
group is purely surgical. Movable kidneys, if caus- 
ing ureteral kinking, should be anchored in order to 
promote free drainage from the kidneys, stones in 
the tireter or kidneys should be removed, hypertro- 
phied prostates enucleated, strictures dilated. The 
surgical indications in each case are to be met in a 
manner which best suits the individual case. 

CONCLUSIONS. 

1. Colon bacillus pyelitis is quite common and is 
often overlooked. 

2. The vesical symptoms are often the first indi- 
cation of the condition. 

3. The infection is as a rule hematogenous. 



4. The original focus of infection must be found 
and eradicated. 

5. Cases falling under Group I are to be placed 
on medical treatment, not neglecting to treat the 
bladder. 

6. Pelvic lavage is to be employed when the medi- 
cal treatment is seen to be inadequate, and is of 
especial value in the chronic cases. 

7. Surgical measures are indicated in cases falling 
under Group II. 

^ REFERENCES. 

1. Cr,\btree, E. Granville, and Cabot. Hugh : Colon 
Bacillus Pyelonephritis, Its Nature and Possible Preven- 
tion, Journal A. M. A., February 24, 1917. 

2. WvssoKOMiTSCH, U. '.Ztschr. of Hyg., 1886, i. 3. 

3. Kraus and Briedl : Ibid, 1897, xxvi, 353 ; also 
Kraus, Handbuch der Urologie, Frisch W. Zuckerkandl, 
1904, i. 385. 

4. Brewer. G. E. : Observations on Acute Haemic In- 
fections of the Kidney, American Journal of Urologv, 1913, 
ix. 549. 

5. Draper, J. W., and Braasch, W. F. : The Function 
of the Ureterovesical Valve, Journal A. M. A., lanuary 
4, 1913. 

6. Franke: Grcnsgeb. d. Med. u. chir., 1911, xxiv, 623. 

7. Cabot, Hugh, and Crabtree, E. Granville: The 
Etiology and Pathology of Nontuberculosis Renal Infec- 
tions, Surgerx, Gynecology, and Obstetrics, 1916, xxiii. 
No. S, 495. 

123 Reid Avenue. 

Case reports will appear in the author's reprints. 



A Case of Pulmonary Abscess 

By DAVID GREENBERG, M. D., 
New York, 

Adjunct \'isiting Physician and Associate in Gross Pathology, Lebanon Hospital. 



The case herein reported presented considerable 
difficulty in diagnosis, perhaps due to the relative 
infrequency with which chronic pulmonary abscess 
of this type is met with. Our patient was seen by a 
number of physicians during a period of about 
twelve months and his condition remained unrec- 
ognized. It was only after a period of observation 
lasting about three weeks that we were able, with 
the aid of the x ray and laboratory, to make a prob- 
able diagnosis. W'e were not fortunate enough to 
obtain the patient's consent for an operation and he 
left the hospital on his own responsibility. 

Case I. — E. P., aged fifty, widower. Besides the 
ordinary di.seases of childhood, the patient had had a 
severe illness at the age of nine, which lasted several 
weeks. He did not know the nature of his illness, 
nor did he remember any of its symptoms. In 1914 
he had rejaeated attacks of vomiting after eating, 
associated with pain in the epigastric region and 
constipation. This lasted for about a year and re- 
sulted in the patient losing over a hundred pounds 
in weight, and left him in a weakened condition. 
He had never fully recovered from this weakness and 
had never worked since. Three years ago he had a 
skin eruption involving face, arms and legs. This 
eruption came on suddenly and lasted a short time. 
There was no sore throat at the time. His wife died 
at the age of forty-two of unknown causes. She had 

•From the service of Dr. Henry J. Wolf. 



had eight miscarriages and three living children, all 
of whom died in early infancy of causes apparently 
other than luetic. 

The patient's bowels had been constipated for the 
past year or so, appetite poor for the past two or 
three years. For the past year there was almost com- 
plete anorexia. He slept fairly well, but was disturbed 
by a nocturia, which had lasted for about three 
years. He also had frequent inicturition during the 
day. The patient had taken an excess of beer, wine 
and whiskey up to two or three years ago. (Patient 
had been in the liquor business.) 

The present condition dated back to about Sep- 
tember, 1919, when the patient had an attack of pain 
in the right side of his chest, associated with dyspnea 
and a moderate rise in temperature. At the time 
he was observed at the Beth-Israel Hospital and the 
following data were then obtained ; 

Temperature between 100° and 101°, moderate 
cough and expectoration. The blood count showed 
a slight leucocytosis. The urine showed a few white 
blood cells. An x ray of the chest showed a triangu- 
lar area of clouding at the right hiluni, base toward 
hilum and the ajjc.x directed outward. The picture 
(lid not change at a subsequent examination done 
sixteen days afterwards. The condition was then 
tluiught to be unresolved pneumonia. He left the 
hospital on a release. 

One month after leaving the hospital, while the 



July 19, 1922.] 



GREEKBERG: PULMONARY ABSCESS. 



99 



patient was still in bed, he had an attack of hemop- 
tysis, coughirij, up about three pints of blood. Since 
then the patient had had a cough which was pro- 
ductive in character and constantly becoming worse. 
About that time his gastric symptoms returned and 
he had had considerable nausea, vomiting and pain 
after eating. He was losing weight and lately there 
developed marked dyspnea and weakness. 

He entered Lebanon Hospital about a year after 
the onset . of his lung symptoms, complaining of 
hiccough, dull ache in the right chest, a rather severe 
cough and productive sjuitum. The sputum was 
stringy, mucopurulent and odorless in character. He 
also had anorexia and frequently a sense of oppres- 
sion in the epigastric region, occasional attacks of 
cramplike pain, associated with diarrhea. 

In general appearance the patient was asthenic, 
anemic, quite dull looking, apparently there had been 
considerable loss of weight. The pupils were slightly 
irregular, right somewhat larger than the left, and 
reacted sluggishly to light ; the eye grounds were 
negative. The only positive chest signs were those 
of emphysema with an area of moderate dullness, 
diminished breathing, at 
times distant bronchial 
breathing over the right 
lower lobe posteriorily. 
This area did not extend 
quite to the posterior 
axillary line. These signs 
became somewhat more 
marked later in the 
course of the illness, es- 
pecially after the chest 
puncture, so that rales 
and distant bronchial 
breathing were more 
constantly found. The 
abdomen was retracted, 
soft, the skin wrinkled, 
loss of subcutaneous fat, 
liver barely palpable. 
There was a marked 
clubbing of the fingers 
and toes. The knee jerks were markedly diminished. 

While in the hospital the patient grew perceptibly 
weaker and duller, his cough had become worse and 
more productive, his sputum was slightly rusty for a 
few hours after the first chest puncture. The tempera- 
ture ranged between 98° and 100.5° F., pulse between 
70 and 92, respiration between 18 and 26. His ap- 
petite remained poor, in spite of carminatives and 
bitter tonics. He vomited several times during his 
stay in the hospital, was more or less constipated, but 
had occasional attacks of diarrhea. He slept well 
and was quite drowsy during the day. He lost in 
weight slowly but steadily, going down from 123 to 
about 105 pounds. 

The urine showed a faint trace of albumin. The 
sputum showed no tubercle bacilli, but occasional 
elastic fibres, many pus cells. Sputum culture gave 
influenza bacilli and Micrococcus catarrhalis. The 
blood count, done several times, showed an average 
white blood cell count of 14,000, polymorphonuclears 
eighty per cent, to eighty-five per cent., lymphocytes 
fifteen [icr cent, to twenty per cent., hemoglobin sixty 
per cent, to seventy jter cent., red blood cell count 




Fig. 1. — Shows a large area of 
and air or gas above with a thick 



two to three million. Blood pressure, 104 to 110 
systolic, 65 to 70 diastolic. The blood Wassermann 
was repeatedly negative, cerebrospinal fluid three to 
five cells to the c. m., globulin negative. Provocative 
arsphenamine given on November 4, 1920, and sub- 
sequent examination of the blood and cerebrospinal 
fluid was also negative. Gastric content (Ewald test 
meal) total acidity 24, free acid 8, no blood, no 
lactic acid, no Boas Oppler bacilli. Chest puncture. 
Xovemher 4th, in the area just below right angle 
of the scapula, needle had to be introduced about 
three inches, yet a small quantity, »about four c. c. 
of yellowish purulent material was withdrawn, cul- 
ture of which revealed the presence of influenza 
bacilli and Micrococcus catarrhalis. Another chest 
])uncture on the 8th of November, about five c. c. of 
thick, yellowish round pus was withdrawn, which 
was examined for tubercle bacilli with negative re- 
sults, but showed the presence of the other organ- 
isms. Guineapig inoculation of the sputum for 
tuberculosis was negative. 

The patient was radiographed on October 16th 
and November 4, 1920, and the following report 

was submitted by the 
rontgen ray department 
— "Combined fluorosco- 
pic and radiographic ex- 
amination shows : The 
median half of the lower 
two thirds of the right 
lung field occupied by 
dense white homogenous 
ovalshaped shadow. This 
shadow is well circum- 
scribed and shows slight 
pulsations, evidently 

transmitted from the 
heart. The shadow- 
moves slightly with res- 
piration. The heart and 
upper part of the aorta 
are of normal appear- 

cavity formation with fluid below , • ^i i r i. 

fibrous wall. ^ucc aiid SO IS the lett 

lung. These findings 
could best be explained on the basis of a lung ab- 
scess. A cyst is less probable. Neoplasm may, for 
practical purposes, be excluded." 

COMMENT. 

This type of chronic pulmonary abscess, i. e., one 
lasting about a year, with a severe productive cough 
and with large quantities of odorless sputum is in- 
frequent. I was unable to find any detailed report 
of a similar case in literature. Hedblom (1), in a 
rather complete report of cases of pulmonary abscess 
from the Surgical Division of the Mayo Clinic since 
1910, mentions cases of chronic pulmonary abscess 
where the sputum was nonodorous. In tiie other 
report of cases of chronic abscess of the lung that 
I was able to find the s]nitum was, as a rule, foul or 
of a disagreeable, sweetish (fruity) odor. 

As to tlie etiology of chronic abscess, it follows 
rather closely that of acute abscess. Operations on 
the mouth, nose and throat, especially tonsillectomies, 
easily occupy a position of first importance as causa- 
tive factors. The cases reported by Manges (2), 
Bevan (3), Clayton (4), Tcwkslniry (5), Frank 



100 



GREE.\BERG: PULMONARY ABSCESS. 



[New York Medical Journal 
AND Medical Record. 



(6) and others were all apparently due to tonsil- 
lectonw. Next in frequency in the etiology of lung 
abscess must be mentioned the pneumonias, espe- 
cially bronchopneumonia. Holt (7), Hedblom (1), 
Lord (8), Hartwell (9), Deaver (10), Brayton 
(11), emphasize pneumonia as a cause. 

Among other causes Wessler (12) and Jackson 
(13) report many instances following foreign body 
aspirated into the lungs. Contiguous suppuration, 
especially encysted empyema rupturing into the lung 
and liver abscesses rupturing into the lung, occur 
but are rare. Hall (14) reports three cases of 
chronic lung abscess following neglected appendicitis, 




Fig. 2. — Shows thick fibrous wall of abscess c.i\it> v. itli u;ish of 
fluid gone. 

probably due to extension from the liver. The right 
lung seems to be more frequently affected than the 
left, regardless of the etiological factor. 

In reference to the symptomatology the presence 
of an increasingly severe, productive cough, together 
with weakness, usually associated with symptoms 
of fever, such as chills or chilly sensations, with 
languor and anorexia, with loss of weight and pain 
in the chest, may be said to be more often present 
than not. The cough and the large quantities of 
malodorous sputum are the most constant of the 
symptoms. In my case there was also dyspnea and 
marked weakness and loss of weight, with vague 
pains in the right side of the chest — but the sputum 
remained odorless. 

The only constant physical sign, judging by the 
reports in the literature, is dullness to percussion. 
Other signs, such as changes in the respiratory mur- 
mur, rales or signs of a cavity, may be present, but 
usually are not (except late and only in a number 
of the reported cases). 

The diagnosis is usually not difficult when the 
abscess ruptures early in the course of the disease 
as it usually does, giving rise to the characteristic 
sputum. In cases where no such rupture occurs or 
when the sputum is not characteristic there may be 
considerable difficulty in arriving at a diagnosis. The 
conditions with which chronic pulmonary abscess 



may be confused are chronic tuberculosis and cap- 
sulated empyema, bronchiectasis, neoplasm and 
brokendown gumma of the lung and actinomycosis. 

SUMMARY. 

The following points should be considered in the 
diagnosis : 

1. A history of either tonsillectomy or other nose 
and throat operation, or an anteceding pulmonary 
infection, especially bronchopneumonia (influenzal). 

2. A progressively severe cough with large quan- 
tities of malodorous sputum, containing pus cells 
and yellow elastic fibres, but not containing tubercle 
bacilli, ray fungus or spirochetes. 

3. General evidence of infection, such as irregu- 
lar fever, weakness and loss of weight, prostration, 
associated with dyspnea to a varying degree, pleuritic 
pains and leucocytosis. 

4. Signs of dullness and diminished breathing in 
one of the lower lobes, usually the right, with or 
without changes in the respiratory murmur and 
rales. 

5. X rav finding of a circumscribed area of 
parenchymatous lung destruction. 

6. Aspiration in doubtful cases and the examina- 
tion of the aspirated fluid or tissue. 

7. Where a brokendown gumma is suspected a 




Fig. 3. — Shows same area of cavity formation filled with gas and 
fluid. Under the fluoroscope, the level of fluid could be seen to 
change in position with the change of position of patient. 

complement fixation of the blood and celebrospinal 
fluid and perhaps a therapeutic test should be 
employed. 

REFERENCES. 

1. Hedblom, C. A.: Pulmonary Suppuration, Medical 
Record, vol. xcvi. No. 2, September 13, 1919. 

2. Manges. Morris : Abscess of the Lung Following 
Tonsillectomy Nine Cases in Adults, American Journal of 
Surgery, vol. xxx. 1916. 

3. Bevan. a. v.: An Important Sequel to Tonsillec- 
tomy, Surgical Clinics, vol. ii, p. 922; vol. iii. p. 1317. 

4. Clayton. T. A.: Lung Abscess Following Nose and 
Throat Operations, International Clinics, vol. ii, p. 75. 

5. Tewksbury, W. D. : Treatment of Nontuberculous 
Lung Abscess with Pneumothorax. Journal .A. M. A., vol. 
xvii, p. 293, February, 1918; New York Medical Jour- 
nal, vol. ex, p. 849, 1919. 



July 19, 1922.] 



MARCUS: IVEAMNG THE IXFANT. 



■101 



6. Frank, L. : Lung Abscess as a Sequel to Tonsillec- 
tomy, Laryngoscope, vol. xxvii, p. 474. 1917. 

7. Holt, Emmet: Abscess of Lung Following Acute 
Pneumonia, Arcliires of Pediatrics. January, 1904. 

8. Lord. Frederick T. : Abscess and Gangrene of the 
Lung, Boston Medical and Surgical Journal, vol. clx, p. 
544, 1909. 

9. Haetwell. .T. a.: Abscess of Lung, Nelson Loose 
Leaf Medicine, vol. iii, p. 519. 1920. 

10. Deaver. J. B. : Surgical Complications and Sequlx 
of Influenza, Medical Clinics, vol. ii, p. 699, 1918. 

11. Brayton, F. a.: Report of Nontuberculous Ab- 



scess of Lung, Indianapolis Medical Journal, vol. xx, p. 
158, 1917. 

12. Wessler, Harry : Lung Abscess and Bronchiec- 
tasis. American Journal of Rontgenology. 1919. 

13. Jack.son, C. : Foreign Bodies in the Trachea and 
Bronchi. Laryngoscope, p. 258. 1905. 

14. Hall. J. N. : Abscess of the Lung from Ascending 
Infection from Appendicitis, Medical Record, vol. Ixxiv, 
No. 16, October 17, 1908. 

15. Hamman. Louis: Abscess and Gangrene, Oxford 
Medicine, vol. ii, p. 101, 1920. 

1220 Grand Concourse. 



Weaning the Infant 

By JOSEPH H. MARCUS, M. D., 

Atlantic City, N. J.. 

Pediatrist to Atlantic City Hospital, Jewish Seaside Home. Bamberger Home, and Baby Welfare Clinic: 
Physician to Children at Pine Rest Sanatorium. 



DEFINITION. 

By weaning is meant the withdrawing of the 
breast milk and the snbstitntion of stronger and 
other foods. Weaning should be done gradually 
whenever possible, and this gradual method should 
be adhered to. unless contraindicated, in justification 
to both mother and child. There are certain indica- 
tions, however, which make it imperative that sud- 
den weaning be instituted immediately. They are 
as follows: 1, Death of the mother; 2, failure of 
milk supply ; 3. illness of mother, either acute or 
chronic, e. g., severe typhoid, pneumonia, tubercu- 
losis or nephritis : 4, disease of the mammary gland ; 
5. when breast milk is attended by symptoms of in- 
digestion, which are of sufficient import to cause 
continual failure to gain in weight and when every 
effort has been made to relieve this condition. 
Through many of the minor ailinents, such as bron- 
chitis, pharyngitis and indigestion, mothers have 
nursed their babies without any seeming detriment 
either to themselves or to their babies. 

TI.ME REQUIRED I-OR WEANING THE CHILD 

Ordinarily the time consumed in weaning the baby 
completely is from six to eight weeks. If the infant 
has had the benefit of one or two bottles daily from 
the sixth month and on, the task of weaning is com- 
paratively simple. If, however, the infant has been 
kept on the breast exclusively up to the ei.ghth or 
ninth month, certain obstacles will appear when 
weaning is attempted. The infant will not take the 
bottle if a breast is at its disposal, and the only way 
out of the difficulty is to deprive the baby of the 
breast and starve it into taking the bottle. This 
method exacts moral courage from both mother and 
doctor. Continued coaxing is objectionaljle and 
forcing is worse, as it only ]jrolongs the .struggle. 
A .strong willed child will often hold out twenty-four 
to thirty-six hours, but at the expiration of this 
period of time the pangs of hunger are so keen that 
the infant surrenders and food will be accepted. 
Patience will ultimately conriuer these stubborn little 



ones. In extreme cases, a few tube feedings may 
be neces.sary. 

INDICATIONS FOR WEANING. 

1 lie appearance of the first incisors generally in- 
dicates that the time has arrived when the infant 
may pass gradually from the exclusive maternal diet 
to cow's milk and articles of food more solid. As a 
general rule, infants should not be exclusively breast 
fed after nine, or at most ten months, and since the 
early months of breast feeding are by far the most 
important, every effort should be made to have the 
mother nurse her child at least the first five or six 
months. It is not advisable to attempt weaning at 
the beginning of summer, even though we may be 
compelled to keep the infant at the breast a little 
longer, and if the infant at this time is getting a 
mixed feeding (breast and bottle) it should not be 
deprived of the breast entirely during the summer 
season. 

TECHNIC. 

At first one breast feeding should be substituted 
for a bottle which contains a modification of cow's 
tnilk, as nearly similar to mother's milk, as possible. 
(For very young infants, in sudden weaning, whey 
mixtures are usually best.) The infant is kept on 
this bottle formula of modified milk for three or 
four days, or even a week; should no disorders of 
digestion follow, another substitute bottle is given 
for the same period of time. This procedure is con- 
tinued until all breast feedings are replaced by bottle 
feedings. 

At this time we increase the (juality of the mix- 
ture by adding milk and decreasing the content of 
water, until at the twelfth month, the infant is taking 
undiluted cow's milk. At this period, or a month 
or two later, the milk is fed with a spoon, or taken 
from a cup. Toward the close of the first year, a 
variety of foods may be offered, such as thick gruels 
(pf bark-v. farina, granuni, rusk, well cocked rice, 
and oatmeal, beef juice, broths, zwieback, crackers, 
bread and milk. 

2X01 Pacific Avenue. 



Editorial Articles 



ECTOPLASM. 
A blending of science and phantasy, one supple- 
menting the other so as to make a more perfect 
creation, is rare. Conan Doyle, physician and writer 
of fascinating fiction, would nearly fulfill the re- 
quirements. Recently he has had much to say about 
a tenuous substance, elusive, a product of spiritists. 
This material has been given the highly scientific 
term of ectoplasm. A colyumist wag of one of our 
metropolitan dailies suggested that it might be a 
good trade name for a furniture glue, but surely 
Conan Doyle is serious, for he has lectured about 
this substance before groups of adults and told how 
it could be photographed. There are one or two 
important points in the actual accouchement of this 
mysterious material which leave some doubt among 
the more critical of the medical profession, but we 
will ignore these for the moment. We will also dis- 
regard the duplication of these phenomena by clever 
magicians who worked under circumstances less fa- 
vorable than those of the more sincere demonstrators. 
We will concern ourselves only with some material 
which the gifted writer presented some ten years 
ago under the guise of fiction. This material, ac- 
cording to the evidence presented, seems to fulfill 
the requirements of rigid scientific investigation far 
more than that of ectoplasm. As is so frequently 
the case with men who mingle science with phantasy, 
there is always a possibility that the findings of one 
sphere will bj' chance be presented in the other. The 
following excerpts are taken from what A. Conan 
Doyle called The Horror of the HcigJits, a lurid 
title, the story appearing in the book called Danger 
(New York: Doran) : "But soon my attention was 
drawn to a new phenomenon — the serpents of the 
outer air. These were long, thin, fantastic coils of 
vaporlike material, which turned and twisted with 
great speed, flying round and round at such a pace 
that the eyes could hardly follow them. Some of 
these ghostlike creatures were twenty or thirty feet 
long, but it was difficult to tell their girth, for their 
outline was so hazy that it seemed to fade awa)'' in 
the air around them. These air snakes were of a 
very light grey or smoke color, with some darker 
lines within, which gave the impression of a very 
definite organism. One of them whisked past my 
face and I was conscious of a cold clammy contact. 
". . . Floating downwards from a great height 
there came a purplish patch of vapor, small as I 
saw it first, but rapidly enlarging as it approached 
me, until it appeared to be hundreds of square feet 
in size. Though fashioned of some transparent, 



jellylike substance, it was none the less of much 
more definite outline and solid consistence than any- 
thing which I had seen before. There were more 
traces, too, of a physical organization, especially two 
vast shadowy, circular plates upon either side, which 
may have been eyes, and a perfectly solid white pro- 
jection between them which was as curved and cruel 
as the beak of a vulture. . . . On the upper 
curve of its huge body there were three great pro- 
jections which I can only describe as enormous 
bubbles, and I was convinced as I looked at them 
that they were charged with some extremely light 
gas which served to buoy up the misshapen and 
semisolid mass in the rarefied air." There is more 
morphological description as well as an account of 
the behavior of this animal. 

Xow, we ma\' ask, whj- does not A. Conan Doyle 
bring these creatures into evidence with his ecto- 
plasm ; they are far more interesting and the evi- 
dence he gives is far more convincing. They surely 
belong in the same category. Either the monsters 
should be classed with ectoplasm or the ectoplasm 
with the monsters. But to keep the monsters as 
copy for fiction and serve ectoplasm to the spiritisti- 
cally inclined and attempt to give it scientific flavor 
is hardly fair to say the least. Let us add the mon- 
sters to the scientific by all means. 



DEMEXTfA PRECOX AND SYPHILIS. 

Dementia prsecox has been supposed, by not a few 
neurologists, to be due to either hereditary or ac- 
quired syphilis as these conditions have been found 
in the patients' antecedents, while from the clinical 
viewpoint the cases can be conveniently divided into 
two groups. 

The first group is comprised of patients with the 
classical stigmata of hereditarj- syphilis; the second 
group comprises patients offering clinical manifesta- 
tions analogous to those encountered in nervous 
syphilis, viz., unequal pupils, usually not very 
marked, with slow reaction, especially to light; dis- 
turbances of the tendon and cutaneous reflexes; tem- 
porary heniiparcsis or monoparesis, ictus and a dis- 
crete lympiioc)-tosis of the cerebrospinal fluid, as 
well as certain signs whose specific nature has only 
recently been proved, namely, onyxis, acroasphyxia, 
vitiligo, and Mikulicz's .syndrome. To these may be 
added Argyll Robertson's sign. In the great major- 
ity of cases the progressive evolution of the mental 
disturbances end in complete dementia quite like 
psychoses due to syphilis, the only difference being 
that the evolution is much slower. 



July 19, 1922.] 



EDITORIAL ARTICLES. 



103 



The cerebrospinal fluid in dementia praecox has 
been found to give rise to a positive fixation reac- 
tion. In a total of two hundred and sixty cases col- 
lected by Ensor it was present in eighteen and nine 
tenths per cent, and five times out of nineteen in 
Raviart's statistics. In some instances the only 
change in the cerebrospinal fluid has been a slight 
lymphocytosis (Poppea) or hyperalbuminosis 
(Muirhead). 

As to the blood serum, it has been studied by Ivey 
who found the Wassermann positive in one female 
out of three and in two males out of twelve. Klut- 
cheff and Soukhanoff obtained eighty per cent, posi- 
tive reactions in subjects presenting luetic stigmata, 
while in those without them it was positive in only 
twenty-five per cent. Finally, Poppea, taking at 
random several cases of dementia praecox and hav- 
ing the serum examined by Danila and Stroe, found 
that it was intensely positive in nine, positive in five 
and weakly positive in two. Three cases were posi- 
tive to a single procedure and one was negative, 
that is to say, ninety-five per cent, of positive reac- 
tions, while in seven instances in which the reaction 
was doubtful or negative these observers obtained 
a positive reaction following activation by Milian's 
procedure. 

At the autopsy of a subject who had appeared to 
have general paresis, Laignel-Lavastine and Barbe 
found an encephalitis of the neuroepithelial type. 
All these data may seem a priori to be of mediocre 
value, because it is exceptional to find a history of 
hereditary or acquired syphilis in the patient's ante- 
cedents and as far as the socalled stigmata of syphilis 
are concerned we know at present that they cannot 
all be regarded as pathognomonic. 

A certain number of cases of cerebral syphilis or 
general paresis have for a time evolved with the 
appearance of dementia praecox, and even supposing 
that the results obtained by a Wassermann reaction 
are undeniable, it nevertheless remains to be shown 
that in cases of dementia praecox in which it was 
positive in the cerebrospinal fluid that the process is 
not a general paralysis of the insane. The interpre- 
tation is still more delicate when the reaction is only 
positive in the blood serum and cases are not want- 
ing in which it was negative and in all the patients 
examined by Babonneix, Brissot and David their 
clinical and serological researches invariably gave 
negative results. 

From what is at present known we do not believe 
that one should conclude that syphilis plays no part 
in the development of dementia precox. The sub- 
ject ref|uires a more methodical study than it has yet 
received. Supposing that from future statistics it 
will be shown that syphilis does intervene in the 



process under consideration, it will still be necessary 
to determine in what manner it acts, whether directly 
in the nervous system or indirectly by the interme- 
diarv of some endocrine gland. 



THE HEART AND RESPIRATORY SYSTEM 
IN SCARLET FEVER. 

Although there is little to add to the classical de- 
scription of endocarditis and pericarditis complicat- 
ing scarlet fever, that of myocarditis and cardio- 
vascular disturbances has been of late considerably 
enriched. 

Scarlatinal endocarditis is rare — according to 
Broadbent's statistics of 1907 it was only fifty-eight 
hundredths per cent. It occurs with or without 
rheumatism, is usually mild, but frequently gives 
rise to a chronic valvular lesion. It can be easil)' 
overlooked, as the functional symptoms to which it 
gives rise are usually unimportant. Septic ulcerat- 
ing endocarditis is rare and usually ends in death. 
Pericarditis may exist alone or be associated with 
dry serofibrinous or purulent endocarditis ; it is 
prone to be latent and retrogresses rapidly, but if 
purulent, death is likely to occur. 

As to the functional disturbances of the myocar- 
dium, there is tachycardia usually at the onset and 
the older writers insisted upon this symptom as a 
good diagnostic sign of scarlet fever. The pulse 
rate varies from one minute to another and there is 
a marked arterial hypotension as well, but instead 
of tachycardia there may be a relative or absolute 
bradycardia, although in children this is not fre- 
quent. Bradycardia is met with rather constantly 
at the end of the phase of pyrexia, taking the place 
of the tachycardia. It lasts for eighteen to twenty 
days, is of nervous origin, is total, and without auri- 
culoventricular dissociation. Various types of 
arrhythmia, as well as other changes in the pulse, 
are met with. 

The blood pressure is low in the malignant syn- 
drome of the disease in question and adrenalin exer- 
cises a favorable influence. On the other hand, 
there is hypertension with the acute nephritis of 
scarlet fever which retrogresses slowly even when 
the other symptoms of the renal process have dis- 
appeared. 

There exist two syndromes which, for that matter, 
may be combined : First, the myocarditic syndrome 
which does not always depend upon lesions of the 
myocardium, being often due to extracardiac causes, 
especially changes arising in the suprarenals ; and 
secondly, cardiac disturbances due to nephritis. 
These are often early in appearance and predominat- 
ing, so that the patient seems to I)e a cardiac rather 
than a renal subject, presenting edema, enlarged 



104 



EDITORIAL ARTICLES. 



[New York Medical Journal 
AND Medical Record. 



liver, scanty albuminous urine, a small, frequent, and 
irregular pulse and an enlarged heart with a bruit 
de galop. In the subacute types all these symptoms 
are attenuated but become intense if the nephritis 
becomes chronic. As to the treatment of these car- 
diac complications it is the same as in other cases 
of endocarditis and pericarditis. 

The complications arising in the respiratory tract 
in scarlet fever, other than purulent rhinitis, pleurisy 
and empyema, are hardly mentioned in textbooks. 
Cases of serious pseudocroup due to the streptococ- 
cus have been recorded, intubation being rendered 
difficult on account of spasm, while a reflex may 
start from the irritated larynx inhibiting the cardiac 
contractions, hence syncope, sometimes ending in 
death. Bronchopneumonia is not uncommon in the 
more serious cases of the disease, while instances of 
lobar pneumonia have likewise been encountered. 

The predilection of scarlet fever for the serous 
membranes and fibrous tissue has long been known, 
hence pleural collections develop in the rheumatismal 
processes of the atifection with or without endoperi- 
carditis. A streptococcal or pneumococcal pleurisy 
is also known to occur. Finally, as an intercurrent 
complication, acute pulmonary tuberculosis or tuber- 
culous pleurisy may ensue, but scarlet fever is not 
a tuberculigenous disease, therefore these complica- 
tions are uncommon. 



VISUAL DISTURBANCES DUE TO 
QUININE. 

Coutela and Daban {Archives medicockirurgi- 
cnles dii Province, December, 1921) call attention to 
disturbances of sight following the absorption of 
the salts of quinine. Although far less frequent than 
tinnitus aurium, for example, these disturbances 
should not be overlooked. The necessary dose for 
the production of these disturbances varies extreme- 
ly, and although cases are reported following the 
ingestion of ten grams in twenty-four hours in a 
child of six years, of eighty grams in three days or 
after a single dose of twenty grams, thev have been 
known to occur after a dose of one gram, twenty- 
five centigrams or even seventy-five centigrams. 
Nevertheless, it has usually Ijeen after large doses 
have been absorbed for producing abortion or with 
suicidal intent that disturbances of the sight have 
been noted. 

Both eyes are involved about equally, the dis- 
turbance usually manifesting itself ^ few hours 
later, but in some cases they develop late when the 
total quantity of quinine absorbed during a cure is 
important. The patient notices that vision progres- 
sively diminishes, central vision being the last to 



disapp>ear, preceded by a progressive loss of the pe- 
ripheral visual field. Blindness, which generally en- 
sues within a few hours, lasts anywhere from a day 
or two to eighty-four days. It ceases little by little, 
the central vision being the first to return, then the 
visual field enlarges horizontally, more on the tem- 
poral than on the nasal side, while the vertical vision 
improves more slowly and tardily. Central scotoma 
is rarely present. Spontaneous amelioration is the 
rule and only a few instances of permanent blind- 
ness have been recorded and seem to constitute ex- 
ceptional cases. Both pupils during this time are in 
a state of maximum dilatation, the iris being reduced 
to a thin line. When sight has returned the pupils 
frequently remain immovable for some time. 

By the. ophthalmoscope the papilla is white, 
opaque, sometimes swollen, with slightly irregular 
edges. The chalky whiteness, which is striking, per- 
sists, while the edges become precise and visual 
acuity improves. The retinal vessels are remarkable 
for the considerable decrease of their calibre. Bol- 
lack has noted arterial hypertension in them. The 
macula may be cherry red and some observers have 
referred to small white brilliant spots with indis- 
tinct edges situated in the juxtapapillary and para- 
macular regions at the level of the posterior pole. 

The prognosis is not as bad as might be expected 
from the intensity of the disturbances at their onset, 
but it can be affirmed that permanent blindness is 
exceptional. The diagnosis is made from the anam- 
nesis and the coexistence of auditory disturbances. 
The great mydriasis, the bilaterality of the disturb- 
ance, and the ophthalmoscopic findings are sufficient 
data for making a diagnosis. One must not con- 
found the clinical disturbances with visual compli- 
cations which may accompany certain affections re- 
quiring treatment with quinine. It is a matter of 
prudence to ascertain if no other factor exists be- 
sides the intoxication by the alkaloid. When once 
the diagnosis has been made, an attempt should be 
made to eliminate what quinine may still be pres- 
ent in the digestive tract by the use of an emetic 
or a purgative, according to circumstances. The 
vasoconstriction of the optic vessels should be dealt 
with by inhalations of amyl nitrite. On the other 
hand, an attempt should be made to increase the 
afflux of blood by placing the head in a declivous 
position or the exhibition of ocular hypotensors, such 
as pilocarpine or eserine. Both massage and gal- 
vanization appear to be of little or no value. Rest 
in bed with good feeding is essential, while strychnine 
seems to be indicated to stimulate the nervous sys- 
tem. Caffeine is, on the other hand, contraindicated, 
because it increases the narrowing of the retinal 
vessels. 



July 1», 1922J 



EDITORIAL ARTICLES. 



105 



THE UNMARRIED MOTHER 

Sociological workers continue to lament, and 
justifiably, that, in comparison with the advanced 
standards of some of the European countries, the 
few laws of our more progressive states showing 
a recognition of the illegitimate child as a socialh' 
valuable individual look painfully inadequate. The 
studies of the Boston Conference on Illegitimacy, 
1914, report some astonishing facts, particularly as 
to the amount the father is required to contribute 
to the support of the child. In Illinois he must 
give $550 during the first five years of the child's 
life; in Tennessee, he gives $40 the first year, $30 
the second, and $20 the third ; and so on through 
many states. Xo wonder that, to quote Miss Breck- 
inridge in her Social Control of Child Welfare,. 
"the situation was so desperate that physicians, 
social workers and relatives have conspired to save 
the girl's respectability at the risk of the child's life 
and at the cost of all spiritual and educative value 
of the experience of motherhood. This has meant 
a greatly higher death rate among illegitimate in- 
fants, a higher crime and a higher dependency rate." 
Up to the time of the war the illegitimate child was 
never an3^hing but the visible symbol of its parents' 
sin, and as such the bearer of the heaviest burden 
of the crime. The manner of its birth, not its 
eugenic value, was the onlv concern of society. 
Only the desperate situation created by the war 
and the consequent need for men was able to open, 
to a certain extent, people's eyes. The United 
States was, of course, less affected in this way than 
the European countries, consequently we are slow 
in awaking to the true aspect of the problem. 

This awakening, is taking place, nevertheless, as 
is evidenced in various ways. One is the more 
broadminded attitude toward unmarried mothers on 
the part of various institutions making a specialty 
of caring for them during pregnancy and recovery. 
A special point is made of this attitude in a recent 
report of one of these institutions. The erring 
young women are no longer looked down upon as 
moral outcasts, nor incriminated as delinquents, nor 
even patronized as pathetic weaklings, fit objects 
for the bestowal of charitable sentimentalities. Be 
it said, however, that the institution whose attitude 
is quoted declares emphatically and repeatedly that 
none of the types mentioned above are accepted as 
patients ; these are limited to girls of the better 
class who have made a single misstep. Neverthe- 
less, it is something to have arrived at a stage of 
socialmindedness which can recognize that even such 
transgressors are usually ignorant or more sinned 
against than sinning. The transgression is by no 
means condoned, but eni[)hasized as a starting point 



for a new and stronger life and character. The 
young mother usually returns to her home com- 
munity, "stronger than she would likely have been 
otherwise." and resumes her life, its one dark spot 
an eternal secret. The child is well placed by the 
institution in a home where it will receive good 
care from foster parents, often in better circum- 
stances than the family from which its real mother 
comes. It will be seen from this that the institu- 
tion in question does not agree with the sociological 
theory that this procedure tends to obscure the whole 
problem. The institution claims that, by its method 
of handling and treatment, the young woman is not 
forced to marry an unloved man, neither must she 
hide in some large city and try to support her child 
and herself, usually with great hardship to both, 
nor must she face disgrace for herself and her baby 
by returning to her home town and trying to live 
down her error. It is admitted that this is only the 
best way out of a bad situation — and perhaps it is, 
as conditions are now. But it surely is not the way 
to make society realize its mistakes and shortcom- 
ings, nor to force it to take steps to remedy condi- 
tions under which such things can occur. One of 
the most important of these steps would be to make 
provision for better education in se.x matters for 
our boys and girls. 



NEW MEDICAL SCHOOL AND HOSPITAL 
AT PEKING. 
A review of the activities of the Rockefeller 
Foundation for 1921 contains an interesting account 
of the opening of the new medical centre in Peking. 
The report says: "On September 19, 1921, in the 
capital of China a unique academic procession made 
its way through oriental corridors and courts to an 
assembly hall which in its exterior form and decora- 
tions reproduced the classic features of Chinese 
architecture. The cortege was a blending of East 
and West, Chinese officials and other leading citi- 
zens, some of them in national dress, members of 
the diplomatic corps, distinguished guests in the 
variegated, brilliant gowns and hoods of European 
and .\merican universities, the officers, trustees and 
faculty of the Peking Union Medical College, all in 
academic garb, made a striking and symbolic pic- 
ture. Brief words of greeting and ai)preciation from 
representatives of the President of China, the 
cabinet, the medical profession, and educational in- 
stitutions, a statement by the director of the China 
Medical Board, an address on the aims and spirit of 
the college by the chairman of the board of the 
Rockefeller Foundation, and the institution in its 
new setting and with enlarged resources was rededi- 
cated to the .service of the Chinese people. These 
simple ceremonies were one session of a program 
which extended over an entire week and included 
daily clinics, scientific papers on medical and public 
health themes, popular evening addresses, sightsee- 
ing excursions, etc. ... It was really an inter- 



106 



NEWS ITEMS. 



[Xew York Medical Journal 
AND Medical Record. 



national congress of curative and preventive medi- 
cine. The clinics and papers were rated by compe- 
tent judges as highly scientific and significant. The 
contributions of the members of the Peking faculty 
made a most favorable impression upon the visiting 
scientists." 

The buildings of the college have both architec- 
tural beauty and practical serviceability. There are 
many laboratories and lecture rooms, a hospital of 
225 teaching beds, and an outpatient department. 
The plant covers an area of about twenty-five acres 
and comprises a total of fifty-nine buildings. These 
include all the housing facilities, water supply, 
sewerage, electric light and gas services of a modern 
community. On June 30, 1921, the teaching staff 
numbered sixt3--seven, of whom seventeen were in- 
structors in the premedical school. About twenty- 
five per cent, of the teaching corps were Chinese, for 
the most part trained in the United States or Europe. 
Besides the educational personnel were fifteen in- 
terns and residents, twenty-eight nurses, and mem- 
bers of business and administrative departments. 
The service group of assistants totalled 601 and were 
practically all Chinese. The student registration for 
1921-1922 showed fifty-two in the premedical school, 
twenty in the medical school, and eleven in the 
nurses' training school. 

"The college seeks quality rather than quantity. 
It aims not to turn out numerous doctors — Chinese 
institutions must assume this task — but to train lead- 
ers who may serve as teachers and investigators in 
Chinese medical schools, hospitals and health organi- 
zations. In its own work it proposes to develop 
Chinese teachers, who already constitute twenty-five 
per cent, of the teaching staiT, and to give them in- 
creasing rank and responsibiHty as rapidly as they 
are prepared to assume them." 



-<?>- 



N 



ews Items. 



Dr. Sajous Receives Gold Medal. — Announce- 
ment is made that the 1922 American Medicine Gold 
Medal has been awarded to Dr. Charles E. de M. 
Sajous, of Philadelphia, for his noteworthy contribu- 
tions to the study of the glands of internal secretion. 

Openings for Junior Medical Officers in Gov- 
ernment Service. — The United States Civil Serv- 
ice Commission states that there is urgent need for 
eligibles to fill positions of junior medical officer in 
the Indian Service and the Coast and Geodetic Sur- 
vey and that the commission will receive and rate 
applications until further notice. Full information 
concerning salaries, etc., and application blanks may 
be secured from the United States Civil Service 
Commission, Washington, D. C. 

American Therapeutic Society. — Officers to 
serve for the ensuing year were elected as follows 
at the annual meeting held recently : Dr. Charles G. 
Jennings, of Detroit, president ; Dr. Hermon C. 
Gordinier, of Troy, N. Y., first vice-president ; Dr. 
Arthur Parker Hichens, of Washington, D. C, sec- 
ond vice-president, and Dr. C. E. Cooper-Cole, of 
Toronto, Can., third vice-president ; Dr. Lewis H. 
Taylor, of Washington, D. C, secretary, and Dr. 
Spencer L. Dawes, of New York, treasurer. 



Personal. — Dr. Frederick C. Warnshuis, of Ann 
Arbor, Alich., received the honorary degree of Doc- 
tor of Science for work in surgery, public health 
conservation and medical organization, from Hope 
College, Holland, at its fifty-seventh annual com- 
mencement. 

Dr. Jacob Sobel, assistant director of the bureau 
of child hygiene of the New York City Department 
of Health, is retiring after serving the city for 
twenty-three years. More than one hundred physi- 
cians and surgeons of New York City honored him 
at a testimonial dinner on June 21st. Dr. Sobel is 
planning to study diseases of children with Profes- 
sor Pirquet in Europe. 

Dr. Bowman Crowell, who for the past four years 
has been head of the department of pathology in the 
Oswaldo Institute for Medical Research in Brazil, 
arrived in New York on June 27th. Dr. Crowell 
has made a particular study of Chagas disease, which 
is a kind of sleeping sickness endemic throughout 
the interior of Brazil. He has come to the United 
States to become professor of pathology and experi- 
mental medicine in the University of South Carolina. 

Dr. Edward A. Spitzka was appointed Dis- 
trict Medical Ofticer, Second District, United States 
Veterans' Bureau, on July 8. 1922. The Second 
District embraces the states of New York, New Jer- 
se\- and Connecticut. 

Dr. Charles H. Frazier, who was formerly pro- 
fessor of clinical surgery at the University of Penn- 
sylvania, has been appointed by the board of trus- 
tees of that institution, the John Rhea Barton pro- 
fessor of surgery, to succeed Dr. John B. Deaver, 
whose resignation takes effect at the end of the col- 
lege year. 

Dr. J. H. Mason Knox, Jr., of Baltimore, has been 
appointed chief of the state bureau of maternity 
and child hygiene, a bureau created at the last ses- 
sion of the legislature under provisions of tlie Shep- 
pard-Towner Act. Dr. Knox is at present directing 
child hygiene work for the American Red Cross in 
Europe. 

Dr. T. Caspar Gilchrist, of Baltimore, sailed for 
England recently and will spend several months 
traveling abroad. He was scheduled to deliver the 
annual address before the London Dermatological 
Society on July 13th in London. 

Dr. Stuart L. Craig, of New York, sailed for 
Europe on the Majestic, Saturday, July 8th. Dr. 
L. Webster Fox, of Philadelphia, sailed for Europe 
on the Baltic. Saturday, July 8th; also Dr. Edward 
Randall, professor of tlierapeutics, L'niversity of 
Texas ^Medical School, and Dr. John C- Boyd, of 
Washington, D. C. 

Dr. Charles E. Farr, of New York, has been 
elected president of the Yale Medical Alumni Asso- 
ciation. 

Dr. Alec N. Thomson, of New York, has been 
appointed to the staff of the Committee on Dispen- 
sary Developments of the United Hospital Fund. 
Dr. Thomson is director of medical activities of the 
American Social Hygiene Association. 

Dr. Irving S. Haynes was tendered a compli- 
mentary dinner by the medical board of the New 
York Athletic Club, following his retirement from 
active service at the Horlem Hospital. 



July 19, 1922.] 



NEIVS ITEMS. 



107 



American Psychiatric Association. — The an- 
nual meeting was held in yuebec, Canada, June 6th- 
to 9th. Officers for the coming year were elected 
as follows; President, Dr. Harry W. Mitchell, of 
Warren, Pa.; vice-president, Dr. Thomas W. Sal- 
mon, of New York, and secretary-treasurer, Dr. 
Clarence Floyd Haviland, of Albany, N. Y. 

American Neurological Association. — At the 
annual meeting held in Washington, D. C, the fol- 
lowing officers for the ensuing year were elected : 
President, Dr. Harvey Cushing, of Boston; vice- 
presidents. Dr. Herman H. Hoppe. of Cincinnati, 
and Dr. Charles S. Potts, of Philadelphia; secretary- 
treasurer. Dr. Frederick Tilney, of New York. 

Annual Meeting of Canadian Medical Associa- 
tion. — Dr. Da\-id H. Arnijtt, of London, Ont., was 
elected president at the annual meeting held at Win- 
nipeg, June 20th to 23d. Other officers elected were 
as follows: Dr. Walter L. Aluir, of Halifax, N. S., 
vice-president, and Dr. John W. Scane, of Montreal, 
Que., secretary. The association appointed a com- 
mittee to report at the next session on the desirability 
of establishing a college of surgeons in Canada. 

Addition to Broad Street Hospital Opened. — 
The new eleven stor_\- addition to the Broad Street 
Hospital was opened on June 19th. There are ac- 
commodations for one hundred patients and the sev- 
eral floors are financed by various groups ; for in- 
stance the Grand Lodge of the State of New York 
finances the Masonic Floor ; the seventh floor will 
be known as the Roosevelt Memorial floor for chil- 
dren, and will be financed by William Hamlin Childs. 
Mrs. James Barber will finance another floor, which 
will be known as the Nora Nickle Barber Maternity 
floor. Every business firm south of Chambers 
Street will be asked to contribute a stated sum an- 
nually for the maintenance of the hospital. 

New Public Health School at Columbia Uni- 
versity. — .\n institute nt public health has l)een 
established at Columbia University, an undertaking 
made possible by the bequest of the late Joseph R, 
DeLamar, the executors of whose estate have given 
the university $777,772.45 for its school of medi- 
cine. The work of the new institute of public 
health will be chiefly research and the training of 
research workers ; it will also give instruction to 
medical students and others, and will imdertakc giv- 
ing wide publicity in a popular form to the findings 
of scientific investigations — this latter activity being 
stipulated by the will of Mr. DeLamar. The new 
office of professor of public health and administra- 
tion will be filled bv Dr. Haven Emerson. 

Sanitary Science Exhibit in Washington. — .\ 
National Committee on H.xhibits Showing Advances 
in .Sanitary .Science was formed recently in Wash- 
ington, D. C, for the purpose of collecting and pre- 
paring material for a great popular health exhibit. 
Space for this exhibit has been jjlaced at the disposal 
of the committee by the Smithsonian Institution. The 
members of the committee include: Surgeon General 
H. S. Cumming, United States Public Health Serv- 
ice, chairman ; Dr. D. B. Armstrong, National Health 
Council ; Miss Mabel T. Boardman, American Red 
Cross; Surgeon General M. W. Ireland, United 
States Army Medical Corps ; Dr. \'ictor C. Vaughan, 
National Research Council ; Dr. C. D. Walcott, 
Smithsonian Institution ; James .\. Tobey, secretary. 



Faculty Changes in the Harvard Medical 
School. — Leonard T. Troland, who has served 
six years as instructor in psychology, has been pro- 
moted to the'post of assistant professor. Dr. Regin- 
ald Fitz, who has served during the last two years 
as professor of medicine at the University of Min- 
nesota, has been named as associate professor of 
medicine at Harvard. Other appointments in the 
faculty of medicine include Dr. Edward P. Richard- 
son, as assistant professor of surgery ; Dr. Jacques 
Bronfenbrenner, as assistant professor of bacteriol- 
ogy; Dr. Alice Hamilton, as assistant professor of 
industrial medicine; Dr. George C. Shattuck, as as- 
sistant professor of tropical medicine; Dr. David 
Cheever, as assistant professor of surgery; Dr. 
Lloyd D. Felton, as assistant professor of preventive 
medicine and hygiene; Dr. James L. Gamble, as 
assistant professor of pediatrics; Dr. James S. Stone 
and Dr. John Homans, as instructors in surgery, and 
Dr. \\'ilfiam H. Smith and Dr. Frank H. Hunt, as 
instructors in medicine. 

Italian Congress of Radiology. — The fourth 
congress of Radiologj' was held in the Rizzoli Ortho- 
pedic Institute, Bologna, on May 10th and Uth, 
under the presidency of Professor A. Busi. An in- 
teresting program was presented, among the subjects 
discussed being the therapeutic application of radio- 
physical principles, the radiological study of the 
digestive apparatus, deep x ray therapy, and the x 
ray treatment of malaria. During the congress an 
exhibition of radiological instruments was held. 
Officers to serve for the next two years were elected 
as follows : Professor Senator O. Corbino, of Rome, 
honorary president; Professor Bertolotti, of Turin, 
president; Professor Balli, of Modena, vice-presi- 
dent ;_Professor Ponzio, reelected secretary-teasurer. 
The fifth congress will be held in Palermo in Octo- 
ber, 1923. 

Changes in Medical Faculty of University of 
Georgia, — Five new appointments of professors 
for the medical department have been made. Dr. 
Eliot R. Clark, coming from the University of Mis- 
souri, will he professor of anatomy; Dr. Richard V. 
Lamar will be professor of pathology; Dr. Virgil P. 
Sydenstrickcr, from Augusta, will be professor of 
medicine; Dr. Ralph H. Chancy, from Rochester, 
IMinn.. will be professor of surgery, and Dr. Harry 
B. Neagle, from Adrian, Mich., will be professor of 
preventive medicine and hygiene. All the members 
of the present faculty were reelected. At the annual 
commencement exercises it was announced that the 
Rockefeller Foundation, the Carnegie Foundation, 
and the city of .Augusta, Ga., have given the univer- 
sity $40,000 a year. 



Dfed. 

Knox. — hi Santa Barbara, Gal., on Thursday, June 29tli, 
Dr. S. B. P. Knox, aged eighty-four years. 

MuLCAHY.— In New York, on Thursday, June 22nd, Dr. 
William L. Mulcahy. 

Nichols. — hi Boston, on Monday, June 12tli, Dr. Edward 
R. Nichols, aged fifty-eight years. 

Pf.ttit. — In Hamburg, Germany, on board the U. S. SS. 
St. Paul, of which he was ship surgeon, on Wednesday, 
June 21st, Dr. Gaylor Joel Pettit, of New York, aged tifty- 
four years. 

Wanless. — In India, where he was medical missionary, 
on Thursday, July 6th, Dr. W. G. Wanless, of Toronto. 



Book Reviews 



HAY FEVER. 



Hay Fever and Asthma. Care, Prevention, and Treatment. 
By William Scheppegrell, A. M.. M. D., President, 
American Hay Fever Prevention Association : ex-Presi- 
dent, American Academy of Ophthalmology and Oto- 
laryngology; Chief of Hay Fever Clinic, Charity Hos- 
pital, NeviT Orleans. Illustrated with One Hundred and 
Seven Engravings and one Colored Plate. Philadelphia 
and New York: Lea & Febiger, 1922, Pp, x-274. 

The volume under review is one of the latest 
books published on this widespread and interesting 
disease. The book is illuminating from many points 
of view. In the first place the author is thoroughly 
familiar with his subject, both from the point of 
view of a well trained physician and of a well in- 
formed botanist. The earlier chapters of this very 
readable book are devoted to a thorough description 
of the various pollens which may be incriminated 
in the production of hay fever. The geographical 
distribution of these pollens is- carefully gone into. 
The factors associated with their spread — wind, 
effect of temperature, rain and dust — are elucidated. 
Chapters IX and XI are devoted to a discussion of 
the various etiological factors, such as the influence 
of sex, occupation and race, in the production of 
hay fever and asthma. The steps in diagnosis, pre- 
vention and treatment are described in detail. The 
method of testing the wind pollination of Jiay fever 
plants, the collection and identification of atmos- 
pheric pollens, the relation of hay fever to the most 
common plants, trees and grains, are recorded most 
carefully and clearly. An interesting survey of 
hay fever resorts, in various parts of the United 
States and Canada, forms an important addendum, 
which will prove invaluable to the general practi- 
tioner as well as to the patient. 

STOMACH AND ABDOMEN. 

The Stomach and Abdomen from the Physician's View- 
point. By William Russell, M. D., LL. D., ex-Presi- 
dent Royal College of Physicians, Edinburgh ; Professor 
Emeritus of Clinical Medicine, Edinburgh University; 
Consulting Physician, Royal Infirmary, Edinburgh ; 
Author of Arterial Sclerosis, Hypertonus and Blood 
Pressure, and The Sphxgmomctcr. New York ; William 
Wood & Co,, 1921. 

Even the most sincere opponent of the knife in 
medicine must admit that the extension of the field 
of abdominal surgery to embrace practically every 
morbid condition w-ithin that cavity has greatly en- 
larged our knowledge of diseases of the abdominal 
organs. The author of this most practical treatise, 
while writing for physicians and treating of the con- 
ditions which can be dealt with by nonsurgical meas- 
ures, frankly acknowledged; the debt of the diagnos- 
tician to the abdominal surgeon, and expresses his 
preference for operative over postmortem diagnoses. 

The book is divided into seven sections treating 
respectively of the stomach, the pylorus and duo- 
denum, the intestinal .tract, the esophagus, the liver, 
the spleen, and the kidney. Of course, the author 
does not regard every intraabdominal condition as 
belonging to the internist only, but he looks upon 
them all from the family physician's point of view, 
and not primarily from that of the operating sur- 



geon. In the case of appendicitis, for example, he 
rejects the cruel advice to let the patient suffer acute 
agony, and refrain from giving opium lest the symp- 
toms be masked thereby. He pays the surgeon the 
compliment of saying he could not conceivably be 
seriously misled by the mere relief of pain conse- 
quent upon the administration of opium, for the con- 
tinual call for opium may be, and indeed usually is. 
an indication for operation. The author of the work 
is a man of ideas and of practical common sense as 
well, and he approaches his subject from both these 
sides, with the result that the reader has a book 
which he may read and consult often with advantage. 

IN.SANITY AND FOCAL INFECTIONS. 

The Defective Delinquent and Insane. The Relation of 
Focal Infections to Their Causation. Treatment, and 
Prevention. By Henry A. Cotton. M. D., Medical Di- 
rector, New Jersey State Hospital at Trenton ; Lecturer 
in Psychopathology, Princeton University. With a Fore- 
word by Adolf Meyer, M, D., Director of the Henry 
Phipps Psychiatric Clinic, Johns Hopkins Hospital. Lec- 
tures Delivered at Princeton University, January 11, 13, 
14, and 15, 1921. Princeton: Princeton University 
Press: London: Oxford University Press, 1921. Pp. 
xvi-201. 

The work that Cotton has done in showing the 
relationship which exists between psychic and physi- 
cal disturbances has certain points of value. The 
impression which has been caused by his assertions 
has proved detrimental. His enthusiasm no doubt 
has led him to make dogmatic statements which are 
beyond proof and which are distinctly not trtie. He 
has stressed the importance of physical causes of 
psychic conditions, but he has failed to see that these 
physical conditions were first caused by psychic dis- 
orders. It is not to be argued that an infection 
found in a patient suffering from a mental disturb- 
ance should be ignored. The defects in the organ- 
ism should be corrected, infections removed and 
physical measures used to combat physical ailments. 
So far we are in accord. We can also agree with 
the statements of Cotton regarding the small role 
heredity plays in the etiology of mental disease, but 
when he is rash enough to say that "while psycho- 
genic factors, when present, also exert an important 
influence, these may be absent and yet a psychosis 
develop," we must pause and check matters up. 
Were he viewing matters as they exist he w-ould 
clearly see that there can no more be a psychosis 
without psychogenic factors than there can be chick- 
ens without eggs. Psychogenic factors may be 
pushed into the background by the removal of some 
disturbance, wdiich, by lowering resistance, allows 
the formerly hidden conflicts to come to the surface, 
but they remain in the possession of the patient to 
emerge again in any stressful circumstance once the 
defense mechanism is lowered. It is only by bring- 
ing the psychic factors to the surface that the roots 
of the disease may be reached. We may well be- 
lieve Cotton when he states that he has seen psycho- 
tic patients and has not noted the psychogenic fac- 
tors, but his inability to see them does not eliminate 
them. They are always present. Workers in large 
institutions where thou.sands of patients are exam- 



July 19, 1922.] 



BOOK REVIEWS. 



109 



ined assert tliat they are present in every case, so 
it must be that Cotton in looking for foci has over- 
looked the mental and emotional factors which have 
been operating. He speaks of "worry, grief, shock 
and mental overwork" as mental factors. This 
shows that he does not include the many repressed 
mental conflicts which constitute the major portion 
of our psAxhic disturbances. He also attempts to 
cling to the archaic idea that mental disorders are 
disorders of the brain. He finds it difficult to grasp 
the broader terminology speaking of these disorders 
as those of the mind. Just what does he mean by 
the brain? Does he limit it to that mass of boxed 
up material covered with meninges ? I f so he is iso- 
lating himself on a dangerous fsland. 

The weakness of any deductions that can be built 
up on an hypothesis in which as Cotton states that 
"heredity, environment, personality and psychogenic 
factors . . . may all be absent and a psychosis 
may develop" is apparent. It requires no comment 
to show the fallacy of such reasoning. A theory 
constructed along these lines can not be taken seri- 
ously. 

COMPAR.\TIVE ANATOMY. 

A Laboratory Manual for Comparative Vertebrate Anat- 
omy. By LiBBiE H. Hyman. Department of Zoology, 
University of Chicago. Chicago : The University of 
Chicago Press, 1921. 

The author has prepared a useful and interesting 
work on the study of comparative anatomy in the 
dissecting room. Not only has the author given full 
directions for the dissection of the various systems 
discussed, but in connection with each system there 
has been incorporated a brief, generalized and sim- 
plified account of the development and evolution of 
that system. Numerous simple illustrations have 
been added to clarify the text, but the author has 
not intended that these explanations shall take the 
place of the reading matter. The result is a volume 
of unusual lucidity and interest, in a subject that 
usually constitutes difficult reading. 

The print is excellent, the illustrations clear, both 
combining to make the book a very readable volume 
for those interested in this particular subject. We 
believe the average medical student would do well 
to familiarize himself with this and similar works, 
and thereby obtain a clearer conception of the human 
anatomy and its relation to the lower forms of life 
with which we are in such close contact. 

THE M.\YO FOUNDATION. 

Papers from the Mayo Foundation for Medical Education 
and Research and the Graduate School of Medicine of 
the University of Minnesota. Covering the period of 
1915-1920. Octavo Volume of 695 Pages, with Two 
Hundred and Three Illustrations. Philadelphia : W. B. 
Saunders Company, 1921 

These papers summarize the research work done 
by the graduate students in the medical school of 
the University of Minnesota during the years 1915- 
1920. Many of thein contain new material that must 
prove of interest both to the clinician and the in- 
vestigator. Sixty-four papers thus have been con- 
tributed. The alimentary tract, the urogenital 
organs and the nervous system seem to have received 
most attention, but a careful reading shows that prac- 
tically every department of internal medicine has 



been treated in these papers. There is an excellent 
bibliographic index and an index of subjects which 
is all that could be desired. 

It is to be expected that a volume of papers of 
this kind will contain a preponderance of laboratory 
subjects; and this is perhaps the only criticism that 
might be offered, though the reviewer does not feel 
that such criticism would be justified in view of the 
wide range of subjects that have been considered. 
One cannot but feel that the publishers have per- 
formed a real service in collecting and presenting 
these papers and presenting them to the medical pro- 
fession in their present attractive form. Anyone 
interested in the progress of medical thought will do 
well to read die papers contained in this volume. 

RADIATION THERAPY. 

The Principles of Physics and Biology of Radiation 
Therapy. By Bernard Kroenic, Professor of Gynecol- 
ogy and Obstetrics. University of Freiburg, and Dr. 
Walter Friedrich. Chief of Division of Radium Thera- 
py, University of Freiburg. Only Authorized English 
Edition with an Appendix, by Dr. Henry Schmitz, Pro- 
fessor of Gj'necology and Head of Department, Loyola 
University School of Medicine, Chicago, 111. With 
Eighty-six Textual Figures and Twenty Colored and 
Eleven Black and White Plates and Thirty-two Tables. 
New York: Rebman Company, 1922. Pp. 271. 

Radium Therapy. By Frank Edward Simpson, A. B., 
M. D., Professor of Dermatology, Chicago Polyclinic ; 
Adjunct Chnical Professor of Dermatology. Northw-estern 
University Medical School, etc. With One Hundred and 
Sixtv-six Original Engravings. St. Louis : C. V. Mosby 
Company, 1922. Pp. 391. 

Kroenig's work is truly a ponderous monograph, 
well planned, thoroughly investigated and logically 
organized. X ray dose is conceived of in terms 
purely physical and with this new physical unit the 
biological effects of radiation studied. The experi- 
ments recorded divide themselves into two distinct 
classes; those relative to the physics of radiation in 
which section unit dosage and its measurements are 
introduced and those pertaining to the biological 
effects of radiation. An appendix is added contain- 
ing published papers by authors and collaborators on 
subjects pertinent to the contents of the book. This 
publication is worthy of the attention of all inter- 
ested in a scientific approach to the problems of 

radiotherapy. 

* * * 

Simpson's book is well written and profusely illus- 
trated with photographs of the author's own cases. 
It is a concise presentation of our knowledge of 
radium boiled down to the last minute before going 
to press in March of the current year. There is a 
comprehensible and valuable bibliography but the 
author's statements and conclusions are well based 
on his own wide experience. Beginning with the 
discovery of radium, we are led to consider its 
chemical nature and physical properties, its constant 
decay into radium emanation — which can be used in- 
stead of the element itself — the Deburne-Duane- 
i*'ailla apparatus for its preparation and the method 
of measuring its gamma ray activity. There fol- 
lows an informing discourse on tlie absorption of 
the dift'erent rays, filtration and screening, and a 
lengthy chapter on the absorption of the gamma rays 
in water. Of the highest value is that section of 
the volume which treats of the biological effects of 



110 



BOOK REVIEWS. 



[New York Medical Journal 
AND Medical Record 



the rays, the therapeutic apparatus, dosage, reaction 
and technic of radiation. The author's discussion 
of the treatment of benign and mahgnant tumors 
and chronic infections is made easy of reference by 
division into chapters devoted to general surgery, 
gynecology, dennatology, eye, ear, nose and throat, 
and internal medicine with diseases of the ductless 
gland. All in all we have in this medium sized vol- 
ume an important addition to the definite knowledge 
of the nature, properties and uses of radium. Its 
form is understandable, its material accessible, and 
its conclusions sincere. 

POPULAR EXDOCRIXOLOGY. 

Glands in Health and Disease. By Benjamin Harrow, 
Ph. D., Associate in Physiological Chemistry, College 
of Physicians and Surgeons, Columbia University. New 
York: E. P. Button & Co., 1922. Pp. xiii-216. 

The purpose of this book is difficiilt to determine. 
For medical men it has little value, but from the 
general presentation this does not concern the au- 
thor, for clearly he wishes to educate the general 
reading public. While so much activity is going on 
in the field of endocrinology among scientific men 
and the subject is being exploited by commercial in- 
terests, it is natural for the general public to be in- 
terested in the subject. From this viewpoint the 
book is of service, the information presented is at 
least not inaccurate, although it cannot be utilized 
for anything constructive. All that can be said is 
that it is a general popular resume of endocrino- 
logical material written to satisfy the curiosity of 
those whose interest in the subject has been stimu- 
lated by the vast amount of bosh which they have 
found in sensational periodicals. 

SOCIAL PROBLEMS. 

Society and Its Problems. An Introduction to the Princi- 
ples of Sociology. By Grove Samuel Dow, Professor 
of Sociology in Baylor University. New York : Thomas 
Y. Crowell Company, 1922. Pp. xiv-594. 

A consideration of sociology from a conservative, 
retrospective point of view presented in a flat, unim- 
pressive manner. The literature has been freely 
consulted and carefully pruned. The author's wishes 
are frequently used as bases for assumptions which 
do not coincide with reality. His intentions are of 
the best but the results tend to be misleading. Dog- 
matic assertions have advantages for teaching pur- 
poses, from the point of view of the teacher, but in 
a world where people may think independently of 
the pedagogue these same statements do not always 
"hold water." The" material which is quoted could 
have been utilized for more substantial purposes. 

GENETICS. 
Genetics. An Introduction to the Study of Heredity. By 
Herbert Eugene Walter. Associate Professor of Biol- 
ogy, Brown University. With Ninety-two Figures and 
Diagrams. Revised Edition. New York : The Mac- 
inillan Company, 1922. 

An acciirate yet popular presentation on heredity. 
This, the second edition coming ten years after the 
first, has filled the gap which the discoveries of work- 
ers in this field have created. For anyone who 
wishes to become conversant with the elements of 
heredity without delving into the more technical 
works this book may be highly recominended. 



NEW CLASSICS. 
Goethe's Faust. New York: Alfred A. Knoof, 1922. Pp. 

572. 
Les Contes Drolaiiques. By Honore de Balzac New 

York: Alfred A. Knopf, 1922. Pp. 516. 

It is needless to attempt a review of these two 
masterly classics. They appear as part of a series, 
issued by Knopf, in the original language. The 
workmanship on these books is excellent. They have 
been printed on fine paper, bound in limp cloth 
covers and made of a size convenient for the pocket. 
The form and appearance of the edition is extreinely 
attractive. 

FAMILIAL DIFFICULTIES. 

The Ship. A Play in Three Acts. By St. John G. Er- 
viNE. New York : The Macmillan Company, 1922. 

A projected picture of a conflict between father 
and son in a setting of fantasy blended with a some- 
what stolid realit}'. The age long struggle between 
the generations is brought up to date by the delinea- 
tion of commercial achievement. Echoes of the war 
of a pessimistic yet true note coine into the play. 
Four generations serve to bind the plot. The will 
to power, to rule, to dominate — especially the off- 
spring, is definitely portrayed. 

PATHOLOGICAL FICTION. 

Rahab. By Waldo Frank.. New York: Boni & Liveright, 
1922. Pp. 241. 

Rahah is the story of a woman who was appar- 
ently able to find no spiritual satisfaction in a life 
tliat did not include complete gratification of the 
sexual instinct. The wondering reader, instinctively 
atteinpting to rationalize or justify such a view- 
point, vaguely surmises that the author conceives 
himself as the inspired messenger to a puritanical 
Western world, proclaiming the wrongs inflicted 
by a prudish society upon women who desire to live 
their lives according to the dictates of nature. He 
seems to have no conception of the part played in 
life and character building and the attainment of 
spiritual values through the exercise of moderation 
and self restraint and self control. 

The style of the book is futuristic; in other words, 
hectic, involved, bizarre and freakish to the extreme. 
"A quiet pain in the table and her words ... a 
distant pain" is one thought. "It was Englished 
from the French," is another statement. "His beard 
was a grey prayer," is a third. Many passages are 
revolting in their unnecessary physiological details. 
If this Oriental frankness of Rahab consisted of a 
natural and spontaneous sensuality, such as that, for 
instance, of the unexpurgated form of the Arabian 
Nights, it might be excusable, but the book is per- 
meated with a distinctly artificial and purposive 
salaciousness that makes it in many places disgust- 
ing reafling. Minor faults are consistently mis- 
spelled words and numerous typographical errors. 

The only favorable thing tliat can be said about 
it is that there are a few vivid descriptive touches 
and two or three bits of clever characterization ; but 
these are so very few that they are negligible in 
providing any possible excuse for the perpetration 
of a work like Rahab by a writer of Mr. Frank's 
])otentia! ability. 



July 19, 1922.] 



BOOK REV I EM'S. 



Ill 



Medicoliterary Notes. 



Reading- matter for the long, daylight saving even- 
ings, for weekends in the country, and for summer 
vacation periods should be not too "strenuous," yet 
interesting, and profitable — sometimes I Here are a 
few hints about some of the late books. Among 
novels in which the chief interest is character devel- 
opment are Joanna Goddcn. by Sheila Kaye-Smith ; 
Memoirs of a Midget, by Walter De La Mare : 
Intrusion, by Beatrice Kean Seymour; Maria Clmp- 
dclainc, by Louis Hemon ; and The Life and Death 
of Harriet Frean. by May Sinclair. Two novels of 
American life are Beggars' Gold, by Ernest Poole, 
and Children of the Market Place, by Edgar Lee 
Masters, well known as the author of the Spoon 
River Anthology. Mr. Masters is a better poet than 
novelist, how^ever, for Children of the Market Plaec. 
really a history of the Middle West from 1833 
through the early years of the Civil War. is rather 
prosy in spite of some vivid descriptions of episodes 
and a few good character studies, such as those of 
Lincoln and Douglas. 

Others on phases of American life are The Fair 
Rewards, by Thomas Beer, a charmingly written 
story based on theatrical life in New York in the 
'80's ; Birthright, by T. S. Stribling, an interesting, 
if inconclusive, discussion of the socalled negro 
problem ; The Vehement Flame, by Margaret De- 
land, not at her best : Gentle Julia, by Booth Tark- 
ington in his usual manner; and J'andemark's Foll\. 
by Herbert Quick, a story of pioneer days. Good 
detective and mystery stories are Within Four Walls, 
by Edith Baulsir ; The Red House Mystery, by 
Arthur Milne ; The Bright Messenger, by Algernon 
Blackwood; and The House of Souls, bv Arthur 
Machen, the last being four stories of the super- 
natural which will appeal to lovers of Poe, and of 
the uncanny tales of Hawthorne and Bulwer Lytton. 
The more serious minded will find well worth while 
Edwin Bjorkman's Soul of a Child, a study of child 
p.sychology in fiction form. 

Among plays now available in book form are 
Ambush, by Arthur Richman, more interesting to 
see than to read: He Who Gets Slapped, presented 
this winter by the Theatre Guild; Back to Methu- 
selah, by Bernard Shaw, also given by the Guild ; 
The Detour, by Owen Davis ; U^ill Shakespeare, by 
Clemence Dane, author of one of the greatest suc- 
cesses of the season. The Bill of Divorcement : and 
a new volume of Eugene O'Neill's plays including 
Anna Christie, The Hairy Ape, and The Oldest 
Man. A rather superficial but entertaining book 
including sketches of some of the well known Brit- 
ish playwrights and actors is Hasketh Pearson's 
Modern Men and Mummers. Ludwig Lewisohn is 
the author of a critical volume entitled The Drama 
and the Stage: and The No Plays of Japan, trans- 
lated by .\rthur Waley. is a beautifully gotten up 
volume about the national Japanese drama. 

Those interested in reconstruction problems in this 
country will find instructive a little book by Robert 
.VIf)untsic-r called Our Flevcn Billion Dollars, which 
discusses .America's proper attitude to the allied debt 
from the point of view of the conservative American 
business man. Durant Drake, professor of philoso- 



phy at \"assar College, in America Faces the Future, 
takes up in turn what he considers our five national 
ideals— liberty, equality, democracy, efficiency and 
patriotism— and discusses in a sane, broadminded 
and practical manner the application of each to vari- 
ous contemporary problems. 

* * * 

The June Atlantic Monthly contains several arti- 
cles of unusual interest. The Flapper should feel 
honored to be discussed as a social and psychological 
phenomenon by no less an authority than Dr" G. 
Stanley Hall in an article entitled Flapper Ameri- 
cana Novissima. Gino Speranza has a paper on 
immigration and other present day problems in the 
United States. Vernon Kellogg in Being Born Alike 
But Different gives a popular dissertation on hered- 
ity. Ellen N. La Motte and Girja Shanker Bajpai 
contribute papers on the opium trade. Two inter- 
esting poems on Washington and Lincoln with the 
title American Born were written by Samuel Cohen, 
a boy in the Americanization School in Washington! 

* * * 

James Harvey Robinson has in the June Harper's 
an article Js Darwinism Deadi' in which he states 
that we are in danger of taking too lightly our ani- 
ma*l descent, rather than of emphasizing it'unduly. 



-^^- 



New Publications Received. 

ONE. By S.\RAH Warder MacConnell. New York- 
The MacMillan Company, 1922. Pp. 280. 

l'emi'loi des rayons X EN MEDICINE. Par Dr Paul 
DuHEM. Paris: Ernest Flammarion, 1922. Pp. 303. 

THE SECRET PLACES OF THE HEART. By H. G WeLLS 

New \ork: The MacMillan Company, 1922. Pp. 287. 

TUMOURS INNOCENT AND MALIGNANT. By Sir JoHN 

Bland-Sutton. Seventh Edition. New York- Paul B 
Hoeber, 1922. Pp. x-806. 

l'hvpertension arterielle. Par les Docteurs Maurice 
Perrin, and Gabriel Richard. Paris: Librairie T B 
Bailliere et Fils, 1922. Pp. 109. 

a textbook of clinical periodontia. By Paul R. 
Stillman and John Oppie McCall. New York- The 
MacMillan Company, 1922. Pp. xvii-240. 

A treatise on glaucoma. By Robert Henry Elliot. 
Oxford Medical Publication. London: Henry Frowde and 
Hodder & Stoughton, 1922. Pp. xxii-656. 

X RAYS AND RADIUM IN THE TREATMENT OF DISEASES OF 

the skin. By George Miller MacKee, M.D. Philadel- 
phia and New York: Lea & Febiger, 1922. Pp. xi-602. 

questions neurologiques d'actualite. Vingt Confer- 
ences, Faites a la Faculte de Mcdecine de Paris, 1921. In- 
troduction par M. le Professeur Pierre Marie. Paris: 
Masson et Cie, Editeurs, 1922. Pp. 551. 

diseases of the digestive organs with special refer- 
ence TO THEIR diagnosis AND TREATMENT. By ChaRLES 

D. Aaron. Third Edition. Thoroughly Revised. Phila- 
delphia and New York: Lea & Febiger, 1921. Pp. 904. 

A TEXTBOOK OF PRACTICAL THERAPEUTICS WITH ESPECIAL 
REFERENCE TO DISEASE AND THEIR EMPLOYMENT UPON A 
RADIONAL BASIS. By HOBART Amory Hare, M.D., LL.D., 
B.Sc. Eighteenth Edition. Philadelphia and New York: 
Lea & Febiger, 1922. Pp. xiv-1038. 

the mechanism OK THE BRAIN, AND THE FUNCTION OF 
THE FRONTAL LOBES. By ProfcSSOr LEONARDO BlANCHI. 

.Authorized Translation from the Italian by James PI. 
McDonald. New York: William Wood and Company. 
Edinburgh: E. & S. Livingstone. 1922. Pp. 348. 



Practical Therapeutics 



ROENTGEN THERAPY OF DISEASED 

TONSILS AND THEIR ADNEXA. 

By John Remer. M. D., 

AND D. L. Satexsteix. M. D., 

New York. 

In tliis article there are no new principles of x 
ray therapy; only those which have stood the test 
of time are considered in this paper. Their applica- 
tion varies with the character and location of the 
pathological process. The character of the patho- 
logical process, whether inflanmiatory, granuloma- 
tous or neoplastic, determines the intensity of the 
exposure and the location the guide for the technic, 
i. e., the spark gap, milliamperage. distance, filters, 
and other details. 

TYPE OF TONSILS. 

Hypertrophied tonsils in consequence of repeated 
inflammation, resulting in hyperplasia of the lymph 
adenoid tissue, either with or without a prolifera- 
tion of the connective tissue, which may or may^not 
1)6 permeated with leucocytes, are strongly predis- 
posed to acute inflammations because dift'erent or- 
ganisms find lodging places in the crypts. These 
serve as a favorable soil for their development and 
are points of entrance for metastatic inflammatory 
processes in the deeper tissue. 

If the increase in the connective tissue is slight, 
the tonsil is soft; if great, the tonsil is hard almost 
like a fibroid tumor. All degrees are found. Asso- 
ciated with the tonsil changes, one frequently finds 
in varying degrees, similar changes in the surround- 
ing mucous membranes and lymphoid tissues, so 
that there is nearly always a chronic pharyngitis with 
or without the involvement of the orifices of the 
eustachian tubes, and in a fair proportion of cases, 
adenoids and changes in the mucous membrane of 
the nasal passages. We must not forget the bed of 
tissue in which the tonsil lies and the lymphatic 
nodes and glands into which these diseased tonsils 
drain. We must not forget that the organisms pres- 
ent are elaborating toxins which are responsible for 
so many of the constitutional symptoms noted in 
cases of long continued inflammatory tonsils with 
acute exacerbations. The surface of the tonsils 
shows changes characteristic of this inflammatory- 
process. The mucous membrane is thickened, the 
crypts dilated and filled with detritus, exfoliated 
ceils, pus cells, and microorganisms. 

TECHNIC FOR PREPARATIOX OF P.^TIENT. 

In the treatment of tonsils, as in rontgen ex- 
posure for other conditions, it is important that no 
irritating liniment — iodine or anv irritating oint- 
ment — ^be used for at least two weeks previous to x 
ray exposure, during the intervals between ex- 
posures, and for two weeks subsequent to the last 
exposure, nor .should strong solutions of nitrate of 
silver be applied to the tonsils, either before, during 
or after exposure. During this period only bland 
applications are permissible. It is not advisable to 
make exposures during an acute inflammatory con- 
dition of the throat or tonsils. 



POSITION OF THE PATIENT. 

The patient is placed on his abdomen, the head on 
a sufficient number of supports so that the line of 
the spine is brought to the same plane and turned 
to the side resting on the opposite ear, chin tilted 
upward so that the ramus and angle of the jaw are 
drawn away from the neck. When this is done, 
some of the rests are withdrawn so that the head 
may drop about half an inch, in order to increase the 
distance of the angle of the jaw from the neck. We 
then have before us the site through which rays are 
passed down to and through the diseased tonsil, to 
the opposite tonsil and adnexa, that is. the bed in 
which it lies, the soft palate and posterior pharyn- 
geal wall and the vault of the pharynx. 

SITE OF EXPOSURE. 

The site of exposure is an angle made by the 
ramus of the lower jaw as the anterior margin, the 
anterior border of the sternocleidomastoid muscle as 
the posterior margin, the tip of the mastoid process 
as the apex. Beneath this there are no bony struc- 
tures : we have muscle and fat so that we have noth- 
ing practically that will filter out any of the rays. 

SHIELDING THE PATIENT. 

A sheet of lead foil or lead rubber, at least a six- 
teenth of an inch thick, with an opening three and a 
half inches long and two and a quarter inches wide, 
is placed so that the upper margin of the opening is 
just above the tip of the mastoid process and that 
the site of the exposure lies in the centre of the open- 
ing, care being taken to cover with sufficient lead 
so that the hair of the head, the shoulder and the 
neck are protected. This may be accomplished by 
having a single sheet of lead sufficiently large to 
cover all these parts. 

RELATION OF TUBE TO EXPOSURE SITE. 

Care must be taken, and this is most important, 
that the target (anode) is in such position that the 
rays will strike the exposure site and the diseased 
tonsil area at right angles. This position will var}- 
with the patient. 

INTENSITY AND FREQUEN'CY OF THE EXPOSURES. 

As previously described, the pathological process 
is subacute or chronic in character. In an article 
l)ublished by us (1) we show that in order to call 
forth a response in chronic inflammatory tissue, it 
must be exposed to a minimum of one filtered unit 
every two weeks. 

TECHNIC. 

Employing a Coolidge tube and interruptless 
transformer, with the following factors, the tube 
placed at a distance of ten inches, a spark gap of 
seven inches, milliamperage five, a time of three 
minutes and nineteen seconds, through a filter of 
ihree mm. of aluminum (2), an exposure of one 
unit is obtained. These factors are those which we 
employ. .Any other setting of the machine may be 
used, providing the time is changed so that by the 
formula used an amotmt equal to one filtered unit 
is the result. If, for example, a setting six inches 
spark gap five milliamperes and ten inches anode 



July 19, 1922.] 



PRACTICAL THERAPEUTICS. 



ii; 



distance, with three mm. of aluminum filter were 
used, an exposure of three minutes and fifty-one 
seconds would be necessary. The patient is then 
turned to tlie opposite side and a similar procedure 
is followed. 

THE AGE OF THE PATIENT. 

The exposure given, i. e., one unit intensity fil- 
tered, is sufficient for the average adult. This must 
vary with the age of the patient and a less intensity 
administered to a young child. 

CHARACTER OF THE SKIN. 

We must consider whether the patient is blond 
or brunette, and whether we are dealing with a 
fine or a coarse skin. It is well known that there 
is likely to be a quicker and more prolongel skin 
response to the rays in blonds and diat an erythema 
is more easily produced in this type of skin. Con- 
sequently, one mfist be extremel}- cautious in treat- 
ing these patients. 

RESPON.se of THE CELLS. 

Referring again to the article before mentioned 
(1 ) we find: "After a rontgen ray exposure, the re- 
sistance of all cells is influenced and their activity 
is proportionately affected. The more resistant cells 
recover in less time than those of less resistance. 
In the tonsil tissue exposed, there are the pathologi- 
cal round (lymphoid), connective tissue cells, and 
microorganisms. The lymphocytes are cells of least 
resistance, and are, therefore, more readily influ- 
enced. Ordinarily tissue characterized by the pres- 
ence of lymphocytes is exposed to a quarter skin unit 
and they are so inhibited that little or none of their 
activity is recovered at the time of the second ex- 
posure. A varying degree of shrinkage of the swell- 
ing is noticed, and, as explained, it is at the expense 
of the lymphoid elements." We said, "If the inter- 
vals between the exposures are sufficiently long, all 
cells will recover." We therefore make a second 
exposure at the end of two weeks, i. e., before the 
connective tissue elements have had time to com- 
pletely recover from the inhibition of their activity 
as the response to the first exposure. After a second 
exposure, the activity of the cells which have not 
fully recovered is more readily affected as their 
resistance has already been influenced. With each 
successive exposure the resistance is more and more 
influenced and the activity is less and less main- 
tained. When the accumulated effect at the point 
of saturation is reached, the tissue affected becomes 
nonresistant and inactive and degeneration and in- 
volution set in. The rapidity with which this stage 
is reached depends upon the density and the amount 
of the coimective tissue elements present in the in- 
flammatory process, in or about the diseased tonsil. 

After the second, third or fourth exposure, vary- 
ing degrees of shrinkage of the hypertrophied tonsil 
are evident. The effect is not only in the 
visible tonsil but also in all the pathological tissue 
surrounding the affected tonsil. We have mentioned 
the presence of the microorganism and pus in the 
crypts and body of tonsil proper. One of the first 
evidences of the effects of the therapy is the general 
improvement of the patient; namely, those symptoms 
referable to the absorption of the toxin elaborated 
in the pathological area. It has been proven experi- 
mentally that after the second or third exposure the 



tonsils are sterile [2), that is, cultures from the 
crypts arc negative and few or no pus cells are 
present. 

EXPLANATION OF REStJLTS OF EXPOSURE. 

Laboratory experiments have shown that micro- 
organisms do not ordinarily respond to x ray ex- 
posures. We know that microorganisms produce 
toxins at the expense of their environment, i. e., its 
culture medium, either in the test tube or the tissu'j 
in which they are lodged, \^'e said that all cellular 
metabolism is inhibited following an x ray exposure. 
Not only the cellular metabolism in its normal func- 
tion, but also the metabolism as the response to the 
organism present, i. e., toxin formation. As the 
action is more and more inhibited, following each 
successive exposure, less and less, or no toxins are 
produced, and a time comes when no more toxins 
can be produced. Less and less of this toxin is 
absorbed into the circulation, and the body circulat- 
ing fluids, not having increasing amount of increas- 
ing virulence to contend with, are then capable of 
carrying out their functions, that is, to neutralize, 
or, better still, oxidize the toxin present, and at the 
same time functionate as a bactericide, thus pav- 
ing the way for phagocytic action, which is always 
noted during the process of involution. Not only is 
this toxin producing process inhibited in the ton- 
sils, but also in the tonsillar nodes and in the lymph 
glands, which are draining the affected tonsil area. 

END RESULTS. 

We have brought about an absorption of the in- 
flammatory elements in and about the tonsil and 
have rendered this entire area sterile. That portion 
of the nomial tonsil which was not destroyed by 
the pathological process previous to the x ray ex- 
posures was not affected by the therapy, and can now 
carry on whatever function it is supposed to have. 

It must be borne in mind that the effects of the x 
ray are cumulative, i. e., gradual inhibition; that the 
maximum effect, i, e., saturation point and absorp- 
tion of the pathological elements, is not reached for 
at least two weeks, that it remains stationary for 
two weeks and there is tlien a gradual diminution, 
lasting for two weeks or more ; in consequence, there 
is a total time of from six to eight weeks from the 
last exposure to the entire loss of x ray effect, i. e., 
complete recovery of functions of normal tissue ele- 
ments, so that a verdict as to the result can not be 
given under that time, even though pus may be 
expressed from the crypts at the time of the last 
exposure. 

DANGERS OF X RAY THER^\PV. 

Permanent disappearance of hairs and total inhibi- 
tion of glandular function, i. e., permanent alopecia, 
no sweat and sebinn secretions may occur. 

The skin and underlying tissues may atrophy and 
even ulcerate. These dangers follow, either 
from improper technic or overexposure, either in 
a single exposure or from too frequent exposures. 
By improper technic we refer to forgetting to insert 
the fiker and inexact distance. There should be 
no guessing, the distance must be exact. The mil- 
ammetre reading must not be about, but must be 
kept at one point. In fact, any variation of any one 
of the factors will change the intensity. 



114 



PRACTICAL THERAPEUTICS. 



[New York Medical Journal 
AND Medical Record. 



TOO FREQUENT EXPOSURES. 

We Stated that the change following the first ex- 
Xjosure was at the expense of the pathological lym- 
phoid elements and httle or no change in the con- 
nective tissue. So that an inexperienced or impa- 
tient operator, thinking to hasten the process or at- 
tempting to comply with the wishes of the patient, 
makes his exposure at less than biweekly intervals 
and will invariably get into trouble. Giving to a 
voung person the same exposure as an adult, or 
exposing an individual with the socalled blond skin 
will, in the course of time, lead to trouble. Pro- 
longed exposure, i. e., carrying on treatment for 
months in cases to be referred to later, will lead to 
atrophies and telangiectasis. 

TYPES OF CASES SUITABLE FOR X RAY THERAPY. 

As in all surgical procedure, one must choose his 
case for any given technic, by which we mean that not 
every enlarged tonsil should be treated by the ray, 
for if that is done the radiotherapeutist is doomed to 
certain failure in a portion of his cases. Those ton- 
sils in which the inflannnatory process has prac- 
tically come to a rest stage, will not ordinarily re- 
spond to radiotherapy within a hmited time safe 
to overlying tissues. We refer to those tonsils in 
which the many repeated attacks of acute or subacute 
inflammatory processes have resulted in the forma- 
tion of dense fibrous connective tissue, within the 
capsule of the tonsil proper. The inflammatory pro- 
cess has run its course. The only indication for 
therapy in cases of this kind is mechanical obstruc- 
tion, and it is the work of a few minutes for the 
skilled surgeon to enucleate these fibroid tonsils 
with comparative safety. These cases, as a rule, 
leave no aftereflfects from surgical therapy. If 
these cases are treated by radiotherapy, involution 
and absorption will be very slow and damage to the 
skin and underlying tissue will undoubtedly result 
from too repeated exposures. 

In the following types of tonsils good results are 
obtained within safe limits to the overlying tissue: 
Varying sized, socalled mushy and pus filled tonsils, 
i. e., the flabby or soft tonsil with dilated crypts from 
which cheesy, puslike and foul smelling material can 
be expressed. These tonsils are usually associated 
with varying degrees of severity of constitutional 
disturbances, rheumatism, joint symptoms, and even 
complicating cardiac lesions. They may alsobe as- 
sociated with similar processes about the orifices of 
the eustachian tubes and in the vault of the pharynx. 
Cultures made from these tonsils are always posi- 
tive for virulent organisms. These are the cases 
that are referred to when we said that one of the 
first things noticed after the first or .second exposure 
was the im])rovement in the patient's general condi- 
tion, and these are the cases that clear up in a series 
of biweekly exposures, lasting from eight to twelve 
weeks, making from four to six exposures. 

LOCAL THERAPY. 

We often get a history from patients who come 
to us with these affected or diseased tonsils of 
weekly, biweekly or daily visits to the jjhysician who 
swabs, cauterizes, sprays or uses other local pro- 
cedures, with the result that there is temporary im- 
provement for varying periods. Of cour.se, one can 



readily understand that with local therapy alone 
the deeper processes are not much influenced. 

CONSTITUTIONAL TREATMENT. 

There is a general building up of the patient, 
tonics, vaccines, but nothing is done to remove the 
resistant pathological tissue which flares into activ- 
ity as soon as the patient's general resistance is 
lowered. 

ADVANTAGES OF RADIOTHERAPY. 

All the possible dangers of surgery are eliminated. 
The following are complications associated with sur- 
gical methods, as reported by competent men. While 
these accidents are rare, they do occur in a certain 
percentage of cases. 

From local or general anesthesia. — In the young, 
debilitated, and in patients with cardiac and other 
grave general conditions (status lymphaticus). 

From infections. — It is immaterial whether the 
cause is from aspirated infected clots or from em- 
bolus. These cases are diagnosed as tuberculosis. 
There are many infections into the eustachian tube 
following tonsil and adenoid operations. 

Siir.f/ical traumatism. — Either at the time of opera- 
tion or as the result of scar tissue formation. 

CONCLUSIONS.. 

We do not affirm that x ray therapy has cured 
anything. The pathological process has been inhibited 
to a point where the local tissue, assisted by the 
bodv's protective forces, were able to carry on their 
work which before the exposures they were not able 
to, as the pathological elements had already acquired 
almost adult morphological and physiological char- 
acters and therefore with a resistance too great for 
these forces to overcome. We also take advantage 
of every possible therapeutic measure to assist the 
body forces to carry out this work, namely, local 
cleanliness, sedatives, vaccine therapy and the build- 
ing of the patient's general condition. 

REFERENCES. 

1. Satenstein and Remer: Rontgen Ray Dosage from 
the Pathological Point of View, Archives of Dermatology 
and Sypliilotogy, March 21, 1921. 

2. Murphy. James B., Witherbee, W. D., Craig. 
Stuart L., Hussev. R. C.. and Sturm. Ernest: The 
Atrophy of Hypertrophied Tonsils and other Lymphoid 
Structures of the Throat Induced by Small Doses of X 
Ray, Journal A. M. A., January 22, 1921. 

116 West Fifty-eighth Street. 
170 West Fifty- ninth Street. 



X Ray Treatment of Skin Diseases. — H H. llazen 
(.imericaii Journal of Rontgenology. April, 1922), con- 
cludes that rontgen rays are probably the most useful single 
therapeutic agent that the dermatologist jjosscsses today. 
It is of the greatest value in Ixith malignant and benign 
tumors, keratoses, warts, eczema, acne, lichen planus, some 
forms of tuberculosis, sycosis and folliculitis of the back 
of the neck, tinea tonsurans, tinea barbae, some cases of 
pruritus, granuloma annulare and mycosis fungoides. At 
the same time a word of warning must be issued, for since 
the war scores of physicians with totally inadequate train- 
ing are rushing into rontgen ray therapy and it is certain 
that some disastrous results will follow. In no case should 
an erythema dose be administered to the skin, except after 
careful ccmsideration of malignancy. In addition, it should 
always be remembered that an erythema dose over a large 
area of .skin is much more apt to result in disastrous 
sequelae, especially telangiectasis, than is the same sized 
dose over a small area. Treatments should never be con- 
tinued for more than six months, except under very special 
circumstances. 



Proceedings of Societies 



NEW YORK ACADEMY OF MEDICINE. 

Section' in Otology. 

Stated Meeting Held on January 13, 1922. 

Dr. S.^muel J. KoPETZKY in the Chair. 

Labyrinthine Surgery. — Dr. J. Morris.set Smith read 
a paper on this subject in which he dealt with the dif- 
ficulties encountered in diagnosis, present day views of the 
surgical treatment, and the results obtained. The paper 
appears on page 85 of this issue. 

Discussion. — Dr. Edward B. Dench said that Dr. 
Smith had so clearly stated the best and most conservative 
views on the subject that little could be added, and what 
he had to say was chiefly confirmatory of the very excel- 
lent remarks that had been made. He had been gratified 
to hear Dr. Smith emphasize the point in contravention to 
the teaching of the German school some years ago that 
every dead labyrinth should be taken out. He himself 
had followed the opposite theory for many years. If 
there were no labyrinthine symptoms, he proceeded in- 
dependently of them, and in few instances had he sub- 
sequently been obliged to interfere with the labyrinth. 

He also heartily concurred in what had been said about 
the examination of the spinal fluid. A persistent high cell 
count was a good indication for operation. In the invasion 
of the labyrinth there might be an increase of the cells in 
the spinal fiuid up to 100, even though there was no actual 
invasion of the meninges. Following this cell count, as 
Dr. Smith had suggested, one could form a good idea as 
to the limitation of the process. If the count went very 
high — above 500 or 1000 — the extension was apt to be rapid. 
If the cell count of the spinal fluid should greatly increase, 
one would be justified in interfering with the labyrinth if 
there was evidence of a dead labyrinth or a history of 
such symptoms being present shortly before the patient 
came under observation. If a case was allowed to go 
on with these manifest symptoms, without operating, one 
felt that he had done wrong ; the opposite was also true, 
and if meningitis developed one would be in doubt as to 
whether, if Nature had been allowed to wall off the cavity 
more thoroughly, the patient might have recovered. Many 
years ago he had seen a patient with a grave and acute 
mastoiditis, and sudden labyrinthine symptoms with high 
temperature. The patient was seen on the fifth day after 
the onset. On the third day the temperature had been 
high, and when he observed the case the temperature was 
normal. The labyrinth was dead. The mastoid was clean 
and there was no injury to the labyrinth, so he advised let- 
ting the patient alone, and he made a good recovery. In 
a similar case later, the patient died. Dr. Smith was abso- 
lutely right in saying that at the present time we are much 
in doubt even in the presence of certain clinical symptoms. 
In certain cases operation may seem to be necessary, but 
with delay the patients get well : in other cases, where it 
seems best to delay operation, the patient may go on to 
death. It was very difficult for anyone to make any 
broad statement excepting where there were distinct symp- 
toms of frank invasion of the labyrinth, and then the 
labyrinth should be taken out. The cases that go slowly 
are the puzzling ones, and it was gratifying to hear Dr. 
Smith say frankly that there were times when one did 
not know what to do. 

In answer to Dr. Dench's inquiry whether he re- 
ferred to the spinal fluid count or to the increased blood 
count when he spoke of increased leucocytosis. Dr. Smith 
replied, "In the blood count, where there was involvement." 
Dr. Dtnch disagreed with this statement, for in cases where 
the labyrinth alone was involved there was a certain in- 
crease of leucocytes. Perilabyrinthitis cases were inter- 
esting and confusing. A certain number of the patients 
recover with removal of the perilal)yrinthine tissue and 
restriction of circulation within the l.xbyrinthine capsule 
to normal, he case of the plumber which had I)een cited 
was hardly invasion, but rather a case of concussion; 
even though there were positive symptoms. Dr. Dench 
said he would not have operated in a case of that kind. 
He also expressed gratification that Dr. Smith had not 



split hairs on the subject of diffuse purulent labyrinthitis, 
for it was difficult to make a differential diagnosis in these 
conditions at the present time. He had seen a number of 
acute cases with meningeal symptoms, and even where the 
cell count was high many of the patients got well without 
operation. There was no invasion of the spinal fluid with 
bacteria. Changes m the chemical constitution of the 
blood might cause the socalled serous meningitis ; these 
patients recovered without operation. The acute cases, 
where there were frank symptoms and spinal fluid cell 
count was increased, were not necessarily fatal. Dr. Per- 
kins had once operated on a boy — a patient of Dr. Dench's 
— with high temperature and all symptoms of meningitis. 
In addition to removal of the labyrinth and incision of the 
dura over the area triangularis, a decompression operation 
had been done in the middle fossa, and when the boy came 
under Dr. Dench's observation there was almost as much 
brain tissue outside as inside. Under treatment with Da- 
kin's fluid he made a complete recovery, but died six 
months later from a reinfection. He had a meningeal 
fistula and refused operation for closure. 

Dr. Dench was interested in what Dr. Smith had said 
about the possible tearing of the dura over the area tri- 
angularis. He himself had had a case at St. Luke's Hos- 
pital a couple of years ago. The patient had had no laby- 
rinthine symptoms when a radical operation had been 
done for a chronic middle ear suppuration. He came in 
a month later with acute invasion of the labyrinth. At 
operation an erosion was found over the horizontal semi- 
circular canal, which undoubtedly occurred subsequently 
to the radical operation. In taking out the labyrinth, the 
dura was torn externally to the internal auditory meatus. 
Infection was expected, but the man made a good recovery. 
That could be explained — for the fluid was always under 
pressure and tended naturally to wash out any infection 
from the subdural space rather than to allow it to pene- 
trate — just as by constant irrigation. 

With reference to the treatment of the labyrinth if it 
was accidentally injured during the operation. Dr. Dench 
said he agreed with Dr. Smith. Two years ago Dr. 
Richards reported a case in which the stapes was removed 
accidentally and the patient had meningitis and died, and 
Dr. Richards was inclined to formulate a rule that in 
such cases one should drain the labyrnith. Dr. Dench 
said that four or five weeks later he had a similar case 
at St. Luke's Hospital and packed over the oval window, 
etc., with iodoform, and the patient made an uninterrupted 
recovery — with a dead labyrinth, of course. One could not 
make a definite rule, excepting that the labyrinthine cavity 
must be made as aseptic as possible, and that one should 
be more careful than otherwise if the labyrinth was ac- 
cidentally injured. 

The value of spinal puncture in these cases was some- 
times lost sight of. Spinal puncture in beginning laby- 
rinthine involvment had some value, unless in a case where 
the infectious organisms were actually in the spinal fluid: 
the restoration of the intracranial pressure had a certain 
amount of therapeutic value. 

Dr. W. L. Dean, Iowa City, expressed gratification at 
the conservative tone of the paper. In his own experience, 
the more conservative he had been in treating labyrinthine 
cases the better the results secured, so far as life was con- 
cerned. The research work of Wittmaack had some bear- 
ing on this matter. He showed that in some cases of ver- 
tigo accompanying nonsuppurative lesions of the middle 
ear, he had not found hemorrhages in the labyrinth causing 
the vertigo but that the vertigo was due to a disturbance 
of the lymphatic circulation inrcasing the pressure within 
the labyrinth. 

Dr. Dean said he thought of the labyrinthine complica- 
tions of acute suppuration of the middle ear and of acute 
exacerbations of chronic supiniration of the middle ear 
were of three types. Unfortunately there was no way of 
differentiating clinically between the three in the early 
part of the disease. First, there was the hydrops of the 
labyrinth, a condition characterized simply by an increase 
in the amount of normal fluid in the labyrinth. In this 
type, with the return of the normal amount of fluid and 



116 



PROCEEDINGS OF SOCIETIES. 



[New York Medical Journal 
AND Medical Record. 



normal pressure there was a return of function. The 
.second type was the serofibrinous labyrinthitis. Wittmaack 
had shown that the difference between this and suppurative 
labyrinthitis was due to an absence of, and dehiscence in, 
the wall between the middle and inner ear. This con- 
dition might become suppurative in a few hours. In sero- 
fibrinous labyrinthitis the exudates organized and might 
produce permanent loss of function. As there was no 
pus in the inner ear, the mastoid wound might heal per- 
fectly. The third type was the suppurative type, in which 
there was always a dehiscence of the wall between the 
middle and inner ear. This was the dangerous type. 

Dr. Philip D. Kerrison expressed his interest in the 
paper and in the remarks of Dr. Dench and Dr. Dean. 
During the last two years there had been a great deal of 
discussion as to whether in the presence of a dead laby- 
rinth preceded by labyrinthine symptoms the radical opera- 
tion should be performed without the draining of the laby- 
rinth, and the consensus of opinion seemed to be veer- 
ing to a greater conservatism in regard to opening the 
labyrinth ; but it had not yet been possible to differentiate 
the cases or even to determine the different types. The 
conditions so fairly stated by Dr. Dean would explain some 
of them, and the remarks which he had made, if elaborated 
in the form of a paper, would add greatly to the under- 
standing of the subject and would provide a working 
hypothesis for discussion. 

In regard to draining or opening a dead labyrinth at the 
time of a radical mastoid, perhaps each case should be 
decided on its merits. Whenever there was any reason to 
suspect an active labyrinthine lesion, however, or even an 
old labyrinthine suppuration in the sli,ghtest degree likely 
to be rekindled by the mastoid operation, the labyrinthine 
operation was surely the thing to do. In regard to 
operating upon the labyrinth during the acute stage of a 
labyrinthitis, they were all at sea. Whatever might be 
done in a particular case might prove wrong as judged 
by the results. He personally felt that in any considerable 
series of cases more lives would be saved by abstaining 
from surgical intervention until all labyrinthine symptoms 
had disappeared than by operating during the acute stage. 

.^s regards lumbar puncture during an acute labyrinthitis 
or even during the chronic stage, certain facts should be 
kept in mind : Babinski's experiments had quite clearly 
shown that lumbar puncture was frequently followed by 
symptoms clearly induced by intralabvrinthine pressure ; 
this reduction of labyrinthine pressure could only be brought 
about by the withdrawal of labyrinthine fluid, however 
small the amount, into the suliaraclmoid space, and it 
should be clear that this might initiate a meningeal in- 
fection. It would seem, therefore, that lumbar puncture 
during a suppurative labyrinthitis should not be done as 
a routine measure, but only when meningeal symptoms were 
present and called for the definite data which this pro- 
cedure provides. 

Dr. Frederick Whiting said that he had cordially en- 
dorsed Dr. Smith's attitude toward the various problems 
connected with labyrinthine conditions. He did not think 
that any labyrinth which was fuctioning should be 
entered under any conditions. A dead labyrinth without 
manifest disturbance did not call for operation, e.xcept 
where a radical mastoid operation having been undertaken 
there was found some continuation into the labyrinth. 
Under such circumstances, as Dr. Smith had suggested, 
only such operation should be done as was of the most 
conservative nature. In regard to the third class of cases, 
one should refrain from operating except when the find- 
ings of the spinal fluid indicated that there was an active 
process instituted: if there was not such a process, more 
harm was done by operation than by refraining. As he 
understood it, this was the attitude taken by Dr. Smith, 
and he was glad to endorse that position. 

Dr. Kopetzk^- said that it was only by reporting these 
l>orderline cases that definite conclusions could eventually 
1)6 reached. Every one encountered these problems and 
they should be brought before the section and presented 
from the personal point of view. 

Dr. J. MoRRissETT Smith, concluding the discussion, said 
that the hydrops and serofibrinous types of which Dr. Dean 
had spoken would come under the class of localized laby- 
rinthitis. The fact that the labyrinth was still active 
showed that there was not a diffuse condition there, al- 
though it might at any time become diffuse. Where the 



condition became purulent, there was at once a dead laby- 
rinth. The question as to whether one should do a radical 
mastoid alone where there was a dead labyrinth and no 
symptoms brought up an interesting question. It was im- 
portant to have a spinal puncture as soon as it was dis- 
covered that there had been trouble in the labyrinth. If 
the spinal fluid was normal and the patient had no symp- 
toms, it was fairly certain that whatever infective process 
might have been present, had subsequently been walled 
off from the meninges. He agreed with what Dr. Whiting 
had said — if there was a normal fluid and no temperature, 
a radical operation was done and no evidence of visible 
necrosis found, it would be better policy to let the laby- 
rinth alone. 

Referring to Dr. Kerrison"s statement about the danger 
of a spinal puncture in an acute labyrinthitis, Dr. Smith 
said he thought that was more theoretical than practical, 
for in the case of acute labyrinthitis referred to, the patient 
started out with labyrinthine and meningeal symptoms, re- 
peated lumbar puncture was done, and though the count 
went to 8000, the patient recovered. Two years ago, he 
had treated, at the Polyclinic, two cases of fractured skull 
with mastoiditis and secondary meningitis. The fractures 
ran across the mastoid to below the temporal ridge. The 
two cases occurred within six weeks of each other. The 
first patient was unconscious and had a stiff neck; spinal 
puncture showed a cloudy fluid with no bacteria. The 
next day he seemed a little better and another lumbar punc- 
ture was done. A secondary mastoiditis developed, he was 
taken to the operating room and a thorough mastoid opera- 
tion was performed and he promptly died. Evidently the 
adhesions were broken up, death resulting. Within six 
weeks, the other patient was brought in, unconscious and 
with a stiff neck, cloudy fluid and no bacteria. Here the 
puncture was repeated daily; each time the patient showed 
improvement. Then drainage was obtained by simply re- 
moving the cortex. Three months later, the patient was 
demonstrated in the clinic, had a convulsion, was found to 
have a large brain abscess and eventually died. These 
cases both showed improvement following repeated punc- 
tures. Dr. Smith said that in his opinion, repeated lumbar 
punctures, instead of being detrimental, were a distinct 
aid, especially where there was a tendency towards local- 
ization of the process. 

Dr. Smith said that he understood Dr. Kerrison to say 
that in case of accidental injury to the labyrinth during 
operation, he would do a labyrinth operation where laby- 
rinthine symptoms developed, but had evidently misunder- 
stood him and agreed that the case should be kept under 
observation and a labyrinth operation performed iinl\- 
where meningeal involvement indicated it. 



MEDICAL SOCIETY OF THE STATE OF 

NEW YORK. 

One Hundred and Sixteenth Annual Meeting, Held in 

Albany, April 18, 19 and 20, 1922. 

Dr. George W. Cottis, Jamestown, N. Y., Presiding. 

(Concluded from page 719, Vol CXV., No. 11) 

Some Factors of Safety in the Preoperative and Post- 
operative Treatment of Goitre. — Dr. Emil Goetsch, of 
Brooklyn, said that lu- liad worked on a technic for com- 
bating thyroid postoperative acidosis, by means of the admin- 
istration of intravenous glucose solution. .\cidosis was 
likely to develop in the last twenty-four hours after opera- 
tions for hyperthyroidism. The reaction was distre^sing 
and showed nervousness, nausea, vomiting, headache, dry 
tongue, acetone breath, acetonuria. etc. These symptoms 
could be avoided and the patient safely tided over by intra- 
venous glucose medication. The author said tliat the 
epinephrine sensitiveness test and the metabolic rate were 
determined preoperatively, to decide the type of operation. 
In acute cases operation was postponed. Prolonged thyroid 
hyperactivity gave rise to reduced glycogen storage in the 
blood. The'blood sugar in hyperthyroidism was studied be- 
fore, during, and after operation, and compared with normal 
controls. Tlie normal sliowed a definite increase in glycemia 
at operation, continuing high and dropping to normal after 
ten days or so. In hypertliyrnidism, the rise was more 



July 19, 19.'2.] 



PROCEEDINGS OF SOCIETIES. 



117 



Midden, witli a sudden postoperative fall to below normal. 
The adrenals were excited by fear of the operation and 
played a contributing part in the blood sugar disturbance. 
In the blood sugar tests made, acetonuria was regarded as 
an evidence of acidosis. The methods used were qualitative, 
not quantitative. The reaction was indicated by one, two. 
three or four plus. To avoid circulatory embarrassment the 
glucose was injected slowly, the renal threshold level never 
being exceeded. In hyperthyroidism the normal glycogen 
storage was depleted so that there was no response to the 
factors calling for glucose. The glucose was a freshly pre- 
pared, chemically pure solution, administered as soon as 
acetonuria appeared. The dose was from 300 to 750 c. c. — 
This controlled the unpleasant postoperative reaction. 

Dr. Charles W. Webb, of Clifton Springs, N. Y., said 
that Dr. Hubbard, their chemist, had worked out a quanti- 
tative method for measuring the acetone output. Hypo- 
glycemia existed in these cases, and excessive quantities of 
acetone and B-oxybutyric acid were eliminated until con- 
trolled by carbohydrates. When not tolerated by rectum, 
owing to the excessive irritability of the bowel, the intra- 
venous route was used. Before operation, candy and carbo- 
hydrates were given as much as possible, to ward off un- 
pleasant postoperative sequelae. The amount of operation 
was gauged by the metabolic rate determination and 
adrenalin hypersensitiveness. 

Dr. Eugene Pool, of New York, said he w'as grateful 
for this contribution, although he had not quite grasped the 
physiological premises upon which the paper was based. 
These cases were neither medical nor surgical. They were 
both. They needed prolonged medical attention and the 
bringing in of accessory means (surgery and x ray) at the 
right time. Criticism had been made of the Goetsch test. 
If it was done exactly as Goetsch did it, it was valuable, 
but not otherwise. A metabolism plus 90 was an operative 
contraindication, but three quarters of the cases should re- 
ceive surgical aid. Ligation could be done first, w-ith 
lobectomy when the patient could stand it. The thyroid 
was not the only gland involved, but it was the only one 
known. As to acetonuria, this was presumptive evidence 
of acidosis, but there might be compensation for the increase 
of acetone bodies liberated by fat oxidation. Proof of 
acidosis must l)e looked for in the hydrogen ion content 
of the blood. In regard to blood sugar, that question was 
not settled, but positive benefit might be obtained by glucose 
administration before operation. This produced satisfactory 
results and would be followed in future practice. 

Dr. BiELBY, of Albany, said that with better technic and 
a better selection of cases, the best surgeons had got a 
mortality which was practically nil. In his own recent series 
of eighty consecutive cases there was no fatality. He had 
not seen what Dr. Goetsch called acidosis ; there was an 
uncomfortable period twenty-four hours after operation, but 
the patients could be assured that this would pass within 
thirty-six hours. Before operation he had disturbed the 
routine of the" patient as little as possible — had allowed 
nouri.shment and avoided catharsis. He had never refused 
patients, but progressed with operative indications as occa- 
sion warranted. 

Dr. Goetsch, in closing, said that he had found the bowel 
so irritable that patients could not hold a rectal injection 
of glucose, therefore the intravenous method was used. Ex- 
treme hyperthyroidism was a great problem. Acetonuria 
might not be an index of acidosis, but it certainly was an 
accompaniment. Acidosis was a complex problem and the 
best chemists were working on it. The chief point was 
that it could be relieved by carbohydrates. The glucose used 
was chemically pure, with no sulphuric acid, and if freshly 
prepared had no acid reaction and caused no disturbance. 
In regard to the x ray, it was useless in thyroid adenoma, 
a benign tumor, easily shelled out, but in Graves's disease, 
a type of unknown origin, it might be useful, the only 
disadvantage being the uncertainty of standards among 
radiographers, A system of depth of penetration and of 
dosage would help to solve the problem. 

Mixed Tumors of the Parotid and Their Treatment 
by Radium. Dr. F. MrX. Joii.\-sov, of New "\'r>rk, 
grouped these tumors in three types, namely, benign ade- 
noma malignant adenocarcinoma and mixed tumors. The 
first, he said, grew slowly, was encapsulated in the gland 
and rose from acini or glandular ducts ; occasionally malig- 



nant changes were seen. The second type of growth de- 
veloped rapidly, sometimes metastasized and sometimes con- 
tained cysts. The malignant ones were solid. The third 
type arose from embryonal remnants. Radium always 
acted on the same tissues in the same way, therefore these 
tumors probably gave the same reactions as other tumors 
of the same type. Abbe had reported a five year cure. 
The youngest patient treated was four years old, the oldest 
eighty-two. In one case there were eleven recurrences. In 
these cases deep penetration could be used without destroying 
the skin or the cranial nerve if care was used. Radium 
might produce good results in cases unfavorable for surgery. 

Limitations of Rontgen Diagnosis. — Dr. Russell D. 
Car.man. of Rochester. Minn., deplored the tendency of the 
clinician to rely on laborati>ry diagnoses without checking up 
the findings. The technician was competent to make good 
radiographs, but he could not be trusted to make a diagnosis. 
Rontgenography could indicate or exclude many conditions, 
but it could not replace proper clinical examination. An- 
other fault of the physician was to expect to find what the 
x ray did not reveal. The x ray was of great assistance 
in gastric, duodenal or colonic lesions, but it could not 
define the type or possible malignancy. The x ray, the test 
tube, and the microscope constituted a powerful trinity, but 
the physician must keep his seat at the head of the council 
table and bring laboratory aids into a coherent unit. 

Dr. Stewart, of New York, said that only close cooper- 
ation between physicians would prevent the mistakes con- 
stantly made. Team work was essential. Many physicians 
depended on the rontgenologist for advice he was not 
competent to give. They not only asked for the diagnosis, 
but also for the treatment. The rontgenologist could state 
the extent of the involvement, but not w^hether a lesion was 
operable or not. 

Rontgenotherapy in Malignant Disorders. — Dr. George 
E. Pfahler, of Philadelphia, said that malignant disease 
was so loathcsomc, so ubiquitous, and so insidious that all 
means of combatting it must be sought for. Radiation and 
surgery combined achieved the best results. In regard to 
the influence of radiation on various lesions ; epithelioma 
of the skin included two types, basal cell and prickle cell. 
The former responded to radiation. In cancer of the skin, 
electric coagulation was used first to destroy the lesions, 
followed by full radiation. In carcinoma of the mouth and 
tongue, the lesions were difficult, and best treated with 
radium needle insertion, followed later by surgery to repair 
the tissues. In laryngeal cancer a preliminary tracheotomy 
was done, followed by radiation through the thyrohyoid 
membrane. In carcinoma of the breast, a preliminary 
radiumization was used to devitalize the cells. Three weeks 
later the tissue was removed, including fibrous tissue which 
might contain some malignant cells. The radiation was 
given over the mammary region, the supraclavicular region 
and the axillary region. Media.stinal tumors were treated 
with combined radiation and surgery. In carcinoma of the 
uterus, extensive local disease was unsuitable for radiation. 
Systemic symptoms yielded to the rays. Radium was suitable 
in early metastases. Sarcoma cells were more sensitive than 
carcinoma cells. In cervical cancer radium treatment plus 
the x ray gave the same result as surgery. 

Traumatic Backs and Their Treatment. — Dr. James 

Warrex Sever. <if Boston, said that these cases were usually 
seen in industrial accidents, where the psychological clement 
of litigation usually delayed recovery. Ligamentous and 
muscle tears were usually undiagnosed at first, and treat- 
ment was delayed. This prolonged the injury and the 
average disability was about six and a half months. Con- 
trasted with this, the injuries from direct violence (frac- 
tures and dislocations) were sooner recognized and treated. 
The disability averaged six months. Such injury, in older 
subjects, tended to light up hypertrophic arthritis which was 
often latent, and claims were made for long disability. This 
was unfair from a compensation viewpoint. Usually the 
patients did well without operation, if put to bed in fixa- 
tion. On rising from bed, a light brace protected the back 
from strain. 

Dr. Sever, in closing, said that it was unfair that long 
continued compensation should be paid for coincident 
arthritis. In regard to tuberculosis of the spine, the kyphosis 
was progressive, that in fractures never became large and 



118 



PROCEEDINGS OF SOCIETIES. 



[New York Medical Journal 
AND Medical Record. 



did not progress. In fracture, the treatment was psycholo- 
gical as well as anatomical : people got along well if they 
did not know they had a fracture. If they did. they went 
to pieces mentally and physically. 

Operative Treatment of Idiopathic Scoliosis. — Dr. 

Armit.\ge Whitm.an, of New York, said that this series 
excluded scoliosis from known causes. The cases occurred 
usually in girls with bad posture and poor health. The x 
ray showed lateral curvature with wedging of the vertebra.-. 
Such deformity progressed, causing internal misplacement 
and early death. Treatment was by correction, as much as 
possible, followed by a fusion operation. The older the 
patient, the better the fusion. 

Lieutenant Colonel M.^cKenzie Forbes, of Montreal, said 
that physiological scoliosis had been tried as a corrective to 
pathological scoliosis, and the result was a failure. The 
greater could not be cured by the less. In cases where the 
deformity was progressive and correctable, the fusion opera- 
tion, while severe, was justifiable, as a life saving procedure. 
Where long segments were fused a firm ankylosis was 
necessary. 

Urinary Calculi. — Dr. Thomas F. Laurie, of Syracuse, 
said that a crystallizable substance, with agglomeration, must 
be present to form calculi. Slight infection usually was the 
starting point. Renal calculi were a constant menace and 
should be removed. Pain in ureteral calculi was from dis- 
tention above the stone. Stricture produced the same pain. 
The stone could usually be shifted and brought down. 
Large stones required crushing before removal. Suprapubic 
cystotomy might be necessary. One should never neglect 
to look for a second stone. All stones were not opaque to 
the X ray, but it was good advice to take a second picture, 
when in doubt. 

Treatment of Bladder Tuberculosis. — Dr. Edward L. 
Keves. of Xew York, said that alter preliminary nephrec- 
tomy for renal tuberculosis, there remained a chronic pain- 
ful rebellious condition of the bladder. The patients were 
often in prolonged torture. Bladder ulcers were often due 
to secondary infection. These could be treated, the urethra 
stretched, strictures removed, and nitrate of silver cautery 
made use of. Any means that would help to make life 
more tolerable for the patient was worth trying. 

Dr. Edwin Beer, of New York, said that patients now 
came for examination and operation earlier, and the old, 
enormous tuberculous kidney was an antique. Education 
as to the seriousness of vesical irritation was still necessary. 
There was one class of cases with frequency, strangury, etc., 
in which relief was obtained by high frequency treatment ; 
but in tuberculous cystitis with mixed infection, nothing 
short of continuous irrigation would give relief. 

Diagnosis of Bone and Joint Lesions by the X Ray. — 
Dr. FnKUKKicK H. Baetjer, of Baltimore, Md., said that 
bone was looked upon as fixed, but that in periods of years 
it underwent changes. There were three age periods of 
bone : 1, the growing period, from one to twenty years, when 
the epiphyses were united to the cartilage and there was 
increase in length and width of bone ; 2. period of maximal 
health, from twenty to forty years ; 3, period of decline, after 
forty. In different age periods different lesions attacked 
the bones. In the hip, for instance, during the first period 
fracture occurred as epiphyseal separation. In the second 
period the synovial membrane slipped. In the third period, 
the bone was brittle owing to absorption of calcium salts 
and fracture of the femoral neck occurred. In childhood 
the flexible bones suffered green stick fractures; in older 
people long oblique fractures occurred : in the aged, com- 
pound, comminuted fractures. Disease of the bone also 
varied with age periods, in accordance with the structure 
of the bone. Infection might enter the bone through the 
cartilage, through the long medullary canal which was rich 
in fat, or through the cancellous bone at each end which 
was more vascularized. There might be as a result, bone 
production or Ixme destruction. The lesion might be benign 
or malignant; if the latter, the surgeon did not want to 
operate. Lesions might be identified by their point of origin : 
the medullary canal, the cortex, or the periosteum. Invasion 
of tissue showed malignancy. 

Bone lesions in children followed three age periods : first 
from one to three; second from three to six; third from 
six to fourteen. To the first belonged scurvy, rickets, lues. 



Scurvy .showed destruction of the bone ends ; rickets soften- 
ing of the epiphyses ; lues, bone production and periostitis. 
From three to six years tuberculous lesions of the joints 
were common ; after six years Perthe's disease was most 
often seen. Lesions also showed an age and sex incidence. 
From one to five years lesions were equal in the two sexes ; 
from then on. the male played more dangerous games and 
later had more dangerous trades, and consequently suffered 
a higher proportion of trauma. After fifty the two sexes 
became equal again in this respect. In regard to neoplasms, 
bone disease might occur from carcinomatous metastases, in 
the female following cancer of the breast, in the male, 
cancer of the prostate. Infectious arthritis might take 
place at any age. and no known source of infection had 
been proved. Atrophic arthritis was probably an atypical 
form. Hypertrophic arthritis was a disease of elderly people, 
and not of the young. This short classification might serve 
as a guide to students and give them some definite idea what 
to look for. 

An Improved Method of Applying Radium Through 
the Cystoscope. — Dr. Leo Buerger, of New York, de- 
scribed certain improvements in the cystoscopic armamen- 
tarium which had developed that enhanced the accuracy of 
and increased the potency of intravesical radium therapy. 
Their results with these new procedures had been so grati- 
fying and encouraging that they hoped, in the near future, 
to be able to report a series of cases that would bear 
testimony to the value of the proposed methods and further 
to show that in a certain field of carcinoma of the bladder, 
as good end results were obtainable in the use of the cysto- 
scopic method as with the combination of radium and sur- 
gery. The field for cystoscopic radium therapy was three 
fold, namely, 1, for treatment of carcinoma alone without 
surgery ; 2, for the treatment as a preliminary step to 
surgery, and 3, for the treatment of metastases. There were 
distinct circumstances that might lead one to adopt the 
cystoscopic methods of radium work, as, 1. when the patient, 
by reason of his age, habits, special prejudices, knowledge 
of physical mediocrity, or what not, would refuse any oper- 
ative interference; 2, when we ourselves would deem surgical 
intervention contraindicated for one reason or another. They 
gave cystoscopic radium application preference when the 
growth was small and appeared amenable to radiation, but 
was so situated that an extensive operation compromising 
one ureter and requiring ureteral implantation would be the 
only correct surgical procedure ; when dealing with that type 
of small carcinoma which they had heretofore successfully 
treated with snare and fulguration alone, but which was 
occasionally followed by local recurrence or invasion of the 
bladder wall ; because the growth was in the main a papilloma 
with evidences of carcinoinatous change, was small, was 
readily accessible, but because of its potentialities for deep 
infiltration, needed more intensive treatment than fulguration 
and the snare, even though they had time and time again 
obtained cures in this type of growth without radium and 
without surgery. This feeling that radium was required 
they had acquired through the knowledge of their ability 
to foretell in advance as to which of the small papillomata 
were already attended with malignant cell invasion of the 
wall of the bladder, and in which such infiltration was absent. 

Changes in Virulence of Tubercle Bacilli. — Dr. Ed- 
ward R. Baldwin, of Saranac Lake, called attention to the 
fact that methods for determining differences in virulence 
of tubercle bacilli had been unsatisfactory. There was 
need of a dependable method for making these determina- 
tions. A method of estimating the virulence of tubercle 
bacilli was presented, which was based on guineapig inocu- 
lation. The application of this method had shown that a 
culture known as R 1 of human tubercle bacilli, thirty 
years old, retained but slight pathogenicity. A culture, 
H 37, isolated seventeen years ago. was still quite patho- 
genic. A culture of bovine turbcrcle, B 1, twenty years 
old, was still virulent for rabbits. Experiments recently 
published on the pathogenicity of acid fast timothy, butter 
and reptilian bacilli for mammals was still in need of con- 
firmation. It must be remembered that pathogenicity for 
rabbits and guincapigs might not be a measure applicable 
to man. A reliable means of estimating the presence or 
absence of virulent strains of tubercle bacilli would provide 
a valuable aid in prognosis. 



Abstracts from Current Literature 



SURGERY 
Operations on the Foot. — A. G. Cook (Journal of 
Orthopedic Surgery, September, 1921) giving the report 
of the commission on stabilizing operations upon the foot 
gives the following conclusions: 1. Metal plates, wires, 
screws, nails, are objectionable and unreliable. 2. Silk- 
ligatures and bone grafts are also objectionable and unreli- 
able. 3. Arthrodesis produces excellent results in lateral 
instability, especially where there are good calf muscles. 
The best results are to be found after the triple arthrcj- 
desis of Ryerson or the subastragalar arthrodesis of Davis. 
Arthrodesis of the ankle joint is rarely indicated. 5. As- 
tragalectomy with backward displacement of the foot gives 
by far the best results, when done after the method of 
Royal Whitman, first for calcaneus, calcaneovalgus, etc. : 
second, for dangle feet, and third, for lateral deformity. 
In some cases the result has been so perfect and the foot so 
symmetrical that it would have been difficult to tell that 
the foot had been operated on, had one not been able to 
see the scar. 6. Horizontal transverse tarsectomy. after 
the method of G. G. Davis, gives as a whole inferior re- 
sults to the astragalectomy and is a more difficult, bloody 
and less surgical procedure. 7. Living ligaments, after the 
method of Gallic, Putti. Peckham and others, have given 
success in isolated cases, but as a general rule have not been 
successful and are not held in universal esteem. A great 
many of the fixation cases that were examined were done 
after the ordinary tendon transplantations had failed, and 
it would seem that the place for tendon transplantations is 
as an adjuvant to a stabilizing operation. 

Plastic Operations. — L. Eloesser {Surycry. Gynecology 
and Obstetrics, .\pril, 1922) give the following findings 
in plastic operations : 1. A graft of the whole thickness 
of skin, whether done at one sitting as a Wolfe-Krause 
graft, or at several, as an Italian plastic, always remains 
an island surrounded by scar. 2. It turns blue on exposure 
to cold and is little resistant to infection or trauma. 3. A 
pedicled flap whicli retains the normal vascular connections 
does not have these disadvantages. 4. A procedure is de- 
-scribed for making a semidetached flap, severing the skin 
of the pedicle but retaining its vessels. Such a flap has 
much of the freedom of a free graft but does not have its 
disadvantages. 5. More blood runs through the pedicle of 
an Italian plastic flap than through the line of union with 
its new bed. no matter how narrow the pedicle, or how 
long the line of union. 6. The vascularity of the pedicle 
should not be damaged by mattress or tension sutures. 7. 
Infection should be limited by covering the defect left by 
an Italian flap with an immediate Thiersch graft. 8. The 
viability of the flap is determined by temporarily occlud- 
ing the pedicle with a rubber band before finally severing 
it. 9. The defect, after excision of a flexion contracture 
of a finger, may be covered by a flap from a neighboring 
finger. 10. Drooling may be relieved by transplanting 
Stcnson's duct backward. 

Treatment of Closed Fractures. — Stanley and Gatel- 
lier (British Journal of Surgery, October, 1921) state in 
summary that the simplicity and the ease of application of 
the Parham-Martin bands establishes their superiority for 
closed fractures to all other means of operative splinting. 
Their application is carried out with the minimum of opera- 
tive manipulation, and perfect apposition is ensured and 
maintained. They are better than wire for encircling the 
bone. We have been able to observe the remote results of 
fractures thus treated in cases where we have been obliged 
to rcoperate. and in a series of radiographs. They show 
that the objections made to metallic osteosynthesis, which 
are very real, cannot be applied to the u.se of Parham's 
bands. The consolidation is certainly not delayed, there is 
no necrosis at the point of contact of the band, and it is 
surrounded by callus (a small clear space may remain V 
Furthermore, any organic iron salts that may be formed 
have no toxic effect on the tissues; the callus is not ex- 
cessive in quantity, and is frequently reduced to a minimum. 
Lastly, the bands very rarely give trouble from their 
presence, and may with confidence be left buried. Trans- 
verse fractures require to be treated with metal or bone 
plates (or splints) encircled by the bands. The authors' 



results with bone plates have been disappointing, though 
they admit Nageotte's principles m theory, and believe the 
work of Gallic and Robertson to be most valuable, though 
needing clinical confirmation in its application to recent 
fractures. They are satisfied with their results with Sher- 
man's metal plates and bands, but their failures corrected 
their technic. Certain principles in technic must be ad- 
hered to if perfect results are to be secured. 

Excision of the Head of the Femur in Arthritis De- 
formans (Osteoarthritis) of the Hip Joint. — Harry I'latt 
{liriiish Medical Journal, April 29. 1922) recommends the 
following technic ; 1, The removal of the overhanging por- 
tion of the femoral head, leaving the stump of the neck 
long enough and the upper end rounded off to simulate the 
new head. 2. The stump of the neck should be fitted deep- 
ly into the acetabulum by full abduction of the limb. 3. 
The detached great trochanter should be reattached to the 
femoral shaft at a lower level. The other technical details 
include the use of a wide osteotome with a curved shaft to 
reproduce the rounded stump of the neck ; the surface of 
the cancellous tissue and the area left by detachment of the 
trochanter should be thoroughlj'' impregnated with Horsley's 
wax ; the latter area should then be covered by a small apo- 
neurotic flap elevated from the vastus externus muscle and 
turned upward : Brackett's posterolateral route of approach 
is the most adequate. For si.x weeks an abduction frame 
is applied, the hip being completely immobilized by fixed 
extension for the first three weeks only ; after that massage 
and active motion are given daily. During the intervals 
active motion is encouraged. After six weeks a caliper 
walking splint is applied and the patient uses crutches, and 
a few weeks later full weight is borne on the caliper ring 
and the crutches are discarded. The physiotherapy is con- 
tinued for some months and the caliper splint is retained 
for at least three to six months. This operation is indi- 
cated for pain or malposition in moderately advanced cases 
at any age, provided the general condition will stand a 
major operation. The degree of mobility attained depends 
upon the amount of bone removed from the femoral head. 

Experiences with Parasacral Anesthesia in 130 
Vaginal Operations. — Friedrich Burgkhardt (Zentral- 
blatt fur (.yniikologtc, April 29, 1922) administers codeona! 
or bromurai on the night before the day of operation and 
one hour before the operation an injection of laudanum 
0.04 gm. and scopolamine 0.0004 gm. The room should be 
darkened, the patient's ears should be stuffed with cotton 
and her face covered. All unnecessary noises in the oper- 
ating room should be avoided. The steps of the operation 
should be explained to the patient to obtain her cooperation 
and to reassure her. In all but one of the 130 cases the 
anesthesia was successful. There is no danger in injecting 
250 ex. of a 0.5 per cent, novocaine suprarenin solution, 
which should be prepared fresh just before the operation. 
Careful handling of the tissues to be injected is necessary 
to avoid sequcl.-e like hematomata and infections. Only 
one coat of iodine is used for disinfection. The cases in- 
cluded vaginal total extirjiations with and without para- 
rectal incisions, Schauta-Werthcim operations for pro- 
lap.se, extirpations with dissection of the ureters for cer- 
vical carcinoma, perineal plastics, vaginal fixations. White- 
head operations for hemorrhoids, Bartholinian cysts, rectal 
plastics for fistula, vaginal C;csarean section, carcinoma 
of the vulva with bilateral extirpation of inguinal lymph 
nodes and vesicovaginal fistula. This technic gave invalu- 
able results even in the most extensive vaginal operations. 
In some cases at the most fifty drops of ether or ethyl 
chloride had to be used. In three cases abscesses formed 
but soon healed after their incision and drainage. There 
were no disturbances in wound healing, of the general con- 
dition and no secondary hemorrhage. Injection into the 
veins must be carefully avoided. 

The therapeutic application of parasacral anesthesia was 
also tried in obstinate cases of sacral and coccygeal pains 
that yielded to no other treatment, such as those occurring 
in the climacterium and those based on a general neurosis. 
In these cases the sacral concavity is filled extensively 
with the solution and especially in the region about the 
sacrococcygeal joint and about the coccygeal tip. 



120 



ABSTRACTS FROM CURREXT LITERATURE. 



[Xew York Medical Journal 
AND Medical Record. 



Fracture of Femur.— E. L. Eliason (Annals of Sur- 
gery, August. 1921) asserts that in patients under eight 
j-ears of age the Bryant or perpendieular treatment gave 
the best figures, eighty-five per cent, excellent, or one hun- 
dred per cent, good results. In this group all results were 
reported as good. In the eighty-eight cases ten years of 
age or older, the pritnary reduction and dressing was not 
satisfactory in a single case. A small group of eight cases 
later set in plaster under traction, all showed shortening 
or nonunion. The next group of twenty cases dressed in 
the flexed position with weight traction gave twenty-five 
per cent, good results with no deformity. In operative 
cases infection occurred in none of the drained wounds. 
Every case, however, showed slight infection around the 
Steinmann nail. Internal fixation failed to hold the frac- 
ture in twenty-one of fifty-four cases. Causes of this 
failure were in the greater number of cases due to the 
position in which the limb was splinted, twenty being 
dressed in the flat position, and to a much less extent to 
infection, only three cases. Nonunion, or better, imion de- 
layed longer than seven weeks, was most often due to faulty 
fixation of the fracture, and occurred in 22.2 per cent, of 
the operative. U.86 per cent, of the nonoperative. and ten 
plus per cent, of the entire series. It is hardly fair to in- 
clude these figures as other than undetermined, as they 
have not been heard from finally. Operation gave 81.6 
per cent, good results ; nonoperative methods gave 73.9 per 
cent, good results in the entire series of 115. It must be 
remembered, however, that this last figure is helped enor- 
mously by including the twenty-four youngsters with one 
hundred per cent, good results. Of the operative proce- 
dures, the use of plates and screws with wound drainage 
and the limb dressed in plaster, in flexed position, with 
postoperative traction maintained, gave ninety per cent, 
perfect results, plus ten per cent. good. All other opera- 
tive methods gave but thirty-three and one third per cent, 
perfect results plus thirty-three and one third per cent, 
good results. Plaster castings are not a good permanent 
dressing unless traction is used and the case kept under 
close observation until union is firiu, and especial care being 
taken as shrinkage of the limb occurs, a new cast be ap- 
plied. This last is very important, for if there is too much 
room in the cast at the fracture site, each time the patients 
raise themselves in bed the psoas muscle acting against 
the fracture will loosen the internal fixation. If these 
precautions are taken, however, plaster makes an excellent 
dressing if cut out so as to permit knee and ankle motion. 
From these facts we see that the best treatment was opera- 
tion with plate fixation and drainage, and the same amount 
of attention given to external fixation, flexed position and 
traction as would be given were the case treated by the 
closed or nonoperative method. 

Surgery of the Lung. — S. Lloyd (Annals of Suriicry. 
November, 1921) states that indications for operations on 
the lungs are as follows : 

1. For tuberculous cavities where gas injections into 
the pleural cavity, cither because of too rapid absorption 
of the gas or because adhesions prevented the collapse of 
the lung, extrapleural thoracotomy should be performed. 
This may be completed or in stages, depending upon the 
condition of the patient. 

2. For bronchiectasis, extrapleural thoracotomy may be 
performed, although incision and drainage or lobectomy 
offer a better chance of a radical cure. 

3. For foreign bodies which cannot be removed by bron- 
choscopy, thoracotomy, with direct removal by incision 
through the lung, would be the method of choice. 

4. For hemorrhage with incrca.sing hemothorax, com- 
pression of the lung and displacement of the heart and 
mediastinum, thoracotomy with suture of the bleeding 
point is indicated. 

5. For abscess, thoracotomy and drainage of the abscess, 
attaching the pulmonary pleura about the opening of the 
lung to the parietal pleura in order to effect direct drain- 
age, will give the best results. 

6. For tumors of the chest wall, including the ribs and 
pleurre, complete removal with a pediculated skin flap from 
the abdomen has been successful. 

7. For tumors of the lung, tlioracotomy and direct ex- 
cision by partial or complete lobectomy offers the only 
chance of curing the patient. 

8. For empyema, early and frequent aspiration, followed. 
if necessary, by intercostal incision and drainage. 



Causes of Failure in Operations for Chronic Appendi- 
citis. — Charles J. Rowan (Minnesota Medicine, June, 
1922) from a study of his own and other men's results ad- 
mits that there is room for improvement in the operative 
treatment of chronic appendicitis. To secure better results 
the following points are of great importance: 1. These 
patients should have more careful examination and often 
more prolonged observation, especially if the condition is 
not in every way typical. 2. No patient should be regarded 
as having typical chronic appendicitis unless a history of a 
former characteristic acute attack is obtainable. 3. Extra 
care and consideration should be used before advising oper- 
ation in neurotics, especially those with colitis or vis- 
ceroptosis. 4. More exploratory incisions should be used 
in preference to the muscle splitting incision, and always 
in atypical cases ; the exploration should not end with the 
discovery and removal of a diseased appendix. 5. A con- 
siderable amount of trouble complained of after operation 
may be due to adhesions, therefore, Gibson's suggestion is 
valuable as to using picric acid instead of iodine in the 
preparation of the site of operation. 

Tendon Transplantation. — ;\I. A. Bernstein (Surgery, 
Gynecology and Obstetrics, January, 1922) says that ten- 
don transplantation has a definite indication in the opera- 
tive treatment of anterior poliomyelitis. If the results ob- 
tained are not satisfactory, the indications in a broad sense 
were not well defined. Tendons should be transposed from 
the same plane when possible. When transposed from an 
opposite group, muscle training must be carried out, over 
longer periods. Tendons must be transposed with their 
sheath and peritenous structures so that the vitality of the 
tendon is not interfered with. When a tendon is trans- 
posed with its sheath adhesions are not likely to occur. 
The operation must be carried out with care, avoiding 
trauma, exposure of the tendon to the air, and with as little 
handling as possible. 

HEART AND BLOODVESSELS 
Cardiac Disease and Occupation. — R. O. Moon (Brit- 
ish Medical Journal, May 20, 1922) states that cardiac 
patients need not necessarily be confined to sedentary work, 
but that they may engage in more active work, provided 
that it is selected and gauged by the power of the myocar- 
dium. It is important to determine how far the work seems 
to suit the man, how far he is physically attuned to it, and 
also as to the keenness about his work and the keenness 
for his wages. In deciding the future occupation of a boy 
with valvular disease (usually rheumatic), some sedentary 
work is advisable, as there may be a recurrence of the 
rheumatic attacks, and besides, boys are likely to overstrain 
themselves at heavy work. Much depends upon the man's 
education, previous training, general mental equipment and 
temperament. A man should work well w'ithin the limits 
of his capacity so as to leave a margin of safety. Mental 
and emotional stresses may cause a cardiac breakdown 
nearly as often as physical exertion. Cardiacs should not 
be sent to a convalescent home in the country when they 
really require a suitable occupation near their own home. 

Cardiac Pain. — John Hay (Lancet, May 6, 1922), as- 
serts that all forms of cardiac pain are in essence of the 
same nature though varying in degree. It is not an evi- 
dence of any particular variety of pathological condition, 
but rather an indication of functional disability. Too much 
attention must not be given to the pathology. In fatal 
angina pectoris, the heart may show no evidence of cither 
coronary disease or changes in the aorta, valves, or myo- 
cardium. The degree of pain is no indication of the ex- 
tent of the actual disease. It is very important to deter- 
nu'ne whether a pain about the thorax or epigastrium is 
cardiac in origin or not, but this is not always easy. The 
classification of cardiac pain into submammary and supra- 
mammary does not hold with any degree of certainty, al- 
though the supramammary is the more ominous type. It 
should be remembered that visceral distress reaches con- 
sciousness indirectly, the related segments being excited, 
and pain is felt in the areas of the correlated cerebrospinal 
nerves. .Mthough anginal pain is more usually left sided, 
it may he most marked to the ri.ght of the middle line, ex- 
tending to the right arm. In typical attacks ot angina pec- 
toris the combination of anguish and sense of imminent 
death cannot be luistaken, hut in the atypical forms, espe- 
cially when the symptoms are slight, the initial warm'ngs 
may be mistaken for indigestion or rheumatism and neuritis. 



July 19, 1922.] 



ABSTRACTS FROM CURREXT LITERATURE. 



121 



In subjects of angina there is a marked tendency to aero- 
phagia which may cloud the picture. 

In giving the prognosis other signs of myocardial fatigue 
should be sought, such as dyspnea, a sense of constriction, 
complete lassitude and the fear of impending death. After 
considering the improvement following rest, the condition 
of the nervous system should be considered — how it re- 
sponds to mental and physical rest and sedatives, especially 
in women, who frequently show palpitation with faintness 
and exhaustion, constriction of the chest, shoulder and arm 
pains and hyperalgesia. If the attacks become more fre- 
quent and more severe in spite of rest and care, the myo- 
cardium is becoming weaker and death may occur at any 
time. The prognosis is favorable in the toxic, neurotic 
and hysterical cases. The patient should be taught to be 
honest with himself and lead a more leisurely life. Prob- 
ably the tenderness in the accessory muscles of respiration 
is the result of cardiac stress, reaching them through the 
spinal cord. 

Angina Pectoris. — Max Grossman (Wiener klinischc 
Wochcnschrift. April 20, 1922), asserts that this disease 
is due to a spasm of the first part of the aorta, which 
produces no obstruction to the circulation but does cause 
vascular pains. It is likely that in the severe cases changes 
and spasms of the coronary vessels occur; probably the 
radiation of the pain is produced by the advance of the 
spa-sm in the arteries of the affected region. This con- 
ception explains not only the prompt effect of the vaso- 
dilator remedies but also the marked similarity of the 
clinical picture of the socalled true and false angina pec- 
toris. The difference does not lie in the mechanism of 
origin of both forms, but only in the organ affected. In 
the first case the spasm results in a syphilitic, atheromatous, 
or otherwise changed aorta, and in the second case in an 
anatomically intact aorta. Rontgenological investigations 
which are in progress may support this view. The exciting 
causes of an attack of angina pectoris act on the aorta 
through the sympathetic nerve. 

The Effect of Amyl Nitrite and Atropine with Special 
Consideration of Stenocardia. — With the aid of the mer- 
curial ii--cilliinieter. Sigisnuind Peller (Wiener Archiv fiir 
Inncre Meiiicin. April 5, 1922), showed that the pulse fre- 
quency and the pressure of the vagus were not implicated 
in the characteristic changes ushering in angina pectoris 
and that therefore they were not caused by weakening, ex- 
clusion or overcoming of the negative chronotropic and ino- 
tropic vagus effect, but only by accelerating stimulation or 
by myogenic processes in the heart. A shortly lasting vagus 
pressure influenced neither the pulse frequency nor the at- 
tack,^ but a pressure of five to twelve minutes led to 
the induction of attacks and to a reduction of pulse fre- 
quency and of the pressure, with relief from the attack 
and rest at night for the patient. Amyl nitrite produced 
a fluctuation of six to eight beats in the pulse; atropine 
showed the same results. If the spasm in the coronary or 
aortic root region is relieved by amyl nitrite or atropine, 
the uncomfortable sensations disappear and the stimulation 
for the accelerator nerve and auricular musculature disap- 
pears. If the other effects of amyl nitrtie (direct action 
■on the vagus centre and better circulation in the heart) did 
-not increase the heart action, the pulse frequency and pres- 
sure would fall. For this reason there is reduction of the 
pressure at (jne time and no cliange or even perhaps a rise 
of pressure from amyl nitrite at another time, but never- 
theless even the last condition does not produce an attack 
of angina pectoris. 

The Heart in Infectious Disease. — Paul D. White 
{American Journal of tlie Medical Sciences. March, 1922) 
.says that the heart is affected in two ways in acute in- 
■fectious disease : First, by direct permanent damage to 
endocardium, myocardium, and pericardium, and second by 
temporary poisoning. For both of these conditions it is 
necessary, first, to combat the infection itself by specific 
therapy, if there is such, and by good nursing care. The 
symptomatic therapy of cardiovascular symptoms and 
signs in the prevention of failure is on a very uncertain 
basis at present and needs further investigation. The 
routine employment of digitalis Iti .^uch infectious diseases 
a^ typhoid fever and pneumonia is unwarranted. Finally, 
th<- fre(|uent occurrence of the effort syndrome during and 
loliowing infectious disease and simulating at times cardiac 
■disease is in need of emphasis. 



Stenosis of the Isthmus of the Aorta and Its Differ- 
ential Diagnosis. — --\. Edelman and R. Maron {Wiener 
.irchiv fur Innere Medizin, April 5, 1922) maintain that 
this condition is occasionally overlooked in life. They re- 
port a case with marked dullness over and on both sides 
of the sternum, a protrusion and a thrill to the right of the 
sternum, pulsation in the jugular vein and an Oliver-Car- 
darelli symptom ; the heart sounds were heard the loudest 
over the aorta ; the cardiac dilatation with the aortic con- 
figuration and the rontgenogram led to the diagnosis of 
aortic aneurysm and aortic insufficiency. The Wasser- 
mann reaction was negative. The finding of a new symptom 
led to a change in diagnosis — a large number of super- 
ficial, fairly symmetrically coursing, markedly pulsating 
and atheromatous vessels, located bilaterally in front, later- 
ally and especially posteriorly, over which a systolic sound 
was audible. A distinct pulsation of the abdominal aorta 
was not demonstrable. The blood pressure in the arms was 
200 mm. Hg and in the legs it was 55 mm. Hg. There 
was also a striking disproportion between the total length 
of the body and that of the lower extremities. The riint- 
genogram showed that the left cardiac border was abso- 
lutely free above in spite of the enormous widening of 
the ascending aorta and the first portion of the arch ; 
neither the most peripheral portion of the arch nor the 
uppermost portion of the descending aorta was demon- 
strable. The pulse was increased in the vessels and capil- 
laries of Aie upper part of the body, it was impalpable in 
the abdominal aorta and very weak, apparently retarded, 
in the femoral artery, and not demonstrable in the tibial 
and dorsalis pedis arteries. The lower extremities were 
cool to the touch. There was an enormous superficial, col- 
lateral circulation between the upper and lower vascular 
areas, bridging over an obstruction which was visualized 
rontgenographically — a malformation at the isthmus. If 
the stenosis is slight or the collateral circulation is ade- 
quate, the back pressure on the heart may be easily over- 
looked. Any excessive exertion or exhaustion may be in- 
jurious and therefore they should be avoided. 

An Arteriovenous Aneurysm Treated by Ligation of 
the Left Subclavian Artery. — Charles Noon (Bnti.di 
Medical Jaurnal. May 6, 1922), reports a case of an arterio- 
venous aneurysm between the second part of the left sub- 
clavian artery and the left subclavian vein, associated with 
extreme swelling of the left upper extremity. The severe 
varicose ulceration of the forearm and the marked vari- 
cosities of the veins of the forearm made septic thrombosis 
a dreaded possibility. It seemed inadvisable to attempt a 
separation of the artery from the vein and therefore a li.ga- 
tion of the first part of the subclavian artery was done, 
which was followed by recovery of the patient. Success 
in this operation depends upon the elimination of hemor- 
rhage, shock and sepsis. Hemorrhage is avoided by a 
careful aseptic technic and careful ligation of the vessel- 
mere compression and avoidance of dividing the arterial 
casts by the ligature. To avoid gangrene of the upper 
extremity, as many of the affected vessels should be saved 
as possible and sufficient time should be allowed for the 
establishment of a collateral circulation. 

Mitral Stenosis Followed by Death From Cerebral 
Embolism. — S. Saxon Barton ( .Medical f'res.<:. May .i. 
1922) reports a case in which a woman aged forty-seven 
complained of occasional attacks of dizziness accompanied 
by loss of power in the right hand and inability to speak. 
There was no other complaint. Pliysical examination re- 
vealed a faint presystolic murmur in the mitral area but 
not other abnormal physical findings. The condition was 
treated lightly by the patient and family and after a few 
weeks she suddenly fell unconscious while attending to her 
household duties and died shortly after. This case shows 
that it is advisable not to give a good prognosis in cases 
of mitral stenosis even if the lesion is apparently well com- 
pensated. 

An Aortic Murmur. — Thomas Lindsay (British Medi- 
cal Journal, May 13, 1922.). recalls that: 1. An aortic 
systolic bruit is often heard over the aortic cartilage in 
the absence of any diseased condition. 2. That many such 
bruits are due to the position of the arms at the time of 
examination, or rather to the contraction of the muscles 
of the shoulder girdle. .?. That such bruits mostly disap- 
pear with the patient stripped to the waist and the arms 
hanging loosely by the side. 



122 



ABSTRACTS FROM CURRENT LITERATURE. 



[New York Medical Journal 
AND Medical Record. 



Pertinent Considerations in Hypertension. — W. W. 

Sylvester (Southern Mcdici)ic and Surgery. May, 1922) 
believes that a diet which is reasonably satisfying and, at 
the same time, sufficiently poor in salt, is not easy to ar- 
range. Blood and urine examinations are important for 
controlling the treatment and no pressure is rightly called 
irreducible unless the daily chloride excretion has been re- 
duced to practically zero. A certain amount of salt is con- 
sidered indispensable ; in normal individuals about two 
grams, but the limits for nephritics have never been de- 
termined. The salt intake must be worked out for the 
individual. Reduction of the blood pressure to almost or 
quite normal, may still leave the patient an invalid, either 
from weakness due to the strict salt privation or, if salt is 
given, to allow the pressure to go up. 

Factors in Prognosis of Hypertensive Renal and Vas- 
cular Disease. — O. P. J. Falk {Journal of the Missouri 
State Medical Association, May, 1922) considers that there 
are three special fundamental factors in the prognosis. The 
first is the condition of the arterial tree evidenced by the 
reduction of systolic pressure accomplished by treatment ; 
another fact of importance is that a consistent diastolic 
reading of over 100 offers a less favorable prognosis than 
a reading under 100. The second factor is the functional 
capacity of the kidneys based on the following determina- 
tions : a, urine examination ; b, phthalein test ; c. amount 
of nitrogenous rentention ; d, Mosenthal test for concen- 
trating power. The third factor is the integrfty of the 
myocardium which may be made out by Barringer's method 
of determination of myocardial reserve by observing blood 
pressure and pulse rate changes after measured exercise. 

Heart in Relation to Habitus. — I. D. Hirsch (Archives 
of Radiology and Electrotherapy, June, 1921) concludes 
that the position and shape of the heart varies with the 
habitus, and that habitus must be taken into consideration 
in estimating cardiac size. Reasoning by analogy, the car- 
diac function, particularly as regards muscular tonus, may 
perhaps vary with the habitus. Only by actual measure- 
ment of the curves of the heart can the changes in contour 
be made out in early cases, and the value of the curves 
varies with the habitus. The radial value of the curves 
of the left ventricle and right auricle vary with the habi- 
tus. The radii measurements are a more accurate and 
valuable expression of impending or established change in 
the architecture of the heart chambers than the socalled 
standard measurements. 

RADIOLOGY 

Pyelography. — Frank Kidd {British Medical Journal. 
May 13. 1922) asserts that it is absolutely necessary for 
the urologist to have his own x ray plant. No anesthetic 
should be used for taking pyelograms. Only one kidney 
should be done at one time. He insists on using a 5.5 Cli. 
ureteral catheter with an olive tip. The author's technic 
in male patients is as follows : 

Two drams of a five ])er cent, solution of stovaine is 
injected into the urethra and held there for ten minutes. 
The urethra is then irrigated with a pint of 1 :4000 mer- 
cury of cyanide solution and the bladder is irrigated by 
catheter with eight ounces of the same solution. A 24 Ch. 
single cathcterizing cystoscope, armed with the ureteral cath- 
eter, is then introduced and the cystoscope is withdrawn. 
The urine from the kidney is collected in sterile tubes for 
bacteriological and cytological examination. It is useless 
to judge the size of the renal pelvis by the amount of urine 
coming away, as there may be a reflex oliguria or polyuria. 
The patient now lies on his back with the knees and hips 
bent. The plate is placed behind the kidney area and the 
compressor and x ray tube are placed in position, the radio- 
grapher making the exposure on command. At that time 
the patient holds his breath for a few seconds. A syringe 
is filled with sterilized twenty per cent, sodium bromide 
solution, beginning with ten c.c, as the normal pelvis only 
holds six c.c. The patient is instructed to tell at once if 
he feels the slightest dull ache or pain. If none is felt, one 
or two c.c. more are injected and the exposure is made. 
The same amount of solution as was poured in should be 
aspirated with the syringe and the ureteral catheter should 
be left to drain. The plate is now developed and if it is 
satisfactory no further plates are taken. If the shadow is 
faint and irregular, another plate is taken, this time filling 
the pelvis first with ten c.c. and if no pain is felt, up to 
twenty to thirty c.c. If the kidney is infected, it is irri- 



gated with four c.c. of a five per cent, collosol silver with 
1 :1000 mercury oxycyanide solution added to every nine 
c.c. of twenty per cent, sodium bromide solution. This 
should be done only by expert urologists and then not as a 
routine. 

This technic is valuable in diagnosing the normal kidney, 
congenital abnormalities, dilatation of the renal pelvis asso- 
ciated with Dietrs crises, movable kidney, inflammatory 
stricture of the ureter following chronic infection or cal- 
culi, renal tumors and painless hematuria, for the differen- 
tiation of other abdominal tumors, renal pain, calculi and 
renal infection. Ureterograms help to exclude phleboliths, 
glands, etc., and impacted calculi. They also show that 
the pyelitis of pregnancy is due to a ureteral dilatation 
from the loss of tone in the ureteral musculature rather 
than to pressure from the uterus. 

For cystograms, ten per cent, colloidal silver solutions 
are used, as the bromide is irritating to inflamed bladders. 
Bladder pouches are beautifully shown with the cystogram ; 
also the outline of the bladder and prostatic cavities after 
prostatectomies and the existence of a back flow from the 
bladder into the kidney from back pressure, using the re- 
ver.sed Trendelenburg posture. A rectovesical fistula was 
also demonstrated. 

X Ray Diagnosis of Echinococcus Cyst of the Lung 
Simulating Aortic Aneurysm. — Robert Lenk (Wiener 
hlinische li'ochenschrift. April 13. 1922), reports a case 
in which a woman, thirty-seven years old, was referred 
for a rontgenographic examination of her thorax because 
of dyspnea. Clinically there was only a slight shortening 
of the breath sounds in the right subclavicular region. 
The rontgenogram showed the right side of the diaphragm 
about three fingers' breadth higher than the left, completely 
movable with respiration. In the upper part of the right 
lung there was a small lateral zone entirely free and a 
dense homogeneous shadow as large as a child's head 
sharply outlined externally and below, not definable from 
the median shadow above and medially against the second 
rib in the anteroposterior direction and seemingly super- 
imposed upon the ascending aorta; the trachea and aortic 
arch were displaced to the left. There was no pulsation and 
no elevation on swallowing and coughing. On turning 
the patient slightly to the left, the shadow could be separ- 
ated from the aorta which was found intact ; with further 
turning it was completely separated. The frontal ex- 
jKisure also showed a circular shadow surrounded by air 
containing lungs and reaching to the anterior thoracic wall 
below the ape.x of the lung. The shadow was spherical and 
appeared as a part of the lung. The diagnosis rested be- 
tween a malignant tumor and a cyst. .\ bronchial carci- 
noma was excluded because of the free area in the lung; 
primary pulmonary sarcoma is very rare and metastatic tu- 
mors are multiple, leaving the diagnosis of cyst, of which 
the most common is the echinococcus type. An encapsulated 
abscess or cavernus was excluded because of the absence 
of air. the normal structure of the surrounding lung and 
the existing signs of displacement. Operation confirmed 
the diagnosis. 

Radium in Cancer of Bladder. — G. G. Smith (Sur- 
gery. Gynecology and Obstetrics. November, 1921), in a 
study of a series of cases of carcinoma of bladder con- 
cludes that it is useless to attempt to cure with radium 
infiltrating carcinomata which involve large portions of the 
bladder wall. Necrosis of the bladder will be brought 
about by any dosage which will niaterially influence the 
tumor. Certain superficial cancers of the bladder may be 
reduced in extent by the application of screened radium 
emanation to their surface. This may occur without ne- 
crosis of bladder wall. To accomplish this effect, 400 milli- 
curie hours, with screening of five tenths millimetre silver, 
applied not oftener than once in six weeks, has been suc- 
cessful, and has not caused any considerable reaction in 
the bladder. The greatest effect is produced by the first 
three or four applications of radium. If the tumor begins 
to grow again, further treatment with radium applications 
has little deterrent efl'cct. The best way to employ radium 
in cancer of the bladder is by the implantation of bare 
emanation tubes in the tumor, allowing one tube to each 
cubic cenlimetre. Steel needles containing radium may 
be employed in the same way, except that they must be 
withdrawn after adequate exposure has been made. The 
necrosis caused by the implantation of radium in bladder 
tumors persists for at least three months. 



July 19. 1922.] 



IBSTRACTS FROM CURREXT LITERATURE. 



123 



Radium in Carcinoma of the Prostate. — H. C. 
Bumpus {American Journal of Rontgenology, May, 1922) 
concludes that the average duration of cancer of the pros- 
tate, if untreated, is approximately three years, and that 
rontgenograms show that metastasis to the bone occurs 
in about one third of the cases of cancer of the prostate. 
Metastasis from a typical carcinoma of the prostate, in 
which the cells, because of their tendency to early metas- 
tasis, produce only slight local enlargement, may be fre- 
quently mistaken for Paget's disease. The clinical study 
of these cases demonstrates that in order to treat success- 
fully cancer of the prostate with radium it is necessary to 
use in the aggregate large doses (3.000 to 4,000 mg. hoursj, 
exposing all parts of the gland to comparatively small 
doses. It is demonstrated that the increased duration of 
life following radium treatment in cases of cancer of the 
prostate is in direct proportion to the amount of radium 
radiation applied. No one method of application radiates 
all portions of the gland. The malignant gland must be 
radiated by urethral and rectal exposures, and by needles 
inserted directly into the neoplasm in order to produce com- 
plete radiation of all portions. It is demonstrated micro- 
scopically, that large doses of radium placed directly into 
the gland affect only a limited area; this is substantiated 
by the clinical findings which prove that the course of the 
disease after such treatments is but slightly affected. In 
the parts of the gland affected by the radium, fibrous tissue 
is produced which enmeshes and compresses the cancer 
cells, preventing their further proliferation. If this process 
could be brought about in the entire growth, complete ces- 
sation of the disease would result. Sacral anesthesia is a 
useful adjunct in the application of radium needles, mak- 
ing it possible to place the radium accurately and to change 
the position of the needles without pain ; thus a more thor- 
ough radiation of the gland is accomplished, 

Rontgen Ray Stimulation of the Pancreas in Experi- 
mental Pancreatic Deficiency, — William F. Petersen 
and Clarence C. Saelhof (American Journal of the Medical 
Sciences, March, 1922), draw the following conclusions: 
In experimental pancreatic deficiency due to partial pan- 
createctomy rontgen irradiation of the pancreatic rest may 
be followed by a transient increase in sugar output, then 
by an increase in carbohydrate tolerance. This latter may 
occur without the preliminary increase in sugar excretion. 
The increased tolerance may be transient or may extend 
over a period of several weeks after irradiation. The 
increased tolerance is not due to the preliminary increase 
in sugar elimination. When increased sugar elimination 
is brought about by some other irritant (turpentine ab- 
scesses) no increase in carbohydrate tolerance is later ob- 
served. The effect on the blood sugar varies. Usually a 
temporary increase in the blood sugar can be determined, 
followed by a lowering of the level that takes place in 
from five hours to several days after the irradiation. When 
evidences of acidosis e.xist at the time of irradiation they 
may diminish or disappear with the improvement in the 
sugar tolerance. ' The effect of irradiation on the pancreas 
is due to direct stimulation of cellular metabolic processes 
and not solely due to alterations primarily vascular. This 
stimulation is merely an example of the ,\rndt-Schulz ob- 
servation that cell irritants in small doses stimulate meta- 
bolic processes. When the irradiation is used in too large 
a dose, injury to the pancreatic function is apparent in a 
diminution in carbohydrate tolerance. When tissues other 
than those containing the pancreatic rest are irradiated no 
effect is observed on the carbohydrate tolerance other than 
the primary augmentation of sugar excretion. The titer 
of the serum diastases, which may be altered by irradiation 
of the liver, .-ieeins to be without influence on the tolerance. 

Histological Changes of the Different Types of Car- 
cinoma After Exposure to Radium Rays. — iN'icholas M. 

.Mter (Jnurniil of Medical Research. .May, 1920) observed 
that different types of carcinoma show characteristically 
different Ixfliavior towards the rays of radium, dependent 
mainly on the state of differentiation of the different types 
of carcijioma. The action of radium rays is more effective 
on the more undifferentiated and embryonic types of car- 
cinoma, while on the differentiated forms, radium has a 
hastening effect. If the effect of the rays of radium is 
proportional to the absorbed amount, the nuclei and proto- 
plasm of different types of carcinoma and benign tissue 
absorb different amounts of the rays. 



Chest X Ray Densities.— D, C. Jarvis (American 
Journal of Rontgenology, .-Xpril, 1922), from a study of 
granite dust inhalation concludes that: 1. Film densities are 
like the shifting sand of the sea, and because a density is 
present at the first examination seems to be no reason for 
expecting it to be present at a subsequent one. 2. The evi- 
dence tends to show that film densities bring into prominence 
the lung and pleural lymphatics, 3. The same densities 
are brought into view by various factors, there apparently 
being no way in which the rontgenologist can determine, 
without the aid of the clinical history, the exact cause of 
the densities he is viewing, 4, When other dusty trades 
are investigated the necessity for serial rontgenograms in 
studying a chest condition will be more appreciated. 5. 
There seems to be a definite manner in which densities 
progress from stage to stage in the development of chest 
film densities, 6. It is a question whether the rontgenolo- 
gist should report on the basis of stages with their patho- 
logical import rather than on the basis of the causal factor, 
which latter it would seem is the clinician's province to 
determine, 7, The usual basis for diagnosing tuberculous 
activity is seen so many times on films of granite cutters 
as they leave and reenter the trade, that it hardly seems 
possible to consider the phenomena more than an indica- 
tion of a lung working under stress, 8, It would seem 
that the next step in tuberculosis is the economic one, 
when by means of wholesale x ray examinations occupa- 
tions will be determined which produce a suitable prepar- 
ation of the soil for the development of tuberculosis. 

X Ray in Diagnosis of Hilum Tuberculosis, — S, Mel- 
ville (Archi-ees of Radiology and Eleclroltierafy. Novem- 
ber, 1921), states that hilum tuberculosis in the adult would 
appear to be a definite form of pulmonary tuberculosis, 
and that such affection can be diagnosed not only clinically 
but is capable of important confirmatory evidence radio- 
graphically. That exaggeration of the shadows at the 
hilum or peribronchial tissue is of no value per se as posi- 
tive evidence of pulmonary tuberculosis, having regard 
to the fact that any and every irritative affection of the 
bronchial tube element will produce shadows of equal 
density and significance. That the radiographic picture of 
hilum tuberculosis follows very closely the clinical picture 
drawn by Riviere and others. That the closest cooper- 
ation between the clinician and the radiologist is more 
than ever necessary if advance in our present knowledge is 
to be possible. That the radiologist needs to be on guard 
in his interpretation of the clinical significance of hilar 
and peribronchial shadows. 

Lymphopenia Following Exposures of Rats to Soft 
X Rays and the Beta Rays of Radium. — J. C. Mottrani 
and S. Russ (Journal of Experimental Medicine, September, 

1921) report observations on rats given treatment with 
"soft" rays similar in character to those used by Murphy, 
supplemented by the use of beta rays of even less pene- 
trating power than those soft rays. The animals showed 
an initial fall in the number of circulating lymphocytes, 
provided that the blood counts were made soon after the 
exposure to the radiation. In view of these findings the 
terms "destroying" and "stimulating" used by Murphy, may 
be misleading, sine they are likely to give the impression 
that different effects arc otaineu after short and long ex- 
posures to X ray. The authors have found that the lympho- 
penia following a large dose may last for a week or ten 
days, while that following a small dose lasts only a few 
hours. The lymphocytosis occurring after large or small 
radiations follows a primary lymphopenia. 

Studies on X Ray Effects. — Waro Nakahara and James 

B. Murphy (Journal of E.vperiinental Medicine. April, 

1922) report the effects of soft x rays generated by a 
special water cooled tube with a window of thin glass which 
will allow the passage of rays usually held back by the 
thicker glass of the standard tubes. Small doses of the 
very soft x rays stimulated the lymphoid cells, with prob- 
ably a small amount of destruction preceding the stimu- 
lation. There was also a marked dilatation of the supra- 
renals. particularly between the corte.x and the medulla. 
Mice treated for one minute by the special apparatus, oper- 
ated at one half inch spark gap and eleven milliamperes 
showed a high degree of resistance to cancer transplants, 
this varying with the time of inoculation after treat- 
ment. The resistance was not increased before three days 
after and svas at its highest point ten days after treatment. 



124 



LETTERS TO THE EDITORS. 



[New York Medical Journal 
AND Medical Record. 



NEW YORK MEDICAL JOURNAL 

and MEDICAL RECORD 

Philadelphia Medical Journal and the Medical Xews 

A Semivwiitlilx Review of Medicine and Surgery 

Gregory Stragnell, M. D., Editor. 

Address all communications to 
A. R. ELLIOTT PUBLISHING COMPANY, 
Publishers, 53 Park Place, at West Broadway, New York. 



Subscription Price: Under Domestic Postage, $6; Foreign 
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Remittances should be made by New York Exchange, post office 
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monev sent by unregistered mail. Remittances from Foreign Coun- 
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Entered at the Post Office at New York and admitted for transpor- 
tation through the mail as second class matter. 



NEW XORK, WEDNESDAX, JULY 19, 1922 



Letters to the Editors. 



AUTOTHERAPY. 

Cincinnati, May z6, 1922. 
To the Editors: 

In May 3, 1922, issue uf the New York ISIedi- 
CAL Journal and Medical Record appeared a let- 
ter from Dr. Samuel A. Lewin, which states: "In 
the issue of February 1, 1922, you published a paper 
by Dr. Thomas M. Stewart, of Cincinnati, Ohio, on 
Autotherapy, in which credit is given for this form 
of treatment to Duncan, Waag, Brodin and others. 
Permit me to inform you, and through you Dr. 
Stewart, that in October, 1910, Dr. L. D. Rogers, of 
Chicago, was the first physician to experiment with 
autotherapy. He employed this method, using the 
patient's blood, etc." In reply it seems to me that 
it would be proper for Dr. Lewin to give us the 
references to the literature to support his plea. 

In the November, 1910, issue of the Chironian 
there appeared an article by Dr. Charles H. Duncan, 
of New York, under the title of Autogenous Virus 
in the Treatment of Sepsis, although Dr. Duncan 
had employed autotherapy including blood serum 
previously to the publication of his first article. 
About eight years after Duncan's original article, 
so far as I can determine. Rogers published his first 
article on the subject of Blood as a Therapeutic 
Agent. During these eight intervening years there 
were published many articles by Dr. Duncan and 
others dealing with the subject of autotherapy, giv- 
ing full credit to Dr. Duncan, as author and founder 
of autotherapv. 

To the extent of my ])reseut knowledge I can say 
that Rogers never published an article along these 
lines till he begun in the year of 1918 to publish 
articles relative to blood as a therapeiuic agent. 
This he called autohemic therapy. I can refer to 
manv medical articles that have ap])eared in stand- 



ard medical journals by such men as Kolmer, Fox, 
Hellario, and Dearborn on the general subject of 
Blood as a Therapeutic Agent, between 1910 and 
1914. These and many more articles published 
years before 1918, may be fovmd on the subject of 
blood as a therapeutic agent by any one interested 
in the subject. I am not aware that Rogers had 
advocated, much less discovered, the therapeutic use 
of any other secretion 'from the body than blood. 

In a comparison of Autotherapy, by Charles H. 
Duncan, M. D., with Autohemic Therapy, by L. D. 
Rogers, M. D., I can say that for myself Duncan 
is clear, while Rogers is involved. Duncan gives 
exact directions how to prepare filtrate^ from blood, 
pus or other secretions for treatment purposes. 
Rogers does not clearly state his method but gives 
details only to those who take his course of instruc- 
tion. Furthermore, Duncan gives credit to those 
who preceded him in the work and does not enlarge 
upon his own original work in perfecting a technic 
that is as simple as the conditions permit and a 
method of treatment as practical as it is effective in 
cases in which autotherapy is indicated. 

Duncan shows that Lux in 1820 in Germany had 
the idea when he stated that every contagious disease 
contained in its secretions the remedy for its cure. 
This was before the days of bacterial culture. Lux 
used the discharges diluted and gave the remedy by 
mouth. Then again, Duncan in his book brings be- 
fore the reader the works of Jenner, Pasteur, Koch, 
Wright, Denys and others. He also quotes Gilbert 
who in 1894 advocated the use of pleural and peri- 
toneal serums in small quantities for therapeutic 
purposes, and this is autotherapy prior to 1910. 

This is quite enough to show that Dr. Rogers waN 
not the first physician to experiment with autotlier- 
apy. Dr. Duncan makes no such claim for himself, 
but does explain in a scientific way the status of 
autotherapy prior to his own work and gives exact 
directions as to the details and technic as worked 
out by him. In conclusion there is an old Latin 
proverb which says : "Not by whom, but how." 
Thomas M. Stewart. M. D. 



PROFESSIONAL STR:\IN AND SUICIDE. 

New York, June 20, 19X. 

To the Editor: 

Among the professions of the United States, 
physicians head the list of suicides for the year 
1921. The following figures are interesting: Doc- 
tors, eighty-six; judges, fifty-seven; bank presidents, 
thirty-seven ; clergymen, twenty-one ; editors, ten ; 
mayors, seven ; members of the legislature, seven. 

This record seems to indicate that the occupational 
strain is greater in medicine than in atty of the other 
professions. .Should not our scheme of medical 
jjractice. as relates to hours and relief, be revised 
and, if so, how should this be accomplished? 

We should be pleased to have you give this matter 
pnl)licity in order that we may sectire a number of 
rc])lies containing suggestions that may be helpful 
in a consideration of this important matter. 

S. Dana Hubbard, M. D.. 

Director, Bureau of Public Health Education, 
Dr])artmfnt of Health. 



New York Medical Journal 



and 



Medical Record 

Philadelphia Medical Journal ;";;;! Medical News 
A Semimonthly Review of Medicine and Surgery, Established 1843. 



Vol. CXVI, No. 1.1 



XKW VuKK. WKHXESDAY. Ar(;rST 



l!il"_' 



Whole Xo. ll'J.'JS 



Eczema* 

By H. BROOKER MILLS, M. D.. F. A. C. P., 

Philadelphia, 

Professor of Pediatrics, Medical Department, Temple University; Pediatrist to the Samaritan and Garretson Hospitals, and 
Consulting Pediatrist to the Hebrew Sheltering Home and Day Nursery. 



Probably no condition of infancy gives the gen- 
eral practitioner and the pediatrist, as well as the 
demiatologist. more trouble to clear up than eczema. 
There is also probably no ailment of infancy for 
which more remedies, largely local, are used, with 
less satisfactory results. 

According to Porter and Carter, the condition 
may be divided into infantile eczema and seborrheic 
eczema, the former tending to clear up spontaneous- 
ly toward the end of the first year, while the sebor- 
rheic variety is inclined to persist. The same 
authors also state that some cases of infantile ec- 
zema are the result of the postnatal continuation of 
the antenatal activities of the skin, which in utero 
provide the vernix caseosa as a protection against 
the surrounding amniotic fluid. 

In breastfed infants the trouble is in the milk as 
a whole, while in bottlefed infants it is more often 
due to one or more of the ingredients of the milk 
than to the milk as a whole. In support of this 
statement may be mentioned Czerny's theory of fat 
metabolism and Finkelstein's salt theory. 

However, a number of theories have been ad- 
vanced other than dietetic, among which may be 
mentioned thyroid deficiency, external irritation, 
and disturbance of the nervous system. The most 
recent theory, and the one that bids fair to produce 
the best results, is that of food anaphylaxis, which 
has been extensively studied by a number of investi- 
gators, among whom may be mentioned O'Keefe, 
Shannon, and Sidlick and Knowles. 

According to Shannon, who did the protein tests 
on the backs of the infants instead of the forearms, 
as is usually done, the dietary treatment in the case 
of breastfed babies consists of either removing or 
limiting the offending foods from the dietary of the 
mother. The question will naturally be a.sked how 
long this elimination or limitalicjn of food from the 
mother's diet must be kept up, and it has been found 
by Shannon that about three months is necessary, 

•Read before the Logan Medical Society of Philadelphia, May, 1922. 

Copyright, 1922, by A. R. 



while a child may personally take these foods in 
from four to six months. A peculiar and interesting 
point is that, after a baby has been weaned, it is 
frequently able to eat the' foods that had been re- 
moved or limited in the mother's diet while it was 
on the breast, and yet not bring back the eczema. 

O'Keefe found that forty per cent, of his patients 
were cured by the omission from the mother's diet 
of the articles of food to which the infant was 
proved to be susceptible, and that twenty per cent, 
more were definitely benefited. While almost all 
articles of foods that one could possibly think of 
have been found to be the offenders, eggs have prob- 
ably headed the list, and have been removed from 
tlie mother's diet even without testing the infant. 
So many articles have been found to be offenders 
in a given case that it was not possible to remove 
them all and keep the mother properly nourished. 
, In those cases some foods would be eliminated en- 
tirely and others limited in quantity. It is impor- 
tant for these mothers to eat a large variety of 
foods, but only a small quantity of each individual 
food. In this way, while it is true there will be a 
larger number of protein substances capable of 
causing trouble, yet the elimination of the small 
quantities of these foods that were being taken 
would not reduce the amount of nourishment re- 
ceived by the mother as much as would be the case 
had she been taking large amounts of them, and at 
the same time she could be permitted, and should be 
encouraged, to take more of those foods of which 
she had been taking but limited quantities, and which 
did not give a protein reaction. 

Intercurrent disease always seems to have an un- 
favorable effect in these cases, and particularly 
teething. According to Shannon it is believed some 
persons acquire sensitization for some foods before 
birth, but in the majority it is acquired after birth 
through the breast milk. 

^ In at least one case reported by Sidlick and 
Knowles the reaction of food protein's was negative. 

Elliott Publishing Company. 



126 



BASSLER: ABDOMINAL CONVITIONS. 



[New York Medical Journal 
AND Medical Record. 



hut was positive to tlie Staphylococcus pyogenes, the 
child at that time suttering from an abscess of the 
cheek, which was found to be due to this germ. 

Quoting from Sidlick and Knowles's article : "Re- 
action to more than one protein in the same patient 
is a common occurrence. Reactions to test proteins 
which apparently have not entered into the diet of 
the patient have also been recorded. Also nonpro- 
tein substances, such as apothesine. quinine, and pro- 
caine have been found to cause skin reactions. The 
explanation of these apparent inconsistencies is to 
be found in the work of Schloss, Wells, and Osborne. 
Schloss has pointed out the importance of recogniz- 
ing that many foods are biologically related. Wells 
and Osborne, from their extensive investigations, 
concluded that the chemical structure rather than 
the biological origin. of the proteins determines the 
specificity of the anaphylactic reaction. How non- 
protein substances operate to cause skin reactions 
has not been answered as yet. It has been suggested 
that chemicals such as arsenic, quinine, and other 
substances form compounds and alter the proteins 
of the body in a manner so as to form foreign pro- 
teins. Experimental evidence is lacking. 

From the preceding it may be inferred that pro- 
teins biologically related or chemically similar to an 
otifending protein, though the latter may have been 



omitted from the patient's diet, may continue to 
cause the dermatosis. The condition of the gastro- 
intestinal tract may favor or inhibit the absorption 
of unaltered proteins to which the patient is sensi- 
tized and thereby either preclude the possibility of 
a clinical cure or help to increase the number of 
clinical cures." 

It is undoubtedly true that there are cases of ec- 
zema due to fat metabolism, as mentioned by Czemy, 
the fat intolerance in some cases being sufficiently 
marked to cause, as he states, pylorospasm, which 
is proved by the fact that improvement in the ecze- 
matous condition promptly follows the feeding of a 
low fat diet, such as skimmed milk, buttermilk, and 
melted butter, thus getting rid of the butyric acid. 
In some cases, however, a reduction in weight would 
be likely to occur as a result of the elimination or 
limitation of the fat contents of the food, and at 
times this may be overcome by increasing the carbo- 
hydrate percentage in the food. Sugar intolerance 
is also a cause in some patients, which promptly 
improves on its elimination or reduction, and the 
same is true of protein intolerance, which is largely 
benefited by boiling the milk. Occasionally, where 
milk has to be eliminated entirely for a limited 
period, simple sugar dilutions or cereal decoctions 
may be employed temporarily with marked benefit. 



Chronic Abdominal Conditions Encountered in Adults 

and Children 

The Importance of Their Early Recognition and Treatment in Childhood 



By ANTHONY BASSLER, M. D., F. A. C. P., 
New York. 



Practically up to the present time it has been the 
gastroenterologist's attitude in a number of abdo- 
minal conditions to consider the case as idiopathic, 
congenital only at times, and to encompass the condi- 
tion met with in the life entity of an adult. Yet it 
is true that many of the conditions he is dealing 
with began in early childhood and should have been 
recognized at that early date and treated properly. 
The same attitude exists among pediatrists, who as- 
sume tliat the vast majority of childen start with 
an anatomically normal abdomen, with the exception 
of course of such congenital conditions as imper- 
forate anus, strictured pylorus, etc. The object of 
this article is to draw attention to the significance of 
the child start of many of the conditions the gastro- 
enterologist is dealing with in adults, and again to 
draw attention to these states in children for the 
pediatrists. With those whose practice is limited to 
internal medicine or gastroenterology I am not aware 
of what age the patient must be before he is consid- 
ered as properly of age for them. With myself it has 
been the rule not to care for any that are younger 
than fourteen years, considering these to belong 
properly in the realm of pediatrics. Nor am I aware 
of what age the patient should be liefore the pedia- 
trist considers him more pro[)erly to be considered 



by an internist or gastroenterologist. My own stand- 
ard of departure was arbitrarily set at puberty, 
which is thirteen to sixteen years in boys, twelve to 
fourteen in girls, and in the law of presumptive 
puberty it was set on the average of boys — namely 
fourteen years. Considering that the average age 
of the patient in the pediatrist's practice is quite 
young, because of the large number of feeding cases 
in infancy and early childhood, and, on the other 
hand, that the average person the gastroenterologist 
or internist deals with is definitely an adult, there 
seems to be a period in the child's life where he is 
"neither fish, nor flesh, nor good red herring," from 
the specialist's point of view. The family physician 
is in contact from birth on and the significance 
here may be more worth while with him than 
debate on lines of departure in the specialties men- 
tioned. Lines of departure in specialties are always 
overlapping and extending, as can be noted by the 
proctologist doing general surgery in the abdomen, 
gynecologists doing laparotomies in disorders above 
the brim of the pelvis, cardiologists undertaking 
gastrointestinal work, neurologists doing brain and 
spinal cord surgery, etc. This is all healthy enough 
if the work of departure is well done, and it is now 
apparent that the pediatrist must add to his interest 



August 2, 1922.] 



BASSLER: ABDOMIXAL CONDITIONS. 



127 



in subjects much that gastroenterology has taught 
and used in the adult, and the gastroenterologist must 
have interest in many of the disorders he has to 
handle in the adult as of more significance in that 
they should be cared for in early childhood, either by 
the family physician, the pediatrist, the gastroen- 
terologist. or the internist. 

An analysis of ptosis cases in adidts suggests 
strongly that symptoms of the condition were pres- 
ent in the child in many of them. There are many 
normal individuals with lower than average organs 
in the abdomen, and there never have been any symp- 
toms attendant upon the condition. A study of 
ptosis cases strongly suggests that there is no definite 
symptomatology of ptosis. Those cases that occur 
are bound up in the physical and vital deficiencies 
inherent in the individuals, these deficiencies being 
largely present when the individuals were children, 
though they were not observed as such, and were 
not improved ; or they may have been somewhat 
deterred and not become evident until the strain of 
adult life added its factors of vital reduction which 
broke the restraining shell, and then the material of 
which the person is made manifested itself. 

Textbooks on diseases of the stomach have em- 
phasized the importance of this subject in the young 
for years. It is now fourteen years since the fol- 
lowing was offered by me (1): "A congenital pre- 
disposition to prolapse of the internal viscera is seen 
in the characteristic body form and fragility of tis- 
sue and debility of the nervous energy noted in those 
individuals in whom these are always existent in the 
individual all the way_from infancy to the grave. 
A close observation of infants and children has 
proved to me that the elements of splanchnoptosis 
are exceedingly common in the young, and the modes 
of life, methods of feeding, illnesses of infancy and 
childhood, etc., are conditions causing the continua- 
tion or its liability as extra factors. In the light of 
the judgment that is given to us and the observa- 
tions that we daily have in the practice of medicine, 
is it not more logical to suppose that splanchnoptotic 
conditions or tendencies date usually from die pre- 
natal or early postnatal days of life? Robust par- 
ents give birth to the largest proportion of robust 
children and the progeny of wealthy parents (who 
have lived along hygienic lines themselves) and 
whose children when they become adults give birth 
to children make up the second largest ])roportion. 
The parents who give birth to children during the 
years of the stern competition of life in quest of 
affluence or those who live lives improper in habits 
reap almost as many neurasthenics in their offspring 
as those who are always more or less poverty 
stricken and are thus compelled to live under unfa- 
vorable hygienic conditions with their bad consti- 
tutional results. 

"Primarily, sjilanclmoptosis is a status of debility 
or a kind of chronic neurosis represented in a chronic 
devitality of the sympathetic system. However 
pathologically this is produced, it represents to a 
more or less degree poor tissue soil in early life. 
Whether this is due solely, as Stiller has suggested, 
to embryonic defect (vitium prima formationis), or 
to the physical tribulations of the infant and child, 
or only to ac{|uired conditions in late life, will al- 
ways remain in the order of a problem and different 



in each adult case that is seen. The children that are 
born of poorly nourished parents, or those in whom 
tuberculosis, syphilis, alcoholism, or chronic disease 
or status of debility is present, have the largest 
number of offspring of the poorest quality. Added 
to these are the mysteriously wrought effects in chil- 
dren of neurasthenic and neurotic parents. Then 
come such conditions as improper feeding of the 
infant and child, the living of the child under un- 
hvgienic conditions for complete continued health, 
rachitis with its damaging effects on the nervous, 
muscular, osseous and ligamentous tissues, more or 
less mild and unrecognized states of scurvy and the 
infectious diseases of childhood to which the child 
is especially prone (scarlet fever, diphtheria, measles, 
enteric conditions, etc.) and the aftertreatment of 
which is not considered of much importance in medi- 
cine, but which, nevertheless, often leave a legacy, 
the state and kind of which would cause anxious 
moments in the adult but which do not receive 
much attention in the child. Now come the school 
days with their close confinement and too few mo- 
ments of outdoor play and recreation, followed by 
the grind in college, shop or factories, then the wear- 
ing incidents in business, homes and in women the 
hearing of children and dangers of postpuerperal 
relaxations of the abdominal cavities. Along these 
lines many of the adults who apparently were born 
healthy but who, nevertheless, have anatomical 
splanchnoptosis, finally present symptoms which 
clinically are associated with visceral prolapse." 

Of late, and largely through the study, work and 
teachings of C. G. Kerley (2), attention has been 
directed to ptosis in the child as well a.s to many 
other abdominal conditions that are constantly en- 
countered in gastroenterological practice in the adult 
To him largely belongs the credit of awakening an 
interest among pediatrists and the profession gen- 
erally. In ptosis, however, to gastroenterology be- 
longs the credit, because those who have worked 
with these cases have always maintained the early 
or congenital beginnings. Delayed as this attention 
is on the part of pediatrists it is most gratifying, 
now that it is here. There is no doubt that the con- 
dition diagnosed in the child will mean eventually 
fewer cases in the adult, and considering the fact 
that by proper feeding, abdominal support, massage, 
conservation of physical energy and the building up 
of vital strength, so easy to carry out in the child, 
will mean a marked benefit for health in a consider- 
able proportion of people with ptosis twenty years 
from now, who are more numerous today than they 
should be. To this is added the fact that the pedia- 
trist has the best period of life to accomplish per- 
manent results, for work done during the period of 
growth in skeleton and soft tissue makeup in the 
child, when these are more plastic and responding 
quicker in benefits, gives him an opportunity for 
results that are distinct advantages. Since it is ap- 
parent that certain customs, such as excessive drink- 
ing of fluids (milk, water) especially when food is 
in the stomach, and eating bulky and low caloric 
value foods, are still in vogue in some old ideas of 
feeding children, it seems they should require modi- 
fication in these children. 

Pylorospasm is commonly met with in the adult. 
Most often it is judged as symptomatic and reflexly 



128 



BASSLER: ABDOMINAL CONDITIONS. 



[New York Medical Journal 
AND Medical Recori>. 



brought about by pathological conditions elsewhere 
than in the stomach and duodenum, most often in 
chronic disease of the appendix or minor patholo- 
gies like bands and kinks in that vicinity. Pyloro- 
spasm second to this i^ obsen-ed as a reflex from 
spastic conditions of the colon (spastic constipation ), 
this being a concomitant condition associated with 
chronic intestinal toxemia of anaerobic infections, 
more particularly those due to the Bacillus welchii, 
the gram positive cocci and the Bacillus putrificus. 
\'agotonia, when definitely present, is commonly a 
resulting state from these infections, and never the 
etiological cause of the spasticity. W'ith this condi- 
tion a spastic sphincter ani often exists without local 
disease in the rectum. Many cases of pylorospasm 
exist in which there is no definite cause assignable. 
These have been designated as neurotic, although 
in my opinion they are expressions of irritative 
efifects on the stomach from dietetic errors. 

The importance of pylorospasm in children has 
been brought to fuller consideration not only by 
Kerley, but especially by Grulee (3). His latest 
article draws attention to its frequency, the impor- 
tance of it as an entity, bringing attention to the fact 
that it often is a very serious and even fatal condition 
in children. In the last five cases of marked pyloro- 
spasm in the adult without definite disease in the 
abdomen or biological error in the intestines, four 
gave a pylorospastic history beginning early in child- 
hood, all becoming intensified as the years passed. 
Idiopathic pylorospasm is a variable afl^ection, but 
it can occur in childhood and may continue into adult 
life. It is important, therefore, that the early cases 
be recognized, as they would thus be more amen- 
able to treatment, and no doubt some of the adult 
patients saved. 

The condition to which I would definitely draw 
attention here, and to my knowledge for the first 
time, are the chronic toxemias in the intestines in 
childhood. Twenty-one per cent, of several thou- 
sand histories in adults show these to have orig- 
inated in the first decade of life, the average being 
the eleventh year. Any enterocolonic condition that 
lasts for a week or more may be assumed as its 
origin, even if such had been deemed as of simple 
dietetic origin. For more definite assumption on this 
is the degree of intestinal trouble or weakness that 
the child has had, especially if this has been followed 
by poor health. As Herter has shown, these condi- 
tions are common in children, upon which subject 
Kendall and a considerable group of Boston pedia- 
trists have written well. In so far as the adult is 
concerned in the studies of intestinal bacteria, many 
times the same biological pictures are met with as 
in the young with enteric states. If for no other 
reason the child is of interest in a gastroenterological 
way, it is here that its greatest significance is met 
with. Considering the large number of adults who 
have this trouble studies should be made of the child 
in this connection and the condition corrected early 
in life. 

That children are affected with intestinal parasites 
needs no echo here. Recent studies in tropical coun- 
tries in addition to hookworm infections, show that 
the child can harbor about all the parasites that in- 
fect the adult. The stools of not a few children 
whom I have examined show considerable infections 



in the North, because I have met with the Giardia 
and even the Entemeba histolytica as well as the pin 
and round worms. It is more than probable that in 
not a few adults thus infected their infection really 
began in early or late childhood and should have 
been diagnosed and handled at these early years of 
life. 

In the last year I have been studying cases of 
incomplete rotation of the colon. The marked in- 
stances of more or less left sidedness of the right 
colon have been known for years. But what are 
far more numerous than these are the just short of 
complete rotation where the caput cecum, ileocecal 
valve, and all of the ascending colon ciccupies its 
proper anatomical position in the right side of the 
abdomen but the hepatic flexure is not fixed in 
proper position posteriorly, is freely movable, and 
tends to a left sided position. The hepatic flexure 
of the colon in complete rotation occupies a fixed 
position in the posterior wall of the abdomen directly 
under the liver. Numerous instances of lack of this 
fixed position exist and many of these have been 
designated as prolapse of the hepatic flexure. But 
most of these are just small percentages short of 
complete rotation of the hepatic flexure and proper 
posterior fixation of it. These no doubt exist in 
children because they are prenatal in timing and a 
few of my cases give a symptomatology that dates 
early in life. In instances of more complete non- 
rotation, when symptoms occur, they are more mat- 
ters of adult life and need not be considered here. 
Why in the lesser degrees of nonrotation the symp- 
toms are more likely to occur in early life than in 
the more complete cases, is as difficult to say as it 
sounds unreasonable in comparison between the two. 
It may be that in the more complete forms the symp- 
toms do not occur until the body is ripe for active 
reflexes, this being suggested in the fact that studies 
of the symptoms of these cases in the adult (while 
often having definite ones like melena, constipation, 
etc.) are mostly of the reflex order and largely 
epigastric. 

The vast majority of megacolon cases in the adult 
were present in their childhood. Most of these, 
however, do not give an early symptomatology and 
not infrecjuently it is rather stumbled upon in an 
-x ray examination. Kerley and others have reported 
some, however, causing abdominal distention and 
malnutrition, and if the adult cases could have been 
diagnosed early no doubt these would be less trouble- 
some in adult years. 

There is no doubt that loops of the colon and 
redundancy of the sigmoid existed in childhood in 
the cases we see in adult life. Without definite 
assertions on the part of surgeons and gastroen- 
terologists as to when they did occur in the case 
under analysis far too many have been and still are 
being considered in an idiopathic and symptom pro- 
ducing way and too much surgery is being engaged 
in in this anomaly. An occasional case may warrant 
it, but when one handles them in detail and persist- 
ently in medical ways most of them are improved 
sufticiently well. This being true with the adult, it 
is all the more significant that these cases were diag- 
nosed early in life, and dietetic, massage and other 
directions employed early. 

The symptoms that should awaken investigation 



August 2, 1922.] 



KINLAW: SUBDIAPHRAGMATIC ABSCESS. 



129 



in tlie young are varied, but they can be grouped 
as follows : paroxysmal pain in the abdomen, mostly 
in the epigastric region ; obstinate constipation or 
tendency to loose movements of the bowels ; inter- 
mittent or more or less constant distention of the 
abdomen (pot belly); recurrent vomiting; steady 
anorexia ; acidosis attacks ; anemia ; malnutrition and 
irritable disposition. 

The list of disorders in the abdomen that the gas- 
troenterologist is handling daily in his work have 
tlieir analogues in children. Most of the adult pa- 
tients he sees had the same condition in childhood. 
This being so and such children arriving to adult 
years in good and fair nutrition and general health 
whether no symptoms of the disorder existed during 
childhood, or such that did exist being minor and 
easily handled, warrants the gastroenterologist in 
assuming that only an occasional one of them should 
be considered as surgical disorders. Much can be 
done for them medically in adult years, and still 
more for the same disorders in childhood. It is 
therefore important that these cases be diag- 
nosed as early in life as possible, preferably during 



childhood. Those cases that escape the pediatrist 
or the rontgenologist in these early days should be 
watched for by the family physician who should 
have more of such children examined by x ray than 
today is thought necessary. On him more than on 
the pediatrist (who may not see the case because of 
the absence of symptoms or the presence of minor 
symptoms which are quickly controlled, and the gas- 
troenterologist who sees them late in their lives be- 
cause they had existed almost throughout the course 
of the individual life) should hope that they would 
have been diagnosed before he sees tliem. Many of 
such would have been saved more or less illness in 
early life, would have had less symptoms when 
adults, and not a few real abdominal cripples in late 
life would have been far short of that status of 
semiinvalidism. 

REFERENCES. 

1. Bassler: Diseases of the Stomach and Upper Ali- 
mentary Tract, first edition, p. 660-666. 

2. Kerlev.C. G. : Journal of Diseases of Children, April 
1920, vil. xix. p. 277-286. 

3. Grulee: Journal A. M. A., April 22, 1922. 

21 West Seventy-fourth Street. 



Two Cases of Subdiaphragmatic Abscess Complicating 

Appendicitis 



By W. BERNARD KINLAW, M. D.. 
Philadelphia, 

Resident Physician, Episcopal Hospital. 



C.'\SE I. — A boy, G. R. W., aged eight years, was 
admitted to Dr. Ashhurst's service, in the Episcopal 
Hospital, on January 16, 1921, at 11 p. m., with a 
diagnosis by the family physician of empyema. The 
history of the case is as follows : 

The family history was negative ; personal history 
included whooping cough at seven years, and occa- 
sional colds ; no other diseases, no operations. The 
chief complaint was cough and dyspnea. The pa- 
tient was perfectly well, with the exception of a 
slight cold, until three weeks ago (December 26, 
1920) when he was taken with pain in the upper 
abdomen. This pain came on gradually, was dull in 
character, not relieved by pressure on the abdomen, 
not radiating to the back, side, or lower abdomen. 
The next day the pain continued, not severe but 
annoying. A dose of castor oil was given but re- 
turned, and there developed a slight, hacking, non- 
productive cough. The mother thought he had had 
no fever, and the condition remained about the same, 
the boy having little appetite, staying in bed part 
of the time and being up part of the time, apparently 
in this state for the following two weeks. 

Twenty days after the onset the condition became 
much worse. The cough became much more severe, 
at times nearly causing exhaustion. A yellowi.sh 
frothy sputum with a foul odor was coughed up. 
The ]>atient's breath was also foul smelling and there 
was marked dyspnea. He did not complain of ab- 
dominal pain. He vomited everything he had eaten 
and vomited and gagged after a severe coughing 
spell. He was seen by the family doctor, who .said 



he thought the child had empyema and should go to 
the hospital. 

On admission the boy was poorly nourished and 
extremely sick, with rapid and labored respirations, 
attacks of violent coughing, very foul breath, and 
somewhat cyanotic. There were enlarged veins 
under the eyes and over the chest and abdomen. The 
temperature was 104° F., respirations 4<S a minute, 
pulse 144. The pupils were slightly dilated, reacted 
to light and accommodation, eyes somewhat sunken. 

The tongue was heavily coated and there was 
a very foul breath. The veins of the neck were 
prominent, pulsation of the carotids was visible. 
There was a bulging of the interspaces on the right 
side, expansion was more marked on the left side. 
The apex beat was faintly visible and felt in the fifth 
interspace, one and a half cm. to the left of the 
nipple line. On percussion the left lung was reson- 
ant throughout. The right chest presented dullness 
both anteriorly and posteriorly, below the third rib. 
It was resonant above the third rib. The heart was 
apparently pushed to the left. There were crackling 
rales of all varieties throughout the left chest and 
upper part of the right chest. The breath sounds 
were much exaggerated over the left side. The 
right side, above the third rib, presented exaggerated 
breath sounds, and crackling rales. Below the third 
rib the breath sounds and voice sounds were much 
diminished. 



The abdomen was slightly distenc 



There was 



no rigidity or tenderness except on deep palpation 
in upper right quadrant where there was slight ten- 



130 



KINLAIV: SUBDIAPHRAGMATIC ABSCESS. 



[New York Medical Joursai. 
AND Medical Record. 



derness. No masses were palpable. The liver ex- 
tended two and a halt cm. below the costal margin. 
The spleen and kidneys were not palpable. The 
bladder was not distended. 

This patient came under my care in the receiving 
ward : and believing the family physician's diagnosis 
of empyema to be correct, and after consultation 
with Dr. Ashhurst over the telephone, a needle was 
inserted at the angle of the scapula, in the seventh 
right interspace, in order to relieve the urgent symp- 
toms. After the needle had gone in about two and 
a half cm. a greyish, purulent material was with- 
drawn, having a foul odor, not the odor of colon 
bacillus however. The needle was then attached to 
an aspiration outfit and 580 c. c. of pus was evac- 
uated. Following the removal of pus the coughing 
stopped entirely, the cyanosis became much less 
marked, respirations much improved, the child was 
able to lie down (which he could not do before with- 
out a violent attack of coughing with marked cyano- 
sis) and he was apparently much better. The child 
soon went to sleep and slept until about 7 :30 the 
next morning (about eight hours) when he became 
restless, the pulse was very weak. The boy died 
at 8 :30 a. m. 

A necropsy was performed, for the report of 
which I am indebted to Dr. C. Y. White. 

The pathological diagnosis was : Bronchopneu- 
monia, acute pleurisy (fibrinous), subdiaphragmatic 
abscess, gangrenous appendicitis, localized suppura- 
tive peritonitis, acute diflfuse nephritis and acute 
toxic splenitis. The appendix was about seven cm. 
in length, was retrocecal, and pointing toward the 
liver and gangrenous. From it ran a straight tract, 
which terminated in a large subphrenic abscess, 
which was intraperitoneally situated in the right 
posterior intraperitoneal subphrenic space. About 
one hundred c. c. of pus still remained in the abscess 
cavity, which by the adhesions was apparently of 
about two weeks' duration. The needle, which sup- 
posedly was passing through a thickened pleura, had 
perforated the diaphragm without entering the pleura 
and gone into the abscess cavity, which was bounded 
above by the diaphragm, below by the upper surface 
of the posterior portion of the right lobe of the liver, 
in front by the right lateral ligament and on the left 
by the reflection of parietal peritoneum covering the 
right surface of the vena cava. 

In 1914 Dr. Ashhurst had admitted to his service 
another case of appendicitis, complicated by sub- 
phrenic abscess, which, as it has not been reported 
before, is included in the present report. 

Case II.- — A boy (J. M. ) eleven years of age, ad- 
mitted Xovember 13, 1914. The family history was 
negative. The patient had had an attack, similar 
to the present one. three years ago. Four days be- 
fore admission the child was seized with cramplike 
pains in the abdomen, following an indiscretion in 
diet. The pain was at first generalized over the ab- 
domen but later became localized to the right iliac 
fossa. The bowels were constipated, and the patient 
vomited after the beginning of the pain. There were 
no pulmonary, cardiac, or genitourinary symptoms. 

The physical examination was negative except the 
abdomen which was somewhat distended through- 
out; liver and spleen not palpable. On light palpa- 
tion there was some rigidity and tenderness in the 



right iliac fossa. By pressure there was evidence of 
a mass in the same locality. Peristalsis was active 
throughout, and there was gurgling in the right iliac 
fossa. There were no scars, or hernia. The ex- 
ternal genitalia were negative. The temperature was 
99° F., pulse 128, respirations 24, urine negative. 

A diagnosis of acute appendicitis with abscess 
formation was made, and Dr. Ashhurst operated im- 
mediately, finding an appendiceal abscess with a 
gangrenous and perforated appendix. The appen- 
dix was removed and the abscess opened and 
drained, a rubber tube was placed' to the pelvis and 
an iodoform drain to the stiunp of the appendix. 

The boy was put in the Fowler position, and was 
given continuotis enteroclysis. He did quite well, 
having the drains removed in a few days, tempera- 
ture and pulse being normal. He continued to im- 
prove until the eighth day after the operation when 
his temperature rose to 101° F. and his leucocvtes 
were found to ntmiber 27,500, of which eighty-one 
per cent, were polymorphonuclear. The next daj' 
his temperature was still high. 

The operative incision was healed except for a 
superficial granulating area in its lateral half, there 
being no sinus and no discharge. There was no ten- 
derness here or elsewhere except high in the right 
loin, over the lower right ribs and at the costal mar- 
gin in the midaxillary line. There was slight but 
distinct pitting of the skin on pressure over these 
regions, but none elsewhere. On deep inspiration it 
appeared that the right costal margin moved further 
away from the midline than did the left (Hoover's 
sign). The lungs were negative. 

A diagnosis of subphrenic abscess was made, and 
operation done the same day, November 22, 
1914. A finger inserted into the incision of the 
first operation, found no pus pockets here, but dense 
adhesions walling otT the right flank. So a small 
gridiron incision was made at the edge of the ribs 
in the midaxillary line. When the thickened peri- 
toneum was opened, the ascending colon presented. 
This was packed oflf, and a subphrenic abscess be- 
tween the liver and diaphragm was evacuated by 
burrowing upward with the finger. It contained 
about fifty c. c. of creamy inodorous pus. The cul- 
ture showed short chains of streptococci. A tube 
was placed for drainage and the wound drained for 
several days. The temperature gradually subsided 
and the boy made a good recovery and was dis- 
charged with both wounds healed entirely, twenty- 
four days after the second operation. When seen 
nine months later he was free from symptoms. 

COMMENT (1). 

The statistics of Lance (1909) on subphrenic ab- 
scess comprising almost one thousand cases indicate 
that about twenty per cent, are catised by appendici- 
tis, thirty per cent, by lesions of the stomach and 
duodenum, thirteen per cent, by lesions of the liver 
or gallbladder, and thirty-seven per cent, by miscel- 
laneous affections (pancreas, spleen, large intestine, 
jjleura and other organs). 

Appendicitis may give rise to subphrenic abscess 
in various ways. It occurred in twenty out of one 
series of 2400 cases of appendicitis under the care 
of Dr. John B. Deaver. four of the patients recov- 
ering. The intraperitoneal variety was present in 



August 2, 1922.] 



BLUMENFELD: DIAPHRAGMATIC HERNIA. 



131 



two thirds of 106 cases analyzed by Eisendrath. He 
found recorded only six left sided cases of sub- 
phrenic abscess due to appendicitis. 

According to Barnard, who fully discussed the 
subject in 1908. special attention should be paid to 
the following points in diagnosis : 

1. Previous history (usual causes of the condition, 
c. g., gastric or duodenal ulcer, appendicitis, hepatic ab- 
scess, or other conditions). 

2. Character of onset. 

3. Constitutional signs of pus. 

4. Abdominal signs and symptoms, including bulging 
during respiration, tenderness, rigidity, dullness or tympany 
due to perforation of air containing viscus. A swelling due 
to subphrenic abscess is immobile because fixed by ad- 
hesions. 

5. Thoracic signs and symptoms. Most important are 
dullness, associated with upward displacement of lung; 
diminution or absence of breath sounds, vocal resonance 
and vocal fremitus. Amphoric resonance of abscess con- 
tains air. Apex beat of heart may be displaced upward but 
seldom laterally. Hoover's sign is of value in differen- 
tiating between empyema and subphrenic abscess (if the 
abscess is subphrenic the excursion of the costal border 
on the affected side is increased, being decreased on the 
affected side if due to empyema). 

6. Fluoroscopic examination shows fixity or lessened 
mobility of the diaphragm on the affected side. 

7. Aspiration is dangerous unless followed by imme- 



diate operation, therefore should not be done until patient 
is ready for any operation that may seem proper. 

In the first case reported herewith, the subphrenic 
abscess was in direct continuity with the gangrenous 
appendix ; in the second case, as is more usual, the 
abscess appeared as a secondary complication, prob- 
ably being due to direct spread of infection before 
or during the original operation. If the subphrenic 
abscess is due to spread of infection along the retro- 
peritoneal lymphatics it seldom gives rise to symp- 
toms so soon after the first operation. Two other 
cases of appendicitis complicated by subphrenic ab- 
scess have been reported by Dr. Ashhurst (2) ; in 
the first of the subphrenic abscess developed before 
operation, from direct intraperitoneal spread of in- 
fection ; in the second it did not develop until six 
months after operation. In the total four cases, two 
patients recovered and two died. These were ob- 
served in a series of two hundred cases of appendi- 
citis with complications (abscess, diffuse peritonitis, 
gangrene, etc.) requiring drainage of the wound. 

REFERENCES. 

1. Deaver and Ashhurst: Surgery of the Upper Ab- 
domen. 

2. Ashhurst: Transactions of Pluladclplun .-icademy 
of Surgery, 1911, xiii, 154-157. 



Congenital Diaphragmatic Hernia 

By LOUIS BLUMENFELD, M. D., 

Brooklyn, N. Y., 

Assistant Physician, Swedish Hospital; Attending Surgeon, Jewish Hospital Clinic. 



From Holt's Diseases of Infancy and Childhood 
we get the following paragraph : 

"Diaphragmatic hernia is due to a congenital defi- 
ciency in the diaphragm, which is usually on the left 
side. Of 118 cases collected by Livingston, eighty- 
three were on the left side, eighteen on the right, 
four were central, two were double, in one the 
diaphragm was absent. With small openings only 
a single coil of intestine, with large ones a consid- 
erable part of the abdominal contents may be found 
in the thorax. This causes displacement of the 
heart, usually to the right side, prevents the full 
expansion of the left lung, and if the deformity 
occurs early in intrauterine life the lung may re- 
main rudimentary. If a large deficiency exists, in- 
fants may live but a few hours ; with smaller ones, 
life may be prolonged indefinitely." 

The symptoms noticed soon after birth are usually 
cyanosis, rapid respiration, a sunken abdomen, an 
overdi.stended chest, and dyspnea. Infants often 
live but a few hours. In those who survive a longer 
time dyspnea is generally the most prominent symp- 
tom. It may be constant, it may occur in severe 
paroxysms, or there may be attacks of cyanosis 
often of great severity, these being produced by an 
accumulation of gas in the stomach or in the thoracic 
part of the intestine. Other symptoms may at times 
suggest intestinal obstruction. The physical signs 
vary from time to time. Sometimes those of pneu- 
mothorax are present ; at others there is so much 
dullness with the feeble respiratory sounds, as to 



suggest fluid. The signs are usually upon the left 
side, with displacement of the heart to the right. 
A positive diagnosis can often be made by means 
of the X ray after the administration of bismuth. 
The condition is not amenable to treatment. 

Case. — -S. R., aged twenty-four, secundipara. 
Family and personal history both were negative, 
and venereal history was denied. Menstrual periods 
began at the age of fourteen and was of the twenty- 
eight day type, the fl^ow lasting from four to si.x 
days at each period. She was married at twenty- 
one \ears of age, and a normal male child was born 
one year later. The pregnancy, labor, and puer- 
perium were normal. The last menstrual period was 
on February 20, 1921. There were no untoward 
symptoms during the pregnancy. Labor commenced 
on November 16th at 5 p. m. As soon as the patient 
realized she was in labor she went to the Swedish 
Hospital. The abdominal examination showed the 
fetus in a left occipitoanterior position; the fetal 
heart being heard in the left lower quadrant beating 
at the rate of 128 a minute. The vaginal examina- 
tion confirmed the abdominal diagnosis. The three 
stages of labor were rapid and uneventful, delivery 
taking place at 8:30 p. m., three and a half hours 
after the first labor pain. 

Upon being born the child gave a little gasp and 
a faint cry and made a forced attempt at inspira- 
tion. With every attempt at inspiration the inter- 
costal and subcostal spaces would retract, the shoul- 
ders heaving upward, and the thighs and legs flexing 



132 



BEHREND: ABDOMINAL DISEASE IN CHILDREN. 



[New York Medical Journal 
AND Medical Record. 



upon the abdomen. I aspirated the mucus from 
the child's mouth and pharynx with a catheter, 
held the child feet up, slapped its back, threw a 
handful of water on its chest, but could get no 
deep inspiration or cry. The labored and forced 
efforts at inspiration as described above were evi- 
dent. Suspecting a mucus plug in the larynx or 
trachea I passed a catheter into the child's larynx 
to aspirate any mucus that may be present but the 
larynx and trachea seemed clear. (I had inserted 
a catheter into the trachea in two previous cases 
of asphyxia neonatorum with immediate and ex- 
cellent results.) I tried all of the described methods 
of artificial respiration but none seemed to relieve 
the progressive and increasing asphyxia, the only 
result being the forced attempts at inspiration. 

The child was becoming quite cyanotic and I re- 
sorted to oxygen inhalations. Soon after the admin- 
istration of oxygen the cyanosis disappeared and the 
child assumed a healthy color in spite of the ineffi- 
cient respirations. The tugging and labored efforts 
at inspiration persisted. As long as I kept the child 
in a basin of water at body temperature and sup- 
plied it with oxygen the color remained good, but 
as soon as I took the oxygen away the cyanosis 
returned. The respirations at this time were about 
eight to the minute. If, during the administration 
of oxygen I pressed upon the abdomen to prevent 
any oxygen from entering the stomach, the cyanosis 
would at once return. 

The point of greatest intensity of the heart sounds 
was in the right anterior axillary line at about the 
fifth interspace. The apex beat could be felt dis- 
tinctly in this area. The heart rate was about forty- 
five a minute. The efforts at inspiration gradually 
became weaker and less labored and the child died 
an hour and a half after birth. 

The only external physical defect present. was a 
marked right talipes eciuinovarus and to a less de- 



gree a left talipes equinovarus. A premortem 
diagnosis of congenital atelectasis with transposition 
of the organs was made. Dr. L. A. Thunig, attend- 
ing pathologist at the Swedish Hospital, performed 
the autopsy. 

On opening the abdomen the liver was found much 
enlarged and filling the greater part of the abdom- 
inal cavity. The only other visible content of the 
abdomen was the sigmoid which was well filled and 
distended with meconium. The descending colon 
disappeared through a slit in the diaphragm caused 
by the separation of the diaphragm from the pos- 
terior abdominal wall. The opening pbout one 
quarter of an inch to the left of the aorta. On re- 
moving the anterior chest wall the thorax was found 
filled with small intestines right up to the neck. It 
also contained the whole stomach and the large in- 
testines. The heart and lungs were not visible. On 
])ushing aside the small intestines from the right 
side of the thoracic cavity the pericardium was ex- 
posed. The apex corresponded to the fifth inter- 
space in the anterior axillary line. The lungs were 
rudimentary and occupied the posterior part of the 
thorax. The diagnosis was left sided congenital 
diaphragmatic hernia. 

Dr. Thunig reports having seen a case of left 
sided congenital diaphragmatic hernia in which the 
infant lived nine days. The most prominent symp- 
toms in his case were dyspnea during and after 
nursing and also during defecation. An enema 
would materially reduce the degree of dyspnea and 
cyanosis. The dianosis was made during life. 

A premortem diagnosis of left sided congenital 
diaphragmatic hernia could have been possible in my 
case on accoimt of the dyspnea, displaced heart, and 
especially upon the increased cyanosis when pres- 
sure was exerted upon the abdomen forcing the 
meconium from the sigmoid in the abdominal cavity 
into the descending colon in the thoracic cavity. 



Acute Abdominal Conditions in Children* 

By MOSES BEHREND, M. D., F. A. C. S., 
Philadelphia. 



The difficulties which attend the dift'erential 
diagnosis of acute abdominal conditions in children 
were thoroughly impressed upon me, when during 
the past few weeks I was called in consultation in 
several cases of acute surgical disease of the abdo- 
men. The ages of the children r.anged from three 
to twelve years. In the younger children, on ac- 
count of indefinite subjective information, it was 
difficult to arrive at a diagnosis. In these cases one 
must use a combination of the objective findings 
and a certain amount of intuition which can be ac- 
quired only through long experience derived from 
previous training in general practice. The general 
inspection then of the child, in addition to other 
physical signs, must evidently mean more to him 
even than the history given by parents and the 

•Read before the Northern Medical Association, Philadelphia, 
April 28, 1922. 



meager information derived from the patient. The 
desire of the little patient to hide symptoms on ac- 
count of fear, and not infrequently jjersistent crying, 
naturally cause the abdomen to become rigid and add 
more difficulties to the final diagnosis of the case. 

The opinion expressed before, that the best single 
differentiating sign between appendicitis and pneu- 
monia is the playing of the ate of the nose, has 
again been proved during the past winter. This sign 
is rarely found in the early stages of appendicitis, 
while it is always present in ])neumonia before even 
a demonstrable lesion is found in the lungs. 

The first case which demanded our attention was 
one which required the finest judgment both in the 
determination of the diagnosis and in deciding 
whether the operation should be performed at once, 
or delayed on account of a spreading peritonitis. 
The diagnosis as to the particular kind oi infection 



August 2, 1922.] 



BEHREND: ABDOMINAL DISEASE IN CHILDREN. 



133 



was not easy, because six weeks before the abdominal 
condition presented itself there was a history of 
pharyngeal diphtheria. The patient was a female, 
five years old, very intelligent and ready to assist 
us in making a diagnosis. It was evident that an 
abdominal condition was present, but on account 
of the generalized tenderness of the abdomen, with 
a little more rigidity in the right iliac fossa than in 
other parts of the abdomen, a definite diagnosis 
was difficult. While we considered that appendicitis 
was the most frequent of all acute abdominal con- 
ditions, still on account of the patient's previous 
history of diphtheria, a diagnosis of diphtheritic or 
pneumococcic peritonitis was made with a possi- 
bility of appendicitis, although we did lean more 
strongly towards the former. An added reason for 
making this diagnosis was the resemblance of the 
picture presented to those cases in which in the past 
operation had been performed. 

The treatment is as perplexing as the diagnosis, 
inasmuch as most surgeons are agreed that it is best 
to wait until the pus has become localized before 
operating on these patients. If the pus should show 
a tendency to localize they will recover, but 
if there is no tendency to localization, then the wait- 
ing policy does absolutely no good. The mortality 
in such cases is exceedingly high. In every case 
of pneiunococcic peritonitis in which we had oper- 
ated the patient died, with the exception of the 
case under discussion. On account of the fatal char- 
acter of this infection I believe the best policy is 
to operate as early as possible. In these cases we 
have operated at all stages, and it would seem that 
if they could be seen early enough prompt surgical 
intervention would give the best results. A writer 
on this subject made the statement recently that if 
these patients were operated upon early enough a 
great many of them could be saved. In our case 
the patient was operated upon about twentj^ hours 
after the onset of the abdominal symptoms. Upon 
opening the abdomen a large volume of pus exuded, 
most of which was in the pelvis ; the appendix 
seemed normal, but was removed. A large sized 
tube was inserted in the pelvis, the patient placed 
in the Fowler position and received salt solution 
by bowel. The bacteriological examination confirmed 
our diagnosis. ' 

When a child is sent to the hospital with a diagno- 
sis by a physician special care must be given either 
to confirm or disprove this diagnosis. While we 
are well aware that pneumococcic peritonitis is much 
more common in girls than in boys, yet when a boy 
five years old was sent to the hospital, with symp- 
toms identical with those presented in the previous 
case, we made a diagnosis of pneumococcic perito- 
nitis. The patient was admitted with a diagnosis of 
meningitis, but on account of the preponderance of 
abdominal symptoms we were asked for an opinion. 
He was very sick, toxic, emaciated, with dry coated 
tongue, eyes sunken, sordes around the corners of 
the mouth. The abdomen was rigid throughout, 
tender and slightly distended. There were no phys- 
ical signs of meningitis at the time our examination 
was made. An operation was i)erformed. The 
abdomen presented the characteristics of a late gen- 
eralized peritonitis, the intestines being matted to- 
gether. The pus was localized in the pelvis ; the 



appendix was apparently not the cause of the infec- 
tion. Slides made from the pus revealed a mixed 
infection of streptococcus and pneumococcus with a 
preponderance of the former. We realized that this 
patient was more seriously ill than the former, and 
our prognosis was made accordingly. He died with- 
in a week after operation, notwithstanding sup- 
portive measures, hypodermoclysis, stimulants, and 
antistreptococcic serum. Immediately after death 
the tonsils were excised, the pus was cultured and 
revealed streptococci. The tonsils may have been 
the source of infection. 

It takes much courage to disagree with estimable 
physicians in a diagnosis when the differentiation 
must be made between appendicitis and some other 
intraabdominal condition. This occurred in two in- 
stances when in consultation with well known 
pediatrists and again with a general practitioner who 
does good surgery. The first patient was a boy 
about ten years of age. The history revealed that 
he had some abdominal pain with a little tenderness 
in the right iliac fossa, which was especially well 
marked on rectal examination. In the presence of 
appendicitis a rectal examination is good confirma- 
tory evidence, but where it does not exist a rectal 
examination may lead to erroneous conclusions. 
When I examined this boy there was no rigidity or 
tenderness, pain was absent, the patient being in 
absolute repose. Operation was not advised. The 
following day a diffuse urticaria developed. In the 
second instance there was considerable controversy 
as to whether the condition was pulmonary or 
abdominal. It was impossible to detect any signs of 
pneumonia. The abdomen, however, was rigid, and 
the child was plainly suffering from an appendicitis 
of several days' duration. Operation confirmed our 
diagnosis. In this case drainage was necessary. In 
another instance the case proved to be one of gastro- 
enteritis following an incliscretion in diet. 

When fat or robust children are seized with sud- 
den pain in the right iliac fossa followed by the 
cardinal symptoms of vomiting and rigidity, one 
must give the closest consideration to these mani- 
festations in individuals of this type, because the 
appendicitis is usually of the fulminating type, gan- 
grene ensuing in a com]Mratively short time. In 
one case, the patient was a plump child twelve years 
of age. She had complained of pain on the right 
side in the early morning hours, followed by the 
characteristic symptoms referred to above. On ex- 
amination, while there was still some rigidity left, 
subsidence of symptoms had occurred. On account 
of past experience with a case of this type we advised 
operation which was accordingly performed a few 
hours after the consultation. We found a some- 
what swollen appendix, with numerous seat worms 
scattered over its mucous membrane, the surface of 
which was covered with petechial hemorrhages. 
While delay of operation cannot always be ascribed 
to the tardiness of the i)hysician, I am sorry to admit 
that many cases reach the surgeon too late. There 
is no excuse for the many gangrenous appendices 
and the many pus cases that we encounter. When 
the physician is in doubt a consultation can always 
be arranged in a comparatively short time. A long 
convalescence can be sub.stituted by a stay in the 
hospital for from ten days to two weeks. Today 



134 



BEHREND: ABDOMINAL DISEASE IN CHILDREN. 



[New York Medical Journai, 
AND Medical Record. 



the public is better educated and is alive to the fact 
that appendicitis is a surgical condition. Still there 
are many instances where we encounter parental 
objection and concealment of the child's symptoms 
from the physician. Home treatment of appendicitis 
cannot be too much deprecated and discouraged, as 
illustrated by the following case ; 

The child, a boy, ten years of age, presented symp- 
toms of a spreading peritonitis and marked rigidit\' 
in the right iliac fossa. He was toxic and the case 
was considered one of the severest types of appendi- 
citis ever encountered in a child. At operation the 
appendix was found gangrenous, an abscess was situ- 
ated in the pelvis and gallbladder region. The wound 
was practically left open, and several tubes and 
Mikulicz drains were employed. For one week this 
child hovered between life and death, subsisting 
solely on albumen water by the mouth and Murphy 
drip by the bowel. He was vomiting at intervals 
during this entire period and the abdomen was dis- 
tended. He looked very sick. His facies resembled 
somewhat those found in intestinal obstruction, but 
the rapid pulse, the sunken eyes and anxious expres- 
sion quickly changing to that of impending death 
were absent, and the dusky hue so often found in 
mechanical ileus was absent. The pain was con- 
tinuous. All these symptoms being present, the 
condition had to be ditiferentiated from a general 
suppurative appendicitis, but this was excluded as 
the perpetual wakefulness and bright alert eyes, and 
the persistent distention of the abdomen with the 
glasslike and dusky hue were not present ; the child 
had many naps during the day and night. While 
much has been written on the beneficent effect of 
morphine in general peritonitis we have seen no 
curative effect. On the contrary, it prevents excre- 
tion, and interferes with normal interchanges neces- 
sary to determine state of patient. The patient had 
a stormy convalescence but recovered. 

The greatest diagnostic acumen must be exercised 
in children from one to three or five years of age. 
In the past season we have operated on several chil- 
dren around the third year of life for abdominal 
conditions, especially appendicitis. Strange to say 
the first physician called missed the diagnosis in 
each instance, perhaps because the symptoms were 
not sufficiently localized, the case being considered 
a simple gastrointestinal attack. The only sign that 
distinguished these cases from a gastrointestinal at- 
tack was the persistent rigidity in the right iliac 
fossa. If this alone is found it may be considered 
sufficient cause for operation in the absence of all 
other phenomena. The temperature, pulse and leuco- 
cyte count are simply confirmatory, greater credence 
being always given to physical signs. In these young 
[)atients it is especially important to differentiate their 
symptoms from pneumonia. Though this seems at 
times impossible it can be done if we bear in mind 
certain cardinal points which characterize both con- 
ditions. Rigidity of the abdomen, in the absence 
of rapid breathing and playing of the alse of the nose 
and the flushed face, stamps the case appendicitis. 

Probably the most perplexing acute abdominal 
condition is the presence of gallstone colic in chil- 
dren. These cases are not suspected becau.se they 
are rare, but we must be mindful of their existence, 
the most important point being the seat of the pain 



and the presence of rigidity higher up on the ab- 
dominal wall under the costal border. These patients 
had the characteristic colic found in adults, which 
was only relieved by morphine. In both of the 
children at operation the gallbladder was found to 
contain many stones. It was much thickened which 
necessitated its removal. Both patients did well and 
are still in the best of health. 

With one exception we have been considering suc- 
cessful cases. Two cases were referred to the 
surgeon too late for operation. One of the patients 
was treated for ptomaine poisoning for several days 
before being sent to the hospital. It was truly a 
case of poisoning, without the ptomaine however. 

In the second case the child complained of head- 
ache, the abdominal symptoms not appearing promi- 
nently until the next day when she told her playmates 
of pain in the abdomen. When the family physician 
was called too much stress was put on the head 
symptoms and not enough on those of the abdomen. 
When I was called in consultation an advanced gen- 
eral peritonitis was present in both cases. 

The symptoms in both these cases may be con- 
sidered together as they were identical. IBoth chil- 
dren had distended silent abdomens, absolutely no 
peristalsis being heard ; the respirations were rapid, 
40 to 50 a minute. In both cases the abdomen was 
generally tender, the expression was anxious, wake- 
fulness was the rule, the pulse was good, rapid, 
bounding at first then weakening, the complexion 
was florid at first, then gradually becoming dusky, 
until the facies looked green before death. 

It is still a mooted point among surgeons as to 
the best time to operate in a spreading peritonitis, 
but I do not believe there can be any doubt in the 
mind of any surgeon as to the proper course to 
pursue in the last two cases mentioned. The great 
majority of these cases are fatal and it seems to 
make very little difference whether we wait until 
the supposed localization of pus takes place or if 
we operate at once. Most surgeons agree that it is 
best to wait in a case of spreading peritonitis, but 
we have never seen a patient recover who had gen- 
eral peritonitis of colon infection. To illustrate 
this point a little more fully I called in consultation 
another surgeon who advocated the waiting policy in 
cases of general peritonitis, namely, the Ochsner 
treatment. We were absolutely opposed to opera- 
tion in this case. Much to our surprise our consult- 
ant advised operation. The patient died about twelve 
hours after operation. Closely following this case 
another of the same type came under observation. 
For purposes of comparison my friend and surgeon 
was again called in consultation. He advised waiting 
until localization of pus had taken place. This was 
consistent with his views. As stated before this 
patient died, which helps to confirm our conclusions 
that when general peritonitis of certain types is well 
established treatment of any kind is of little benefit. 

In conclusion, the difiiculties of diagnosis of acute 
abdominal conditions in children must be apparent 
to all. While ajipendicitis is the most frequent 
affection one must always hear in mind other types 
of infection especially that due to the [jneumococcu^. 
The decision as to whether the case should be oper- 
ated in early or late will depend on the duration of 
the ailment and the experience of the surgeon. 



August 2, 1922.] 



GLASSBURG: FURUNCLES OF EAR CANAL. 



135 



Furuncles of the Ear Canal 

A Report of Ten Cases of Furnnciilosis of the Posterior Portion of the External Auditory 
Canal Occurring in Children and Simulating Acute Mastoiditis 

By JOHN A. GLASSBURG, M. D, 
New York, 

Assistant Attending Laryngologist and Otologist, New York Children's City Hospital, Randall's Island; Surgeon, Ear, Nose 

and Throat, Stuyvesant Polyclinic. 



One of the common diagnostic pitfalls in the ear 
diseases of children is the differentiation of an ob- 
scure or an atypical case of furuncnlosis of the canal 
from an acute mastoiditis. Furunculosis of the 
external auditor}- canal, described by various authors 
as acute circumscribed external otitis (otitis externa 
circumscripta acuta ) , otitis externa circumscripta, 
or just plain furuncle of the auditory meatus, is 
due to an infection of a hair follicle or a sebaceous 
gland. The inflammation is found mostly in adults, 
but may be found in children. Because of the com- 
parative rarity of the incidence of this disease in 
infants and young children and its consequent easy 
confusion with acute mastoiditis, this paper is pre- 
sented, reporting ten cases occurring in children 
under five years of age. 

Kerrison (Ij divides the etiology into two divi- 
sions, predisposing and exciting causes. Under the 
head of predisposing causes he includes constitutional 
and general factors. Under the head of exciting 
causes he includes local infection, either from a 
purulent discharge from the middle ear, or from an 
abrasion caused by external irritation. This classi- 
fication, though a simple one, is not sufficiently in- 
clusive, and does not cover all the possible etiological 
factors. Therefore, a different classification is here 
offered, consisting of four divisions: 1, External 
or mechanical ; 2, internal or aural ; 3, general or 
constitutional : 4, reflex or trophoneurotic. 

CLASSIFICATION. 

The external or mechanical form of infection is 
the most common, and is caused by scratching, prob- 
ing or traumatic cleaning of the ear during the re- 
moval of cerumen or foreign bodies by instrumenta- 
tion or irrigation. The internal or aural form of 
infection is next in importance, and is caused by a 
prexisting middle ear suppuration or infected chronic 
eczema. The general or constitutional form of in- 
fection is relatively uncommon, and as a rule it acts 
as a predisposing factor and is associated with one 
of the other forms of infection. Any debilitating 
disease, and particularly diabetes, gastrointestinal 
disorders, rheumatism or gout may be responsible. 
Hunter Tod (2) mentions the extensive use of 
bromides as an occasional cause. The reflex form of 
infection was described by Urbantschitsch (3) who, 
as quoted by Dench, "reported instances where a 
derangement of the trophic nerves of one side, due 
to a local lesion, was followed quickly by the de- 
velopment of a furuncle in that portion of the canal 
of the opposite side, supplied by the corresponding 
nerve." Dench (4 ) supplements this by a report 
of two cases of his fiwn, one in which a boy had a 
severe traumatic external otitis of one ear, and 
though he was in an excellent general physical con- 



dition, an abscess developed in exactly the same 
location in the canal of the other ear. In the other 
case the abscess in one meatus was followed within 
twenty-four hours by an exactly similar condition 
in the same location of the meatus of the opposite 
side. Because of the identity of the locality of these 
abscesses and the absence of any other exciting cause 
he places these furuncles in the reflex trophoneurotic 
group. 

SYMPTOMATOLOGY. 

The symptoms of furunculosis of the meatus are 
a feeling of fullness in the ear, itching in the ear, 
pain, deafness, tinnitus, difficulty in mastication, 
sleeplessness, tenderness of the auricle or tragus, 
swelling of the skin in and about the ear, glandular 
enlargement, tenderness over the mastoid or parotid 
gland, protrusion of the ear away from the head, 
edema over the mastoid, redness or purplish dis- 
coloration of the skin in front of the tragus and 
fever. In infants and young children the subjective 
symptoms are, of course, not to be obtained and the 
diagnosis is consequently difficult. The intensity and 
the frequency of the symptoms are dependent upon 
the locality and the size of the furuncle. This is 
best understood by reference to the anatomy and 
pathology of the structures involved. 

ANATOMY AND PATHOLOGY. 

At birth the exterrtel auditory canal shows no 
osseous portion, but is simply a fibrocartilaginous 
slit. After birth the diiiferentiation into an external 
cartilaginous and an internal osseous portion begins 
in two ways. First, by the deposition of newly de- 
veloped bone around the tympanum, the anterior, the 
inferior and most of the posterior wall are formed 
and secondly, by the bending inwards of the outer 
plate of the squama the superior wall is formed. The 
completion of the osseous canal is usually accom- 
jjlished during the first year. The fibrocartilaginous 
portion contains numerous hair follicles, sebaceous 
glands, and ceruminous glands. These glandular 
structures are not found in the osseous portion and 
therefore furunculosis of the canal is limited to the 
external portion. A swelling situated on the pos- 
terior wall in the internal bony portion of the canal, 
especially if superiorly, should be considered as an 
extension from the mastoid cells, as in this locality 
the antrum is separated from the canal by only a 
very thin plate of bone. In adults the differentiation 
of a furuncle in the cartilaginous canal from a tume- 
faction in the osseous canal is usually not difficult, 
but in infants with a narrow lumen, a short and im- 
perfectly developed bony canal and a furuncle low 
down in the fibrocartilaginous portion this distinc- 
tion is a most difficult task, and herein arises the 
confusion between acute mastoiditis and furuncu- 
losis. 



136 



GLASSBURG: FURUNCLES OP EAR CANAL. 



[New York Medical Journal 
AND Medical Record. 



The anterior wall of the cartilaginous canal is 
crossed by the fissures of Santorini, which lend 
mobility to the ear and drain the parotid gland. 
Through these fissures, when the furuncle is located 
on the anterior wall, the infection from the ear 
travels to the parotid and we have the consequent 
parotid gland swelling and tenderness. 

The feeling of fullness in the ear, the itching, 
the deafness and the tinnitus depend on the degree of 
obstruction. The pain upon mastication is due to 
the intimate relation between the tragus and the 
intermaxillary articulation. This sign when found 
is pathognomonic. The sleeplessness is due to the 
pain, the intensity of which depends on the depth 
of the inflammation. The displacement of the ear 
anteriorly is due to the postauricular swelling. 

DIFFERENTIAL DIAGNOSIS. 

The differential diagnosis of furunculosis of the 
external auditory canal is between exostosis, aural 
polypi, granulations of the external meatus, peri- 
chondritis of the auricle, carious teeth, parotid 
abscess and acute mastoiditis. The difficult differ- 
entiation is from mastoiditis, and will be treated in 
detail a little later. The other conditions can be 
dispensed with in a few words. An exostosis is a 
bony prominence, therefore hard to the touch and 
usually not sensitive, whereas a furuncle is soft to 
the touch and very sensitive. A polypus is freely 
movable and not tender, whereas a furuncle is not 
movable and very tender. Granulations are not 
painful and give a history of a long duration, whereas 
a furuncle is an acute process. Perichondritis is a 
diffuse process which may involve the entire auricle, 
whereas a furuncle is a circumscript process found 
in the canal proper and does not spread to the auri- 
cle. Carious teeth are readily differentiated by the 
absence of any aural tumefaction and the presence 
of tender, infected teeth. Parotid abscess shows a 
tender swelling over the parotid gland and pressure 
over this swelling may cause the discharge of pus 
through the fissures of Santorini into the external 
auditory canal. 

The difi^erential diagnosis of furunculosis of the 
externa! auditory canal from acute mastoiditis is de- 
tailed in the following table : 



not 



sensitive 



to 



Furunculosis Mastoiditis 

History 

1. Former attacks unusual. 

2. No mechanical irritation. 



1. Former attacks common. 

2. History of mechanical irri- 
tation. 

3. Onset rapid. 

4. Height of disease at the third 
day. 



Onset gradual. 
Disease besins usually three 
weeks after an acute puru- 
lent otitis media. 
Usually associated with an 
acute purulent otitis media. 



May or may not be associ- 
ated with an acute purulent 
otitis media. Subjective Symptoms 

1. Pain is less than in furun 



1. Pain is greater than in mas- 
toiditis, 

2. Tender spots in canal. 

3. More crying on the insertion 
of the speculum due to pas- 
sage over furuncle. 

4. Pain on irrigation. 

5. Pain over parotid (in fur- 
uncles of anterior wall). 

6. Pain on mastication (pathog- 
nomonic sign). 

7. Hearing normal or dimin- 
ished, according to size of 
the furuncle. Objective Symptoms 



culosis. 

2. No tender spots in canal. 

3. No crying on the insertion 
of speculum, except from 
fear. 

4. No pain on irrigation. 

5. No pain over the parotid. 

6. No pain on mastication. 

7. Marked deafness. 



1. Canal narrow at the orifice. 

2. Tumefaction in the external 
fibrocartilaginous canal. 

3. One or more tumefactions 
(furuncles have a tendency 
to appear in crops) 



1. Canal narrow at the fundus. 

2. Tuniefaction in the internal 
osseous canal. 

3. One tumefaction. 



4. Tumefaction on the posterior 
superior wall. 



5. Auricle 
touch. 

6. Auricle displaced forward 
and downward. 

7. Skin freely movable. 

8. Edema and bone tenderness. 



4. Tumefaction on the posterior 
inferior wall or on the an- 
terior wall. 

5. .\uricle sensitive to touch. 

6. .\uricle displaced forward. 

7. Skin tense over mastoid. 

8. Edema over the mastoid, but 
no bone tenderness. (Ten- 
derness is usually obtained 
but this is not bone tender- 
ness. It is due to the skin 
being moved and traction 
made on the tender auricle. 
This traction can be avoided 
by exerting firm pressure in- 
wards, avoiding stretching 
the skin away from the ear.) 

9. Tympanic membrane not per- 9. Tympanic membrane per- 
forated, forated and discharging. 

10. Tympanic membrane may be 10. Tympanic membrane shows 
normal or slightly congested. the signs of an acute puru- 

lent otitis media. 

In spite of all the above detailed signs, there are 
cases when the diagnosis cannot be definitely made 
and the patient has to be kept under observation for 
a few days. In children, the subjective symptoms 
are unreliable and should be disregarded and the 
diagnosis made on the physical findings. The cases 
reported are typical and they accentuate the great 
difliculties encountered in making this differential 
diagnosis, and at the same time show how the diagno- 
sis was made. 

Case I. — Agnes S., nine months old, was restless 
and fretful for three days and did not sleep well 
at night. She kept continually pulling at her right 
ear and tossing from side to side. She refused to 
nurse. The temperature was 99.6° by rectum. She 
was referred for paracentesis with the diagnosis of 
acute otitis media with mastoid involvement. 

Examination of the ear was very difficult, be- 
cause of the continued crying and struggling, and it 
was evident to all present that the crying was louder 
when the auricle was touched, and especially when 
the speculum was introduced. Tenderness over the 
mastoid could not be definitely ascertained, because 
the child kept crying no matter what part of the head 
was touched. On drawing the ear downward and 
backward a fair view of the meatus was obtained, 
showing a red tumefaction in the canal. The tym- 
panic membrane could not be seen and this tumefac- 
tion had been mistaken for a congested drum, but it 
was entirely too far forward to be the tympanic 
niembrane. Furthermore, a probe could be passed 
between the swelling and the anterior wall, thus 
definitely localizing the inflammation as starting from 
the posterior wall. The swelling was incised and a 
small amount of pus was obtained. The child's 
symptoms did not seem to abate for she was restless 
the whole night, but on reexamination the ne.xt day 
the speculum could be pushed past the furuncle and 
a normal intact drum was seen. The symptoms 
gradually subsided, and at the end of a week the 
meatus presented a normal appearance. 

Case II. — Mary P., three years old, had a running 
ear for about a year and a half, which gave her no 
trouble, except for the discharge. For about a week 
the child had been picking at her ear and for the last 
two days complained of ]iain. This pain had be- 
come so severe that the car could not be irrigated 
without throwing the child into a fit of agony. The 
mother stated that the discharge had been growing 
less and less during the whole week. 

Examination showed a bulging ear, standing away 
from the head, a swelling and tenderness over the 



August 2, 1922.] 



GLASSBURG: FURUNCLES OF EAR CAXAL. 



137 



mastoid, and a temperature of 100°. Considering 
the old middle ear suppuration, the sudden diminu- 
tion of the discharge, the mastoid swelling and ten- 
derness, the pain, the sleeplessness, the rise in tem- 
perature and the displacement of the ear, the first 
consideration was acute mastoiditis. On careful 
examination it was observed that the displacement 
of the auricle was forward, and not forward and 
downward, and that if pressure on the mastoid was 
firmly but carefully made, using the thumb and 
pressing inward, avoiding traction on the auricle 
there was no pain. The orifice was narrowed and 
showed a dittuse swelling of the posterior wall, which 
was large enough to dam back any discharge from 
above. Pushing the speculum past this furuncle 
caused a great deal of pain, but the drum could be 
seen with a profuse discharge coming from it. The 
furuncle was incised and the child made an unevent- 
ful recovery. 

Case III. — Sam K., three and a half years old, 
was brought to the clinic with a diagnosis of acute 
mastoiditis. The history showed that he had had an 
attack of pain in the ear four days ago, which still 
persisted, only being intensified, in spite of the 
fact that the "ear had been opened," using the 
mother's words, on the first night of his attack. No 
discharge had been obtained and the mastoid became 
very tender, the child cried and was sleepless. The 
doctor who had treated the child advised the mother 
to take him to the hospital as he had mastoiditis. 

Examination showed no displacement of the ear, 
but revealed edema over the mastoid region. Tender- 
ness was acute and because of the child's struggling 
it could not be determined whether this was deep 
or superficial. There was no discharge, but the drum 
was congested, although the landmarks could be dis- 
tinguished. There was a swelling of the posterior 
wall down deep in the canal which gave an appear- 
ance of the sagging in mastoiditis. However, it 
seemed that the swelling was not far enough down 
to be in the osseous portion. The canal was unusu- 
ally short and narrow and the locality could not be 
positively diagnosed. Upon touching the auricle 
the child cried, but he was a very bad patient and 
too much trust could not be put in this sign. A 
tentative diagnosis of acute mastoiditis was about 
to be made when the mother volunteered the infor- 
mation that the child had told her it hurt him to 
chew. Pain upon mastication I consider a pathogno- 
monic sign of furunculosis, and having obtained this 
information I incised the swelling and pus was 
evacuated. The relief that night was marked and 
the child slept well. The next day he was playful 
and more cooperative. The drum still showed a 
little congestion. Gradually the supramastoid edema 
and tenderness disappeared and the recovery was 
complete. At no time was there any discharge from 
the middle ear. 

Case l\. — Harry G., twenty-three months old, 
was reported by the ward nurse as sick. For two 
nights he did not sleep well, and the last night he 
cried so much that the other children were disturbed. 
Physical examination was negative. The report of 
the routine ear examination was tenderness and 
swelling of the mastoid, with the diagnosis of acute 
otitis media with probable involvement of the 
mastoid. 



My examination corroborated the swelling and 
tenderness over the mastoid, but upon waiting until 
the child was quiet and then making careful pressure 
inward, avoiding traction on the sensitive auricle, the 
child would not cry. The ear showed a narrow lumen 
at the orifice, a tumefaction on the posterior wall, 
somewhat inferiorly, a slightly congested tympanic 
membrane and a forward displacement of the auricle. 
The diagnosis was changed to furuncle of the pos- 
terior inferior wall. The abscess was incised, and 
the child slept well for three nights. At the end of 
this time he was again reported ill. with a similar 
history of crying and sleeplessness. In addition the 
nurse stated that she had observed the child pulling 
at the ear. Examination at this time showed that the 
swelling and tenderness over the mastoid had sub- 
sided, the auricle had returned to its normal posi- 
tion, the tympanic membrane was normal, but there 
was a newly formed furuncle on the anterior wall 
opposite the former one. This was incised, and the 
child was referred to the pediatrist for the improve- 
ment of his general nutrition. 

Case V. — Milton C, three years old, gave a his- 
tory of frequent attacks of acute tonsillitis, mouth 
breathing, nasal obstruction and occasional pains in 
the cars for a period of about two years. The tonsils 
and adenoids had been removed a year before fol- 
lowing an attack of acute purulent otitis media. He 
had been in comparatively good health from that 
time until four days before, when he began putting 
his finger in his ear, but refused to admit the pres- 
ence of any aural pain. During the night he awoke 
several times, put his hand to his ear, but when in- 
terrogated refused to admit any pain. The mother 
stated that she believed that denial of pain was due 
to the fear of being taken to the doctor. In the 
morning the child was peevish, cranky and restless, 
but still denied aural pain. The mother called in 
her family physician, who found a congested drum 
and performed a paracentesis. The child felt worse 
that night and showed no improvement the next day. 

Examination of the orifice as well as irrigation 
showed no discharge. The mother, who was an 
intelligent woman and had had a great deal of ex- 
perience with the care of the ear during the child's 
previous illness, as well as in the ear troubles of 
her otlier children, tested for tenderness over the 
mastoid and discovered acute pain. She reported 
this to her physician who referred the case. 

Examination showed tenderness over the mas- 
toid region, but because of the child's conflicting 
and untrutliful replies and maneuvres it could not 
definitely be distinguished whether it was skin or 
bone sensitiveness. The auricle was very tender to 
the touch. The canal showed a slight tumefaction, 
red in color, on the posterior wall. The tympanic 
membrane was slightly congested, the landmarks 
were easily distinguished, and the incision made 
was of good size, but there was no discharge. The 
child was placed on hot alkaline irrigations and ob- 
served daily. In two days the tumefaction was defi- 
nitely visible and distinguishable as a furuncle of 
the fibrocartilaginous wall. It was incised and the 
child made an uneventful recovery. 

Case VI.— Bertha L., four years old, a mentally 
defective child in my service at Randall's Island, 
was presented with the diagnosis of acute otitis me- 



138 



GLASSBURG: FURUNCLES OF EAR CANAL. 



[New York Medical Journal 
AND Medical Record. 



dia and mastoiditis. The child was a helpless, low- 
grade idiot, who could not talk, walk or even stand, 
and the subjective signs were therefore unreHable. 

The ear showed a marked edema over the mastoid 
region. Pressure did not elicit any marked reac- 
tion. The child simply moved her head away, but 
this did not eliminate the presence of tenderness for 
in the low grade defective there is a diminution in 
the perception of the tactile and pain senses. The 
auricle was displaced forward and downward, but 
comparison with the other side showed a similar 
deformity, both ears being large and batlike, and 
this displacement was therefore considered one of 
the stigmata of degeneration. The lumen of the 
canal was very narrow and entirely obstructed by 
a diffuse swelling in the fibrocartilaginous portion. 
It was impossible to see the drum. The obstructing 
swelling was incised freely and pus was evacuated. 
A cotton tipped probe could then be passed between 
the swelling and the anterior wall, demonstrating 
that the tumefaction was from the posterior wall. 
The following day a small Boucheron speculum 
could be pushed past the furuncle and an intact 
drum was seen. The postauricular edema gradu- 
ally subsided and the child made an uneventful 
recovery. 

Case VII. — Ellen L., three years old, had a sup- 
purating ear for nine weeks. A week before I saw 
her she began complaining of pain and itching in the 
ear. The pain was aggravated by the irrigations. 
The auricle had been gradually pushed forward and 
a tender swelling had developed behind it. The 
child could not sleep, would not eat, and was very 
irritable. The temperature was 100.8° by rectum. 
Because of the pain during the irrigations, the 
mother discontinued them. Hearing on the affected 
side was impaired to such a marked degree that if 
the mother happened to call the chlid on that side 
there was no response. The history of the existence 
of a running ear for nine weeks with the sudden 
development of temperature, pain, and a tender 
swelling over the mastoid region warranted the 
diagnosis of a suspected acute mastoiditis. 

Examination, however, showed that if the pres- 
sure over the mastoid was directed inward, avoid- 
ing traction on the concha, there was no tenderness, 
that the skin was tightly adherent, that the auricle 
itself was very sensitive, that there was an eczema 
at the meatus, and that there was a furuncle of the 
fibrocartilaginous canal with an impacted thick pur- 
ulent secretion about it and behind it. The furimcle 
was incised and by suction the impacted pus was 
evacuated. The ear was placed on daily suction 
treatments, and a bland ointment was prescribed 
for the eczema. At the end of two weeks the en- 
tire discharge cleared up. 

Case Vlll. — Annie S., four and a half years old, 
was sick for eight days, suffering from a small ten- 
der swelling in front of the left ear, and a purulent 
discharge from the ear. At the beginning of the dis- 
ease there had been pain on mastication, which sub- 
sided soon after the onset of the discharge. Two 
days before I saw her, she manifested an attack of 
severe pain in the ear, and the' discharge gradually 
diminished until it stopped completely. The tem- 
perature rose to 101° by rectum. The ear was dis- 
placed forward and there was a tender swelling 



over the mastoid region. The day before I saw her 
a paracentesis was done with no relief of the symp- 
toms. 

Upon examination I found a small furuncle on 
the anterior wall, which probabh' had caused the 
first symptoms, i. e., pain and swelling of the parot- 
id gland. In addition, there was an angry red fur- 
uncle obstructing the lumen at the lower end of the 
posterior wall of the fibrocartilaginous canal. The 
drum was lacerated and covered by a purulent dis- 
charge, but whether this came from the middle ear 
or was dammed back from the old furimcle by the 
new furuncle could not be definitely determined. 
The ear was cleansed carefully, suction being used, 
and the new furuncle was incised. At the end of 
a week the postauricular tenderness and swelling 
subsided and the discharge cleared up, demonstrat- 
ing that there had never been any involvement of 
the middle ear and that the purulent secretion that 
covered the tympanic membrane came from the 
furuncle. 

Case IX. — Fannie L., four years old, was rest- 
less, peevish and feverish for nine days. She kept 
continually pulling at her left ear and complained 
of severe aural pain. The temperature was 100° 
by rectum. The history showed previous attacks 
of acute otitis media. The tonsils and adenoids 
were removed a year ago. 

Examination of the ear showed a forward dis- 
placement of the auricle, supramastoid edema and 
tenderness, and a moderate degree of tenderness of 
the auricle. The posterior half of the tympanic 
membrane was congested, and there was a red 
swelling on the posterior portion of the canal. The 
case had been diagnosed as acute mastoiditis. Care- 
ful inspection, however, revealed that the swelling 
of the canal was rather inferiorly situated and that 
the congestion of the drum was a diffuse extension 
process from the swelling. The tenderness over the 
mastoid region was markedly lessened when the 
pressure was exerted inward avoiding traction on 
the auricle. A diagnosis of furunculosis was made 
and the suspected furuncle was incised. No pus 
was evacuated, but by the following day the sub- 
jective symptoms had abated, the supramastoid 
edema was lessened, the tenderness was diminshed, 
the temperature was down to normal, the tympanic 
membrane congestion was about gone, and there was 
a free discharge from the furuncle. The close 
simulation of the furuncle to acute mastoiditis in 
this case was due to the deepseated locality with the 
consequent long duration of coming to the surface. 

Case X. — Thomas C, fourteen months old, was 
referred with a tentative diagnosis of acute otitis 
media and mastoiditis. The mother stated that for 
about four days the child's general behavior had 
been showing a distinct change. He refused his 
food, was cranky and irritable, and for the last two 
davs cried without apparent provocation, especially 
during the night. The day before, the mother 
noticed a marked swelling behind the left ear, which 
was tender to the touch. She became alarmed and 
took the boy to her family physician, who warned 
her of a possible impending mastoiditis and advised 
surgical intervention. 

Examination showed a tender swelling over the 
mastoid region (which tenderness, however, was 



August 2, 1922.] 



SMITH: MASTOIDITIS. 



139 



not obtained upon careful inward pressure), a for- 
ward displacement of the ear, a tender auricle, and 
a temperature of 100.8° by rectum. The tympanic 
membrane could not be seen becatise of the ex- 
tremely narrow lumen, but a swelling of the pos- 
terior portion of the canal was distinguishable. 
Comparison with the other side showed a lumen of 
normal width in the unaffected ear. The absence 
of real bone tenderness over the mastoid, the ab- 
sence of a discharge, the absence of a downward as 
well as a forward displacement of the auricle, 
pointed against mastoiditis while the presence of the 
orificial narrowing of the lumen as compared with 
the healthy side, the shortness of the duration of 
the disease and the presence of the tumefaction on 
the canal wall, (in spite of the fact that I could not 
inspect the tympanic membrane) made me incline 
toward regarding the tumefaction as a furuncle. 
Upon this assumption I incised the swelling and 
evacuated pus. The following day the width of the 
lumen was increased, demonstrating that the nar- 
rowness was due to an inflammatory diffusion from 
the furuncle. The tympanic membrane was visible 
and normal in appearance. Gradually all the symp- 



toms .abated and at the end of ten days the child 
was discharged as cured. 

In concluding, I wish to draw attention to the 
fact that the symptoms that simulated mastoiditis 
were the external ones, the displacement of the ear, 
and the supraniastoid tenderness and swelling. In 
addition, in those cases where there had been previ- 
ously a running ear, the cessation of the discharge 
and the rise in temperature enhanced the suspicion. 
However, in almost every case the otoscopic picture 
revealed the presence of the real condition — furun- 
culosis. Painstaking examination usually eliminates 
the other conditions, but as shown there are cases 
where even the most careful examination leaves one 
bafffed and then the only test is the test of time, the 
ear being carefully observed from day to day until 
the furuncle matures. 

REFERENCES. 

1. Kerrison, p. D. : Diseases of the Ear, 1913, p. 107. 

2. Tod, Hunter: Diseases of the Ear, 1903, p. 17. 

3. Urbantschitsch, V. : Arch, fiir Ohren, vol. xxxv. 

4. Dench, E. B. : Diseases of the Ear. 1904, p. 219. 

231 East Eleventh Strei.t. 



Acute Mastoiditis* 

By CLARENCE H. SMITH, M. D., F. A. C. S., 
New York, 

Assistant Professor Diseases of Ear, New York Post-Graduate Medical School and Hospital. 



One of the commonest diseases which the physi- 
cian is called upon to treat during the early spring 
months is suppurative otitis media. Most cases of 
this disease are for various reasons treated by the 
general practitioner. In some cases the otologist is 
called on to open the drum. Sometimes the doctor 
in charge opens it himself, and in others the drum 
has already ruptured before the physician has seen 
the patient, but once the discharge has commenced 
very often the observation of the progress of the 
disease toward resolution or otherwise is in the 
hands of the general practitioner. 

The question which in each case presents itself 
is, Will this particular patient's ear inflammation 
resolve or will it go on to mastoiditis? In most 
instances we are at a loss to answer and it would 
seem wisest, at the risk of being considered alarm- 
ists at times, to use, from the very outset, every 
possible precaution to obviate the latter development. 
When to open the drum, whether to open it early or 
to wait in the hope that the inflanunatory secretion 
will he absorbed or drain through the eustachian tube, 
is a question that has been widely discussed. The 
pendulum has swung both ways. It would seem that 
the best indication is to observe closely the amount 
of bulging present, and not open the drum for 
redness without bulging. 

The ofieration of myringotomy is with ordinary 
care devoid of danger. It should not be a stab 
wound, but an incision through about a (|uarter of 
the drum's periphery. The posterior inferif)r ()uad- 

•Read before the Bronx Medical Association, March 1, 1922. 



rant is generally the site for this incision. The cut 
is oftenest made from below upward, but where the 
bulging is most prominent in the upper half of the 
drum it might be better to begin in this region and 
incise from above downward. A danger which is 
present when this little operation is done roughly, 
is the disldcation of the stapes from the oval window 
with a subsequent invasion of the labyrinth followed 
Ijy meningitis. This has happened. 

It is probable that in every case of suppurative 
otitis media there is some degree, however slight, 
of inflammation in the mastoid with pus in variable 
quantity. The direct communication which exists 
between the middle ear and the mastoid cells would 
seem to preclude the possibility of the limitation of 
the involvement to the tympanum. One, too, has but 
to consider the quantity of discharge which pours 
out in a moderately severe otitis media, remember- 
ing as well the smallness of the middle ear cavity, 
to realize that this secretion could not all be con- 
tained in that minute space. Up to a certain point 
this inflammation by continuity is only of scientific 
interest, and that is when the mastoid cells become 
so involved in the jjrocess that they are more or less 
tilled with the products of inflammation, and necrosis 
attacks the delicate .septa which are the boundaries 
of the cells. When this stage is reached we have 
what is known as an operative mastoiditis. 

One of the most . difficult problems which the 
otologist has to solve is this question. When is a 
given case, which has been under observation as one 
of mastoid involvement, no longer to be treated 



140 



SMITH: MASTOIDITIS. 



[New York Medical Journal 
AND Medical Record. 



palliatively and surgical intervention indicated ? Na- 
ture has a way of surprising us occasionally and 
cases which are quite apparently hopelessly operative, 
will resolve without surgical intervention. It is not 
safe, however, to trust too much to fortune, and 
remember that it is the patient who is carrying the 
risk. What can happen, we are often asked, if such 
a patient is not operated upon ? Complete recovery, 
po.ssibly but not probably, recovery with some im- 
pairment of hearing, partial recovery with a chronic 
purulent otitis media, or complications such as inva- 
sion of the blood stream or meninges. 

There are certain salient points in the diagnosis 
of an operative mastoiditis on which all otologists 
are fairly well agreed. Few cases have all the classi- 
cal or typical signs and symptoms and often the 
diagnosis is based upon one or two outstanding 
points. 

MASTOID TENDERNESS. 

If one can demonstrate this sign clearly, and if it 
is persistent for let us say five or seven days after 
the drum has been opened, or is increasing in its 
area, the value of this sign is very great. Its absence, 
however, does not mean much as a fair proportion 
of badly broken down mastoids have no tenderness 
whatever, due sometimes to a thickened cortex. Then 
again it is not easy to elicit this sign in a struggling 
crying child, and a good many of our cases seem to 
be in children. Tenderness can be evoked on pres- 
sure over the antrum in many cases of acute otitis 
before the drimi has been opened, after which in 
favorable cases it speedily disappears. 

AURAL DISCHARGE. 

When a middle ear abscess first commences to dis- 
charge generally the quantity is quite profuse and 
this is expected. It is then straw colored, or muco- 
purulent. In the second week the quantity, if the 
case is going to resolve, should diminish. If, how- 
ever, the discharge is still profuse through the second 
or third week, it is strongly suggestive of an in- 
volved mastoid. The only way to judge this ac- 
curately is to put the patient in a good light, care- 
fully cleanse the canal of all secretion and then wait 
for a few minutes to see how soon the discharge 
reappears through the dnmi opening. The manner 
in which this discharge wells out at times, is, when 
one considers the smallness of the middle ear cavity, 
positive evidence of a suppurative mastoiditis. 

FEVER. 

In purulent otitis media before the drum is 
opened a temperature, up to 105° in children, is 
fairly common, and one is not surprised when some 
amount of fever persists for say five or seven days. 
However, if the temperature continues elevated it 
is a symptom which should be considered. One 
often sees a case which has no very outstanding acute 
symptoms but which has run along for two or three 
weeks with a fairly constant evening temperature 
around 101°. That is almost invariably an oper- 
ative mastoid. Fever is almost always absent 
in an adult, but the absence of .fever does not nega- 
tive the diagnosis of mastoiditis, as one often sees on 
operation a badly necrotic mastoid in a patient who 
has been afebrile throughout. 



PAIN AND INSOMNIA. 

When a middle ear is draining freely there should 
be no pain, it is the retention of discharge which 
gives this symptom, and if the drum opening is 
patent, of course this pent up secretion is in the 
mastoid cells. Like bone pain of other varieties 
this is worse at night and disturbed sleep is a fairly 
constant symptom of mastoid disease. Actual pain 
may not be present, there may be instead a feeling of 
fulness, of discomfort, of distinct difTerence between 
the diseased and the normal side. Xeuralgic pains 
are sometimes noticed. On the other hand, there 
are many cases in which these symptoms are not 
noticeable. 

CHANGES IN THE DRUM AND DROOPING OF THE 
POSTEROSUPERIOR CANAL WALL. 

It is by examination of the drum and the canal 
wall that one can tell best the amount of trouble 
present. There may be an absence of pain, tender- 
ness, and fever, but in all cases of operative mas- 
toiditis these drum changes and generally a profuse 
discharge are present. The drum membrane is 
thickened, reddened and markedly bulging in the 
posterosuperior quadrant. There is a thickening of 
the canal wall in that spot caused by periostitis, and 
a consequent drooping and blending together of the 
canal wall and the upper part of the drum membrane, 
with a loss of the usual demarcation between the 
two. These changes are best brought out by com- 
parison of the two sides, the narrowing of the inner 
end of the auditory canal on the diseased side show- 
ing plainly in contrast with the normal ear. 

SUMMARY. 

The clinical picture to be looked for is made up 
of mastoid tenderness, profuse aural discharge, 
fever, pain and insomnia, and a drooping of the 
posterosuperior canal wall. The difficulty one meets 
is the absence of one, two or three of these symp- 
toms. There are, it seems to me, a fairly large 
proportion of cases of operative mastoiditis with but 
two of these essentials, the changed drum and the 
profuse aural discharge, and it is in these cases that 
the patients are sometimes reluctant to be operated 
upon, a fact easily understood, free as they are from 
the driving urge of pain and fever. It is here that 
the X ray is sometimes of value when it can demon- 
strate the breaking down of the intercellular septa. 
Marked and progressive diminution of hearing of 
the conducting mechanism type may be considered 
as evidence of a nonresolving mastoiditis. A coated 
tongue and the sallow complexion which goes with 
septic absorption are also signs which should urge 
us to operative intervention. 

Occasionally in the adult and comparatively often 
in children we have seen pus from the suppurating 
mastoid break through the cortex and form beneath 
the periosteum what is called a subperiosteal abscess. 
This is generally above the auricle which is pushed 
downward and forward. Or there may be post- 
auricular edema from the inflanmiation of the under- 
lying bone. Then there is a variety of swelling under 
the fascia of the temporal muscle where the pus 
follows the oval outline of the muscle. Occasionally 
we have a swelling in front of and above the auricle 
where the pus breaks through the zygoma. Some- 



August 2, 1922.] 



SMITH: MASTOIDITIS. 



141 



times the inner surface of the tip of the mastoid 
process is eroded through and an abscess is formed 
beneath the sternocleidomastoid mu^cle, called a 
Bezold abscess. Of course these various swellings 
are positive indications for the mastoid operation. 

Of late years the postoperative period has been 
shortened and the dressings have been made much 
less painful by the use of a smaller amount of drain- 
age in the mastoid wound. Three weeks is a fair 
average of the length of the postoperative period 
with this method of dressing. There is much less 
pain in changing the dressing when the drain is less 
than a foot in length than in the method where the 
packing was inserted by the yard. There is another 
distinct benefit too, in the absence of deformity, as 
with this new way of dressing the wound there is 
left no depression over the mastoid area, the only 
remainder of the operation being the scar of the 
incision. 

The complications of mastoiditis are in the order 
of their occurrence, erysipelas, infection of the lat- 
eral sinus, meningitis and cerebral abscess. 

After a mastoid operation, like any other opera- 
tion on the head, there seems to be a special tendency 
to the development of erysipelas. This is rarely 



up to say 105°, followed by a remission and sweat- 
ing. 

The clot may be enormous in size. In one of my 
cases it extended to the torcular and I was unable 
to get free bleeding posteriorly. At times no clot is 
demonstrable and hemorrhage is met with immedi- 
ately on slitting the sinus. In these cases no doubt 
at times a mural clot is present which is washed 
away by the gush of blood. However, in other in- 
stances where no clot is seen, the condition is doubt- 
less phlebitis or septicemia. A marked leucocytosis 
and a high polymorphonuclear percentage are invari- 
aWy present, and the invading organism is nearly 
always to be found on blood culture. The treatment 
of this condition is either ligation or resection of the 
internal jugular vein with removal of as much of 
the septic clot from the sinus as possible. 

A typical example of infection of the lateral sinus 
was seen in m\' practice a few weeks ago. and as it 
illustrates the disease so thoroughly, a brief history 
of the case may not be remiss. 

C-\.sE. — W. V. K., two years of age, a patient 
of Dr. Talmage, was operated upon on January 25> 
1922, at the Bronx Eye and Ear Infirmary, a mas- 
toidectomy being performed on the right side, after 



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Chart. — Temperature chart in a case of infection of the lateral sinus. 



fatal and seldom serious except in the very young 
or the aged. The temperature range is of the septic 
variety, has wide variations, and sometimes is ob- 
served for a few days before the appearance of the 
eruption. Of course one is then at a loss to account 
for the fever until the characteristic erythema is 
seen. I have had some help in the treatment of 
this complication from intramuscular injections of 
phenoiodine. I remember particularly two cases in 
which this was used with great benefit. In one case 
the patient was five months old in whom erysipelas 
developed after a double mastoid ojieration, and in 
the other the patient was an old lady in the sixties 
who had a similar complication after mastoidectomy. 

Infection of the lateral sinus is a fairly common 
complication of mastoiditis. I think that in about 
two per cent, of my operated mastoid cases this com- 
plication appeared. 

The tyjjical picture is shown pathologically by a 
thrombus in the sigmoid sinus which contains the 
same organism as that in the aural discharge, this 
clot throwing off toxins into the general circulation 
periodically every twenty-four or forty-eight hours, 
these toxins being absorbed or becoming the starting 
point of a metastasis. The liberation of these 
poisonous jjroducts is marked by the symptoms of 
sepsis with a sharp chill, a sudden rise of temperature 



an acute nfiddle ear infection which had lasted seven 
days, during which time, in spite of free drainage 
the temperature range each day had reached about 
105°. The patient did well until the fifth day, when 
the temperature rose from 100° to 104°. From 
that time he had seven of these elevations of tem- 
perature on successive days, as seen by the accom- 
panying chart. During this period he was being 
watched carefully, of course, and nothing was found 
amiss except some adenitis on the other side of his 
neck. After his fourth rise of temperature a blood 
culture was taken, which was rejjorted positive for 
the pneuniococcus after forty-eight hours' incubation. 
A blood count showed a white count of 21,000 and 
polymorphonuclears eighty-nine per cent. Dr. W. C 
-McFarland .saw him then in consultation and we 
agreed that in view of the septic temperature, 
positive blood culture, and leucocytosis, a diagno- 
sis of infection of the lateral sinus was justifiable. 
'J'he next morning I resected the internal jugular 
vein from a point above the clavicle.^to just above the 
facial vein, and then opened the sigmoid sinus. No 
clot was seen. He had one postoperative rise of 
temperature to 104°, after which the fever kept per- 
manently below 101° and gradually receded to nor- 
mal. The neck wound drained |irofuscly for about 
ten days. At the time this report was presented it 



142 



BLAUNER AND ORGEL: TONSILLECTOMY. 



[New Vork Medical Journal 
AND Medical Record. 



had quite healed, and the mastoid wound was still 
discharging. Physically he was in good condition. 

The most dreaded complication which we meet 
is meningitis. Kerrison classifies the different va- 
rieties as circumscribed pachymeningitis, diffuse 
purulent leptomeningitis, circumscribed leptomenin- 
gitis, and serous meningitis. Lumbar puncture fur- 
nishes us with the most reliable data as to the nature 
and gravity of the lesion. I have known of a few 
cases in which the meninges were involved appar- 
ently coincidently with the onset of the ear inflamma- 
tion and in spite of early mastoid operation went 
rapidly on to a fatal outcome. Brain abscess is so 
rare that we need but mention it here. 

In conclusion, I wish to sav that I know one is 



prone to exaggerate the importance of his own sub- 
ject, and I have tried to steer clear of this pitfall 
in presenting my problem. I think all of us should 
consider each case of purulent otitis as a potential 
mastoiditis and treat it seriously from the outset. In 
that way possibly more patients can be saved from 
an operation which though comparatively safe is 
attended by much discomfort. We should study the 
various signs and S3'mptoms mentioned above in 
connection with each case and ascertain under what 
category it falls. This is not a plea for early mastoid 
operation but rather an appeal to our discrimination 
and judgment in deciding when such intervention is 
inevitable. 

114 E.\ST Fifty-fourth Street. 



An Analysis of the End Results of Tonsillectomy 
and Adenoidectomy 

By SAMUEL A. BLAUNER, M. D., 
New York, 

Associate Pediatrist to the Lebanon Hospital, 

and SAMUEL Z. ORGEL, M. D., 
New York, 

Assistant Pediatrist to the Lebanon Hospital Dispensary 



This statistical report of one hundred cases of 
tonsillectomies and adenoidectomies is presented to 
show, if possible, a basis for indications for the 
removal of hypertrophied and diseased tonsils and 
adenoids. Whether these lymphoid structures have 
functions other than acting as a barrier to infectious 
diseases, is a moot question, but it is highly probable, 
judging from clinical experience, that their removal 
does not produce any pathological or functional de- 
fect nor expose the organism to increased risks. 
However, the question remains whether removal of 
tonsils and adenoids eliminates the cause for which 
operation is performed. The analysis of our cases 
is an attempt to place this problem on a firmer basis. 

We were led to this question because of the many 
conflicting statements regarding the effect of the re- 
moval of these organs and furthermore because of 
the belief of many mothers that ailments of varied 
nature would be cured by this operation and their 
insistent requests for operation. To meet this prob- 
lem as scientifically as possible, we decided to analyze 
at least a hundred cases of removal of more than a 
year's standing, entering into a careful preoperative 
and postoperative history, careful ]>hysical examina- 
tion and collecting all other data that might be of 
value in coming to a tentative conclusion. 

Our material came from the Lebanon Llospital 
Dispensary and the patients were operated on either 
in our dispensary, in other institutions or at home. 
Because of the various methods of operation, we 
soon found that it would be advisable to divide our 
cases into two general groups, namely tonsillectomies 
and tonsillotomies, and consider the various causes 
for removal under these heads. We also considered 
the effect of operation on glandular enlargement so 
common among children : diseases contracted since 



removal; diagnosis at time of examination and the 
general condition at time of examination. 

Causes for rcmovaL — Frequent colds, fifty-five; 
mouth breathing, forty-four ; malnutrition and ane- 
mia, sixteen ; tonsillitis, eighteen ; otitis media, nine ; 
asthma, four; cardiac lesions, four; advice of school 
nurse, seven ; stunted growth, diphtheria and chorea, 
one each. 

A careful perusal of Table I shows ihe usual 
causes for which tonsillectomy and adenoidectomy 
are advised : the effect of the operation, at least a 
}ear later and the general condition of the patient 
during the period of observation. The conclusions 
drawn from an interpretation of these figures show 
that tonsillectomy and adenoidectomy are beneficial 
to a certain extent, but not as much so as has been as- 
serted. It shows that many children are unnecessarilv 
operated upon; that only in selected cases will benefit 
be derived, and that mothers, as a result of persistent 
propaganda, are seeking operation for the relief of 
many conditions, only to be disappointed later. In- 
asmuch as it does good in a certain number of cases, 
the problem is to discover these indications. 

Tlie most fretjuent cause for which operation is 
sought is socalled colds. By these colds we mean 
nasopharyngitis with or without tonsillar (nonexu- 
dative) involvement. In the hundred cases, fifty- 
five ]iatients were operated upon for frequent colds. 
In a way it is unfortunate that not all operators per- 
formed the same operation for, as a result, we find 
that in thirty-six cases tonsillectomies were i)er- 
formed and in nineteen tonsillotomies. Our analy- 
sis of the cases shows that of the total number oper- 
ated upon, forty-nine per cent, showed improvement 
and fifty-one per cent, no im])rovement, some of the 
conditions even growing worse following operation. 



August 2, 1922.] 



BLAUNER AND ORGEL: TONSILLECTOMY. 



143 



If these cases are separated according to tlie 
type of operation performed, we tind that the ton- 
sillectomies show fifty-eight per cent, improvement, 
while the tonsillotomies only thirty-two per cent. 
Before interpreting these figures, we must allow for 
a certain number of patients, who would have im- 
munized themselves and would have shown improve- 
ment even without operation. It is a common ob- 
servation that certain children will sutTer from these 
colds for a \'ear or more, and suddenly, for no ap- 
parent reason, except that they have become im- 
munized as a result of previous infections, have 
few if any colds the following year. So in analyzing 
these figures it is well to remember that probably, 
among the cases reported improved, a certain per- 
centage of the patients showed improvement as a 



cases, the mothers' histories show improvement in 
ten of the cases following operation. We feel that 
a better way of judging is not by the word of the 
mother, but by our own observations of the child. 
Our figures in Table II show that in only four of 
the total of sixteen cases grouped under this head, 
were the patients in what we would call good gen- 
eral condition. Here again it must be evident tliat 
operation for this cause must not be advantageous, 
and if we consider that possibly there may be other 
conditions beside the operation that have entered 
into the improvement of these four patients, it is 
evident that we should hesitate to remove tonsils and 
adenoids with any promise of improvement in mal- 
nutrition and anemia. 

TonsiUitis must be separated clinically from naso- 















TABLE I. 


















Tonsillectomies 




Tonsilloto 


nies 




Effect of operation on cause 


Cause of 
Operation 






A 








A 










No. 


No. of cases 


Improved 


Not improved 


Worse 


No. of cases hnprov 


-d Not improved Worse 


Improved Not improved Worse 


Frequent 
























colds 


55 


36— 62J^% 


21—58% 


15—42% 


none 


19—34^% 6—32 


7o 


9— 477o 


4—21% 


27—49% 24—43/2% 4— 7Kj% 


Mouth 
























breathing .. 


44 


28—66% 


18— d47o 


10—36% 


none 


16—24% 4—25% 


8-50% 


4—25% 


22—50% 18—41% 


4—9% 


Malnutrition 
























and anemia. 


16 


13—81% 


10—77% 


3—23% 


none 


3 — 19% none 




2—67% 


1—33% 


10—62/,% 5—31% 


1—6/% 


Tonsillitis. . . 


18 


18—100% 


15—83% 


3—17% 


none 


none none 




none 


none 


15—83% 3—17% 


none 


(rheumatic 6' 
























Otitis media. 


9 


8—89% 


5— 62M% 3— 37M% 


none 


1—11% 1—100% 


none 


none 


6—66% 3—34% 


none 


Asthma .... 


4 


3—75% 


none 


3—75% 


none 


1—25% none 




none 


1—100% 


none 3 — 75% 


1—25% 


Cardiac 
























lesions .... 


4 


3—75% 


1—33% 


2—67% 


none 


1 — 25% none 




none 


1—100% 


1—25% 3—75% 


none 


Advice 
























of Qurse. . . 


7 


5--7l% 


2—40% 


2—40% 


1—20% 


2—29% 1—50% 


none 


1—50%; 


3—43% 1—14% 


3—43% 


Stunted 
























growth 


1 






















Diphtheria. . 


1 


3—100% 


2—67% 


1—33% 


none 


none none 




none 


none 


2—67% 1—33% 


none 


Chorea 


1 










TABLE II. 
















Glands palpable at 


east one year 


after operation 






General Condition at time of examination 


Catise 


/ operation 




Location of glands 


Nature of operation 


Good 


Fair 


Poor 


Frequent coldi 


38 




anterior cervical 24 


tonsillectomy 


14 




21—49% 


12—22% 


16—29% 










submaxillary 


14 


tonsillotomy 


24 










Mouth breath 


ing 


31 




anterior cervical 20 


tonsillectomy 


13 




1 6—36% 


13—30% 


15—34% 










submaxillary 


11 


tonsillotomy 


18 










Malnutrition 


and 


anemia 4 




anterior cervical 3 


tonsillectomy 


2 




4—25% 


6—37/% 


6—37/% 










submaxillary 


1 


tonsillotomy 


2 










TonsiUitis 




6 




anterior cervical 3 


tonsillectomy 


6 




8—42% 


5—29% 


5—29% 










submaxillary 


3 














Otitis media 




4 




anterior cerv 
submaxillary 


cal 2 
2 


tonsillectomy 


4 




7—78% 


1—11% 


1—11% 


Asthma 




2 




anterior cervical 1 


tonsillectomy 


2 




2—50% 


1—25% 


1—25% 










submaxillary 


I 














Cardiac lesions 


2 




anterior cervical 2 


tonsillectomy 






1—25% 


3—75% 


none 














tonsillotomy 












A(ivicc of nurse 


4 




anterior cerv 


cal 3 


tonsillectomy 






3—43% 


2—28/% 


2—28/% 










submaxillary 


1 


tonsillotomy 












Heterogeneous group 1 




anterior cervical 1 


tonsillectomy 






1—33% 


2—67% 


none 



result of this selfimmunity and these benefits should 
not therefore be ascribed to the operation ; in other 
words, we believe that this operation will show re- 
sults at best in only half the cases, and then only 
if a tonsillectomy is performed. 

Mouth breathing ranks second as a cause for 
which this operation is performed. This complaint 
is usually associated with that of colds, so that the 
mother's hope is often to relieve I)oth conditions by 
a single sweep of the knife. With moiitli breathing 
we usually find the symptoms of dryness and parch- 
ing of the mouth, tongue and lips, snoring at night, 
restless sleep and other disturbances. Our statistics 
show, however, that only about a third of the pa- 
tients were relieved of either the primary or second- 
ary symptoms, which makes it evident that mouth 
breathing per sc is not a definite indication for the 
performance of this operation, and therefore no 
operation should be performed unless it can be 
shown that the adenoids, and not an intranasal ob- 
struction, are the cause of the symptoms. 

In the malnutrition and anemia series of sixteen 



I)haryngitis (socalled colds). It is not infrequent 
for patients suffering from naso]iharyngitis to have 
an accom[)anying congestive (iionexudative) tonsil- 
litis. Clinically tonsillitis with follicular exudate 
seldom involves the mucous membrane of the naso- 
pharynx and is a distinct clinical entity. In 
this type of tonsillitis, which unfortunately is often 
rheumatic, we find our best results from o])era- 
tive procedure. It must be understood that the 
favorable results obtained through this operation in 
])ure tonsillitis is referable only to the tonsillitis itself 
and not to the general rheumatic tendency, of which 
the tonsillitis may be only a local manifestation. But 
as tonsillitis and rheumatic manifestations frequently 
accompany each other, it is well to look upon the 
tonsils as the focus of infection, and feel that the 
removal of tlie tonsils may at the same time remove 
the rheumatic tendency. In our series of eighteen 
cases of pure tonsillitis, six patients, or thirty-three 
and a third ])er cent., gave a history of rheumatic 
symptoms, and eighty-three per cent, manifested no 
further tonsillar attacks, thus showing, as far as one 



144 



BLAUNER AND ORGEL: TONSILLECTOMY. 



[Xew York Medical Journal 
AND Medical Record. 



can by statistics, that tonsillitis is an indication for 
a complete enucleation operation, with the hope that 
the secondary rheumatic tendency that usually ac- 
companies this condition may possibly be removed 
at the same time. 

In our nine cases of chronic otitis media, we 
found that the removal of the tonsils and adenoids 
was distinctly indicated. In four of these cases, 
where observation had lasted over a year, all avail- 
able treatment had failed to cause a cessation of the 
discharge. Tonsillectomy and adenoidectomy were 
performed as a last recourse. In three cases there 
was an immediate cessation of the discharge within 
a week, and in the fourth, a marked improvement. 
In the total series of nine cases, six were cured and 
three unafifected ; indicating that in the majority of 
instances the tonsils and adenoids were a source of 
irritation and that their removal tended to clear up 
the discharge. Indication for operation for all 
chronic ear discharges is evident. 

Digital examination of the nasopharynx revealed 
the presence of adenoid tissue in five of these cases, 
the three unimproved cases being among this group. 
We were unable to induce the mothers of the three 
otitic children in whom the discharge persisted to 
consent to the removal of the remaining adenoid 
tissue. 

Four children had definite cardiac lesions existing 
previous to operation for a period of from six 
months to three years. In this group of cases the 
idea was not that of possibly eradicating the cardiac 
lesion, but rather of preventing any further damage 
to the heart, for in the presence of a cardiac lesion 
the tonsils are usually a focus of infection. That 
this is true in part is well shown in one of our cases. 
This child, previous to operation, complained of an 
almost continual pain in the precordiuni, palpitation 
and dyspnea upon exertion. Two months after 
operation, a tonsillectomy having been performed, 
the child was up and about, a regular attendant at 
school and had entirely forgotten about her previous 
state of ill health. Judging by the general condi- 
tion of these children at time of examination, one 
being in good condition and the other three in a fair 
state of health, we believe that the presence of a 
cardiac lesion in a child should be an indication for 
tonsillectomy and adenoidectomy so as to prevent, 
if possible, any further damage to the heart. 

Under the head of miscellaneous we have grouped 
the remaining indications for operation in our col- 
lected cases. These consisted of four cases of 
asthma: seven cases advised by the school nurse 
to have the operation performed ; and a heterogene- 
ous group, in which the causes were varied, such as 
stunted growth, chorea, and recurrent attacks of 
diphtheria. 

Improvement was not seen in any of the asthmatic 
cases following operation. The general condition 
was good in two cases, fair in one and poor in one. 
If we were to judge from this, we would 
hardly place asthma as an indication for tonsillar re- 
moval. We believe, however, that the number of 
cases is entirely too small to reach a definite con- 
clusion. 

In the seven children operated upon on the advice 
nf the school nurse, we have a group of children 
who, previous to operation, were in the best of 



health. The only indication for the performance of 
the operation was the presence of tonsils that were 
visible to the naked eye. The only question to be 
considered here in reality is the effect of tonsillar 
removal upon healthy children. From our few 
cases, the indication would seem to be that tonsillar 
removal in healthy children does harm, for fifty- 
seven per cent, of these children were in a poorer 
state of health after operation. We cannot state 
that the changed general condition was directlv due 
to the tonsillar removal, for we do not think we' have 

TABLE III. 



Cause of 


Diseases 
contracted since 


Diagnosis 
at time 




operation 


tonsillar renw 


val 


of examinatic 


IH 


Frequent colds 


colds 


28 


colds 


13 




quinsy 


1 


bronchitis 


S 




asthma 


2 


chorea 


3 




enuresis 


5 


asthma 


I 




diphtheria 


3 


influenza 


1 




otitis media 


4 


anemia 


2 




rheumatism 


2 


enuresis 


2 




miscellaneous 


25 


tonsillitis 

sinusitis 

miscellaneous 


3 

I 
21 


Mouth breathing 


colds 


16 


colds 


7 




quinsy 


1 


bronchitis 


7 




asthma 


2 


chorea 


3 




enuresis 


1 


anemia 


1 




diphtheria 


4 


influenza 


1 




otitis media 


1 


enuresis 


1 




rheumatism 


2 


tonsillitis 


2 




miscellaneous 


25 


sinusitis 
miscellaneous 


1 
IS 


Malnutrition and 


colds 


4 


colds 
bronchitis 


9 


anemia 


diphtheria 


I 


2 




miscellaneous 


13 


asthma 
anemia, 
miscellaneous 


1 

1 
5 




colds 


9 






Tonsillitis 


diphtheria 
rheumatism 


2 
2 


colds 
bronchitis 


5 
6 




miscellaneous 


S 


chorea 
miscellaneous 


1 
13 


Otitis media 












colds 

otitis media 


4 
3 


colds 


3 




miscellaneous 


2 


miscellaneous 


1 


Asthma 


colds 


1 


colds 


1 




asthma 


4 


asthma 


2 


Cardiac lesions 


colds 


3 


colds 
miscellaneous 


1 

4 


Advice of nurse 


colds 


5 


colds 


2 




diphtheria 


1 


chorea 


1 




enuresis 


1 


asthma 


1 




rheumatism 


1 


enuresis 


1 




endocarditis 


1 


myocarditis 


1 




miscellaneous 


6 


miscellaneous 


2 


Heterogeneous 
group 


colds 


1 


chorea 
miscellaneous 


1 
2 



had a sufficiently large number of cases to judge. 
What does seem evident is that there was no definite 
benefit derived from having the operation performed. 

The case of stunted growth, a hypothyroid child, 
was, as would be expected, uninfluenced by the oper- 
ation, but showed prompt improvement under glan- 
dular therapy. 

The case of diphtheria was a child in whom re- 
l)eated attacks of clinical and bacteriological diph- 
theria occurred ; the patient was a diphtheria carrier. 
Here we find that the operation alleviated the at- 
tacks of diphtheria, and also changed this child from 
being a carrier to a noncarrier. 

A tonsillectomy was performed in the case of 
chorea with two ideas in view ; one, the cure of the 
chorea, which remained unaffected, and secondly, to 
prevent the occurrence of a cardiac lesion if possible. 
If we accei)t the idea that chorea is only a symptom 
of rheumatism and if the operation is done with the 
view of removing a possible focus of infection pri- 
marily to protect the heart, then this condition is an 
indication for operation. 



August 2, 1922.] 



KAIDEX: TONSILLECTOMY /.V CHILDREN. 



145 



From Table II it will be seen that persistently pal- 
pable glands of die neck are not and should not be 
used as an indication for tonsillectomy and adenoid- 
ectomy. These glands were found palpable in the 
majority. of our cases regardless of the cause for 
operation or the kind of operation performed. There 
is no doubt that the enlargement of these glands is 
due to some focus of infection in the head and un- 
less the enlargement is directly tracable to a diseased 
tonsil and adenoids it is doubtful if operative proce- 
dure has any effect. 

It can be readily seen from Table I that if a tonsil 
and adenoid operation is to be performed, that ton- 
sillectomy should always be the operation of choice. 
Our statistics show that those children in whom a 
tonsillotomy was performed, with few exceptions, 
were unimproved or grew worse after operation. 
The prime factor in all cases where this operation 
is even thought of should be that the physician be 
perfectly sure that the tonsils and adenoids are the 
primary foci of infection, that they are not kept sec- 
ondarily infected from some other chronic focus of 
infection in the head. 

In dealing with children up to fifteen years of 
age, one must remember that there is a normal hy- 
perplasia of the tonsils and adenoids during this 
period ; that probably one of the functions of these 
lymphoid structures is to protect the lower air pas- 
sages against infection, and that these structures 
should not be removed solely because they are en- 
larged or detritus is seen in their crypts. Should 
the physician decide that the tonsils are the primary 
foci of infection and a tonsillar operation indicated, 
we believe that his duty is to insist upon a tonsillec- 
tomy being performed. 

The most important anatomical characteristic of 
the tonsils consists of fossuke or crypts that are 
branching channels extending from the tonsillar sur- 
face to the fibrous capsule where they end blindly. 
The lymphoid tissue that remains after an incom- 



plete tonsillectomy or tonsillotomy undergoes hyj^er- 
trophic changes and scar tissues form over the cut 
surface, which tends to produce pockets and par- 
tialh- occlude the remains of the crypts. Instead of 
eliminating a chronic focus of infection the ultimate 
result is often worse than the original condition. 
From an anatomical and clinical point of view a 
tonsillectomy is incomplete unless the entire tonsil 
together with its fibrous capsule is removed. 

CONCLUSIONS. 

1. Tonsillectomy and adenoidectomy are of ad- 
vantage in tonsillitis and chronic otitis media. 

2. Tonsillectomy and adenoidectomy are of value 
in half the cases, or less, in colds, mouth breath- 
ing and malnutrition and anemia. 

3. In the other series enumerated in our tables we 
did not arrive at any definite conclusion because of 
the paucity of cases. 

4. It is our observation that more advantageous 
results are obtained in the various causes for opera- 
tion, where a complete tonsillectomy and adenoidec- 
tomy were performed. We therefore would advise 
tonsillectomy and adenoidectomy as the choice 
wherever such an operation is indicated. 

5. Inasmuch as tonsillectomy and adenoidectomy 
have distinct indications, nurses should not be put 
in a position of responsibility in judging these indi- 
cations. We see on an average a hundred children 
a week, who at the behest of the nurse come to the 
dispensary for tonsillar removal, children who are 
otherwise in good health and most of whom have 
never suffered an illness involving tonsillar and ade- 
noid tissue. A strict admonition is given the mother 
that these structures must be removed or the child 
will be excluded from school, the only indication 
being that the tonsils are visible to the naked eye. 
It is true that removal of these glands may not be 
detrimental (denied by the endocrinologist), but that 
is not sufficient reason, unless there are other dis- 
tinct medical indications. 



Tonsillectomy in Children with Endocarditis and Frequent 

Tonsillar Infections 



By MAXWELL H. KAIDEN. M. D., 
New York. 



A review of the experimental and clinical litera- 
ture bearing upon endocarditis, tonsillitis, acute 
articular rheumatism, chorea and erythema nodosum, 
gives one the impression if not the conviction that 
all these diseases are of bacterial origin. Thus ; 
Rosenow asserts that acute endocarditis is always 
due to bacterial invasion, and that acute articular 
rheumatism, tonsillitis, chorea, and erythema nodo- 
sum are but phases or manifestations of the same 
disease. 

Wood has proved experimentally that the strep- 
tococcus and other varieties of organisms can enter 
the blood stream through the tonsils and produce 
cardiac, renal and articular infections. He has fur- 
ther shown that these svstemic invasions occur 



sooner and with greater virulence when the tonsils 
are the primary focus. Oille has recently demon- 
strated that a streptococcus bacteriemia is present in 
most cases of active bacterial endocarditis. Det- 
vviller and Robinson found that strains of Strepto- 
coccus viridans isolated from the mouth of norma! 
individuals are similar to those isolated from the 
blood of patients suffering from acute bacterial en- 
docarditis, and that such organisms are capable of 
producing experimental heart lesions in the rabbit. 

Withers holds that the trend of English, (lerman, 
and American thought indicates that the streptococ- 
cus is the most frequent causative organism in acute 
endocarditis. He presents two cases of acute endo- 
carditis in children, one followinsr a socalled cold 



146 



K.-IIDEX: rOXSILLECTOMV IN CHILDREX. 



[New York Medical Journal 
AND Medical Record. 



in the head and the other what is known as a sore 
throat. Osier and McCrae mention tonsilhtis, 
arthritis, chorea, and erythema nodosum as the im- 
portant causes of endocarditis. Osier recommends 
removal of the tonsils during the acute attack of 
endocarditis, if the latter can be proven to be of 
tonsillar origin. 

Fleischner advocates tonsillectomy when it can be 
shown that tlie tonsils are the seat of a focal infec- 
tion, whether endocarditis is present or not. Even 
durin