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Illinois 
Medical Journal 


OFFICE OF PUBLICATION 155 N. RIDGELAND AVE., OAK PARK, ILLINOIS 


Published Monthly 








Vol. XLII, No. 2 


_OAK PARK, ILL., FEBRUARY, 1923 | 


_ $3.00 a Year 





CONTENTS 


Editorials (For Titles See Extended Table of Contents). 85-106 
ORIGINALS 

Ectopic Gestation with Report of Cases. Thomas W. 
Nuzum, M. D., Janesville, Wis 

Cancer. William M. Harsha, M. D., Chicago 

Choriocarcinoma Following Extrauterine Pregnancy. ohn 
Beverly Moore, M. D., Benton, IIl 

The Edematous Cardiopath. Joseph M. Patton, M. D., 


Surgery of the Upper idee Under Local Anesthesia. 
Robert Emmett Farr, M. D., Minneapolis, Minn 


The Treatment of Chronic Fatigue Intoxication. Edward 
H. Ochsner, M. D., Chicago 








Pernicious Anemia. R. D. Robinson, M. D., Chicago... “™ ~*~ 


Anatomy, Physiology and Diseases of the Circulatory 
System and Management and Treatment of Such Dis 
eases. H.C. Houser, M. D., Westfield, Ill........... 133 
Diabetes Mellitus. Richard F. Herndon, M. D., Spring- 
field, Ill 
Industrial Eye Injuries. Frank Allport, M. D., Chicago, . 
Thoughts on Medical Organization. A. F. Kaeser, M. D., 
Sie Ca enn kgdwaueeh ans 149 
The Etiol and Management of Neurasthenic Cond- 
itions. Frank R. Fry, M. D., St. Louis, Mo 151 
Some Thoughts on Preventive Saar with Special Re- 
ference to Focal Infection. George H. Parmenter, M. 
ce < ". § Ata) * eee ry 


Continued on page 14 





Entered as Second-Class Matter July 21, 1919, at the Post Office, Oak Park, Illinois, under the Act of March 3 
Acceptance for mailing at special rate of postage provided for in Section 1103, Act of October 8, 1917, authorized aly rte 1918 





— “Modern and Homelike~ 


Unlike most sanitariums, the Milwaukee has but little of 


the institutional, hospitalized atmosphere. We have gone 
to the opposite extreme by providing eleven different build- 
ings—six of them luxuriously and comfortably furnished for 
the care of patients. The newly opened Colonial Hall (illus- 
trated below) is*the finest building of its kind in the coun- 
try and is used for the treatment of the psycho-neuroses 
only. Fifty acres of virgin forest provide quiet, restful 
surroundings—yet two minutes’ walk reaches street car and 
railroad lingm to nearby Milwaukee and Chicago. Separate 
psychopathi¢ hospital. Equipped for all modern methods of 
treatment. Write for attractively illustrated booklet, mailed 
free on request. 


Rock Sleyster, M.D., Medical Director; W. T. Kradwell, 
M.D., Asst. Med. Dir.; Chauncey Beebe, M.D., Asst. Phys.; 
A. J. Patek, M.D., Attdg. Phys.; Richard Dewey, M.D., 
Consulting Psychiatrist. 


Wilwaukee Sanitarium, Wauwatosa, Wis, 





for Nervous and Mental Diseases ——Established 1884 





‘The Advertising Pages have a Service Value for the READER 


that no truly Progressive Physicion com efferd te - 
This issue 8,000 











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ILLINOIS MEDICAL JOURNAL 


THE OFFICIAL ORGAN OF 


THE ILLINOIS STATE MEDICAL SOCIETY 





ILLINOIS MEDICAL JOURNAL 


Published | by The Illinois State Medical Society un- 
der the direction of the Publication Committee of the Council. 








GENERAL OFFICERS, 1922-1923 


PRONE sc ccccccccesescseees Epwin P. Stoan, Bloomington 
Des 6 ik 0s 06 4h00c0enees E. H. Ocusner, Chicago 
First Vice-PReSIDENT............ Frank R. Morton, Chicago 
Seconp Vice-PresIpENT............. W. E. Suastip, Pittsfield 
I, o's 4 caeesendaensesceees A. J. Marxtey, Belvidere 
SECOBTARY . cc cccccvccccceccoceccese Ws. D. Cuapman, Silvis 


(Ex-officio Clerk of the Council) 








THE COUNCIL 


Term 

Expires 

District 1—David B. Penniman, Rockford 1923 
District 2—E. E. Perisho, Streator 1923 
District 3—S. J. McNeil, Chicago 1923 
R. R. Ferguson, Chicago 1924 
John S. Nagle, Chicago 1925 
District 4—H. M. Camp, Monmouth 1925 
District 5—Charles S. Nelson, Springfield 1925 
District 6—Henry P. Beirne, Quincy 1924 
District 7—L. O. Frech, Decatur 1925 
District 8—Cyrus E. Price, Robinson 1923 
District 9—-W. H. Gilmore, Benton 1923 


Charles S. Nelson, Springfield, Chairman. 








MEDICO-LEGAL COMMITTEE 


J. W. Van Derslice, Secretary, 155 N. Ridgeland Avenue, 
Oak Park. 




















EDITOR 
Dr. Cuartes J. WHALEN...... 25 E. Washington St., Chicago 
GENERAL COUNSEL 
Rosert J. FOLONIB.......0-e00: 89 S. LaSalle Street, Chicago 
MEDICO-LEGAL COMMITTEE 

Term 

Expires 

C. B. Kinc, Chairman, 4100 W. Madison St., Chicago 1925 
Tuomas D, Cantrect, Bloomington 1924 
J. R. Baturncer, Chicago 1924 
C. A. Hercures, Matteson 1923 
R. L. Green, Peoria, Secreta 1923 
W. F. Grinsreap, Cairo 1925 








State Society will pay no bills for legal services except those 
contracted by the Committee. Notify the Chairman at once. 
Do not employ attorneys. 


Send original articles and all communications ae, to 
advertisements to Dr. Charles J. Whalen, Editor, 6221 Ken- 
more Avenue, Chicago. 


gy lembership correspondence to Dr. Wm. D. Chapman, Silvis, 
l, 


Society proceedings and news items and changes in the 
mailing list to Dr. Henry G. Ohls, Managing Editor, 927 
Lawrence Avenue, Chicago. 

Contributors will submit all copy for publication typewritten 
on standard size paper and double spaced. Copy not com- 
plying with this rule will be returned, if convenient. 


Subscription price of this Journal to persons not members 
of the Illinois State Medical Society is $3.00 per year, in 
advance, postage prepaid, for the United States, Cuba, Porto 
Rico, Philippine Islands, Hawaiian Islands and Mexico. $3.50 
per year for all foreign countries included in the postal union. 
Canada, $3.25. Single current copies, 35 cents. Back numbers, 


after three months from date of publication, 50 cents. 


Park, Itv., Fesruary, 1923 














Editorial 


STATE DEPT. OF HEALTH DISTRICT 
HEALTH SUPERINTENDENTS OPPOSE 
STATE MEDICINE 

Resolution of District Health Superintendents 
of the Illinois State Department of Public Health, 
including northern, central and southern Illinois 
groups unanimously adopted at their recent meet- 
ings. 

Resolved: That District Health Superintend- 
ents favor the advertising campaign proposed by 
the Illinois State Medical Society and the assess- 
ment of ten dollars imposed on each member 
thereof for that purpose; endorse the Medical 
Practice Act to be submitted by Illinois Medical 
Society to the session of the legislature and also 
endorse the principles enunciated by the House 
of delegates of the American Medical Association 
at the 73rd session in St. Louis in May, 1922, 
reading as follows: 

“The American Medical Association hereby de- 
clares its opposition to all forms of ‘state medi- 
cine’ because of the ultimate harm that would 
come thereby to the public weal through such 
form of medical practice. 

‘State medicine’ is hereby defined for the 
purpose of the resolution to be any form of med- 
ical treatment provided, conducted, controlled or 
subsidized by the federal or any state govern- 
ment or municipality excepting such service as 
provided by the army, navy or public health serv- 
ice and that which is necessary for the control of 
communicable disease, the treatment of mental 
disease, the treatment of indigent sick, and such 
other service as may be approved by and admin- 
istered under the direction of or by a local county 
medical society and are not disapproved by the 
state medical society, of which it is a component 
part.” 

The District Health Superintendents also wish 
to bring to the attention of the Illinois Medical 














Society that all their activities are in accordance 
with the tenets set forth in the resolution as 
adopted by the A. M. A. 





AN APOLOGY 

In the ILtinors MepicaL JourRNAL, January, 
1923, page 7, Section 3, in the article outlining 
the provisions of the new Medical Practice Act, 
there was an extra line injected which read as 
follows : 

“Dees ees a helova lands.” 

The insertion of this line was deliberate and 
was put in by someone who desired to belittle 
and bring ridicule on any attempt to regulate 
the practice of medicine. 

The obnoxious phrase was written in after 
final proof had been O. K.’d by a member of 
the State Legislative Committee. Its appear- 
ance in the Journal in connection with the ar- 
ticle mentioned, has caused the editor much 
embarrassment and has created a need for a great 
deal of explaining. The Editor and Assistant 
Kditor were powerless to prevent the insertion of 
words or phrases after the final proof was sent 
in. 

The Journal is published by one of the most 
reliable firms in the West. On discovering the 
cbnoxious language alluded to, the editor asked 
the publishers of the Journal to investigate and 
place the responsibility. In due course the chair- 
man of the Board of Directors of the corporation 
expressed sincere regret for the occurrence and 
gave assurance that they had taken immediate 
and drastic action to prevent a repetition in any 
future issue of the Journal. 

The Legislative Committee and the editor of 
the Journal are satisfied with the apology of the 
publishers and feel sure there will be no repeti- 
tion of this unfortunate act. 





ALL ARE INVITED TO ATTEND THE 
A. M. A. MEETING AT SAN FRANCISCO 
JUNE 25-29 

California invites you to attend the American 
Medical Association Convention in San Francisco 
June 25 to June 29, 1923. You are also in- 
vited with your families and friends to attend 
the California State Medical Association Meet- 
ing Friday and Saturday before the American 
Mecical Association holds its Convention in the 
same city. Some five or six other National and 


86 ILLINOIS MEDICAL JOURNAL 





District Medical Associations will meet in San 
Francisco between June 21 and June 30. 

Members of the Illinois Medical Association, 
in particular, are urged to attend the Convention 
and to spend their vacation in California. 
Through contacts with various financial, civic, 
tourist and automobile agencies, we are prepared 
upon request to assist you in planning your trip, 
in making you comfortable while at the Conven- 
tion, in arranging side trips of any length or 
character, and in any other way acting as your 
host while in our state. 

We are now making arrangements for a nun- 
ber of automobile caravans from eastern points 
to San Francisco. From early information it 
seems that this is going to be a popular method 
of crossing the continent. If you and your 
friends desire to come by automobile, communi- 
cate with us and we will assist you from the 
moment you leave home until you get back. Ii 
you plan to come in any other way, write to us 
and we will be glad to help you with your ar- 
rangements. You are requested to write to Dr. 
W. E. Musgrave, 806-9 Balboa Bldg., San Fran- 
cisco, for any information of whatever character 
about this Convention, or about vacation oppor- 
tunities anywhere in California. 





ANNOUNCEMENT 

The Seventh Annual Clinical Session of the 
American Congress on Internal Medicine will be 
held in the amphitheatres, wards and laboratories 
of the various institutions concerned with medi- 
eal teaching, at Philadelphia, Pa., beginning 
Monday, April 2, 1923. 

Practitioners and laboratory workers inter- 
ested in the progress of scientific, clinical and 
research medicine are invited to take advantage 
of the opportunities afforded by this session. 

Address inquiries to the Secretary-General. 

Sypney R. Miiter, President, 
Baltimore, Md. 
FRANK SMirurtes, Sec’y-Gen’l, 
1002 N. Dearborn St.. 
Chicago, Tl. 


AN ALTERNATIVE 


An old lady describing the symptoms of her ail- 
ment to a noted but eccentric physician, said: “Th« 
trouble, doctor, is that I can neither lay nor set.” 

Whereupon the good old doctor answered her 
thus: “Then, madam, I would respectfully suggest 
the propriety of your roosting.”—Judge. 


February, 1923 











y, 1923 
n San 


‘ation, 
sntion 
ornia. 
Civic, 
pared 
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nven- 
th or 
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ethod 
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rest 








February, 1923 


WHY SOME STATES ACCEPT THE SHEP- 
PARD-TOWNER MATERNITY ACT 

Twelve states pay 95 per cent of the total tax. 

Complete statistics of income for the calendar 
year 1920 made public Oct. 1, 1922, shows TIli- 
nois is third in list of incomes paid. 

Of the total income tax New York paid 23.69 
per cent; Pennsylvania, 12.13 per cent; Illinois, 
8.68 per cent; Ohio, 6.76 per cent, and Massa- 
chusetts 5.82 per cent. These five states to- 
gether paid 57.08 per cent of the combined per- 
sonal and corporation tax of the country. These 
states, with seven others, Michigan, Indiana, 
Iowa, New Jersey, California, Missouri, and 
Maryland, twelve states in all, paid 95.83 per 
cent of the total tax. 





THE PROPOSED NEW MEDICAL 
PRACTICE ACT 

At present, Illinois may or may not have a law 
in relation to the practice of medicine. The law 
of 1917 was declared invalid, and the law of 1899 
is now awaiting the decision of the supreme court 
as to its constitutionality. 

The bill for a new Medical Practice act as 
prepared by the legislative committee of the 
State Medical Society has been introduced into 
the General Assembly to meet this condition of 
uncertainty. 

It provides for two forms of license: 1, to 
practice medicine in all its branches, and 2, to 
treat human ailments without drugs or medi- 
cines and without operative surgery. 

The old law also provided for two forms of 
licenses, but the limited license permitted its 
holder to call himself a Chiropractor, an Osteo- 
path, a Naprapath, or most anything else, pro- 
vided he did not hold himself out to the public 
as being licensed to practice medicine in all it< 
branches. It is not unusual to find a person 
holding himself out to the public as being a 
number of kinds of healer or practitioner. This 
manner of deceiving the public is not prohibited 


by the present law. 

Under the proposed law the applicant for a 
limited license must designate in his application 
the system or method of treatment that he has 
studied, and if he gets a license, he is limited 
by its terms to the form of treatment that he 


EDITORIAL 87 


was examined in. Surely no one should be heard 
to complain at such a provision in a law. Just 
common honesty demands that one should pro- 
claim himself only what he is. 

The Christian Scientists asked for the follow- 
ing exemption: “nor shall any person treating 
human ailments without drugs or medicines and 
without operative surgery, by spiritual means or 
prayer be subject to the provisions or any of the 
provisions, sections, subdivisions, sentences, 
clauses or penalties of this act, but should this 
section, or any part of it be held invalid or 
unconstitutional, the entire act of which this 
section is a part shall become and be invalid 
and of no force nor effect.” 

The committee very fully safeguarded the 
rights of the Christian Scientists by utilizing the 
language of the constitution and inserted the 
following exemption: “or prohibit the treat- 
ment of human ailments by prayer as an exercise 
or enjoyment of religious profession or worship.” 

Every doctor of medicine and every other 
citizen of Illinois should read this bill with the 
aid of a lawyer, and get behind it and see that 
it becomes a law. There is nothing in the bill 
that any honest man should fear. Dishonest 
men are not much afraid of our present law. 

The Journat publishes the completed bill in 
this issue. 





A BILL FOR 
AN ACT to revise the law in relation to the prac- 
tice of the treatment of human ailments for 
the better protection of the public health. 

Section 1. Be it enacted by the People of the 
State of Illinois, represented in the General As- 
sembly: This Act shall be known as the Medical 
Practice Act. 

Section 2. No person shall practice medicine, or 
any of its branches, or midwifery, or any system or 
method of treating human ailments without the use 
of drugs or medicines and without operative sur- 
gery, without a valid, existing license so to do. 

Section 3. No person, except as otherwise pro- 
vided in this Act, shall hereafter receive such a li- 
cense unless he shall pass an examination of his 
qualifications therefor by and satisfactorily to the 
Department of Registration and Education, herein- 
after referred to as the Department. 

Section 4. Each applicant for such examination 
shall: 

1. Make application for examination on blank 
forms prepared and furnished by the Department; 





88 


2. Submit evidence under oath satisfactory to the 
Department that: 

(ay He is twenty-one years of age or over; 

(b) He is of good moral character; 

(c) He has the preliminary and professional edu- 
cation required by this Act; 

3. Designate specifically the name, location and 
kind of professional school, college or institution of 
which he is a graduate and the system or method of 
treatment under which he seeks, and will under- 
take, to practice. 

4. Pay in advance to the Department fees as 
follows: 

(a) For the examination to practice medicine in 
all of its branches, or to treat human ailments with- 
out the use of drugs or medicines and without oper- 
ative surgery, or for any special or supplemental 
examination, ten dollars; 

(b) For the examination to practice midwifery, 
five dollars. 

Section 5. Minimum standards of professional 
education to be enforced by the Department in con 
ducting examinations and issuing licenses shall be 
as follows: 

1. For the practice of medicine in all of its 
branches: 

(a) For an applicant who is a graduate of a 
medical college before the passage of this Act, that 
such medical college at the time of his graduation 
required as a prerequisite to graduation a four years’ 
course of instruction in such medical college, or its 
equivalent, the time elapsing between the beginning 
of the first year and the ending of the fourth year 
having been not less than forty months, and which 
was reputable and in good standing in the judgment 
of the Department ; 

(b) For an applicant who is a graduate of a med- 
ical college after the passage of this Act, that such 
medical college at the time of his graduation re- 
quired as a prerequisite to admission thereto a two 
years’ course of instruction in a college of liberal 
arts, or its equivalent, or in such medical college, 
and at least a four years’ course of instruction in 
the treatment of human ailments in such medical 
college, or its equivalent, the time elapsing between 
the beginning of the first year and the ending of the 
fourth year in such medical college having been not 
less than forty months, and, in addition thereto, a 
course of training of not less than twelve months 
in a hospital, such college of liberal arts, medical 
college and hospital having been reputable and in 
good standing in the judgment of the Department; 

2. For the practice of any system or method of 
treating human ailments without the use of drugs 
or medicines and without operative surgery: 

(a) For an applicant who is a graduate before 
the passage of this Act of a professional school, 
college or institution which taught the system or 
method of treating human ailments which he speci 
fically designated in his application as the one which 
he vould undertake to practice, that such school, 
college or institution at the time of his graduation 


ILLINOIS MEDICAL JOURNAL 





February, 1923 


required as a prerequisite to graduation a four years’ 
course of instruction in such professional school, 
college or institution, or its equivalent, the time 
elapsing between the beginning of the first year and 
the ending of the fourth year having been not less 
than forty months, and which was reputable and 
in good standing in the judgment of the Depart- 
ment ; 

(b) For an applicant who is a graduate after the 
passage of this Act, but before July 1, 1925, of a 
professional school, college or institution which 
taught the system or method of treating human 
ailments which he specifically designated in his ap- 
plication as the one which he would undertake to 
practice, that such school, college or institution at 
the time of his graduation required as a prerequisite 
to admission thereto a four years’ course of instruc- 
tion in a high school, or its equivalent, or in such 
professional school, college or institution, and at 
least a four years’ course of instruction in the treat- 
ment of human ailments in such professional school, 
college or institution, or its equivalent, the time 
elapsing between the beginning of the first year and 
the ending of the fourth year in such professional 
school, college or institution having been not less 
than forty months, such college of liberal arts and 
professional school, college or institution having 
been reputable and in good standing in the judg- 
ment of the Department; 

(c) For an applicant who is a graduate on or 
after July 1, 1925, of a professional school, college 
or institution which taught the system or method 
of treating human ailments which he specifically 
designated in his application as the one which he 
would undertake to practice, that such school, col- 
lege or institution at the time of his graduation re- 
quired as a prerequisite to admission thereto a one 
year’s course of instruction (a two years’ course of 
instruction after 1928) in a college of liberal arts, 
or its equivalent, or in such professional school, col- 
lege or institution, and at least a four years’ course 
of instruction in the treatment of human ailments 
in such professional school, college or institution, 
or its equivalent, the time elapsing between the be- 
ginning of the first year and the ending of th 
fourth year in such professional school, college or 
institution, having been not less than forty months, 
such college of liberal arts and professional school, 
college or institution having been reputable and in 
good standing in the judgment of the Department; 

3. For the practice of midwifery: 

(a) That he has studied midwifery sufficiently in 
the judgment of the Department to have been able 
to become proficient therein. 

Section 6. The course of instruction in high 
schools, or other schools, and colleges of liberal arts 
required by any medical college or professional 
school, college or institution, or required under any 
of the provisions of this Act, shall have been such 
as shall be satisfactory to the Department, and shall 
he evidenced with respect to any application in the 


manner required by the Department. 
All examinations provided for by this 


Section 7. 








1923 


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February, 1923 


Act shall be conducted under rules and regulations 
prescribed from time to time by the Department. 
Examinations shall be held not less frequently than 
jour times every year, at times and places prescribed 
by the Department, of which applicants shall be 
notified by the Department in writing, and may be 
conducted wholly or in part in writing. 

Section 8. Examination of applicants who seek 
to practice medicine in all of its branches shall em- 
brace the subjects of which knowledge is generally 
required of candidates for the degree of doctor of 
medicine by reputable medical colleges in the United 
States, and shall be such in the judgment of the 
Department as will determine the qualifications of 
applicants to practice medicine in all of its branches. 

Section 9. Examination of applicants who seek 
to practice any system or method of treating human 
ailments without the use of drugs or medicines and 
without operative surgery shall be the same as re- 
quired of applicants who seek to practice medicine 
in all of its branches, excepting therefrom materia 
medica, therapeutics, surgery, obstetrics, and theory 
and practice, and shall be such in the judgment of 
the Department as will determine the qualifications 
of the applicant to practice the particular system or 
method of treating human ailments without the use 
of drugs or medicines and without operative surgery 
which he specifically designated in his application 
as the one which he would undertake to practice. 
If the applicant is a graduate of a professional 
school, college or institution in which obstetrics was 
taught to him as well, in the judgment of the De- 
partment, as such subject was taught at the same 
time in medical colleges in the United States reputa- 
ble and in good standing in the judgment of the 
Department, he may, upon his request, be examined 
in obstetrics. 

Section 10, Examination of applicants who seek 
to practice midwifery shall be such in the judgment 
of the Department as will determine the qualifica- 
tions of applicants to practice midwifery. 

Section 11. 
kis examination shall be entitled to an appropriate 
The following kinds of licenses shall be 


Every applicant successfully passing 


license, 
issued: 

1. To practice medicine in all of its branches, to 
applicants passing examinations therefor; 

2. To treat human ailments without the use of 
drugs or medicines and without operative surgery, 
to applicants passing examinations therefor, the 
applicant under such a license to be specifically re- 
stricted by the terms thereof to the practice of the 
system or method which he specifically designated 
in his application as the one which he would under- 
take to practice, but such of these applicants as shall 
have successfully passed the examination in ob- 
stetrics under the requirements of Section 9 of this 
Act shall also be specifically licensed in the same 
instrument to practice obstetrics ; 

3. To practice midwifery. 

Section 12. Any person licensed under the pro- 
visions of this Act to practice any system or method 
of treating human ailments without the use of drugs 


EDITORIAL 89 


or medicines and without operative surgery shall 
be permitted to take the examination in materia 
medica, therapeutics, surgery and obstetrics, and 
shall receive a license to practice medicine in all 
of its branches if he shall successfully pass such 
examination, upon proof of having successfully com- 
pleted in a medical college, or in any professional 
school, college or institution teaching any system 
or method of treating human ailments, reputable 
and in good standing in the judgment of the De- 
partment, courses of instruction in materia medica, 
therapeutics, surgery and obstetrics, deemed by the 
Department to be equal to the courses of instruc- 
tions required in those subjects for admission to the 
examination for a license to practice medicine in all 
of its branches, together with proof of having com- 
pleted (a) the two years’ course of instruction in 
a college of liberal arts, or its equivalent, described 
in Section 5 of this Act, and (b) a course of training 
of not less than twelve months in a hospital reputa- 
ble and in good standing in the judgment of the 
Department. But if such applicant for a license to 
practice medicine in all of its branches shall already 
have a license to practice obstetrics, he shall not be 
required to take an examination in that subject 
under the provisions of this Section. 

Section 13. The Department may, in its discre- 
tion, issue a license without examination to any 
person who has been licensed to practice medicine, 
or to practice the treatment of human ailments 
according to any system or method, in any other 
State, Territory, Country, or Province, upon the 
following conditions: 

1. That the applicant is of good moral character ; 

2. That if the applicant seeks to practice medicine 
in all of its branches 

(a) He is a graduate of a medical college, reputa- 
ble and in good standing at the date of his gradua- 
tion in the judgment of the Department; 

(b) The requirements for a license to practice 
medicine in all of its branches in the particular 
State, Territory, Country or Province in which he 
is licensed are deemed by the Department to have 
been substantially equivalent to the requirements 
for a license to practice medicine in all of its 
branches in force in this State at the date of his 
license ; 

3. That if the applicant seeks to treat human ail- 
ments without the use of drugs or medicines and 
without operative surgery 

(a) He is a gradaute of a professional school, 
college or institution which taught the treatment of 
human ailments by the system or method which he 
specifically designated in his application as the one 
which he would undertake to practice, and which 
was reputable and in good standing at the date of 
his graduation in the judgment of the Department; 

(b) The requirements for his license to prac- 
tice the treatment of human ailments without the 
use of drugs or medicines and without operative 
surgery, according to the system or method which 
he specifically designated in his application as the 





90 ILLINOIS MEDICAL JOURNAL 









one which he would undertake to practice, are 


deemed by the Department to have been substan- 


tially equivalent to the requirements for a license 


to practice such system or method in force in this 
State at the date of his license; 


4. That the State, Territory, Country or Province 
in which such applicant was licensed shall be then 
according a like privilege to persons so licensed 
under the authority of the laws of this State; 


5. That the Department may in its discretion 
issue a license without examination to any graduate 
of a professional school, college or institution teach- 
ing the treatment of human ailments, reputable and 
in good standing in the judgment of the Department, 
who has passed an examination for admission to the 
medical corps of the United States Army, or that 
of the United States Navy, or that of the United 
States Public Health Service, or who has passed 
any other examination deemed by the Department 
to have been at least equal in all substantial respects 
to the examination required for admission to any 
such medical corps; 

6. That applications for licenses without examin- 
ation shall be filed with the Department under oath 
on blank forms prepared and furnished by the De- 
partment and shall set forth, and applicants there- 
for shall supply, such information respecting the 
life, education, professional practice and moral char- 
acter of applicants as the Department may require 
to be filed for its use. 

Section 14, Every person receiving a license un- 
der this Act shall pay to the Department the fol- 
lowing fees: 

1. For a license to practice medicine in all of 
its branches, or for a license to practice any system 
or method of treating human ailments without the 
use of drugs or medicines and without operative 
surgery, five dollars; 

2. For a license to a person without examination, 
twenty-five dollars ; 


3. For a license to practice midwifery, three 
dollars. 

Section 15. Every person holding a license under 
this Act, and every person holding a license or cer- 
tificate under any prior Act in this State regulating 
the practice of medicine or the practice of the treat- 
ment of human ailments in any manner as a pro- 
fession, shall have it recorded, if not already so 
recorded, in the office of the recorder of deeds in 
every county in which he regularly practices, and 
the recorder of deeds shall write or stamp thereon 
the date of such recording. Until such license or 
certificate shall be recorded the holder thereof shall 
not exercise any of the rights or privileges con- 
ferred therein. The recorder of deeds shall keep 
in a book provided for that purpose, and open to 


public: inspection, a complete list of such licenses 


and certificates heretofore or hereafter recorded by 
him and his predecessors in office, including the 
dare of the issue of each license or certificate, the 
name of the person therein, and the date of the re 
cording thereof 








Section 16. The Department may revoke or sus- 
pend the license or certificate of any person issued 
under this Act, or issued under any other Act in 
this State, to practice medicine, or to practice the 
treatment of human ailments in any manner, or to 
practice midwifery, or may refuse to grant a license 
under this Act, and may cause any license so re- 
voked or suspended to be marked canceled on the 
records of any recorder of deeds, upon any of the 
following grounds: 

1. Procuring, or aiding or abetting in precuring, 
or attempting to procure, such an abortion as was 
made unlawful at the time under the provisions of 
the criminal code of this state; 

2. Conviction of a felony, or commission of any 
act involving gross moral turpitude; 

3. Gross malpractice resulting in permanent in- 
jury or death of a patient; 

4. Obtaining a fee, either directly or indirectly, 
cither in money or in the form of anything else of 
value, or in the form of a financial profit as personal 
compensation, or as compensation, charge, profit or 
gain for an employer or for any other person or 
persons, on the representation that a manifestly in- 
curable condition of sickness, disease or injury of 
any person can be permanently cured; 


5. Making a wilfully false or fraudulent repre- 
sentation for the purpose of obtaining practice in 
his profession, or for the purpose of obtaining money 
or anything else of value; 


6. Habitual intemperance in the use of ardent 
spirits, narcotics or stimulants to such an extent as 
to incapacitate for performance of professional 
duties ; 

7. Holding one’s self out to treat human ail 
ments under any name other than his own, or the 
personation of any other physician; 

8. Holding one’s self out to treat or, in fact, 
wilfully treating, human ailments under any system 
or method of treatment other than that authorized 
by such license ; 

9. Having been declared insane by a court of 
competent jurisdiction and not 
been lawfully declared sane; 

10. Employment of fraud, deception or any un 
lawful means in applying for or securing a license 
or certificate to practice the treatment of human 
ailments in any manner, or to practice midwifery, 
or in passing an examination therefor, or wilful 
and fraudulent violation of the rules and regula- 
tions of the Department governing examinations ; 

11. Holding one’s self out to treat human ail- 
ments by making false or grossly improbable state 


thereafter having 


ments, or by specifically designating any disease. 
or group of diseases, and making false claims of 
one’s skill, or of the efficacy or value of one’s medi- 
cine, treatment or remedy therefor; 

12. Professional connection or association with, 
or lending one’s name to, another for the illegal 
practice by another of the treatment of human ail- 
ments as a business, or professional connection or 
association with any person, firm or corporatio1 


February, 1923 





Py, 1923 


or sus- 
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February, 1923 


holding himself, themselves or itself out in any 
manner contrary to this Act; 


13. Other unprofessional or dishonorable con 
duct. 

Section 17. (a) No license or certificate shall be 
suspended, revoked or refused upon any of said 
grounds unless the holder thereof, or the applicant 
therefor, shall have been summoned to appear before 
the Department by a citation signed by the director, 
and unless the person so summoned shall have been 
given a hearing before the Department. No citation 
shall be issued except upon a sworn complaint, filed 
with the Department, setting forth the particular 
act or acts charged against the person to be cited. 
Upon the filing of such sworn complaint the director 
shall forthwith issue a citation containing a copy 
of it, and notifying such person of the time and 
place when and where a hearing of such charges 
shall be had, and commanding him to file his written 
answer thereto under oath within twenty days after 
the service on him of such citation, and notifying 
him that if he shall fail to file such answer default 
will be taken against him and his license or certifi- 
cate may be suspended, revoked or refused, as the 
case may be. In case such person shall fail to file 
his answer, having received such citation, the license 
of such person may in the discretion of the Depart- 
ment be suspended, revoked or refused, as the case 
may be, without a hearing, if the act or acts charged 
in such citation shall constitute sufficient grounds 
for such action under this Act. Such citation and 
any notice in such proceedings thereafter may be 
served by registered mail. The hearing may be had 
at a date not less than thirty days after the issue of 
such citation. At the hearing such person shall be 
accorded ample opportunity to present to the De- 
partment in his defense, in person or by counsel, 
such statements, testimony, evidence and argument 
as he may desire to bring to its attention. The 
Department, at its expense, shall provide a stenog- 
rapher to take down the testimony and preserve a 
record of all proceedings at the hearing, and the 
Department shall furnish a transcript of such testi- 
mony and proceedings to any person interested in 
such hearing upon payment therefor of five cents 
per one hundred words for the original and three 
cents per one hundred words for each copy thereof. 
The citation, answer and all other documents in the 
nature of pleadings filed in the proceeding, shall be 
the record thereof. Upon a showing of reasonable 
grounds the director may extend the time for filing 
such answer, may continue such hearing from time 
to time, and may, within thirty days after any order 
of suspension, revocation or refusal of any license, 
upon the written recommendation of the committee 
of physicians of the Department, set aside such 
order. The Department may at any time after 
such suspension or revocation of any license restore 
it to the person affected without examination, upon 
the written recommendation of such committee. 


(b) In all cases where the Department suspends, 


revokes or refuses a license on the foregoing 


EDITORIAL 91 


grounds, the circuit court of the county where such 
hearing shall be held, and the superior court of 
Cook County, if the hearing shall be held there, 
shall have power to review such suspension, revo- 
cation or refusal by writ of certiorari to the De- 
partment. Such writ shall be issued by the clerk 
of such court upon praecipe. Service upon the 
director, assistant director, or superintendent of the 
Department, shall be service on the Department, or 
service thereof may be had upon said Department 
by mailing notice of the commencement of the pro- 
ceedings and the return day of the writ by regis- 
tered mail to the office of the Department at least 
ten days before the return day of said writ. Such 
suit by writ of certiorari shall be commenced within 
twenty days of the receipt of the notice of the de- 
cision of the Department by the person whose li- 
cense shall be so suspended, revoked or refused. 
In cases where such license has been suspended or 
revoked such court may, upon the filing of such 
suit by writ of certiorari, upon a hearing and proper 
showing of probable error in such action of the 
Department, suspend the operation of such suspen- 
sion or revocation during the pendency of such suit. 
The department shall not be required to certify the 
record of its proceedings to such court unless the 
person commencing the proceedings shall pay to the 
Department the sum of 5 cents per 100 words of 
testimony taken before the Department and 3 cents 
per 100 words of all other matters contained in said 
record. 

(c) Judgments and orders of such court under 
this section, upon the application of the Department 
or of the person who shall be affected, shall be re- 
viewed only by the Supreme Court and only upon 
writ of error, which the Supreme Court, in its dis- 
cretion, may order to issue only upon showing of 
probable error if applied for not later than the 
second day of the first term of the Supreme Court 
following the rendition of the judgment or order 
sought to be reviewed, but if the first day of said 
term is less than thirty days from the rendition of 
said judgment or order then application for said 
writ of error may be made not later than the second 
day of the second term following rendition thereof, 
but not otherwise. The writ of error so issued shall 
operate as a supersedeas. 

Section 18. The Department shall have the power 
to administer oaths, subpoena and examine wit- 
nesses, and issue subpoenas duces tecum requiring 
the production of such books, papers, records and 
documents as may be evidence of any matter under 
inquiry before the Department, in the same man- 
ner as witnesses are subpoenaed in equity cases in 
the circuit court. The Department may, upon its 
own initiative, and shall upon the written request 
of any person cited to appear before it in accord- 
ance with the provisions of Section 16 of this Act, 
issue subpoenas for the attendance of such wit- 
nesses and the production of such books, papers, 
records and documents as it shall require in the 
transaction of its business, or shall be designated 
in such request, but the person applying for such 








92 ILLINOIS MEDICAL JOURNAL 


subpoenas shall advance the witness fees and fees 
for service of subpoenas provided for in suits pend- 
ing in the circuit court. Service of such subpoenas 
shall be made by any sheriff or constable or other 
person in the same manner as in cases in such court. 
In case any person so served shall wilfully neglect 
or refuse to obey any such subpoena, or to testify, 
the director may at once file a petition in the circuit 
court of the county in which such hearing is to be 
heard, or has been attempted to be heard, or in 
the circuit or superior court in Cook County, set- 
ting forth the facts of such wilful refusal or neglect, 
and accompanying said petition with a copy of the 
citation, and the answer, if one has been filed, to- 
gether with a copy of the subpoena and the return 
of service thereon, and may apply for an order of 
court requiring such person to attend and testify, 
or produce books and papers, before the Depart- 
ment, at a specific time and place. Any circuit 
court of the State or the superior court of Cook 
County, or any judge thereof, either in term time 
or vacation, upon such showing shall within proper 
judicial discretion order such person to appear and 
testify, or produce such books or papers, before 
the Department at a time and place to be fixed by 
the court or judge. If such person shall wilfully 
fail or refuse to obey such order of the court or 
judge, without lawful excuse, the court shall punish 
him by fine or by imprisonment in the county jail, 
or by both such fine and imprisonment, as the na- 
ture of the case may require and may be lawful 
in cases of contempt of court. Every witness at- 
tending before the Department at any hearing under 
this Act shall be entitled only to such compensa- 
tion for his time and attendance and payment of 
traveling expenses as is or shall be allowed by 
law to witnesses attending such courts, which shall 
be paid by the person requiring, or by the Depart- 
ment if requiring on its own initiative, such testi- 
mony or evidence. The Department, upon its own 
motion, or upon application of any person interested 
in any such hearing, may issue a dedimus potesta- 
tem directed to any commissioner, notary public, 
justice of the peace, or to any other officer author- 
ized by law to administer oaths, to take depositions 
of persons whose testimony may be deemed by 
the Department necessary in any such 
Such dedimus potestatem may issue to any part of 
Illinois, or to any other State, or any territory, of 
the United States, or to any foreign country. The 
Department shall have the power to adopt rea- 
rules to govern the dedimus 
potestatem, the taking of such depositions and the 
payment of all expenses thereof. 


hearing. 


sonable issue of a 


Section 19. The Department shall have power 
and it shall be its duty 
1. To make rules for establishing reasonable 


minimum standards of educational requirements to 
be observed by medical colleges, or by any profes- 
sional school, college, or institution teaching any 
system or method of treating human ailments, or 
by colleges of midwifery, and to determine the 
reputability and good standing of all schools, col- 





February, 1993 


leges, and institutions now, heretofore, or hereafter 
existing. 

2. To require satisfactory proof whether any 
medical college, or professional school, college or in- 
stitution teaching any. system or method of treating 
human ailments, or any college of midwifery, en- 
forced at any particular time in the past the stan- 
dard of preliminary education requisite to admission 
thereto. 

3. To standard of literary or 
scientific colleges, high schools, seminaries, norma] 
schools, preparatory schools, graded schools, and 
the like, in the discharge of its duties. 

Section 20. The provisions of this Act. shall 
not be so construed as to discriminate against any 
system or method of treating human ailments, or 
against any medical college, or any professional 
school, college or institution teaching any system 
or method of treating human ailments, on account 
of any such system or method which may be taught 
or emphasized in such medical college, or in such 
professional school, college or institution. 

Section 21. Nothing in this Act shall be con- 
strued to prohibit any person from using any anti- 
septic prescribed by the Department of Public 
Health of the State for the prevention of the spread 
of communicable diseases, nor from using antidotes, 
or rendering any other service, in any case of emer- 
gency if without charge or compensation. 

Section 22. All licenses and certificates hereto- 
fore legally issued by authority of law in this State 
permitting the holder thereof to practice medicine, 
or to treat human ailments in any other manner, 
or to practice midwifery, and valid and in full force 
and effect on the taking effect of this Act, shall 
have the same force and effect, and be subject to 
the same authority of the Department to revoke 


determine the 


or suspend them, as licenses issued under this Act. 

Section 23. If any section, subdivision, sentence or 
clause of this Act shall be held to be invalid or un- 
constitutional, such decision shall not affect the remain- 
ing parts of this Act. 

Section 24. If any person shall hold himself out 
to the public as being engaged in the diagnosis or 
treatment of ailments of human beings; or shall 
suggest, recommend or prescribe any form of treat- 
ment for the palliation, relief or cure of any phy- 


sical or mental ailment of any person with the 
intention of receiving therefor, either directly or 
indirectly, any fee, gift, or compensation whatso- 


ever; or shall diagnosticate or attempt to diagnosti- 
cate, Operate upon, profess to heal, prescribe for, 
or otherwise treat any ailment, or supposed ail- 
ment, of another; or shall maintain an office for 
examination or treatment of persons afflicted, or 
alleged or supposed to be afflicted, by any ailment; 
or shall attach the title Doctor, Physician, Surgeon, 
M. D., or any other word or abbreviation to his 
name, indicative that he is engaged in the treat- 
ment of human ailments as a business; and shall 
not then possess in full force and virtue a valid 
license issued by the authority of this State to 
practice the treatment of human ailments in any 








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February, 1923 


manner, he shall be guilty of a misdemeanor, and 
upon conviction thereof shall be punished by a fine 
of not less than one hundred dollars nor more than 
five hundred dollars, or by confinement in the 
county jail not more than one year, or by both 
such fine and imprisonment, in the discretion of the 
court. 

Section 25. Any persons who shall practice 
medicine in any of its branches, or shall treat human 
ailments by any system or method, or shall prac- 
tice midwifery, without a valid existing license un- 
der the laws of this State so to do, shall be guilty of 
a misdemeanor, and upon conviction thereof shall be 
punished by a fine of not less than one hundred dollars 
nor more than five hundred dollars, or by confinement 
in the county jail not more than one year, or by 
both such fine and imprisonment, in the discretion 
of the court. 

Section 26. Any person who shall treat human 
ailments by the use of drugs, or medicines, or oper- 
ative surgery (except any drug or medicine re- 
quired by law to be used in midwifery, when such 
person is entitled to practice midwifery) and shall 
have only a license to treat human ailments with- 
out the use of drugs or medicines and without 
operative surgery, shall be guilty of a misdemeanor, 
and upon conviction thereof shall be punished by a 
fine of not less than one hundred dollars nor more 
than five hundred dollars, or by confinement in the 
county jail not more than one year, or by both 
such fine and imprisonment, in the discretion of the 
court. 

Section 27. Any person who shall treat human 
ailments in any manner not constituting midwifery, 
and shall have only a license to practice midwifery, 
shall be guilty of a misdem@anor, and upon con- 
viction thereof shall be punished by a fine of net 
less than one hundred dollars nor more than five 
hundred dollars, or by confinement in the county 
jail not more than one year, or by both such fine 
and imprisonment, in the discretion of the court. 

Section 28. Any person, not being licensed in 
this State to practice medicine in all of its branches, 
who shall hold himself out by any sign or adver- 
tisement, or by a writing of any kind, to treat hu- 
man ailments without therein attaching to his name 
a word or words indicating the system, method or 
kind of practice which he is lawfully licensed to 
pursue in this State, shall be deemed guilty of a 
misdemeanor, and upon conviction thereof shall be 
punished by a fine of not less than one hundred 
dollars nor more than five hundred dollars, or by 
confinement in the county jail not more than one 
year, or by both such fine and imprisonment, in the 
discretion of the court. 

Any person, not being licensed in 
this State to practice medicine in all of its branches, 
or not being licensed in this State specifically to 
practice midwifery either separately or in connec- 
tion with the treatment of human ailments without 
the use of drugs or medicines and without opera- 
tive surgery, who shall practice midwifery, shall 
be deemed guilty of a misdemeanor, and upon con- 


Section 29. 


EDITORIAL 93 


viction thereof shall be punished by a fine of not 
less than one hundred dollars nor more than five 
hundred dollars, or by confinement in the county 
jail not more than one year, or by both such fine 
and imprisonment, in the discretion of the court. 

Section 30. Any person who shall obtain a fee, 
either directly or indirectly, either in money or in 
the form of anything else of value, or in the form 
of a financial profit either as personal compensation 
or as compensation, charge, profit, or gain for an 
employer, or any other person or persons, on the 
representation that he can permanently cure a mani- 
festly incurable condition of sickness, disease or in- 
jury of any person, shall be guilty of a misdemeanor, 
and upon conviction thereof shall be punished by 
a fine of not less than one hundred dollars nor 
more than five hundred dollars, or by confinement 
in the county jail not more than one year, or by 
both such fine and imprisonment, in the discretion 
of the court. 

Section 31. Any person who shall hold himself 
out to treat human ailments under any name other 
than his own, or by the personation of any physi- 
cian, shall be guilty of a misdemeanor, and upon 
conviction thereof shall be punished by a fine of not 
less than one hundred dollars nor more than five 
hundred dollars, or by confinement in the county 
jail not more than one year, or by both such fine 
and imprisonment, in the discretion of the court. 

Section 32. Any person who shall hold himself 
out to treat human ailments by any system or 
method of treatment other than that for which 
he holds a valid, existing license under the laws of 
this State, shall be guilty of a misdemeanor, and 
upon conviction thereof shall be punished by a fine 
of not less than one hundred dollars nor more than 
five hundred dollars, or by confinement in the 
county jail not more than one year, or by both such 
fine and imprisonment, in the discretion of the 
court. 

Section 33. Any person who shall employ fraud 
or deception in applying for or securing a license 
under this Act, or in passing any examination there- 
for, shall be guilty of a misdemeanor, and upon con 
viction thereof shall be punished by a fine of not 
less than one hundred dollars nor more than five 
hundred dollars, or by confinement in the county 
jail not more than one year, or by both such fine 
and imprisonment, in the discretion of the court. 

Section 34. Any person who shall in connection 
with any application or examination before the De- 
partment file, or attempt to file, with the Depart- 
ment as his own, the diploma, license or certificate 
of another, shall be guilty of a felony and shall be 
punished therefor as the law shall prescribe at the 
time for forgery. 

Section 35. Any person who shall _ wilfullv 
swear or affirm falsely, or make or file any affidavit 
wilfully and corruptly, in filing or prosecuting his 
application for a license before the Department, or 
in submitting any complaint, evidence or testimony 
to the Department under the provisions of this Act, 
or under any rule or regulation of the Department, 

















shall be guilty of a felony and shall be punished 
therefor as the law shall prescribe at the time for 
perjury. 

Section 36. All such fines 
benefit of the Department. 

Section 37. This Act shall not prohibit dentists, 
pharmacists, optometrists, or other persons, from 
lawfully carrying on their particular profession or 
business under any valid, existing Act of this State 
regulatory thereof, nor prohibit gratuitous services 
in cases of emergency, nor prohibit the treatment 
of human ailments by prayer or spiritual means as 
an exercise or enjoyment of religious profession 
or worship. 
Section 38. 


shall inure to the 










The following Acts are hereby re- 
pealed: “An Act to regulate the practice of medi- 
cine in the State of Illinois and to repeal an Act 
therein named,” approved April 24, 1899, and “An 
Act to revise the law relative to the practice of the 
art of treating human ailments,” approved June 
25, 1917; and all Acts and parts of Acts in conflict 
or inconsistent herewith are hereby repealed. 

Section 39. Whereas an emergency exists, there- 
fore this Act shall be in force and effect from and 
after its passage and approval. 


















WE ARE DOING THE BEST WE CAN 

The Lay publicity committee of the Illinois 
State Medical Society, in its campaign for sub- 
scriptions, receive many letters demanding that 
the committee attempt to correct the 57 varie- 
ties of menacing conditions confronting the pro- 
fession throughout the state. The Editor in his 
official capacity receives an unlimited number of 
letters demanding that he and the organization do 
something to protect the medical profession from 
the evils confronting it. The Editor realizes 
his many limitations and with the other officers 
of the society is doing the best he can to safe- 
guard the interests of the doctors of the state. 

We quite agree that there is much to fear in 
the future from menacing legislation and from 
an apathy on the part of the officials to enforce 
the laws now on the statute books. 

The solution of the problem lies entirely with 
the rank and file and it is to this source that we 
must look for action in the time of danger. 
Physicians can control the situation by their 
ballots and other activities, if properly directed, 
if they desire to do so. Apparently, they do not 
care to do so, and therein lies the whole difficulty. 
Physicians are so lacking in political foresight 
that they misuse the vote shamelessly. How else 
can we explain the present and past experience 
of a Congress that is so cowardly and platitudin- 
ous that it is a by-word among the people of 


























94 ILLINOIS MEDICAL JOURNAL 









America? These people are in official positions 
because of the apathy of the physicians of their 
respective states. It is high time that the doctors 
of the country are awakened to a realization that 
they have civic as well as professional duties to 
perform. 





THE LAY PUBLICITY EDUCATIONAL 
CAMPAIGN OF THE STATE SOCIETY 
Every member of the Illinois State Medical 
Society is being solicited for a contribution to 
the fund for carrying on a lay-educational cam- 
paign through the newspapers of the state. 

It is time the public is made familiar with 
what the science of medicine has done in the 
saving of human life; also made familiar with 
the dangers of quackery and charlatanism. 

Through glaring spectacular statements, and 
bought and paid for space in newspapers and 
periodicals, the Charlatans have distorted medi- 
cal facts and are menacing the health welfare 
of the people, by playing on the credulity of the 
unsophisticated. 

So brisk is trade in the cults, that even black- 
smiths, carpenters, plumbers and dressmakers are 
being recruited to take easy courses of from three 
to six months duration and hang out shingles as 
healers. 

At the last meeting of the Illinois State Medi- 
cal Society, it was voted to fight the “quacks” 
with their own medicine. The Council of the 
Society at its September meeting appointed a 
committee to devise ways and means to educate 
the public to the dangers of medical practice 
by the untrained and uneducated. The Commit- 
tee was instructed to prepare and supervise data 
to be printed in the daily newspapers and periodi- 
cals that will open the eyes of the public as to the 
progress of medical science, what medicine has 
done and is doing for humanity, which is in- 
tended to specifically impress upon the people at 
large, that a sick man needs a doctor and not a 
mountebank. Articles for the lay press will be 
handled by a reliable organization, familiar with 
the best methods of securing results from pub- 
licity propaganda. 

Educational data will be placed before the 
public largely through the lay press, assisted by 
lectures, pamphlets, etc. The subject-matter for 
the press, pamphlets, and the themes for the 
addresses to be made in public places, will be edu- 
cative, elucidative and general. Exploitation of 


February, 1925 


mm, tin Gin Gp 


ry, 1923 


sitions 
f their 
doctors 
mm that 
ities to 


NAT, 
ITY 

[edical 
ion to 
1 cam- 


r with 
in the 
r with 


s, and 
‘S and 
medi- 
relfare 
of the 


black- 
TS are 
| three 
tles as 


Medi- 
lacks” 
of the 
ted a 
lucate 
actice 
mmit- 
» data 
Tiodi- 
to the 
e has 
is in- 
ple at 
not a 
ill be 
with 
pub- 


2 the 
ed by 
r for 
r the 
 edu- 


on of 


February, 1923 


individuals or paternalistic theories wil] be dis- 
barred. This campaign will be along lines show- 
ing the virtues of the real in contrast to the dan- 
gers of the bogus. It will open the eyes of the 
men who are too ignorant to distinguish medical 
skill from “buncum” and clear away the fogs 
from those who should know better, but who do 
not,—turned in the wrong direction, perhaps, by 
some careless physician who is prone to despise 
the “day of small things,” and laughed away the 
seeming trivial pain that a patient complained of 
because only appendectomy or a cancer of one of 
the great organs was of moment enough for con- 
sideration. 

The United States Government has found it 
expedient to advertise government securities in 
this day of get-rich schemes. Purveyors of nat- 
ural resources, such as leather, wool, butter and 
eggs, are advertising daily the difference of their 
products over the synthetic wares flooding the 
markets. 

Medicine must retain its traditional dignity, 
but when the health welfare of the people is 
jeopardized, she must arise and expose the in- 
vaders. 

The proposed campaign cannot be prosecuted 
without funds; it must be supported by popular 
subscription. It is hoped that every doctor will 
subscribe to this worthy cause. Serious disease 
diverted from the incompetent will result in the 
saving of thousands of lives and will prevent 
much permanent invalidism. 

This campaign will achieve two great objec- 
tives: A gradual, but ultimate restoration of 
the medical profession to its merited place in the 
public sympathy and confidence and the inestim- 
able benefits to humanity through the consequent 
prevention of disease and the preservation of 
life. 

For the convenience of those who have mislaid 
their letter of Appeal from the State Society, we 
hereby reproduce the pledge card: 

Please sign and mail to the Illinois State Medical 

Society. 
To the Officers of the Illinois State Medical Society 
and Members of the Council. 


“I am in accord with the proposed newspaper edu- 
cational campaign in the press of Illinois, unani- 
mously adopted by the House of Delegates of the 
State Society at the 1922 meeting and the plan recom- 
mended by the Council of the Society, and as evidence 
of my desire to co-operate with the Officers of the 
Council and of the State Society, I hereby enclose my 


EDITORIAL 95 


to aid in defraying the expenses 


MAKE CHECKS PAYABLE TO THE ILLINOIS 
STATE MEDICAL SOCIETY. 


Sign the above pledge card, make out a check pay- 
able to the Illinois State Medical Society and mail 
both in an envelope addressed as follows: 


ILLINOIS STATE MEDICAL SOCIETY, 
clo Cashier, Sheridan Trust & Savings Bank, 
4738 Broadway, 

Chicago, Illinois.” 





SUBSCRIBERS TO THE LAY EDUCA- 
TIONAL FUND OF THE ILLINOIS 
STATE MEDICAL SOCIETY 

Below is a list of subscribers to the Lay Educa- 
tional Fund as per letter sent members in Decem- 
ber. This list has been carefully checked to 
make sure of accuracy. If an error has crept in, 
kindly note same and forward to the committee: 


F, 
E, 
B. 
Chicago 
Chicago 
Belvidere 


Chas. A, Albright 
G. and A. Alguire 
B. A, Arnold 


A. G. Aschauer 
Isaac Abrahams 


Springfield 
Chicago 


i BR ci wvacenecedeseseendsnsaler Chicago 
W. H. Allyn Waverly 


H. L. Baker 
H. R. Baumgarth 
W. F. Buckner 


Chicago Heights 
Rock City 








ET On REE eS Astoria 
Naik icrd.nianicdsv-Aede tne seule Chicago 
re Te etree ee See eee Pesotum 
ee ae a See Joliet 
OS Se ene | Ses Forrest 
ie I ils a aiaits cow's a redn Meenas Lowpoint 
George Edwin. Baxter........................Chicago 
TO 8 Wide odvi'ded ed ivdeed decad ocean Cicero 
Frank L. Brown..... Div awhdhae wes tabetws . Chicago 
NE a ae tl RED: DR Athens 
ta oukdsavnuenens nosh akah meee Chicago 
EE Pa ee ..++.--Eemden 
Ri I os. cake mieten aea an .......Wermont 
Pe sa caid daeheridatn cesver ant West Point 
Day Mi NT Cv ebis od ne cnewuetaveedéenuvauen Morris 
I bP it iv scbdadaveevanstebevsnnaus Chicago 
EE eee Chicago 
ee See eee Quincy 
os ES er eerie Chicago 
Ce eee ee en eee ee Du Quoin 
I Sis iui cuwesinaanwnneneewas ....Decatur 
| Serer aha: scribed Waka cor AL Chicago 
IR ia” Sa nasa ao dam eee mas ....Canton 
SR cc ch Socx kama acdwkene es acceel Peoria 
she oe we ance aeade Chicago 
NN a acai oa cinGinavied aectakxere eee Chicago 
Ea EEE 
I occ cane npeew ie ene bmatindmae Evanston 
way edn wailed ecru cnwsenman Chicago 
DD idicserwnxecsdaudaws kxheonwnie Decatur 
ee niin aos anhes. anaemia Jerseyville 
I ok a edi ane ae serene Chicago 
i 2. 2 ales kane sade wep ee eae cate Barry 
es nae aera Weasel Ottawa 
I i ce whan irk aa wes eae Chicago 
eer De Kalb 
NS dic wcaigdy catia wa wala aka ae La Grange 
I ng ao orld a ta ahca aite's SAN WA wR Moline 
ee a sin ovexakadeanecessene Rockford 
ee cin weak vides 4 Waisman Lincoln 
Siac 4 icaibie watediresenig athe ea eohsowe Du Quoin 
I on acne ngs aiae wwk ean 6in aan Manito 
Oe EE ee 
CR . necudurvonutwetudunws adel aeale Chicago 
NN cna oda dp wan teni ci wainien an earee Chicago 
ee ee Chicago 
Sa NG inacmccteedandéeaapevanderied Chicago 
i ae "ee ..East St. Louis 
a Le a ann hse niet ween Chicago 
EEE EL IEEE EE 
6 os. canna nhawenon Park Ridge 
| fo ee ree w iecotlecasaonreidtaacaneaall Oglesby 
ON Re Se Sep er eer re Bloomington 
cits his geek ee me nea Lawrenceville 
Nt wins eee ane Sie can paar Newman 
Rn rede pusesmaeeacnedeee Carlinville 
ioc adic aid nankie ak ean ee eae Chicago 
ee MIDs cc ccncceuneesnees rer: Rochelle 
ES eer ee rr Waukegan 
a ae datkeeasnaneatsawenwme Adair 
Oe onc 5 went a emer aee Ne Re Aurora 


96 ILLINOIS MEDICAL JOURNAL 


February, 1923 


A ie rid algae ee a a Alexis 
Be ee,  ncne bccn nih auus eden peuian .- » Peoria 
A. Miltom Com. .:%..568..3: Frctin: Abi aoatva ecadeblebtai aac eas Argo 
Beer Ceetet +s. oc icc dcccccswecddccccccus Chicago 
TE Pe eo Re Re oe Moline 
[ME nn ee ee a Canton 

Be SESS ae et Murphysboro 
ee ER ecicniewandcindauxwiescuun Chicago 
Ne ee ane NG ae oe irars wardacke w Chicago 
i Pe a. wh ctinea snbs eek and hcmeaewn Savanna 
Ws I ed iritenesneesecantinaswonen Chicago 
Tr ee ae Chicago 
ye Ee ee Silvis 
i inn cule occ aimed oeeaweweeue Decatur 
Re Oy ch ti sccksiuncvtietcanweneoesaen Chicago 
iy ti cncrkabhencenngensxvhadeume Ridgefarm 
DM ciwndt ehoudaddis sateecdennanteieen Peoria 
a ee areca ishing wae Evanston 
i I IN ss wane acing wadaunnd Deerfield 
a i Re ce ned el athchn tian ea waiieden Sullivan 
EE Ros chaiwanandreugeeydcbawiebekaas Avon 
Bee nda teckeagdckcngundieswacsed Elgin 
ee Rs dhs eccisscnesealtecedeawens Chicago 
i i, MS Sik isa gih: denim obec bem Bushnell 
ee eg ee eee Carlinville 
sv cn wie enaeaadadwenee Chicago 
RE ths PI oot cdnnnicemnbenekehaeeeee Chicago 
og a ree ee Evanston 
Bh NS nanan ade naesnnienecaaenelena “Rantoul 
5s idedervaneatdesaenceeecors Chicago 
SEIN teansotu dsunskwieeseannaril Des Plaines 
Pe Wa inca xdessnnanaQuee conden Granite City 
Se I, id acvannamisbead Ridawedatenne Lomax 
i, Pe Rc ind eine dry anced Seaweed RR Peru 
ee 
EE  eicicin shin nit ghd whick den awiidele Chicago 
Ee a 
i ee heat ice hreccles te nelene kan naam Dixon 
BE th, Rs Sniciscdnniwasewksuceaneeck Chicago 
Ee ae Pe ee Quincy 
IED gig en kines kewedeeduccniexewaws Dundee 
EE 
ED cad sescridetiedenkeadseeebensaan Chicago 
ano pica cen abarenascehGunn Mattoon 
NE Oe is ivan ie wece hwnd weenie Belleville 
UR iain wiuiiats wanian wingers kee tema Chicago 
ee nist ier eciantdieequiacemmen Chicago 
Ee eres East Moline 
Retr BE WEED, «ow oun coccccwcccccnssces Chicago 
ER oo Saw cube sien meetin’ Chicago 
ERE Pee eee er Pe Pee Chicago 
SE SNE... vo ebatandbanncceedhdsbccaan Chicago 
ia dts anise Digi Skis aoalee keane Erie 
Bl Rd oicxsunktssdieudenctnpacsdatowel Olney 
thnk wa dies Sti wdeunnnk’ wesseesss adkiverside 
le, SR, aod alk: Uebdae eacks neuen . Richmond 
SE RE ee re rE ee ey ee Pee Chicago 
ls Ns citer dd nln beaters dewecbariene Chicago 
Pe a I edsSngiidaatt oattraes . «<e.Chicago 








.- — pg. eo ef a om eee ted bet Gee 





iry, 1923 


.. .Alexis 
oe Peoria 
_... Argo 
- «Moline 
. Canton 
physboro 
- Chicago 
. Chicago 
Savanna 
. Chicago 
Chicago 
. +» Silvis 
Decatur 
. Chicago 


dgefarm 
. - Peoria 
-vanston 
Deerfield 
Sullivan 
... Avon 
_..Elgin 
Chicago 
Bushnell 
rlinville 
Chicago 
Chicago 
vanston 
Rantoul 
Chicago 


Plaines 
ite City 
Lomax 

..Peru 
Moline 
Chicago 
nmouth 
: Dixon 
chicago 
Quincy 
Dundee 
Milford 
chicago 
[attoon 
Heville 
yhicago 
‘hicago 
Moline 
chicago 
hicago 
‘hicago 
‘hicago 
.. Erie 
. Olney 
yerside 
hmond 
hicago 
hicago 
hicago 








February, 1923 EDITORIAL 97 
ee i SI ava sanVereschesccsenctew es (Sie Ue, TOR whine cacesdcvanndacs seasons Chicago 
ee ceeiihnne dds sekenneies waeewekaewi ee .. SE ENE hv cndcccscndvenddesecsocvess come Paris 
eR eer Cairo 
Dy Ci Ronski thas tnkidedatrndRaesaoed ee ee TE ON nic vncesccecescvecsductevenessal Quincy 
NE SR as cnccccacasnctdcsedesdoes Se. TE, Be MEMES ib ssececcessecctansausviesine Plymouth 
i; ME iceuntess cadeesetesescesvbubacud Chlemmw © J. Weed 0c cccccccccccsccccccscecseceseses Chicago 
W. W. Gourley..................0065 Downers Grove ‘Ludwig Ilse ............ . Chicago 
i tS eb candeensseveseeneseuennweenee Geneseo . 
W. H. Garrison............ 0000. cceeceees White Hall Edmund Jacobson ...............+. te eeeeee Chicago 
Wen, V, Gooder.....<ccccccccdecocicccnwece Marengo J- P. 6356s RatancewewedeeTesedwe UEEd Varna 
By ic catscesivescsesdtncscameaee La Salle L. B. Jolley...............seeeeseeeeseees Waukegan 
i ME I, co wescvansccsencesdhweee Cave In Rock 1- Arthur Johnson............-..-+-+++s+5. Rockford 
John F, Golden... .........c.cccsccccecccencs Chicago Edmund Jacobson ............ ++. ..0ssceeeees Chicago 
EE cnningde since wWeevececdeneboudete Chicago H. E. Middleton.............-2.++seeeeeeeeeees Alton 
ey a ene ae ee Chicago Fred Wade Jones...........--...00sseeeeeeees Alton 
Dy Ae EN  6eccserereesescesneicossacad Chicago L. B. Joslym..........-.--+++0+e+s0+++++ ++. Maywood 
Benj. Goldberg .........ccscceceeecuuscececs Chicago A. G. Johmson.........-..-...+seeeeeeeees Galesburg 
SL AE bn cndcssissecvadncnctisbentnnns Lostant Warren Johnson ...-..-.....-+.+s0esessesees Chicago 
Be  aekdi den entd cianeewe thera theme Chicago 
: ain Se Mian cksessenecsceccqesseecneqtadl Henning 
i mee... mee Chicago Franke J. Fkasss..sccsssseeecsssseeeesseee Chicago 
TIO oo ccranscaccsersavtu'ewensaeis Chicago . 
M, J. Hubeny .......cccccsscessdcdscdeesées Chicago Charles E. Kahike.............. 0. 0000ss000u Chicago 
Gi de ID coer cncvssesanea¥euebesees Lexington Emmet Keating..............-+00sssseeseeees Chicago 
S. F. Harter....... ccc ccccccccccccccuce Stronghurst A. A. Kmapp..........-----e0eeeeeeeeeee eens Peoria 
hy i innscveccessenescsesdsvadeswiogl Chicago F. L. Kmapp.....-..--- +++: -+0sss0ssees sees Chicago 
SIS vn svecsencdesvsdvessvenciseds Cairo F. J. Kaster...........-+0eeeeeeeeeseeeeeeees Chicago 
rere Chicago W. W, Kumtz............-.--0seeeeeeeeeeeees Barry 
IE aiccinssccesncodedddtdeasicendiia Chicago LL. P. Kosakiewicz...........-..-+0+s00s00: Chicago 
R. O. Hawthorne.....................++++Monticello Girard W. Krost...........sesessseeeeeeeees Chicago 
‘ff [yer »...East St Lowis L. C. Kmight........---0-+00.eeeeeseee sees Carthage 
We Sn Dio iiciovcyecqssetedinansbies Chicago 5S. Krumbholz .....-....--+++++0+ss0sseeeee0s Chicago 
Ge is CR ctcctecrtedsecsessbbbucesen Evanston <A. Krueger ........---+00se00seeeeeeseeeees Chicago 
i ee... ce cdueenseavesteake Janesville G. T. Kaiser............000eeeee ee eeeeeees Highland 
Frank F, Hoffman.............cccccccccccees Chicago Charles R. Kerr..........-.2000eeeeeeeee evens Chenoa 
M. O. Heckard..........cccceccccccceccucees Chicago W. L. Karcher...............+00sseesseeees Freeport 
H. N. Hefflin...........cccccccceccecccccces Kewanee <A. C. Kame.....-...0.seecceccecceseseeee ss SVCRMOFE 
PE ertinccrcidideiacvintesevestekaiwsels Chicago W. A. Knoop.........--..00s+++s00eeees: Chesterfield 
ee ee eg caccansvacecdbcactcus Chicago 2. V. Kimball...........--..0see0seseee ees Hillsboro 
iy Sh ME naceatneeascctsseeeeisioseboonens Streator J. M. Kaiser.............-s0ssesseetee eres seed Aurora 
George H. Hansen..............ceeceeeeeeee Chicago P. B. Kionka................----+++0+: Melrose Park 
iB nce cieicnndscacselsstisterssnes Chicago Thomas H. Kelley.............-++s.s0eseeeee Chicago 
Be ee MR cay ccccnteeneccveveabacssnsol Chicago C. B. King.........-. 2.0022 seeeeeeebeeterees Chicago 
a” rere rere Springfield Ralph King .......--...--+seeeeeeeeeeeeeeees Olney 
Wee Is occ ceccscscavcovectseseeed Kewanee Karl J. Kaiser................00sses05+.¢.+-Aurora 
ee ins vavcusseduavectsnctee toveie Moline J. C. Krafft.............--- 0000220 -+++.++Chicago 
We Be BR ovisccccccpradsveasksexcendast Chicago H. E. Kerch..............00eeeeeeeeedeeeeees Dundee 
SN Be Bi icncdcnssccenesouvesssuesduge Sidell 
WE Te FR ins oiccdcessaccecsitesictesse Freeport Francis Lane . er ee - 
Ce ME etctcncnannteeenanereekenseeea CD. EE cc ciicichswcnsiews anacenksae st uabainn Chicago 
DID sniinencacenssdcasnassatnseeheseen ee: | Me ee PR ci devacacescsuveedenassessapane Moline 
Marion D. Henderson.............6...-++008 cn cneeceses ecanptesescusiamneeell Depue 
R. C. Heiligenstein............ Misisseasdee ee A, WE, BR ics vec ccecccccevceets East St. Louis 
Pere re Tec rT ee Se: TR I ca snvnvcsencvecsnseceeseatees Chicago 
Gobet TROTMAR 0.6.6 scc ccs ccscessdstevsnces - 7 a ye RE ei East St. Louis 
i Sy | | SE es eee Fe Bis iincsdiccvseswatvedndeoeden East Moline 
SE veg ioe dscnegsceeeneesteadaehuee ee er a ere errr Oak Park 
Pin iadescacsiancecctadssscecead ee ee TTT te ee Chicago 
CN TS vic iaine ceeeccsasacaacesivesenied ee ee ens shat avecesexsenen nanan East Moline 
Chastes We. Tlalll.....ccccccccccccsveceees Farmer City Arthur E. Lord............ccceccessscecccecne Plano 
ne oc pad paeenw ete eenane 9 OE  ccicacaesiecacdsvenssenwnd Chicago 
Reid Owen Howser... ........ccccccccceteeses ee PU eee rece clsadineuseudans Ellsworth 





i icincnhaeacuners bcubedtbesail Gibson City 

iv unaap abdewssanvenasecunmennl Chicago 

Se Kcaetcibinevenvecedtasnesaons Cerro Gordo 

RT Elgin 
Pi INNS ccendvindsndeesaseéckausasueal Elgin 
DL Catthiectitanedccndwatneeenene tie Chicago 
Pe i PR pint rivesadaennbenednmewnane Griggsville 
Oe Rs dc ce cd entassenewanancavmedere Pana 
I I i og haan wake aeMenteell Decatur 
EEE re ee Evanston 
ia PN o'0'0-000s00is0s sce ceeccveveen Chicago 
EERE OTE Chicago 
NN ETE EOL ETT Chicago 
Ras tueededtanciepeeirveadubae Chicago 
i ee iin d oeiaceneneaweaa Buffalo Prairie 
 ecnGedsdenixsnatenstdaddwus cous Macomb 
NS xcwigmimunentaekenanewenalen Chicago 
i i  cececepeenehe cant Spring Valley 
EE nk oe kau geaibowanarewake CaCee Chicago 
I cnc hanuwenmenenwinnes manaee Springfield 
ee Nc bc agupensantasiaaenedeie’ Chicago 
ED ic cendkewsindasns cob anneies een Chicago 
A ere errr re Belvidere 
ie cua ngdae ean ade hamnenae Chicago 
ite rnabeekaesuneseeeeeaien Franklin 
ccna nee aexanenenenie Chicago 
EE A Re ree Freemont 
SR ne cn ccuen kes ad eaewe nana Chicago 
NN cc ce cawanabneeeeaKkekan Chicago 
nek ic geneaces ae ane .....Mendota 
Oe rere 
le IR, scree ctacceseceevewenenee Galesburg 
| EES SEs er ee Bloomington 
NN EEO DEE EOE LE Elgin 
eS acca piu daebicastvsewenewent Chicago 
Charles Molz .............s00++++.0-.-. Murphysboro 
I wtnccuvesccstinasedesasees La Salle 
arin t numer nniwnnny aed Rock Island 
Re i ices i wa meebo ines Caea See Rantoul 
Gn 6 cana end weedacadenaiel Chicago 
ks 64 ane nana ec cen alee eeaal Urbana 
LPL ETE IO EET Bradford 
NY Ws Din oscnnscssccndsecevavven Chicago 
cn dnd unaalamna een ebeetaniil Chicago 
ns on. cnn ea kw es bakicewenaeuell Wilmette 
in cba ace dncneenenenn ame Galesburg 
i i tok sna cid ab aean eae en ncordiateen Chicago 
NI os cites tedden incedeenh nanan Dupo 
NE nina ounvanenenkun exes eesnauneel Troy 
i ci aeeinddks deen emit East St. Louis 
BOONE DRMIOROY. 6 icsccscseccccetansedes Rockford 
sc cdcvtgaenedeusdandeicserbedean Dundee 
ER ioc onc cedegeunbetekeaeweneheee Auburn 
tc sciavenceensecasenasoune Naperville 
a on oe as Sn eg aeeaeeenbens Pontiac 
is ER, c vaaweskeaesdcessonsana Chicago 
EE ere ee Elmhurst 
i a's <5 chine smkeasaeceeeneeaauan Marshall 
ILE PEAR PEE Chicago 
ee ii een his when ulax lw aSeered Virden 
Sie Is cnivnnnwnseccnenensentes Naperville 


ILLINOIS MEDICAL JOURNAL 


February, 192: 


Oe eR cs nckcncneceweweeéou Chicago 
Re  citcteditekats consseewnenwawe Springfield 
Th, Be cc ccesevccscccsessccecssessecs Chicago 
PL neskédsdvdessadeeveuscekouw Kankakee 
SRS r ee rE Chicago 
Be ans Cai ounehaaahnna ene Kewanee 
ele Ry is.ks ke ecmewisencsecacsaesuaee Wheaton 
NE. cs ntwnsinbamnnneeikwhanal Chicago 
Pi Se Ea tte snddteadessssescivaweseuel Chicago 
DIN, x cvkidecadamebdonsenencetel Springfield 
Bo RE eT 
EE, ME ieceniecarewrnsinnnasneeseann Chicago 
TT eer Chicago 
PI icc ieitdesnwy aid donnenenwed meee La Salle 
i notes ecu 6eSbenennewedieds Murphysboro 
Sn RN ciricerecekiweinsencnescousene Sycamore 
Eo ccscnccedorenenrevetsaeeill Chicago 
a ne ee: Trivoli 
eee enn Chieago 
AE iit itaie au ened nseeiaceindiwn’ Chicago 
Se ad cag nneanasedeekacwaceweae Morris 
RE Ee el 
SN TN iii ccs cau miceneiweennesaewenwl Chicago 
ee Te aera ee Chicago 
Se No, nosh wcneakvdbnnniaell Chicago 
ee ee es Freeport 
as arn deal arp tak des Segendiatbecw ances abel Dundee 
ee Rit bics cpaseveccenadenseaneee Princeton 
Me ced warns eersciin toi Riaee ae anoonele Chicago 
SE hckkntuenavensaveskwensaecemenel Chicago 
S.No 6. ov cuscnndecsscouscaned Chicago 
SS EE meen Chicago 
oe eae wee Chicago 
PE co ccninexiveiddendeasidanedee Chicago 
ene Vecaeaiecnakcenewsauceee Streator 
ent tedineinnst abun ckaceneabe Chicago 
Re iis wea dicinraniy'e Ata ote hed aa Chicago 
NG Se Chicago 
iad a wt ennien aaa Farmington 
I SE. 0 ig nvanesisdecewtankemhankee Geneseo 
Ee ee ae Rutland 
i aa eancnttpitedennnaeene eee Robinson 
NN «4:5 anagem wun Guat eae Chicago 
is I: cc cnncdinpandecoananied Beecher City 
OR eer er ee ee Chicago 
Eee ee Wheaton 
i ce aoe ng: cuban waiembnenneh ad Chicago 
ie tee IS cc ddancsckeenacausssaeonesenl Alton 
ST IN ns ciinecntwenndaccauseaueane Canton 
TE 
Eg Er Highland Park 
Di ee nbt0 cdateseensnsdesiandceqabarae Liacoln 
Be PR cs od vevadesdeensseusetewenennes Ullin 
Se PL, cnctckdccsdeettieuggekerinael Chicago 
CN I ivr cnsccuds aca iebateeneann Columbia 
Dh ER oi cad ceawendkensnden es aucune Decatur 














ary, 192 
. Chicago 


Pringfield 
- Chicago 
Cankakee 
- Chicago 
Kewanee 


Wheaton 
: Chicago 
Chicago 
ring field 
- Moline 
Chicago 
Chicago 
a Salle 

hysboro 

‘camore 











February, 1923 


ee ene Iverdale 
stab ikistendecnveesncsnanaevensed Chicago 
Oe i ics we nem rmdiieleniiewes Chicago 
Fe, PIN, oink ce dcutscccccscoasenes Chicago 
El Mbenetissssasesicetescecsounsieosnid Chicago 
2 ee ee er Chicago 
ee eee Freeport 
Oe is Sa cece caxduasuasneaencanawean Chicago 
ye cis pada dint ekaeNedwensekaeae Galesburg 
DN TE: icdidsnetesssaverrase+nineesanie Belleville 
Oe  N nwiknn 26d paesneed es onniten Murphysboro 
s,s 60s oh cekerndboeneraasenbe Chicago 
SSE, CRG sSanbeeseennseenad der wncponie Warren 
Anthony Reid ........ jieebsedwecddesemmesed Chicago 
Nts ae askin ibe ie ass helm eines La Grange 
Di Wadiresanseaentesenatcnanincenes Chicago 
Se er re ere Naperville 
ET ee re ree” Oak Park 
PE RG icccscen incr daacetananeena’ Chicago 
=e ere Clifford 
i A ee I sian desvtaessnecdsansdcat Red Bud 
St a, SE cir ad pends shherssencsieaaands Chicago 
 iicivaksdanitnnkn seasnsheenenenede Lena 
Ba hs Sere swadeusccancedswesewavsavane Chicago 
a ER cee acnian een wie irhd anneeae eerie Chicago 
8 0 ee ea eee Atwood 
BE Si I cance tapeanseansenmepmaeiad Chicago 
Bs Bc ME Reiasancae ceusenscaevcehond Williamsville 
DAA a eee rnn dad siete ab8 6 weed aoe sees Chicago 
Ge is IS is086dceeeenrsesécsdocesackead Bartlett 
8S 0 SR eer rer Princeton 
BE Ba Es vince cadcwesneuns sacunceadnes Chicago 
Re A ES bkrienakneskencnenensaskeesenaeel Alpha 
Be Pe iccccnanvencvateshextadasnes Rockford 
Oe OT ee Chicago 
DM etincicnnsnanécenertesdannewedid Chicago 
NE Ss Sa vi vninnedsetndenerensenenal Chicago 
eG NE. Gaccnenenewcsundsranceccenaeee Mascouth 
EE 
SPUD. Bis SIs v5 oe cecesnnusesenccousas Chicago 
Se re eee Chicago 
OR ee 
Clifford E, Smith............ a eathcaamatnsiiel De Kalb 
Oy SL nite viketadde cen akandcennnceneGih Eureka 
Se eee re Bloomington 
MR, Me RS canswcntacwwsensesserveeceul Chicago 
er et baka cbencnsecennvhcut mire Harvard 
Joseph Semerak ............cccscceesccace Oak Park 
SE | s.chanancacassncseeetecenmanad Chicago 
5 < eer re eer Moline 
C.F Bi vccctasavas cwastesasncans Charleston 
A ere Chicago 
Robt. Sonnenschein ........-.--.---e0-eeeeee Chicago 
See Co Ge, BI. ce cesesceccvcns Granite City 
PD Be ME sdcndsnevesscassiccessonnan Chicago 
ie. Eo i rddaweskcicnseencetscsanneants Chicago 
3 4 ee Geneva 
Re en ene ae Chicago 
Carl G. Swenson............cccceccecceceees Chicago 
 & Se SCRE rear Litchfield 
od bai an decinaeand hill Chambersburg 
Be WEEE os i nin casdadcaksanbocumeasael Streator 


EDITORIAL ory 


Sc inscccecnscnoncducbcsvenaetasess Ipava 
TG i Is co nniiniinwesennnabiaiees Canton 
Oe i iieneaidesictnnscwencsenseadwese Morris 
PEs MNS 66a 4 6s edesewanasetdusnecatane @ak Park 
I Sib, REC <tnawecchaxccahebaaseccbar Chicago 
CO Oi RS i. cnn onsindsanadeneeessazaia Batavia 
De: Sct ew bi varswikaianbecanewanune Savanna 
ee Me itkckinnareewasedaueasdnabe Pittsfield 
John Huston Spyker.............cccccccccccs Decatur 
ie eM cuvncicienndnsamaiadeanaeenacs Chicago 
MG ae. SS cine scnawdv eon snndvencaeseses Galena 
Be ie I ii cisindeccndninonsexaenanandiieen Ipava 
a Chicago 
Se _ Chicago 
Ig LE tite ii eeawadinasnceenansennianas Chicago 
Ny i MN inctdeuwkieceiivewscsiwiaanne Chicago 
MID cei cdeestasctvcsanccvaceensd Chicago 
ON RE Chicago 
i, a A i020 4860es ends exnwaRerccancine Olney 
enh PNG vnc casicanveneiawseatenenbeanke Decatur 
i a i cnetnveswecuasuatieianawad Long Point 
a (ieenade hinteseneieans Manteno 
BE eRe ticcwwiekuncadueiedrenestalen Peoria 
Di. es ic kkinndvisstecendiacueede Bridgeport 
ie We ni eicccaseusescdadeesecaneesed Rockford 
Wi SE) ete dgecipenedenesé cinees oaal Rockford 
NE ND 6: ckcnecn dn ckseesusecnvsaawse O'Fallon 
i, Wie MIN che5b6NeddaRAcd dr ananewswowseuied Olney 
Sk Sy MN ac nckeeandevesaurhekandanaaed Chicago 
Oy ae Byron 
ee rer Lawrenceville 
Sh Ss PE adsednkonecscecncessataans Chicago 
MEE. SEE wa wether ne incdes canskstecncsaweed Chicago 
ND is dincnnukreesvccnenbis used East St. Louis 
Be Me, BN Ka vetessndsiseekenncneemadaaded Chicago 
Wes EE Avtncicinasaeniseisvesstneenciasa Chicago 
es EN ess ceccscankvenswouses Beardstown 
yk abn cs cawearesexanewuskadasi Chicago 
is Sis. cxentcwesidndndeeeabeunten Chicago 
iy ie Ws ban swniwkceanenascsasensensadand Chicago 
i Ee sankdagennine thnunoncKed East St. Louis 
a ee eee, Chicago 
eg er re are Chicago 
De Be PKG anus nats keeoneeereenevasauaans Chicago 
er: Wyoming 
gg pp re eee: Wyoming 
ee A Shs saan anebasedcedceade ped Chicago 
A eer Decatur 
ME ic cnaguinceskterdseiebaanmeawaed Chicago 
og ee peer Chicago 
Re, We ba acicntdcrnencwedisannweakaue Herscher 
Ws Oe IR i otacctncdseceiehaasaueutant Quincy 
sf 2 er ‘ertasiesenil Monmouth 
We Se EE cba senvdcvccscnawaseneds Rock Island 
SN i Wav eneanss. seakdeneduacen Woodstock 
a Ms) Wa Acai beee dene ebbkeraiadenesdes La Salle 
ie. Wis WN aideeesaweaesessnbendecheus Chicago 
BE Wie, WN Sdvcacecccecesiesctaceveus Chicago 
Se ER Chace eneaiediwsdienwes anaes aed Sparta 
RO rere ET Chicago 
Dt MT iGckhensudeskiussea snake vedadean Marshall 
ee eee pidauiankees taeaxewael Chicago 





a ies sh bn win em ieee elie .. Chicago 
PE oats awe 'e 5 waa & mamneormenimins xen Joliet 
0 Sr rr re ar re Chicago 
L. H.. Wiman.. La Moille 
M. S. Wien. .Chicago 
J. T. Woof ...Chicago 
Geo. A. Nash... Gibson City 
C. S. Wilson.... Freeburg 
E. Ci. Wes. icc eees .. Downs 
C. E. Woodward. . Decatur 
FE. Windmueller Woodstock 
Theo. B. Wood... Chicago 
G. T. Weber Olney 
J. A. Weber... Olney 
F. J. Weber Olney 
se a Cale iadcins dS cennee soul Olney 
G. V. Wyland. uibb hea aah Sedan anaes Chicago 
od cas wipiw ale orm were ..-Joliet 
S. H. Waterman ... Chicago 
T. G. Wallin.... ..Chicago 
Geo. W. Webster Chicago 
\. A. Whamond .Chicago 
H. Woehlck Chicago 
C. J. Whalen Chicago 
K. N. Wakeberg ... .Chicago 
Carl H. Wilkinson ..De Kalb 
A. Yuska . .Chicago 
EK. Young Mansfield 
T. Z. Xelowski .Chicago 


Be ee IR, civnwenuseaseuisananeewens Cameron 

Note.—Rock Island County Medical Society con- 
tributed $100 to the fund. Rock Island County So- 
ciety is the only county organization that contributed 
to the fund up to the time of going to press with this 
issue. 

25 E. Washington St., 

Chicago, Ill. 
Lay Pusiiciry Com MITTEE, 


MEDICAL EDUCATION SUBSIDY 

John B. Deaver delivered an address on this sub- 
ject before the American College of Surgeons, 
which is published in Surgery, Gynecology and Ob- 
stetrics. Said Dr. Deaver: 

“We who are doing the world’s work must see 
to it that our influence in this respect is not usurped 
by those who sit at their desks and think out spe- 
cious arguments, fortified by vast financial power 
placed at their disposal by well-meaning men who 
are not themselves qualified to judge in this sphere. 
but must be guided by advisers who are not always 
infallible. I am thinking of the recent furore in 
favor of the full-time teacher in clinical branches. 
I am musing over the creation of great clinicians 
overnight by the feat of powerful influence. I am 
impressed by the rapid metamorphosis of the fledg- 
ling, nurtured, shielded, not to say mentally con- 
fined within the limits of sympathetic institutions 
and departments. I am not questioning the motives 
of the originator of this audacious movement but I 
am concerned for the students, and would be 
alarmed. for the profession were it not for my great 


100 ILLINOIS MEDICAL JOURNAL 


February, 1923 


confidence in the sober sense of that great body 
of a democracy such as this, which will eventually 
work its way towards its own proper method of 
dealing safely and sanely with conditions. Still | 
marvel at that new super-intelligence, which in rapid 
pursuit of its ideal, sets aside the principle of natu- 
ral selection, the well-proved motive of human 
endeavor (high reward) and the cardinal virtue for 
the attainment of practical results—experience. In 
my heart I am thankful that such men had no voice 
in the selection of a generalissimo for the allied 
armies, and I note with curious reflection that the 
vast resources upon which the idea floats were not 
obtained and are not conserved by similar fancies. 

“During the last five years, as you know, the 
tendency has been toward the full-time clinical 
teacher. Its central idea was good, but its applica- 
tion, begun before the war, if I mistake not, was 
influenced by the German idea of efficiency, which, 
as you all know, failed utterly to include the human 
element in its equation. Without wishing to appear 
reactionary, but with the interest of the profession 
in mind, I do not hesitate to say that I doubt the 
wisdom of the present course. It is an extreme, and 
the pendulum must soon swing in the opposite di- 
rection. The professor of clinical branches should 
not only be allowed, he should be obliged, to be in 
direct professional contact with the public. The 
science and art of surgery are one and inseparable. 
There can be no art that is not based on science. 
and there is no science without its practical appli- 
cation. Of the chaste union of the two shall spring 
the fruit of the tree of life for the untold millions. 
born and unborn, whose lives and whose happiness 
shall depend upon sane surgical science and safe 
surgical skill. Science has been kept sane only by 
constant contact with observed and demonstrable 
facts, like the giant who renewed his strength by 
contact with mother earth. Practice is kept sane 
and free from danger of the rule of thumb only by 
a constant infusion of science. The problem of to- 
day is to avoid conflict between these essential ele- 
ments of a real union, to provide for their proper 
function, to inculcate into the minds of the young 
the true conception of their relations and responsi- 
bilities, and to deliver to society the greatest good 
to the greatest number. The last consideration is 
the most momentous one, for it means results, and 
it is by results that we shall justly be judged. 

“We must deplore, therefore, anything which de- 
tracts from that high standard of service to the 
community which the community has a right to 
demand, in view of the extraordinary freedom and 
power which it has conferred upon us. It is our 
profound belief that the system of full-time salaried 
chairs for the clinical branches which has been 
forced upon a number of our foremost institutions 
by powerful influences is not only contrary to the 
spirit of American institutions, and contrary to th: 
proper workings of the human mind, but that it is 
sure to result in degeneration of that art which i- 
the true power of science, and in the deterioration 








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y, 1923 


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February, 1923 


of the instruction to the student in how to deal ef- 
fectively with the problems which he must confront 
in his chosen life work. To me the plan smells of 
the midnight oil of the theorist (to say nothing of 
the oil which has lubricated the ways for its launch- 
ing). It has in it none of the red blood of the real 
administrator working to get results with humanity 
as God made humanity. In its application as I have 
witnessed it the plan shows no appreciation of the 
jact that the head of a clinical chair must be a 
clinician. Is not the clinical art also a science? 
Does it not rest upon knowledge and does it not 
depend upon aptitude, ability, experience and hard 
work? Can anyone become a clinician by merely 
calling himself by that name? Does appointment 
to a professional chair make him a teacher? Or is 
it no longer true that in addition to knowledge, 
which is not so common a possession, the success- 
ful department head must have qualities.of personal 
integrity, stimulating personality, and administra- 
tive ability? 

“In attempting to remedy the evil of the clinical 
professor overloaded with private practice and 
neglecting his teaching, his department, and his 
scientific work, these men of admirable intentions 
have gone to an equally unjust extreme. Orderly 
evolution was going on, even rapidly, if one consid- 
ers world movements; but it apparently was not 
rapid enough for those who seek to reach the 
heights in a bound. But this is the day when the 
professor may try his theories on the whole human 
race, and the Pied Piper of Hamelin has his coun- 
terpart in Russia and would-be imitators every- 
where. 

“If I mistake not, there are signs of returning. 
sanity. The domination of those who have. shown 
their inadequate grasp of the whole problem is be- 
ing loosened. Let us hope that the education of 
our youth will be entrusted to men who are out- 
standing figures in the field, which they are pre- 
senting to the impressionable mind. Let us all fully 
realize that science is the beginning of practice, and 
that practice is the goal of science.” 





FEDERAL AID CONDEMNED BY FRANK O. 
LOWDEN, FORMER GOVERNOR 
; OF ILLINOIS. 

Ex-Governor Lowden: in the October, 1922, issue 
of The Woman's. City Club Bulletin says: 

The framers of the constitution recognized the im- 
perfections of democracy and sought to guard against 
them in the instrument they framed. They proceeded 
upon the theory that full sovereign power. resided ‘in 
the people. 
upon the government. There were some rights so 
Precious that they would not intrust them even to a 
government of their- own creation, such as the right 
of freedom of religious worship and freedom of 
speech. They guarded the life and the liberty and 


the property of the individual and placed them for- 
ever, as they hoped, beyond the whim or malice of a 
Majority, -no;.matter how--large: -- They knew that the 


But they did not confer -all that power. 


EDITORIAL 101 


tyranny of a majority was no less intolerable than 
the tyranny of a king. .Complete. sovereign power 
today abides, not in any government, either federal 
or state, or in all governments combined, but is found 
in its fullness only in the people of the United States. 
This is the real significarice of a’ written constitution 
such as ours. The lesson of history is that no indi- 
vidual, as a king in a kingdom, and no selected group, 
as in an aristocracy, and no majority, as in a democ- 
racy, can be trusted with supreme power. The out- 
standing merit, therefore, of our constitution is that 
the people so far have refused to divest themselves 
of their own inherent sovereign pewer over the fun- 
damental rights of the individual. 

Among the subjects upon which our federal and 
our state constitutions have imposed limitations upon 
the government they created is the subject of tax- 
ation, These constitutional limitations have been of 
immense value. And yet taxation is increasing much 
more rapidly than wealth itself. 

The real friend of popular government is not he 
who constantly tells the people that they can do no 
wrong, but he who warns them against dangers of 
their own creation. If democracy is failing in any 
respect, let: us point it out. In that way only shall 
we be able to correct it. History teaches us that one 
of the most fruitful causes of the downfall of nations 
has been increasing cost of government until it became 
too great to be borne by the people. The advocates 
of the democratic form for a long time believed that 
this was less likely to be true in a democracy than 
in other forms of government. It was thought that, 
where the people governed, they would see to it that 
the expenses of government which they themselves 
must bear, were kept well within the ability of the peo- 
ple to pay. Does experience justify these hopes? James 
Bryce published a great work called “Modern Democ- 
racies.” That work is an accurate, exhaustive study 
of the democracies of the world. Its author all his 
life was a distinguished champion of the democratic 
principle in government. A more sympathetic critic 
hardly could be found. The one thing he concluded 
in which democracy is most disappointing to its 
friends is in the waste and extravagance which seem 
generally to attend democratic government. This 
thought is found running all through the two volumes 
of his work: Among other things, he says: 

“So far from securing economy, as John Bright 
and the English Radicals of his time fondly ex- 
pected, democracy has proved a more costly 
though less incompetent form of government than 
was the:autocracy of Louis XV in France or that 
of the Czars-in Russia.” 

One prolific cause of rapidly increasing cost of gov- 
ernment is to be found in the number of public agen- 
cies that have authority to levy taxes. There is the’ 
federal government; there is the state government; 
there is the local, municipal government. In. many 
states there is the school board. All of ‘these have 
the power independently of one another to impos- 
taxes. In addition, where the’ bonding power has 
been reached by the municipality, there has been a 


2-9 





growing tendency to create a new district for some 
new purposes covering the same territory already 
occupied by other municipalities. And then in many 
states, besides all these, there are so-called improve- 
ment districts. The taxes levied by any one may 
seem insignificant, but when all taxes are totaled 
they already dangerously approach confiscation in 
many cases. Nor is the line of demarcation between 
these several jurisdictions clearly observed. More and 
more the government appropriates for purposes which 
properly belong to the state. The state is urged all 
the while to appropriate for objects for which the 
local communities themselves should care. This re- 
sults in endless duplication in cost of administration 
and consequent extravagance 

What has come to be known as “pork barrel” legis- 
lation is generally condemned. However, wherever it 
is proposed to expend public money upon any object 
whatsover in any community, we find the people of 
that community as a whole back of the project. Rep- 
resentatives and senators in Congress are held re- 
sponsible for “pork barrel” legislation. The fact is 
that severally they are yielding only to the importuni- 
ties of their own constituents. Everybody is against 
all “pork barrel” legislation except that in favor of 
his own community. In fact, the people of a congres- 
sional district or a legislative district frequently by 
re-election reward their member for securing an ap- 
propriation for their district, while condemning “pork 
barrel” legislation as a whole. Since, however, they 
have no influence in the election of members beyond 
their own district, this general condemnation is of no 
avail. 

The people seem to act on the theory that it is 
always laudable to get whatever money they can from 
the public treasury for their own community. They 
seem to feel that this costs them nothing. They will 
ask for an armory, for a post office building, or im- 
provement of a creek which one time contained water 
enough to bear an Indian canoe, with all the earnest- 
ness in the world. At the same time they would not 
think of voting taxes upon themselves to defray the 
cost of the project. They forget that while they are 
doing this, other communities all over the state, or 
all over the nation, as the case may be, are doing 
precisely the same thing. So the cost in the end to 
them is just as great as though they had voted the 
taxes upon themselves for. the improvement. 

The farther removed the particular public treasury 
be, the more: the people appear to believe they are 
getting something for nothing when they seek an 
appropriation. It follows that the local municipality 
should be required to provide its own revenues for 
its own needs and should not be given aid by the 
state. Likewise, the state should be compelled to 
provide its own funds for purely state needs. Lastly, 
the federal government should appropriate only for 
those interests which are purely of national concern 
and clearly within the purposes for which the federal 
union was established. No more expensive phrases 
have been invented in recent years than “state aid” 
and “federal aid.” 

During the war, the federal government engaged in 


102 ILLINOIS MEDICAL JOURNAL 


February, 1923 


all sorts of activities which theretofore has been car- 
ried on by the states. This perhaps was inevitable 
The bureaus in Washington then tasted the delights 
of power over fields which before had been excly- 
sively occapied by the states. They were loath to 
give up this power. Propaganda, that new-found 
weapon of all causes, good and bad, was employed to 
perpetuate these now powers. Federal aid was the 
potent phrase with which they conjured. They sought 
to break down the opposition which naturally existed 
among state officials to encroachment upon their own 
proper fields of activity. They found the most effect- 
ive weapon at their hands was the offer of federal 
aid. Federal aid, generally speaking, is a bribe of- 
fered to state governments to surrender their own 
proper functions. There is scarce a domain in the 
field of government properly belonging to the munici- 
pality or the state which the federal government is 
not seeking to invade by the use of the specious 
phrase “federal aid.” Education, public health, pri- 
vate employment are a few instances which readily 
come to mind. The bureaucrats who initiate these 
movements for an extension of their own power 
draw great strength from the class specially affected. 
This rapid extension of federal administration not 
only means greatly increased expenses because of 
duplication of efforts, but it means the gradual break- 
ing down of local self-government in America. For 
the bureaucrat at Washington assumes to control not 
only his own administration in that field but that of 
the state as well. There was not a department of 
state government in Springfield even during the war 
that did not protest that if the government would 
withhold its hands it could better and more efficiently 
administer its affairs without this governmental aid 
and interference. 

And whatever tends to atrophy local self-govern- 
ment weakens the republic. I quote from Bryce in 
“Modern Democracies” : 

“Democracy needs local self-government as its 
foundation. That is the school in which the citi- 
zen acquires the habit of independent action, learns 
what is his duty to the state, and learns also how 
to discharge it.” 

The employes of the city or the state or the nation 
all the while become a more important factor in in- 
creasing the cost of government. Where numerous, 
they now are generally organized in the several 
branches of the public service. Whatever the nominal 
purpose of the organization, their keenest activities 
are directed toward an increase in pay. These organi- 
zations have come to be so powerful that they exer- 
cise a very great influence upon. legislatives bodies. 
The different organizations are usually found co-op- 
erating closely when the question is an increase of 
salary for members of any one of them. Though 2 
large majority of our people still earn their own live- 
lihood in private pursuits, the minority which derives 
its sustenance from the public treasury has become 
large enough, thoroughly as that minority is organ- 
ized, to frighten city councils, state legislatures, and 
even Congress into complying with their demands. 
Tt is uinfertunate that nearly always those who seek 

















ary, 1923 


been car- 
nevitable. 
delights 
m excly- 
loath to 
-w-found 
loyed to 
was the 
Y sought 
y existed 
1eir own 
st effect- 
~ federal 
ribe of- 
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1 in the 
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seek 





February, 1923 


for any purpose to get money out of the public treas- 
ury are thoroughly organized. The taxpayer as such 
never are. It thus happens that the militant minority 
is often more powerful than the unorganized and 
perplexed majority. This fact in itself is the strong- 
est argument of which I know against extending 
governmental activities beyond absolute need. It gen- 
erally is better to put up with all the imperfections 
in private operation of any agency or industry than 
to increase the number of public employes. I tremble 
when I think of the consequences if the number of 
public employes shall be greatly increased. I recall 
an instance which illustrates the point. Several years 
ago I was a member of Congress. For part of the 
time while there I served as a member of the House 
Committee on Postoffices. After exhaustive hearings, 
and with much care, the postoffice appropriation bill 
was framed. The bill had the unanimous support of 
all members of the Committee, whether Republicans 
or Democrats. It was necessarily voluminous as it 
covered a great number of subjects. When it was 
submitted to the House and read paragraph by para- 
graph, though of course it met frequent objections, 
it was sustained by an overwhelming vote upon every 
proposition but one. In the preparation of the bill, 
the salaries of the different classes of employes had 
received much consideration and the Committee unani- 
mously believed that it had done the right and equi- 
table thing. One numerous class of postoffice em- 
ployes, however, had not been accorded the increase 
it demanded. When this provision was reached, a 
member was found to move a very considerable in- 
crease in the salary of that particular class. This 
motion swept the House. The amendment was voted, 
not because the men who favored it had any less 
confidence in the Committee’s action in fixing this 
particular salary than they had in the action of the 
Committee with reference to other provisions of the 
bill. In this particular case, however, the members 
were afraid of the organized opposition of this class 
of employes, scattered as they were throughout the 
districts of most of the members of the House. 

Let the proportion of public employes continue to 
increase as rapidly as they have in late years and we 
will within a reasonable time witness this phenome- 
non: Our population divided into two classes, those 
holding public office, still a minority it is true, and 
all others working to support the minority in office. 
From that condition to the soviet form of govern- 
ment it is but a single step. 





SOME RELIEF FROM THE FORMER 
NARCOTIC RESTRICTIONS 


A few weeks ago Secretary Mellon of the treasury 
department approved Treasury Decision 3426, which 
rescinds that portion of Article 119 of Regulations 35 
requiring the druggist who fills a narcotic prescrip- 
tion to show on the back of the prescription the sig- 
nature and address of the person to whom such pre- 
scription or narcotic preparation was delivered. 

This treasury decision also modifies Article 148 of 
Regulations 35, relating to the recording of names of 


EDITORIAL 103 


those to whom exempt narcotic preparations are sold 
by substituting “name” in place of “signature.” In 
other words, the druggist who dispenses an exempt 
narcotic preparation may now write the name of the 
party to whom it is delivered in his record book in- 
stead of requiring the purchaser to sign his or her 
name on the registry. This removes a source of con- 
siderable embarrassment where such sales are made to 
well known customers. Of course, if the purchaser 
of an exempt narcotic preparation is not personally 
known to the druggist he must then ask the name 
in order to make record of it himself. 

The ruling further amends Article 117 of Regula- 
tions 35 by permitting physicians who prescribe nar- 
cotics for incurable diseases or for aged and infirm 
patients to so indicate by endorsing on the prescrip- 
tion “dispensed in treatment of incurable disease” or 
“patient aged and infirm (giving age) and drug neces- 
sary to sustain life.” Or, as an alternative, the phy- 
sician may hereafter simply endorse on the prescrip- 
tion, “exception 1, Article 117,” in the first instance, 
or “exception 2, Article 117,” in the latter. 

Thus both pharmacy and medicine are afforded a 
measure of relief from an annoying and useless re- 
quirement by the issuance of T. D. 3426. 





NAVY ADOPTS NEOARSPHENAMINE 


The following letter of Rear Admiral E. R. Stitt, 
Medical Corps, United States Navy, was approved 
on August 17, 1922, by the Bureau of Medicine and 
Surgery, in charge of Rear Admiral W. C. Braisted, 
Washington, D. C., and published for the informa- 
tion of the medical officers of the United States 
Naval Service, in the U. S. Naval Medical Bulletin, 
October, 1922: 

“July 7, 1920. 
“To the Bureau of Medicine and Surgery: 

“Subject: Recommendation that neoarsphenamine 
be substituted for arsphenamine in connection with 
use on board ships and at certain stations of the 
Navy. 

“1. I would recommend that the use of arsphe- 
namine be discontinued on board ships of the Navy 
and in its place be substituted neoarsphenamine. 
This same recommendation would apply to stations 
and smaller hospitals. 

“2. In the larger hospitals where facilities for 
the administration of arsphenamine are satisfactory, 
the choice between arsphenamine and neoarsphena- 
mine should be left to the discretion of the com- 
manding officer. 

“3. This recommendation is made for the fol- 
lowing reasons: 

“(a) In discussing fully this matter with the di- 
rector of the hygienic laboratory he is of the 
opinion that most of the accidents attending the 
use of arsphenamine have been connected with 
errors in technic. In view of the simplicity of 
technic when using neoarsphenamine, many un- 
toward results would be eliminated. 

“(b) In the clinic of the Brady Institute, neoars- 


phenamine is used exclusively, and Doctor Young 








and his. associates are unable to note any. lessened 
therapeutic efficiency with this drug than when 
arsphenamine is tsed.” 





EVERY MAN AND WOMAN WHO REFUSES 
VENEREAL EXAMINATION SHALL 
BE QUARANTINED 
Every One Exposep To VENEREAL Di1sEASE May BE 


HELD ror Tuirty Days, AND So ON 
MORE MEDICAL PRUSSIANISM 


Last month we called attention to the growing 
menace of bureaucracy in this country, and the ex- 
tensive parts so unhappily played by the medical 
politicians in its insidious spread. Since we penned 
that editorial, a flagrant instance has come to our 
notice. The Illinois State Board of Health has pro- 
mulgated a set of rules and regulations, avowedly 
intended to restrict the dissemination of venereal 
diseases, embodying the most arbitrary and despotic 
interference with individual liberty of conduct which 
we have yet seen attempted by bureaucratic ukase— 
and that is saying a good deal. Time and space will 
not permit a detailed analysis and criticism of this 
interesting piece of sovietism in a supposedly demo- 
cratic country; nor is it necessary to our purpose. 
As an example of its general character we may cite 
its requirements that the druggist shall report to 
the State Board every sale of a drug ordinarily em- 
ployed for the treatment of a venereal disease, un- 
less upon a physician’s prescription. Other clauses 
in the edict are of a similarly meddlesome nature. 
It is to be understood that, in virtue of their pro- 
mulgation by the State Board of Health, these reg- 
ulations have all the force and effect of law, and 
are subject to criminal penalties. 

Now, syphilis and gonorrhea and other venereal 
diseases are very serious affairs. No one, least of 
all a representative of medical science and practice, 
has the least desire of disputing that. And every 
right-thinking citizen is heartily in favor of all rea- 
sonable public measures for limiting their ravages 
and preventing their spread, even to the extent of 
imposing a certain degree of inconvenience and sac- 
rifice upon individual citizens who are unfortunate 
enough to suffer from such diseases, or to be con- 
cerned in their consequences. So are many other 
social. conditions that we can think of serious evils. 
But that venereal diseases, or any of those other 
evils, constitute such an emergency as to call for a 
practical suspension of the bill of rights is a propo- 
sition to which only the most fanatical reformer, 
blind to everything .except his own fatuous obses- 
sion, will subscribe. The remedy is worse than the 
disease. 

There, in fact, lies the root of the mischief in all 
this paternalistic, bureaucratic legislation and regu- 
lation. Certain evils bulk large in the vision and 
thought of a certain class of self-constituted reform- 
ers. They are ready to trample under foot all legal 
safeguards and individual rights which democracy 
has hought at the cost of blood and struggle through 
years of evolution and revolution, to bring about 


104 ILLINOIS MEDICAL JOURNAL 


February, 1923 


the correction of these incidental evils. At the time, 
the evils that they are attacking bulk larger in the 
public mind—because they are more obvious—than 
the abuses which are invoked to correct them. And 
thus these abuses are allowed to insinuate them- 
selves into the State, and to grow to proportions 
which at last subvert the whole foundation of demo- 
cratic government. 

Thus, in this particular instance, we are con- 
fronted with the horror and danger of venereal 
disease. So overwhelmingly do they obsess the pro- 
fession and the public at the present moment that 
in writing as we do we actually risk the accusation 
from those obsessed of being in favor of syphilis 
and gonorrhea. There is a loud demand for their 
supression and abolishment. The public endorses 
the demand, and a commission, with State authority, 
but without any direct legislative authorization, de- 
crees that every man and woman who refuses ex- 
amination shall be quarantined and his or her house 
placarded, that any person who has been exposed 
to venereal disease may be held for thirty days, and 
so on. Thus there is vested in the health board the 
power to wreck domestic happiness, social standing 
or business position, without any normal process of 
law—to set aside, in fact, as we have said, the bill 
of rights, under the protest that it is to correct one 
evil in the social system. 

It is a most dangerous tendency of our present- 
day life, this tendency to resort to bureaucratic rule, 
or even to legislation, for the cure of every ill; and, 
we are bound to repeat, the medical profession is 
particularly prone to it. As an example of the 
lengths to which it is carried, we have this very day 
run across an article in a current medical journal 
by a physician whose pet obsession is that every- 
body ought to adopt a certain posture when they 
evacuate their bowels, and in the course of his pa- 
per this man seriously proposes that “There should 
be a law on the statute books of the government 
requiring and enforcing the installation of toilets 
that are low enough and of a design to permit the 
natural or primitive posture at stool.” He really be- 
lieves it too—and will get it enacted into law if he 
can. It would be laughable if it were not so serious. 

The time is coming, of course, when there will be 
a popular revulsion against all this paternalism and 
bureaucracy. When that time arrives, the medical 
profession, which, through its politicians, has been 
loading the public with these irksome burdens, will 
be held in execration, unless it first breaks its own 
bands asunder, and frees itself from the machina- 
tions of its political betrayers—Medical Brief, Jan- 
uary, 1923. 





POWER AS TO QUARANTINING SYPHI- 
LITIC PROSTITUTES 
(Duncan vy. City of Lexington et al. (Ky.) 244 S. 
W. R. 60) 
The Court of Appeals of Kentucky, in affirming 
a judgment in favor of the defendants, says that the 
plaintiff asked for a writ of prohibition against the 





Febr 


city, 
prev 
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havi 
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the 











Y, 1923 


e time, 
in the 
i—than 
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February, 1923 


city, its health board and various health officers, to 
prevent the enforcement against her of a city ordi- 
nance providing for the quarantining of persons 
having syphilis. She asked also for a mandatory 
injunction ordering her release from quarantine. In 
the absence of proof, and under the pleadings, it 
must be taken as true that she was arrested on a 
warrant issued by the health officer on reasonable 
grounds for believing that she had syphilis, and 
was being detained, after an examination voluntarily 
submitted to which proved her infection, in the 
hospital quarters of the city jail with others of her 
own sex similarly affected; that in these quarters 
she was completely separated and removed from 
those confined in the jail under charge or conviction 
of crime; that the quarters were regularly desig- 
nated as a quarantine area for such purpose, were 
properly equipped therefor, and in charge of com- 
petent physicians and nurses; and that she was de- 
tained therein in quarantine and for treatment only, 
and would be released as soon as the disease yielded 
to treatment and ceased to be communicable and a 
menace to the public health. 

The principal, if not the sole, questions for deci- 
sion were whether or not the city had the power to 
pass an ordinance providing for the arrest and de- 
tention in quarantine, in a properly equipped, man- 
aged and designated hospital, of known prostitutes 
afflicted with syphilis in an active, virulent, infec- 
tious and communicable form. That such power is 
inherent in a municipal corporation, even in the 
absence of constitutional or legislative provision 
with reference thereto, this court does not doubt; 
but this court need not decide or discuss that ques- 
tion, since Section 2059 of the Kentucky Statutes 
expressly authorizes the establishment of boards of 
health in cities such as Lexington, and Section 3058, 
which is a part of the charter of second-class cities, 
confers on the city council authority “to establish 
and enforce quarantine laws and regulations to pre- 
vent the introduction and spread of contagious dis- 
eases in the city, and within two miles thereof. . . 
to establish and maintain public hospitals within or 
without the city . . . to secure the general health 
of the inhabitants by any necessary measure . . 
to constitute a board of health, and elect or appoint 
necessary health officers?” 

Construing these and several related statutes, this 
court held in Hengehold v. City of Covington, 108 
Ky. 752, 57 S. W. 495, that cities of the second class 
are expressly authorized to empower the local 
health board to order the removal of persons in- 
fected with smallpox to a properly equipped pest- 
house, and to enact “additional reasonable regula- 
tions to prevent the spread of epidemic diseases.” 
By no course of reasoning can the fact that small- 
pox, an epidemic disease, was there involved differ- 
entiate that case from this one involving syphilis, a 
contagious disease, since the provisions of the char- 
ter of the city under which that conclusion was 
reached refer to contagious rather than epidemic 
diseases. Whether or not such power may be con- 


BOOK REVIEWS 105 


ferred on the health officer alone was also involved 
and decided in that case, the reason for holding that 
it could be so conferred being stated to be that “in 
such cases the necessity for immediate action is im- 
perative, and it is not unreasonable to permit the 
health officer, or less than a quorum of the board, 
to order such removal in a case where it does not 
appear that the removal would endanger the pa- 
tient’s life.” The court is, therefore, clearly of the 
opinion that the city had the power to authorize 
the health officer alone to cause the plaintiff's re- 
moval to and detention in the hospital quarters of 
the city jail especially prepared, equipped and desig- 
nated as a quarantine area for persons afflicted as 
admittedly she was. 

The court does not pass on the validity of the 
provision of the ordinance authorizing the health 
officer to quarantine persons “reasonably suspected 
of having” the diseases named, or on the legality 
of the plaintiff’s arrest on orders of the health officer 
issued. on information and belief merely, since it 
stood confessed on the record that she had syphilis 
in a contagious form, which was established by an 
examination voluntarily submitted to after her 
arrest.—J. A. M. A. 


Book Reviews 





Recipes For INsTITUTION CoLLECTED AND Epitep By 
THE Cxicaco Dietetic Association. New York. 
The Macmillan Company, 1922. Price, $1.50. 

This work has been compiled from recipes contrib- 
uted by some seventy dietitians, members of the Ameri- 
can Dietetic Association, who are actively engaged in 
Institutional Cafeteria or Tea—-Room work. The 
recipes are therefore practical and workable, and have 
the merit of individuality. 


Tue Mepicac Curnics oF NortH America (Issued 
Serially, one number every other month). Vol. VI, 
Number III, November, 1922. By New York intern- 
ists. Octavo of 365 pages and 21 illustrations. Per 
clinic year (July, 1922 to May, 1923). Paper, $12.00; 
Cloth, $16.00 net. Philadelphia and London. W. B. 
Saunders Company. 

Contributors to this number are Drs. Allen, Bass, 
Blumgarten, Boas, Buerger, Bullowa, Cecil, Fishberg, 
Guion, Canter, Kraus, Mosenthal, Hornstein, Otten- 
berg, Pardee, Ratner, Riley, Sherrill. 


A Manuat or Gynecotocy. By John Osburn Polak. 
Second edition thoroughly revised. Illustrated with 
139 engravings and ten colored plates. Philadelphia 
and New York. Lea & Febiger, 1922. Price, $4.50. 
In this work an attempt is made to embody the 

progress that has been made in Gynecology during the 

last decade. The text has been thoroughly revised and 
reillustrated, and the chapters on menstruation, pelvic 
inflammation, ectopic pregnancy and sterility have been 
entirely rewritten. More space has been given to the 
pathology of the several lesions and more emphasis 
placed on its relation in the symptomatology, . In this 











work all theoretical discussions have been omitted, and 
in question that are still debatable the writer has 
presumed to give his individual opinion. 


DISEASES OF THE Nose AND Turoat. By Cornelius G. 
Coakley, M. D. Sixth edition, revised and enlarged. 
Illustrated with 145 engravings and 7 colored plates. 
New York and Philadelphia. Lea & Febiger, 1922. 
Price, $4.25. 

In this work as in previous editions the author 
has attempted to provide a compact manual answering 
the needs of both students and practitioners. This 
edition has a new chapter upon diseases of the nasal 
vestibule and attention is called to additional articles 
of sinusitis in children, Vincent’s angina, parapharyn- 
geal abscess and a direct examination of the upper air 
and food passages. 


Gettinc Reapy To BE A Moruer. By Carolyn Conant 
Van Blarcom, R.N. With an introduction by J. 
Clifton Edgar, M.D. and Frederick W. Rice,” M.D. 
New York. The Macmillan Company, 1922. Price, 


$2.50. 


Feepinc, Diet AND THE GENERAL CARE OF CHILDREN. 
By Albert J. Bell, M.D. Illustrated. Philadelphia. 
F, A, Davis Company, 1923. Price, $2.00 net. 

This book is intended for mothers and trained 
nurses, All reference to treatment which should be 
administered by the physician has been omitted and 
information helpful to the mother and the nurse has 
been included. The author gives considerable space 
to the subject of food, with reference to the teeth. 
In this work are included diet lists for the first twelve 
years of life, specifying varieties and definite amounts 
of food, with their food values, age, weight and height 
are included as well as mentions of foods rich in 
vitamins, substances essential to life are emphasized. 


DISEASES OF THE Ear, Nose AND THROAT, MEDICAL AND 
‘Surcicat. By Wendell Christopher Phillips, M.D. 
Sixth revised edition. Illustrated with 578 half 
tone and other text engravings, many of them orig- 
inal; including 37 full paged plates, some in colors. 
Philadelphia. F. A. Davis Company, 1922. 


In this work much revision has taken place over the 
fifth edition. The author has eliminated methods and 
procedures which have become obsolete and has added 
many items of new and up-to-date material. 


PRINCIPLES AND Practice oF INFANT FeEepinc. By 
Julius H. Hess, M.D. Illustrated. Third revised 
and enlarged edition. Philadelphia. F. A. Davis 
Company, 1922. 

In the preparation of this edition the chapters on 
vomiting, colic and flatulence, constipation and ab- 
normal stools have been completely rewritten. The 
classification, nomenclature and pathogenesis of the 
nutritional disturbances have been revised to conform 
to the latest researches. New chapters dealing with 


tickets, scurvy, spasmophilia, acidosis and anemias 
of infancy have been added. 


106 ILLINOIS MEDICAL JOURNAL 





February, 192; 


Mepicat Dracnosis. By Charles Lyman Greene, M.D. 
Fifth edition revised and enlarged with fourteen 
colored plates and six hundred and twenty-three 
other illustrations. Philadelphia. P. Blakiston’s 
Son & Company. Price, $12.00. 

The fifth edition has been revised and greatly en- 
larged. It contains 75 more illustrations than the for- 
mer edition. Every section has been expanded by im- 
portant additions. The sections dealing with poly- 
graphic and electro cardiographic technic and inter- 
pretations has been greatly enlarged. 


ENLARGMENT OF THE Prostate, By John B. Deaver, 
M.D., assisted by Leon Herman, M.D. Second edi- 
tion with 142 illustrations. Philadelphia. P. Blakis- 
ton’s Son & Company. 

In recent years surgery of prostatic obstruction has 
been perfected to a remarkable degree. In the second 
edition the author has brought the subject up-to-date. 
The book is essentially practical theoretical considera- 
tions has been omitted, laboratory test found practical 
in the authors experience is fully described. The 
chapter on diagnosis has been fully revised and a sec- 
tion on the use of the cystoscope in prostatic hyper- 
trophy added. The section on embryology has been 
rewritten. 





Correspondence 





INFORMATION WANTED 
Cuicaco, Itu., January 31, 1923. 

To the Editor: The hardships encountered by 
new members of the profession could easily be 
lightened if you would support a suggestion 
that part of the Journax be set aside for in- 
struction, meeting and management of patients’ 
records, narcotic records, which are considered 
necessary by the Internal Revenue Department. 

The necessary procedure to get patients in 
County Hospital, Municipal Sanitarium, etc. 

What hospitals are closed to others than mem- 
bers of the staff ? 

What to tell a patient who wants to go to 4 
definite hospital that is not open to members 
of the Chicago Medical Society ? 

How to get on a hospital staff, methods ethical 
of publicity, or so-called advertising one’s name 
and location. J. E. W. 





A FATAL PROGNOSIS 
This is the story of Johnny McGuire, 
Who ran through the town with his trousers on fire. 
He went to the doctor's and fainted with fright 
When the doctor told him that his end was in sight. 
—Jack-o-Lantérn. 


Fe 


EC 


—_ — - oO 


ane, wet CO 











ary, 1923 


ene, M.D. 

fourteen 
nty-three 
lakiston’s 


eatly en- 
| the for- 
d by im- 
th poly- 
id inter- 


Deaver, 
‘ond edi- 
. Blakis- 


‘tion has 
e second 
to-date. 
msidera- 
practical 
d. The 
d a sec- 


> hyper- 
as been 


923. 

red by 
ily be 
restion 
or in- 
tients’ 
idered 
‘ment. 
its in 








February, 1923 


Original Articles 





ECTOPIC GESTATION WITH REPORT OF 
CASES.* 


Tuomas W. Nuzvum, M. D., 
JANESVILLE, WIS. 


Ectopic gestation occurs sufficiently often, is at- 
tended with such alarming symptoms, ‘and if not 
early recognized and properly treated, is attended 
with so high a mortality rate that it is properly 
classed as one of the major causes of an acute 
abdomen. 

The primary attachment occurs in the tube in 
the majority of instances, and when the tube be- 
comes over-distended, which occurs at the end 
of 4-8 weeks, it ruptures, causing more or less 
severe pain, shock and hemorrhage often accom- 
panied by vomiting and syncope, at which time 
the fetus dies or the ovum becomes attached to 
some of the surrounding viscera, also retaining 
some attachment to the ruptured tube. 

From this time on the ovum continues to grow 
and form for itself a sack composed of the uterus, 
broad ligaments, omentum and intestines, a num- 
ber of cases having been recorded where full term 
pregnancy was reached. 

1. The most frequent cause of this condition is 
tubal disease, this making the descent of the im- 
pregnated ovum from the peritoneal cavity to the 
uterus through the tube more or less difficult 
and slow. 

2. Double uterus with more or less deformity 
of the tube. 

3. Sterility from lack of development, stric- 
ture of the tube, peritoneal adhesions or accessory 
tubal ostia. 

The intestines, omentum, uterus, broad liga- 
ments and peritoneum becomes vascularized and 
so firmly attached as to form a portion of the sack 
from which it is quite impossible to separate 
them. 

The ovum may rupture into the broad liga- 
ments and there develop, or the fertilized ovum 
may remain in the ruptured graafian fallicle. 
Williams has proven that the fertilized ovum has 
traveled from the corpus luteum of the opposite 
side, and may have become enlarged to such an 
extent as to become stuck in the tube. 


_ 


*Read before annual assembly of Tri-State District Medical 
Association, at Peoria, Ill., Oct. 30, 81, Nov. 1, 2, 1922. 


THOMAS W. NUZUM 107 


A history of gonorrheal salpingitis has been 
found in 66 per cent. of the cases by Kustuer. 

Obritz found adhesions of the tips of the 
fimbriae in fifteen out of twenty-three cases. 
Mandel and Schmidt ligated one tube in fertilized 
rabbits and pregnancy occurred in the distal 
end of the ligated tube and in the opposite tube. 
When both were ligated they developed in the dis- 
tal end of each. When the ligatures were applied 
to the uterine ends extra-uterine pregnancy did 
not occur though dead ova were found in the 
tubes. 

2. On physical examination the uterus is en- 
larged, the parts are blue and congested and the 
uterus is pushed to one side when the ovum has 
obtained considerable size. Often a decidua is 
shed which is a complete cast of the inside of the 
uterus. This has diagnostic significance when 
found. 

The early symptoms are: 1. Missed or un- 
natural menstrual period followed by more or 
less dribbling as a rule, and breast phenomena 
which are common to early pregnancy. 2. At the 
end of 4, 6 or 8 weeks a sudden attack of pain, 
faintness, shock and maybe nausea and vomiting 
occurs from which the patient may rally after a 
time, unless the amount of hemorrhage is great 
and continues, in which case prompt surgical re- 
lief is necessary to prevent a fatal issue. 

Rupture may take place into the broad liga- 
ments, in which case the fetus may continue to 
develop and possibly go on to term, or into the 
peritoneal cavity, where the fate of the ovum will 
depend upon the amount of hemorrhage or 
whether the placental attachment has remained 
intact, in which case abdominal pregnancy may 
occur as in one case here reported. 

Diagnosis. By bimanual examination one can 
determine before rupture takes place that there 
is a small tumor mass in one fornix and this in 
connection with the symptoms will warrant one 
in making the diagnosis. 

Many cases, when the rupture takes place 
early and hemorrhage is not extreme, recover 
without a diagnosis having been made, or the 
symptoms are attributed to miscarriage and the 
uterus curetted, as I have many times observed, 
or as appendicitis, uterine colic or merely colic. 

I have known cases even where the symptoms 
were alarming, the amount of hemorrhage quite 
large and the necessity of immediate operation 








108 ILLINOIS MEDICAL JOURNAL 


seemed urgent, recover after exacuation of a so- 
called pelvic hematocele. 

The diagnosis is usually easy if one can secure 
a careful and intelligent history and link this 
with the physical findings. 

The missed or unnatural period, the dribbling 
over period of weeks, breast symptoms which are 
strongly suggestive of pregnancy, attacks of pain 
more or less severe, the sudden onset of pain, 
collapse, shock, syncope, nausea and maybe vomit- 
ing are all indicative, and in a short time showing 
evidence of severe or extreme loss of blood such as 
rapid feeble pulse, pale, blanched countenance, 
and nausea, sub-normal temperature, cold, 
clammy sweat, and upon bimanual examination 
cne can determine the presence of a mass at the 
side or posterior to the uterus. 


1. Without a careful history one might easily 
mistake the conditions for an appendiceal abscess, 
especially where the mass is on the right. 


2. A ruptured stomach or duodenal ulcer sel- 
dom occurs without a history of digestive dis- 
turbances of a recurrent nature which have ex- 
tended over a long period of time. ‘The sudden 
onset following a full meal, the intensity of the 
pain, the location of the pain are quite in con- 
trast with that of a ruptured ectopic. 


3. A gangrenous or ruptured gall bladder 
would give symptoms much like the former and 
here one must consider the history of former di- 
gestive disturbances, attack of colic with pain 
extending to the right scapula, jaundice, more or 
less marked tenderness and rigidity in the hepatic 
region and a palpable mass may often be made 
out below the liver margin. 


4. A cyst with a twisted pedicle may cause 
menstrual disturbances which simulate a ruptured 
ectopie, but the symptoms come on more grad- 
ually, are less severe, and unless there is much 
peritonitis and distention one can outline the 
tumor by bimanual examination. 

5. A diverticulum with obstruction of the 
bowels gives a history of former attacks of pain 
of a colicky nature ; the pain comes in paroxysms; 
often the peristalses can be seen and felt on the 
surface; vomiting is severe and soon becomes 
fecal ; great shock and prostration quickly super- 
vene, more especially if the small intestine is in- 
volved and without speedy relief the patient dies 
of toxemia. 


6. Pus tubes are usually bilateral; there is a 


February, 1923 


history of vaginal discharge, urinary disturbance 
and often menstrual disturbance, with aggrava- 
tion of the pain at that time. Physical exani- 
uation reveals the uterus “Eingamuert” or set in 
a stone wall, as the Germans express it. 

In some cases the diagnosis may still be in 
doubt, but there is very evident an acute abdom- 
inal condition which requires immediate surgical 
relief. 

The prognosis in the vast majority of cases is 
grave without early surgical intervention, but 
when operated on early with the aid of trons- 
fusions when required, the percentage of recover- 
ies is large; without early and proper surgical in- 
terference the percentage of mortality is high. 
Medical treatment is limited to relief of pain 
and to combat symptoms as encountered. 


REPORT OF CASES. 


1. Mrs. B., a young married lady of 22, had 
the usual signs of extrauterine gestation and pain, 
nausea, syncope, shock extreme and a mass could be 
felt in the right fornix and Douglas’ culdesack. 
Upon the history and findings a diagnosis of extra- 
uterine gestation was made and an operation speed- 
ily performed. 

The right tube was ruptured and adherent to the 
sack. The uterus was double each body having a 
separate cervix and the septum in the vagina reached 
to within two inches of the ostium vaginae. 

She made a good recovery and five years later 
gave birth to a fine son and this was followed rap- 
idly by 4 or 5 more children. 

2. Another was a young married woman with her 
first pregnancy. She has been very ill for nine days, 
was treated for abortion and curetted, also treated 
for displaced uterus. When I saw her she was 
suffering from peritonitis, but the history and find- 
ings were classical for a neglected extra-uterine 
gestation which had ruptured, bled profusely, ex- 
cited an active peritonitis and upon opening the 
abdomen we found a ruptured appendix, complicat- 
ing the case with an extensive peritonitis which rap- 
idly proved fatal. 

The pelvic contents were evacuated through the 
vagina and consisted of some three pints of in- 
fected blood clots. 

Our records show 29 cases of ectopic gestation 
with three fatalities. Another was due to influenza 
complicated by double pneumonia which came on 
one week after operation when the patient was well 
on her way to recovery. This occurred at Ft. 
Sheridan during the first onset of influenza and 
she was in the hospital where the boys were drop- 
ping away fast. 

On the day of her death four died in that hos- 
pital inside of thirty minutes, all of flu-pneumonia. 

This lady was the wife of an officer. The 
diagnosis had been made before it ruptured, but 











§ 
I 
‘ 
1 
1 








ary, 1923 


turbance 
aggrava- 
| exami- 
or set in 


ll be in 
abdom- 
surgical 


Cases jg 
on, but 
f trans. 
recover- 
zical in- 
is high. 
of pain 


22, had 
nd pain, 
could be 
ildesack. 
f extra- 
n speed- 


t to the 
javing a 
reached 


rs later 
ed rap- 


vith her 
ne days, 
treated 
he was 
id find- 
-uterine 
sly, ex- 
ing the 
nplicat- 
ch rap- 


igh the 
of in- 


“station 
fluenza 
ime on 
as well 
at Ft. 
ra and 
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onia. 
The 

d, but 








WILLIAM 


February, 1923 


operation refused; later she was curetted by our 
superior officer and only came to operation after 
rupture had taken place and her condition from 
pain, shock and hemorrhage was extreme. 

Two cases of severe type refused operation and 
recovered after a protracted illness. 

The last case which I wish to present was as fol- 
lows. Her weight three months before was 157 
pounds, at present 132 pounds. 

Her family history was good, with the exception 


’ that one sister died from cancer of the breast. She 


had never been ill. 

Last January she was seized with severe pain in 
the abdomen suddenly; she had been constipated for 
two weeks before; she went to bed, took enemas 
which gave relief, was confined to bed for two days, 
and has not been well since, having suffered from 
abdominal pain and was compelled to take physic 
each afternoon. 

Physical examination: Appetite is poor, gas on 
stomach, distress after eating, constipated, heart 
rapid and feeble, pulse 110 and temperature 99%, 
coughs some and raises a trifle, sleeps poorly and 
sweats at night, has much abdominal pain, is very 
nervous, passes urine often with marked distress, 
urine was negative, tonsils are diseased and large, 
menses absent since January last. There was a 
bloody watery discharge which had been present for 
four weeks past; pelvic examination revealed a large 
hard tumor mass which filled the pelvis and ex- 
tended to the navel. 

The uterus was moderately enlarged, was crowded 
up above the pubes and a small polypus extended 
out from the cervix. 

The vagina and all parts were very blue, no fetal 
heart nor bruit could be heard, nor had she felt 
motion at any time. The breasts were large and 
contained milk. 

The x-ray revealed a child present. She re- 
turned home under the care of Dr. Dewire and I am 
indebted to him for the following report: 

“Patient was taken seriously ill on May 27 and Dr. 
Dewire summoned, complains of aching over body, 
throat dry and feverish. Temperature 101 F., pulse 
120 and weak. Some cough and expectoration. 
Some small liquid bowel movements and very fre- 
quent pains of griping nature; very restless. 
Anodynes and antipyretics given and hot applica- 
tions applied to abdomen. June 1, patient weaker, 
still coughing, breathing labored, abdomen tym- 
panitic and tender, pulse rapid, temperature 102, 
respiration 45, pulse 120; June 2, Dr. Nuzum in 
consultation, pelvis full, vagina and cervix blue, mass 
back of womb and motion of child felt in it. Uterus 
not palpable because of distention. Patient put in 
knee chest position and gravity helped to relieve 
Pressure in pelvis. This position maintained from 
10 to 20 minutes every four hours. June 6, Dr. 


Nuzum saw her again; mass higher in abdomen, 
womb plainly palpable, anterior to mass and empty. 
Congestion a little. better, but patient growing 
weaker, Peitonitis subsiding. Lips and extremities 


M. HARSHA : 109 


purple, circulation poor, but no heart audible. Feet 
and ankles became edematous and patient died on 
morning of June 7. Autopsy at request of family at 
2 P. M. A woman somewhat thin, with well formed 
and filled breasts, abdomen rounded like six months’ 
pregnancy. Opening in mediam line. Great mass 
back of womb, dark blue, full of fluid and contain- 
ing placenta adherent to everything. Intestines 
matted, placenta of normal size for six months at- 
tached to intestines, tube obliterated or stretched 
beyond recognition, transverse and descending colon 
full of hard feces. Left tube occluded and full of 
pus. 

Girl baby normal for six months; weight, 2 Ibs. 
and 8 oz.; length of body and head, 10% in.; cir- 
cumference of head, 9 in., of chest, 9% in. Hair on 
head about % in. long and brownish color; nails im- 
perfect. No deformities of arms or limbs. 

Child a little thin but fairly plump for mother’s 
condition. Autopsy by Dr. T. W. Nuzum; report 
by Dr. Dewire. 





CANCER* 


Witii1aM M. Harsna, M. D., 
CHICAGO 


There is no subject of greater general interest 
now than that which has been assigned to me. 


It is only possible to consider a few phases of so 
important a disease in a short paper. Volumes 


have been written on it in the past two decades. 
A great deal of research work, experimental, clin- 
ical and statistical, has been done in that time. 
In short, war on cancer has been declared. 

A former Chicago man, the late Roswell Park, 
in 1899, I believe, started the first society in the 
United States for the study of cancer, at Buffalo, 
and Dr. Gaylord, who is still with that in- 
stitution, and has done a great deal of research 
in cancer, has favored us here with his reports. 
Many associations at home and abroad have 
been formed since that time for the same 
purpose, notable among which is the American 
Society for the Control of Cancer, the American 
Society for Cancer Research, etc. Numerous 
others have been working in England, Germany 
and other countries. Doubtless the successful war 
waged on other diseases and the increasing in- 
cidence of cancer in almost every country, if not 
all, have stimulated the effort to combat the 
disease, and much has been accomplished, not- 
withstanding the pessimistic view prevailing. 

Thirty years ago, Professor Agnew said (as 
quoted in the Jour. Am. Soc. for Cont. of Cancer) 
that he had never cured a cancer of the breast. 


*Read before Section on Public Health and Hygiene, Illinois 
State Medical Society, May, 1922, at Chicago. 





Every surgeon now has cases cured for many 
years. 

Thirty years ago the mortality from diphtheria 
in Chicago was approximately 35 per cent. Then, 
after the cause was discovered, antitoxin came 
into use, early diagnosis was made and the mor- 
tality dropped to 3 per cent, and should be zero. 
War was also waged on tetanus, malaria, typhoid, 
syphilis and tuberculosis, with the result that all 
these were put on the list of controllable diseases. 

‘All this and more in thirty years. During that 
time, with all the sanitary advance that has been 
made in fighting these known germ diseases, there 
has been a steady increase in cancer. An increase 
of about 1 per cent. to 2.5 per cent. a year, I be- 
lieve, is the estimate. 

It is said that one woman in ten after forty 
years of age will have cancer, and one mar in 
eleven. There are about 80,000 deaths per year 
in the United States. ' 

Notwithstanding all the study referred to, the 
cause is unknown, although much has been 
iearned about the subject which may lower the 
death rate when the knowledge is generally ap- 
plied. It is now generally agreed that cancer is at 
first a local disease and when accessible, especially, 
cure follows complete removal. There are few 
men of authority who deny this at present—I 
know of no surgeon. Dr. Bulkley, a noted skin 
specialist, is one in opposition to it. 

The belief in the past that cancer was a con- 
stitutional disease discouraged many from asking 
early operation, and this contributed to the high 
death rate by postponing operation, rendered 
surgery less effective, and reacted on the operative 
treatment, thus establishing the vicious circle. 

ixperimental, clinical and statistical research 
has now fairly settled this question, but people 
generally have not yet been convinced as they 
should be. The prevailing disbelief in operation 
for cancer is an echo of the former theory of the 
constitutional character of the disease. 

That skepticism is emphasized further by the 
fact that people generally hear and know more 
about one death from cancer than they do of five 
eases that are cured. The one death advertises 
itself, the five cures are not paraded. Early oper- 
ation will cure 90 per cent. of accessible cancers 
and a considerable number of those more or less 
ineccessible. Radium and x-ray will also cure 
some of these. Every experienced surgeon can 
show numbers of cases illustrative. 


110 ILLINOIS MEDICAL JOURNAL 





February, 1923 


Irritation of one kind or another is now known 
to be the exciting cause of most, if not all, can- 
cers. Full acceptance of this fact is bound to be 
the most influential factor in lowering the mor- 
tality. The jagged or foul tooth starts the cancer 
of the tongue or cheek. The hot rice of the China- 
man or the betel nut chewed by the natives of 
India, and possibly the hot tea or coffee used by 
other people are factors in mouth cancer. The 
pipe, maybe the cigar, of the smoker—man or 
woman—often starts cancer on the lower lip. 

Dr. W. J. Mayo is a strong believer in the 
effects of heat, in whatever form or place, in 
provoking the start of cancer. 

The abuse of food and drink will doubtless be 
shown to explain the large number of stomach 
cancers, as well as those of the alimentary tract, 
including the liver. 

Statistics generally show that cancer of the di- 
gestive organs is more frequent than that of any 
other part of the body, especially in men. 

Exceptions to this are found in India, where 
cancer of the stomach is rare, and among aborig- 
ines and people in institutions where a frugal 
diet is enforced. 

It seems from available figures that cancer of 
the stomach is a part of the cost of high living. 

People who eat much meat and raw vegetables 
are the greatest sufferers from cancer of the in- 
testinal tract, while those who, from religious or 
other reasons, cook their vegetables and eat little 
meat, have the lowest mortality. The North 
American Indians are cited as exceptions to the 
influence of meat eating, but here again the other 
more natural habits of primitive man, and a 
more generally restricted diet, come in to offset 
the meat eating. 

Again, skin cancer is most prevalent in those 
countries where filthy habits prevail, and is least 
frequent where cleanliness is the rule. In India, 
where we have noted that stomach cancer is rare, 
skin cancer is very prevalent. In Japan, where 
the bath is universal, skin cancer is rare. The 
theory of chronic irritation by dirt and neglect is 
borne out. Where cleanliness is considered next 
tc godliness, ‘no skin cancer; where cleanliness is 
considered next to foolishness, much skin eancer! 
In parts of India where the natives wear the 
Kangri basket, with an earthen vessel in which 
they burn charcoal to keep warm, frequent burns 
on the skin result in cancer. Where they chew 


the betel nut they have frequent mouth cancers. 











ry, 1923 


known 
ll, can- 
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ie mor- 
cancer 
China- 
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ised by 
The 
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February, 1923 WILLIAM 


We all know some sad examples of x-ray burns 
resulting in cancer starting in the skin. We 
know, too, that old sores, scars, warts or moles, 
Jevcoplakia, intractable ulcers or eczemas, are 
often the starting point. Gall stones start cancer 
in the gall bladder, ulcer of the stomach is many 
times the cause in disease of that organ. Trouble- 
some hemorrhoids precede cancer of the rectum 
and eczematous nipples often start cancer of the 
preast. Lacerations of the cervix uteri, together 
with catarrhal irritations, are believed respon- 
sible for many cancers there. 

Irritation has been shown to be at least the 
exciting cause of cancer in the chimney sweep— 
the gardener who handles soot to sprinkle the 
plants, the coal tar and aniline dye worker, as 


well as those of other occupations bringing about. 


chemical or other irritations. Bloodgood claims 
that in 1,200 cancers of the skin a previous de- 
fect in the skin was shown in the history. 

Some of the factors mentioned, such as the 
eating of raw vegetables, the effect of dirt on the 
skin, filthy habits, etc., have been cited as evi- 
dence of the parasitic nature of the disease. 
(Ochsner.) In my opinion there is all along the 
line an explanation through irritation as the ex- 
citing cause, with no proof of parasitism, and no 
final solution of the ultimate cause. It is ad- 
mitted, however, that the theory of parasitism is 
not disproven. 

Cancer is not contagious and has not been 
proven to be a parasitic disease. A majority of 
surgeons, especially those in research work, dis- 
believe in the parasitic theory. I recall that twen- 
ty-five years ago Professor Senn (Principles of 
Surgery) argued against its infectious character, 
the argument today being perhaps the strongest, 
i.e., that the identity of the cell growth in cancer, 
in whatever tissue it is lodged or metastasized, 
e. g., @ squamous cell from the skin lodged in the 
liver maintains squamous cell type. In known 
germ diseases the same does not hold. 

A most convincing argument against the con- 
tagious theory, at any rate, is the immunity of 
surgeons, nurses or relatives of cancer patients. 
It has been so rarely found in man and wife that 
it can easily be a coincidence. Efforts at trans- 
ference in man from one to another have rarely 
been successful, and when successful, apparently 
the growth has not kept up the usual life history 
or development. The victim of cancer, however, 
is an easy prey to transference of his own disease 


M. HARSHA ill 


to one part or another of his body. The disease 
is individual to him. So much is he susceptible to 
transplantation that some tissue change is pre- 
sumed to make him susceptible. Cancer is seem- 
ingly individual to its host, and does not easily 
transfer its habitat. No characteristics chemical 
or microscopical change of blood tissue or secre- 
tions has been demonstrated, however, in cancer 
patients; and-.so far as we know, food, environ- 
ment, climate, occupation, have little to do with 
preparing the system for cancer, except as they do 
so through irritation. 

If the aborigines are more immune, it may be 
we shall have to return to a more simple life, with 
normal work and frugal fare. It may become 
known through further study what influence is 
required to make a person susceptible to cancer. 
If senility is a cause, it is not progressive with 
age. Jonathan Hutchinson pointed out many 
years ago there is a local senility as well as gen- 
eral. 

Of course cancer has a predilection for the per- 
son or the tissue that has reached its maturity 
and is ready to decline, but strangely enough it 
does not increase its ravages progressing with 
age. 

From forty to sixty-five is, I believe, the time of 
greatest frequency; an average age is about fifty 
years. It is rarely hereditary, but Miss Slye and 
others experimenting with mouse cancer find an 
element of susceptibility of tissues that is consid- 
ered hereditary, very much, I take it, as we con- 
sider heredity in tuberculosis. No method of 
immunization has been discovered for cancer in 
man. 

What has been said as to the predisposing cause, 
local character of the disease in early stages, and 
curability through radical early operation, leads 
to the conclusion that there is a great respon- 
sibility on the physician who is first consulted by 
a patient with suspected cancer, or with a sus- 
pected precancerous condition. In addition to 
caring for cases of suspected cancer, it is the 
function of the physician to advise his patient 
about the risk from neglected warts, ulcers, fis- 
sures, tumors, vaginal discharges, digestive dis- 
turbances, or other precancerous conditions, and 
to be an apostle of clean, simple and temperate 
living. 

If it is necessary for a patient to consult a 
dentist regularly for the protection of his teeth, 
why should he not consult a physician who can 








112 


and should make a thorough general as well as 
special examination to see that there is no in- 
sidiqus approach of. cancer. 
presents cancer in an early stage, a prompt, thor- 
ough operation, with follow-up by x-ray or 
radium; is the best treatment. The late J. B. 
Murphy showed that in a large percentage of 
cancers there was no spread of the disease until 
late in the case, many of them proving fatal 
Needless to say, Dr. 
Murphy was a staunch supporter of the local char- 
acter of the disease in its beginning, and he had 
proven that early operation would cure. 

Notwithstanding the great increase in the 
rumber of cancers, there has never been a time 
when the outlook for the individual patient was 
as favorable as at present. 
if the patient is seen early by a thorough surgeon, 
cures in cancer of the breast should reach 86 per 
cent., of the skin 98 per cent., of the lip or 
tongue 90 per cent., of the bone 75 per cent. 

Dr. Mayo has shown cures in approximately 
one-third of stomach cancer cases from operation. 
Broder of the Mayo clinic, 23 per cent. plus of 
cures in cancer of the genito-urinary tract. Mar- 
tin thinks uterine cancer should show operative 
cures of 25 to 48 per cent. They should show 
better with early diagnosis. ‘These enumerated 
are the more frequent sites. Stomach, intestinal, 
breast, skin, genito-urinary tract operations at 
present are supplemented by x-ray and radium 
with great advantage, and in inoperable cases 
much has been done by thesé’ agents. Through 
early diagnosis and prompt surgical treatment, 
the mortality should be less than half the present 
ligures. 

Until the ultimate cause is found our best 
known means of prevention are restriction and 
care in eating, drinking and the use of tobacco; 
cleanliness and proper care of the skin, mucous 
membrane and intestinal tract; the avoidance of 
all local irritations, especially those caused by 
heat; the proper treatment of tumors, ‘ulcers, 
scars, moles, warts, keratoses, irritating dis- 


before metastasis occurred. 


charges, digestive disorders, etc., and a more 
simple mode of life, with moderation in all 
things. 
SUMMARY. 
Cancer is on the increase, approximately 1 per 
cent. to 2.5 per cent. annually. Cancer of the 
‘stomach heads the list among Caucasians, and its 


ILLINOIS: MEDICAL. JOURNAL 


Where the patient - 


Bloodgood believes . 





February, 192; 


increase and distribution suggests that it is a dis. 
ease of civilization. The cause is not known, but 
it. starts through chronic or recurring irritation. 
Cancer is not a constitutional disease starting 
from within, but a local disease excited from 
without by some form of chronic or repeated 
irritation, through some unknown cause. Many 
precancerous conditions lead up to cancer, e. g,, 
moles, warts, fissures, ulcers, scars, burns, kera- 
stoses, ete. 

Cancer remains a local disease until death in 
about 20 per cent. of cases, and until late in life 
in many. Heredity does not play an important 
role, although it is probably a small factor. 

Early operation cures nearly all accessible cases 
if done well and radically. X-ray and radium 
will cure many, superficial cases and possibly 
many deeply seated. Great responsibility for 
early diagnosis rests with the physician, and gen- 
eral and special examinations should be made at 
intervals. Early diagnosis is not always easy— 
easy diagnosis means often advanced disease and 
formidable operation. 

Further study may solve the problem of sus- 
ceptibility of a subject, from which other dedue- 
tions as to etiology or immunity may be made. 
There never was a time when a patient with can- 
cer had so good a chance for recovery as nov, 
through early diagnosis, removal of cancerous or 
precancerous conditions, radical operation, radium 
and x-ray. 

I believe the death rate from cancer will be cut 
in two in the next decade, through the general 
application of the present knowledge on the sub- 
ject. 

It is certain that the frequency will be greatly 
reduced by early attention to tumors, moles, warts, 
kerastoses, irritating discharges, digestive disor- 
ders, care in diet, and cleanliness and a more 
simple and wholesome life. 

BIBLIOGRAPHY. 
Hoffman, F. L.: 


The Mortality from Cancer Throughout the 
World. 


Bainbridge, W. S.: 
Bulkley, L. Duncan: 
Bloodgood, Jos. C.: 
Young, Hugh H.: 


The Cancer Problem. 

Cancer, Its Non-surgical Treatment 
Prevention of Cancer Series. 
Prevention of Cancer Series. 
Martin, F. H.: Prevention of Cancer Series. 

Rodman, W. L.: Prevention of Cancer Series. 
Fridenwald, Julius: Prevention of Cancer Series. 


Mayo, W. J.: Mayo Clinic. 

Broden, A. C.: Annals of Surg., May, p. 574. 
Ochsner, A. J.: Chic. Med. Soc., May, 1922. 
Murphy, J. Murphy Clinic. 


DISCUSSION. 


Dr. William Fuller: Discussions on malignant 


disease are always interesting as was the presenta- 
tion to which we have just listened. Dr. Harsha’s 











Ty, 1923 


is a dis. 
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starting 
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WILLIAM 


February, 1923 


observations on the incidence of cancer of the differ- 
ent peoples of the world are especially interesting 
and important. 

It seems to me, however, that the most important 
point, the thing most vital to us is to know if there 
is such a thing as a cure for cancer among our own 
people now, I think one of the most discouraging 
things we hear in medical meetings is the statement 
we often hear to the effect that we have no cure for 
cancer. Uttered among medical men only this state- 
ment may have in it an element of truth; but in a 
general way it contains an element of untruth. It is 
a statement which will more likely discourage a 
cancer victim than any other and is often sufficient 
to send him to a soyrce for help from which no good 
can ever come. 

Now, then, to say that we have no cure for cancer 
is wrong. Timely surgery, in all that that term 
means, applied by a surgeon, in all that that word 
means, will more often cure a cancer than it will 
fail to cure it. This is true of cancer situated inside 
the body, as well as cancer outside the body. Radio- 
therapy, in the hands of one thoroughly skilled and 
schooled in its use and application, and in touch with 
the question of malignant disease, will frequently 
treatment; when the surgeon could have stated with 
effect a cure. ' 

What is that bugbear that crops up every time the 
surgeon meets with a malignant growth, with but 
few exceptions? To be sure, it is the valuable time 
which has long since passed when it was amenabie to 
certainty that a cure would likely follow appropriate 
treatment; when the surgeon could say, your growth 
is local; is confined to the place in which it started; 
that complete extirpation of this area takes with it 
all the cancer cells that make up this growth; and 
that the operation, or whatever the treatment will not 
leave behind in some distant area more cancer than 
is removed. 

A cancer of the lip seen and operated early 
enough will not leave the neck and mediastinum 
full of cancer cells to show their presence in an 
early “return” of the growth, 

Under the present regime of the practice of 
medicine we may not hope to see at an early date a 
material reduction in the mortality of malignant dis- 
ease. The devotees of the numerous cults are “treat- 
ing” cancer. Let us be perfectly fair and say that a 
goodly number of the regular medical profession 
are still cauterizing, burning, watching and tinker- 
ing with malignant growths. I have recently seen 
three growths “treated” in the physician’s office for 
a period of weeks without the least suspicion that 
malignancy was being dealt with. 

Surely it behooves the scientific medical man to 
make, or to have made, some provision that prac- 
tically all this work fall into his hands for treatment 
if he is the only one qualified to treat it. His life 
spent in the clinic room or the laboratory qualifying 
himself to deal with cancer gains nothing if he never 
meets the cancer patient. When the obstacles be- 
tween him and the patients can not be overcome, 


M. HARSHA 113 


what earthly good to him is his scientific knowl- 
edge? Sufficient education, the proper kind of edu- 
cation on the part of the public, and what is even 
more important, the education of those who are to 
carry out the treatment, put to very early and 
timely use will cure much more cancer than we 
are curing today. 

For example, let us take the entire number of 
malignant growths that will develop in the human 
race from today on and subject them to the proper 
kind of treatment at the earliest manifestation, what 
would the mortality likely be in a few decades? 
Would it not likely be lowered by startling figures? 

As it will scarcely ever prove possible to meet 
with all cancer patients at that time when inter- 
vention by the medical man means so much it re- 
mains a fact that operations for malignant growths 
must be based upon a rather wide scope. That is to 
say that in two growths apparently alike one will 
demand the widest kind of a dissection, taking with 
the growth all adjacent glands and possibly glands 
and other tissues remote from the original focus. 
Again a growth will be met with where a limited 
operation may be done with some assurance that a 
cure will be effected. But as this distinction must 
of necessity be more often a guess diagnostically 
than otherwise, such a procedure should be consid- 
ered with much forethought, if not great reluctance. 

The crux of the cancer question, then, as it seems 
to me is much more the making use, and effective 
use, of the knowledge we already possess, than striv- 
ing for more knowledge. More knowledge is needed 
of course; but that which we are now in possession 
of will correct a multitude of our sins in our effort 
to cure cancer if we can ever learn the value and 
the meaning of the words “early” and “timely,” and 
will disseminate and spread the proper educational 
hints among the doctors and people alike. 

Dr. Hugh O. Jones, Chicago: I believe the sub- 
ject of cancer presented before this Section of the 
Illinois: State Medical Society is timely and in the 
proper place. : 

The study of vital statistics of recent years shows 
that there are three factors, largely causative, of the 
mortality in the middle age group. That is, kidney 
diseases, heart diseases and cancer. 

As the author of the paper has shown and as 
the other speaker mentioned, while we do not know 
the cause of cancer we do know that early intelligent 
interference gives results. And I think that a mes- 
sage from this Section to the profession at large 
on the subject of cancer and an intelligent ‘propa- 
ganda for the laity calling their attention to the early 
symptomology, and the conditions which might 
later lead to cancer, would bring them under the 
careful supervision of the proper men and will help 
a great deal in reducing the increased moftality 
caused by this condition. I think this would be a 
great movement toward any life extension program 
that might be instituted by a Section in Public 
Health. 

Dr. William M. Harsha, Chicago (closing the dis- 








114 ILLINOIS MEDICAL JOURNAL 





cussion): As Dr. Fuller said, people have the idea 
that operations are not of advantage in cancer, due 
to the many failures that have happened when 
cancer was operated on late. There is another 
factor. One case of cancer dies, and it is advertised. 
Everybody knows about it. The five or six that get 
well under any kind of treatment don’t parade it. 
You meet people now on the streets every day 
who have had cancer ten, fifteen or twenty years ago, 
and they are not on exhibitién. So that we don’t 
have the benefit of that part of it. 

One thing that I neglected to say and that occurs 
to my mind, is that statistics show that the aborig- 
ines have very few cancers, native Indians and the 
like. And, also, the figures show that among the 
inmates of institutions where they have an enforced 
frugal way of living, there are very few cancers, 
especially of the stomach. In other words, cancer 
seems to be a disease of civilization. The more we 
take of meat and drink, the more cancer we have as 
a rule. 

We have the incidence of cancer of the stomach or 
intestinal tract very high in this country, in Eng- 
land, Holland, Switzerland and Germany; and we 
have it very low in India and those places where 
they cook their food and don’t eat meat. A re- 


turn to the simple life may be one of the important 
ways to save the race. 





CHORIOCARCINOMA FOLLOWING EX- 
TRAUTERINE PREGNANCY* 


JOHN BEVERLY Moore, 
BENTON, ILL. 


Choriocarcinoma, chorioepithelioma, or syn- 
cytioma malignum, synonymous terms for the 
same malignant condition, has been frequently 
reported in literature, but in comparatively few 
instances has the tumor originated in the Fallo- 
pian tube or the ovary. 

Pollison and Violet in a report of 455 cases 
cite 12 or 2.5 per cent. as arising in tubal preg- 
nancy. The statistics of Zimmermann’? show 
that the patients in whom choriocarcinoma de- 
veloped gave a history of hydatid mole in 40 
per cent.; normal labor, 25 per cent.; abortion, 
30 per cent., and extrauterine pregnancy, 2 to 3 
per cent. Vineberg,® in a recent review of litera- 
ture, add 78 cases to the 455 reported by Pollison 
and Violet, but as far as can be determined only 
one was in the tube. In his citation of Teacher’s* 


series of 88 cases, 3 or 4 per cent. followed extra- 
uterine gestation. 

Risel,® in his study of primary choriocarcinoma 
of the tube, feels that, despite the adverse condi- 


_- —- 


*Read before the Surgical Section, Illinois State Medical 
Society, May 16, 1922. 








February, 1923 





tions which obtain in ectopic pregnaney, chorio. 
carcinoma is here rare. 

In more or less authentic cases ranging in age 
frem Marchand’s*® 17-year-old girl to de Senar- 
clens” patient of 38, most of the tumors seem to 
follow soon after an ectopic pregnancy. All of 
them were operated upon and there was early 
recurrence with metatases especially common in 
the lungs within a few months. The course was 
rapid with fatal termination in every instance. 

The prognosis is usually better in uterine than 
in tubal choriocarcinoma. The mode of removal 
or size of the tumor apparently has no influence 
on the prognosis. Bleeding and a tumor mass are 
by far the most prominent symptoms. Some give 
a typical history of ectopic pregnancy as that of 
Hinz,* whose patient had pain five weeks after 
the last menstrual period, with bleeding and 
weakness. A diagnosis of right tubal abortion 
was followed by operation in which the right 
tube and ovary were removed. Normal chorionic 


villi were found on histological examination. 
Three weeks later she complained of bleeding 


with pain in the lower right quadrant. Two 
weeks after this an examination revealed an en- 
largement of the uterus and a mass over the 
right cornua. The latter was removed. The 
operation was followed by a rapid loss of weight, 
pain in various regions, jaundice and death in 
seven weeks. An autopsy tissue resembling blood 
clots was found in the lungs, liver, abdominal and 
pelvic cavities, and all sections contained the 
characteristic elements of choriocarcinoma. 

All of the patients had been operated upon at 
least once and death occurred from a few hours 
following the operation to several months. 

Bazy® aptly describes the tumor mass found in 
bis case as resembling a sponge soaked in blood. 
Merely touching the surface of the tumor caused 
frightful hemorrhage. In view of the hopeless- 
ness of the treatment, Bazy believes in prophy- 
laxis and thinks every tubal gestation should be 
considered as malignant and removal early. 

In nearly all of the cases a reflex decidua! for- 
mation was present in the uterus. Metatases have 
been found most commonly in the lungs, vagina, 
liver and brain. Unfortunately autopsies have 
not been obtainable in all instances, so the extent 
of the metatases have to depend upon the physical 
examination and symptoms. 


Our case of choriocarcinoma developed in a well- 
proportioned, well-nourished woman, 24 years of age; 





four 
child 
Four 
ing ' 
This 
with 
distr 
and 

noti 
asm 


February, 1923 


married eight years, with two healthy children, ages 
four and six years; one miscarriage before the first 
child, no complications. Menstrual history regular. 
Four months ago she had a scanty flow of blood com- 
ing on six days after the regular menstrual period. 
This lasted two months, flowing from two to ten days 
with short intervals between, associated with pelvic 
distress and pain in the back. The flow of blood ceased 
and the last two months there was a serous discharge 
noticed with no bad odor. Ten weeks ago she observed 
a small mass in the lower abdomen which grew rapidly. 

On physical examination her general appearance was 
good, with a normal amount of subcutaneous fat. 
Weight at the time was 135. Her normal weight was 
150 pounds. Temperature 98, pulse 84, hemoglobin 85. 
There was a firm, movable, globular mass arising from 
the pelvis occupying the right and middle portion of 
the lower abdomen and extending almost to the 


JOHN BEVERLY MOORE 115 


oozing points. As far as could be determined, there 
was no involvement of the musculature, the attach- 
ment of the uterus being only by fibrous adhesions. 
The uterus appeared normal in all respects. There 
was no infiltration of the broad ligament. The omen- 
tum with enlarged veins spread over and disappeared 
within the mass. The small bowel and sigmoid ad- 
hered in places so intimately that it was necessary to 
cover raw bleeding surfaces. The attachment to the 
bowel was even more intimate than that to the uterus. 

The entire mass was easily removed with the right 
tube and ovary. There was no other tumor masses 
discernible within the abdomen, although a small 
amount of blood-tinged fluid was present on opening 
the peritoneum. 

On gross examination the tumor mass somewhat re- 
sembled the liver in shape, was approximately seven 
inches in the anterior posterior diameter and ten inches 











Fig. 1. Choriocarcinoma. Deeply stained masses 
of syncytium invading the stroma. Mag. 120. 
umbilicus. The cervix and vaginal mucous membrane 
showed nothing abnormal. The uterus appeared to be 
a part of the tumor mass. 


A diagnosis of uterine fibroid was made and she 
was operated on November 7, 1921. 


The operation revealed a dark red, fleshy, firm 
tumor mass about the size of a man’s head arising 
from the pelvis in the cul-de-sac and showed rounded 
elevations studded with coarse granulations resembling 
a cauliflower. The tumor was very vascular, bleed- 
ing easily from the granulations. It arose from the 
tight tube, the fimbriated end of which was spread out 
bell-shaped, disappearing within the mass. Parts of the 
ovary were recognized in the tumor. It was adherent 
to the broad ligament, posterior part and fundus of 
the uterus, forming a cap over the organ. It was 
easily separated from the latter, leaving small punctate 


Fig. 2. Choriocarcinoma. Masses of syncytium in 
apposition with Langhan’s cells. Mag. 275. 


from left to right. 


The outer surface was irregular 
with many broad flat nodules covered with coarse 


granulations. The color was dark red. The entire 
mass in many respects resembled very much a placenta 
with its cotyledons, but was firmer in consistency. On 
one side was a greyish white area, which appeared 
macroscopically to be the ovary. On cross section the 
tumor was solid, granular, dark.red in color and 
streaked with grey strands of fibrous tissue. Much 
blood oozed from the cut surface. 

The histology of the tumor is quite characteristic of 
choriocarcinoma. Large or small irregular groups 
of Langhan’s cells either alone or in disorderly relation 
with syncytium or masses of syncytium are penetrating 
the stroma (Fig. 1). The latter is a loose structure 
with long spindle cells separated by an edematous fluid 
and displaying considerable round celled infiltration. 









116 


Areas of hemorrhage are present in large numbers 
throughout the entire mass, some sections appearing 
to consist only of blood with tumor constituents. 

The normal structure of chorionic villi is entirely 
absent. The Langhan’s cells are larger than normal 
with hyperchromatic nuclei and frequently contain 
mitotic figures. In some places the syncytium is in 
close apposition with and appears to fuse with the 
former cells. (Fig. 2 and Fig. 5.) Here the nuclei 
are fairly regular and the acidophilic staining reaction 
of the cytoplasm easily distinguishes these masses 
from all other cells. In other areas isolated portions 
of syncytium varying in size and spread profusely 
throughout the hemorrhagic strom is the predominating 
feature. (Fig. 4.) The nuclei are deeply stained and 
may form large giant cells with nuclei of enormous 
size. 

The recovery was uneventful until the 10th day, when 
she complained of bladder distress. Seven days later 
a foul blood-tinged vaginal discharge appeared, and 
two soft ulcerating areas were found in the anterior 
vaginal wall. On the 17th day she complained of 
severe pain in the right lower chest, with a scant ex- 
pectoration of dark blood. Impaired resonance and 
diminished breath sounds were present in the right 
base. The pain became a little less severe and she 
was removed to her home, where she was permitted to 
sit up a part of the time, although she was failing 
rapidly. At this time a mass had appeared under the 
liver which was, as far as could be determined, a part 
of the liver and probably a metastasis in the latter. 

She died four weeks after the operation in a sudden 
attack of dyspnea. We were unable to obtain an 
autopsy. 

We wish here to give a short summary of 
Risel’s® case which in many respects is similar 
to the one just reported. 

A woman of 35 with regular menstrual periods had 
three normal pregnancies. Five years after the last 
pregnancy she had bleeding every 8-14 days, which 
lasted for 8 days, the last two accompanied by severe 
pain. On vaginal examination an ill-defined mass the 
size of a child’s head was felt posteriorly. Diagnosis 
was ovarian cysts and left pyosalpinx. 

On operation a tumor was found behind the uterus, 
adherent to the surrounding structures so that com- 
plete removal was impossible. In appearance it re- 
sembled a placenta, and sections showed it to be a 
chorioepithelioma. 

After an uneventful recovery the patient was ap- 
parently well for two months but died five months 
later with metastases in liver and lungs with no in- 
dications of tumor. growth in the uterus. With the 
exception that this patient lived for seven months 
after the operation the two cases have almost identical 
courses and findings. 

Although it was impossible to obtain an autopsy 
we believe that we are justified in stating that 
the tumor was primary in the tube, secondary to 
tubal: pregnancy. The blood appearing early 
was due to decidual reaction in the uterus, ceas- 





ILLINOIS MEDICAL JOURNAL 


February, 1923 












Febrt 








ing in eight weeks, not to reappear. The location 
of the tumor mass appearing to arise from within 
the fimbriated end of the tube, the normal ap. 
pearance of the uterus and the absence of multiple 
tumor masses at the time of operation all strongly 
support this conclusion. 


BIBLIOGRAPHY 


1. Polleson and Violet: Ann- 3 , i 
mR Re Ain, nn-de Gynec. et d’obst., Paris, 

2. Zimmermann: Arch. f. Gynaec., 1920, 113, 370. 

8. Vineberg: Surg. Gync. & Obst., 1919, 28, 123. 

4. de Gouvea: Brazil Med., 1916, 30, 325. 


Pe ee Ztscher, f. Geburtsh, u. Gynak., Stuttg., 1905, 
‘  gnchand: Monatschrift, f. Geburt. und Gynak., 1895, 
"7. de Senarclens: 


190, Thies de Lausanne. 


_Hinz: Ztscher, f. 


f 


burtsch, u. Gynak., Stuttg., 1904, 


52, . 
6 9. ead Ann de Gynec. et d’obstr., Paris, 1913, 2nd series, 


DISCUSSION 

Dr. J. J. Moore, Chicago: The rarity of this tumor 
is shown by the fact that in a careful perusal of the 
literature Dr. J. B. Moore found only fourteen cases; 
also there were only 770 cases of chorioepithelioma of 
the uterus reported. We all know that there are a 
great many more cases that are not recorded. Since 
there were only 14 cases reported of the tubes and 
ovaries, it shows that this condition is either fre- 
quently overlooked or that it occurs but rarely. We 
purposely left out the chorioepitheliomas of the ovary, 
because there is still a question about certain of these 
tumors being teratomas. Such teratomas of the ovary 
occasionally resemble very much the choriocarcinoma 
of the ovary. At the same time we have teratoid 
tumors of the testicle that are diagnosed as choriomas. 
Ewing says we should not call these choriocarcinomas 
until the individual has had metastases in the lungs. 
Those cases that are reported had growths in the lung 
which had the typical characteristics of the chorio- 
carcinoma of the uterus. 

Dr. Carey Culbertson: This case is an extremely 
interesting one and Dr. Moore is to be thanked for 
having worked it up so well and for reporting it. 

Such cases are really pathologic curiosities, they 
are so rare. In my experience at the Cook County 
Hospital, since 1913, I have seen but one case of 
chorioepithelioma following a tubal pregnancy and 
we have many cases of tubal pregnancy there. Both 
Kynoch and Ries have recently reported cases of 
chorioepithelioma following ovarian pregnancy, but 
from the masses described it would be difficult to say 
whether the growths arose from a tubal or ovarian 
pregnancy. Relative to the case so well described by 
Dr. Moore, that it is a chorioepithelioma there is no 
question from the sections that were shown. I prefer 
the term chorioepithelioma to that of choriocarcinoma. 
It is true that in some of these tumors the growth is 
made up almost entirely, as far as the sections show, 
of syncytium and in others almost entirely of Langhans’ 
cells, but as a matter of fact nearly all sections show 
both types of cells, exactly as these sections show. 
Hence, they are chorioepitheliomata, and it is not easy 
to group them into subdivisions. 

Now there is one lesion, a pathologic entity that 


has b 
whicl 
stand 
a fac 
so-cal 
conta 
tured 
























rial 
pre bi 

















plant 
Dous 
mate 
expl: 
nan¢ 
epitl 
nan 


























ecto 
We 
and 
ok rg 
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Y, 1923 


cation 
Within 
al ap- 
ultiple 
rongly 


» Paris, 


» 1905, 
+» 1895, 


» 1904, 


| series, 


turror 
of the 
Cases; 
ma of 
are a 
Since 
s and 
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We 
vary, 
these 
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‘atoid 
mas, 
omas 
ungs. 
lung 
orio- 


mely 
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they 
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and 
Both 
; of 
but 


February, 1923 JOSEPH M. PATTON 117 


has been described during the last year by Sampson, 
which has to be taken into consideration from the 
standpoint of differential diagnosis and which may be 
a factor in explaining ovarian pregnancy, that is the 
so-called “chocolate cysts of the ovary.” These cysts 
contain a hematoma of the ovary ruptured or unrup- 
tured, in the wall of which is found mucosa endomet- 
rial in type These cysts rupture, and in doing so 
probably carry along clumps of this mucosa and im- 
plant them in various portions of the cul-de-sac of 
Douglas, giving ‘rise to adenomyomas. If we have 
material of that sort in the ovary, its presence can 
explain ovarian pregnancy. Having an ovarian preg- 
nancy it is easy enough to see how we get chorio- 
epithelioma just the same as if we have tubal preg- 
nancy. I am not in accord with the opinion that every 
ectopic pregnancy should be regarded as a malignancy. 
We see a great many ectopic pregnancies, chiefly tubal, 
and some of them show relatively little actual path- 
ology. I have seen two cases of tubal pregnancy this 
past winter with no distortion of structure of the 
tubes, in both cases the implantation being in the 
fimbriated end, the spill of blood being into the peri- 
toneal cavity and small in amount. This undoubtedly 
explains those cases of ectopic pregnancy that are 
never recognized and that disappear spontaneously. 

Dr. J. B. Moore, Benton (closing the discussion) : 
I want to thank Dr. J. J. Moore and Dr. Culbertson 
for their interesting discussion. I have nothing further 
to add. 





THE EDEMATOUS CARDIOPATH.* 
Josepn M. Patron, M. D., 
CHICAGO. 


In apology for the symptomatic character of 
my title I call attention to the frequency of edema 
in cardiopathic states and to its marked effect 
on the minds of the subject and his friends. Aside 
from cardiac angina there is probably no symptom 
of heart disease whose presence so far disturbs 
the equilibrium of the patient or whose dis- 
appearance causes as great satisfaction. If the 
physician is unable to relieve edema it will be 
dificult for him to maintain control of his pa- 
tient, whereas the relief of this symptom will 
able the patient to cheerfully face an inevitable 
fatality with comparative composure and with 
complete faith in his medical attendant. 

Without -considering the physical or physi- 
vlogical laws governing the occurrence of edema 
is far as the tissues affected by it are concerned, 
it is plainly the effect of diminished circulation in 
the kidney and to such modification of the special 
excretory ‘function of the kidney as may result 
from changes in the organ itself. This latter 


meee 


“Read at the meeting of . Tri-State District Medical Asso- 
ciation, at Peoria, Ill., Nov. 1, 1922. 


question brings forward the time-honored argu-, 
ment as to the relation of heart and kidney dis- 
ease. The historical features of this will be 
vmitted. Our views, however, of the evidence at 
land of the kidney’s responsibility in these cases 
has undergone some change in the light of mod-, 
ern observations as to the relation of kidney 
ability, as evidenced by function tests and reten- 
tron products in the blood, to organic changes in 
the kidney structure affecting its physiological 
integrity. 

It was for a while thought that a definite slow- 
ing of kidney activity as shown by the pheno- 
phthalein test, especially when supported by the 
rentention of non-protein nitrogen and creatinin 
in the blood, was sufficient evidence upon which 
to base conclusions of the presence of definite 
types of kidney change, especially when supported 
by those urinary findings which were regarded as 
positively indicative of some type of nephritis. 
Present opinion, however, based upon the corre- 
lation of clinical and necropsy findings, appears 
to throw doubt, within certain limits, upon the 
reliability of function and retention tests, as wel! 
as urinary findings, as evidence of definite kidney 
change in connection with eardio-renal disease, 
it having been shown that these findings, in both 
1egards, may be present, except perhaps in marked 
degrees, in conditions of passive congestion of the 
kidney only. The fact that pathologists are at 
times unable to definitely discriminate micro- 
scopically between the effects of passive congestion 
of the kidney and certain types of organic 
changes, and have to depend on microscopic ex- 
amination to settle the question, especially in 
the glomerular types of nephritis, may go far to 
excuse the clinician if his deductions should be 
wrong in this connection. 

Richardson defines two main types of kidney 
changes: One in which toxins irritate the cells 
lining the glomeruli which proliferate and pack, 
these bodies, preventing the passage of blood 
(glomerular nephritis) ; and one in which there 
are arteriosclerotic primary changes in the ar- 
teries supplying the glomerulus and ultimately a 
fibrosis. These processes may be combined, but 
usually they run true to type, though the differ- 
entiation may be very difficult. 

Cabot admits inability to explain retention in- 
crease with passive congestion only, but main-. - 
tains the fact, holding that clinical interpretation. 
rests more on the degree of retention than on 





118 ILLINOIS MEDICAL JOURNAL 






the fact of its presence. He thinks that an in- 
crease of nonprotein nitrogen to around one 
hundred mmg., about three times the normal, 
with also a marked increase of creatinin over the 
one or two mmg. normal, is in the present state 
of our knowledge indicative of nephritis, though 
our knowledge on this point is yet transitional. 

The presence in the urine of albumin, casts, 
leucocytes or blood corpuscles is not definitive of 
the existence of nephritis, or of the extent of such 
if it be present. 

The prognostic value of these urinary and blood 
findings while not of absolute value is relatively 
of great importance, especially when taken in con- 
nection with the state of the arteries and the 
condition of the heart muscle. General arterio- 
sclerotic changes, together with alterations of the 
heart, which cannot be charged to intrinsic 
causes, indicate the probability of associated 
arteriosclerotic types of kidney changes. Myocar- 
dial changes with physical alteration of the heart 
which cannot be charged to evident arterial dis- 
ease is indicative of the presence of more acute 
types of nephritis, probably the glomerular. 

There is, however, a period in connection with 
intrinsic myocardial conditions where the urinary 
findings due to passive congestion of the kidneys, 
and the associated degree of retention products, 
so closely approximate those of certain types and 
stages of nephritis as to make a correct clinical 
interpretation of their indications an impossibil- 
ity. Our inability, therefore, to tell offhand what 
the kidney will or will not do forces us to rely 
rather upon the art of medicine than its science in 
dealing with the situation. Of the three factors 
involved in the equation: the pump force of the 
heart, the resistance in the arterial tract and the 
special function of the kidney, the foremost, of 
course, is the dynamic ability of the heart. With- 
out the movement of blood through the kidneys 
we cannot expect improvement in the situation, 
and as we are dealing with more or less dilation 
of the left side of the heart in all of these cases, a 
more complete emptying of the left ventricle is 
the first thing to be obtained. 

As some type of rhythmic disturbance of the 
heart is almost always a feature of these cases, 
we may be led to consider whether the correction 
of these irregularities, in the light of modern 
observations by the polygraph and the electro- 
cardiograph, is not the most important feature 
of their management. The classical rhythmical 





February, 1923 








irregularities, however, that are distinctive of ab- 
norinal conditions at the seat of origin of auricv- 
lar impulses, and in the auriculo-ventricular 
transmission are more characteristic of those 
myocardial states that may for a considerable 
period precede the development of the positive 
dynamic deficiency which causes the edematous 
condition. Aside from the irregularity produced 
by left ventricular preponderance, and the auricu- 
lar disturbance which is a feature of positive 
mitral stenosis, we are not called upon to take 
electrocardiographic findings as definite indica- 
tions for therapeutic measures in edematous 
cases. Mackenzie has warned us against the dan- 
gers of basing therapeutic measures on positive 
deductions from graphic findings and emphasizes 
the comparative value of more careful observa- 
tion of the classical evidence of circulatory con- 
ditions. 

The fact that the auricular fibrillation of 
mitral stenosis and the irregularities associated 
with dilatation of the left ventricle respond to 
digitalis relieves us of the necessity of consider- 
ing their rhythmic changes as anything more 
than features of the dynamic state of the heart 
whose failure has added edema as a further evi- 
dence of its insufficiency. In increasing the 
efficiency of the heart it is of first importance 
that we reduce the work of that organ. Rest in 
bed should be maintained as long as edema is in 
evidence, as many moderate edemas disappear 
with this simple measure alone especially when 
combined with proper diet and elimination by 
the bewels. The efficiency of the heart is further 
increased by reducing the resistance in the vas- 
cular area which is always increased in persons 
over forty years old, even though there be no 
distinct evidence of arterio-sclerosis. 

This reduction of resistance is to be accom- 
plished by vaso-dilators, the best of which is 
opium whose action is sufficiently slow to enable 
us to maintain a continuous effect through doses 
so small as to produce no objectionable side 
effects. Considerable edema may be entirely re- 
lieved by rest and opium without other medica- 
tion. Upon this fact was based the objectionable 
method of thoroughly narcotizing a patient for 
a week or ten days in order to rest the heart. 

It has been maintained that digitalis does not 
raise the blood pressure and therefore vaso-dila- 
tors are not necessary in connection with its 
administration. There is contrary experimental 











Ty, 1923 


e of ab- 
auricn- 
tricular 
F those 
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February, 1923 


evidence, and even if it does not clinical experi- 
ence plainly shows that the effect of opium, in 
the average case after middle life, adds greatly 
to the relief afforded an over-taxed heart. The 
usual dose is one-fourth of a grain of gum opium 
with the average dose of any solid preparation 
of digitalis, and from three to five drops of the 
deodorized tincture of opium with the average 
dose of any liquid preparation of digitalis. Pro- 
portionately smaller doses of opium may be com- 
bined with less digitalis for continuous admin- 
istration when advisable. Morphin is not ad- 
vised for this purpose. Nitrites may be used, but 
are not satisfactory, except in emergency, be- 
cause of their evanescent effects. Their action 
cannot be graded and controlled as certainly as 
that of opium. 

The output of the heart is increased by the 
use of the so-called digitalis group of drugs. 
That foxglove is the only one of this group that 
is useful is a modern view with which I do not 
agree, but that it is the most reliable and efficient 
is absolutely certain. There is no such thing as 
a best preparation of digitalis. A carefully 
standardized preparation made from a properly 
assayed sample of the leaf will yield uniform 
results whether used as a tincture, infusion, 
powder or glucocide, with certain variations, de- 
pending on variable qualities of plant specimens, 
which may evade standardization, and on variable 
human reactions which do not follow those of 
laboratory experimentation. Assimilation and 
elimination being equal we should obtain definite 
results from any standard preparation of dig- 
italis, but these conditions are variable and thus 
specific reactions based on definite dosage per 
kilogram body weight of the individual is not 
always obtainable. Moreover, individual idio- 
synerasies in reaction, or the lack of it, to certain 
preparations of digitalis are frequently met with 
and must be dealt with empirically. 

Those preparations of digitalis which are 
adapted for intravenous or hypodermic use are 
necessary for emergencies and where absorption 
by the stomach cannot be trusted, but in ordi- 
nary conditions standard galenical preparations 
will give as reliable results, and at times more 
80, than can be obtained from more eulogized 
preparations of the drug. Dosage must still be 
regulated by effects on clinical symptoms, im- 
provement in rate, rhythm, character of the 


JOSEPH M. PATTON 119 


pulse, relief of dyspnea and increase of kidney 
function. 

I question the advisability of rapid digitaliza- 
tion of the heart in one or two days except in 
cases of emergency. We should take from four 
to six days to get the heart thoroughly under the 
effect of digitalis and then modify the daily 
dosage as determined by symptomatic conditions. 
If increase in kidney function is then negligible 
and edema shows no improvement we should 
specially stimulate the kidney, which we will 
refer to later. 

Strophanthus is a drug formerly much 
praised, but lately disparaged by some clinicians. 
That it has not the punch to control a dilated 
heart that is characteristic of digitalis is ad- 
mitted, but in selected cases it gives very satis- 
factory results, especially in mitral stenosis with 
a tight mitral opening. Even though dilatation 
be sufficient to result in the characteristic edema - 
about the loins and the ankles and arrhythmia be 
marked and persistent, strophanthus will often 
give better results than digitalis, which may in- 
crease the auricular arrhythmia and result in a 
digitalis block. In these cases the ventricle dis- 
poses of all the blood it gets, but in those in 
which the mitral is rough and rigid, but the open- 
ing patent the ventricle develops a hyposystolic 
state in which strophanthus has not the power to 
relieve. 

The tincture of strophanthus should be em- 
ployed, administered in freshly made laurel- 
cherry water or with a couple of drops of dilute 
hydrocyanic acid to obviate gastrointestinal dis- 
turbance. Strophanthin should only be used in- 
travenously and for emergencies. It acts more 
quickly than digitalis and’not more than two or 
three doses are advisable. 

Caffein is a much employed drug for its ef- 
fects on both heart and kidneys. As ordinarily 
given by hypodermic and by mouth in tablet form 
I have not been impressed by its utility. Intra- 
venously its effects are often questionable. The 
best results I have seen were in cardiorenal lesions 
with moderate dropsy and marked by lowered 
kidney function. Here a freshly made salt may 
be given, using equal parts of sodium benzoate 
and alkaloid caffein dissolved in distilled water. 
This gives approximately a forty-two per cent 
salt and the dose is arranged to equal about two 
grains of the benzoate of caffein. 

While I do not deny the value of the other 












120 


drugs of the digitalis group, the effects in 
edematous cases is practically negligible, and I 
will not take time to consider them. 

In certain cases of edema we may have regu- 
lated the heart action, reduced resistance to the 
arterial flow, employed rest, position, light diet 
relatively salt free, limited liquids, and all with- 
out result as far as getting rid of the edema is 
concerned, We must then stimulate the kidneys 
for whether we are satisfied or not as to the con- 
dition of those organs, the fact remains that even 
kidneys with a very limited functional activity 
may be stirred into sufficient action to eliminate 
a considerable dropsy. The fact that diminished 
function and increased retention do not always 
mean a dying kidney emphasizes the necessity of 
cleaning up the situation so as to give time to 
strengthen the heart whose failure is probably 
at the bottom of the trouble. 

Of the special kidney stimulants in use the 
theobromine preparations are probably most em- 
ployed. The sodio-salicylate of theobromine, long 
known as diuretin, being mostly used. It is a 
useful drug, though at times disturbing to the 
stomach. It should be given in twenty grain 
doses every four hours for six doses and then in- 
termitted for a few days. It is not efficient in 
ten grain doses two or three times daily. If the 
effect of one course is good, it may be maintained 
when the kidneys slow up by giving twenty grains 
as a daily dose, It is best given in distilled water. 

Calome! is a valuable diuretic in some cases. 
It is of little use given in small and frequent 
doses. It should be given in 3 grain doses three 
times daily for two days—eighteen grains in all. 
It is essential that during its administration the 
bowels should be kept from moving by giving from 
five to seven drops of the deodorized tincture of 
opium half an hour after each dose of calomel. 
The bowels may be flushed out with salts four 
hours after the last dose of calomel has been 
taken. When it is impossible or inadvisable to 
block the bowels for the two days this treatment 
should not be used. 































Theocin is a valuable diuretic in some cases. 
The sodium salt may be used if desired. It is 
convenient for administration and rarely dis- 
turbs the stomach. 












It is effective in two or three 
grain doses two or three times daily, given every 
second or third day. Its continuous administra- 


Like all diu- 


retics it is most effective in those cases where 


tion is not necessary or desirable. 





ILLINOIS MEDICAL JOURNAL 





passive congestion is at the bottom of the kidney 
defection, but has appeared to me to be adapted 
to relieve those cases when the kidney defect was 
primarily due to moderate arteriosclerotic block of 
the afferent arteries with secondary glomerular 
defects. 

The action of these remedies may be supple- 
mented at times by the various vegetable duretics 
or by the acid tartrate of potash as in the old 
Imperial Drink of the London Hospital, but the 
simultaneous administration of two of these 
agents is not advisable. I remember having to 
introduce three quarts of fluid into a patient 
who had collapsed from the very rapid reduction 
of an extreme dropsy from the administration of 
diuretin and calomel at the same time. It is 
the rule that by the proper adjustment of the 
three factors—heart force, arterial resistance and 
kidney stimulation,—one can secure the relief of 
edematous states even in the presence of failing 
heart and kidney. However, there are occasions 
when we must resort to bandaging the lower 
limbs to increase kidney circulation where the 
blood pressure is too low, elimination by the 
bowels by eleterium, jalap and the like to reduce 
back pressure on the kidneys just as we relieve 
an over-distended pleura by removing part of an 
effusion in order that the vessels may resume 
absorption, incision of the skin of the legs to 
reduce the local tension of a chronic edema to a 
point where circulation may be reestablished, 
sweating by hot baths or jaborandi where uremic 
conditions seem imminent, all more or less useful 
measures which are called for in those cases 
where the kidney is mainly at fault and the heart 
is only contributory to the occurrence of the 
edema. 





SURGERY OF THE UPPER ABDOMEN 
UNDER LOCAL ANESTHESIA.* 


Rorert Emmett Farr, M. D., 
MINNEAPOLIS, MINN. 


Time will not permit a full discussion of the 
relative merits of local and general anesthesia, 
the effects of each upon the heart, lungs, kidneys, 
liver and other organs, and the relative merits of 
each in relation to shock, acidosis, nausea, vomit- 
ing, thirst, gas pains, wound strain and so on. 
I shall assume without argument that operations 
which can be carried out with satisfaction under 





*Read by invitation before the Illinois State Medical Society 
in Chicago on May 16, 1922. 


February, 1923 






ry, 1923 


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February, 1923 


local anesthesia may be considered more safe 
than where general anesthesia is employed. The 
objections to the use of the local anesthesia 
method, such as psychic incompatibility, the loss 
of time, strain upon the surgeon, and the inter- 
ference with wound healing I can refer to but 
briefly. 

It is my desire to spend most of the time at my 
disposal in considering local anesthesia when 
applied to surgery of the upper abdomen as it has 
been taken for granted by most general surgeons 
that this method is not efficient when applied 
jo surgery of this region. It will be admitted, 
| think, that, provided local anesthesia can be 
used efficiently in surgery of the upper abdomen, 
it should be employed. My personal experience 
leads me to believe that the use of local anesthesia 
in the upper abdomen is feasible and it is my 
rurpose today to speak especially of the technica! 
points in relation to its use. 

To begin with, let me say that I consider the 
use of local anesthesia a system in itself and that 
its success depends much more upon the type of 
surgery employed than upon the manner of in- 
ducing anesthesia, and that the pitfalls and the 
failures of the method when attempted by 
surgeons are as often due to overt acts in relation 
to the surgical technic as to errors in the manner 
of inducing anesthesia. A system, therefore, 
which is not based upon an appropriate surgical 
technic as well as upon an appropriate anesthesia 
technic, will fail. 

In order to make it possible to carry out any 
of the major procedures when working under local 
anesthesia in this region certain principles must 
be rigidly observed and the margin of error may 
be greatly reduced by attention to certain factors 
which, while of secondary importance, are of suf- 
cient importance to greatly influence the 
chances of failure. Each step in carrying out any 
procedure is so vitally dependent upon its ante- 
cedents that the adage, “A chain is as strong as 
its weakest link,” may be applied. 

Anesthesia Technic. The thoracic nerves in- 
volved may be reached by paravertebral anes- 
thesia, an infiltration block or by direct infiltra- 
tion, The splanchnic nerves involved may be 
reached by the posterior method of Kappis, the 
anterior method of Wendling or that of Braun, or 
by the method which I shall describe below. 

A thorough trial of all methods has convinced 


ROBERT EMMETT FARR 121 


us that the more simple the procedure the 
greater satisfaction will result from its use. We 
therefore prefer the infiltration or infiltration 
block which reaches the ultimate arborizations of 
the nerves at or near the line of incision. We in- 
troduce the solution under pneumatic pressure. 
The solution is used freely. Anesthesia is com- 
plete in from three to five minutes and the in- 
cision may be made at once. We establish 
splanchnic anesthesia as a rule only after opening 
the abdomen and depend upon a visualization of 
the splanchnic area as our ally in carrying out 
this procedure. 

Local anesthesia may be used in children with 
the same relative satisfaction as in adults. I 
know of no condition in which the use of local 
anesthesia may be said to be more appropriate 
or more satisfactorily employed than in treating 
hypertrophic pyloric stenosis in infancy. Here 
again a few simple rules should be followed. The 
patient’s stomach contents should be evacuated 
through the tube immediately before operation. 
He should be restrained by attaching the feet to 
one end of the table while the psycho-anesthetic 
grasps the arms and makes traction. The in- 
cision should be transverse and at the level of 
the lower border of the liver. The abdomen 
should be entered without the patient's knowl- 
edge, that is, without painful sensation. The 
abdominal wall should be retracted vertically 
and the pylorus should be elevated by the use of 
a pair of delicate, rubber-tipped forceps. 
Evisceration of the small intestine should be 
scrupulously avoided and this is entirely possible, 
provided the proper strategy is employed. 

In surgery of the upper abdomen the presence 
of extensive adhesions and malignant disease, or 
in some instances an extremely high position of 
the liver, especially in adipose patients, may pre- 
clude the possibility of completing the work under 
local anesthesia. In all instances, however, a 
more or less complete survey may be had and 
general anesthesia may be superimposed upon 
local at any stage, provided this becomes neces- 
sary. 


The essential adjuncts to success in carrying 
out the method consist of an accurate diag- 
nosis, proper planning of the incision both 
as to direction and length, the proper position of 
the patient’s body which allows us to make use of 
the force of gravity, the co-operation of the pa- 
tient, which is obtained largely through the tact 





122 


of a trained psycho-anesthetist, and the quality 
of surgical technic which is demanded by local 
anesthesia as well as by the patient’s best inter- 
ests. 

In introducing the anesthetic solution every 
effort is made to avoid the production of pain. If 
the proper precautions are used the patient need 
be caused pain at but two stages of the infiltration, 
and this in only the mildest degree; first, during 
the production of the initial wheal and, second, 
during the piercing of the aponeurosis at the 
outer end of the proposed incision. After the 
production of the initial wheal all subsequent 
intradermal wheals are made from beneath and 
are painless, A subdermal rather than an intra- 
dermal infiltration is depended upon for the 
anesthetization of the skin and after depositing a 
liberal amount of solution beneath the aponeurosis 
at the outer edge of the rectus the deeper in- 
filtration is carried across the rectus muscles, at 
least one of which we divide in all surgical work 
in the upper abdomen. 

While making the incision the abdominal wail 
is elevated in order to avoid pressure upon the 
structures beneath. The patient is placed in the 
reverse T'rendenlenburg position, and if the ab- 
dominal wall is perfectly anesthetized the abdom- 
inal viscera should fall away through the force 
of gravity alone when the peritoneum is incised. 

By utilizing the patient’s co-operation the in- 
traperitoneal viscera may be caused to advance 
and recede beneath or through the incision and 
visual examination may be carried out. This 
may, when necessary, be followed by a careful 
digital examination.. If the examination should 


prove painful or if an operation is decided upon, 


anesthesia of the splanchnic system may be es- 
tablished provided the proper strategy is used. 
By taking advantage of the co-operation of the 
patient who is requested to breathe deeply, or to 
avoid straining, as the case may be, by retracting 
the liver edge upward and the duodenum down- 
ward the solution may be injected beneath the 
postparietal peritoneum. Even where adhesions 
are extensive, local infiltration may be used as 
the dissection proceeds. 

We have proven to our own satisfaction that 
this technic is efficient in carrying out a com- 
paratively large number of secondary cholecystec- 
tcmies in cases in which cholecystosomy had pre- 
viously been made. Very rarely during the past 


ILLINOIS MEDICAL JOURNAL 


February, 1923 


five years has it been necessary to administer 
a general anesthetic in order to complete the 
operation. In the more simple eonditions where 
adhesions are absent one has still less difficulty, 

Take for instance the case of the gall bladder 
which is obviously diseased and excision is de- 
cided upon. The following technic may be em- 
ployed: A gauze pad is slipped between the 
duodenum and the gall bladder and the duodenum 
retracted downward. Another pad is laid over 
the pyloric antrum and the stomach is retracted 
toward the left. A third pack in the pouch of 
Morris exposes the field to the right. ‘The patient 
is now instructed to take a deep inspiration and 
the gall bladder will present in most cases so 
that every spectator in the operating room may 
plainly see it. It may now be grasped in an 
artery forceps, or a gauze tractor may be slipped 
about it, if it is greatly distended or its walls 
thickened, and maintained in an elevated posi- 
tion while the patient is asked to repeat the ex- 
pulsive effort. By making traction upward while 
lifting the abdominal wall the liver is rotated 
and “up-ended” beneath the costal margin. All 
of this may be done without distress to the pa- 
tient in most instances. The visualization will 
allow one to anesthetize the splanchnic area with- 
out difficulty, after which any operative pro- 
cedure desired may be carried out. 

The separation of the gall bladder from its 
hepatic attachments is greatly facilitated by in- 
troducing a copious amount of the solution be- 
tween the gall bladder and the liver. This makes 
the dissection more easy and rapid. It decreases 
hemorrhage and painful sensation. 

In stomach operations the greatest difficulty 
encountered is the necessity for traction. How- 
ever, by making a vertical retraction of the mov- 
able portions of the stomach and avoiding the use 
of clamps many stomach operations may be car- 
tied out with facility. We have not hesitated 
to divide the ribs in order to obtain a better ex- 
posure of the lesser curvature in making gastric 
resections. ‘To illustrate the strategy that may 
be employed I might mention one maneuver by 
which gastric traction is avoided. After gastro- 
enterostomy has been decided upon a tacking 
forceps may be placed at the junction of the 
greater curvature and the gastrocolic omentum 
on the anterior surface, marking the point at 
which the future opening is to be made. The 





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February, 1923 


colon is allowed to escape from the abdominal 
cavity. It is elevated vertically just to a degree 
sufficient to eliminate the folds. The jejunum is 
visualized and is picked up with long rubber- 
tipped forceps, thereby eliminating the blind 
groping for this viscus. After the opening is 
made in the meso-colon, instead of introducing 
a hand behind the lesser curvature of the stomach 
and forcing this organ through the opening, the 
appropriate point is identified by the means of 
the towel clip which was previously placed upon 
the lesser curvature. A second towel clip may 
be placed opposite this indicator on the other side 
of the gastrocolic omentum and the posterior 
stomach wall drawn through. The gestroenter- 
ostomy may then be performed without.the use 
of clamps. All vessels are grasped in forceps and 
ligated and the contents of the stomach and 
jejunum aspirated by suction. 

Provided it is thought necessary to explore or 
remove the appendix the Trendenlenburg posi- 
tion may be assumed and the appendix visualized 
by means of vertical retraction. 

I wish to call attention to the desirability of 
so handling the patient that he may reach the 
operation hour in a proper state of physical and 
mental quiescence. During the operation his 
physical comfort must be most carefully looked 
after. From the time the anesthetic is begun 
until the operation is completed every effort 
should be made to anticipate and prevent both 
mental and physical suffering on the part of the 
patient. A well-trained psycho-anesthetist is an 
exceedingly valuable ally, as through the efforts of 
this individual the surgeon may be relieved of the 
handicap under which one may find himself when 
using local anesthesia. 

The actual cause of physical suffering is al- 
most entirely in the hands of the surgeon. There 
ere two very important reasons for its prevention ; 
first, it is obviously the surgeon’s duty to prevent 
in every manner possible needless suffering on 
the part of his patient ; second, the production of 
pain during the introduction of the anesthetic 
or during the manipulations carried out by the 
surgeon will result in a reflex combative action 
which will in most cases interfere with the per- 
formance of the future steps of the operation. It 
matters little whether the production of pain 
results in restlessness of the patient and a con- 
sequent inability to control him, or in an attack 


ROBERT EMMETT FARR 123 


of vomiting or contraction of the abdominal 
muscles, giving the much-dreaded expulsive ef- 
fort. Failure is apt to result in any case. 

In introducing the solution but one painful 
wheal should be made in the skin, all secondary 
wheals being made from beneath. The skin 
should be anesthetized by subdermal infiltration, 
and all layers of the abdominal wall should be 
anesthetized before the incision is begun. The 
nerves should be attacked proximally in every 
instance and as the infiltration advances the 
amount of solution injected may be correspond- 
ingly decreased. The abdomen is opened between 
instruments which elevate its walls. The intra- 
abdominal pressure should be nil. Exposure 
should be permitted by utilizing the force of grav- 
ity and visual rather than digital exploration 
should be employed as a matter of preference. 
Retraction should be of the elastic type and a 
rigid forceful spreading of the abdominal wound 
should be avoided. Visualization of the splench- 
nic area allows one to introduce the anesthetic 
solution subperitoneally. Through the co-oper- 
ation of the patient the respiratory function be- 
comes an important adjunct. The use of clamps 
should, as far as possible, be avoided. The illumi- 
nation should be such that all pockets and deep 
cavities may be visualized. The pathology should 
be attacked wherever found and no attempt 
should be made to forcibly eviscerate the organs. 
The incision should be so planned that the path- 
ology may be reached with the least possible em- 
barrassment. 

If the above simple principles are carefully ob- 
served one may, without great embarrassment, 
perform a considerable percentage of his major 
surgery in the upper abdomen with facility, dis- 
patch and satisfaction. By following the plan 
of beginning operations under local anesthesia 
and resorting to mixed anesthesia when necessary, 
any surgeon may increase the scope of local 
anesthesia in his own hands with surprising ra- 
pidity. Furthermore, it is my belief that adher- 
ence to the regime outlined above will result in 
increasing any surgeon’s efficiency with corre- 
sponding benefit to the surgical patient. 


DISCUSSION. 

Dr. David C. Straus, Chicago: I enjoyed Dr. 
Farr’s paper very much. I simply want to make a 
few remarks and in the main second what he has 
mentioned. I want to call attention to a case in 
point where some form of local anesthesia was in- 





124 ILLINOIS MEDICAL JOURNAL 


dicated in a patient, 72 years of age, who had to be 
submitted to a rather severe operative procedure. 

This patient was admited to my service at the 
Cook County Hospital February 25 with a diagnosis 
of subphrenic abscess. He had been operated upon 
in November, 1921, for a ruptured appendix. The 
wound drained for some time, eventually healed and 
then reopened again, discharging pus. Six weeks 
before admission to the hospital the wound healed. 
From that time on he had some pain in the right 
side. Two days before admission he began to have 
pain, swelling and tenderness in the right upper 
quadrant of the abdomen just below the costal 
margin. He had had no chill and no fever. Exami- 
nation showed that the man was greatly emaciated, 
that the right diaphragm was displaced upward to a 
marked degree arid this was confirmed by a roent- 
genogram, substantiating the diagnosis of subphrenic 
abscess. The only other important finding was a 
localized swelling beneath the right costal margin 
anteriorly and this was quite tender on pressure. 
This mass was dull on percussion and this area of 
dullness was continuous with the lower margin of 
the liver dullness. The evening temperature was 
98.8, pulse 86 and respiration 24. I believed from 
these findings that the patient was suffering from a 
subphrenic abscess and that this was pointing an- 
teriorly beneath the costal margin. 

Accordingly under ether incision I made a short 
right rectus incision with its center over the center 
of the mass. When the fibers of the rectus muscle 


were separated a considerable amount of thick yel- 


low pus escaped. I was not sure whether this col- 
lection of pus communicated with a subphrenic col- 
lection or not, but I certainly did not wish to infect 
the general peritoneal cavity by any further inter- 
ference at this time, so I merely put in a drain. 
There was very little discharge from this wound 
after that. Three days later another roentgenological 
examination was made to determine whether there 
was any change in the subphrenic pathology. There 
was not. It was evident that the subphrenic space 
had to be opened and drained. As the patient had 
been subjected to an ether anesthesia but a few days 
before, it seemed extremely desirable to avoid an- 
other ether anesthesia and the patient’s age contra- 
indicated the use of nitrous oxide. Accordingly 
four days after the original operation under para- 
vertebral anesthesia I resected the ninth and tenth 
ribs in the posterior axillary line. I cut down to 
see whether there were adhesions between the 
diaphragmatic and the parietal pleura. I found the 
adhesions were well developed there, so that it was 
perfectly safe to cut through the parietal pleura and 
the diaphragm at once without any danger of in- 
fecting the general pleural cavity. I at once cut 
through the chest wall and the diaphragm and 
drained a large subphrenic collection. The patient 
did not complain of any pain during the entire 
operation. He made an uneventful recovery and 
was discharged cured on April 17. 

I agree with Dr. Farr that one should not ask 


February, 1923 


the patient whether he has any pain or not. I be. 
lieve the patient should be told that the only dis. 
comfort will be during the administration of the 
local anesthesia and that the operation itself will be 
absolutely painless, though he may feel pulling or 
pressure locally but no pain whatsoever. This 
morning I operated upon three patients under local 
anesthesia and I am sure that those of you who 
were present will substantiate me when I say that | 
am confident none of them felt any pain. I believe 
we should extend the realm of local and paraver- 
tebral anesthesia. 

Dr. E. C. Roos, Decatur: I would like to say in 
regard to local anesthesia, that Dr. Farr has de- 
veloped this method of anesthesia perhaps more than 
any man in the country, especially the infiltration 
method. I had the pleasure some time ago of seeing 
Dr. Labot of Paris, France, use his paravertebral 
method of local anesthesia at the Mayo Clinic at 
Rochesttr, Minn. I saw him use it in a number of 
abdominal cases. A general anesthetic had to be 
resorted to in the majority of these cases before the 
operation had progressed very far. Of course, Dr. 
Labot worked under the great handicap of having 
some other surgeon operate on the case he had an- 
esthetized. Most general surgeons are not ac- 
quainted with the technic necessary for operating 
under local anesthesia. 

I have also seen a great deal of work in Dr. 
Farr’s Clinic. Perhaps in 99 per cent. of the abdom- 
inal cases I have seen him do under local anesthesia, 
no general anesthetic was resorted to. 

I think it is the general opinion of the men using 
local anesthesia in this country that the infiltration 
method is the method to be adopted by the average 
general surgeon. The man who uses paravertebral 
anesthesia has to be an expert at spearing nerves, 
for that is what it amounts to, and there is more or 
less danger connected with this method. I am 
sure we all enjoyed Dr. Farr’s motion pictures. 
They speak for themselves. 

Dr. Hugh McKenna, Chicago: I want to say | 
appreciate very much the pleasure of hearing this 
discussion. I think Dr. Farr is quite right in saying 
that local anesthesia is no longer an experimental 
proposition, but the important thing is to learn how 
to do it. I say to learn how to do it, because we 
have seen a master do it this afternoon. 

We had occasion to see a lot of local anesthesia 
used during our military service, something like 652 
hernias among other things, representing a total of 
about 900 operations in one year and probably 60 
per cent. of these were done under local anesthesia. 
I know that although the operations were done 
very clumsily as compared to the manner in which 
Dr. Farr has done them, the question of putting in 
your initial injection after your primary wheal one 
inch anterior to the spine to catch the iliohypogas- 
tric nerve just under the external oblique, we got 4 
deep anesthesia and had no trouble in handling those 
cases. 

I particularly want to ask Dr. Farr in the question 


—_— lr lr ll a tlC Ol OOO 





ry, 1923 


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February, 1923 


of intraabdominal operations on the stomach or 
intestines where he gets complete anesthesia has he 
any difficulty in getting a paresis of the bowel or a 
distension of the bowel by fluid from an involvement 
of the sympathetic system. 

Dr. Robert Emmett Farr, Minneapolis, Minn. 
(closing the discussion): I wish to thank the gen- 
tlemen for their discussions. In answer to Dr. Mc- 
Kenna I would say if there is one advantage of local 
anesthesia over any other form, excepting spinal 
anesthesia, which is a form of local, it is the post- 
operative absence of gas pains. I have attributed 
that to careful handling of the viscera. Just recently 
I had a letter from Dr. P. B. McLaughlin of Sioux 
City. He has done a great deal of work under local 
anesthesia. He made a very interesting observation. 
He had a case of intussusception in an adult with 
about 18 inches of the bowel invaginated and was 
unable by any means at his command to force the 
intussusceptum out. He then injected the mesentery 
and while waiting a few seconds to see whether he 
would have a cessation of the pain, the bowel re- 
jaxed and the thing dropped out. He sat down 
and wrote me a letter. I have seen the bowel do this 
when I had it outside, but in this case it happened 
right in the abdominal cavity. The main point I 
want to make is that it is my notion that it is going 
to be the simplest thing in the world to do abdominal 
surgery under local anesthesia when we realize cer- 
tain things. You get a relaxation of the- abdominal 
wall and the absence of reflexes and your patient 
has no pain when you handle the viscera. We have 
occasionally torn off a gall bladder while showing 
visiting surgeons how much traction can be put 
on the gall bladder with no complaint from the pa- 
tient. I think we are right on the edge of realizing 
what we can do in this class of work if we follow 
certain principles. 





THE TREATMENT OF CHRONIC FA- 


TIGUE INTOXICATION* ** 
Epwarp H. Ocusner, B. S., M. D., F. A. C. S. 


Attending Surgeon, Augustana Hospital, 
CHICAGO 

In a paper entitled “A Serious Menace and a 
Way Out,” published in the Intino1s MepicaL 
JournaL of February, 1922, and in a second 
paper entitled “The Symptomatology of Chronic 
Fatigue Intoxication,” published in the same 
journal but in the September, 1922, number, I 
have presented some of the facts upon which I 
base my belief that Chronic Fatigue Intoxication 
is a distinct disease entity with as definite symp- 
toms as any of the systemic diseases which have 
been recognized as disease entities for centuries. 


“Paper read before the Chicago Medical Society on Wednes- 
day, October 25, 1922. 


."*Permission to publish granted only on condition that copy- 
Tight be waived. 


EDWARD H. OCHSNER - , 125 


With this introduction permit me now to out- 
line the treatment which I have used in many 
instances to relieve patients suffering from this 
condition. 

In the treatment of patients suffering from 
this affection, four objects must constantly be 
kept in mind. 

1. Maintain or improve the nutrition of the 
patient as the individual case may demand. 

2. Prevent the further accumulation of fa- 
tigue material. 

3. Ameliorate the symptoms as much as pos- 
sible. 

4. Remove the already accumulated fatigue 
material. 

While I will not take these points up categoric- 
ally because this does not seem convenient or 
feasible, all the suggestions made are for the 
purpose of accomplishing these four objects. 

In the early cases little difficulty will be en- 
countered in maintaining good nutrition, if one 
will simply see to it that the patient has a diet 
in which the necessary ingredients of proteids, 
hydrocarbon, carbohydrates, salts and vitamines 
are properly proportioned, the variety is suffi- 
cient, the food is prepared so it will be easily 
digestible, and attractively served, so that the 
patient’s appetite will be maintained. In the 
more advanced cases the problem is a good deal 
more difficult. Here the nutrition has often 
grievously suffered, the gastric and intestinal 
juices have been much altered, the patient often 
is so exhausted that he finds it difficult to prop- 
erly masticate his food. This exhaustion may 
reach such an extreme degree that some of the 
patients actually find it a hardship to eat. I 
have watched some of them eat and recall one 
patient in particular who just opened her mouth, 
put the food in, swallowed it whole just as a 
chicken or young crow eats. Not being supplied 
with a crop and a gizzard much of the food 
naturally went through entirely undigested and 
acted principally as an intestinal irritant. In 
such cases it may actually become necessary to 
pass all food through a meat chopper before it is 
served. 

Nearly all of the severe cases suffer much from 
hyperchlorhydria, eructation and belching of gas, 
and constipation. One of the most important 
matters in the dietary is to prohibit the inges- 
tion of such liquids as tea, coffee, alcoholic bev- 
erages and water with the food, in order that the 








gastric juice may not be too much diluted and 
then, too, the gastric distress is markedly less- 
ened. The hyperchlorhydria must be overcome 
by the judicious use of the various antacids. In 
one individual one antacid works best, in the 
other another, and if the first one does not give 
the desired result, others must be tried out until 
the right one is found. The antacids will also 
assist somewhat in overcoming the pyloro-spasm 
and the cardio-spasm, the latter of which is prob- 
ably the chief cause of the eructation and belch- 
ing, as it prevents the normal escape of swal- 
lowed air. The pvloro-spasm is in part un- 
questionably caused by the attempt of the py- 
lorus to hold back the excessively acid stomach 
contents. In addition the antacids help to over- 


come the reduction in alkalinity of the blood, 


and ameliorate to a considerable degree the 
nervous irritability from which so many of these 
patients suffer. 

Because of the pyloro-spasm the emptying 
time of the stomach is often greatly delayed, and 
then most careful attention must be paid to the 
feeding interval, for the taking of a new meal 
when the previous meal is still in the stomach, is 
likely to still further derange the digestion and 
cause the formation of toxins in the gastro-in- 
testinal tract. Asa rule I find that these patients 
do best on three meals a day and that few of 
them can safely take food oftener than that in 
the twenty-four hours. On quite a number of 
occasions I have found it necessary to cut them 
down to two meals a day and on a few occasions 
temporarily to one. 

In addition I have every reason to believe that 
the toxic substance deposited in the tissues, and 
so often circulating in the blood, is a protein 
substance and not until I realized and recognized 
this fact and eliminated practically all animal 
proteids except milk, cream and butter from the 
dietary of these patients, did I begin to get re- 
sults. Hence I prohibit the use of all meats 
including fish and sea food, meat soups, meat 
gravies and eggs, though eggs in moderation in 
the cookery seem to be tolerated fairly well. 

As many of these patients, particularly in the 
later stages, suffer from severe chronic constipa- 
tion, it is well to see that they have enough 
roughage in their diet such as cereals, carrots, 
enions, egg plant, squash, parsnips, string beans, 
tomatoes, mushrooms, stewed fruit, spinach, 
green peas, lettuce, celery, coldslaw, etc. Cooked 


126 ILLINOIS MEDICAL JOURNAL 


February, 1923 


cabbage must be avoided as it is difficult for 
these patients to digest and is apt to cause a 
great deal of gas. Coldslaw on the contrary is 
very well tolerated by most of them. 

Many and various disturbing symptoms appear 
from time to time during the course of treatment 
and these call for much ingenuity in their suc- 
cessful handling. Two of the most difficult ones 
to deal with are pain and insomnia, but they can 
usually be successfully met without the use of 
opiates and hypnotics and every effort must be 
made, if the case is to terminate in a cure, to get 
along without the use of opium or any of its 
derivatives. To relieve the distressing symptoms 
during the time that the accumulated fatigue 
material is being eliminated is of the utmost im- 
portance, for if the former is not done effectually 
the latter is almost impossible of accomplish- 
ment because pain and discomfort are two of the 
most important factors in the further produc- 
tion of fatigue material. 

One of the most distressing of these symptoms 
is cold feet, naturally more in evidence during 
the winter months. I have had a number of 
patients describe it not as discomfort but as 
actually almost unbearable pain during their 
waking hours, and so annoying and distressing 
at night as to rob them of hours and hours of 
sleep. In. these cases bed socks alone are of rela- 
tively little value. If, however, the feet and legs 
are rubbed for five minutes using a mixture of 
two drams of tincture of cantharides added to 
one pint of 50 per cent. alcohol and the bed socks 
are then worn, the patient will be entirely re- 
lieved for the night and if comfortably warm 
and dry foot wear is worn in the daytime they 
will be soon entirely relieved of this discomfort. 

To look after the discomforts and to relieve 
them as much as possible is very important, but 
it is even more essential to see to it that no new 
fatigue material is deposited. One of the most 
widely applicable and I would say most neglected 
of all therapeutic agents which we possess is rest 
and in this disease particularly do we need to 
employ it. In the less severe cases the ordinary 


vocation, unless too strenuous, can be continued 
but the patient should be advised to take as 
much rest as possible when not actually at work 
and to pursue his work with moderation. In 
these cases an occasional fifteen minutes of abso- 
lute relaxation with the patient lying perfectly 
flat, feet and arms outstretched and relaxed, is 














iry, 1923 


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February, 1923 


of great assistance. The value of this was well 
understood by Gen. Stonewall Jackson who used 
it with marked success in his army. Of all the 
generals of all times he had probably the most 
mobile army that ever existed in the history of 
the world. It was so mobile that the Northern 
generals never knew where he would strike next 
and greatly over-estimated its numerical 
strength, and he accomplished it by making use 
of the following trick: During forced marches 
he would every few hours direct his soldiers te 
stretch themselves out perfectly flat on the 
ground and with all of their muscles relaxed re- 
main in this position for ten or fifteen minutes. 

Nothing could be more unsatisfactory than to 
attempt to treat these people the same way that 
neurologists treat hypoplastic, constitutional in- 
feriors and patients suffering from functional 
neuroses. The two conditions are as far apart 
as the antipodes and must be treated along 
entirely different lines if we would succeed in 
any considerable per cent of these cases. 

Because of the slow, oftentimes unreliable 
thinking processes and impaired judgment as 
well as their inability to adjust themselves readily 
to new conditions and environment, these pa- 
tients should be strongly urged not to change 
their occupation or to go into new important 
ventures. This observation is made because so 
many of these patients become dissatisfied and 
restless, constantly have a longing to try new 
things with the hope of getting relief in some 
distant part of the world, and are often advised 
by their physicians and others to change their 
occupation. This usually does the patient more 
harm than good and practically always leads to 
financial losses and sometimes to financial dis- 
aster. I have seen a number of these worn-out 
city folk buy chicken farms, truck farms and 
general farms, try it for two or three years, lose 
most of their money, and return to the city 
utterly broken in spirit and in purse. I have 
seen overworked farmers sell their farms, go into 
business in the city with the same unfortunate 
end result. The paths of least resistance are 
the ones which have been most traveled. If these 
people must work, they will find it easier ‘and 
less exhausting to follow along the beaten path. 
They will do best to continue right on in their 
familiar haunts and occupations and not make 
new ventures or try to learn new trades. Even 
the much advised change of scenery and travel 


EDWARD H. OCHSNER 127 


is of no permanent value. I have a number of 
these patients who have'traveled from sanitarium 
to sanitarium and from country to country 
without the slightest relief, who were per- 
manently cured when placed on proper treat- 
ment right in their own home. 

In the more severe cases it is sometimes neces- 
sary to have the patient stop his work entirely 
and to interdict physical exercise of all kinds. 
The physical exercise stunts that so many of 
these patients are put through must all be 
stopped if a cure is to be accomplished, because 
instead of eliminating fatigue material they 
cause the further production and accumulation 
of it. In the very extreme cases it may actually 
be necessary to temporarily put the patient to 
bed and even to feed him in order to prevent the 
further production of fatigue material. This is 
imperative in all cases of chronic fatigue intoxi- 
cation suffering from high blood pressure. 

In the feeding of these cases it is sometimes 
even necessary to see that the patient does not 
ingest too much food, for some of them have 
unnatural; ravenous appetites due to the hyper- 
acidity of the stomach, and the elimination of 
the excess food ingested actually produces new 
fatigue material. 

One of the important things in preventing ac- 
cumulation of new fatigue material is to help 
the patient get rid as nearly as possible of all 
handicaps; thus the patient with uncorrected 
hypermetropia, myopia and astigmatism, should 
be tested out most carefully and proper glasses 
fitted in order that he may, not be continuously 
subjected to exhausting eye strain. Ankylosed 
joints should be limbered up if possible, de- 
formed joints should be straightened and made 
useful, and all bodily defects that can be relieved 
should be relieved as soon as possible. The un- 
usually tall man should be given suitable tools 
and all unnecessary stress should be done away 
with. 

Proper diet, rest, and looking after the symp- 
toms as they arise, sometimes make these patients 
more comfortable, but these alone will never cure 
them. Sometimes again they are actually made 
more uncomfortable and unhappy by these pro- 
cedures alone, because the enforced idleness gives 
them more time to think about their pains and 
discomforts. Removing the cause alone may 


actually lengthen life but sometimes it makes it 
This and attempting to 


even more intolerable. 








128 ILLINOIS MEDICAL JOURNAL 






relieve the symptoms as they arise from time 
to time is not sufficient ‘to effect a cure. And if 
this course alone is relied upon the patient soon 
drifts from one physician to another, then from 
one quack to another, until he gives up in de- 
spair, or is finally relieved from his suffering by 
a premature death due to an intercurrent affec- 
tion or suicide. In order to forestall these un- 
desirable endings we must devise means by 
which the already accumulated fatigue material 
can be removed from the body. Various measures 
must be employed to accomplish this. The 
active treatment should have for its object the 
elimination of all accumulated fatigue material 
in the shortest possible time with the least risk 
and discomfort to the patient. Good air, both 
day and night, is absolutely essential in order 
that the products of fatigue may be properly 
oxidized and converted into a form which may 
be easily eliminated. Suitable baths are also 
valuable adjuncts. The baths which [ have 
found the most beneficial are sponge baths every 
morning at a temperature varying from 68 to 
72 degrees F., according to the temperature of 
the room. Three weekly tub baths at a temper- 
ature of 93 degrees F., and in extreme cases, par- 
ticularly where the vasomotor disturbances are 
pronounced, a Sitz bath at 95 degrees F. with a 
shower at 80 degrees F. simultaneously for a 
period of five minutes every evening before 
dinner. In the extreme cases the use of castor 
oil is very important. Some of these patients 
can be saved only if they are given one ounce of 
castor oil every evening on retiring or the first 
thing in the morning, in order that the end 
results of the faulty digestion may be cleared out 
of the gastro-intestinal tract daily and the 
fatigue material which may have found its way 
into the gastro-intestinal tract after massage 
may also be removed. 

In order that the ever present and fearfully 
exhausting muscle spasm be relieved, we must 
actually dislodge the already accumulated fa- 
tigue material, so that the patient may again 
relax his muscles. The bow that is always bent 
is sure to break. We must loosen the strings or 
the patient cannot get well. And in order to 
dislodge this fatigue material from the tissues 
and to permanently rid the system of it, the 
measures already mentioned must be supple- 
mented by carefully supervised, intelligent mas- 








sage. Not only must massage be supervised but 
even the best masseurs must be painstakingly 
taught the fundamental principles involved in 
order that they may intelligently follow the di- 
rections prescribed in each individual case. 

When the patient is completely relieved of all 
of the symptoms and of all of his fatigue spots, 
the time for physical exercise and physical re- 
education of the atrophied muscles has arrived. 
Now this remedy is indicated and of great bene- 
fit, but if used too early it is distinctly harmful. 
The exercises must be gradually increased always 
stopping short of exhaustion. For this purpose 
1 have found the booklet which I published some 
years ago entitled “Physical Exercise for In- 
valids and Convalescents” of great assistance and 
convenience, because the exercises therein out- 
lined are very simple and the dosage can be very 
carfully regulated. Later more strenuous exer- 
cise such as golf, tennis, walking, rowing are indi- 
cated and moderate fatigue encouraged, but 
exhaustion guarded against in order that a re- 
lapse may be averted. 

CONCLUSIONS 

To teach a person to disregard minor bodily 
discomforts and to bear with equanimity un- 
avoidable pain is a real service. To encourage 
him to disregard preventable pain is often a posi- 
tive injury. To make a person unmindful of 
pain, to deny the existence of a definite ailment 
which does in fact exist, and to disregard the 
evident symptoms, is not by any means curing 
him of his malady. These are often even poorer 
makeshifts than a narcotic. The advice so uni- 
versally given these poor sufferers by Christian 
Scientists, psychotherapists and, I am sorry to 
say, sometimes even by regular physicans, to dis- 
regard their pain, is about as illogical and absurd 
as to advise a householder to disregard the sme! 
of smoke from the basement where normally 
there should be no fire, or to disregard the sounds 
caused by the jimmying of a downstairs window 
by a burglar. There may, of course, be times 
when it is prudent to disregard the burglar and 
there may be times when it may be absolutely 
neeessary to disregard pain, but such occasions 
surely must be rare. There is a vast difference, 
however, between on the one hand neglecting to 
pay attention to the smell of smoke from the 
basement, the noise of the jimmy of the burglar 
and the pain of this affection, and on the other, 


February, 1923 





iry, 1923 


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February, 1923 


lying awake nights smelling for smoke, and 
listening for the burglar and pinching one’s self 
every few minutes to look for pain. Both ex- 
tremes should be avoided as they are equally 
irrational and harmful. I cannot see any funda- 
mental difference between the Christian Science 
healer who denies pain and the psychotherapist 
and regular physician who disregard pain, or the 
former when he reads some meaningless jargon 
to his dupe and the latter when they say “Forget 
it” to their patients. While it is bad to magnify 
every little ailment it is stupid to disregard 
actual pain. Pain is a warning signal which can 
be no more safely permanently disregarded by 
the individual than can the red danger signal be 
safely disregarded by the railway engineer. As 
children we learned to keep our hands out of 
fire, to avoid falling downstairs, or cutting our- 
selves because it hurts. As adults we are pro- 
vided with similar safeguards. The process of 
self-hypnotization and auto-suggestion so com- 
monly indulged in nowadays by many individuals 
who pretend to be well when in fact they are 
thoroughly miserable is of very doubtful value. 
“What can’t be cured must be endured,” like 
most epigrams, expresses only half the truth. 
The other half of the truth is, “What can be 
cured should not long be endured.” 





PERNICIOUS ANEMIA 
R. D. Rosrnson, M. D. 
CHICAGO 


Pernicious or primary anemia is characterized 
by progressive degeneration of the red blood, al- 
teration in the blood producing tissues, changes 
in the spinal cord and other tissues generally. 
Of unknown etiology, insidious gradual onset, 
with indefinite early signs, by the time a posi- 
tive diagnosis is reached we know we are dealing 
with an incurable malady, but nevertheless one 
which responds at times, very rapidly to treat- 
ment. 

To go into detail as to the theoretical causes 
of this disease would be almost like delving into 
the etiology of eclampsia or cancer. Changes in 
the stomach, infections, alterations in the spleen, 
bone marrow, infestation with parasites, notably 
the Balantidium Coli and Bothriocephalus Latus, 
intoxication from the large bowel, have or have 
had their supporters as causative agents, but not- 
withstanding the fact that about 6,000 die of 


R. D. ROBINSON 129 


pernicious anemia annually in this country, and 
a large amount of research work is being done, 
almost all agree that the cause is yet unknown. 

Of all the theories, there is one which makes 
a strong appeal, namely, infectious. We are 
accustomed to associate any disease which runs a 
protracted temperature, even though very slight, 
with an infection of some kind, and especially 
one in which there might be a slight temperature 
for weeks, often associated with a large spleen. 
These characters most strongly resemble proto- 
zoan infections, and of these the spirochetic. 
Comparing for a moment syphilis and pernicious 
enemia we find: 

Prolonged low grade temperature in both. 

Both are blood cell destroyers. 

Both show splenic enlargement in many cases. 

Both diseases yield to arsenic or its derivates 
in a matked degree, which group of agents are 
almost specific for any spirochetic infection. 

Finally, there is a marked analogy in the spinal 
cord changes, with predilection for the columns 
of Goll and Burdach and similar qualitative find- 
ings in the spinal fluid. Of the contributing or 
predisposing factors in causation, age stands out, 
about three-fourths of the cases occurring beyond 
the age of 36, with about twice the incidence in 
males. Geographically the disease is more com- 
mon in Europe, especially in the Thames valley 
and Switzerland. 

Actuarial statistics show about one per cent of 
the deaths due to pernicious anemia, which is 
about three times as high as the figure given by 
the U. S. Health Board, but is accounted for by 
the fact that a more thorough investigation is 
made as to cause of death by the insurance com- 
panies. 

Pathology. There is no characteristic patho- 
logical change. A straw or lemon yellow tint of 
the skin, with absence of emaciation is perhaps 
the most constant finding. Due to the prolonged 
anemia, fatty degeneration of the liver, kidney 
and heart muscle is frequent while atrophy of the 
stomach is noted in many cases. A smooth, 
glistening tongue, with glossitis is fairly common. 
The spleen is often smaller at necropsy, but dur- 
ing life the spleen is enlarged usually. In a 


series of 50 spleens examined at the Mayo clinic, 
the average weight was 400 grams, with two of 
the series having weights of 1,600 and 2,200 
grams; the normal spleen weighs about 200 
grams. Both liver and spleen show increased de- 








130 


position of iron pigment. 
dark, shows deficiency of fat globules, with in- 
crease of nucleated red cells; in certain aplastic 
types the marrow shows no change. About 
eighty-five per cent of cases show spinal cord 
changes, consisting of ecchymoses in the posterior 
columns, most frequent in the cervical region, 
with small areas of degeneration, a multiple com- 
bined sclerosis. 

Symptomatology. 1 believe it was Osler who 
once remarked that the medical acuity of a com- 
munity could be gauged by the number of per- 
nicious anemias diagnosed. 

The onset is insidious. On close questioning, 
symptoms referable to the gastro-intestinal tract 
extending over a period of months may be elic- 
ited. Muscular weakness, languor and breath- 
lessness on exertion, coupled with pallor, are 
the symptoms which call the patient’s attention 
to his malady. Anorexia often becoming an aver- 
sion to food develops, while epistaxis and ecchy- 
moses occur occasionally. ‘There is always a 
hypochlorhydria, often achylia, with occasional 
pain of colicky type in the epigastrium. Inflam- 
mation of the tongue and gums occur frequently, 
while half of the cases show diarrhea at some 
time, often with occult blood. Hemorrhages 
from the gums, nose, stomach, or bowel, produc- 
ing hematemesis or melena are common, and to- 
gether with the age of the patient and the pallor, 
suggest malignancy of the stomach or bowel. 
The urine is usually pale and of low specific grav- 
ity, but at times may be dark or smoky from 
urobilin, due to blood destruction. 

Symptoms referable to the nervous system are 
common, probably the most usual being numb- 
ness and tingling of the extremities. A tabetic 
syndrome, with lancinating pains, loss of reflexes, 
girdle sensations and paresthesias due to involve- 
ment of the postero-lateral columns is seen. A 
type, due to involvement of the pyramidal tracts, 
with increased reflexes and spastic gait is de- 
The presenting symptom in a case I 
have in mind was numbness and paresthesia, 
even before the pallor and weakness were noticed. 
On inspection a patient with pernicious anemia 
seems well nourished, with a pale lemon or subic- 
teroid tint, blanching of the mucous membranes 
of the eye lids and lips, sometimes with little 
cherry red petechial spots, with a flabbiness and 
loss of turgor of the skin, and frequently some 
edema of the ankles. The patient seems tired, 


scribed. 


ILLINOIS MEDICAL JOURNAL 


The bone marrow is 


February, 1923 


the pulse is collapsible and sometimes has a can- 
ter rhythm. A hemic murmur at the apex is 
common, and pulsating carotids are noticeable. 

The Temperature. At some time during the 
course of the disease a temperature develops, most 
usually during a blood crisis,—a mild pyrexia, 
varying from 97 to 100, present for a period of 
weeks is almost always found; in the terminal 
stages a subnormal temperature is common. 

The Blood. On pricking the ear, the drop 
seems to flow out with greater ease than the nor- 
mal, suggesting a greater fluidity, which is just 
the case, because there are less cellular elements 
in the plasma. 

The total. blood volume is diminished,— 
marked diminution in the red blood cells is 
found. This varies, sometimes reaching ex- 
tremely low figures,—even down to 150,000 per 
cubic millimeter. The average case shows one 
and a half to two millions of erythrocytes. No 
type of anemia so regularly produces so low a 
red count. Almost all the qualitative findings 
are present in the red blood cells. 

Poikilocytes, with fragmented, crenated, ovoid 
and other bizarre forms are seen; in the same 
field may be seen large round red cells, with 
twice the diameter of a normal one,—the mega- 
locytes. Some writers consider the anisocytosis, 
or variation in size of the red cells, with pre- 
ponderance of megalocytes, as a rule forty per 
cent or more, as a pathognomonic sign of per- 
nicious anemia. Microcytes, little red cells, per- 
haps only two or three microns in diameter occur, 
while occasionally an erythrocyte is seen, which 
has stained with both the hematoxlyn and eosin 
giving a purplish color—the polychromatophile. 
Basic stipling is common. This condition may 
be simulated by small particles of dirt lying in 
the body of the blood cell, or by a slight precipi- 
tate in the stain. Nucleated forms, nomoblasts 
and megaloblasts are common, much more 80 
during a blood crisis than normally. In counting 
a hundred leucocytes, perhaps two or three nu- 
cleated reds might be found, in the average case. 

Another finding, considered almost patho- 
gnomonic, is an elevation of the color index,—a 
plus one index, which simply means, that, al- 
though there is a great diminution in the number 
of red cells, the individual cell is carrying more 
than its allotted quota of hemaglobin. A norma! 
individual with 5,000,000 erythrocytes, should 
have 100 per cent hemoglobin. Suppose we have 




















ry, 1923 


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February, 1923 


a pernicious anemia case, with a hemaglobin 
reading of 50, and a red count of 2,000,000 and 
we wish to determine the color index, an un- 
known quantity X. Formulating an equation,— 
the normal 5,000,000 reds is to 100 per cent 
hemoglobin, as the abnormal 2,000,000 is to X 
which when calculated shows X to be 40, or the 
amount of Hb. the patient should have theo- 
retically. Our Hb. reading, however, shows fifty 
per cent, or he has 50/40 as much Hb., or he has 
1.25 plus index. This finding, when high is a 
very valuable diagnostic sign. Before leaving 
the red blood cell, I call attention to the fact 
that there are certain malignant types of per- 
nicious anemia in which there are no nucleated 
forms, viz.: the aplastic type, which is considered 
as a sign that no effort is made on the part of 
the bone marrow to renew the vanishing red cell. 
A cell is described, and occasionally seen, in the 
leukemias and pernicious anemia, known as the 
Tiirck cell or irritation form. It is a large cell, 
resembling a large lymphocyte, with an eccentric 
nucleus, sometimes with nucleoli, whose proto- 
plasm stains dark blue, being vacuolated. They 
are rare,—often requiring a prolonged search 
through many fields to find one. They are 
simply indieative of a pathological blood. 

The White Cells. There is a reduction of the 
polymorphonuclear with a relative lymphocytosis. 
Myelocytes are sometimes seen. The blood plate- 
lets are reduced. To recapitulate the blood find- 
ings: 

1. Plus one color index. 

2. Megalocytosis. 

3. Polymorphonuclear leucopenia, with lymph- 
ocytosis. 

4. Presence of nucleated forms, stipple cells, 
poikolocytes, Tiirck cells. Myelocytes are usually 
found, although the blasts are absent in the 
aplastic type, while all the other forms may be 
seen in other blood states, but the combination of 
the first three findings bespeak pernicious anemia. 

Diagnosis. A patient usually of middle age, 
36 or over, pale, fairly well nourished, even 
slightly puffy, comes complaining of fatigue, loss 
of strength, and perhaps gastro-intestinal symp- 
toms,—sometimes nervous symptoms. The blood 
examination suggested by his pallor and blanched 
mucous membranes, shows a plus one index, a 
low hemoglobin, evidence of profound blood de- 
struction as exemplified by the megalocytes and 


R. D. ROBINSON 131 


poikilocytes and oligocythemia, with occasional 
nucleated forms, and a decrease in the white cells. 
This case is classical,—it is pernicious anemia ; 
it has reached the stage where a positive diag- 
nosis is easy and certain. It is in the earlier 
cases, in which the distinguishing features, the 
embryonal characteristics and high index have 
not appeared, which are confusing. 

Differential Diagnosis. Because of the pale 
mucous membranes, pallor of the skin and weak- 
ness, all symptoms of any type of anemia, those 
conditions producing similar signs are first to be 
differentiated, and because of the age incidence, 
and gastro-intestinal symptoms,—carcinoma of 
the stomach stands first. 

Both conditions produce an anemia, but the 
anemia of cancer is of the secondary type, with 
a low color index, and without the marked quali- 
tative and embryonal characters. Both condi- 
tions usually have hypochlorhydria or achylia, 
both may at times give a positive Weber test in 
the stool. The x-ray may clear. up the diagnosis 
by showing filling defects in the stomach, altera- 
tion of pyloric function, perversion of peristalsis, 
altered mobilty and six-hour residue in cancer. 
The cachexia, loss of weight and the course of 
cancer, leading to palpable tumor and enlarged 
liver clarifies the problem. Persistent small 
hemorrhages, such as occur from hemorrhoids, 
may be confusing until the cause of the bleeding 
is located. Carcinoma of the rectum may develop 
a high degree of cachexia, before symptoms suffi- 
cient to direct the patient’s attention to the dis- 
ease have developed, especially if situated well 
up toward the sigmoid, and may cause confusion 
until the examining finger or proctoscope clears 
up the difficulty. 

The anemia accompanying syphilis, in the 
absence of cutaneous or bony signs must be 
thought of especially in the so-called malignant 
type. The two diseases are sometimes associated, 
and even the nervous manifestations are similar 
at times. The diagnosis here would hinge on the 
blood findings of a true primary anemia, in 
contra-distinction to a secondary type, history 
of infection and contrasting courses of the two 
diseases. 

Parasitic diseases, notably hook worm infesta- 
tion, may produce such a high grade of anemia 
as to closely simulate the primary anemia, with 
pallor and weakness, but is ruled out by the find- 








132 ILLINOIS MEDICAL JOURNAL 





February, 1923 


ing of the ova in the stools; eosinophilia of 10 or. cialy the subleukemic type, in which there may 


15 per cent is the rule in hook worm infection. 
Addison’s disease, because of the asthenia and 
pigmentation, might have to be ruled out. The 
triad of asthenia, gastric disturbance and pig- 
mentation, usually with a positive tuberculin 
test, and slight secondary, or absence of blood 
changes, differentiates this malady from per- 
nicious anemia. 7 

Cirrhosis of the liver, plumbism and chronic 
Bright’s disease. have symptoms in common with 
primary anemia, but are readily ruled out on 
clinical and laboratory evidence, with absence of 
the primary blood changes. Occasionally it hap- 
pens that the first symptom which attracts the 
pernicious anemia patient’s attention is some 
derangement of nerve function, due to cord 
changes, which very closely simulate tabes dorsa- 
lis. I have in mind a case, in a man of 42, in 
which the presenting symptoms was a numbness 
in the hands, with loss of stereognostic sense and 
girdle sensation about the arms. These symp- 
toms persisted and in addition paresthetic symp- 
toms, with unsteadiness of gait developed, making 
it clear that an involvement of the columns of 
Goll and Burdack had taken place. This case, 
however, had no Jancinating pains, but did have 
an involvement of the crossed pyramidal tracts as 
evidenced by bilateral Babinskis, ankle clonus 
and a slight spasticity. 

Negative Wassermann on the spinal fluid and 
blood, absence of globulins and a normal cell 
count on spinal fluid and absence of any cranial 
nerve involvement, with a positive blood picture 
of pernicious anemia, settled the diagnosis as a 
pernicious anemia. 

Differential Diagnosis of Blood Conditions. 
I have touched on the differential points of sec- 
ondary anemia in contrast with the primary 
types, but feel there are some other blood dyscra- 
sias requiring differentiation : 

Chlorosis occurs principally in young girls, 
and may show almost a normal blood, or an 
oligocythemia, with a low hemoglobin,—down to 
10 or 45 per cent. Clinically, the two conditions, 
pernicious anemia and chlorosis, are very similar, 
with weakness, vertigo, fatigue, palpitation, but 
the chlorotic usually has a good color, with pearly 
sclerae, and absence of the pallor. A course of 
suitable iron preparation, diet and rest differenti- 
ates the latter by the therapeutic test. 

The chronic form of myeloid leukemia, espe- 


be only a slight leucocytosis, instead of the usual 
100,000 or more, is ruled out by the prese1ce of 
the myelocyte in large numbers, as contrasted 
with pernicious anemia in which there is only an 
occasional one, not over one per cent, with 
leucopenia. 

The presence of large numbers of nucleated 
reds in the VonJaksch anemia is the only point 
of resemblance. The disease shows a marked 
splenomegaly, and occurs in infants only. 

Carcinomatosis of the bone marrow, has sey- 
eral points in common with pernicious anemia. 
The age incidence is the same, the blood changes, 
aniscytosis, megalocytosis, poikilocytosis are the 
same, and there may even be a plus one index,— 
a contsant flooding of the blood stream with ery- 
throblasts and a leucoytosis of 20,000 or 25,000 
with increase of the blood platelets, as contrasted 
with a decrease or absence of the platelets, a 
leucopenia, and only an occasional nucleated red 
cell, differentiates microscopicaly the two condi- 
tions, while an examination of the usual sites of 
the primary growth, namely the adrenal, breast, 
thyroid and prostate clear up the diagnosis clini- 
cally. 

Hemolytic Icterus. The characteristic features 
of this condition, of which there are two types, 
the familial and acquired, are enlarged spleen, 
usually associated with an enlarged liver, chronic 
jaundice, with exascerbations, normal bile—col- 
ored stools and bile in the urine. It may be con- 
fused with pernicious anemia in the early stage, 
before the jaundice develops. The blood findings 
in this disease are those of an extensive secondary 
anemia. It is important to accurately diagnose 
hemolytic icterus, as removal of the spleen cures 
it, while it only palliates pernicious anemia. 

Course and Prognosis. The average course 
would be about 12 to 18 months. Acute cases 
terminating fatally in a few weeks are reported, 
while Cabot reported a large series, in which ten 
patients had lasted seven years,—and he regarded 
6 cases out of these 1,200 cases as cured. From 
an extensive perusal of the literature, I conclude 
that pernicious anemia falls prognostically in the 
same class as tubercular meningitis,—if the pa- 
tient gets well he did not have the disease. Ad- 
disonian anemia is subject to remissions often of 
a year in duration. This is the ordinary type. 
The aplastic type gets progressively worse regard- 











y, 1923 


e may 
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S sey- 
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anges, 
re the 
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h ery- 
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ats, a 
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-ypes, 
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February, 1923 


less of treatment, always with a poorer blood pic- 
ture, until terminating fatally. 


TREATMENT 


Of the treatment of pernicious anemia, it may 
be stated at the outset that the cases seem to do 
well on most any treatment, from the usual I. Q. 
and S. tonic to splenectomy, that is for a time, 
or they seem to get along nicely without any 
treatment, under the ministrations of the chiro- 
prack or osteopath, also pro tempore. 

The medicinal treatment is the same as for 
active lues, the arsenicals, especially neosalvarsan 
and sodium cacodylate. Two three grain injec- 
tions of the cacoclylate daily for a week, alter- 
nating with ferric arsenate 1 cc daily, with six 
to nine decigrams of neosalvarsan, given every 
two weeks, will rapidly bring the red count up 
to 3,000,000 or 4,000,000, with marked improve- 
ment in symptoms,—even of the cord symptoms. 
Rest in bed for a period of several weeks, pref- 
erably in the open air, with as much nutritious 
food as the stomach will tolerate, is an important 
adjunct to treatment. 


Blood Transfusions. In a moderately severe 
case, two or three injections of a pint of whole 
blood, a week apart, will produce a remarkable 
amelioration of symptoms. It is known that a 
red cell from a proper donor will live and func- 
tion for a month or more in the recipient’s blood 
stream; whether the benefit is obtained through 
adding additional functionating erythrocytes to 
take the place, in part, of the crippled, impover- 
ished ones, or by producing an added stimulus to 
the hematopoietic organs, there is a greater pro- 
duction of new cells, is problematical. It would 
seem that both factors are at work. Splenectomy 
has been performed by many men. 

In a series of 47 cases splenectomized at the 
Mayo clinic, with a six per cent operative mor- 
tality, 78 per cent of the series were dead in three 
years, with an average period of nineteen months 
of life following operation; five patients were 
alive and in good condition four years and six 
months after operation. Improvement in the 
anemia, apparently due to decrease of hemolytic 
activity lasts about six months. Exascerbations 
Were more prone to occur from incidental dis- 
eases, like influenza, in those whose spleens had 
been removed. A more rapid and satisfactory 
Tesponse to transfusion was noted in this series. 
On the whole from this series of cases, the writer 


H. C. HOUSER 133 


claimed a prolongation of life in one-fifth of the 
series. 

Dr. Mayo says in substance, that splenectomy 
does not seem to be based on sound reasoning, 
that while it may bring about a temporary re- 
mission, it will not effect a cure. Probably some 
of the cases, so favorably reported on, were not 
pernicious anemia, but hemolytic icterus. It is 
worthy of trial in border line cases, but in view 
of the operative mortality, good reason must 
exist for supplanting transfusions with splenec- 
tomy. 

1971 West 111th St. 





ANATOMY, PHYSIOLOGY, AND DIS- 
EASES OF THE CIRCULATORY SYS- 
TEM, AND MANAGEMENT AND 

TREATMENT OF SUCH DISEASES* 


H. C. Houser, M. D. 
WESTFIELD, ILL. 


The circulatory gystem is composed of the 
heart, the arteries carrying pure blood toward all 
parts of the body, the capillaries, and the efferent 
vessels, or veins. The entire system is one in- 
tricate arrangement of tubes, with no macro- 
scopic opening in any part. The heart is the 
main propelling force, and the vessels, both affer- 
ent and efferent, are largest near the heart, and 
dwindle to mere threadlike vessels, the capil- 
laries. 

The heart is a hollow muscular organ, enclosed 
in a fibroserous sac, composed of two layers, 
namely, the visceral layer, or epicardium, lying 
next to the organ, and the parietal, or outer 
layer. Ther are four chambers or cavities, two 
above, the auricles, and two below, the ventricles. 
There is an opening between the right and left 
sides of the heart during fetal life, the foramen 
ovale, but this aperture closes at birth, if con- 
ditions are normal, thus leaving the halves com- 
pletely and permanently separated. The right 
heart receives the impure blood coming from the 
body tissues by way of the superior and inferior 
venae cavae, and the left heart receives the puri- 
fied blood from the lungs through the pulmonary 
veins. 

Between auricle and ventricle, on both sides 
of the heart, there are valves that permit the 
unobstructed flow of blood from above downward, 


*Read before the Clark County Medical Society, Sept. 14, 
1922. 





134 ILLINOIS MEDICAL JOURNAL 


and completely prevent any return flow. This 
arrangement is carried out throughout the entire 
circulatory system, the valves assuring a current 
in one direction only. 

Due to a specially arranged reflex located in 
the heart muscle itself the contractions continue 
regularly when we sleep, the rate being slower 
than when awake. But the contractions of the 
muscles through which the blood vessels take 
their course, assisted by the valves referred to 
above, have a great deal to do with the proper 
maintenance of a good circulation. 

The heart is about five inches or 125 m.m. 
long, three and one-half inches or 87 m.m. 
broad, and two and one-half inches or 62 m.m. 
antero-posteriorly. Its size is roughly estimated 
as being about the size of the closed fist, varying 
greatly at different ages and in different indi- 
viduals, many conditions, accompanied by ap- 
parently good health, affecting the size of the 
heart. The heart is a peculiar type of striped 
muscle, especially adapted ¢0 continuous work 
and strain. This muscle tissue is continuous to 
some extent in all the vessels leading to and 
from the heart, and the well-being of the indi- 
vidual depends in a great measure upon the con- 
dition of these muscular fibres in the vessel 
walls. f 

The blood is sent out through the aorta to all 
parts of the body, then carried back through the 
capillaries to the veins, thence to the right 
auricle by way of the superior and inferior venae 
cavae, then to the right ventricle, then to the 
lungs by way of the pulmonary arteries to be 
purified: then by the pulmonary veins to the left 
auricle, thence to the left ventricle, this entire 
circle being repeated every twelve to twenty 
seconds during life. 

The function of the circulation is to carry 
nourishment to the tissues, and to remove the 
end-products of metabolism from the system. 
Complete success in this attempt means health, 
and any deviation from it results in some patho- 
logic condition. 

The diseases of the circulatory system are so 
complex and so numerous that I shall mention 
only a few of the more common ailments we meet 
with and attempt to correctly diagnose. The 
entire list includes the various forms of pari- 
carditis, endocarditis, incompetency, stenosis, 
hypertrophy, dilatation, myocarditis, degenera- 
tion, neuroses, and diseases of the arteries, chief 





February, 1922 


among which are the aneurysms, and arterio- 
sclerosis. 

It is very seldom that any one of the above 
mentioned conditions is found until others in 
the group have been grafted on as a complication, 
For instance, a stenosis will soon produce in- 
competency, dilatation, hypertrophy, endocard- 
itis, and almost any other condition common to 
the circulation if such condition is not relieved. 

A great many cases of pericarditis, myocard- 
itis, antl endocarditis are never diagnosed for 
various reasons. In some cases the symptoms 
are mild, and the afflicted party does not report 
to a physician. Others report, but after a more 
or less superficial examination are given tonics, 
instructed to get more sleep and rest, and less 
food, and the condition improves to such a stage 
as to never cause further difficulty, or dissap- 
pears altogether. 

Cases of pericarditis with effusion, if marked, 
usually cause enough discomfort to keep patient 
and physician busy until the difficulty is diag- 
nosed and an effort made to correct the condi- 
tion. It is often necessary to aspirate the serum 
or pus from these cases, and the prognosis in 
such events is rather unfavorable. 

Aortic incompetency soon results in a con- 
siderable irregularity in the circulation. There 
is soon dilatation and hypertrophy of the left 
ventricle, too much blood is thrown into the 
arteries at each cardiac contracture, causing a 
strain on the arteries, often resulting in arterio- 
sclerosis, followed sometimes by atheroma, 
aneurysm, or apoplexy. In time, if the condition 
is not corrected the pressure extends back to the 
left auricle, thence to the vena cava, all parts of 
the body become congested, back pressure is ex- 
erted on the pulmonary arteries due to an over- 
loaded circulation in the lung, and soon the right 
heart is involved in a manner similar to the left. 
Kidney function is disturbed, and the liver is 
markedly enlarged due to passive congestion. 
Edema of the feet occurs, and occasionally ger- 
eral anasarca supervenes. 

As long as the muscle retains its tonicity the 
patient may fare well, but when, due to the con- 
stant strain, the heart fails to compensate, all 
the symptoms gradually increase in severity, and 
the patient rapidly assumes a grave condition, 
with a very decidedly poor chance of any relief. 
The patient often complains of throbbing head- 
ache, vertigo, and tinnitus. A condition of gen- 





_ 


f — ee ee & © SS © 








February, 1923 


eral arterial anemia exists, due to failure of a 
normal amount of blood being sent into the cir- 
culation with each heart contraction. The patient 
appears anemic, often has headaches, flashes of 
light before the eyes, and dizzy spells. Hot 
flushes and sweating, caused by flushing of the 
peripheral circulation often canse a diagnosis of 
tuberculosis to be made. Dizziness, if it does 
occur, is often very distressing, and is most 
marked upon arising from the recumbent to the 
erect position. Exertion may produce marked 
dyspnea, even early in the disease, the condition 
being due to an interference with the blood 
entering the heart from the lungs, producing a 
pulmonary congestion. Precordial oppression, 
cardiac palpitation, and a dull aching pain radia- 
ting to the shoulders, and thence down the arms, 
especialy the left, often occur as early and per- 
sistent symptoms. When compensation fails, 
the dyspnea and general venous stasis become 
markedly worse. Sudden death, as a result of 
involvement of the coronary arteries, is more 
common in this form of valvular disease than in 
all other forms combined. 

Inspection shows the apex beat displaced 
downward and outward, visible in the sixth or 
seventh space, usually markedly heaving in char- 
acter; the larger arteries near the heart throb 
forcibly; the pulse in this disease is known as 
the Corrigan, or water-hammer pulse; it is quick 
and full, but recedes abruptly. 

Aortic stenosis has some of the same char- 
acteristic symptoms as aortic incompetency, but 
the apex beat is not so forceful, and edema is 
usually not marked. 

A marked systolic thrill is common in the 
aortic region, heard at the base and transmitted 
to the vessels of the neck. 

In mitral incompetency a systolic apical mur- 
mur is heard, and is conveyed to the left axilla, 
and may even be heard at the back, thus dis- 
tinguishing the condition from aortic stenosis. 

Mitral stenosis is characterized by a presystolic 
thrill at the apex, a murmur near the normal 
apex beat, localized, presystolic, and rough in 
character. The second pulmonic sound is ac- 
centuated. 

In tricuspid incompetency the venous pulse is 
the most valuable symptom in making the diag- 
nosis. This can often be detected in the veins 
of the neck, being more marked when the patient 
is in the recumbent position than when sitting 


H. C. HOUSER 135 


or standing. Often, however, the pulsating liver 
is the most reliable means of recognizing this 
condition. While we are referring to this type 
of valvular disease I wish to report the follow- 
ing case: 

Patient about fifty years of age, male. Farmer. I 
was called to see him to relieve a condition the patient 
called asthma. I found him sitting up in bed, suffer” 
ing a great deal from dyspnea. Examination showed 
a wide aorta, apex in sixth space below and external 
to the nipple, indicating a severe myocarditis. Heart 
very incompetent, but regular at 110 while patient was 
quiet. The pulse was very small in volume. Blood 
pressure was 150 diastolic, 205 systolic; pulse pressure 
of 55. The entire venous system and liver were en- 
‘gorged. When lying down the jugulars were very 
large and full, but cleared up and were empty when 
the patient was in the sitting posture. There was 
marked pulsation in the jugulars due to incompetent 
tricuspid opening. There is history of colics in his 
early twenties for three or four years. These were 
probably of gall bladder origin as he has soreness in 
that region now, and has had some few attacks lately. 
He had some very doubtful looking teeth. He gives 
a history of a large painless carbuncle on his neck a 
year ago, lasting two months with a typical discharge, 
and without general sepsis or loss of time from work. 
This was probably a gumma, as boils and carbuncles 
are painful. Potassium iodide and mercury, alternated 
with tincture digitalis, started him on the road to im- 
provement, but he had many relapses of a severe 
nature, followed by marked changes for the better. 
During one of these periods the family thought he 
was on a sure road to recovery, when without any 
warning he rose to the sitting posture and fell back 
dead. This case was probably luetic, the heart being 
the most affected organ. ‘ 

Tricuspid stenosis is rare, and is seldom 
uncomplicated condition. Venous stasis, dropsy 
and especially hydrothorax are common in this 
type of valvular disease. 

Pulmonary incompetency is also rare, and 
usually difficult of diagnosis. 

Pulmonary stenosis results in cyanosis and 
distention of the systemic veins. A systolic thrill 
may be felt at times over the base. A systolic 
murmur, most often heard in the third left 
space near the sternum, is transmitted a short 
distance upward and to the left. 

All the above mentioned types of cases require 
careful study and repeated examinations if the 
physician would give his patient the best results. 
A great deal of weight is given by some ex- 
aminers to the finding of a murmur or leakage 
of the heart as the layman often terms the con- 
dition. Too hasty a prognosis must not be given. 











Osler says that “with the apex-beat in the normal 
situation and regular in rhythm, the auscultatory 
phenomena may be practically disregarded.” 
The prognosis in these cases varies consider- 
The duration 
and severity of the condition, the mode of living 


ably with each individual case. 


followed and the general interest assumed by 
the patient are all very important factors to be 
considered. 

Hypertrophy and dilatation of the heart are 
conditions that often complicate the conditions 
we have just been considering. 

Regulation of diet, rest, and resort to the 
usual drugs adapted to these conditions will give 
slow and sure results in the favorable cases, but 
will result in more or less disappointment in com- 
plicated cases or those of too long duration. In 
a great majority of these cases the prognosis is 
rather unfavorable. The one unfortunate fea- 
ture of treating any of these cases is that as soon 
as a patient gets marked relief he begins to relax 
in his efforts and improvement stops, and in 
many cases a relapse occurs, usually worse than 
the original trouble, and the prognosis is very 
unfavorable as to ultimate recovery. 

The neuroses, palpitation, tachycardia, brady- 
cardia arrhythmia, Stokes-Adams disease, and 
angina pectoris are often reported to the physi- 
cian for treatment, as most of these condtions 
cause considerable pain or discomfort directly in 
the cardiac region. Of these diseases we are 
called upon to treat a greater percentage of cases 
of angina than any other because the pain is 
severe, and the patient and relatives become 
alarmed. ‘There are so many variations in de- 
gree that the prognosis is very uncertain. Some 
forms, especialy those accompanied by sclerosis 
of the coronary arteries, often prove suddenly 
fatal. The treatment consists of absolute rest, 
restriction of diet, inhalations of amyl nitrite, 
and the use of nitroglycerin, morphin, bromides, 
and other sedatives. Patients having one attack 
of this kind should be very cautious in their mode 
of living for some time to avoid recurrences. 
Cases have been known without recurrence, 
which is, of course, the most desirable termina- 
tion. 

Arterio-sclerosis is met with rather frequently. 
This disease is usually spoken of by the laity as 


136 ILLINOIS MEDICAL JOURNAL 





February, 1923 


hardening of the arteries, and is looked upon as 
a very serious malady by many. 

There is every graduation from the mildest 
type to the one that produces death almost in- 
stantly by apoplexy. It is the fact that a fatal 
termination is possible that causes the patient to 
be concerned about the disease. Pain and the pos- 
sibility of sudden death are the two things that 
cause our patients the most uneasiness. Many 
chronic ailments that are really eating at the 
vital elements of the body are often neglected 
because there is no suffering connected with the 
condition, and the patient does not feel that 
serious harm can come from it. 

Aneurysm is a rare condition, and probably 
often not diagnosed when it does exist. Its 
treatment consists mainly in an attempt to pro- 
duce coagulation in the sac. In some cases sur- 
gical or mechanical measures are resorted to, 
with more or less doubtful results. 

The management of cases of disease of the 
circulatory system resolves itself into a rather 
complicated affair in many cases, as the diagnosis 
is often made late in the disease, due to failure 
of the patient to report to his physician for early 
examination. The first thing to be considered 
is rest. This should be absolute rest, in bed. 
It is often difficult to get much co-operation from 
the patient in this matter after the first few 
signs of improvement appear. The recumbent 
position should be maintained long enough to 
be sure of results. Better too much time spent 
in bed than not enough. The time varies in each 
instance and careful examination, repeated often, 
is the best guide as to how long these patients 
should rest. 

Diet is another phase of treatment that must 
be considered in some cases. In most instances 
the enforced rest causes the system to be easily 
satisfied as far as quantity is concerned. it is 
only necessary for the attendant to select a bland 
diet of easily digestible foods. If the patient 
still retains an unusual appetite it is necessary 
to regulate quantity and quality of foods. The 
main idea is to give the patient’s digestive sys- 
tem as little to do as is consistent with a proper 
nourishment of the tissues, thus leaving any 
excess energy that may be present to help in re- 
pairing the defects of the weakened circulatory 
system. Some cases come to us early, are rather 














[923 








February, 1923 RICHARD F. 


difficult to handle as far as rest and diet are 
concerned, and get themselves and some physi- 
cian into a real task later. 

Different types of these conditions require 
varied means of medication and mechanical treat- 
ment. 

If the disease is only a complication, as of 
rheumatism, scarlet fever, syphilis or other in- 
fectious conditions, the treatment of both disease 
and complication must go hand in hand. 

In any case in which the heart is affected, it 
js often necessary to resort to some form of stim- 
ulants to keep up the muscle tone until improve- 
ment can be secured. The most common among 
the preparations employed are digitalis in some 
form, strychnia, strophanthus, cactus, the am- 
monium salts, opium in small doses, and amyl 
nitrite. The drug fitting the case is selected, 
the dose regulated according to conditions pres- 
ent and changes or none made from time to time 
as suggested by the progress of the case. 

Fat-free tincture of digitalis in doses from 
five to fifteen minims three or four times daily 
is a common favorite in most forms of heart dis- 
turbance. It raises blood pressure but this is 
often considered of less importance than the 
stimulating effect imparted to the heart muscle. 
This drug must be used cautiously. The heart 
rate and blood pressure should be watched care- 
fully. If there is a tendency to a continuous rise 
in pressure, or to a gradual slowing of the pulse 
rate, the drug must be withdrawn for a time. 
A patient taking digitalis, if resting in bed, 
should be cautioned against sudden exertion, 
such as changing to a sitting posture, as these 
patients often die suddenly with the heart in 
systole, the result of chronic digitalis stimula- 
tion, aggravated by a sudden acute muscular 
strain. If digitalis is being used, and pain is 
present in the cardiac region, it is well enough 
to continue as long as the pain is not aggravated 
by the medicine. If it is made worse it becomes 
necessary to reduce the dosage, or discontinue 
the drug. Other indications for its discontinua- 
tion are nausea and vomiting, thready and ir- 
regular pulse, and diminution in the amount of 
urine excreted. 

If arterio-sclerosis be present nitroglycerin 
should be added to the prescription to counter- 
act the effect of the digitalis on the muscular 
walls of the vessels. 


HERNDON 137 


DIABETES MELLITUS* 


RicHarpD F. Hernpon, M. D., 
SPRINGFIELD, ILLINOIS 


Recent contributions to the literature of dia- 
betes mellitus, although varied and often appar- 
ently conflicting, have given the subject a definite- 
ness previously lacking. For this reason it would 
seem to be worth while to sum up some of its 
more important phases. In doing this the recent 
literature has been freely quoted, particularly the 
writings of Joslin,’ Allen? and Woodyatt.* 

ETIOLOGY OF DIABETES 

The direct cause of diabetes is infection and 
inflammation. Allen has set up the dictum “with- 
out pancreatitis, no diabetes.” Woodyatt regards 
the so-called diabetic predispositions as simply in- 
herited susceptibilities to pancreatic infections.‘ 
There are three chief forms of injury: 1, ob- 
structed biliary or pancreatic secretion, the imme- 
diate harmful agent being chemical, but the cause 
back of it usually bacterial; 2, bacterial inflam- 
mation; 3, absorption of soluble toxins. The 
problem of acute and subacute pancreatitis is still 
far from being solved. Concerning the occur- 
rence of low grade and slight degrees of pancreatic 
inflammation almost nothing definite is known. 
The careful routine examination of autopsy ma- 
terial at various hospitals has shown pancreatitis 
in about three per cent of the cases. It seems 
probable that with adequate diagnostic methods a 
new domain of pancreatitis will be developed from 
indigestion, dyspepsia, gastritis, biliousness, auto- 
intoxication, catarrhal jaundice and other in- 
definite abdominal troubles and vague impair- 
ments of health. 

These inflammatory changes may actually ini- 
tiate diabetes, but as a rule produce only func- 
tional deterioration which after a variable 
period of time breaks down under the metabolic 
strain with the appearance of diabetic manifesta- 
tions. The sequence of events is probably as 
follows: Inflammatory changes are initiated in 
the pancreas with actual or functional deteriora- 
tion of the island cells. These cells respond with 
an actual or attempted increase of secretory ac- 
tivity for a longer or shorter time while appear- 
ing morphologically normal. At length secretion 
is discharged more rapidly than it can be formed, 
the normal fine granulations become more and 





By before the Sangamon County Medical Society, June 
8, 1922. 








138 ILLINOIS MEDICAL JOURNAL 


more sparse and are replaced by hydropic vacu- 
oles. In the strictest sense this hydropic vacula- 
tion is not an expression of diabetes but of cellu- 
lar dissolution due to diabetes. Finally nuclear 
degeneration and complete disintegration of the 
cells result. In the very great majority of cases 
the factor of safety in the pancreas is sufficient 
to prevent the development of diabetes. In the 
other cases there is no evidence that these primary 
inflammatory lesions are progressive in char- 
acter. In no case has it been shown that all the 
insular tissue has been destroyed. The subsequent 
welfare of the patient, therefore, is simply a 
question of whether the remaining islands are 
spared or destroyed by diet. In the main the in- 
ability to draw a sharp pathological line between 
diabetes and non-diabetes merely expresses the 
fact that no such line exists. There are all grada- 
tions between normal and diabetic with and with- 
cut demonstrable impairment of food assimila- 
tion. With allowance for functional variations a 
person is diabetic in proportion as the islands of 
Langerhans are lacking. However, the char- 
acteristic active symptoms of diabetes may be 
absent with anorexia, impaired food absorption, 
emaciation or cachexia when the pancreatic de- 
struction would certainly bring on diabetes if the 
patient were otherwise healthy. This is prob- 
ably the explanation of the usual lack of diabetic 
symptoms in cases of acute pancreatitis and pan- 
creatic cancer. 

The Nature of the Diabetic Anomaly. One 
single specific defect characterizes diabetes. This 
consists in an inability on the part of the body to 
utilize as much glucose as may be utilized by the 
normal body when the supply exceeds certain 
limits. Whereas in normal individuals the more 
glucose is given the more is utilized, the reverse is 
true in diabetes when the amount exceeds certain 
limits ; that is, the more glucose is given the less 
is utilized. In non-diabetic individuals the limit 
to the utilization of glucose is only apparent, in 
diabetics it is real. However, the difference is only 
a quantitative one for the diabetic appears to be 
capable of utilizing a limited amount of glucose 
as well as the normal individual. The cause of 
this anomaly is a deficiency of the endocrine func- 
tion of the pancreas. The internal secretion of 
the pancreas, so far as we know it at all, is a 
single highly selective function having to do with 
the utilization of glucose and nothing else. Pre- 
sumably it performs this function by secreting a 





February, 1923 


substance which combines with or acts upon 
glucose rendering it available for oxidation. 
Facts indicate that the gland is stimulated by 
glucose to provide for the disposition of glucose. 
Accordingly it is necessary to conclude that the 
only way to lessen its work is to lessen the amount 
of glucose that enters the metabolism. That a 
weakened pancreas in the presence of a sufficient 
supply of glucose might be stimulated into a state 
of fatigue and decreased function, and that a 
sufficient diminution of the glucose supply might 
then lessen the stimulation, place the organ in a 
state of comparative rest, and permit it to re- 
cuperate up to a certain limit is also quite con- 
ceivable, and affords a logical explanation for 
many facts.* Every evidence points to the origin 
of the internal secretion of the pancreas in the 
pancreatic islands. In diabetes these cells regu- 
larly show pathologic changes. These consist first 
in the disappearance of the normal fine granula- 
tions, then hydropie vacuolation, and finally 
nuclear degeneration and complete disintegration 
of the cells. The classical feeding experiments 
of Allen on partially depancreatized dogs have 
shown that these changes can be produced and 
controlled by diet. For this reason the term ex- 
haustion has been used as synonymous with 
vacuolation. The process represents a clear cut 
example of the anatomic break down of an 
endocrine organ by functional overstrain. Treat- 
ment of diabetes by diet, therefore, is not mere 
palliation of a sympton but a genuine means of 
checking the progress of a definite pathological 
change. 

The anomaly of metabolism ordinarily termed 
acidosis in which abnormal amounts of acetone, 
aceto-acetic and 8-hydroxybutyric acids appear 
in the tissues, blood and urine is not due directly 
to any impairment of the internal secretion of the 
pancreas. It is simply the result of the incom- 
plete oxidation of certain fatty acids in the ab- 
sence of sufficient oxidizing glucose. It is not 
peculiar to diabetes or constantly associated with 
it. It occurs in other diseases. It can be made 
to appear in normal individuals by starvation or @ 
diet containing too low a proportion of carbo- 
hydrate or too high a proportion of fat, and 
when this is done it can be made to disappear 
again simply by the addition of more carbohydrate 
in the diet. In other words, the quantity of 
oxidizable glucose available fixes an upper limit 
to the amount of ketogenic fatty acid that can be 











, 1923 


upon 
ition. 
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February, 1923 


completely oxidized at the same time. The abso- 
lute magnitude of this ratio has not been deter- 
mined but it lies in the neighborhood of 1.5 to 1.° 

Dangers of the Diabetic State. It is an es- 
tablished fact that when diabetes is controlled, 
that is, when the diabetic is on a diet which he 
can completely utilize, his metabolism and gen- 
eral resistance are normal, and he has lost only 
in strength in proportion to the restrictions neces- 
sary in his diet. This is not true during the 
diabetic state, by which is meant the presence of 
hyperglycemia and glycosuria. The presence of 
this state, even though it may persist for long 
periods with practically no symptoms, carries with 
ita constant menace. It is almost to be regretted 
that it does not carry with it some acute symptom 
such as pain to serve as a danger signal. If a 
person overtaxes a weak stomach the resulting 
distress punishes the error and forces him to 
desist, but if he overtaxes a weak pancreas, noth- 
ing but intelligence can show him what is wrong. 
- The chief dangers of the diabetic state are: 
1. Sooner or later it actually reduces the in- 
dividual’s tolerance or ability to utilize food. 
While it has never been shown that there is a 
spontaneous tendency for the diabetic anomaly to 
become more severe, it can be shown upon any 
diabetic that overfeeding produces first pancreatic 
fatigue, then exhaustion and finally actual loss 
of power. These changes may be rapid or exceed- 
ingly gradual, but are always present. When an 
individual who has shown hyperglycemia and 
glycosuria for years comes to a state where the 
pancreatic function is too low to support life, it is 
not due to a chronic progressive tendency of tlie 
disease but to chronic inefficiency of treatment. 
It is probable that there is no inherently hope- 
less severity even in the diabetes of the very young 
but merely a greater sensitiveness to injurious 
influences, particularly those of diet. 

2. It is the first step towards acidosis and 
coma. Any patient with an uncontrolled diabetes, 
even though slight, may be thrown into coma 
by an indiscretion in diet, overexertion, fatigue, 
worry, shock, infection or accident. In fact, this 
iswhat usually happens. Coma is still responsible 
for the great majority of deaths in diabetes and 
almost all of these are preventable. Except in 
cases of complete diabetes, acidosis and coma are 
simply complications and do not represent the 
logical end of the disease. 

3. It lowers the body’s resistance against acute 


RICHARD F,. HERNDON 139 


and chronic infection. Head colds, tonsillitis, 
bronchitis, pneumonia, tuberculosis, furuncles, 
carbuncles, infected cuts or scratches, etc., are 
common in uncontrolled diabetes and are un- 
usually severe and often terminate fatally, usually 
with coma. In controlled diabetes they are 
scarcely if at all more frequent or severe than in 
normal individuals. 

4. It increases the individual’s susceptibility 
to arterio-sclerosis. The arterio-sclerosis of 
diabetes is of the senile or degenerative type and 
is no different from the arterio-sclerosis of non- 
diabetic individuals. It is regarded by some al- 
most as much as a cause as a result in the diabetes 
of the aged. In other cases its more frequent and 
earlier appearance and more rapid development 
are only a part of the general decrease in the 
body’s power of maintaining normal function and 
repairing wear and tear which accompanies the 
diabeteic state. The same remarks apply to the 
retinitis of diabetes,® which is nothing more than 
the retinitis of cardio-vascular renal disease modi- 
fied in its appearance and stage of occurrence by 
the metabolic disturbances associated with the 
diabetes. 

5. It increases the susceptibility of older in- 
dividuals to gangrene. The reason diabetes 
develop gangrene more frequently than norma! 
individuals is not because the circulatory changes 
are different or greater, but because their diabetic 
state has lessened the power of their tissues to 
withstand the ischemia resulting from the di- 
minished circulation and of resisting infection.® 
That is, the same diminution in circulation which 
produces no, negligible or few changes in a non- 
diabetic individual results in gangrene in the 
uncontrolled diabetic. 

6. It increases susceptibility to cataract, neu- 
ritis, asthenia out of proportion to loss in weight, 
and the host of other disorders listed in classical 
text-books. It will be noted that all but one of 
the dangers of the diabetic state which have been 
mentioned are in reality complications and not 
part of the diabetes itself. Food in excess of 
tolerance lowers resistance by poisoning the or- 
ganism. Allen has said that with due regard to 
prepositions it may be said that few die from 
diabetes, many die with diabetes. 

The Food Supply.* Much of the confusion in 
the treatment of diabetes arises from the almost 
universal custom of thinking of the food supply 
as simply so much carbohydrate, protein and fat, 





and so many calories without further analysis. 
Carbohydrate, protein and fat are three separate 
and distinct substances, no one of which can be 
expressed quantitatively in terms of another. If 
we speak of food supplies or diets as made up of 
so much carbohydrate, so much protein and so 
much fat we simply name them in terms of three 
variables. As a matter of fact, carbohydrate, pro- 
tein and fat are not in reality the substances that 
present themselves in the body for the final 
oxidation that results in the liberation of energy. 
‘They must be resolved by the processes of diges- 
tion and intermediary metabolism into simpler 
substances before they can be burned in the tis- 
sues. It is not the starch in the bowel nor the 
glycogen in the liver that taxes the endocrine 
function of the pancreas, but the glucose into 
which these carbohydrates are resolved. The 
carbohydrates of the diet and tissues that do 
not already exist in the form of glucose are con- 
verted into it prior to oxidation. This occurs 
almost gram for gram so that we may say 
that 100 grams of utilizable carbohydrate in 
the diet, if digested amd absorbed, will introduce 
into the metabolism 100 grams of glucose. The 
protein of the diet ceases to be protein and 
becomes a mixture of the amino-acids before it 
can be absorbed from the bowel. These amino- 
acids insofar as they are catabolized are deamin- 
ized and presumably at the same time oxidized 
to yield oxy or hydroxy acids. Part of these 
are converted into and oxidizer as glucose 
and part as products which are equivalent to the 
higher fatty acids in that they are capable of 
yielding 8-hydroxy and aceto-acetic acids, while 
a third small portion is destroyed in as yet un- 
known ways. Thus analyses have shown that 100 
grams of mixed protein when completely absorbed 
and catabolized are capable of introducing into 
the metabolism 58 grams of glucose and approxi- 
mately 46 grams of fatty acid. Neutral fats, 
while they may be absorbed in part as such, and 
may be deposited in the tissues as such, must be 
saponified into glycerol and fatty acids before 
they can be oxidized and used as sources of 
energy. Complete saponification yields about ten 
parts by weight of glycerol and ninety parts by 
weight of higher fatty acids. Glycerol is capable 
of conversion into glucose almost gram for gram. 
So we may say for clinical purposes that 100 
grams of mixed fat in the diet, if completely 
absorbed and catabolized, will introduce into the 


140 ILLINOIS MEDICAL JOURNAL 


February, 1925 


metabolism about 10 grams of glucose and 90 
grams of higher fatty acid. Thus, as a mutter 
of fact, carbohydrate, protein and fat are not 
the actual foodstuffs we are dealing with when it 
comes te the final metabolic processes, for all the 
foods of the diet, except a small fraction of the 
protein, resolve themselves in the body into two 
things, glucose on the one hand and higher fatty 
acid (or acetone forming equivalents) on the 
cther. 

It follows from the foregoing that the ration- 
ale of dietetic management of diabetes is to bring 
the quantity of glucose entering the metabolism 
from all sources below the quantity that can 
be utilized, and to adjust the quantity of fatty 
acids in relationship to the quantity of glucose 
so that complete oxidation will result. If and 
when, under these conditions of relative rest for 
the pancreas, the glucose using function improves, 
the food supply may be gradually increased inso- 
far as this can be done without disturbing these 
relations. 

THE TREATMENT OF DIABETES 

While the riddle of diabetes is still far from 
being solved, sufficient advancement has been 
made to render its treatment scientific rather than 
empirical. In 1917 Joslin’ definitely outlined the 
treatment of diabetes as follows: 1, the preven- 
tion of acidosis ; 2, the attainment of a substantial 
carbohydrate balance; 3, the avoidance of inani- 
tion; 4, simplification of treatment, the better 
education of the patient, and. the maintenance 
of closer cooperation with the physician. 

Acidosis is naturally the bugbear of doctor and 
patient, as it is the factor which kills. An un- 
complicated glycosuria or hyperglycemia is never 
fatal. It is not only more rational but it is 
easier to prevent acidosis than to treat it, and 
certainly patients presenting themselves without 
acidosis must not be made worse or have their 
lives imperiled by treatment. For this reason, 
while it is not always necessary, it is probably 
always wiser that the first change in the diet 
should be the omission of the fat. Subsequent!) 
the protein should be omitted, and then the carbo- 
hydrate reduced until the patient is either sugar 
free or fasting. If the patient presents himself 
with acidosis the same procedure may vsually be 
carried out. However, unless there has been 
recent radical changes in the diet, and probably 
even then, it is best to begin fasting at ouce. 
In these cases the blood sugar is already un- 























y, 1925 


nd 90 
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February, 1923 


desirably high and little sugar can be metabolized. 
Anything, then, that aggravates the diabetes and 
delays the clearing up of the glycosuria probably 
also acts injuriously upon the acidosis. The only 
known rule up to the present is, if a patient de- 
velops acidosis on feeding, to fast him, and if he 
develops acidosis on fasting, to feed him. These 
remarks concern the dietetic management of acid- 
osis. It is, of course, understood that the patient 
showing any but very slight degrees of acid 
poisoning will be put to bed, kept warm, furnished 
with adequate nursing care, have the bowels moved 
by one or more enemas (cathartics are to be 
avoided for fear of upsetting the stomach or 
bowels with consequent vomiting and diarrhea) 
and be given at least a liter of liquid every six 
hours. The question of alkali therapy in diabetic 
acidosis is not entirely settled. Joslin is definitely 
against it. Allen, Fitz and Stillman certainly do 
not encourage it. Cabot states that its only use is 
to rally the patient and clear his consciousness 
when the arrival of relatives has been delayed. 
Christian and Mosenthal, on the other hand, still 
employ it. Theoretically, of course, the diabetic 
patient needs alkali. The therapeutic point 
of the whole matter, however, is that attempts 
to treat acidosis by neutralization of its 
products is illusory and often dangerous even 
as a temporary measure, and will always lead 
to failure in the end. Successful treatment 
can only consist in stopping the abnormal 
acid production, which is the essential dis- 
turbance. Under all circumstances it must be 
understood that control of the metabolism by fast- 
ing or food is the essential means of treatment, 
and that failure in this attempt must end fatally 
in spite of any dosage of alkali. It has been 
repeatedly shown that although the patient’s blood 
alkali can be kept at a fully normal level he will 
die in deep coma nevertheless. The dangers of 
alkali administration consist in: the liberation 
of combined, quiescent and harmless acid bodies 
from the tissues; depletion of the body chlorides 
which are distinctly useful; irritation of the 
stomach or bowels with resulting vomiting or 
diarrhea and consequent inability to take or retain 
the fluids which are so necessary; the production 
oi abnormal diuresis necessary to remove the acid 
salts; depression of the kidney function by the 
excretion of so much acid, the kidneys may be ac- 


RICHARD F. HERNDON 141 


tually overwhelmed and cease to. act; and actual 
depletion of the body’s bases by the excretion of 
increased amounts of acids. Finally the con- 
stant use of alkali seems to promote the constant 
excretion of acid bodies. 

After the urine has been rendered sugar free 
for twenty-four hours by reduction of the diet or 
fasting, the next step is to determine the carbo- 
hydrate tolerance. This is done by giving five or 
ten grams of carbohydrate, usually in the form of 
five or ten per cent vegetables, and continuing 
to add five or ten or more grams each day, de- 
pending upon the severity of the case, until sugar 
reappears. After the urine has been sugar free for 
two days, protein is usually added and rapidly in- 
creased until the patient is receiving one gram per 
kilogram of body weight. There are very few 
patients who will not bear almost at the onset 
one gram of protein per kilogram. With the pro- 
tein the patient receives some fat but by employ- 
ing egg white, fish and chicken the fats are kept 
as low as possible in order to increase the carbo- 
hydrate tolerance. It seems as if it were worth 
while to sacrifice almost anything to secure a 
tolerance to carbohydrate; with this once estab- 
lished, strength and weight follow as a matter 
of course. 

The return of sugar demands fasting for 
twenty-four hours or until sugar free. Absence 
of food for twenty-four hours will almost in- 
variably free the urine if the presence of glucose 
is promptly detected, hence the necessity for the 
patient to examine his twenty-four urine daily. 
Following this accessory fast day the previous diet 
is gradually resumed again, adding fat last anc 
slowly. Great care should be exercised, more 
indeed than has been often taken, not to break 
down the tolerance a second time. Patients often 
get into trouble by their failure to energetically 
grapple with the reappearance of sugar. One 
day of fasting will accomplish more than many 
cays of a moderately low diet. It is a mistake for 
any but the most highly trained patients to at- 
tempt to meet such a situation without medical 
advice. Subsequently, even though sugar does 


not appear in the urine, it is desirable upon one 
day each week to rest the function of assimilation 
by either a complete or partial fast day. Joslin’ 
suggests the following rule: Whenever the carbo- 
hydrate tolerance is less than 20 grams of carbo- 


142 ILLINOIS MEDICAL JOURNAL 


hydrate, fasting should be practiced one day in 
seven; when the tolerance is over 20 grams of 
carbohydrate, cut the diet in half one day each 
week. The advantage of this procedure lies not 
only in the rest it gives the function of assimila- 
tion, but also, to a considerable extent, in the 
fact that the patient’s attention is sharply called 
to his disease one day in seven, with the recol- 
lection of his original condition and the neces- 
sity of avoiding the difficulties following the reap- 
pearance of sugar. 

Optimal Diets. After the urine has been ren- 
dered sugar and acid free and the food tolerance 
estimated, it is desirable to outline what Woodyatt 
has termed the optimal diet. Briefly this consists 
in: 1, enough protein to maintain nitrogen 
equilibrium ; 2, as much glucose as the functional 
insufficiency of the pancreas will permit; 3, as 
much fat as can be oxidized without the appear- 
ance of ketone bodies in the urine or other signs 
of acidosis. 

Of glucose, protein and fat, protein is the only 
one which can be considered an indispensable ele- 
ment. Glucose and fat may heat and run the hu- 
man engine but protein is the substance of which 
the engine is made. Any diet, therefore, which 


fails to provide for the replacement of nitrogen 
must result disastrously in the long run. An in- 
dividual] is said to be in nitrogen balance when the 
food supplies at least enough nitrogen to make 
good the losses due to wear and tear on the protein 


tissues. As a result of previous experiments this 
can now be approximated closely enough for clin- 
ical purposes: by the relation between the body 
weight and the protein intake. Indeed these cal- 
culations do not need to be made t»o closely as 
the weight of the individual may be materially 
altered by undetermined variations in the water, 
fat, salt and mineral content of the body, which, 
of course, do not materially affect its nitrogen 
requirements. In general, the Chittenden standard 
of one gram of protein per kilogram of body 
weight is considered sufficient. However, this 
matter can not be considered as definitely settled. 
Children need considerably more than a_lults. 
‘Joslin states that it is often advisable to give 1.5 
grams, but remarks that it is surprising how few 
of his patients care to take that much. Newburg 
and Marsh found two-thirds of a gram saf- 
fixient to maintain nitrogen equilibrium in some 
of their patients. Finally it must never be for- 
gotten that fifty-eight per cent. of the protein is 


February, 1993 


utilized in the body as glucose. This undoubtedly 
accounts for the frequent recurrence.of glycosuria 
on many of the high protein diets. 

The first estimation of the carbohydrate toler- 
ance, following as it usually does a more or less 
rigid reduction in the total diet, is often erron- 
eously high. That is, it represents more carbo- 
hydrate than the patient can utilize when given 
continuously. For this reason, and because it 
has been repeatedly shown that, except in cases 
under the most careful supervision, the patient 
invariably gets slightly more food than the esti- 
mate shows, it is best, at least during the early 
stages of treatment, to allow only about two- 
thirds of the calculated tolerance, depending upon 
the severity of the case. In severe cases, and in 
any case showing inanition, where every possible 
calorie must be given in order to maintain 
strength, such a reduction of course is not desir- 
able. On the other hand, the carbohydrate should 
not be kept too low, as it not only deprives the 
patient of the satisfaction of a more liberal diet, 
but may, if continued for too long a period, 
actually result in a diminished power of utiliza- 
tion through lack of training of those functions 
concerned in its metabolism. Naturally the 
method adopted will vary somewhat with eacli 
patient. In estimating the amount of carbo- 
hydrate in the diet it must also be remembered 
that the catabolism of 100 grams of protein 
liberates 58 grams of glucose, and the catabolism 
of 100 grams of fat yields about 10 grams of 
glucose. These considerations are of extreme im- 
portance in cases in which the carbohydrate toler- 
ance has been determined separately. In cases 
in which the tolerance has been determined in 
the presence of protein and fat the rearrange- 
ments necessary, of course, are not so great. 

Body fat constitutes an important source of 
reserve energy, and is important as a supporting 
structure, and in the structural make-up of nerves 
and other tissues. However, fat as a food can 
not be considered indispensable to the human 
body since, as a source of energy, it can perform 
few functions that glucose can not. perform as 
well or better, and with less tax on the metabolic 
processes. Moreover, fat can not be utilized 
adequately as a source of energy except when its 
oxidation is accompanied by the oxidation of 
glucose. In other words, fat burns in the flame 
of glucose. Glucose is the oxidizing agent and 
faulty oxidation results in ketonuria. On the 





y, 1923 


btedly 
‘osuria 


toler. 
or less 
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- Cases 
atient 
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February, 1923 


basis of experiments, and on chemical and clinical 
observations, Woodyatt advances the hypothesis 
that the ratio of the higher fatty acids to glucose 
in the diabetic diet should be as 1.5 is to 1 if 
acidosis is to be avoided. The practical applica- 
tion of this hypothesis would mean that a diabetic 
obtaining and utilizing 100 grams of glucose from 
any and all sources should be able to oxidize com- 
pletely 150 grams of higher fatty acids, an amount 
obtainable from 170 grams of fat. Although 
diets containing higher ratios have frequently 
been employed successfully, particularly those re- 
cently used by Newburg and Marsh, at present 
Woodyatt’s calculations seem to be a conservative 
appraisal of the metabolic processes involved in 
the oxidation of ketogenic acids. These facts 
should be kept in mind, although the close com- 
putation of such diets is unnecessary except in 
cases so severe that every possible calorie must be 
allowed. 

Endogenous Food Supply. The method just 
cutlined is largely that developed by Allen and 
Joslin and is undoubtedly more logical and less 
emperical and has yielded better results than any 
we have had heretofore. However, Woodyatt* has 
recently emphasized some very important facts in 
connection with both diet restriction and fasting 
which demand thoughtful consideration. He 
points out that when a man fasts he does not 
cease to produce heat. Normal men on a fast 
liberate at least 15 calories per kilogram of body 
weight when quiet, and on light exertion this 
may be increased to 25 or 30 calories per kilo- 
gram. Thus an ordinary individual weighing 50 
kilograms will during fast produce 12-1500 
calories per day, and in doing so actually mobilize 
and burn in the neighborhood of 75 grams of pro- 
tein and 125 grams of fat and a little carbo- 
hydrate from glycogen. These well-known facts 
simply emphasize the magnitude of the food sup- 
ply from the tissues in fasting. Lusk* has further 
shown that: when there is much fat present little 
protein is consumed ; when there is little fat much 
protein is burned ; and when there is no fat pro- 
tem alone yields the energy of life. But as long 
as there is life something burns. Now if the 
ciabetic patient reacts during a fast in the same 
way a non-diabetic individual does, and if he 
produces 1200 to 1500 calories, and in so doing 
burns 100 to 125 grams of fat, the ingestion of 
an equal amount of fat should leave his metabol- 


RICHARD F, HERNDON 143 


ism in the same state as before. The supply of 
fat would come at one time from the tissues, at 
another time from the diet, but the quantity 
thrown into metabolism and presenting itself for 
disposition would be the same in both cases. The 
same statement holds true to some extent for 
protein. Thus differences in the catabolism of 
a man when receiving no diet and when receiving 
a diet of 1500 calories may be slight, for as the 
diet falls the endogenous food supply rises to 
take its place, and vice versa. The lower the diet 
the less its significance in calculating the food 
supply from all sources. If these premises are 
sound why should we ever practice complete fast- 
ing in diabetes? Why, particularly in diabetes 
associated with undernutrition, for the purpose 
of desugarization should the patient be compelled 
to draw from his tissues the fat that he might 
draw from his diet, especially if in drawing from 
his tissues he lowers his fat reserve to the extent 
that he increases his protein losses? The striking 
results that have been obtained by Newburg and 
Marsh® with fat replacement diets bear signif- 
icantly on this point. These workers completely 
ignored the extent of the glycosuria and acidosis 
of their patients at entrance, and routinely placed 
them on a diet containing from 900 to 1000 
calories, of which about 90 grams were fat, 10 
grams protein and 14 grams carbohydrate. In 
all their 73 cases both the glycosuria and acidosis 
were rather rapidly controlled, despite the large 
amounts of fat contained in the diet. After the 
patients had been sugar free for one to two 
weeks this diet was gradually increased until it 
contained enough protein to maintain nitrogen 
balance and sufficient calories to maintain weight 
and strength. However, the fat was always kept 
proportionately high, apparently without either 
lessening the carbohydrate tolerance or inducing 
the dreaded acidosis. 

Defense of Fasting and Undernutrition. 
Undernutrition and fasting have been and are 
being criticised and attacked by many. Acknowl- 
edgment is always to be made of the shortcomings 
of the treatment itself, inherent in its negative na- 
ture as a mere rest of a weak function without 
any positive element of cure. However, at present 
this criticism applies to any and all methods of 
treatment. It must also be acknowledged that at 
first the 'treatment was often carried too far, and 
perhaps in some cases is still being carried too 
far. One should never forget that there is a 








144 


ILLIN 





human element with which we have to deal.'® 
One is not practicing medicine in a laboratory. 
It is much safer to teach diabetics to eat too little 
rather than too much. There are few, if any, 
diabetics starving themselves to death from not 
eating, but there are many who would starve 
themselves to death by eating, did they not escape 
actual death by starvation by dying prematurely 
in coma. It may be stated as a general rule, to 
which probably the only exception is the tem- 
porary diabetic glycosuria developing in the 
course of an acute infection, that a gain in 
weight means a loss in tolerance. It is not the 
quantity of food that should be metabolized but 
the quantity that can be metabolized that is im- 
portant. On any plan of overfeeding what de- 
velops is the diabetes and not the patient. Prac- 
tically all cases show a relatively high tolerance 
at first. Overfeeding destroys this tolerance and 
with it the chance for improvement. 

The principle of fasting for the purpose of 
desugarization is far too good to renounce. It is 
simple, rapidly effective and, if carefully super- 
vised, almost devoid of danger. It may be com- 
pared to our two most powerful drugs, digitalis 
and morphin, both of which are poisons if the 
therapeutic dose is exceeded, yet because they 
are poisons no one thinks of discontinuing their 
use. While fasting is probably equivalent to a 
protein-fat diet, it must be remembered that in 
uncontrolled diabetes the blood sugar is already 
abnormally high and more glucose is available 
than can be utilized. It should not, of course, be 
continued too long. In markedly undernourished 
or emaciated individuals it is equivalent to an 
almost pure protein diet, and in these cases is 
least efficacious and most often dangerous. Its 
use par excellence is for the return of glycosuria 
during treatment. In addition there are four 
very practical advantages in the employment of 
fasting. First, the diabetic patient must be early 
impressed with the fact that he must become and 
remain sugar free. Fasting is the most rapid 
means of accomplishing this and avoids the dis- 
appointment attending the persistence of glyco- 
suria. Second, the limited and simple diet pre- 
scribed following the fast is one the patient can 
easily understand. Thus almost at once he can 
be taught by easy stages to compute his diet and 
confusion and discouragement at the lessons in- 
volved avoided. Third, its definiteness and sim- 


YOIS MEDICAL JOURNAL 








February, 


1923 


plicity is such that the patient can employ it 
himself upon the reappearance of sugar. He can 
hardly be expected to use it unless its feasibility 
has been demonstrated to him by previous em- 
ployment. Fourth, by its use the responsibility 
for treatment is placed directly upon the patient 
and renders the chances of his following direc- 
tions far more probable. 


Education of the Patient. Rendering the urine 
sugar and acid free, determining the food toler- 
ance, and prescribing a so-called optimal diet is 
really only the first and easiest step in the man- 
agement of diabetes. The first effects of treat- 
ment are usually so magical that they scarcely 
appear attributable to the simple methods em. 
ployed. However, the responsibility for main- 
taining this favorable state must rest in a large 
measure on the patient himself. He must learn 
what diet is best for him and constantly control 
his condition by examination of his urine. There 
is no disease in which an understanding of the 
methods of treatment avails so much. 
tient who knows the most, other things being 
equal, can live the longest. The diabetic patient 
should be made to understand at the outset that 
he is taking a course in diabetes. For successful 
completion of this course he should at least be 
able: 1, to test his urine for sugar; 2, to record 
a summary of his diet ; 3, to calculate the amount 
of carbohydrate, protein and fat it contains; 4, 
to state his diet on his weekly fast day; 5, to 
describe what he is to do if sugar reappears in 
the urine. To acquire this requisite knowledge 
requires diligent study, to apply it requires char- 
acter, patience and self-control, but the price 
offered is worth while for it is life itself.” 

BIBLIOGRAPHY 


1, Joslin, Elliott P.: The Treatment of Diabetes Mellitus, 
second edition, 1917 

2. Allen, F. M., Stillman, Edgar and Fitz, Reginal: Total 
Dietary Regulation in the Treatment of Diabetes. Mono 


graphs of the Rockefeller Institute for Medical Research No 
11, October, 1919. 


8. Woodyatt, R. T.: Objects and Methods of Diet Adjust- 
ment in Diabetes, Arch. Int. Med. 28:125 (Aug.), 1921. 

4. Woodyatt, R. T.: Abstract of Proceedings of Seventh 
Annual Meeting of the American Society for the Advance 
ment of Clinical Investigation, 1915, 25-2 

5. Wagener, H. P., ont Wilder, R. M.: “The Retinitis of 
Diabetes Mellitus. J. A. M. A. 76:8 (Feb. 19), 1921. 

6. Bernheim, B. M.: sect ne and Real Gangrene Asso 
ciated with Diabetes. Correlation of Medical and Surgical 
Effort. Am. J. Med. Sc. 163:5 (May), 1922. 
m Joslin, Elliott P.: A Diabetic Manual, 


The pa- 


second edition, 


_8. Lusk: Elements of the Science of Nutrition, third edi 
tion, 1917. 


9. Newburgh, L. H., and Marsh, P. L.; The Use of 3 


High Fat Diet in the Treatment of Diabetes Mellitus. Arch. 
Int. Med. 26:647 (Dec.), 1920. 
10. Joslin, Elliott P.: Today’s Problem in Diabetes ba 


Light of Nine Hundred and Thirty Fatal Cases. J. A 
78:20 (May 20), 1922. 











ary, 1923 


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February, 1923 


INDUSTRIAL EYE INJURIES* 
Frank Autport, M. D., 
CHICAGO 
Paper No. 1. 


‘The substance of this paper should be consid- 

ered under two headlines, viz. : 
First, Prevention. 
Second, Cure. 

Let us first endeavor to ascertain what can be 
accomplished in the way of “Prevention” of 
ocular injuries in industrial occupations. 

First, one of the most important barriers to 
eye damage is a thorough ocular examination by 
an oculist before an applicant is given employ- 
ment. It is not sufficient to have such examina- 
tions made by a general practitioner, a nurse or 
a layman, who merely tests vision with test types 
and makes a general or cursory survey of the eyes. 
Most important pathological conditions are only 
detectable by an experienced observer. Slight 
strabismus, minute corneal, vitreous and lenti- 
cular opacities, hidden iritic adhesions, fundal 
changes, abnormal visual fields, refractive errors, 
ete., can only be detected by the experienced 
oculist—and it is these very conditions that are 
important to diagnose. It is essential to be 
cognizant of such abnormalities, and to possess 
records of such findings. It may be very altruistic 
to assume the honesty of all men, but we—who 
are disillusionized know that all men are not 
honest. My own experience leads me to believe 
that only a minority of men are honest when it 
comes to seeking financial remuneration for 
physical damages from rich corporations. Indeed, 
I am not perfectly sure I would not be dishonest 
myself under such circumstances. I suspect I 
would enlarge upon all possible physical ail- 
ments, feeling that after all I had worked hard 
ior the company, and had been damaged while in 
its employ, that there was no telling what might 
happen as a result of my accident, that I had 
a family to support, that the company was rich, 
while I, who did their dirty work was poor, and, 
after all, why should I not get any money I 
could, without leaving behind any very strong 
conviction of real dishonesty. If, therefore, I, a 
reasonably honest, and I trust a reasonably intel- 
ligent man, could under stress of circumstances 
dally with the truth, is it not reasonable to as- 


—_—_—_ 


*Read bef i i i 
Nor ne : ~ the Chicago Society of Industrial Surgeons, 


FRANK ALLPORT 145 


sume that others, less endowed than I, would do 
the same? Thus it happens that industrial sur- 
geons (particularly) are constantly brought in 
contact with more or less spurious demands for 
financial compensation for bodily damage, and 
one definite means of defeating such spurious 
claims is to have accurate physical records of all 
applicants for work, before work is assigned. 

Not infrequently I see patients who have sus- 
tuined some trifling eye accident, who at the same 
time have a senile cataract. Blindness as a re- 
sult of the accident is the claim, and yet I know 
that there is no possible connection between the 
two conditions. The report of a proper physica! 
examination, before employment, would probably 
clear up this claim at once, especially if physical 
examinations were required at intervals of, let us 
say, every two or three years. Men seeking em- 
ployment, invariably, represent their vision and 
hearing to be of the best possible quality. They 
want work and they do not underestimate vision 
and hearing, but, when they seek compensation 
for injuries, they represent these functions to be 
as poor as possible, for reasons that are obvious 
te all. I, also, occasionally see patients who have 
sustained a slight head contusion, who in a few 
days complain of a bad smelling, discharging ear. 
An examination discloses an almost complete ab- 
sorption of the drum head, and much necrosis and 
granulation tissue, conditions it takes months or 
even years to develop and conditions which, of 
course, have nothing whatever to do with the head 
contusion of a few days ago. Such cases would 
have no standing in court if previous reports of 
such ear disease could be produced. Proper 
physical examination of applicants for work 
should be made before men are placed at occupa- 
tion. Such examinations would cost something, 
of course, but not so very much after all, and it 
is, in reality, a form of insurance a business man 
cannot afford to ignore, for it will surely save 
him thousands of dollars in due ‘course of time 
by being in a position to defy many spurious 
claims for damages. Employers should regard 
such examinations as a legitimate and necessary 
form of insurance. 

Proper eye and ear examinations prior to em- 
ployment will exclude from factories, ete., ap- 
plicants suffering from contagious diseases, such 
as trachoma, hypertrophic papillary conjuctivitis, 
foul discharging ears and other contagious dis- 


- eases, thus lessening the diseases in shops and the 








146 ILLINOIS MEDICAL JOURNAL 


legal liabilities attendant thereon, to say nothing 
of the diminution of human suffering and dis- 
aster. 

It must also be remembered that the most ef- 
ficient and valuable services from workmen can 
only be performed when men are in the best 
physical condition and are working under the 
most advantageous circumstances. The physical 
examination of applicants, before employment, 
discloses their weaknesses, discards some alto- 
gether and enables the employer to place those 
who remain at work in places harmonious with 
their defects, thus enhancing their value as work- 
ing units and also permitting the employee to 
seek medical or surgical advice for the correc- 
tion of (perhaps) unsuspected diseases. A man, 
for instance, who has poor eyes can, perhaps, be 
fitted with glasses, or undergo treatment or oper- 
ation for his relief and ean also be given employ- 
ment somewhat consistent with his infirmity. A 
man whose ears have been found diseased or de- 
fective can seek the advice of an aurist, and be 
placed at work where good hearing is not neces- 
sary to successful employment. Thus, it will be 
seen that proper physical examination before em- 
ployment, and at subsequent suitable intervals, 


is not only valuable to the employer in protecting 
him from fictitious claims for damages, and in 
enabling him to obtain better and, consequently, 
more profitable labor, but it is also beneficial to 
the employee because it discloses defects and dis- 
eases, and enables him to seek relief, and it also 
prompts his employer to give him work har- 


monious with his physical condition. The only 
thing it antagonizes is dishonesty and this fur- 
nishes no excuse for doing the right thing. 
Second, the proper lighting of shops is un- 
questionably of great importance in the preven- 
tion of accidents and is a subject that is con- 
stantly assuming larger proportions in the minds 
of shop owners, architects and illuminating engi- 
neers. Insufficient illumination can undoubtedly 
procure diseased ocular conditions, but so also 
may excessive and improperly directed illumina- 
tion. Daylight is the best illuminant and should 
be utilized as much as possible. The next best 
illuminant is the one that most nearly simulates 
daylight. Illumination should be ample but not 
excessive, as too much light may be as injurious as 
insufficient light. Not only should illumination 
be ample and proper, as provided by enormous 
window spaces and by the best kind of artificial 


February, 1923 


illumination, but the lighting should be properly 
directed so that each bench, wheel, vat, machine, 
etc., is individually well lighted and shaded s 


‘that the men can see distinctly and work without 


ocular effort, and most automatically. Some shop 
owners with semi-liberal minds, restrained by 
economical restrictions and possessing conceit, as- 
surance and determination, equip their shops with 
illumination according to their own ideas, unham- 
pered by the scientific and experienced advice of 
an illuminating engineer. They are, perhaps, de- 
termined to do the thing on a big scale and they 
install lights and plenty of them, in short their 
lights are an injury and an embarrassment to the 
employees. They are bad for the eyes. There is, 
perhaps, too much light, or at least it is improp- 
erly and unscientifically placed. It stares you in 
the face, it is dazzling, it makes work hard. Illu- 
mination should be ample but not excessive. It 
should be evenly diffused and should not fall di- 
rectly in the eyes. It should come from above, 
behind and from the left. It should not throw 
shadows on the work. Bad lighting forces the 
workman to pay too much attention to seeing 
distinctly. This should be done without effort, 
thus enhancing his value by increasing his out- 
put and, incidentally, saving his eyes. 

Improper illumination produces mistakes in 
work, wastage of material, and a greater liability 
to accidents. Twenty-five per cent. of shop acci- 
dents are produced by improper illumination, and 
the least number of accidents occur in July and 
August, because these months furnish more day- 
light than any other months in the year. The 
proper lighting of steel mills increases their 
output 2 per cent. and in textile and shoe fac- 
tories the increase is 10 per cent. It only costs 
about 0.25 per cent. of a man’s wages to properly 
light a shop. Thus if a man earns $3.00 a day, it 
will cost about one cent and a half a day to fur- 
nish him with proper illumination. 

Shop owners should employ illuminating engi- 
neers to install their lighting, it will be cheaper 
in the end. Such men are quite agreed as to the 
superiority of the tungsten lamp. Its light closely 
resembles daylight and is cheap and durable. 
They should be supplemented with white porce- 
lain enameled reflectors, and the entire lighting 
system should be kept clean. 

White walls and woodwork and clean windows 
will add about 30 per cent. to the efficiency of 
natural or artificial illumination. 


nn =e aetetlC rl. CU OlCO COU WCCO 





February, 1923 


Third, I am happy to say that shop goggles are 
being worn more and more by shop workers. Not 
very long ago most men almost disdained the 
wearing of goggles. Some felt it was cowardly, 
others said they were a nuisance, interfered with 
their work, became easily fogged, etc. Almost all 
shops were glad to furnish goggles, but most 
of them laid in the shop unused. Many of the 
men are densely ignorant foreigners whose mental 
habit refuses to adopt innovations. The habit 
of wearing goggles gradually grew, inspired by 
educational pamphlets, talks, notices, pictures, 
ete., and now a vast majority of workers in shops 
wear goggles. They have learned that it is a 
good thing, that it saves the eyes, that it is a 
necessity. The Pullman Company declares that 
35 per cent. of shop injuries are eye injuries and 
that most of them could have been prevented by 
the wearing of goggles. There are many kinds of 
goggles on the market, but the best of these is the 
“Saniglass” goggles. They fit well, have side 
shields, and the glass is clear, thick and very 
strong. The glass can, of course, be ground to 
correct the workman’s refractive error, if he has 
any, and can be colored in any tint to harmonize 
with the man’s occupation. 

In the American Stee] Foundries shop eye acci- 
dents were reduced 75 per cent. in two years by 
wearing such protection. In order to give an idea 
as to the kind of occupations producing the most 
eye accidents in the ordinary steel shops, I will 
say that undoubtedly hammering, (No. 1) pro- 
duces more eye accidents than anything else. 
Then comes 2, emery wheels ; 3, molten metals; 4, 
electric flashes; 5, riveting; 6 machine tools; 7, 
bursting of water and lubricating glasses, and 8, 
belting. 

Fourth, improper tools and the absence of suit- 
able protective devices for machines produce many 
eye accidents. 

Most hammering accidents are caused by using 
tools with burred or mushroomed edges. When 
such tools are used steel particles are easily broken 
off and fly with great velocity into the eye, and 
produce serious consequences. Tools should be 
kept in good condition and when the edges become 
even slightly mushroomed, they should be imme- 
diately repaired, a precaution which will save 
many eyes from blindness. Modern shops are 
being more and more furnished with all kinds of 
stfety devices, for they have been found to be 
both beemficial and economival. Shops should be 


FRANK ALLPORT 


147 


kept cool, clean, light, and as nearly dustless as 
possible, for men can accomplish more and work 
better under such circumstances. Emery wheels 
should be protected by glass or leather guards or 
hoods, and dust particles should be sucked away 
by an exhaust system. Emery wheel accidents are 
very frequent and some men who work at emery 
wheels have their corneas speckled by the oft- 
repeated assault of emery wheel particles. I have 
seen the glasses or goggles of emery wheel work- 
ers speckled so that they look almost like glazed 
glass, so often have the glasses been struck with 
flying particles. 

Vats containing molten metal should be han- 
dled carefully and should be surrounded by pro- 
tectives. Goggles, or still better, leather masks 
with goggles, should always be worn when han- 
dling molten and babbitt metal for burns from 
splashing molten metal are most gruesome and 
discouraging in their character. 

Electric flashes can be avoided by using en- 
closed switches and fuse boxes. Riveting and 
punching machine accidents can best be avoided 
by care and the use of goggles. Milling machines, 
shapers, etc., should be protected by what is known 
as glass chip guards. Water and lubricating 
glass accidents can be much reduced by using 
the very best glass and by protecting the glass 
with suitable guards as the contents are under 
constant and strong steam pressure. 

Eyes are sometimes injured by being struck 
with broken belting caused by improper jointing. 
Endless or glued joint belts should be used in- 
stead of hooks or lacings to make a joint. Belts 
should never be replaced on a pulley by a stick 
as is so frequently done. Serious eye accidents 
sometimes result from such practices. Excessive 
light or heat in shops, particularly steel shops 
where electric welding is done may produce retinal 
and other eye injuries. The temperature and 
light in these furnaces is tremendous. Cast iron 
furnaces possess a temperature of 2,000° F., and 
in electric welding the temperature may rise to a 
height of 12,000° F. Such heat and glare may 
produce retinal and optic nerve changes and 
burns of the skin, conjunctiva and cornea. 
Screens of blue or red glass should be used and the 
workman should wear an aluminum helmet. 
Retinal changes may occur from grinding carbon 
or manganese steel, where the worker looks con- 
stantly into a steady stream of sparks and while 
doing this work amber goggles should be worn. 





148 ILLINOIS MEDICAL JOURNAL 


Amber goggles should be worn by glass blowers 
to prevent cataracts and by silver burnishers, who 
look protractedly upon highly polished surfaces, 
to prevent retinal changes. Goggles should be 
worn when the oxyacetylene torch or electric are 
in use. 

Fifth, the individual who has come to be known 
as “The Shop Oculist” deserves a section all to 
himself, as he is one of the greatest menaces to 
eyesight in the average shop. Fortunately the 
public has become considerably educated concern- 
ing such matters and the career of the “Shop 
Oculist” is on the wane. He still exists, however, 
in many shops and until he is utterly extermi- 
nated, the propaganda against him should con- 
tinue. He is one of the great body of workmen 
who has acquired an undeserved reputation for 
removing foreign bodies from the eyes of his 
brother workmen. He is ready at any time to 
suspend his dirty work, and with unwashed 
hands endeavor to remove a particle of any na- 
ture whatsoever from the eye of some unfortunate 
workman. He proceeds to his unwarrantable 
work, as I have said, with dirty hands, with con- 
ceited assurance, with poor illumination and tools, 
und without lenses and cocain or adequate knowl- 
edge. Sometimes his efforts are successful and 
harmless and this, of course, adds to his assur- 
ance, egotism and reputation. But frequently, 
alas, in endeavoring to remove a tightly driven 
foreign body from the cornea, with dirty hands 
and tools, with improper illumination and a mov- 
ing and roving eye and without cocain or anti- 
septic precaution, he only succeeds in mutilating 
and infecting the cornea and, finally, after having 
done his best, or rather his worst, advises the in- 
jured victim to do what he should have advised 
him to do at the start, viz., go at once to a com- 
petent oculist. The appearance of such eyes when 
they come into my hands is often appalling and 
requires heroic treatment, but at the best a large 
sear usually remains which, more or less, im- 
pairs vision in accordance with its density, extent 
and location. But many of these cases go on 
to a violent infection, ulceration, hypopyon, 
panophthalmitis, and enucleation. It seems to 
me, as I look back over a large and varied expe- 
rience of ocular accidents, that I have seen more 
eyes destroyed by the improper initial treatment 
of minor injuries than from any other one cause. 
The removal of foreign bodies from the cornea 
should be considered. a serious affair and should 


February, 1923 


not be undertaken by laymen or general prac- 
titioners. I hope I do not offend my general 
practitioner friends when I say this, but, as a 
tule, they have no more qualifications to do this 
work than I have to treat measles or mumps, 
Some particles are easily removed from an wnan- 
aesthetized cornea, but most of these invaders have 
to be dug out with a spud or a cataract knife and 
herein consists the danger. They should be re- 
moved under strict aseptic precaution by an expe- 
rienced and steady hand with proper illumination 
and lenses, and with the infliction of as little 
damage to the cornea as possible. This is fre- 
quently a tedious and nerve-racking affair and 
only experienced and patient ophthalmologists are 
adapted to the work. Foreign bodies are some- 
times deeply imbedded and are almost impossible 
of removal, even by the exercise of great skill, ex- 
perience and tact, and the use of fluorescin to 
outline the site of injury. Such injured men 
should be given the best chance for the preserva- 
tion of vision and such an opportunity does not 
follow the ministrations of the “Shop Oculist,” 
Shop Nurse, and I am sorry to say, not always 
the Shop Doctor. Such cases should be sent im- 
mediately to a competent oculist, thus saving eyes, 
vision, suffering and expense. 

Sixth, attention should be paid to the fact 
that certain occupations are apt to injure vision 
and every precaution should be taken to prevent 
this disaster. For instance, di-nitro 
which is used in manufacturing anilin dyes, 
injures vision by inhalation, which can be pre- 
vented by ample ventilation or by using closed 
mixing vessels. Bi-sulphid of carbon, used in 
vulcanizing rubber, produces a vapor which in- 
jures vision by producing retinal and optic nerve 
changes with a very poor prognosis. Nicotine 
may be absorbed in tobacco factories, with char- 
acteristic ocular symptoms. Both tobacco work- 
ers and tea tasters may develop amblyopia. Paper 
hangers, painters, workers in arsenical prepara- 
tions, ete., develop the fact that arsenic is absorbed 
principally through the respiratory tract, pro- 
ducing eye pain and irritability, optic neuritis 
and atrophy, etc. Eyes are damaged in plumbers 
and painters where lead is used. Lead enters the 
body through the fingers and lungs. Headaches, 
poor vision, scotema, ptosis, paralysis, etc., are 
noticed. 


benzine, 


Carbon monoxid very occasionally pro- 
duces optic nerve and retinal disturbances and 


paresis of the ocular muscles. Most of the ocular 





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February, 1923 


disturbances from chemical causes can be avoided 
py strict cleanliness, especially of the hands, and 
by thorough ventilation. Wood alcohol is used 
in many industries and workmen should always 
be acquainted with the fact that they are dealing 
vith a deadly poison, capable of producing blind- 
yess, from optic nerve atrophy, and even death. 
It is used, for instance, in cleaning off shellac 
‘rom the interior of beer vats, where the fumes 
become very strong, especially when the ventila- 
tion is poor. This menace can be combated by 
using as little of it as possible, and by extreme 
deanliness, and thorough ventilation. High ex- 
plosives in mining, railroad construction, etc., 
produce many serious accidents. Bursting bottles 
in charged water factories and lime burns in 
masons, bricklayers, plasterers, etc., often produce 
disastrous ocular damages. Great care under such 
circumstances, with a full realization of the dam- 
ages involved, will prevent many sad accidents. 
The eyes of miners are not only threatened by 
explosions, in dislodging coal, but by nystagmus 
from working underground with insufficient il- 
lumination and from working while lying on the 
back. Mines should be abundantly lighted, ab- 
normal postures while at work should be avoided, 
errors of refraction should be corrected, the health 
should be kept up to the highest standard, and 
the hours of submerged work should be as short 
as possible. Certain occupations, involving ex- 
posure of the eye to heat and lighf may produce 
‘Jowly developing cataracts. This is conspic- 
vously the case with glass blowers but may occur 
in any industry where the eyes are exposed for 
long periods of time to intense heat and light. 
The greatest protection consists in wearing thick 
(olored glasses that disperse both heat and chem- 
ical rays. 

I am well aware that this paper has not com- 
pletely covered the subject. It would have to be 
much longer to do this, and I did not feel at 
liberty to occupy too much time. Enough has 
een said, however, to demonstrate that almost all 
‘ecupations possess dangers to eyesight that 
thould be thoroughly understood and carefully 
guarded against. But before closing this article 
I wish to say just a few words for the benefit of 
the great army of office workers whose eyes are 
‘cing damaged bp protracted work on books, 
\apers, ete., by poor illumination, and without 
laving their eyes properly corrected by glasses 
pethaps purchased at an optician’s or stores where 


A. F. KAESER 149 


“Examinations are Free.” All of these details 
should receive proper attention by those who are 
earning a living by visual work performed in an 
office or store. 

In a later paper I intend considering the 
treatment of eyes that have been injured in Indus- 
trial Occupations. 

? West Madison Street. 





THOUGHTS ON MEDICAL 
ORGANIZATION* 
A. F. Kagser, M. D. 
HIGHLAND, ILL. 


The unrest so prevalent everywhere is seen in 
the medical profession and even more than in 
the profession, it is noticed in the attitude of the 
laity toward the healing art. For that reason if 
results are not secured promptly the patient 
flops from one physician to another and soon he 
leaves the physician for the irregular. Patients no 
longer wait all day for the family physician to 
come, even if the case is not urgent; if they have 
made up their minds to consult someone, he 
must be seen at once or if he is not available they 
go to someone else. I remember very well a 
patient telling me that thirty years ago he 
thought nothing of waiting all day for his own 
physician if he was engaged somewhere else. 
But even more noticeable is the unrest by the 
patient demanding results at once and if not 
obtained he is in the hands of the irregulars. 
Sometimes a patient will be treating with his 
physician and an irregular at the same time, un- 
beknown to the physician. 

All unrest has of late been ascribed to the re- 
sults of the war, but that is only a factor. We 
are living in an era of disquietude and it is prob- 
ably only a stage of evolution of the human race. 
The conditions of twenty years ago will never 
return, and that holds in medicine as well as in 
all other phases of life. 

Then what about medicine of tomorrow? I 
may as well state here that the outlook to me is 
not so hopeless as often pictured. Medicine has 
lived hundreds and hundreds of years, ever grow- 
ing better and coming nearer to an exact science. 
It has lived down many superstitions and of late 
it is living down many of the irregulars. But 


*Read before the Madison County Medical Society, at God- 
frey, Tll., on June 2, 1922, 





150 


nevertheless there are many things we must do 
to keep to the fore and these things fall into two 
classes; 1. We must ever keep improving medi- 
cine to the highest degree and the individual 
physician must ever keep himself informed of the 
best in medicine and (2) we must see that no 
harmful laws are passed to retard medicine as a 
science or the physician as an individual. We 
must keep on improving medicine and also our- 
selves. Medicine and surgery as a whole have 
made great progress in the last thirty years. 
We need think only of diphtheria antitoxin and 
of the prophylaxis in typhoid and tetanus, in the 
Salvarsan treatment of syphilis and then the use 
of x-rays in treatment and diagnoses. 

On the surgical side it is even more striking; 
in fact surgery has been completely revolution- 
ized and every day things are accomplished which 
were not even dreamed of thirty years ago. We 
need not worry about medicine progressing, but 
rather must we be on the guard that the rank 
and file in the profession keep themselves con- 
tinually informed as to the progress made by 
the few: We are too prone to fall into a rut. 
The day’s work is tiresome and we would relax 
by taking up some amusement, rather than sit- 
ting down with the latest medical journals. 
Then again we think we can’t afford to attend 
the County Medical Society for one-half day 
each month because something might slip away 
from us, or again if it is summer we would rather 
spend that time on the golf course. The man 
who fails to regularly attend his County Society 
meeting misses the best and least expensive way 
of getting post-graduate work that there is in 
medicine. No matter what the subject is, I have 
never failed to learn something valuable at these 
meetings, something that comes up in my daily 
practice. 

By not doing our work thoroughly we are 
giving the irregulars their opportunity. If we 
neglect to take the proper interest in our cases 
the patient feels it. This trouble generally arises 
in the chronic cases. We treat our acute case 
well and we rarely have much criticism here. 
How often have you heard a physician say, “Well, 
I like to have the fever cases, because in due time 
I get them over it and they are well again, but 
these chronics that keep coming week after week, 
those get my goat.” Right here, gentlemen, these 
chronics are the ones you want to knuckle down 


ILLINOIS MEDICAL JOURNAL 


February, 192: 


to and work out; when you have done that you 
have really accomplished something. But in. 
stead of getting down and making a real diag. 
nosis you ask a few simple questions, give the 
patient a bottle of medicine which will last for Jf 
a week and then when he comes back the same 
thing is repeated. That gets you nowhere and 
before you know it the patient is in the hands 
of the irregulars. Most physicians are fairly 
regular in blood pressure readings and in urine ff 
examinations, but we woefully neglect the blood 
counts. Do you know that the diagnosis of 
neurasthenia is going to be something very rare 
in the future, because just like muscular rheuma- 
tism is covers a multitude of diagnostic sins. J 
When you find a little tenderness somewhere in 
the right lower quadrant of the abdomen it is 
easy to conclude that it is appendicitis. If it isa 
female and the case is not acute be sure that it is 
not the right ovary giving the trouble, or pos- 
sibly the gall bladder. Or even a much more 
serious mistake, is to overlook the possibility ofa — 
renal calculus or a hydronephrosis. If the 
trouble is found at operation to be in the gall 
bladder ‘or ovary it is not so serious because it 
can be corrected through the same incision, but 
if the trouble should be in the urinary organs 
the error is great. That this error occurs often 
is proven by the statement of one eminent St. 
Louis urologist who states that three-fourths of 
all cases of hydronephrosis and urinary calculi, 
that come to him, have had their appendices re- 
moved and that 90 per cent have had no relief 
from the appendectomy. I believe in removing 
every diseased appendix, but I also believe in 
making a careful diagnosis beforehand. Of 
course errors in diagnosis often are excusable and 
because of that we are trying continually to in- 
prove our diagnostic methods. It requires much 
time and many appliances which are not always 
at the general practitioner’s personal command 
to clear up these obscure cases. Medicine is far 
too broad a field for one man to know it all and 
this has been recognized for a long time and has 
given rise to the men who limit their work. The 
first man who limited his practice to the eye, 
ear, nose and throat in Chicago was the laughing 
stock of the profession, but he proved himself 
to be right and specialism has developed to such 
a degree that just lately I saw where medicine 
was divided into seventeen different fields in one 
California hospital. Thre is no question but 





ary, 1923 


that you 
But in. 
al diag. 
give the 
last for 
he same 
ere and 
e hands 
e fairly 
in urine 
1e blood 
10sis of 
ery Tare 
rheuma- 
ie sins. 
rhere in 
it is 
'f it isa 
hat it is 
OF pos- 
*h more 
lity of a 
If the 
the gall 
cause it 
ion, but 
organs 
rs often 
ent St. 
irths of 
calculi, 
lices re- 
o Telief 
moving 
lieve in 
nd. Of 
ble and 
- to im- 
s much 
always 
mmand 
e is far 
all and 
and. has 
s. The 
he eye, 
ughing 
himself 
to such 
edicine 
in one 
on but 


February, 1923 


that the tendency toward specialization is greater 
than ever before and that it will appear in one of 
two forms: 1. Either it will be a continuation 
of the present condition where the general prac- 
titioner, when he feels lost, sends his patient to 
the specialist that he thinks needed in the case; 
but more and more will it be seen that the patient 
sees this specialist early and because of that fact 
the field for special study will increase steadily, 
while the work of the general man will decrease 
or then we will have the alternative of 2. Group 
medicine which has appeared in many different 
forms and being in its infancy it is quite natural 
to see that it has many defects. When you have 
worked out a scheme where group medicine in- 
cludes the general practitioner, as a part in the 
group, you have worked out the future of medi- 
cine. Medical societies teach, yea preach that 
every practitioner must be interested in medicine 
as a whole and in medical organization. Well to 
me it seems that group medicine is simply put- 
ting this idea into a practical working basis. 

Of one thing we must ever be on our guard and 
that is the ill feeling which is only too likely to 
crop out between individual practitioners and of 
late even between the practitioners and the spe- 
cialist. When ill feeling is developed among 
doctors it always reflects itself in the attitude of 
the public toward us and our noble profession has 
received another black eye. The irregulars are 
only too anxious to find some cause of disagree- 
ment among physicians and this is just to their 
liking. 

2. Coming now to the second group of things 
that we should see that no harmful laws are 
passed to retard medicine as a whole or the 
physician as an individual. 

Two months ago at a medical meeting the 
councilor of the district to our east said that one 
state in the west licensed 29 different kinds of 
irregulars. That means that these classes could 
treat the sick. Now if they treat the sick, why 
are they not required to show that they have the 
equivalent in education as the physician? By 
not having a proper knowledge don’t. they often 
let the time pass when a case is curable to the 
time when it has become incurable? Don’t they 
endanger an appendicitis case in waiting until 
the appendix has probably ruptured? By not 
being informed on these points don’t they en- 
danger the patient? 

Just one year ago the State Senator from 


FRANK R. FRY 151 


this district asked me to come and see him in 
regard to some pending medical legislation. I 
got there in a hurry. He told: me that if the 
physicians didn’t wake up they would surely have 
something put over on them. He told me how 
one class of irregulars had simply stormed. the 
legislative committee; they were making a tre- 
mendous noise; in this county they had one of 
the very best lawyers about ready to flop to their 
side, and all this time the medical men were 
doing nothing. Of course you know the legis- 
lators are human and they are easily led to be- 
lieve that where there is the most noise there are 
also the most votes. A representative, you know, 
is supposed to represent and he will think that 
the most noise means also the greatest number 
of people and he will represent them. So let’s 
get together and make some noise of our own. 

Dr. Edward Ochsner says: The Medical Prac- 
tice Act fence has been built too high and has too 
many holes at the bottom. We have built it so 
high that we require our medical students to 
study six years before they are allowed to treat 
the sick; and the irregulars with practically no 
training can crawl] in through the holes in the 
bottom of the fence. 

Many of the laws as they are passed are dam- 
aging enough, but worse than the laws themselves 
is the spirit in which they were passed, the abso- 
lute disregard of the wishes and the desires of 
the medical profession. The Sheppard-Towner 
bill will be followed by more drastic legislation 
and before we are aware of it we will be face to 
face with real “State Medicine.” We have been 
able to fight that thing off so far but this Ma- 
ternity bill makes a strong bid for ushering in 
State Medicine through our back door. 





THE ETIOLOGY AND MANAGEMENT OF 
NEURASTHENIC CONDITIONS* 


Frank R. Fry, A. M., M. D. 
ST. LOUIS, MO. 


I wish to express my dep sense of the honor 
done me in an invitation to address this old and 
important medical organization. Also it is very 
gratifying that you are willing to entertain a 
message from the neuropsychiatric side of med- 
ical endeavor. I assure you I am personally am- 
bitious that the message represents, in some de- 


*An read at the 48th Annual M 


dress of the 
Southers Medical Assotiation, Cairo, Tll., Nov. 9, 1922. 





152 ILLINOIS MEDICAL JOURNAL 


gree at least, the fact that neurology is moving 
forward in helpful relation with the other 
branches of our profession’s work and progress. 


To speak on any phase of neurasthenia would 
seem a fairly bold undertaking for reasons that 


suggest themselves to both audience and speaker. 
The subject is old enough, trite and vague 
enough in the minds of all of us to excuse one 
for sidestepping rather than to accept the chal- 
lenge of again approaching it. 
your number in whose wisdom I have great faith 
has sent the challenge. 

As you are aware, neurasthenia is included 


However, one of 


among the neuroses, so-called. 
mit me to say that the modern tendency in con- 
templating these neuroses is not to define them 
severally as distinct entities in any important 
sense, but rather as phases of aberrant function- 
ing in certain associated mechanisms. For here 
we have found, as we have in the whole field of 
medical science, that we have been too prone to 
contemplate this and that function and the reac- 
tions attending it in a relatively isolated way, 
failing too often to grasp in full significance the 
broad physiological conception of the interde- 
pendence of all functions. The problem always 
before us is not simply functions but the great 
biological and physiological scheme of the or- 
ganization of functions, the integration of al! 
functions. We are awakening to the value of our 
hiological and physiological instruction in the 
practical affairs of our daily work as practi- 
tioners. 


In passing per- 


From this standpoint I ask you to join me in 
approaching the special theme before us this 
evening. To this end let us indulge ourselves in 
some brief reminiscences of fundamentals. For 
our present thought we may tap, as it were, the 
evolutional scheme at a level where organization 
has reached a complexity of function that in- 
volves more immediately and evidently our own 
comparative studies of physiology. 

Physiology teaches us that the organization of 
functions is. attained by the integration of re- 
flexes. Starting with the conception of the 
simple reflex as the unit of dynamic activity in 
the nervous system, the scheme expands with the 
“compounding,” the “conditioning” and “elab- 
oration” of reflexes from the simplest type to the 


February, 1923 


highest complexity of structure and function, 
We are all familiar with the old laboratory figure 
of the pithed or decerebrated frog flicking from 
his flank a bit of acidulated paper by a fully eo 
ordinated effort of his hind leg. Here are co- 
ordinated and associated movements, technically 
speaking, accomplished by a system of reflex 
activities evidently defensile in their intent. The 
details of what further performances Mr. Frog 
may accomplish with his scanty brain intact are 
of course matters of physiological record ; but we 
need not concern ourselves with them here. For 
this simple figure may serve (I trust with pleas- 
ant fraternal memories of our laboratory days) 
to arrest our minds in a freshened contemplation 
of a basic fact, namely, that even in the case of 
man, representing the highest complexity of or- 
ganization, the most exalted functions are thus 
definitely correlated with all functions of all 
levels of the organism; and all on a definite de- 
fensile scheme. 

Intellect, in the broad sense of the term is the 
highest pinnacled of the sentinals of this de- 
fensile system. Yet, we must remember that 
even this in its exercise must conform entirely to 
the structural, the biological and physiological 
arrangement upon which it has been foun- 
dationed ; and this is the most important teach- 
ing of modern orthodox psychology. 

For example, to make a practical application 
of this point, we may not judge any individual 
patient’s mental capacity to adjust himself in 
the struggle of life, whether socially or physic- 
ally, until we have full insight to his particular 
case, to the whole make-up of his physical and 
psychical self—his personality. Intellectually he 
may be in certain directions superior, yet from 
his emotional side so handicapped that on oc- 
casion he cannot defend himself against reactions 
that present a “silly” contour. In fact we often 
conceive of the erratic behavior of neurotic as a 
sort of reversal to a lower-level type of defence, 
when in states of inhibition of normal mental 
control, they instinctively are trying to escape 
from or to repress this lower-level turmoil within 
themselves. In other words it is a reaction of de- 
fense, an attempt at defense, with portions of 
the normal defensile equipment out of order. 

“Pain is the psychical adjunct of an impera- 
tive protective reflex.” (Sherrington.) With this 





ry, 1923 


nction, 
’ figure 
g¢ from 
lly e0- 
are co- 
nically 
reflex 
t. The 
. Frog 
ct are 
but we 
For 
pleas- 
days) 
ation 
ase of 
of or- 
2 thus 
of all 
te de- 


is the 
is de- 
- that 
ely to 
ogical 
foun- 
feach- 


‘ation 
‘idual 
If in 
1ysic- 
cular 
| and 
ly he 
from 
1 O¢- 
tions 
often 
as a 
ence, 
ental 
cape 
ithin 
f de- 


s of 


February, 1923 


definition as a starting point we may follow up 

the scale. Other protective mechanisms have 

their type or grade of psychical accompaniments. 

These are correlated with other reaction of their 

own level and again integrated with the reactions 
of higher levels and up to the “supralevel” sphere 

as we sometimes express it. Thus we have a 

snap-shot of the integrative plan. 

The organ of this integrative process is the 
central nervous system. The study of it is the 


particular concern of the neuropsychiatrist in an 
effort to interpret its practical relations to all 
S other fields of correlated activity. In proportion 
as he is successful in accomplishing this the 
neuropsychiatrist attains an official relation to 
the profession and in a sense to the rest of society 


as well. 

For many years psychologist and physiologists 
have been busy trying to solve the inter-relations 
of psychic and somatic influences in the produc- 
tion of the neuroses. In its simplest form, the 
question is: whether certain visceral reactions 
may by a peculiar type of stimulation start up 
certain classical psychicaly reactions, or, on the 
other hand, whether the visceral reactions are the 
result of psychic stimulation, from other sources, 
which acts on the nervous mechanisms control- 
ling the viscera. As we all know the psychic 
phenomena of the neuroses are characterized by 
a large emotional coloring or component. On 
this point Sherrington, the eminent physiologist, 
observes, “That marked reactions of the nervous 
areas regulating the thoracic and abdominal 
organs contribute characteristically to the phe- 
nomena of emotion has been common knowledge 
from time immemorial. The fact of the connec- 
tion is admitted on all hands, but as to the man- 
ner, opinion is at issue.” This problem of 
psychic and somatic etiology in some of its pro- 
portions is presented to us in practically every 
neurotic patient that seeks our attention. What 
I am here citing must remind us‘that we cannot 
afford to decide carelessly the bearings of it in 
the individual instances that come to us.. We are 
too often prone to do so in off-hand fashion, thus 
doing an injustice to ourselves and our patients. 

In considering the neuroses the most modern 
orthodox explanation, so to speak, has its origin 
in the conception of harmful conflicts, created 
within the mind in its effort to repress unpleas- 
‘nt Memories and experiences, Jt. is assumed 


FRANK R. FRY 153 


that the emotional reactions attending these re- 
pressions and conflicts often reach an intensity 
to cause a serious “drainage of nervous energy” 
with a lowered resistance, harmful degrees of ex- 
haustion, ete. 

As individuals we are all conscious, even 
from early childhood, of these mental conflicts 
over various matters, ethical, social, cultural, 
physical and what not, and we are conscious also 
of our efforts to repress the unpleasant features 
which lead to these conflicts and which result 
from them. We also can notice that there is a 
difference in degree or manner or activity of 
these repressions. Some of them are quite 
planned and deliberate until we have thereby di- 
vested our minds of certain desires or impulses 
or unpleasant memories. Some of these repres- 
sions on the other hand are nondeliberate in the 
sense that they are habit—like and not accom- 
plished with “conscious thought or deliberate 
decision.” We can also conceive of this latter or 
non-deliberate type of repressions as never hav- 
ing had a place in our conscious memory, either 
in their origin or their operation (or at least if 
they had, all memory of them having been 
obliterated. ) 

It is at this point that the Freudian idea of 
the unconscious and the proposition of psychoan- 
alysis has been injected into modern psycho- 
logical thought. In brief the contention of 
Freud and his follows is that there is a large 
part of the mind of which we are entirely un- 
conscious but which nevertheless exerts great in- 
fluence upon our conscious thoughts and feelings 
and actions. They hold that many memories 
and impulses, conflicts, repressions, etc., remain 
buried in these depths of the mind and never 
rise to consciousness unless dragged there, as it 
were, by the process of psychoanalysis. This as 
vou know is the technical method by which these 
buried memories are lifted into the consciousness 
of the patient where he may adjust to them on a 
conscious basis and thus divest himself of the 
disturbing effects of them. The details of these 
methods are of course too extensive to describe 
here as are also those of the Freudian conception 
of the origin of the conflicts. The value of the 
Freudian teaching in eluciding certain psycho- 
logical problems is admitted by progressive 
psychologists quite generally, many of whom 
however do not accept all of the deductions made 








154 ILLINOIS MEDICAL JOURNAL 


therefrom. As to the process of psychoanalysis 
in its strict interpretation and employment there 
are many reasons for the most conservative opin- 
ion even on the part of those who are well in- 
formed about it clinically. Meantime we are all 
becoming daily more aware of the immense 
amount of humbugging and chicanery and out- 
and-out quackery that are being propagated 
under this name and guise. (The Freudians 
have no patent rights on the term). In all of 
these healing cults of whatever growth there is 
a more or less successful adaptation to the prin- 
ciple and the laws of suggestability. Superficially 
the Freudian conception is open to abuse of this 
kind. 

All neurotics have morbid contentions of some 
kind within their personality. This is all the 
more evident when as patients they apply to some 
source or other for assistance and relief. The 
direction to which they turn for professional 
help is determined by various circumstances. A 
goodly proportion of them are wafted to the 
medical profession. They strike us at various 
sectors according to their conception of what 
kind of aid they are most in need of. Our ob- 


ligation in attempting to care for them is a 
multiple and complex one: the obligation to the 
patient as an individual, the obligation of the 
individual practitioner to himself, to his pro- 


fession and to society. The responsibility 1s 
great and serious. As members of the organized 
profession of medicine we recognize and try to 
prepare to accept this responsibility. This is 
evident in the modern methods of organizing and 
co-ordinating the various branches of our scien- 
tific work. Neuropsychiatry is anxious for and 
striving for a proper footing in this kind of or- 
ganization. In fact we modestly admit some 
share in the accomplishment of it. But like the 
rest of you we are far from willing to rest on 
our honors, for we all sense the ever present 
necessity of improvement and a still farther 
quest for opportunities. The very best stimulus 
in this direction is a constant, frank and sociable 
criticism amongst ourselves. If we are thor- 
oughly honest and vigilant in this we can always 
afford to neglect that of outsiders. In line with 
this spirit of injunction, permit me to suggest 
that too few of us have gained sufficient interest 
in the psychic side of the neuroses, and, to be 
more sévere, T believe more of us should be try- 


February, 192; 


ing to do so. Because of this belief on my part, 
and that of others, I have made bold, ty 
tediously I fear, to open our discussion this even. 
ing with a preface of some general biologic! 
and physiological observations, and I beg to x. 
peat that it is only along these lines that we may 
hope to adjust psychic reactions with all other 
reactions in the patient whom we would study a 
a unit. Speaking to this point Dr. Lewelly 
Barker, of Johns Hopkins, in his usual forceful 
way of utterance says “There is too much of the 
bad habit of expecting that the mental problems 
and mental conditions should be intelligible out 
of one’s understanding of mere words and pon- 
derings, when, as a matter of fact, one should 
have some first hand experience with real and 
tangible human reactions and life factors and 
the methods of work with them.” In order to 
further impress this contention I will quote an 
excellent clinical definition of neurasthenia, and 
offer some comment thereon: 

Neurasthenia is a state of habitual valetudinarianism 
with no corresponding or characteristic organic lesion. 
It manifests itself in a series of phenomena which 
are objectively of little importance, since they do not 
endanger the life or affect the general health of the 
individual, but which are subjectively monotonous, 
pertinacious, and wearisome. Among these symptoms 
the principal is a sense of profound lassitude, which 
finds no relief in bodily rest. In certain cases there 
are obsessions, doubts, and hesitancies, which, how- 
ever, do not obscure the intelligence, but rather refine 
it, inclining it to introspection. Sometimes cases of 
tuberculosis, heart disease, influenza, tabes, progressive 
paralysis, dementia precox, and many other chronic 
diseases are preceded or accompanied by long attacks 
of a neurasthenic nature. True neurasthenia, how- 
ever, occurs by itself, and persists as an entity with a 
limited number of symptoms, which are repeated 
from day ‘to day. There is an acute neurasthenia 
which passes away, but which gives reason to suspect 
the presence of a latent predisposition; and there is 4 
constitutional neusasthenia which is liable to remis 
sions which seem to be recoveries. The distinction 
between these two forms of neurasthenia is not @l- 
ways easy. There is also an associated form of 
hysterio-neurasthenia (Charcot), and varieties of 
traumatic neurasthenia and hemi-neurasthenia have 
been described. All these varieties with their dis 
tinctive names, which require no explanation, poist 
to the affinity which exists between neurasthenia and 
hysteria. 

I have never encountered a better clinical def- 
nition at least in the same amount of language. 
Tf we reyard it attentively our first reflection 





Pn gee Bere 


Row BS BF 


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Uary, 1933 


my part, 
bold, too 
this even. 
biological 
eg to re. 
t we may 
all other 
study as 
Lewellys 
| forceful 
ch of the 
problems 
gible out 
and pon- 
e should 
real and 
tors and 
order to 
quote an 
nia, and 


narianism 
nic lesion, 
na which 
ey do not 
th of the 
motonous, 
symptoms 
Je, which 
ses there 
ich, how- 
rer refine 
cases of 
‘ogressive 
r chronic 
g attacks 
ia, how- 
ty with a 
repeated 
rasthenia 
O suspect 
here is 8 
o remis- 
istinction 
; not al- 
form of 
eties of 
tia have 
heir dis- 
mn, point 
enia and 


al defi- 


nguage. 
flection 


February, 1923 


must be upon the psychic problem involved and, 
secondly, how are we to determine its bearings. 

Professor Tanzi, the eminent Italian, whom I 
have just quoted, alludes here to the affinity, as 
he styles it, between neurasthenia and hysteria. 
Let us read also the few lines in which he briefly 
sets forth a conception of hysteria: 

Hysteria is a constitutional, and generally hereditary, 
disposition of the nervous centres to react anomalously 
under the influence of stimuli which in normal persons 
escape notice or are insignificant. These anomalous 
reactions by which hysteria manifests itself from 
adolescence onwards, and sometimes from childhood, 
in all the spheres of innervation, may be positive or 
negative, permanent or transient, frequent or rare, 
partial or general, trivial or important, in different 
cases and at different times, but they are not without 
limits and laws. Among the stimuli that are capable 
of provoking them, the most important are the emo- 
tions, which are powerful and uncertain in their effects 
even in healthy and well constituted persons. In its 
relation to physiological laws hysteria is thus illegality, 
not anarchy. It is less a disease than an anomaly of 
the nervous equilibrium, to which there may perhaps 
correspond an anomaly (not very marked) of the 
chemical equilibrium. For this reason hysteria is 
neither the cause nor the effect of anatomical changes. 
It never leads to dementia, and its manifestations, even 
though localized and prolonged, are never irreparable. 

Here again we note that the psychic problem 
obtrudes in the same way. Some would hold 
there is no essential difference in it in the two 
types of neuroses. 

Professor Tanzi’s view here expressed that a 
constitution predisposition or hereditary defect 
of some kind is the basic etiological factor in all 
neuropaths is universally held by standard stu- 
dents and authorities. What this is, what it con- 
sists in, none of them, of course, can affirm. Yet 
there is a fascination in speculating over it. 
When we think of mere structural defect in this 
connection, we are reminded of the mysteries of 
structure to the utmost we can follow it, and of 
the greater mysteries that lie beyond our sense 
investigations. Yet this mere intellectual quest 
enables us to forsake the crude conceptions we 
were wont to entertain. From the physiological 
or functional side we are also tempted to picture 
an explanation of this short-coming which we 
call, “constitutional.” We envisage here a greater 
array of items for our imagination to play with. 
Our minds here run to chemical agencies. The 
intricacy of these chemical reactions in the prob- 
lems of “conduction,” their influence on “syn- 


FRANK R. FRY 155 


apse” and “threshold yalues,” in fact in the 
whole integrative functioning of the nervous sys- 
tem. We try to conceive of the normal functions 
of these physio-chemical agencies being quite 
directly disturbed by toxic materials of exogenous 
and endogenous origin. But here again we are 
warned mot to block our minds to broader view 
by indulging in mere fancies concerning consti- 
tutional animalies. 

For example when a person allows himself to 
adopt the belief that all neurasthenic patients 
are explanable on a basis of mere toxic states 
there is no end of the measures along this one 
theory he may resort to. According to his enter- 
prise the scheme expands to include trials of 
elimination, anti-malarials, endocrine substances, 
serums, and what not. If he is very bold, his 
patient may lose a section of her large intestine, 
a sacrifice to the fetish of auto intoxication. If 
she escapes with her life it will be probably to 
christian science or some such cult, there to des- 
seminate a noppobrium fully deserved by the 
culprit, but which reflects, in the eyes of the un- 
descriminating public, on the profession. 

Some years ago I wrete an effusion under the 
rather whimsical title of “The Neurasthenic at 
the Threshold.” At the time the idea of physio- 
logical threshold was rather new in the vocabu- 
lary of some who were discussing phases of 
neurasthenia. In the course of my remarks I 
tried to make a kind of metaphorical play on the 
word, to the point that the long abused neuras- 
thenic had at last reached the threshold of a 
more sane consideration on the part of our pro- 
fession. To some extent I think my optimistic 
views then expressed have been realized, but even 
yet we have not gotten said neurasthenic clear 
across the threshold into our nursery for the 
tender handling which he is entitled to. 

Once upon a time, as the story books read, the 
neurasthenic was regarded largely as some kind 
of a cross between a joke and a real patient to be 
exploited by any orfe who was willing to give him 
a try. If some sportive, so-called, surgeon, 
wanted to see how his lamb might cavort when 
deprived of a few seemingly offensive viscera, 
there was no forcibly intelligent protest. But we 
have now certainly reached the point where our 
protests are backed up by the kind of scientific 
evidence and argument that should appeal to 
every physician worthy the name. We do not 





156 ILLINOIS MEDICAL JOURNAL 


like to believe that mere mercenariness clouds 
this scientific appeal in any quarter. Let us ex- 
amine our hearts, in light of a newer science if 
you please, but in the closet as well. 

I believe my title says something about treat- 
ment, but why worry about treatment. There is 
a splendid panacea for worries of this kind, and 
that is diagnosis. I might modify this by saying 
assimilable diagnosis. You nor I can gain the 
right attitude and inspiration for treatment of 
a case unless we can critically assemble and as- 
similate the items upon which its correct diag- 
nosis depends. It goes without saying that this 
idealism is not attainable in every instance. Too 
often emergency, lack of opportunity and of co- 
operation, etc., prevent. Hence proportionately 
we flounder in trials of therapy. Nevertheless 
the ideal is in the minds and nearest the hearts 
of all real workers in our profession and we shall 
continue to strive for it. As to the manner of 
striving there is more or less confusion of opinion 
amongst us always. Out of his confusion grow 


the almost endless discussions of such topics as 
laboratory findings and their value, the place and 
value of specialist, of group medicine, the seduc- 


tive efforts of commercial laboratories, etc., and 
above all, the relation of these matters to the 
general practitioner. 

Meantime, in the midst of this discussion over 
ways and means, the neuropsychiatrists above all 
others are insisting on the very old conception of 
holding the patient as the central figure in each 
diagnostic and therapeutic scheme. Even in the 
greatly broadened and complicated scope of our 
modern medicine we must not forget, in our spas- 
modic enthusiasm over methods of treatments, 
to fit the patient properly into the scheme of 
practice. Or conversely, the scheme of practice 
must be best fitted to the patient’s actual interests. 
The general practitioner is, of course, the indi- 
vidual who must maintain this guardianship of 
the individual patient’s interest. His credentials 
with the profession and with society must de- 
pend on his ability to accomplish this service; 
and the specialist of every description is ac- 
credited properly only when his conduct con- 
forms to these requirements. Within the “do- 
main of medicine” our patients must continue 
to receive this comprehensive attention to all 


their ails or they will wander elsewhere in quest 
of it. 


February, 199, 


SOME THOUGHTS ON . PREVENTIV: 
SURGERY WITH SPECIAL REFER- 
ENCE TO FOCAL INFECTION. 


Grorce H. ParMENTER, M. D. 
BEECHER CITY, ILL. 


Many factors go to determine longevity. Cer. 
tain people inherit a poor physical equipmen 
which makes them susceptible to acute or chron 
disease and they die early as a result, while 
others inherit disease which cuts short life. We 
will for our purpose leave out of consideratioy 
those who start life with inferior physical equip. 
ment and consider only those who start life 
with good physical make-up. In other words 
those whose life expectancy should be good. Ii 
there are conditions which are discoverable ani 
removable which if not interfered with will cut 
short life it would be well for physicians to bk 
alive to such conditions in order to remedy them 
and it is important that they be remedied early 
before great damage is done. One condition 
o1 class of conditions at least which will do 
this is focal infection. 

From the beginning of life the organism re. 
ceives damage from various sources. Normal 
physiologic processes as digestion and metabolism 
probably produce at times by-products which are 
injurious to body cells. Intestinal bacteria pro- 
duce toxins that are harmful and hardly any 
of us will escape entirely a period of time now 
and then when there is absorption of harmful 
intestinal toxins. Acute diseases such as measles, 
scarlet fever, typhoid fever or acute respiratory 
tract infections all will produce toxins that are 
injurious to vital organs but the acute infec- 
tions act temporarily and the damage is usuall) 
not great. Probably there are some obscure 
states of altered matabolism which produce tox 
products which are injurious to body cells 
There are, no doubt, other agents that do dam- 
age to body cells but which we know nothing 
about; tobacco, tea, coffee, alcohol may be men- 
tioned as contributing factors. “These agents 
constitute what we call normal wear and tear 
of life. It is the accumulation of the harmful 
effects of such agents which produces the con 
ditions found in people who are old. Yet a per 
son of ordinarily good physical equipment should 
carry this inevitable load to the 70th or S0t! 
milestone, but give him an additional load of 
focal infection and he may go only to the 40th 





Uary, 192. 


ENTIVE 
FER- 
IN. 


). 


ity. Cer. 
quipment 
or chronic 
ult, while 
life. We 
sideration 
cal equip. 
start life 
er words 
good. If 
rable and 
1 will cut 
ans to be 
edy them 
lied early 
condition 
| will do 


anism re- 

Normal 
etabolism 
which are 
eria pro- 
rdly any 
time now 
harmful 
3 measles, 
spiratory 
that are 
te infee- 
s usually 
obscure 
uce toxic 
dy cells. 
do dam- 
nothing 
be men- 
e agents 
and tear 
harmfu! 
the con- 
et a per- 
it should 
or 80th 
load of 
the 40th 


February, 1923 


or 50th or 60th milestone depending on how 
great the additional load may be. A man is as 
old as his oldest vital organ or his most damaged 
vital organ. 

Primarily focal infections are most commonly 
found in tonsils or teeth or both. The foci may 
be in nasal passages or accessory sinuses. Sem- 
inal vesicles and prostate and ovaries and fal- 
lopian tubes in the female may harbor infection. 
Gall bladder, appendix and kidney pelves are 
other points but these are not primary but are 
seeondary to other foci of infection. In order to 
have infection in an appendix, gall bladder, 
kidney pelvis or any deep organ bacteria must 
enter the body at some point and the commonest 
point of entrance is tonsils or teeth or both. 
In children tonsils are guilty, probably oftenest 
but in people of middle age or over the teeth 
are probably harboring the most of the infectious 
agents which feeds the blood stream with bac- 
teria, but both teeth and tonsils may be guilty 
in these older people. 

Bacteria entering the body in this way are 
carried through the blood stream to various or- 
gans and set up acute or chronic processes in 
appendix, gall bladder, kidneys, muscles, heart 
muscle, joints, ete. Thus focal infections are 
primarily the cause of appendix, gall bladder, 
kidney disease and many pathological heart con- 
ditions. An infected appendix, gall bladder or 
kidney is dangerous not only because of danger 
of acute exacerbations but because of the focus 
of infection which daily supplies bacteria which 
entering the blood stream endangers other vital 
organs. 

So the physician having in mind the welfare 
of his patient must consider the chronic appen- 
dix, ete., as a focus of infection as well as from 
the standpoint of danger from an acute attack 
which endangers life immediately. Aside from 
acute attacks there is a more remote danger 
from an infected appendix or gall bladder or 
whatever the infected organ may be. That is 
danger that is removed 10-20-30 or even 40 or 
50 years. 


We see almost daily people who are in ad- 
vanced stages of cardio-vascular-renal disease 
with high blood: pressure, damaged heart mus- 
cle and arteries and damaged kidneys. There 
may or may not be albumin in the urine in these 


cases. Very often there is not but the micro- 


GEORGE H. PARMENTER 157 


scope will show casts and there is lowered specific 
gravity and other evidence of chronic¢’ kidney 
changes. It does not necessarily follow that there 
is no kidney disease because the nitric acid or 
heat test for albumin is negative. These people 
are usually between 50 and 60 but may -be older 
or younger. Invariably these people are carry- 
ing or for many years have carried foci of in- 
fection and it is pretty nearly the rule to find 
a mess of infected teeth and tonsils in such cases. 
At the ages mentioned the tooth infection is 
usually most in evidence but tonsils are often 
infected as well. It is quite common to find 
chronic appendicitis and gall bladder disease in 
addition. In many cases tuberculosis is added, 
it having become activated as a result of lowered 
resistance brought about by focal infections. In 
this connection mention should be made of cer- 
tain types of infected tonsils. A tonsil does 
not have to be enlarged to be carrying infection ; 
neither is it essential that there be frequent at- 
tacks of acute tonsilitis or sore throat. Some 
very small tonsils carry even more infection than 
some very large ones. The infected tonsil may 
be a very small one or may be buried and hidden. 
Such tonsils are as dangerous or even more dan- 
gerous than some of the markedly large and 
smooth appearing ones. The infected tonsil may 
not appear abnormal at all but there is a zone 
of redness over the anterior pillar or by palpa- 
tion enlarged submaxilary glands are felt and 
these are as sure signs of tonsil infection as we 
have unquestionably mean tonsillar infection and 
are decided indications for removal. 

In the fairly well advanced cases of cardio- 
vascular-renal disease the damage is great and 
nothing we can do will produce 100 per cent. 
cures. Kidneys, heart and vessels are too greatly 
damaged to be completely repaired, We can not 
remove the fibrous tissue produced by long con- 
tinued infection and replace it with normal] renal 
tissue. If we can eradicate the foci of infection 
we may be able to arrest the process and give 
the patient many more years of life than he 
would have otherwise. But if the foci are in 
tonsils, teeth, gall bladder and appendix it is 
a pretty big job to clean them up as they should 
be. Many patients are going to refuse such an 
extensive surgical procedure. However, we will 
see many people whose damage is not so great 
and whose foci of infection can be removed and 
these get good results from removal of the foci 








158 ILLINOIS MEDICAL JOURNAL 


of infection. In those who have greatly damaged 
cardio-vascular-renal systems the foci should still 
be removed if possible and this will often arrest 
the process but even so a fibrous kidney may 
still contract enough to destroy the function of 
the remaining normal] kidney structure. 

We can do much to prevent the late effects of 
focal infection by watching carefully children 
and young adults for infections, especially in 
teeth and tonsils. At these ages more infection 
probably will be found in tonsils than in teeth. 
I believe, however, that sometimes tonsil infec- 
tion is secondary to infected and carious teeth. 
This is in children whose first set of teeth is 
carious and infection harbored there and daily 
carried back to tonsils, sooner or later produces 
infection there. — 

In every infected tonsil or tooth there is a 
potential appendix or gall bladder operation or 
operation for kidney stone or pyelitis, ete. There 
is also the probability of heart muscle and endo- 
cardial inflammation with crippling of valves 
or myocardium and the condition we call cardio- 
vascular-renal disease or degeneration. Of course, 
in looking at an early case of focal infection we 
can not always say that any of these conditions 
will inevitably follow but we can recognize the 
great probability and advise accordingly. Noth- 
ing has been said about rheumatism which is 
due to focal infection. All physicians are familiar 
with this manifestation of focal infection. There 
are cases of rheumatism which are not apparently 
benefited by removal of foci of infection and 
when the physician advises removal of infected 
tonsils or teeth in. cases of rheumatism he will 
quite often be told that so and so was advised 
to have tonsils or teeth removed and assured 
that it would cure his rheumatism but has not 
been benefited by this proceedure. No doubt such 
cases do occur and the reason doubtless that no 
benefit is received is that the focus was not 
entirely removed or there were other foci or 
the bacteria had through metastasis become firmly 
established in muscle or joint structures and re- 
moval of the primary focus of infection did not 
remove all the infection responsible. This does 
not make it less proper proceedure to remove 
any focus of infection that can be found and 
removed in such cases. The focus if allowed to 
remain will produce other damage besides rheu- 
matism, therefore, should be removed. 





February, 199; 


In the later cases of cardio-vascular-renal dis. 
ease it is proper to remove all foci of infection 
which can be removed and by so doing an arrest 
of the process may be secured but it is far better 
practice to clean up these foci in children and 
young adults not waiting until gall bladder. 
appendix, etc., are infected or until marked dam. 
age is done to heart, arteries and kidneys. But 
in practicing in this way one encounters much 
difficulty in getting people to see the advisability 
of even minor surgical proceedure. An infection 
in tonsils may not be known to parents of chil- 
dren but a child may have pyelitis secondary to 
such an infection. Pyelitis causes symptoms as 
a rule that are referred to the bladder and much 
difficulty may be encountered in getting parents 
to see the connection between bladder symptoms 
and infected tonsils. 

Quite often they have well developed prejudice 
against surgical proceedure and assert that the 
creator put tonsils there for a purpose ; therefore, 
they should not be removed. One who advises 
removal of tonsils as often as he sees a case 
in which removal is needed soon becomes known 
as a crank on the subject. Additional difficulty 
is encountered in this line of endeavor because 
many physicians are passing these cases by with 
out advising surgery or rather advising against 
it saying that the infected tonsil is not doing 
any damage as yet. Some physicians give this 
advice honestly but others do it because they 
think it pleases the patient or relatives better 
than would advice for a surgical measure. These 
latter are men who are practicing principally 
with a pleasing personality, ability to mix well 
with the people and a desire to say that which 
pleases most at the time. They have little rea- 
son to fear that later developments will show 
their advice to have been wrong for ordinarily 
the patient or relatives will not connect the 
primary cause with late developments. They do 
not connect the late cardio-vascular-renal dis- 
ease, etc., with infected tonsils which should have 
been removed 20 to 40 years previous. Even if 
they do the physician will have enjoyed their 
confidence for the 20 to 40 years that will have 
elapsed and profited thereby. So why should he 
worry. He is about ready to retire anyhow. 
Such men are the ones who agree with the grand- 
mother saying, “Yes, I think you are right; the 
trouble is stomach and teeth.” Perhaps it is 








Tuary, 1993 


r-renal dis. 
f infection 
Fan arrest 
s far better 
ildren and 
1 bladder, 
rked dam. 
neys. But 
ters much 
dvisability 
1 infection 
ts of chil- 
ondary to 
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and much 
& parents 
symptoms 


prejudice 
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therefore, 
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S & Case 
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February. 1923 C. H. 


acase in which there is no leading symptom and 
about all the findings there are are fever and a sore 
gum where a tooth is about to erupt. If such 
be the case it is easy for a doctor to say the 
trouble is stomach and teeth and he can get 
by with the family with such a diagnosis. If 
he would examine the urine perhaps he would 
find bacteria and tonsils would show evidence 
of infection. Some of us do not go to the trouble 
to investigate such things and consequently re- 
main as ignorant of the true condition as are 
the patient and relatives. Many a case of pyelitis 
has no diagnostic feature except a microscopic 
urine examination. The above outlines pretty 
accurately a case seen recently. The diagnosis 
is pyelitis secondary to infected tonsils. In this 
case a great deal of difficulty was encountered 
and it would have been easier to allow the case 
io drift along with no mention of need of a 
tonsil operation but removal of tonsils in this 
case doubtless would do away with the source 
of infection and recovery would follow in all 
probability especially if some good urinary anti- 
septic such as hexamethalyn were used for a few 
months following tonsil removal. This patient 
recovered nicely from this attack after about two 
weeks, but still carries the dangerous infection 
in tonsils. 

It is easier to side step the issue in many such 
cases and allow people to carry foci of infection 
and die earlier than they should, but still sing- 
ing your praises and paying you good money for 
worthless gargles and throat washes. It prob- 
ably is quite often more profitable to do so for 
if you do not say that which pleases, another 
doctor can and most likely will be found who 
will learn what the patient or relatives want to 
hear and will say it for the sake of pleasing. 
Such doctors are more adept at learning what 
people like to hear and saying it than they are 
at learning the right way to practice medicine. 

However, if one does his duty he will at least 
let people know the facts as far as possible; 
then if they choose to go on carrying these 
dangers it is their own business. I know of 
many who are doing this in spite of having been 
advised of the danger. 

This makes no pretense at exhaustion of the 
subject but aims to recall some work we can do 
to give people longer life. We may prevent an 
abdominal operation by removing a tonsil or 
tooth at the proper time. 


and assuring. 


ANDERSON - 159 


TREATMENT OF THE INSANE* 


C. H. Anperson, M. D., 


Managing Officer, Anna, Ill, State Hospital 
Anna, Ill. 


The first approach to a patient should be kind 
All fear and antagonism should 
be allayed. The patient should be caused to feel 
that they are among friends who will look after 
their needs with kindness and thoughtfulness. 

The first service rendered a patient after ad- 
iuission is a warm bath and a shampoo. This 
will tend to allay nervousness and promote a 
period of rest. The patient is then placed in bed 
und made as comfortable as possible. A physic 
is then administered the patient. This is done to 
secure better elimination. The number who 
neglect proper elimination is quite surprising. 
Auto-intoxication from constipation plays an im- 
portant role in the etiology of insanity. The 
importance of this factor has been unduly magni- 
tied by some surgeons who have claimed mar- 
velous results from a colectomy or an excision of 
a section of the colon. The operation for colec- 
tomy is performed on the theory that a section 
cf the colon becomes atonic, loses its vermicular 
motion and consequently becomes a storehouse of 
ioxic material from which the entire system be- 
comes poisoned. 

From this it will be seen that the first atten- 
tions given a patient are rendered with a view 
of creating the impression that they are ill and 
have come to the hospital for the purpose of 
treatment and not to a quasi-penal institution. 
This impression serves as a proper background 
for all that is to follow. 

Every patient should be brought to realize that 
they are ill and the hope of a cure should replace 
the feeling of despondency which dominates the 
mental picture of so many patients. Every serv- 
ice should be kindly, gently but firmly rendered. 
Kindness and gentleness robs them of the feeling 
of the stupendous loss of their immediate family 
circle. Firmness initiates the system of personal 
discipline so essential to future recovery. The 
patient should not feel too sensibly the loss of 
unnecessary ministrations of misguided and eften 
foolish relatives. Much is to be gained by a com- 
plete separation of the patient from family and 
home surroundings. A new environment must 
be created in which the patient can start anew on 


; *Read at forty-eighth annual meeting of Southern Tinois 
Medical Association at Cairo, November 2, 1922. 





160 ILLINOIS MEDICAL JOURNAL 


be left 
Time must be given for 


the road to recovery. Old scenes must 
behind if not forgotten. 
thought and reflection. 

Among the early services rendered is a careful 
and painstaking physical examination of all the 
organs of the body and if a physical derangement 
can be found which either promotes or serves as a 
hasis for the mental derangement the highest art 
of the physician should be exerted in its correc- 
tion. Elimination is carefully studied and if 
found inadequate every effort is made to im- 
prove it. 

Karly attention is given to the teeth and tonsils 
for the purpose of discovering any existing foci 
of infection from that source. Many cases could 
Le recited that cleared up as soon as all diseased 
teeth were properly treated and all cases of pyor- 
The value of 
Cot- 
ton, superintendent of the Trenton State Hos- 


rhea and pus pockets eliminated. 
cral hygiene cannot be overestimated. Dr. 


pital, claims brilliant results and has gained in- 
ternational fame by efforts to cure insanity by 
the elimination of foci of infection. He believes 
that focal infection is probably the most fre- 
quent of all causes of insanity. 
be located 
fossae, uterus, kidneys, bowels and in many other 


These foci may 


in the teeth, tonsils, sinuses, nasal 


organs of the body. 

A routine Wassermann test is made on the 
blood and on the spinal fluid when indicated for 
the purpose of discovering a possible syphilitic 
infection. An approved method of treatment is 
given all patients suffering from syphilis or a 
parasyphilitie sequella. 

All patients 
placed in the diagnostic group until a careful ex- 


admitted to the hospital are 
amination both mental and physical is made and 
# correct classification is determined. Classifica- 
tion not only refers to the form of disease but to 
the mode of treatment. The classification as to 
the form of disease is mainly useful for statis- 
tical purposes only. The adoption of the thera- 
peutic classification was one of the great innova- 
tions in the treatment of the insane in Illinois. 
By this system of classification all patients re- 
quiring a certain kind of treatment are grouped 
together. In this way individual care can most 
nearly be approximated. 

Returning to the promotion of patients in the 
classification for treatment, all patients showing 


active mental derangement pass automatically 


February, 1993 


from the diagnostic group to the acute mental, 
The acute mental cases are divided into two 
groups: One to which hydrotherapy is indicated 
und the other occupational therapy. 

A reference here to the meaning and applica- 
tion of occupational therapy will be in order, 
Occupational therapy is the scientific application 
It should be 
prescribed with the same exactness in the cor- 


of occupation in the cure of disease. 


rection of faulty mental and physical habits as 
(rugs are prescribed for the cure of physical dis- 
eases, 

The druggist is called upon to fill the prescrip. 
tion for drugs and so the occupational therapist is 
expected to act as technician in filling the pre- 
scription for occupational therapy. 

Most every insane person has acquired some 
abnormal habit, either physica! or mental. Some 
are depressed, retarded and inactive. Others are 
elated, active and divertable. Some are destruc- 
tive, others irritable, and still others untidy. The 
above list of abnormalities could be extended in- 
definitely. The type of occupation prescribed is 
usually in terms of mechanical, intellectual, mo- 
notonous or varied employment. 

The maniac cases usually improve most readil\ 
under the influence of mechanical employment. 
Retarded cases do best when assigned varied em- 
ployment. The prescription is written with the 
lea of correcting an individual faulty habit. 
Patients may go directly from the diagnostic 
group to the infirm group either as infirm-bed, 
infirm-up or infirm tubercular cases, They may 
vo directly from the diagnostic group to the Edu- 
cational-Habit Training group. This group in- 
cludes patients who are more or less deteriorated 
and have acquired some especially faulty habit, 
such as untidiness, destructiveness or habits of 
irritability. A piece of burlap may be given a 
destructive patient to ravel who has acquired th 
habit of spending the entire day tearing clothing 
or bedding. In this way the habit of raveling bur- 
lap may be substituted for the habit of tearing 
clothing. After this habit is well formed some- 
thing more complicated and useful may be sub- 
stituted. Patients who have acquired the habit of 
soiling their bedding and clothing by disregarding 
the promptings of nature should be taken to the 
toilet at regular intervals both day and night. 
The list of other pathological habits could be ex- 


The application of oeecupa- 


tended indefinitely. 

















Uary, 1999 


P mental, 
into two 


indicated 


applica- 
in order, 
plication 
hould be 
the cor. 
labits as 


ical dis- 


rescrip- 
rapist is 
the pre- 


“1 some 

Some 
lers are 
lestruc- 
v. The 
ded in- 
‘ihed is 
al, mo- 


readily 
Vinent. 
ed em- 
ith the 
habit. 
rhostic 
n-bed, 
y may 
» Edu- 
ip in- 
rated 
habit, 
its of 
Ven a 
«dl the 
thing 
r bur- 
aring 
come- 

sub- 

vit of 

‘ding 

» the 

ight. 

>» X- 


upa- 








SOCIETY 


February, 1923 


tion in the treatment of insanity is based on the 
theory of the substitution of a normal habit for a 
pathological one. The treatment of the insane is 
largely one of re-education. 

Patients who are committed to the hospital be- 
iore deterioration occurs often go immediately 
from the diagnostic group to the educational— 
this 


group are of a higher class than the former, con- 


acupational therapy group. Patients of 
sequently the form of occupation employed is 
more intricate and varied. The test of success in 
treatment is not measured by the work performed 
or the articles manufactured but rather the pa- 
tient. The finished product is the patient. 

The guiding rule in the treatment of patients 
in this class is that the product of their labor 
shall have no intrinsic value. This distinction 
is diligently maintained to prevent the occupa- 
tional group from gradually merging into the vo- 
cational or industrial. 

Patients in the vocational group are taught 
some useful vocation which may be followed for 
a livelihood after discharge from the hospital. 
Patients in the industrial group are employed in 
the laundry, bakery, kitchen, dairy, farm, garden 
and numerous other departments of the institu- 
tion, 

It will be seen from the foregoing that employ- 
ment is the basis for the treatment of a majority 


ef all admissions to the hospital. 


THERE IS SUCH A THING AS AN ARIS- 
TOCRACY OF BRAINS 

The President of Dartmouth College has as- 
serted that too many men go to college; he 
deems it necessary to define the individuals to 
whom in justice to the public good, the privilege 
shall be extended, and to specify those from 
He be- 
‘ieves there is such a thing as an aristocracy of 
brains, made of men intellectually alert and in- 
tellectually eager, to whom increasingly the op- 
portunities of higher education ought to be re- 


whom the privilege should be withheld. 


stri ted, 





WHY THEY MISSED FAME 
Lots of men would leave their footprints 
rime’s eternal sands to grace 
Had they gotten mother’s slipper 
\t the proper time and place. 


—Atlanta Constitution. 


PROCEEDINGS 161 


Society Proceedings 


CHRISTIAN COUNTY 

At a meeting of the Christian County Medical So- 
ciety held in this city on the evening of January 16 
the following officers were elected: 

President, Dr. C. M. Seaton, Morrisonville; vice- 
president, Dr. F. A. Martin, Pana; secretary-treas- 
urer, Dr. D. D. Barr, Taylorville; delegate, Dr. G. 
L. Armstrong, Taylorville; alternate, Dr. T. A. 
Lawler, Taylorville; member legal committee, Dr. 
J. N. Nelms, Taylorville; members public health 
committee, Dr. J. H. Miller, Pana, and Dr. W. H. 
Mercer, Taylorville. 

Censors: Dr, T. A. Lawler, Dr. W. H. 
and Dr. J. N. Nelms, all of Taylorville. 

Our meting was the best we have had for four 
years and the spirit of activity freely 
flowed and there is a fine prospect for the future. 

D. D. Barr, Sec. 


Mercer, 


business 


COOK COUNTY 
CHICAGO MEDICAL SOCIETY 
Special Meeting, January 10, 1923. 
Memorial to William Edward Quine, President of 
the Society, 1872. 
President Hugh N. MacKechnie in the Chair. 
Biographical Sketch—Dr. Wm, Allen Pusey. 
The Physician and Teacher—Dr. Frank Billings. 
A Friend to Women—Dr. Alice Lindsay Wynekoop. 
As | Knew Him—Bishop Jospeh Hartzell. 
The Man—Mr. John T. Richards. 
Joint Meeting of the Chicago Medical Society and 
Chicago Roentgen Society, January 17, 1923. 
1. “Sinus Disease and Lung Infection”’—Kennon 
Dunham, Cincinnati, Ohio. 
Discussion—Austin A. Hayden, John A. Cav- 
anaugh, Joseph C. Beck. 
2. “The Diagnosis of Intracranial Tumors by Vcn- 
triculography”"—Walter E. Dandy, Baltimore, 
Md. 
Discussion—Cassius C. Rogers, Allen  B. 
Kanavel, Geo. Davenport. 
Regular Meeting, January 24, 1923. 
1. Ancient and Modern Med.cine in China—Ed. H. 
Hume, Dean of the College of Medicine of 
Yale in China. 
2. Fundus Changes in the Eye in Cardio-Vascular 
H. Wilder. 


Discussion—Oscar Dodd. 


Diseases—Wm. 


3. Cardio-Dynamics of Arterial Hypertension—Ar- 
thur R. Elliott. 
Regular Meeting, January 31, 1923. 
1. Proposed Activities if Sheppard-Towner Funds 
Are Made Available—Isaac D. Rawlings, 
Director of Public Health, Springfield, II. 











162 ILLINOIS MEDICAL JOURNAL 


2. The Sheppard-Towner Act—Wm. D. Chapman, 


Silius, Ill. 
Discussion—Mrs. Kenneth F. Rich, Charles J. 
Whalen, Mrs. Ira Couch Wood, Ed. H 
Ochsner. 


CHICAGO OPHTHALMOLOGICAL SOCIETY 
February 20, 1922. 
Dr. Frank E. Brawley in the Chair. 
RETINITIS PIGMENTOSA? 
Dr. Michael Goldenburg 
Mrs. L. 
had no eye trouble in youth or at any time until 


reported the case of 
B., colored, age 38, who stated that she 


October, 1917, when her left eye was struck by a 
piece of wood. This cye was enucleated in Decem- 
ber, 1917. About three weeks after the accident to 
the left eye she began to have severe frontal head- 
aches, marked photophobia; various colors appear- 
ing before the right eye. At the time of the accident 
patient went unattended, but within five weeks after 
the accident she required some one to accompany 
her, not because she was unable to make her way 
along the streets, but because when she arrived at 
the doctor's office she had to enter through a small 
She was unable to make her way 
through this hall, and when she entered the office 


dark hallway. 


she was unable to find a chair. Patient cannot give 
any information as to consanguineous marriages. 
\t the time of enucleation of the left eye the vision 
of the right eye was very poor, everything appear- 
ing blurred even in the presence of good illumina- 
tion. About three months after the enucleation 
vision in the right eye started to improve and soon 
she was able to distinguish objects, and to thread a 
needle under good illumination. There was not 
much change in vision from this time up to the 
time of entrance into the hospital. 

In the hospital it was found that she had a four 
plus Wassermann. 

On admission she had tubular vision 20/20, Oph- 
thalmoscopic findings: Disc fairly wel! defined, 
small crescent of pigment on temporal side of disc, 
disc appeared pinkish, lamina cribrosa not visible. 
shallow physiologic cup. Arteries markedly con 
Typical bone corpuscle pig 
ment in periphery, anterior to vessels. In several 


tracted and straight. 


places the pigment follows the vessels in a straight 
line and anterior to them. fundus tesselated; no 
atrophy or arterio-sclerosis of choroidal vessels ap- 
Perimetry disclosed a contraction to 10 
Refraction: small error, not improved by 


parent, 
cle verees 
glasses 

His only object in presenting this case was that he 
had never seen a case of retinitis pigmentosa in a 
colored person before and thought it worth while 
reporting. 

DISCUSSION 
lr. Harry S. Gradle asked whether the case might not be 


ne of luetic retino-choroiditis instead of retinitis pigmentosa. 
Dr. Goldenbure replied that the patient was getting a regular 


February, 1993 


course of antisyphilitic treatment. He had seen two cases jn 
which there was some question as to whether it was retinitis 
pigmentosa or syphilis. In these cases he found some parts of 
the field with pigment of a darker character. It did not assume 
the feathery arrangement seen in retinitis pigmentosa ag jp 
this particular case. 

Dr. George F. Suker did not believe there was a case of 
retinitis pigmentosa reported in the literature where the disease 
started at the age of this individual. Retinitis pigmentosa began 
early in life; it might go on for years without manifesting any 
symptoms to speak of but eventually there would be symptom 
itology of one form or another. Vision might remain absx 
lutely normal for years, but sooner or later there would be a 
dimming and marked contraction of the field of vision. It 
was not necessary in retinitis pigmentosa to have the pigment 
symmetrically distributed throughout the periphery of the retina 
It may even at first be limited to nasal or temporal half of 
the retina for many years, but eventually it will involve th 
other half also. 

In this particular case he thought the element of syphilis 
was a strong possible feature, and then the case would not be 
one of true retinitis pigmentosa, but a retinitis, syphilitica 
pigmentosa, pure and simple, giving the same characteristics 
of poor night vision as in a true retinitis pigmentosa. Further 
more, the pigment spots would later on, or even now, assume 
the bone corpuscle outlines, the same characteristics as one 
saw in retinitis pigmentosa. Another difference between this 
case and retinitis pigmentosa was that this nerve head was not 
a waxy yellow with an evident neuritis but presented a clear 
cut optic atrophy picture, as seen secondary to lues. Retinitis 
pigmentosa was a retinal lesion, pure and simple, while in this 
case there was already considerable choroidal involvement, much 
more so than obtained in a classic retinitis pigmentosa. So far 
as the symptomatology and the visual fields were concerned, 
they were practically the same in the two diseases, but the 
pathology was quite different. 

Dr. Robert von der Heydt stated that he had had an oppor- 
tunity to study this case with the large Gullstrand binocular 
ophthalmoscope. The lesions he saw were absolutely confined 
to the retina and their depth was beautifully shown stereo- 
scopically. 

Dr. Thomas Faith suggested the patient might have had 
monocular vision before one eye was lost. 

Dr. Goldenburg said the patient did not know her vision 
was bad until this eye was destroyed. She gave a history of 
having poor vision in the eye for sometime past. He thought 
there was no question about the case being one of retinitis 
pigmentosa. In colored people the nerve head could not show 
up as typically as in a Caucasian. This was due to contrast. 
The proliferation of the pigmented was secondary to atrophy of 
the chorio-capillaris and destruction of the tissues anterior to 
this layer. The proliferation took place around the equator and 
is the condition progressed, it extended on toward the nerve 
head. In a syphilitic case one did not get the tubular vision as 
in this case and did not get the marked straightening out of the 
His own interest in this case was that it occurred in 
. colored individual and he had never seen it before. If the 
case were luetic, he presumed active antileutic treatment would 
he of material benefit. 

Dr. Harry S. Gradle thought it would be well to hold the 
diagnosis of retinitis pigmentosa in abeyance until it was seen 
how the patient progressed under antileutic treatment. 


vessels. 


NEOSALVARSAN FOR TOXIC AMBLYOPIA 

Dr. Cottle reported the following cases for Dr. 
G. F. Suker: A. S., gave a history of a moonshine 
debauch following ‘which he became blind, and re- 
mained the same for two months when he entered 
the hospital. 

At this time his vision was 3/200, discs definitely 
pale, and form fields constricted. There was also a 
well marked central scotoma for red. Patient had 


a chancre twelve years previously, but no other 
specific history, nor cone of antiseptic treatment 














Wary, 1923 


WO Cases in 
Vas retinitis 
Me parts of 
Not assume 
itosa as in 


a case of 
the disease 
ntosa began 
festing any 
> Symptom. 
main abso 
would be a 
vision. It 
he pigment 
the retina 
ral half of 
nvolve the 


of syphilis 
uld not be 
syphilitica 
racteristics 

Further 
W, assume 
TS aS one 
ween this 
d was not 
‘d a clear 
Retinitis 
ile in this 
ent, much 
. So far 
oncerned, 
, but the 


an oppor- 
binocular 

confined 
n stereo- 


lave had 


er vision 
istory of 
: thought 
retinitis 
not show 
contrast. 
trophy of 
terior to 
ator and 
he nerve 
vision as 
it of the 
urred in 

If the 
it would 


old the 
fas seen 


OPIA 
or Dr. 
nshine 
nd re- 
ntered 


initely 
also a 
it had 
other 
iment 














February, 1923 


Wassermann tests on blood and spinal fluids were 
negative. The patient was put on K. I. and daily 
sweats. For over seven weeks this was done, at 
which time the vision was still the same. 

On January 27, 1922, the patient was given 0.3 
grains of neosalvarsan intravenously. Two days 
later the vision was 15/200 and 10/100. The patient 
also noted that he could see finer print. One week 
later another injection was given. Four days later 
the vision was 19/200, and two days after this 
99/200. On February 14 an injection of 0.6 was 
given, and two days later the vision was 20/200 
(10/70 7/50). This is the condition at the time of 
writing. 

M. Z., gave a history of excessive indulgence in 
alcohol and tobacco, and one night he went on a 
spree and within thirty-six hours was unable to see 
any more than large objects a few feet in front of 
him. For eight months this condition prevailed, 
with but very slight improvement. He then entered 
the hospital. 

His vision on entrance was R. E. 15/200; L. E. 
20/200. The temporal sides of the discs were definitely 
pale. There was a central scotoma for red without 
much construction of the form fields. Serologically the 
patient was repeatedly negative, and for ten days 
under close observation in the hospital no change 
in vision was observed. Neosalvarsan 0.3 grams 
was injected intravenously. At this time there was 
started a daily injection of strychnin, which was the 
only other medication given. One week after the 
first, another injection was given, which was fol- 
lowed in five days by an improvement in vision in 
the left eye to 20/30. After another injection, one 
week later, the vision in the right eye was improved 
to 20/100. 

DISCUSSION 

Dr. Suker stated: The question was why, in three cases— 
and a fourth one under observation—ncosalvarsan or arsenical 
preparations accomplished so much good. Of the three cases, 
the third one was a soldier in whose case repeated spinal 
punctures were made. Methyl alcohol poisoning caused a ven- 
tricular and spinal hydredema; and, in the first few hours of a 
retrobulbar neuritis, there was not manifested any particular 
change in the disc, except a slight elevation of the disc edge, 
particularly on the nasal side. This entricular and spinal-canal 
hydredema disappeared usually within forty-eight to seventy- 
two hours and then the optic disc picture ensued. There was 
really a moderate evanescent pressure edema of the nerve 
which was followed by the retrobulbar neuritis. 

The beneficial results obtained in these cases depend on two 
factors. First, the relief of pressure by repeated spinal punc- 
tures; second, the seemingly chemical antidote of the arsenic 
and as a nerve stimulant. Whether it was an antireacting agent 
was a difficult matter to determine; nevertheless, the fact was 
that neosalvarsan and other arsenics did considerable good. 
These patients were in the hospital for several weeks before 
anything was done for them other than spinal drainage as 
reported. Many serologic examinations were made, all proving 
negative. These patients did not receive ordinary pilocarpin 
Sweatings and usual treatment, but the spinal canal was drained 
almost dry on several occasions and the arsenicals used. He 
suggested a trial of these preparations and drainage of the 
spinal canal in similar cases. The vision of these patients was 
now apparently stationary and the discs did not show any 


further atrophy as shown by maintaining a constant visual 
tield 


ILLINOIS MEDICAL JOURNAL 163 


TUMOR OF CONJUNCTIVA AND SUB- 
JACENT TISSUE 

Dr. Robert Blue presented the case of a young 
man in the early twenties, with a tumor of the right 
bulb of an unusual type. This tumor was situated 
beneath the bulbar conjunctiva, slightly elevated, 
sharply defined, and highly vascular. It did not 
extend into the cornea, but was confined strictly to 
the conjunctiva and subjacent tissue. 

The history was that some twenty months before 
the patient discovered a growth in the eye without 
any irritation whatever. He had observed the case 
for eight months. During that time the tumor had 
not increased in size. The diagnosis was a benign 
neoplasm of unknown nature. 


LEFT HOMONYMOUS HEMIANOPSIA 


Dr. Edward F. Garraghan presented the case of a 
man, single, sailor by occupation, who had been a 
rather heavy drinker. He first saw him about the 
15th of November, 1921, during an attack of pneu- 
monia. At that time the vision was blurred, but this 
condition gradually cleared up entirely. Two months 
later the patient noticed that objects on his left side 
were lost to view, and he found difficulty in walking 
because he could not see to his left. On examina- 
tion his vision was 20/20 in each eye. There was no 
paralysis of any of the external ocular muscles. The 
fundi of both eyes were negative. The field showed 
complete blindness of the temporal half of the right 
eye and the nasal half of the left eye. It was a 
typical case of left homonymous hemianopsia. Pa- 
tient gave a history of a luetic lesion about twenty 
years ago. He gave a four plus Wassermann reac- 
tion, the Wernicke sign was present, and the lesion 


“was, therefore, most likely confined to the optic 


tract. 
INCREASED INTRAOCULAR TENSION 


Dr. Thomas Faith read the paper reporting clini- 
cal observations on this subject. 


DISCUSSION 


Dr. William A, Fisher stated that the essayist had cited cases 
where miotics had been given by ophthalmologists of good 
repute, where he would have given mydriatics. Plus tension, 
without any eye pathology that could be seen, required miotics 
and a search for the cause. Plus tension with a cause that 
could be seen required a mydriatic and the removal of the 
cause. 

All of Dr. Faith’s reported cases would have been given the 
same treatment he gave them, if he had followed this pro- 
cedure. His first case, plus tension, traumatic cataract, required 
atropin, but it might have been quite as well had he also 
removed the lens which was causing the plus tension. 

Within the year, he had had a case of tension in each eye 
of 54 with 20/25 vision, where eye pathology could not be 
found; pilocarpin was instilled, enemas given and six teeth 
extracted, two at a time ten days apart. When the gums had 
healed, enemas and pilocarpin were discontinued. Tension 
remained normal and vision improved to 20/15 plus. 

Another case of tension 60, vision in each eye 20/200. Eye 
pathology could not be found. The teeth, tonsils and sinuses 
were normal. Miotics and enemas were given and tension 
returned to normal, and vision 20/25 in the left eye but 20/200 
in the right which had an old scar. This case was seen by 





164 ILLINOIS MEDICAL JOURNAL 


one of the members of the society who advised an immediate 
operation. 

Dr. Fisher believed that many cases of plus tension would 
escape an operation if the teeth, tonsils, sinuses, alimentary 
canal and blood were treated when necessary, and miotics or 
mydriatics used as indicated. 

Dr. Harry S. Gradle said: Dr. Faith’s paper was timely, 
because many cases of plus tension due to mechanical causes 
were overlooked, in the eagerness of a search for glaucoma. 
In these cases there was more or less mechanical obstruction 
of the canal of Schlemm. One might not be able to see it in 
the early stages, but sooner or later it would appear. These 
cases were particularly apt to be found in younger people. He 
recalled to mind two young women, 20 and 22 years old respec- 
tively, in whom plus tension developed as a sequence of cyclitis, 
proved to be of tubercular origin. In some of these cases it 
was impossible to reduce the tension, and operation became 
necessary to establish a free outlet to the anterior chamber. 
One could make a diagnosis practically in all cases by a careful 
examination of the anterior aspect of the eye for evidences of 
exudation manifesting themselves on the posterior surface of 
the cornea. 

In many of these cases one could bring the tension down to 
normal by the injection of 1/1000 adrenalin underneath the 
conjunctiva. 

Dr. Frank E. Brawley mentioned a case of simple chronic 
glaucoma, seen in consultation, with a small synechia. 
was no way of telling when this occurred. 


There 
The glaucoma had 
lasted for several weeks at the time he saw the case. Dilatation 
was effected under cocain, but after twenty-four hours miotics 
had to be resumed. The case went on to enlargement of the 
fields and quiescence under the miotics. 

Dr. Faith agreed with Dr. 


Gradle that many of these 


cases were instances of mechanical obstruction. He reported 
a case he had watched carefully for weeks, but did not men- 
tion it in his paper, in which iridectomy was done with the 
idea that he had a primary glaucoma to deal with. Tension 
He searched for 


There 


was no exudation until several weeks after the tension had 


was reduced temporarily but came up again. 
foci of infection and removed them as well as he could. 
come down to normal. What brought the tension down he 
helieved was the improvement in general health and giving 
the patient a mixed stock vaccine. Then he saw shreds of 
exudate posterior to the ciliary body, but up to that time he 
could not see anything that looked like it. Where one would 
miss the exudates with the ordinary loupe and ophthalmoscope, 
he might be able to see them readily with improved methods 
of examination, as with the slitlamp. 


COMPARATIVE ANATOMY OF THE EYE 
Dr. George FE. Keiper of Lafayette, Indiana (by 
invitation), read a paper on this subject illustrated 
by stereopticon slides showing various types of eye 
from the simple eye spot to the eye of man and 
especially of the bird, as the most perfect organ. 
Dr. Robert Von Der Heydt, 
Corresponding Secretary. 


THE CHICAGO LARYNGOLOGICAL AND 
OTOLOGICAL SOCIETY 
The regular monthly meeting of the Chicago 


Laryngological and Otological Society was held at 
the Hotel Sherman on Monday evening, March 6, 
1922. 

The 
Chair 


President, Dr. Robert Sonnenschein, in the 


ABSTRACT 
Presentation of Cases and Specimens: 
Dr. Joseph C. Beck presented a_ pathological 
specimen of a lipoma of the laryngo-pharynx, re- 
moved from a boy of sixteen. The tumor of the 


larynx had been present for more than a year and 
had reached the pyriform fossa. The glands were 
not involved; the tumor was soft and not painfy! 
The mucous membrane over it moved quite readily 
and there was no pulsation. The trachea was en- 
larged but only a droplet of material could be forced 
out and that showed evidences of fat. Microscopix 
c¢xamination revealed a true lhpoma. Three needles 
of radium were inserted, without effect, which veri- 
fied the usual findings, that lipomata are not affected 
by radiotherapy. 

A year later the patient returned with the growth 
considerably sunken down and the history of loud 
The growth 
was then enucleated under synergistic anesthesia, by 
the suspension laryngoscopy method. 


breathing and snoring during sleep. 


DISCUSSION 
Dr. J. Holinger asked the relation of the 
tonsil and to the Eustachian tube. 


tumor to the 


Dr. Beck stated that the growth was back of the posterior 
pillar and did not extend beyond the margin of the soft palate 
It was entirely from the nasal fossa. 

Dr. C, M, 
come to him with stenosis from a laryngeal growth Some 
forty-off fatty tumors over 


Robertson reported the case of a patient who had 


various portions of the body were 
found and one about the size of that removed by Dr. Beck 
was in the buccal cavity. Laryngeal examination showed a 
mass occupying the right side of the larynx. It did not look 
like a carcinoma and a lipoma was suspected. 
so pronounced that a preliminary 


Dyspnea was 
tracheotomy was necessary 
and before they could prepare for an evisceration of the larynx 
the patient succumbed. Portmortem examination showed that 
the growth in the throat was a true carcinoma, although the 
other tumors in various parts of the body were lipomata. 
Dr. Albert H. Andrews read a paper on “Surgery 


of the Ethmoid Labyrinth.” 
ABSTRACT 
Dr. Andrews stated that it was not his purpose 
to present anything new or startling in the field of 
ethmoid surgery, but, first, to protest against the 
unnecessary sacrifice of the middle turbinat 
and, 


body 
to the method (not 
new) of draining and ventilating the ethmoids. 
Several years ago the writer pointed out the ten- 
dency to maxillary antrum discase following the 
removal of the middle experience 
through the years has strengthened the belief that 
one of the functions of the middle turbinate is to 
protect the antrum, probably by leading discharge 
from the 


second to call attention 


turbinate, and 


frontal sinus and anterior ethmoid cells 
away from the antrum and to cause the discharge 
to drop free into the nasal cavity. Another function 
of the middle turbinate is to direct part of the air 
current past the ostium maxillare in 
that it will rarify and condense the air in the an- 


such a way 


trum with each inspiration and expiration. 

That the middle turbinate and the ethmo‘d cells 
have a function in maintaining a proper lumen o! 
the nostril is indicated by the fact that after removal 
the patient usually finds himself unable to prevent 
the discharge accumulating in the area once occu- 
pied by these structures. Continued crust formation 
is a common sequel. The discharge in this locality 
harbors and f 


favors the development of mucre 


February, 1993 








iTy, 1923 


‘ear and 
ds were 
Painful, 
 Teadily 
Was en- 
e forced 
roscopic 
needles 
ch verj- 
affected 


growth 
of loud 
growth 
esia, by 


r to the 


posterior 
ft palate 


who had 

Some 
ly were 
rr. Beck 
howed a 
not look 
mea was 
ecessary 
e larynx 
ved that 
ugh the 
ita, 


urgery 


urpose 
ield of 
ist the 
; body 
1 (not 
1s. 

1e ten- 
ig the 
‘rience 
*f that 
- is to 
~harge 
1 cells 
~harge 
nction 
he air 
1 way 
1 an- 


! cells 
en of 
moval 
‘event 
occu- 
nation 
cality 


nicro 











February, 1923 


organisms which frequently invade the adjacent 
cavities, the frontal, maxillary and sphenoid sinuses. 

The writer has no doubt that diseased turbinates 
may sometimes cause disease of the ethmoid cells 
and it was his practice formerly to remove the tur- 
binate in the hope that the diseased ethmoids might 
recover. Later it has seemed that diseased ethmoids 
have been the frequent cause of diseased turbinates 
and the plan has been to operate upon the ethmoids 
in order that the middle turbinate might recover. 
It is frequently necessary to swing the turbinate 
away from the lateral wall in order to get at the 
ethmoids. Under thorough cocainization this is 
neither difficult nor painful. The instrument used in 
exenterating the ethmoid cells is the Knight’s biting 
forcep. The instrument is opened about a third of 
an inch and while the shaft is pressed over against 
the septum the blades are introduced under the mid- 
dle turbinate against the bulla ethmoidalis. Then 
with a gentle rocking motion the blades are pushed 
into the ethmoid labyrinth as deep as the cupped 
part of the blade (about three-quarters of an inch). 
The forcep is then closed and the tissue caught be- 
tween the blades is removed. The forcep is inserted 
again, this time with the upper blade in the cavity 
made by the first bite and the lower blade below 
the floor of the ethmoid labyrinth. The instrument 
is pushed back almost to the anterior border of the 
sphenoid, the forcep is closed and the tissue caught 
between the blades is removed. Ventilation and 
drainage has now been provided for both the an- 
terior and posterior cells, except possibly a few 
anterior cells about the naso-frontal duct. 

The advantages of the operation are: 

1: The ease with which the operation can be 
performed under local anesthesia. 

2: The safety of the operation when the operator 
has a fair knowledge of the anatomy of the parts 
involved. 

3: The thoroughness with which this compara- 
simple operation exenterates the ethmoid 
labyrinth as shown on the cadavor. 

4: The after-results show no tendency to crust 
formation or other undesirable conditions. In ex- 
amining some of the patients years after they were 
operated upon by this method no history of recur- 
rence could be obtained and the only evidence that 
the patient has ever had ethmoid disease was the 
finding of an open space when the probe was in- 
serted under the turbinate. 

The dangers of operating are: 

1: To the eye through the orbital wall, the 
lamine, papyracea. With ordinary care, without un- 
usual force, and by keeping the instrument perpen- 
dicular this accident should be easily avoided. 

2: To the cranial cavity through the orobriform 
plate and the horizontal plate of the frontal bone. 
lf the directions are followed as to depth of insert- 
ing the blades this accident cannot occur. 

3: That the operation will not be 


tively 


thorough 
Ventilation with the least 


cnough to effect a cure. 


ILLINOIS MEDICAL JOURNAL 165 


possible interference with function is ‘the object 
sought. Unless there is extensive necrosis the prob- 
abilities are that if this operation fails, the more 
extensive. operations would also fail. Should this 
operation fail more extensive work can be under- 
taken at any time. It is well to remember, however, 
that it is always easier to take out more tissue if 
necessary, than it is to put back what has been 
removed. 
DISCUSSION 

Dr. C. M. Robertson agreed with Dr. Andrews concerning 
the anterior ethmoid cells and preservation of the turbinate, 
and said he did same operation by a little different technic. 
After the labyrinth is cleaned he comes forward to get the 
anterior ethmoidal cells and then fractures the ethmoidal plate 
outward. 

One case of pan-sinusitus, operated five or six years ago, 
was particularly interesting. In that case the ethmoidal was 
pushed over a’ fourth of an inch and after the fracture of the 
bony plate the resiliency of the vertical plate of the septum 
brought it back into a normal position. He considered this the 
most satisfactory case he had seen, as there is now a normal 
physiological function, occupying 
its normal position with the ethmoidal space on the outside 
wall of the nose. 


turbinate carrying out the 


(To be continued in March issue) 


LEE COUNTY 

The Lee County Medical Society held its annual 
meeting at the City Hall in Dixon, January 9, 1923, 
at 2 o'clock P. M. 

The meeting was well attended by members of 
Lee, Ogle, Whiteside and LaSalle counties. Dr. 
Ralph C. Hamill of Chicago gave a very practical 
talk on the “Psychoneuroses.” Dr. Harry M. 
Hedge of Chicago delivered an address on “Prac- 
tical Dermatology,” and Dr. Willard Thompson of 
Dixon read an paper on “Vertigo.” 
These papers were all well received and the dis- 
cussions were unusually interesting. 

Dinner was Nachusa Tavern at 
12:30. After the scientific program, the usual busi- 
ness of the annual meeting was transacted. 


interesting 


served at the 


The officers for 1923 are as follows: president, 
Dr. T. O. Edgar, Dixon; vice-president, Dr. J. H. 
Dale, Ashton; secretary and treasurer, Dr. E. C. 
White, West Brooklyn. 

T. F. Dornevaser, Past President. 





Marriages 





FULLER Bryan Batley to Miss Maybelle Caro- 
lvn Zimmer, both of Chicago, January 6, 

Martin Rosert BromMan to Dr. Mildred Jessie 
Roberts, both of Chicago, December 28. 

Joun Mitton Dopson, Chicago to Mrs. Mary 
Hyde Webb of Detroit, January 17. 

Heimer Encu, Gillespie, Ill, to Miss Helen 
Runnestrand of Hettick, Wis., November 30. _ . 
MAURICE Decatur, to Miss 


JOHN HAYES, 








166 ILLINOIS MEDICAL JOURNAL 


Helen D. Hogan of Assumption, at Assumption, 
October 25. 

Joun C. Kasséeyer, East Dubuque, IIl., to 
Miss Lillion May Minges of Dubuque, Iowa, at 
Oak Park, recently. 

JamMes Herpert MITCHELL to Miss Marion 
Strobel, both of Chicago, December 6. 





Personals 





Dr. Joseph Welfeld, Chicago, held a skin and 
urologic clinie before the Kane County Medical 
Society at Elgin, recently. 

Dr. Robert C. Timms has resigned from the 
city health department, following five years’ 
service. 

Dr. Joseph L. Miller, Rush Medical College, 
spoke on “Protein Metabolism” before the Elgin 
Physicians’ Club, Elgin, December 18. 

Dr. Duncan D. Campbell, on the staff of the 
Chicago State Hospital, has been appointed by 
the Missouri State Eleemosynary Board as super- 
intendent of Hospital No. 2, St. Joseph, Mo., to 
succeed Dr. Aden C. Vickrey, who recently re- 
signed. 

Drs. Franklin H. Martin, Emil G. Beck, Ar- 
thur D. Black, Truman W. Brophy, Frank E. 
David, Ernest J. Ford, Junius C. Hoag, Effie L. 
Lobdell, Albert J. Ochsner and Henry Schmitz 
will leave February 10 for an extended tour of 
South America. 

Dr. Frank C. Mann, Rochester, Minn., gave an 
address on “The Experimental Production of 
Peptic Ulcer” at the regular meeting of the fac- 
ulty of the Laboratory of Surgical Technique of 
Chicago, January 26. 

Dr. and Mrs. Fred Wade Jones, of Alton, 
motored to Homestead, Florida, to visit rela- 
tives. They went via Washington, D. C., and 
will be gone several months. 

Dr. George B. Schwatgen of Aurora was seri- 
ously hurt January 15 when his automobile was 
struck by an Aurora and Elgin electric train in 
Aurora. 

Dr. Franklin A. Turner has been appointed 
director of hygiene of the Rockford public 
schools to succeed Dr. Dudley W. Day, who has 
resigned. 

Dr. Albert Willis, Christopher, was acquitted 





February, 1923 


of the charge of having caused the death of Miss 


Mary Shifflett of Leroy, it is reported. 
Dr. and Mrs. J. D. Chittum, of Sorento, I], 


left January 10, in an automobile for Vero, Fis. 
They expect to go to Washington, D. C., first 
and then south to Florida where they expect to 


spend several weeks in Palm Beach, Miami and 
Tampa. 


Dr. W. E. Shastid of Pittsfield, second vice- 
president of the State Society, is making a tour 
around the world and expects to get home nexi 
summer. 





News Notes 





—Dr. J. R. Neal, chairman of Legislative Com- 
mittee of the State Society, issued Bulletin No 
1, giving a digest of legislative matters including 
a synopsis of bills of interest to the profession 
now before the General Assembly, Jan. 20. An 
members interested can have these bulletins as 
issued by writing to Dr. J. R. Neal, Box 748, 
Springfield. 

—It is reported that Dr. Carl A. Starck of 
Palatine was fined $200 and costs for violating 
quarantine regulations. The specific charge 
against Dr. Starck was for terminating the quar- 
antine of a diphtheria patient on his own initia- 
tive, without reference to local health authorities 
and in violation of the state regulations. The 
charges, which were the second of the kind within 
sixty days, were brought at the request of field 
men attached to the state department of public 
health. 

—Friends of the late Dr. William E. Quine 
will treasure the Bulletin of the Chicago Medi- 
cal Society of January 20 containing the eloquent 
address at the memorial meeting of the Society. 

—The Kankakee County Medical Society 
pulled off a play written by Dr. Arthur H. Goll- 
mar, December 29. The title “The Mirror Be- 
hind the Bar” or “A Glandular Extract From 
the Common Law,” indicates that it was hot 
stuff. It was a parody involving prominent 
members of the medical and legal professions. 
Dr. Gollmar as judge presided over a trial of @ 
suit by “Dr. Endocrine” to recover a fee of $500 
for a “glandular” operation. The subject offered 
an open season for both medical and legal wit 
and humor and was greatly enjoyed. 

—At the meeting of the Society of Medical 
History, Chicago, January 12, papers were pre- 
sented by Dr. Peter Bassoe on “Rarly History of 








ary, 1923 
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February, 1923 


Neurology and Psychiatry in the Middle West,” 
and by Dr. A. S. Warthin, Ann Arbor, Mich., on 
“Noah Webster as an Epidemiologist.” 

—It was announced at the annual meeting of 
the Chicago Dental Society, January 20, that a 
children’s free dental clinic will be opened with- 
in ninety days at the Cook County Hospital in 
a building formerly used as a measles quarantine 
station, with funds from the Pageant of Progress 
Exhibition. It was also announced that $3,000,- 
000 had been given by an anonymous Chicagoan 
to found and maintain a large dental clinic. 

—The chief sanitary engineer of the depart- 
ment of public health recently met with the offi- 
cers of the Fox River and Lakes Improvement 
Association, to complete plans for making the 
waters of the upper Fox River and Lakes safe 
for bathing purposes. Property owners con- 
cerned and members of the association will be 
advised to comply with sanitary regulations 
recommended by the department. 

—Chicago physicians gave a banquet in honor 
of Dr. Royal S. Copeland, health commissioner 
of New York City, January 9, at the Chicago 
Athletic Club. Dr. P. J. H. Farrell was toast- 
master. Dr. Copeland spoke on the immigration 
peril and advocated examination on the other 
side—moral, mental and physical—and alloca- 
tion, so far as possible, according to industrial 
or professional preparation. Dr. Charles E. 
Humiston, former president of the Illinois State 


Medical Society, and Dr. John Dill Robertson, 
formerly city health commissioner, also gave ad- 


dresses. 

—New infant welfare stations were opened 
during December at Freeport, Wilmington and 
Steger. At Freeport, the station will be main- 
tained by the Amity Society, the clinics being 
conducted by Dr. J. A. Poling, city health officer. 
At Wilmington and Steger, the centers were 
established through the efforts of the county nurse 
and superintendent of schools, and the clinics 
will be conducted by members of the local medi- 
cal societies. Dr. Elizabeth B. Ball, pediotrician, 
attached to the state department of public health, 
directed the opening of the station and the first 
clinie at each place, her services having been re- 
(uested by the local agencies concerned. 

—Dr. and Mrs. E. W. Fiegenbaum and Dr. 
and Mre. W. H. C. Smith and son, Theodore. 


DEATHS 167 


departed on January 15th on a trip around the 
world. They will be gone six months. The 
Madison County Doctor wishes “bon voyage” to 
Dr. E. W. Fiegenbaum as follows: 

“After forty-seven years of unremitting toil 


in alleviating human suffering, and unselfish and 
untiring devotion to the interests of his pro- 


fession, during which time he graced the highest 
office in the gift of the profession of Illinois and 
at the same time faithfully cared for this little 
journal, the Chief is at last taking a well deserved 
rest. 

“That Europe may profit by his presence ; that 
Fujiyama may inspire him; that Cheops and the 
Sphinx may look down more kindly on him than 
on any who have stood in their shadow; and that 
finally he may be glad to return to us, is our 
parting wish.” 





WORKMAN’S INSURANCE iN GERMANY A 
FAILURE 

Dr. Friedensburg, for a period of twenty years 
prior to 1911 the president of the Senate of the 
Imperial Insurance Office of Germany, has given 
his views upon the practical results of workingmen’s 
insurance in that country, and they constitute virtu- 
ally an indictment of the system. Some one, in 
summarizing the series of charges, made by Dr. 
Friedensburg, points out the three most significant 
as follows: 

“The first is that the state insurance, specially 
designed to replace pauperism and charity, is itself 
merely pauperism under another form. The sec- 
ond charge is that it has fostered to an incredible 
extent the German evil of bureaucratic formalism. 
The third and the worst charge is that it has become 
a hotbed of fraud, and therefore a spreader of de- 
moralizing practices and ways of thought.” 





Deaths 





Walter Stanley Haines, Chicago, beloved teacher 
in Rush Medical College since 1876, died, January 
27, in the Presbyterian Hospital, from bronchi- 
estasis and chronic nephritis. Dr. Haines was born 
Sept. 27, 1850, in Chicago. His father, John G. 
Haines was twice mayor of the city. After gradu- 
ation from the Chicago High School, the young 
student went to Ann Arbor with his father who 
wished him to enter the University of Michigan. 
After a very brief visit there he attended the Massa- 
chusetts Institute of Technology from 1869 to 1871. 
At that time he contracted pleurisy and a bronchial 
inflammation which rendered him an invalid at fre- 
quent intervals for life. He held the chair of chem- 


istry in the Chicago Medical College from 1872 to 





168 ILLINOIS MEDICAL JOURNAL 


1876, being graduated from the same college in 1873. 
He held an internship in Mercy Hospital following 
graduation and spent several months in Europe in 
study. 

In 1876 he succeeded Dr. Henry M. Lyman as 
professor of chemistry in Rush Medical College, a 
position he adorned with unsurpassed learning and 
a faculty of clarifying the difficult subject that few 
teachers could approach. It was the usual experi- 
ence of students from other schools who had la- 
bored memorizing endless “equations” that his clear 
from a diffi- 
cult “blind” subject to a pleasant and profitable 
one. 


analysis changed chemistry for them 


His kindness and almost feminine gentleness 
endeared him to fifty classes of students, and as a 
member of the faculty his influence moderated the 
asperities during many strenuous years. 

Always a leader in elevating the standards of 
medical education, he with the late Dr. E. Fletcher 
Ingals took a prominent part in placing Rush in 
the forefront of medical institutions. A recognized 
authority in chemical science he was a member of 
the committee of revision of the United States 
Pharmocopeia from 1900 to 1920. He was a mem- 
ber of the Illinois State Food Standard Commission 
since 1909, and was a member of the American 
Chemical Society and the Chemical Society of Lon- 
don. 

He was joint author with Frederick Peterson of 
a standard text-book on “Legal Medicine and Toxi- 


cology,” which appeared in 1904 and passed through 


several editions. An expert in toxicology, both as 
analyst and legal witness, he 


some of the 


was in demand in 
known to the 
Few of his classes enjoyed his 
interruption during the college 
year either by sickness or demands upon his time 
as an expert. 


most celebrated cases 
legal profession. 


lectures ‘without 


In 1916, the Rush alumni presented the college 
with a portrait of Dr. Haines by Nyholm and at 
the same time raised a Haines fund for the college. 
Last year the graduating class placed a tablet in 
his honor in the ampitheater and the Walter S. 
Haines fund was established for the college library 
in which he had long taken an active interest. 

Dr. Haines married. He devoted to 
his science. In the later years his students some- 
what irreverently, but with deep filial affection, 
called him “Daddy” Haines, thus reflecting his dis- 
tress when (if ever) he found it necessary to pluck 
a student. 

With the exception of Dr. Norman Bridge, Dr. 


never was 


Haines was the only survivor in recent years of the 
Rush senior faculty of the years 1870-1880, several 
of his colleagues dying in the prime of life, though 
a fatal prognosis of his severe sieges of sickness was 
made many times. 

FrevericK W. Beristein, Chicago: 
University Medical School, Chicago, 
o. the Illinois State Medical Society 


Northwestern 
1900; member 
; aged 45; died, 


February, 1993 


January 17, at the Wesley Memorial Hospital, from 
peritonitis. 

Epmunp A. Boas, Chicago; Rush Medical College, 
Chicago, 1884; member of the Illinois State Medical 
Society; aged 60; died January 17, from chronic 
nephritis. 

WittiaM Viney CLark, Springfield, Ill.; St. Louis 
College of Physicians and Surgeons, St. Louis, 1908; 
a Fellow A. M. A.; aged 51; died, December 19, 
from a fracture of the skull when he was struck 
by a train, 

Avsert L, Converse, Springfield, Ill.; Chicago Med. 
ical College, 1864; for two terms member of the 
state legislature; chairman of the board of super- 
visors; aged 80; died, December 7. 

KATHERINE W. Corcoran, Chicago; College of 
Physicians and Surgeons, Chicago, 1902; a Fellow 
A. M. A.; aged 52; died, January 17, at the West 
Side Hospital, from diabetes mellitus. 

StePHEN W. Cox, Chicago; Rush Medical College, 
Chicago, 1889; aged 65; died, December 24, from 
valvular heart disease. 

BENTON BRENGLEMAN Duwn, Perry, IIL; Rush 
Medical College, Chicago, 1891; served in the M. C, 
U. S. Army, during the World War; aged 54; died 
in December, from appendicitis. 

Joun Joserpn Ecan, Chicago; College of Physi- 
cians and Surgeons, Chicago, 1905; a Fellow A. M. 
A.; aged 44; died, January 11, from angina pectoris, 

Jutius GRUENEWALD, Glasgow, IIl.; Missouri Med- 
ical College, St. Louis, 1891; aged 65; died, Decem- 
ber 30, from pneumonia. 

Curtis ALLEN Lambert, Chicago; Miami Medical 
College, Cincinnati, 1871; aged 76; died, December 
28, from acute indigestion. 

Henry Ricuines, Rockford, Ill.; Medical Depart- 
ment of the University of the City of New York, 
1864; a Fellow A. M. A.; Civil War veteran; for- 
merly member of the state board of -health; at one 
time on the staff of the Rockford Hospital; aged 
82; died, December 12, from heart disease. 

Rosert Arnot SEMPILL, Chicago; College of Phy- 
sicians and Surgeons, Chicago (University of Ilk- 
nois), 1891; a Fellow A. M. A.; professor of derma- 
tology, Loyola University Medicine, 
Chicago, and professor of dermatology and syphil- 
ology at the Chicago Polyclinic; served during the 
World War in the M. C., U. S. Army, with the 
rank of captain; died, December 19, aged 58, from 
acute dilatation of the heart. 


School of 


WittiAM PHILanper WALKER, Mason City, Il; 
Rush Medical College, Chicago, 1879; aged 66; 
died, December 11, from cerebral hemorrhage. 

Cuartes A. Witcox, Amboy, Ill.; Rush Medical 
College, Chicago, 1870; formerly mayor of Amboy; 
at one time postmaster of Ottawa, and coroner of 
LaSalle county; member of the board of education; 
for several years surgeon for the Illinois Central 


Railroad Company; aged 75 died December 





uary, 1993 


Irom 


il College, 


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St. Louis 
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ember 19, 


as struck 


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ouri Med- 


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December 


Depart- 

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eran; i0of- 
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ital; aged 


Phy- 

IIli- 
ot derma- 
Medicine, 
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luring the 
with the 


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