VOLUME XIll si cahaiaieoenail 1920 — NUMBER 12
Southern Medical Journal
Journal of The Southern Medical Association
Published monthly at Birmingham, Alabama. Annual subscription $3.00. _——— as Second-Class Matter at the Postoffice at Birmin ngham, Alabama, under Act of March 3, 1879
TABLE OF CONTENTS
MEDICIN E—Internal Diseases, Pediat- Herpetic Sore Throat. John Zahorsky, rics, Neurology, Diagnostic Meth- St. Louis, Mo..... bests a ods, Ete. |
TROPICAL DISEASES AND PUBLIC Syphilis as a Problem in Group Diag- HEALTH
nosis. Albert Keidel and Joseph ; ; Earle Moore, Baltimore, Md... 857 Yellow Fever: Its Distribution and . Control in 1920. W. C. Gorgas, H. R. Carter and T. C. Lyster, Yel- The Circulation in Infectious Diseases. low Fever Commission, Interna- Garnett Nelson, Richmond, Va. j tional Health Board sh
, The Relationship of Alcohol to Mod- The Practical Importance of the Ef- ern Health Ideals. Eugene Lyman fort Syndrome in Civil Practice. H. Fisk, New York, N. Y. ;
R. Carter, Jr., Birmingham, Ala..... The Laboratory Phase of Public : é ia Health Work. W. H. Se N Diarrhea Resulting from Biliary In-. Giles, “nig wnaminease
sufficiency. William Howard Lewis,
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TABLE OF CONTENTS—Concluded
SURGER Y—Railway, Industrial, Gyne- EDITORIALS 908
cological, Obstetrical and Urological : . _ . Proceedings of the Louisville Meeting
Bone Tumors: Benign Bone Cysts and The Southern Medical Association a Ing \ we . Le . wecct. 7 4 Osteitis Fibrosa: X-Ray, Gross and th ogee School: Sessions of Microscopic Features. Joseph Colt iat Bloodgood, Baltimore, Md. a Automobile Casualties: A Public g Health Problem The Role of Obstructive Lesions of Community Health the Ureter in the Production of Re- Index to the Journal current or Pesistent Pyelitis. J. N. Baker, Montgomery, Ala. CORRESPONDENCE The Question of Feeding in Typhoid Abnormal Uterine Bleeding. Rein- Fever: A Retrospect. Frank A. hard E. Wobus, St. Louis, Mo... Jones, Memphis, Tenn. SPECIAL ARTICLE BOOK REVIEWS INDEX, Vol. XIII (1920) Fee Splitting. S. H. Hodge, Knox-
ville, Ten. SOUTHERN MEDICAL NEWS
Principles of
BIOCHEMISTRY
c _ In the practice of medicine the advances of biochemical knowledge and technic are furnishing the physician with diagnostic methods of
Daily more and more importance is being attached to Biochemistry.
precision and indications for treatment based upon exact knowledge. In this work Biochemistry is repre- sented in close relationship to physiology, so that the student may perceive the intimate dependence of these two sciences and come to regard physiological chemistry as the foundation upon which we must ultimately build our interpretations of the functions of living matter.
The book contains a full discussion of nutrition, basal metabolism, endogenous and exogenous meta- bolism, hydrogen-ion concentration, ductless glands, acidosis, blood-pressure, vitamines, anaphylactic shock, diabetes, chemistry of respiration, temperature effects, Osmatie pressure, cholesterol, creatinine, ete. Tables and formulae abound throughout the work, standard tests and reactions are given and methods and apparatus are clearly described and illustrated,
Emphasis has been placed upon the practical applications of the subject, and not only to the practice of medicine, but also upon applications to the industries and to general biology. Thus, this text-book is not only for medical students and students specializing in biochemistry and physiology, but for the agri- cultural student, the student of general biology or the industrial chemist engaged in handling biological products
3y T. BRAILSFORD ROBERTSON, Ph.D., D.Sc., Professor of Physiology and Biochemistry, University of Adelaide, South Australia: Formerly Professor of Biochemistry, University of Toronto; Professor of Biochemistry and Pharmacology, University of California. Octavo, 633 pages, with 49 engravings. Cloth,
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Vol. XIII No. 12 SOUTHERN MEDICAL JOURNAL
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Vol. XIII No. 12
SOUTHERN MEDICAL JOURNAL
‘‘Business is the art of serving others without disappointing them”’
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PSYCHOPATHOLOGY
BY EDWARD J. KEMPF, M.D. Clinical Psychiatrist to St. Elizabeth’s Hospital (formerly Government Hospital for the Insane), Washington, D. C.; author of ‘“‘The Autonomic Functions and the Personality.” 762 pages -+ xxiii, 6% x 9%, with 97 illustrations. Printed on beautiful India tint paper, and bound in_ silk cloth binding, with gold stamping. Price, $9.50
Partial Table of Contents
The Physiological Foundations of the Personality; pensation Neuroses; The Psychopathology of Para-
The Psychology of the Family; The Universal Strug- gle for Virility, Goodness and Happiness; Influence of Organic and Functional Inferiorities Upon the Per- sonality; Mechanistic Classification of Neuroses and Psychoses Produced by Distortion of Autonomic- Affective Functions; The Mechanism of the Suppres- sion or Anxiety Neuroses; Repression or Psycho- neuroses, Their Mechanisms and Relation to Psychoses Due to Repressed Autonomic Cravings; Benign Com- pensation or Regression Neuroses, with or without Dissociation or Personality; Manic-Depressive Psy- choses; Elimination or Simulation for Wish-Fulfill- ment in Affective Crises; Pernicious Repression Com-
noia; The Psychopathology of the Acute Homosexual Panic; Acute Pernicious Dissociation Neuroses; The Psychopathology of Chronic Pernicious Dissociation of the Personality with Defensive Hatred, Eccentric Paranoid Compersations and Pernicious Deteriora- tion; The Psychopathology of Chronic Pernicious Dis- sociation of the Personality with Crucifixion and Catatonic Adaptations to the Repressed Cravings; The Psychopathology of Chronic Pernicious Dissocia- tion of the Personality with Hebephrenic Adapta- tions; Predominance of Excretory Erotic Interests; Reconsideration of the Conditioned Autonomic Affec- tive Determinants of Abnormal Variations of Beha- vior ; Psychotherapeutic Principles.
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Vol. XIII No. 12
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December 1920
You Need Vitamines!
Medical Science has decided that the human system
needs vitamines. If they are not supplied the powers of resistance will slip away. Naturally, the run-down condition which is the first sym- tom of the lack of vitamines appears when proper foods are not taken. However, a run- down condition is really only a warning of other ills caused by a lack of vitamines.
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New knowledge about food and nutrition has revealed here-
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tofore unknown causes of disease traced to wrong food or a diet containing insufficient vitamines, the hereto- fore little-known things occurring in some foods and absent in others.
Medical press are constantly airing the question: “Do self-rising flour mixtures destroy the original vitamines in flour either through bleaching or as a result of the mixtures, the nature of which requires the acid and alkali ingredients to lie in continual contact with the flour itself?” If, as many claim, this question is to be answered in the affirmative, it naturally follows that bread, biscuits, and pastry made from self-rising flour lose considerable of the vitamines; therefore, the system does not receive the full value of the food taken. The safe course which is pointed out to the family physician is to recommend pure, plain flour and a baking powder of standard quality, like Calumet, and to be especially watchful in all cases of malnutrition to avoid a diet without vitamines.
Vol. XIII No. 12 SOUTHERN MEDICAL JOURNAL
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Vol. XIII No. 12
Announcement of Merging of Victor Electric Corporation with X-Ray Interests of General Electric Company
An arrangement has been completed which took effect October 1, 1920, under which the entire business of the Victor Electric Corporation and X-Ray interests of the General Electric Company have been merged in a new corporation formed for the purpose and known as the VICTOR X-RAY CORPORATION. The new company, has exchanged its capital stock for the X-Ray patents and good will of General Electric Company and for the assets and business of the old Victor Electric Corporation.
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Dr. W. D. Coolidge of the research laboratory of General Electric Company becomes Consulting Engineer of the Victor X-Ray Corporation. Mr. C. C. Darnell of the research laboratory of General Electric Company becomes the Commercial Engineer of the Victor X-Ray Corporation. Mr. W. S. Kendrick, who for many years had charge of the commercial sale of the Coolidge tube, will be General Sales Manager. Mr. L. B. Miller remains General Manager of Agency Sales.
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HARVESTING DIGITALIS ON TRE MurrorD Drua FARMS, GLENOLDEN, PENNA.
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Vol. XIII No. 12
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11
What Cooks Don’t Know About Food Preparation Increases The Mortality Rate
VERY physician knows that the
best medical care, the most scru- pulous attention to regimen can be discredited and undone by a course of badly-prepared food—or even by a few meals of improperly-prepared food. Indigestible, or badly-assimi- lated food, may be the predisposing, if not the exciting cause, of many ail- ments medical men are commonly called upon to treat.
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Vol. XIII No. 12 SOUTHERN MEDICAL JOURNAL 13
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Common sense reflections at the approach of winter
Sudden temperature variations and dampness. Traditional optimism of man, carelessness, exposure.
Rheumatism, Neuralgia, Lumbago, Sciatica and other painful, inflamma- tory and congestive conditions.
Great and insistent demand on the physician for relief.
ATOPHAN, for nearly ten years supreme among remedies for quicker, better results, safely obtained.
Made in U. S. A. and available everywhere.
Information and specimen box from
SCHERING & GLATZ, Inc., 150 Maiden Lane, New York
14 SOUTHERN
MEDICAL JOURNAL
B. B. CULTURE
A pure culture of Bacillus Bulgari- cus, without doubt the most effective of the lactic Bacilli, especially if is- sued in fresh liquid form.
We have had many pleasing re- ports from Bacteriologists and Clin- icians as to the high viability and ef- fectiveness of B. B. CULTURE.
We shall be pleased to furnish a sufficient supply of the Culture to any physician for clinical trial upon re- quest.
B. B. CULTURE LABORATORIES, Inc. Yonkers, New York
THE TORBETT SANATORIUM AND DIAGNOSTIC CLINICS
With Majestic Hotel and Bath House MARLIN, TEXAS
One Hundred Beds. Four Hundred Bath Capacity Daily.
A modern institution equipped with all the latest laboratory, X-ray and physio-therapy methods used in the diagnosis and treatment of chronic diseases. A graduate doctor in charge of each department—thus utilizing teamwork.
Marlin hot water is similar to the famous Carlsbad.
STAFF
Dr. J. W. Torbett—Superintendent, Diagnosis and Treatment.
Dr. O. Torbett—Diagnosis and Treatment.
Dr. W. K. Logsdon—Urology, Rectal and Skin Diseases.
Dr. Mary L. Webb—General Chronic Diseases and Gynecology and Corrective Gymnastics.
Dr. J. Gordon Bryson—Surgery and Gynecology.
Dr. Edgar P. Hutchings—Eye, Ear, Nose and Throat.
Dr. J. B. White—Roentgenology and Gastro-enterology.
Dr. C. H. Hendry—Pathologist.
Dr. L. P. Robertson—Dentist.
Dr. H. H. Robertson—Dentist. For further information write for folder to
TORBETT SANATORIUM, Marlin, Texas
December 1920
Arsphenamine products should be: Readily Soluble Practically Free from Toxicity Easy of Administration
NEOSALVARSAN
(NEOARSPHENAMINE-METZ) possesses all of these qualities.
Order by either name, and if your local dealer cannot supply you order direct from H. A. METZ LABORATORIES, Inc.,
122 HUDSON STREET, NEW YORK CITY
Vol. XIII No. 12 SOUTHERN MEDICAL JOURNAL 15
REORGANIZATION OF ST. ELIZABETH’S HOSPITAL VIRGINIA UNDER THE GROUP SYSTEM
Announcement is made of the inauguration at St. Elizabeth’s of a policy of expansion to meet the steadily in- creasing utilization of the services of this hospital.
The staff has been increased, and the equipment has been greatly augmented. St. Elizabeth’s is now open as a private medical and surgical hospital, with the most modern prerequisites for surgical work, and for medical and neurological examination, diagnosis and treatment. A department of urology fills a long felt need. The X-ray labo- ratory is fully equipped. The clinical laboratory is prepared to do routine work, bacteriology, pneumococcus group- ing, asthma and hay fever tests, blood chemistry, etc. Folin’s “‘blood system” is routine.
The addition to the staff of a trained dietitian from Columbia University and the Peter Bent Brigham Hospital, Boston, will allow the preparation of special diets to suit the individual requirements of each case. Dietaries in dia- betes and nephritis are arranged by a dietitian of wide experience.
J. Shelton Horsley, M. D., Austin I. Dodson, M. D., Margaret Tholens, B. A., Surgery and Gynecology. Surgery and Urology. Clinical Pathology. Fred M. Hodges, M. D., Nellie H. Van Dyke, B. S.,
Warren T. Vaughan, M. D.,
Internal Medicine. Consulting Roentgenologist. Dietetics.
MYRA E. STONE, R. N., Superintendent.
For information, address: JULIAN P. TODD, Business Manager.
Dr. J. F. Yarbrough’s Private Sanatorium
COLUMBIA, ALA.
Gastrointestinal Diseases, Pellagra, Chronic Rheumatism, “Bright’s Disease,” Diabetes (Allen Method).
Adequate Night Nursing Service Maintained.
CONSULTING STAFF.
Dr. Alfred Smith Frazier, F.A.C.S., Dothan, Ala.
Dr. Ross H. Mooty, B.S., M. D., Columbia, Ala,
Reference: The profession of Houston County. Dr. S. W. Welch, Montgomery, Ala.
THE HOSPITAL—30 ROOMS
eine, canteen
—e A. THRUSTON POPE
CURRAN POPE
A MODERN up-to-date, private Infirmary equipped with steam heat, electric lights, electric _ fans, modern plumbing and superior furnishings. Solicits all cases of functional and organic nervous diseases, disease of the stomach and intestines, rheumatism, gout and uric acid troubles, drug habits and alcoholism. Bed-ridden cases not received without previous arrange- ment. Hydrotherapy, Mechanical Massage, Static, Galvanic, Faradic, Sinusoidal, High Fre- quency, Leucodescent and Arc Light, and X-ray treatments given by competent physi- cians and nurses, under the immediate supervision of the Medical Superintendent. Special laboratory facilities for diagnosis by urine, blood, blood serum, sputum, gastric juice, duodenal tube and X-ray. Recreation hall with pool and billiards for free use of patients. Rates include treatment, board, medical attention and general nursing. The Sanatorium is supplied from Pope Farm with vegetables, fruit, poultry, and eggs, also milk, cream, butter and buttermilk from its herd of registered Jerseys.
THE POPE SANATORIUM
Long Distance Phones ( Incorporated LOUISVILLE, KENTUCKY CUMB. M. 2122 HOME 2122 Established 1890 115 West Chestnut St.
eh itieteadied a ee
a
16 SOUTHERN MEDICAL JOURNAL December 1920
The Buie Clinic and Marlin
Sanitarium-Bath House
connecting with
The Arlington Hotel
MARLIN, TEXAS
A thoroughly modern institution for chronic diseases. Capacity of Clinic and Bath recently doubled, install- ing every modern convenience and improvement. Using Marlin’s famous hot mineral waters and all approved methods of diagnosis and treatments. Marlin waters are similar in analysis to those of the leading spas of Europe, coming from a depth of 3400 feet, temperature 147 F. A daily bath capacity of 800. The following departments are maintained: Internal Medicine, Diagnosis, Urology, Syphilology, Pathology, Roentgenology, Dietetics, Electro-therapy, Eye, Ear, Nose and Throat and Hydrotherapy.
N. D. Buie, M.D., Supt. and Diagnosis,
F. H. Shaw, M.D., Asst. Supt. and Gyne- cology,
Aug. J. Streit, M.D., Eye, Ear, Nose and Throat,
L. M. Smith, M.D., Urology and Syphilology,
S. S. Munger, M.D., Roentgenology,
O. T. Bundy, M.D., Internal Medicine,
H. S. Garrett, M.D., Internal Medicine,
Iva Lee Bouslough, M.D., Pathology,
T. W. Foster, D.D.S.
RT RN i
ROBINSON HOSPITAL, (Inc)
AND TRAINING SCHOOL FOR NURSES BEREA. KY.
IDA M. JONES, R. N. SUPERINTENDENT OF NURSES
- vee —7
STAFF
B. F. ROBINSON, M.D. General Surgery
M. M. ROBINSON, M.D. General Surgery
ALSON BAKER, M.D. Bacteriology and Pathology DON. H. EDWARDS, M.D. Eye, Ear, Nose and Throat
WM. G. BEST, D.D.S. Oral Hygiene and Oral Surgery
J. M. MORRIS, M.D. Internal Medicine and Diagnosis
Roentgenology
J. CAMPBELL THOMPSON, M.D.
8 OP ONS
Vol. XIII No. 12 SOUTHERN MEDICAL JOURNAL 17
CHESTNUT LODGE
Rockville, Maryland
Near Washington, D. C. Baltimore & Ohio Railroad and Electric Line from Washington This sanitarium under experienced management offers superior advantages for the treatment of patients suffering from Nervous and mild Mental Dis- eases, and for elderly persons needing skilled care and nursing; combining the equipment of a modern Psyco- pathic Hospital with the appointments of a refined home. The Hydrotherapy Departments is complete in every detail including the Nauheim Baths for Arterio- sclerosis, Heart and Kidney Diseases.
DR. E. L. BULLARD, Physician-in-Charge
Davis- Fischer Sanatorium 25-27 EAST LINDEN AVENUE ATLANTA, GEORGIA
A modern five-story fire-proof building for surgical and gynecological work. A limited number of medical and obstetrical cases re- ceived. No mental, contagious or alcoholics admitted. Equipped with all modern methods for diagnoses. X-Ray, pathological, bacterio- logical, serological and stomach contents.
Training school for nurses.
APPALACHIAN HALL :—: ASHEVILLE, N. C.
DR BaKNADE San = AN INSTITUTION FOR ‘DET eOe epee “Physicians in Charge THE TREA ENT OF a boat Menge i " ai y er ak
aan LE gh 5 NERVOUS DISEASES oe WE, Shek
Supt. of Nurses
We have recently erected two additional buildings, thoroughly equipped with every modern convenience, including a most complete Hydrotherapy Department.
Situated at an altitude of 2500 ft. in the heart of the Blue Ridge Mountains of West- ern North Carolina. Superb lawn and 25 acres of beautifully wooded grounds.
For information address DRS. GRIFFIN & SMITH, ASHEVILLE, N. C.
SOUTHERN MEDICAL JOURNAL
December 1920
Altitude 1850 Feet Mild Winters
THE CORNICK SANATORIUM
Abundant Sunshine
Breezy Summers
For Pulmonary Tuberculosis
BOYD CORNICK, M.D., Medical Director. C. R. TREAT, Associate and Supt. SAN ANGELO, TEXAS
An institution for the care and treatment of early stage cases of pulmonary tuberculosis. Patients without reasonable prospects of an arrest of the disease are not received. Applicants from a distance admitted only after preliminary correspondence with their family physician. FOR RATES AND OTHER INFORMATION, ADDRESS THE MEDICAL DIRECTOR.
THE SARAH LEIGH HOSPITAL
NORFOLK, VA.
The Staff combined under Group System in 1919, and the equipment greatly improved with the most up-to-date facilities for thorough Diagnosis, and Surgical, Radium and Medical Treatment. Capacity, eighty-five beds.
STAFF
Southgate Leigh, M.D., F.A.C.S. Surgery and Gynecology. James H. Culpepper, M.D. Surgery and Orthopedic Surgery. Stanley H. Graves, M.D., F.A.C.S. Genito-Urinary and Rectal Diseases. Frederick C. Rinker, B.A., M.D. Internal Medicine and Diagnosis. Harry Harrison, M.D. Internal Medicine and N-O Anaesthesia.
S. B. Whitlock, M.D. Roentgenologist.
G. Bentley Byrd, M.D. Obstetrics.
Daphne Conover, B.A.
Pathologist and Laboratory Technician. L. L. Odom, R.N.
Superintendent. S. S. Preston, R.N.
Assistant Superintendent.
TRAINING SCHOOL FOR NURSES
THE MERIWETHER HOSPITAL AND TRAINING SCHOOL FOR NURSES, Inc.
24 GROVE STREET, ASHEVILLE, N. C.
SURGICAL: Dr. Eug. B. Glenn, Chief; Dr. Ben M. Meriwether, Dr. A. T. Pritchard, Dr. Arthur F. Reeves, Dr. J. L. Adams.
MEDICAL: Dr. Chase P. Ambler, Chief; Dr. Clyde
E. Cotton, Dr. M. L. Stevens, Dr. W. J. Hunnicutt, Dr. H. G. Brookshire, Dr. C. C. Orr.
EYE, EAR, NOSE AND THROAT: Dr. E. R. Rus- sell, Dr. J. B. Greene, Dr. R. H. Buckner.
STAFF
A thoroughly equipped and modern Hospital for Surgical, Gynecological, Medical, and Obstetrical Cases.
All modern conveniences, such as vacuum cleaners, electric elevators, sun porches, etc. Two thoroughly equipped operating rooms. Open entire year.
DIRECTORS
Dr. Ben M. Meriwether, President; Dr. E. R. Russell, Vice-President; Dr. Clyde E. Cotten, Secre- tary; Dr. W. J. Hunnicutt, Treasurer; Dr. M. L. Stevens, Dr. Arthur F. Reeves, Dr. Eug. B. Glenn.
NEUROLOGY: Dr. B. R. Smith. GASTROENTEROLOGY: Dr. A. W. Calloway. DERMATOLOGY: Dr. C. W. Brownson.
G. U. AND DISEASES OF THE RECTUM: Dr. P. R. Terry.
PEDIATRICS: Dr. L. W Elias.
ANAESTHETIST: Dr. W. J. Hunnicutt.
peermermnenssapere or
Vol. XIII No-12 SOUTHERN MEDICAL JOURNAL
———
BLACKMAN SANITARIUM
DISORDERS OF NUTRITION AND ELIMINATION 172 Capitol Ave.. ATLANTA, GA.
Physiotherapeutic,Dietetic, Medical
Two of its features:
Treatment of Dia- betes. (Allen Method)
Rest and Fattening Cure. (5 lbs. per week)
Rates, $35 to $50 per week. Good cuisine.
Homelike resort atmos- phere.
Laboratory facilities. Modern equipment.
For Information and Reprints address
W. W. BLACKMAN, M. B.
Devotee
THE WATAUGA SANITARIUM
RIDGETOP, TENNESSEE. ;
For Tuberculosis in any Form.
STAFF: Dr. Wm. Litterer Dr. W. A. Bryan Dr. O. N. Bryan Dr. G. C. Savage Dr. J. M. King Dr. W. W. Winters Dr. H. S. Shoulders
19 miles North of Nashville, Henderson Division of bb. &.N.. Ry;
ss 1 ses
Location ideal, elevation 1,000 feet, buildings modern; hot and cold water, gas lights, perfect sewerage and excellent water supply. Tuberculins and vaccines administered in suitable cases. X-Ray Diagnosis.
Heliotherapy. Rates very reasonable. Inquiries appreciated. Illustrated nooklet on application.
DR. W. S. RUDE, Medical Director.
RIDGETOP, TENN.
SOUTHERN MEDICAL JOURNAL December 1920
hoe Cie
FULLY EQUIPPED FOR MODERN SCIENTIFIC DIAGNOSIS AND TREATMENT
WESLEY HOSPITAL
12th and Harvey Streets, OKLAHOMA CITY, OKLAHOMA CONDUCTED BY THE OKLAHOMA CITY CLINIC
With the diagnostic equipment at our disposal we are prepared to assist in working out obscure and complicated cases. ,
CLINICAL PATHOLOGICAL AND CHEMICAL X-RAY DIAGNOSTIC DEPARTMENT LABORATORY An up-to-date, fully equipped Radiological A laboratory completely equipped in all depart- Laboratory. ments so that all classes of clinical bacteriolog- ical, pathological and chemical work can be done Radiologist, especially trained ‘for gastro-
in the one laboratory.
Our laboratory personnel are thoroughly trained. have had many years’ experience in laboratory work and spend all their time in this special line.
Partial Fee Table
intestinal and renal diagnosis.
We use the serial plate method in gastro- intestinal work and take from 12 to 30 radio- graphs on each case,
Wassermann Test ..$ 5.00
Autogenous Vaccines . 5.00 Renal work is supplemented with ureteral lead
Smt “enema - catheters and pylographic injection of the kidney ood smears oe =.0 .
Sputum . 2.50 | pelvis when necessary.
Pus smears : . 2.50 P
Boop Aaron treatment, 21 doses ~ 95/00 Fluroscopic examination and stereograms of
Blood chemical tests, single... 3.00 chest and all bone work.
Blood chemical tests, complete... ... 20.00
Fees for other work in proportion. RADIUM AND X-RAY THERAPY
All classes of chemical analytical work. Amply equipped for the treatment of all con- Daily Wassermann “runs’’ except Sundays. ditions where Radium and X-Ray Therapy are Bleeding tubes, sterile containers, cul- + as ; Sg Pe ean ee : ee ° S.. “eg - : = icated, either as a primary treatment or an Free: ture media, instructions for collecting ind ! "
and mailing specimens. adjunct to surgery.
Members of the Clinic
Dr. A. L. Blesh
Dr. W. W. Rucks Dr. M. E. Stout
Dr. J. Z. Mraz
Dr. W. H. Bailey Dr. D. D. Paulus Dr. J. C. Macdonald Dr. J. Southgate
Address all communications to WESLEY HOSPITAL, 12th and Harvey Streets, or member of the Clinic at 308 Patterson Building, Oklahoma City, Okla.
21
Vol. XIII No.12 SOUTHERN MEDICAL JOURNAL
SURGICAL MEDICAL GYNECOLOGICAL OBSTETRICAL
A thoroughly equipped and modern general, hospital. Accommodates three hundred patients. All conveniences. Completely equipped. Modern pathological, bacteriological and x-ray laboratories. Sufficient Radium for treatment of all conditions in which Radium is indicated. All laboratories in charge of competent, experienced men.
EDUCATIONAL DEPARTMENTS—tTraining school for nurses in charge of graduate registered nurses. Pupil nurses received on favorable terms. Special six months course in dietetics and labor- atory work given. Graduate nurses received for post graduate instruction.
For information and catalog apply to Mrs, B. E. Golightly, R.N., Superintendent.
BIRMINGHAM, ALA. Long Distance Phone, West End Pr. Exchange 980
DR. CHARLES M. NICE, Medical Director DR. W. C. GEWIN, Surgeon in Charge
Radium-Therapy Department | | Pathological Department
The Birmingham Infirmary Birmingham {nfirmary
Established 1916 BIRMINGHAM, ALA.
Fully equipped for every test Radium in any form for the ther- apeutic administration where indicated.
of clinical value. Only standard
methods used. Fee list, media,
Address communications to
Birmingham Infirmary BIRMINGHAM, ALA.
Dr. W. C. Gewin, President Dr. Chas. M. Nice, Secretary
sterile containers and instruc- tions for shipping specimens upon request.
_ JOHN V. MIX, Director’
a eel
22 SOUTHERN MEDICAL JOURNAL December 1920
HILLCREST MANOR
ASHEVILLE, N. C. LOUIS E. BISCH, M.D., Ph.D. (Resident Medical Director)
Sanitarium
Devoted to the Scientific Treatment of Organic and Functional Nervous Diseases.
A thorough, detailed, individual examination and study made of each patient. All the latest methods of psychotherapy employed—including psychoanalysis. Trained. graduate nursing—large, airy, cheerful rooms—the seclusiveness of seventeen acres of H wooded hills with lawns, orchards, and vineyard—wholesome food, cooked under super- / vision of a dietititian—a congenial, restful atmosphere in an up-to-date building—air, i water, climate and scenery unsurpassed.
Patients are Examined for Admission to Hillcrest Manor At the City Offices Suite 206-208 Haywood Building Asheville, N. C.
(Positively no Insane or Tubercular Persons are Admitted)
7,
Ghe Willows
An ethical seclusion maternity home and hospital for unfortunate young women. Pdtients accepted
any time during gestation, Adoption of babies when arranged for. Prices reasonable. Write for 90- page illustrated booklet.
, , KANSAS CITY MAIN ST. Che Willows “insssuri
5 AS SOM Pi DEE SIT MSEC
Vol. XIII No. 12 SOUTHERN MEDICAL JOURNAL 23
The Kernan Hospital for Crippled Children
BALTIMORE, MARYLAND
One of the largest and best equipped Orthopaedic Hospitals in the country. The grounds cover sixty-five acres, containing private herd of cows, poultry, vegetable garden, parked lands and play grounds.
STAFF Attending Physicians
STAFF
Attending Surgeons R. Tunstall Taylor, M.D. ' Sydney M. Cone, M.D. Compton Riely, M.D. William Tarun, M.D. William H. Baniels, M.D. Frank Martin, M.D. ; John Staige Davis, M.D. i Chas. Reid Edwards, M.D. ' Gideon Timberlake, M.D. ; John P, Bell, D.D.S.
Roentgenologists
J. Fletcher Lutz, M.D. Henry J. Walton, M.D.
Benjamin Tappan, M.D. | A. Duvall Atkinson, M.D. . Irving J. Speer, M.D. Jno. R. Abercrombie, M.D. Consulting Surgeons W. S. Halsted, M.D. John M. T. Finney, M.D. Randolph Winslow, M.D. Consulting Physicians Lewellys F. Barker, M.D. Thomas R. Brown, M.D. W. S. Thayer, M.D.
The Surgical Building For particulars and terms of admission, address
1102 North Charles Street Baltimore, Maryland
a oe 7 The Baker
Sanatorium
Colonial Lake Charleston, S. C.
A new and thor- oughly equipped hospital for the care of Surgical patients.
ARCHIBALD E. BAKER, M D., F.A.C.S. Surgeon in Charge
24 SOUTHERN MEDICAL JOURNAL December 1920
ARLINGTON HEIGHTS SANITARIUM
P.O. BOX 978, FORT WORTH, TEXAS
For Nervous Diseases and Selected Cases of Mental Dis- eases.
(Incorporated under laws of Texas)
a ce eee en ee nr
WILMER L. ALLISON, M.D. Resident Physician BRUCE ALLISON, M.D. Resident Physician R. H. NEEDHAM, M.D. Resident Physician JAS. D. BOZEMAN, M.D. Resident Physician
OCONOMOWOC HEALTH RESORT _ owisconsin®
For Nervous and Mild Mental Diseases and Addiction Cases Five minutes walk from Interurban between Oconomowoc and Milwaukee on main line C. M. & St. P. Ry. 30 miles west of Milwaukee
Built and equipped to supply the demand of the neurasthenic, border-line and undisturbed mental case, for a high-class home free from contact with the palpably insane, and devoid of the insti- tutional atmosphere.
Fifty acres of natural park in the heart of the famous Wis- consin Lake Resort region. Rural environment, yet readily acces- sible. A beautiful country in which to convalesce.
The new building has been designed to encompass every require- ment of modern sanitarium construction, the comfort and welfare of the patient having been provided for in every respect. The bath department is unusually complete and up-to-date. Work-therapy and re-educational methods applied.
} Number of patients limited, assuring the personal attention of the resident physician in charge.
New Building Absolutely Fireproof Arthur W. Rogers, B.L., M.D., Resident Physician in Charge
+
AEA
— ar = ™ = ees
DR. MOODY’S SANITARIUM
SAN ANTONIO, TEXAS
{For Nervous and Mental Diseases, Drug and Alcohol Addict ions and Nervous Invalids Needing Rest and Recuperation
Established 1903. Strictly ethical. Location delightful summer and winter. Approved diagnostic and therapeutic methods. Modern clinical laboratory. 7 buildings, each with separate lawns, each featuring a small separate sanitarium, affording wholesome restfulness and recreation, in doors and out doors, tactful nursing and homelike com- forts. Bath rooms en suite, 100 rooms, large galleries, modern equipments, 15 acres, 350 shade trees, cement walks, playgrounds. Surrounded by beautiful park, Government Post grounds and Country Club. T. L. Moody, M.D., Supt. and Res. Physician. J. A. McIntosh, M.D., Res. Physician. C. W. Stevenson, M.D., Res. Physician.
Vol. XIII No. 12 SOUTHERN MEDICAL JOURNAL 25
LYNNHURST SANITARIUM “rss”
A High-Class Institution for Nervous Diseases, Mild Mental Disorders and Drug Addiction.
Situated in the suburbs of Memphis on 28 acres of beautiful woodland and ornamental shrubbery. Modern and approved methods in construction and equipment. Thorough ventilation, sanitary plumbing, low pressure steam heat, electric light, fire protection, and an abundance of pure water. Special facilities a 4 for giving Hydrotherapy, Electrotherapy, Massage, Physical Culture and Rest Treatment. Experienced nurses and house physician. An improved treatment for Opium-Morphine addiction.
Ss. T. RUCKER, M.D., Director Medical Dept.
KENILWORTH SANITARIUM
KENILWORTH, ILLINOIS (Established 1905)
(Cc. & N. W. Railway, Six Miles North of Chicago.) Built and equipped for the treatment of nervous and mental
diseases. Approved diagnostic and therapeutics methods. An adequate night nursing service maintained. Sound proof rooms with forced ventilation. Elegant appointments. Bath rooms en suite, steam heating, electric lighting, electric eleva-
tor. Resident Medical Staff: Minta P. Kemp, M.D. Sherman Brown, M.D. Sanger Brown, M.D. Consultation by appointment All correspondence should be addressed to
Kenilworth Sanitarium Kenilworth, JIl.
For the Care and Treatment of
NERVOUS DISEASES
Building Absolutely Fireproot BYRON M. CAPLES, M. D., Supt.
Waukesha, ° - : . Wisconsin
26 SOUTHERN MEDICAL JOURNAL December 1920 E
Th Ci e ti \) it Inc. 1873 For Mental and Nervous Diseases. A strictly modern hospital fully equipped for the scientific treat- ment of nervous and mental affec- tions. Situation retired and acces- sible. For details write for descrip- tive pamphlet. F. W. Langdon, M.D., Visit. Consultant Cc. B. Rogers, M.D., Resident Medical Director H. P. COLLINS, Business Manager Egbert W. Fell, M.D.. Box No. 4, College Hill Res. Clinica! Director CINCINNATI, OHIO
“REST COTTAGE?” College Hill, Cincinnati, Ohio
rors and con- valescents.
Completely equipped for hy- drother- apy, massages,
ete. = Cuisineto = meet individual needs,
F. W. Langdom,
M.D., Visiting Consultant
Egbert W. Fell, M.D., Resident Clinical Direc. tor
Cc. B. Rogers, M.D., Resident Medicai Direc- tor
H. P. Collins Business Man- ager
Vol. XIII No. 12 SOUTHERN MEDICAL JOURNAL
27
ANNOUNCING THE OPENING OF DR. SEALE HARRIS’ DIETETIC INSTITUTE
A PRIVATE INFIRMARY FOR THE DIAGNOSIS AND THE DIETETIC AND MEDICAL TREATMENT OF DISEASES OF THE STOMACH AND INTESTINES AND OF NUTRITION.
THE DIETETIC INSTITUTE HAS NO OPERATING ROOM BUT CONVALESCENT SURGICAL PATIENTS ARE ESPECIALLY DESIRED, AS ARE THE FUNCTIONAL NERVOUS (REST CURE) PATIENTS FOR WHOM DIET AND HEALTH INSTRUCTION ARE THE MOST IMPORTANT INDICATIONS FOR TREATMENT. NO TYPHOID, TUBERCULOUS OR OTHER INFECTIOUS CASES WILL BE ACCEPTED.
THE DIETETIC INSTITUTE IS INTENDED TO BE A HOME WHERE PATIENTS WILL BE PROPERLY DIETED AND TREATED AND WHERE THEY WILL BE TAUGHT PERSONAL HYGIENE IN AN ENVIRONMENT FREE FROM THE ANNOYANCES OF A GENERAL HOSPITAL. IT 18 LOCATED ON BIRMINGHAM'S BEAUTIFUL RESIDENTIAL BOULEVARD, HIGHLAND AVENUE,
DR. SEALE HARRIS WILL ALSO CONTINUE HIS OFFICES AT 804-808 EMPIRE
BUILDING, BIRMINGHAM, ALA.
HOURS FROM 10 A. M. TO 1 P. M. AND 3 TO 4 P. M.
BIRMINGHAM, ALABAMA, SEPTEMBER 15, 1920.
The Tucker Sanatorium, Inc.
Madison and Franklin Streets RICHMOND, VIRGINIA
This is the Private Sanatorium of Dr. Beverley R. Tucker
The Tucker Sanatorium is for the treatment of nerv- ous diseases. Insane and acute alcoholic cases are not taken. The Sanatorium is large and bright, surrounded by a lawn and shady walks and large verandas. It is situated in the best part of Richmond and is thoroughly and modernly equipped. * There are departments for massage, medicinal exercises, hydrotherapy, occupation and electricity. The nurses are especially traifled in the care of nervous cases,
THE HENDRICKS - LAWS SANATORIUM, "2° ono most moder oo ee Ui treatment. of beret
CHAS. M. HENDRICKS J. W. LAWS Medical Directors
= losis. High-class accom- modations. Fireproof con- struction. Individual sleeping porches. Excel- lent cuisine. Altitude 4000 feet. Climate ideal all of the year. For further in- formation, address
M. R. Harvey President
SOUTHERN MEDICAL JOURNAL December 1920
Dr. Brawner’s Sanitarium ATLANTA, GEORGIA
For Nervous and Mental Diseases, General Invalidism and Drug Addictions
The sanitarium is located on the Marietta trolley line, 10 miles from center of city, near a beautiful suburb, Smyrna. Grounds consist of 80 acres. Buildings are steam heated, elec- trically lighted, and many rooms have private baths. Patients have many recreations such as tennis, croquet, baseball and automobiling. Reference: The Medical Profession of Atlanta. Address
Dr. JAS. N. BRAWNER, 701-2 Grant Bldg. Atlanta, Ga.
FOR THE TREATMENT OF
Drug Addictions, Alcoholism, Mental and Nervous Diseases
A quiet, home-like, private, high-class institution. Licensed. Strictly ethical. Complete equipment. Best Accomniodations.
Resident physicians and trained nurses.
Drug patients treated by Dr. Pettey’s original method.
Detached building for mental patients.
PETTEY & WALLACE 958 S. Fifth Street SANITARIUM
e e For the Treatment of MENTAL and ] t ] e Ww NERVOUS DISEASES and ADDIC- TIONS. e@ © New Fifty-Room Department completed January, 1915. Now have two new buildings, one for each a nil a r 1m sex. A thoroughly modern and fully equipped private hospital, operating under state license. (Established 1907) Large, commodious buildings offering accommo- JOHN W. STEVENS, M.D. dations to meet the desires of the most exacting. Physician-in-Char Situated out of town in a quiet, secluded place. ‘ea ge Large, shady grounds. Specially trained nurses. srepmene aie Sane Two resident physicians. Capacity 65. References: Rural Route No. -1 Nashville, Tennessee Medical Profession of Nashville.
ease
Vol. XIII No. 12 SOUTHERN MEDICAL JOURNAL 29
Westbrook Sanatorium, Richmond, Virginia
THROUGH THE MEDICAL STAFF,
DOCTORS JAS. K. HALL, P. V. ANDERSON AND E. M. GAYLE
WISHES TO ANNOUNCE TO THE PROFESSION THE OPENING ON NOVEMBER FIFTEENTH OF AN ADDITION TO THE INSTI- TUTION OF TWO BRICK BUILDINGS—ONE FOR MEN AND ANOTHER FOR WOMEN.
HE PLANT now consists of nine separate buildings situated in the midst of grounds which embrace eighty-five acres. The lawn is large and beautifully shaded; there are private walks and drives, and the institution affords the quietness and serenity of the country within sight of the city. Rooms may be had single or en suite, with or without private baths. Small cottages, suitable for one patient, are also available. { Treatment is limited to Nervous Disorders, Mild Mental Affections, and to Alcoholic and Drug Habituation. Nurses and attendants are trained for this special work and the Sanatorium fur- nishes every facility for the rational treatment of such patients. Life in the out-of-doors, combined with properly selected work for each patient, constitutes an important therapeutic measure.
The three physicians live at the Sanatorium and devote their entire attention to the patients. BOOKLET UPON REQUEST
WShortle’s Albuquerque Sanatorium
FOR TUBERCULOSIS
ALBUQUERQUE, - - NEW MEXICO
Altitude 5,100 Feet. Rates Moderate. Climatic Conditions Unsurpassed.
A private sanatorium where the closest personal attention is # given each patient. Complete laboratory and X-Ray equipment i for diagnostic purposes. Compression of the lung and sun-bath | treatment after the methods of Rollier. Steam heat, hot and cold water, electric lights, call bells, local and long distance tele- phones and private porches for each room. Bungalows if desired. } Situated but 1 1-2 miles from Albuquerque, the largest city iH and best market of New Mexico, permits of excellent meals and i service at moderate price. Write for Booklet B.
A. G. Shortie, M.D., Medical Director
FOR DISEASES OF THE LUNGS AND THROAT
THE POTTENGER SANATORIU MONROVIA, CALIFORNIA A thoroughly equipped institution _ for the scientific treatmént of tuber- culosis. High class accommodations. Ideal all-year-round climate. Sur- rounded by orange groves and beauti- ful mountain scenery. Forty-five min- utes from Los Angeles. F. M. Potten- ger, A.M., M.D., LL.D., Medical — tor. J. E. Pottenger, A.B., " Assistant Medica] Director and Ginter of Laboratory. George H. Evans, M.D., i San Francisco, Medical Consultant.
For particulars address:
POTTENGER SANATORIUM, Monrovia, California. Los Angeles Office: 1100-1101 Title Ins. Bidg., Fifth and Spring Streets.
30 SOUTHERN MEDICAL JOURNAL
jonny. cuisey, mv. ST. ALBANS SANATORIUM, Inc. #6 Box? Phone RADFORD, VIRGINIA
The Hydrotherapy Department is complete in every detail. Continuous Nauheim and Tonic Baths,
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Clinical ‘Laboratory fully equipped.
A thoroughly equipped and modern Private Sana- torium for the diagnosis and treatment of chronic medical, nervous and mild mental disorders. It is sit-
> uated 2,000 feet above sea level in the famous blue Oe ee grass region of Virginia. There are two large colonial brick buildings connected by a sun parlor 105 feet long. Rooms single or en suite, with or without private baths. Accommodations for fifty patients. Modern and approved methods used in every department. The nurses are specially trained to care for nervous patients,
For details write for descriptive pamphlet.
December 1920
7
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An Annex for Nervous Women Write for Descriptive Circular
HARVEY COOK, M.D., Physician-in-Chief
Glenwood Park Sanitarium, yore.
SUCCEEDING TELFAIR SANITARIUM
The Glenwood Park Sanitarium is ideally located in a quiet suburb of Greensboro, having all the advantages of the city, yet sufficiently isolated to enable our patients to enjoy restful quietude and entire freedom from the noise and distraction incident to city life.
CLASS OF PATIENTS--Those who need help to overcome the bondage of habit. Rest from over- work, study or care. Diversions for the depressed and disquiet mind—and such as are suffering from any disease of the nervous system. The treatment consists of the gradual breaking up of injurious habits, and the restoration to normal conditions, by the use of regular and wholesome diet, pure air, sunlight, and exercise, with such other remedies as are calculated to assist nature in the work of restoration.
Special attention is given to the use of electricity. Twenty years’ experience has proven it invaluable in cases of nervous prostration, incipient paralysis, insomnia, the opium and whiskey habits, and those nervous affections due to uterine or ovarian disorders.
For further particulars and terms, address W. C. ASHWORTH, M.D., Superintendent.
TLR IRIE, Ie OI
Vol. XIII No. 12
SOUTHERN MEDICAL JOURNAL 31
indicated. For particulars address,
ATLANTA RADIUM LABORATORY
929 Candler Building ATLANTA, GA.
anadium: for the treatment of conditions in which the use of radium is
COSBY SWANSON, M. D., Medical Director
Hospital For General Diag- nosis and Nervous Diseases
“NORWAYS”
1820 E. 10th Street, Indianapolis, Ind.
An institution devoted to the Research, Study and Diagnosis of all problems in Medicine and Surgery, especially of conditions involving the Nervous Sys- tem. All newer methods of Diagnosis, particularly the Chemistry of the blood, spinal fluid, secretions
‘| and excretions of the body are employed. The im-
portance of body metabolism and its relation to diseased conditions is emphasized.
The co-operation of physicians is invited. It is the policy of this Hospital to return patients to their home and family physician for treatment, at the earliest possible moment, after a diagnosis is made. Only at the request of the patient’s physi- cian will any case be kept in the Hospital beyond the necessary period of observation.
A complete staff of skilled specialists in co-opera- tion.
For further particulars regarding rates, etc., write DR. ALBERT E. STERNE or DR. LARUE D. CARTER
“Norway” Hospital for General Diagnosis and Nervous Diseases.
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Dr. J. E. Garrison, Physician in Charge
=
The Thompson Sanatorium
For the treatment and education of tubercu- lous patients. Seventy-five miles northwest of and twelve hundred feet higher than San Antonio. Mild winters, cool breezy summers. Hospital Building and Hollow Tile Cottages with modern conveniences. Beautiful mountain scenery. Prices moderate. Trained nurses.
SAM E. THOMPSON, M.D.
Superintendent and Medical Director
H. Y. SWAYZE, M.D. Associate Medical Director
KERRVILLE, TEXAS
DR. ROBERT BERNHARD DR. P. J. CARTER
DR. ANSEL M. CAINE
DR. PETER GRAFFAGNINO DR. J. RAYMOND HUME
Address communications to
The Southern Radium Clinic, Inc.
Cushachs Building NEW ORLEANS, LOUISIANA STAFF
DR. CHAS. H. VOSS, Radio-Therapist
DR. THOMAS B. SELLERS DR. PAUL T, TALBOT
DR. CHAS. H. VOSS
DR. H. W. E. WALTHER
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SOUTHERN MEDICAL JOURNAL December 1920
RADIUM THERAPY
in connection with
NEWELL & NEWELL
Sanitarium
705-707 Walnut St., Chattanooga, Tenn.
An ample supply of Radium for the treat- ment of all conditions in which Radium is indicated.
SANITARIUM STAFF
E. T. Newell, M.D. E. D. Newell, M.D. G. P. Haymore, M.D. J.H. St. John, M.D.
The Radium Institute of New Orleans
In Connection With
TOURO INFIRMARY
DIRECTING BOARD Dr. S. M. D. Clark Dr. H. S. Cocram Dr. W. Kohlmann Dr. U. Maes Dr. E. D. Martin Dr. R. Matas Dr. F. W. Parham Mr. A. B. Tipping
For the treatment of conditions in which the use of Radium is indi- rated.
All correspondence should be addressed to the Radium Institute.
DR. E.C. SAMUEL, A. B. TIPPING, Radio-Therapist. Secretary.
RADIUM AND X-RAY LABORATORY
425-429 Woodward Building BIRMINGHAM, ALA.
For the treatment of MALIGNANT and BENIGN conditions, in which the use of Radium and ALLIED MEASURES has been
definitely established.
Address:
Dr. WALTER A. WEED, Director 425 Woodward Building, Birmingham, Alabama
y Ys Bas SR Cry RETR Ce oe
ae gt ae
Vol. XIII No. 12
SOUTHERN MEDICAL JOURNAL
Washington Radium & X-Ray
Laboratory WASHINGTON, D. C.
For the treatment of all malignant and benign lesions in which Radium, massive doses of X-ray and Fulguration have been rec-:
ommended.
Address
DR. C. AUGUSTUS SIMPSON, 1219 Connecticut Ave., Washington, D. C.
SCHOOL OF OPHTHALMOLOGY HERMAN KNAPP MEMORIAL EYE HOSPITAL. The following all-day course extending over a period of three months is open to qualified medical practi- tioners. On completion of the course a certificate of attendance is granted to the student with the privi- lege of remaining three months as an assistant in the clinic.
1. Daily Clinics in Dis- 6. External Diseases of
pensary the Eye 2. Refraction 7. Operative Surgery 3. Muscular Anomalies 8. Physiological Optics 4. Ophthalmic Quizes 9. Pathology 5. Ophthalmoscopy 10. Ophthalmic Neurology
The course begins October, January, April and July. A vacancy occurs on the House Staff July, 1921. DR. G. H. GROUT, Secretary 500 W. 57th St., New York City, N. Y.
Nashville Private Maternity Hospital
For the care and protection of unfortunate young women. DR. J. H. PRESTON, Physician
Address: MRS. L. SWEENEY 1230 Second Avenue, South Phone, Main 3791 NASHVILLLE, TENN.
Medical College of Virginia
UNIVERSITY COLLEGE OF MEDICINE MEDICAL COLLEGE OF VIRGINIA (Consolidated)
Medicine-Dentistry-Pharmacy
STUART McGUIRE, M.D., Dean New college building, completely equipped and modern laboratories. Extensive Dispensary service. Hospital facilities furnish 400 clinical beds; individ- ual instruction; experienced faculty; practical cur- riculum. For catalogue or information address J. R. McCAULEY, Secretary
1140 E. Clay Street Richmond, Virginia
The New York Skin and Cancer Hospital
SPECIAL POST GRADUATE INSTRUCTION i—Hospital and Dispensary instruction diagnosis and treatment of diseases of the skin. 2—Instruction in syphilis—diagnosis, laboratory work and treatment. 3—Instruction in X-Ray Therapy. 4—Laboratory instruction in the pathology of skin diseases and new growths, including clin- ical methods for the demonstration of the commoner parasites. 5—Hospital and dispensary instruction in the Will be given as follows: surgical treatment of cancer, Apply to Superintendent For Graduates in Medicine
301 E. Nineteenth Street, NEW YORK CITY
34
SOUTHERN MEDICAL JOURNAL December 1920
UNIVERSITY OF LOUISVILLE
MEDICAL DEPARTMENT
New Orleans Polyclinic
Eighty-third Annual Session begins Sept. Graduate School of Medicine, 20, 1920. Entrance requirements for the 1920-21 session—two years of College work including Physics, Chemistry, Biology and English, in addition to the fifteen units’ work in an acredited, standard high-school. 20, 1920, and closes June 11, 1921.
The two-year premedical course ef in- struction is given in the Academic Depart- ment of the University. A combined B.S., M.D. degree granted after two years of study in College of Arts and Sciences and four years in Medical Department.
Tulane University of Louisiana.
Thirty-fourth Annual Session opens Sept.
Physicians will find the Polyclinic an ex- cellent means for posting themselves upon modern progress in all branches of medicine and surgery, including laboratory, cadaveric work and the specialties.
Well equipped laboratories under full- For further information, address: time teachers; Clinical work in the New
Million-Dollar City Hospital. All-time CHARLES CHASSAIGNAC, M. D. Dean
teachers in Clinical Medicine and Surgery. Post Office Drawer 770 New Orleans
Co-educational. For further information
and catalogue, address the Dean. Tulane also offers highest class education HENRY ENOS TULEY, M_D., leading to degrees in Medicine, Pharmacy
rains and Dentistry. Louisville, Ky.
UNIVERSITY OF MARYLAND, SCHOOL OF MEDICINE
AND
COLLEGE OF PHYSICIANS AND SURGEONS
Requirements for Admission—Two yearsof college work, including modern languages Chemistry, Biology and Physics, in addition to an approved four year high school course.
Facilities for Teaching—Abundant laboratory space and equipment. Three large general hospitals absolutely controlled by the faculty and thirteen hospitals devoted to specialties, in which clinical teaching is done.
The next regular session will open October 1, 1920.
For catalogue apply to J. M. H. Rowland, M.D., Dean, N. E. Cor. Lombard and Greene Sts. Baltimore, Md.
LOYOLA POST-GRADUATE SCHOOL OF MEDICINE
New Orleans, La. Combining New Orleans Post-Graduate Schoo! of Medicine. Louisiana Post-Graduate School of Medicine.
Offers courses in all branches of medicine and surgery.
Special facilities for courses in the Eye, and the Ear, Nose and Throat.
Faculty numbering over eighty. Abundant cadaveric material.
Unlimited clinical material in all the hospitals of New Orleans, the medical metropolis of the
South. Students admitted to all courses throughout the year. JAMES M. BATCHELOR, M.D., President. JOSEPH A. DANNA, M.D., Secretary.
Address all Communications to the Secretary, 1533 Tulane Ave., New Orleans, La.
Vol. XIII No. 12 SOUTHERN MEDICAL JOURNAL
35
The Graduate School of Medicine of the
UNIVERSITY OF ALABAMA
Announces two special courses:
A. Medical Diagnosis B. Surgical Diagnosis
Each course will begin on January 3, 1921 and will continue three weeks.
Tuition $25.00
Classes limited to ten
For further information address the Dean.
JAMES S. McLESTER, M. D. Dean 930 SOUTH 20th STREET BIRMINGHAM
SOUTHERN MEDICAL JOURNAL December 1920
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sonny
SOUTHERN MEDICAL JOURNAL
JOURNAL OF THE SOUTHERN MEDICAL ASSOCIATION
Volume XIII
PUBLISHED MONTHLY AT BIRMINGHAM, ALABAMA
DECEMBER 1920
Number 12
MEDICINE
INTERNAL DISEASES, PEDIATRICS, NEUROLOGY, DIAGNOSTIC METHODS, ETC.
SYPHILIS AS A PROBLEM IN GROUP DIAGNOSIS*
By ALBERT KEIDEL, M.D., and JOSEPH EARLE Moore, M.D., Baltimore, Md.
The last few years have witnessed an important development in the manage- ment of disease in the growth of the group system of diagnosis. As applied to the wide field of internal medicine, this system implies the association or close co- operation of physicians representing most of the important specialties, with, at the head of the group, an internist trained in the interpretation and correlation of data. The advantages of such a system in in- ternal medicine are obvious. We hope to show that a similar system is of great value as applied to at least one of the spe- cialties, that of syphilology.
It is not our idea to repeat the argu- ments in favor of a group plan as applied to internal medicine so clearly advanced by Barker’ and so eloquently elaborated by Stokes? to cover syphilology. We wish, however, to indorse the views of these writers and to cite our own experience in their support.
Inasmuch as a knowledge of syphilis includes within its scope more than an
*From the Syphilis Department of the Medical Clinic, Johns Hopkins Hospital.
1. Barker, L. F.: New York Med. Jour., Sept. 21, 28, and Oct. 5, 1918.
2. Stokes, J. H.: Arch. Derm. and Syph., 2, 473, October, 1920.
elementary familiarity with most other special domains in medicine, it seems hardly necessary to demonstrate that it deserves rank as a specialty of equal if not greater importance than those of dis- eases of the heart, diseases of metabolism or tuberculosis. Tracing the rise of syph- ilis to the rank of a specialty of the first order, we may consider its history as di- vided into several more or less sharply defined periods. During the years which antedated the discoveries of Schaudinn, Bordet, Wassermann, Metchnikoff, Roux, Ehrlich, Noguchi and others, the schools of Hutchinson, Fournier, Finger and Neisser had developed to a high degree clinical expertness in the management of syphilis, so far as the information then available permitted. It is regrettable that the rapid developments made possible by these newer experimental discoveries were allowed to submerge the clinical acumen so painstakingly accumulated by the older syphilologists.
However, these discoveries introduced a new order of things in that they threw into the field of syphilis many new con- ceptions affecting it from the angles of diagnosis, treatment and the status of the disease as an infection. They permitted the classification of hitherto unrecognized manifestations, clarified the status of cer- tain suspected diseases such as tabes, pare- sis and aneurysm, and made possible the recognition of symptomless syphilis. To a high degree they complicated the pre- viously comparatively simple treatment of the disease, at the same time not only increasing the chances of success of treat-
858 SOUTHERN MEDICAL JOURNAL
ment, but also adding to its dangers. By establishing definitely the infectious na- ture of syphilis, these discoveries brought it into the field covered by researches in infection and immunity, made possible at- tempts at its prophylaxis and opened more widely the already important branch of sociology.
During the phenomenally rapid deVel- opment of this newer knowledge of syph- ilis, attempts to correlate the new with the old and to apply it to the older methods of dealing with the disease, introduced ele- ments of uncertainty, previously unap- preciated, which brought about the chaotic condition from which we are just begin- ning once more to emerge. The proper allocation of the relative values of the various isolated discoveries and their ap- plication to the field of clinical syphilology marks the beginning of a new era. There is also evident a dawning appreciation in the minds of workers in special fields and of those men dealing with broader prob- lems in medicine of the necessity for the development of men specially trained in syphilis. Out of this realization there have developed concrete efforts toward the establishment of clinics solely for the man- agement of this one disease, staffed by men engaged in the more exact application of the newer methods to clinical problems. This departure has already begun and will continue to draw material from all the other special fields of medicine. It will undoubtedly culminate in the general recognition of the type of man whose spe- cial knowledge will fit him for the title of syphilologist.
The ideal syphilologist of today, how- ever, is confronted by no easy task. In order to qualify in this role he must, of necessity, attempt to cover the entire field of internal medicine, including its special domains and a part of surgery. This is no longer possible as it was in the earlier days of Fournier, and the only alternative is the group plan as it is at present ap- plied to medicine. As a foundation for his training, internal medicine offers the greatest advantages because from begin- ning to end syphilis is always a problem in that domain, no matter what special features may take it temporarily into other
December 1921
fields. This applies as much to the treat- ment and management of syphilis as it does to diagnosis, although the threapeutic aspect of the disease in its present status is so comprehensive that special knowl- edge is here also a desideratum. Begin- ning from this point he must broaden his knowledge of the special fields, although it is not necessary for him to master all the technical details. As Stokes’ so ably puts it:
“Ability to perform an irreproachable Wasser- mann test, to examine the fundus of the eye, to carry out a complete neurologic examination or to cystoscope a bladder may be graces of accom- plishment, but I believe that they subside into secondary importance in comparison with the vital need for a tremendous breadth of outlook on the disease.”
The technical procedures alluded to be- long in their respective fields and should remain there. The syphilologist must as- sociate himself with skilled colleagues in these fields and foster their co-operation. He is dependent upon them for assistance and must therefore recognize their supe- rior training. His role then becomes a combination of the type of man demanded by the group plan as so ably defined by Barker and the syphilographer as con- ceived by Stokes. In this conception our main divergence from Stokes lies in the preliminary training. We feel that a dermatologic training does not afford a broad enough foundation.
To illustrate our own method of inves- tigating the more obscure cases referred to us in the Syphilis Department of the Johns Hopkins Hospital and in our prac- tice, as well as to bear out the points made above, we append the abstracts of four case reports of not unusual diagnostic problems recently studied.
Case 1.—Male, 42, merchant. Seen August, 1920. Complaint.—Partial facial paralysis, right.
Summary of History.—Father died of apo- plexy. Patient unmarried. In 1908 penile sore followed in three to four weeks by an extensive persistent skin rash and mucous lesions. No other secondary manifestations. Treatment, be- gun at once, consisted of mercury by mouth and iodides intermittently for three years. From 1910 to 1915 he took 27 doses of “606.” The blood Wassermann, originally positive, did not become negative for three to four years, and there were frequent recurrences. Treatment was continued for about one year after a permanently
ite on OD
eeu semesmRpeerReeaaen
Vol. XIII No. 12
negative test was obtained. C. S. F. in 1915 com- pletely negative. No treatment and no mani- festations since 1915.
Present Illness.—Twelve days ago suddenly noticed difficulty and thickness in speech. At the same time face was drawn to the right. No vertigo or shock, but questioning brings out the fact that movements of right arm and leg were clumsy for a few hours. This lasted for about thirty-six hours and then began to clear up.
Physical Examination (summary) .—Healthy looking. Gait normal. Skin and appendages normal. No general glandular enlargement. Signs of chronic fibroid consolidation left upper lobe. Heart not enlarged. No retromanubrial dullness. Soft blowing systolic murmur heard at base. A2 accentuated. No thickening of peri- pheral vessels. Pulse normal. B.P. 178-124. Neurological examination shows anisocoria (right pupil larger than left), irregular pupils reacting only slowly and slightly to light, incomplete right facial paralysis, speech thick and slurring, exag- gerated deep reflexes on the right. Suggestive ankle and patellar clonus on the right. No pa- ralysis or sensory disturbances. Ophthalmoscopic examination negative except for tortuous ves- sels.
Laboratory Reports.—X-ray cardio-vascular stripe: heart and aorta normal in size.
Blood Wassermann negative.
C. S. F—Cells 10. Globulin negative. Was- sermann negative with 1 ¢. c.
Colloidal Gold Curve.—1111100000.
Urine.—On repeated examinations a trace of albumin and a few granular and hyaline casts.
Phthalein.—First hour 25 per cent, second hour 20 per cent. Total, 45 per cent.
Blood Urea N.—6.66 mgm. per 100 c. c.
Nephritic test meals (Mosenthal).—No _ noc- turnal polyuria. Slight inability to concentrate solids and a moderate fixation of specific gravity.
Blood.—R. B. C., 5,392,000. Hgb. (Sahli), 101 per cent. W. B. C., 17,800. No abnormalities in stained smear or differential count.
Discussion.—This patient has had either a thrombosis or a small hemorrhage in the left in- ternal capsule. In a man of his age syphilis is the most frequent cause. His early syphilis was fairly well treated and no objective laboratory signs are discoverable now. On the other hand he has a definite arteriolar sclerosis shown by the hypertension and the findings referable to the kidney, which may have caused the vascular lesion. No evidence of syphilis can be found in the aorta. A provocative Wassermann test was not obtained after an intravenous injection of diarsenol.
Diagnostic Summary.
1. Incomplete right hemiplegia. 2. Arteriolar sclerosis. 3. Chronic arteriolar nephropathy. 4. Syphilis, adequately treated. Suggestions for Therapy. 1. Rest in bed, isolation. 2. Diet and hygienic measures directed to- ward kidney and arterial lesions. 3. No anti-syphilitic treatment.
Progress.—Under the regime outlined, marked
improvement. The residual paresis disappeared,
KEIDEL AND MOORE: SYPHILIS 859
blood pressure dropped to 150 systolic, and the phthalein test improved to normal. Patient has remained in excellent condition.
Case 2.—Male, 42, merchant. Seen March 20, 1920.
Complaint.—Pain and numbness in right arm.
Family History.—Negative. Wife and children healthy. One miscarriage.
Past History.—Denies both syphilis and gonor- rhea. Since 1901 three attacks of severe ab- dominal cramps with nausea, vomiting and diar- rhea. None of these attacks since 1912. Mild indigestion, flatulence, constipation after heavy eating. In 1913 a rash over body and extremi- ties lasting four months. It appeared in irregu- lar circles, slightly elevated, copper colored, with slight crusting and scaling. Practically no itch- ing. Treatment for this rash was local only. No blood Wassermann tests were done then or later. For six years no symptoms. In August, 1919, a similar rash appeared lasting for one month. During the past five months four at- tacks of sudden swelling of the lips and face, quite painless, and lasting from one to three days. From 1896 to 1901 a mild sciatica. In May, 1919, mild influenza.
Present Illness——In July, 1919, pain in right shoulder thought to have followed a sprain while playing golf. This pain has persisted and since January, 1920, has become more severe. It is throbbing, worse about 6 p. m., does not keep him awake at night. Patient describes a skin hyperesthesia and a subjective sense of numb- ness running up behind the right ear and ex- tending down underneath the clavicle. Occa- sional numbness and paresthesia down the ulnar surface of the arm, involving the three ulnar fingers. There are two tender spots on pressure: at the angle of the jaw on the right and deep underneath the outer margin of the right clav- icle. No limitation of motion in the shoulder. No muscular weakness.
Physical Examination (summary).—Well de- veloped. Weight is calculated ideal. No trace of former eruption on the skin. Marked derma- tographia. Three crowned teeth and moderate pyorrhea. No general glandular enlargement Heart, lungs and abdomen all normal. B. P 126-70. Neurological examination practically negative. No reflex or sensory changes, no atro- phy, and no decrease in muscle strength in the right arm or elsewhere.
Laboratory Examinations.—Urine, Sp. gr. 1014. Reaction acid. Albumin negative. Sugar negative. Micro.: no casts, no R. B. C., no crys- tals. An occasional W. B. C.
Blood Wassermann negative.
Blood calcium 8.75 mgm. per cent.
Cc. S. F.—Cells 2. Globulin negative. Was- sermann negative in 0.2, 0.4 and 1.0 ¢. c. quanti- ties. Colloidal gold, 1111000000.
Roentgenologic Studies.—Spine. No cervical rib. The entire spine shows slight changes in- cident to an infectious arthritis.
Teeth.—Negative except for unerupted right upper canine.
Paranasal Sinuses.—Slight clouding of left antrum and some of the ethmoids on the left.
860
Gastro-Intestinal Tract——Fluoroscopic shows heart, lungs and aorta negative. Barium passes down esophagus normally. Stomach is large, atonic, lying in pelvis; no filling defect. Maxi- mum ptosis with curled up appendix; freely mov- able cecum, but some tenderness when palpating over the appendix. ’
Impression——Low grade inflammatory condi- tion in right lower quadrant, chronic in origin.
Neurological Consultation.—Practically nega- tive examination except that pressure over the roots of the brachial plexus causes some pain and the right side of the neck is hypersensitive. Pain and hyperesthesia due to irritation of the cervical nerve roots rather than to destruction.
Orthopedic Consultation.—The left side of the articular process of the sixth cervical vertebra is slightly sensitive on pressure; right side very markedly sensitive. Certainly an_ infectious arthritis of the spine.
Laryngological Consultation—Acute pharyn- gitis. Both antra are dark on trans-illumination.
Discussion.—The occurrence of the skin rashes and the later symptoms had suggested strongly to the patient and his physician the possibility of syphilis. In addition it was necessary to con- sider cervical rib, cord tumor and infectious ar- thritis. On the basis of a completely negative history, examination and laboratory tests, syphi- lis could be absolutely ruled out. There was no confirmation of the suspicion of cervical rib. The evidence presented warrants the following diag- nostic summary:
. Angio-neurotic edema.
. Chronic infectious arthritis, cervical spine. . Infection antrum and ethmoids, left.
. Chronic appendicitis.
. Gastric ptosis and atony.
- Unerupted right upper canine tooth.
. Skin eruption, probably of the erythema multiforme group.
The arthritis, angio-neurotic edema and the old skin eruption are closely inter-related and are in all probability due to sensitization with a bac- terial protein, since a careful history gave no leads pointing to food sensitization. Further- more, two possible sources of focal infection were discovered.
AD Om ON
Case 3.—Male, 54, lawyer. Seen September, 1920.
Complaint.—Swollen joints.
Past History.—In 1896, a single genital sore, hard, round and painless. Incubation period, two to three weeks. Ten days after its appearance a positive diagnosis of syphilis was made and treat- ment begun. No secondary manifestations ever developed. Treatment consisted of large doses of mercury and potassium iodid by mouth and some mercury by inunction and was continued for a period of 18 months. Since 1898 no treat- ment. Two Wassermann reactions, done within the last ten years, were negative.
Present Illness——Seven years ago end joints of all the fingers swelled and became a little stiff. This has gotten progressively worse. Three years ago he consulted an internist who consid- ered the joint changes to be chronic infectious arthritis, but was unable to find any focus of infection with the exception of one suspicious
SOUTHERN MEDICAL JOURNAL
December 1920
tooth, which was extracted without benefit. A year later consulted another internist with the same result. Six months ago there was a sud- den attack, lasting about 48 hours of marked swelling, redness and extreme pain in the right great toe. There have been absolutely no addi- tional complaints with the exception of a slight subjective sense of memory loss. It has recently been suggested to him by a urologist that the joint changes and a spot on the skin of his right temple might possibly be due to syphilis (juxta- articular nodules?). He wishes to know if this is true and if any trace of syphilis remains.
Physical Examination (Summary).—Twenty pounds over weight. A pre-cancerous keratosis of the right temple; no tophi; pupils equal, slightly irregular, but react actively; emphysema; heart slightly enlarged to the left; short, soft blowing systolic murmur at the apex well trans- mitted. P2 accentuated. B. P. 134-85; atrophy of the right gonad due to mumps; marked changes in the joints of the terminal phalanx of each finger, where there is considerable peri- articular thickening, with some deformity and stiffness. Reflexes normal.
Laboratory Examinations.—Blood Wassermann negative.
Cc. S. F.—Cells 6. Globulin 2 plus. W. R,, 0.2, 0.4 and 1.0 c. c. negative. Gold curve luetic zone (2234322000).
Blood Chemisty.—Uric acid, 3.8 mgm. per 100 c. ¢.
Roentgenologic Studies.—Cardio-vascular stripe shows a moderate degree of aortic dilatation of the type usually seen in a patient of this age and build. The walls of the aorta are elastic and the pulsation deep and full. Heart is not en- larged. The diaphragms are quite high, which has a tendency to rotate the apex of the heart slightly outward.
Teleo measurements within normal limits as follows:
Greatest width of aorta, 7 cm.
. R., 5 cm. M. L., 8 cm. L., 15 cm. T., 12cm.
Hands.—The terminal phalangeal joint of each hand and the middle joint of both little fingers show absorption of cartilage without much new bone proliferation. Changes do not suggest lues, but are more characteristic of chronic infectious arthritis. Gout must be ruled out.
Urological Consultation.—Prostate is broader than normal, indurated on both sides, drawn outward and adherent. Induration of moderate degree and extends upward and involves outer portion of seminal vesicles. It is of moderate de- gree, suggests an old chronic gonorrheal process. Prostatic secretion shows 25 per cent pus cells. Few short bacilli, few chronic casts.
Impression.—Chronic prostatitis and seminal vesiculitis with infection, slight.
Discussion and Diagnostic Summary.—So far as syphilis is concerned the history is of an in- sufficiently treated infection, according to pres- ent-day standards. However, this is compen- sated for by the fact that treatment was begun within the first two weeks of the chancre, before the appearance of secondaries, and was kept up
OP ION ILA NOES AIOE
Vol. XIII No. 12
for 18 months. At present the aorta shows no lesions attributable to syphilis; while in the cen- tral nervous system, the other great stronghold of late syphilis, the laboratory examinations showed no evidence of any active process. The presence of a positive globulin reaction and the luetic zone gold curve is partially accounted for by the fact that through an oversight these tests were done after the fluid had stood for 8 days and was slightly infected; in any event, they are probably to be interpreted as the remains of an old inflammatory process, perhaps of a spe- cific nature, with which the patient’s own defense mechanism has been able to deal.
The joint changes are gout. The blood uric acid is twice as high as normal, and this in connection with the suggestive history and the x-ray picture makes the diagnosis.
We are warranted, therefore, in summing up our diagnosis as follows:
1. Syphilis cured.
2. Gout, aggravated by
3. Chronic infectious arthritis.
(4) Chronic prostatitis and seminal vesiculitis.
Therapy Advised.—For the old syphilitic in- fection none. Purin free diet, eradication of the focus of infection in the genito-urinary tract.
Case 4.—Female, 39, housewife. Seen August, 1920.
Complaint.—Severe headaches and dimness of vision.
Family History.—Negative. and well. No pregnancies.
Past History.—Has always enjoyed good health except for the last few years, since when she has had much gynecological trouble, and for the last year a severe cystitis. In January, 1919, some sores in the mouth which did not bother her, but which were considered by her doctor to be syphilis. No Wassermanns were done, but she was given three doses of “606” and ten in- jections of mercury in the buttocks. No further treatment or manifestations until the present ill- ness.
Present Illness.—Excruciating occipital head- aches for the last six weeks, practically con- stant, and so severe that morphia was required to control them. For two or three months some blurring of sight in the left eye.
Physical Examination (summary).—Obesity, pupils equal, irregular, react only sluggishly to light. Ophthalmoscopic examination: right disc hazy on the nasal margin; left disc completely obliterated by swelling with slight edema of the retina around the disc. Vessels normal in both eyes. Otherwise physical and neurological exam- ination completely negative.
Laboratory Examination—Blood Wassermann negative.
Cc. S. F.—Cells, 30.
Wassermann, 0.2, 0.4 and 1 ¢. c. negative.
Globulin negative.
Colloidal gold curve negative (0001110000).
Laryngological Consultation.—“I was unable to make out any evidence of any sphenoidal, eth- moidal or paranasal sinus infection. The tonsils do not show any chronic infection.”
Ophthalmoscopic Consultation. — 1. External Appearance. Essentially normal. Very slight
Husband living
NELSON: CIRCULATION IN INFECTIOUS DISEASES 861
pupillary reaction to direct light. Consensual re- action weakly present.
2. Vision—With present glasses—right 20/15. Left 20/40.. Left vision can not be further im- proved.
3. Accommodation.—Normal in right eye. Di- minished in proportion to the diminution in visual acuity in the left eye.
4. Ophthalmoscopic. Media clear. Right fun- dus shows a healed and inactive peripheral cho- roiditis. Left fundus shows a low-grade optic neuritis. .
5. Visual Fields.—Right visual field normal. Left shows normal form outlines. Blue field somewhat concentrically contracted with a large central relative scotoma running down. in the lower quadrants of the field. Red field some- what concentrically contracted with small rela- tive and large absolute central scotoma.
Impression.—The syndrome in the left eye of optic neuritis ophthalmoscopically, diminished vision and constricted color fields with relative color scotomatae and absolute red scotomata, make a pretty clear-cut picture. There is with- out doubt an interstitial inflammation in the or- bital portion of the left optic nerve. If there is nothing found in the ethmoidal and_ sphenoidal sinuses and in the absence of any intra-cranial symptoms, I think we shall be forced to the con- clusion that this is an active manifestation of syphilis. The clinical picture is certainly similar to that of a luetic optic neuritis.
Diagnostic Summary.—lIn spite of the com- pletely negative serological findings, a tentative diagnosis of syphilitic neuro-retinitis was made. The reaction to the first intravenous treatment lent support to this view. The patient developed, about 4 hours after the injection, an excruciating intensification of her vertical and occipital head- ache. Two days later her headache disappeared and has not returned. After a course of 8 in- travenous injections of neo-arsphenamin, the oph- thalmologist reports that the neuritis in the left eye is subsiding, vision had improved from 20/40 to 20/30, and the relative central scotoma almost disappeared.
315 Professional Bldg.
THE CIRCULATION IN INFECTIOUS DISEASES
By GARNETT NELSON, M.A., M.D., Richmond, Va.
In many infectious diseases the outcome depends on the patient’s endurance, and this, in turn, on the circulation. This is not only true in its relation to the imme- diate outcome, that is, whether the patient survives or not, but it is equally true that in those cases that recover the complete- ness of their recovery or their functionat- ing capacity depends very directly on the amount to which the circulation is crip-
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862 SOUTHERN
pled during the activity of an infection or of equal importance, during convales- cence.
It is only practicable to consider in de- tail some of the infections, and particu- larly those that have a definite effect on the heart muscle or the circulatory appa- ratus as a whole.
The questions that interest us in the beginning therefore relate to the effects various infections may have on the circu- lation, our ability to recognize these effects, and the methods of combating them that may prove useful.
In general these effects may be classi- fied as follows:
1. Actual secondary infection of the muscle, valve or membranes.
2. Hyaline degenerative changes in the muscle.
3. Degenerative arterial processes.
4. Heart strain and exhaustion from prolonged rapid action.
5. The more or less material changes in other organs due directly to a failing cir- culation.
Certain controlling factors contribute especially to the frequency of these infec- tions. These are particularly age, and the specificity of certain germs. In regard to age, the liability of the heart muscle, valves or membranes to secondary infec- tions depends to no small extent on the age of the patient, particularly in the in- fectious diseases of infancy and child- hood, and there is something more to this than the mere fact that these infections are more prevalent during infancy and childhood than at later periods of our lives. It is apparent that the resisting power of the cardiac structure to direct infection is not so well developed during the early periods of our lives as it is later. For example, measles, tonsilar infection and rheumatic arthritis are complicated or followed by endocarditis, myocarditis, per- icarditis in direct proportion, in their fre- quency, to the age of the patient. The very young show such complications or sequelae very frequently, the aged very rarely. This fact is overlooked too often and relatively trifling and easily curable involvements of the circulation are allowed to leave some permanent trace. In all in-
MEDICAL JOURNAL
December 1920
fectious processes, in the young particu- larly, the circulation should be watched until a guarded convalescence permits a clean bill of health.
In addition to age as a predisposing fac- tor, the nature of the infection itself enjoys a position of commanding importance. Al- though gonococci, diphtheria bacilli, tuber- cle bacilli and many others may occasion- ally become lodged and set up true areas of infection, they are not liable to do so, and even when positive complicating in- fections do occur during the course of an acute gonorrhea, diphtheria, etc., the mi- cro-organisms found in these secondary localized areas are some form of strepto- coccus or staphylococcus. Of course the most frequent infectious process to be complicated by cardiac infection is rheu- matic arthritis, being responsible for ap- proximately 40 per cent of all true infec- tions of the circulatory apparatus, and we must bear in mind that the frequency of the instances of these infections does not depend on the severity of the joint infec- tion, mild cases being as much to be feared as the most severe. In addition to the in- fections mentioned, any of the specific fevers have to be watched. Osler reports five instances in one hundred post-mortems for pneumonia, and twelve instances in two hundred and sixteen post-mortems on phthisical subjects.
The next most common pathology to be found is hyaline degenerative changes in the heart muscle. This is of course not due to actual infection, but to degenerative processes depending on prolonged fevers or biological toxemias. These hyaline de- generative processes occur frequently dur- ing the pneumonia, typhoid fever, osteo- myelitis, tuberculosis or any suppurative process. They are far less graphic than the direct infection, recognized with more difficulty, and, therefore, even more fre- quently overlooked.
The arterial degenerative processes con- sist of nothing more nor less than the athero or sclerotic changes which are to be expected as a result of prolonged chemical or biological toxemias. Under the general subject of this paper we would, therefore,
e
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expect these arterial changes chiefly in chronic malaria and syphilis, particularly in the latter.
The fourth pathological condition men- tioned in our classification was: “heart strain and exhaustion from prolonged rapid action.” In the strictest sense this is hardly a true pathology, in as much as there is neither a direct infection nor a hyaline nor fatty degeneration, but the muscle fibres become stretched, causing dilations or loose tone, impairing their special function, such as conductivity, tonicity, contractility, etc. Although true pathological changes may not be present, it is not to be inferred that permanent injury is only infrequently the direct re- sult of such strain or exhaustion. On the contrary, we frequently see patients suf- fering from the so-called weak heart, which bears a definite association with some of the acute infections. In addition to those infectious processes which have been mentioned earlier in this paper, pos- sibly the most frequent cause of this par- ticular type of heart trouble is the “flu.” It has been a frequent observation that numerous casés of rapid heart action, dys- pnea on slight exertion, and a sensation of being too easily fatigued or a definite precordial oppression were encountered following our recent epidemics of the “flu,” especially in those cases in which a too rapid convalescence was attempted.
The fifth effect to be considered is the more or less material change in other or- gans due directly to a failing circulation. The most conspicuous of these are: cere- bral anemia, pulmonary congestions, con- gestions of the liver, or kidneys, and of the gastro-intestinal tract with nausea and vomiting or obstinate diarrhea. It is an interesting phenomenon, for example, to see obstinate diarrhea, in patients conva- lescing from typhoid, promptly relieved by improving the mechanism of the circula- tion.
So much, then, very briefly, for the gen- eral effects of the infectious diseases on the circulatory apparatus.
The ability to recognize these effects is so common to all of us that our success is more a matter of painstaking observation than of ignorance. Still in the hurried
NELSON: CIRCULATION IN INFECTIOUS DISEASES 863
work of a busy professional life we do fail to make these observations with regretta- ble frequency, and it is not to our credit to so often see reports of cases of sudden death in adults or children following an acute infectious disease. We hear too of- ten that “so and so” had pneumonia, for example, and was about well, when on making some trifling exertion he collapsed and died in a few minutes. The truth of the matter generally in such cases is that the patient was by no means about well, but was still suffering from a simple endo- carditis, hyaline degeneration or heart — from which he might have recov- ered.
I stop to mention only three points that are of especial importance in recognizing the circulatory complications. They are: persistent rapid pulse, a pulse whose rate is accelerated too much with too trifling a stimulus or exertion and fails to slow down promptly; and the various forms of arrhythmia; and persistent low systolic pressure. Just here I wish to mention a very practical use of the sphygmomano- meter. I mean as an aid in recognizing arrhythmias. We study our arrhythmias in three ways: first, by feeling the pulse; second, by a combined feeling of the pulse and use of the stethoscope over the heart’s apex; third, by the use of the sphygmo- manometer. The simplest method is by ‘feeling the pulse, and the more common arrhythmias are easily recognized. The combined feeling of the pulse and use of the stethoscope enables us to recognize the little extra beats that have not enough force to throw an impulse through to the wrist. With the sphygmomanometer we recognize those arrhythmias that are ir- regular in force only. Each cardiac im- pulse gives a pulse at the wrist and they are all coming through at properly spaced intervals, but their force is varying and perhaps varying so slightly that neither the finger nor the stethoscope can appre- ciate it. If now we attempt to take the systolic pressure and pump in sufficient air to shut out all sounds below the cuff, then let air escape until the first audible sound gets by, then hold your pressure at this point for one or two minutes, it may be easily observed that either some ventricu-
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864 SOUTHERN
lar contractions fail to force by any sound, or else the sounds are varying decidedly in intensity. By this means we can easily see that we have a definite arrhythmia as far as the force of each ventricular con- traction is concerned. I believe that the development of these arrhythmias is of even more significance than excessive ra- pidity of action. If, for example, in the pneumonia of the aged, while observing the systolic pressure, I detect an early ar- rhythmia in force, I feel warranted in giv- ing a prognosis of a fatal termination. In order to bring this cursory discussion of this vitally important subject to a con- clusion, I wish to speak briefly of the methods at our disposal for combating these disorders of the circulation.
Of course, our sheet anchor is prolonged rest, mentally and physically, for the pur- pose of saving the heart every possible contraction. In the direct infections ex- cept in the very young, our efforts at pre- venting some permanent crippling are doomed to meet with but poor success at best. Many cases of simple endocarditis, especially those complicating rheumatic arthritis, will make a more or less com- plete recovery. In the very young they will frequently get entirely well.
All cases of malignant endocarditis die. This is so absolutely true that if we have made a diagnosis of malignant endocraditis and the patient recovers, we must change our diagnosis.
Many cases of hyaline degeneration, properly handled, make complete recov- eries.
All cases of heart strain or exhaustion should get entirely well, the heart muscle possessing, as we know, a_recuperative power beyond that of any other portion of the body.
The effects of failing circulation on the other portions of the body, such as the brain, lungs, liver, kidneys, etc., can be relieved in direct proportion to our ability to restore the tone of the circulation. These secondary effects, however, of themselves further embarrass the circulation and spe- cial means must be adopted to relieve the processes going on in these more distant
organs.
MEDICAL JOURNAL
December 192v
The best illustration of what I mean is pulmonary edema. Here, although the edema is directly due to cardiac failure, it of itself increases the cardiac embarrass- ment. I report one case briefly.
Mrs. B., white female, age 67, was ill of lobar pneumonia, and on the eleventh day collapsed; in spite of the usual efforts at support. When I reached her bedside a few minutes later she was cyanosed, pulseless, unconscious, cold, clammy, her pupils dilated and death seemed imminent. A rapid examination showed pulmonary edema, involving not only the pneumonic lung, but the other as well. Using my pocket knife, .I opened a vein and took out about 16 ounces of blood. With miraculous suddenness a little color came into her cheeks, her pupils regained normal size, and gradually she became warm and regained consciousness, making an uneventful recovery.
In addition to rest in bed, we should of course employ in the infections any specific treatment at our disposal. I refer here, of course, to antitoxin in diphtheria, quinine in malaria, mercury or salvarsan as indicated, and possibly vaccine or anti- gens in pneumonia.
Aside from rest and specific medication, our most useful drugs are, in the order named: digitalis, caffein, atropin, spar- tein, strychnin.
The only comment I have to make in reference to digitalis is to emphasize what I believe to have been definitely proven in the last few years. Our results from using digitalis have been unsatisfactory for two reasons: first, using unreliable prepara- tions; and second, insufficient dosage, no matter what preparation used. In the past two years we have learned that instead of attempting to get results with the equiva- lent of one grain of the powdered leaves, we should not use less than the equivalent of from four to six or eight grains, the proper initial dose of a reliable tincture being, therefore, not fifteen drops, but from one to two drams.
Caffein will not by any means replace digitalis, but is, possibly, especially indi- cated as suggested by Forchheimer in those cases of lost circulatory tone where abdominal tympanites is a _ troublesome symptom. In my own practice I only use caffein for routine treatment in those pa- tients, especially the aged, who are accus- tomed to, and more or less dependent on, coffee. This is not a point of minor im- portance. Old people accustomed to sev-
Vol. XIII No. 12
eral cups of coffee daily, when ill, need caffein just as distinctly as those who are accustomed to whiskey, when ill, will die if deprived of their whiskey.
The indications for the use of atropin are fairly definite. It should be used in that group of cases where the circulatory disturbances, such as fluctuating blood pressure, alternate flushing and pallor, or other symptoms indicate vagotonia. The result in this group of cases from the use of atropin in large enough doses, such as 1/50 of a grain hypodermically every four hours, are quite as graphic as a speedy response to properly used digitalis.
Spartein is reputed to have a special action on the right side of the heart and to act as an excellent diuretic. Personally I have never been sure I saw it do anything.
Strychnin has no place in the manage- ment of circulatory disturbances except to the extent that it acts as a general mus- cular tonic.
In all cases where rapid heart action is a conspicuous feature the ice bag over the precordium is indicated.
1009 W. Franklin St.
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THE PRACTICAL IMPORTANCE OF THE EFFORT SYNDROME IN CIVIL PRACTICE*
By H. R. CARTER, JR., M.D., Birmingham, Ala.
All of us are prone to look upon this condition as one more or less intimately
associated with the military service be-'
cause most of the literature on the subject was contributed by authors when on ac- tive duty or from observations made upon soldiers or those examined for entrance into the services. Then, too, the unfortu- nate name of soldier’s heart has been for a long time applied to this symptom-com- plex.
That it has been described under many names is well known to all of you, as the irritable heart, soldier’s heart, athletic heart, tropical heart, neurocirculatory-as- thenia, functional C. V. disorder. The
*Read before the Clinical Club of Birmingham, Ala., June 17, 1920.
CARTER: THE EFFORT SYNDROME IN CIVIL PRACTICE 865
above title is chosen because it does not commit us to a conception of the condition as being cardio-vascular in origin as pointed out by Lewis, who originated this name for the condition.
The fact of paramount importance to us as civilian physicians is that in a large percentage of those individuals who showed the condition to the military ex- aminers it had existed prior to entrance into the service. The number is not easily arrived at, as far as the United States is concerned, but Connor, in writing of car- diac-diagnoses in the light of experiences with the Army physical examinations, states:
“From the very first day of the Army heart examinations, however, this neurosis obtruded it- self uopn the consciousness of the examiners in no uncertain manner. It was far and away the commonest disorder and transcended in interest and importance all the other affections com- bined.”
He further states that the condition had existed in these individuals for years prior to their entrance into the service. Lewis states that in all the patients ad- mitted to the British military hospitals during the first two years of the war with this condition 43 per cent showed it prior to entrance into the service.
The first definite account of this condi- tion is that of DaCosta in 1871 from ob- servations made at the Turner-Lane Hos- pital, although Peacock discussed the con- dition not so clearly in 1865.
At times since then it has been reported in the journals and text books, but no gen- eral interest has been given it by the pro- fession.
Alfred Cohn states that during the war something over 250 articles have been written on this subject.
I will depart from the classical method of describing a disease and give symp- toms first. These will be discussed briefly because so much has been written on this subject that details are not needed.
Breathlessness, palpitation, tachycardia, vaso-motor, disturbances, as well as pain and tenderness, are amongst the promi- nent symptoms. They are either brought on by exertion or greatly aggravated by the same.
A short description of the individual symptoms will now be taken up for con-
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sideration. These, of course, vary in in- tensity in the individual case and in the order of their frequency of occurrence. Breathlessness, palpitation, tachycardia, fatigue and exhaustion are nearly always present. The dyspnea may be as marked as in any other condition, but there is never general cyanosis associated with it. Palpitation is also a marked symptom after exertion, but may or may not be present when the patient is at rest. Fatigue and exhaustion are also frequent symptoms. Pain is a less frequent symptom, but was found in half of the patients examined by Lewis. This may vary from a sense of discomfort or tightness in the chest to subjective sensations which are described as approaching angina pectoris in sever- ity. As a rule, it is present on or imme- diately after exertion. Fainting is a symptom which alarms both the patient and his family, and may come on while the patient is at rest or taking light exer- cise as well as following exertion. Giddi- ness is frequently present, more so after exertion. Headache after exertion is a frequent symptom and is, as a rule, throb- bing in character. Sweating, blueness of the flesh or mottling of the extremities is also common. Numbness of the fingers and dermatographism is frequently seen.
DIAGNOSIS
The symptoms which have been briefly given will focus the attention upon the heart. Important points of diagnosis are that the breathlessness is not associated with general cyanosis and Lewis stresses
the fact that breathlessness of purely car- °
diac origin is always accompanied by gen- eral cyanosis, slight, moderate or extreme. The pulse rate is mobile, but tachycardia is not constant. In Lewis’ series the aver- age rate when the patients were at com- plete rest was 85 beats per minute.
There is no cardiac enlargement in the uncomplicated effort syndrome cases. This was stressed by the late Major Meakins and Captain Gunson, R.A.M.C., quoted by Lewis. This fact is sustained by different observers. Smith covers this phase of the question very completely in his recent article.
SOUTHERN MEDICAL JOURNAL
December 1920
DIFFERENTIAL DIAGNOSIS
Chronic myocardial disease is discussed by Lewis. He lays great stress on cardiac enlargement, aortic insufficient and mi- tral-stenosis; that is, in the valvular dis- eases of the heart associated with mur- murs occupying the diastolic phase and the cardiac cycle. He points out that the me- chanical factor of the valvular defect is not the thing of importance, but that the myocardial involvement which is asso- ciated with these conditions is the impor- tant factor. He lays stress upon the great importance of lues as compared with rheu- matism because it tends to affect the base of the heart and often involves the coro- nary vessels. He lays great stress upon the age of the patients and states that myocardial trouble without valvular dis- ease, renal disease, or signs of cardiac enlargement is rare in young men. He also stresses venous congestion as a sign of cardiac damage. Lewis gives the fol- lowing points of differentiation between the effort syndrome and angina pectoris. Angina pectoris occurs in middle or ad- vanced life, always associated with exer- tion. In effort syndrome the attacks, when mild, may appear when the patient is at rest. Angina usually starts in the sternal region. There is less serious pain in the precardium. Radiation and hyperesthesia have the same distribution in both. In angina we often have other signs of car- diac damage, as pulsus alternans, the cases with effort syndrome are as a rule high strung or show a definite neurosis. The rate is rapid and shows exaggerated re- sponse to the exercise test.
Fatty degeneration is to be differen- tiated, great stress being laid upon infec- tions such as diphtheria by Lewis. Fibroid disease, Lewis states, will always show clear signs of cardiac damage. He lays stress upon a conspicuous maximum im- pulse with weak heart sounds associated. Malignant endocarditis, because these pa- tients are frequently afebrile at times, should be differentiated. This condition is so well covered in the standard text books that I will not enter into details. Petechiae in the skin or conjunctiva, the painful nodes in the tips of the fingers, faint blue or purplish in color as pointed out by Os- ler, slight clubbing of the fingers, enlarged
Vol. XIII No. 12
‘spleen, the presence of albumin or blood in the urine are mentioned by Lewis as important. The blood culture, if positive, will be of great value.
Mitral Stenosis.—Much has been writ- ten upon this subject and the fact that it is frequently associated with a tachycar- dia makes it at times a difficult differentia- tion. The examination of the patient in the left lateral position as well as standing and recumbent before and after exercise -will serve to bring out the diastolic mur- mur in most cases. Inhalations of amy] nitrite was used by some of the examiners in the military service to bring out these murmurs.
Here one should be upon his guard not to mistake a third heart sound for a dias- tolic murmur or to take the presence of a reduplicated first sound for a presystolic murmur. The question of the adventitious sounds heard in normal and _ irritable hearts is discussed by King from observa- tions made at U. S. General Hospital No. 9 at Lakeside, N. J.
EXOPHTHALMIC GOITER AND HYPERTHY- ROIDISM
This condition has much in common symptomatically with the symptom-com- plex under discussion, but the studies un- der the direction of Peabody show that there is not the increase of basal metab- olism which is present in hyperthyroid- ism. The tremors are coarse and the characteristic eye signs are inconstant. The work of Sturgis and Wearn with epinephrin show an atypical reaction. Then, too, the tachycardia in hyperthy- roidism is more constantly present when the patient is at rest, and Lewis showed that these cases did not have a hypersensi- tiveness to thyroid extract.
Acute pulmonary tuberculosis must also be differentiated at times. The fact that the effort syndrome cases are afebrile, and the negative sputum examinations with the absence of moisture in the lungs, are points in differentiation.
The differentiation of severe anemias, acute infectious diseases and diseases of purely pulmonary origin will simply be mentioned as they can be excluded by the well known methods of diagnosis.
CARTER: THE EFFORT SYNDROME IN CIVIL PRACTICE
867
Prognosis.—This is based by Lewis on the reaction of the patients to graded physical exercise, but in civil practice it is a complex matter, for here we have to adjust treatment to the patient’s social and occupational condition. Then, too, the question of inferiority as shown by constitutional psychopathic states has a great bearing on prognosis, but that many of these patients can be benefited and not a few cured is borne out by the experience of all who have had to treat this class of case. Lewis in soldiers showed that 20 per cent of his cases were returned for general duty. Thirty per cent for harden- ing or labor and 30 per cent for light or secondary work. This was up to 1918. This shows that he benefited 70 per cent of the patients under his care.
In civil practice we judge that a higher percentage would be improved because there would not be the trenches to look forward to if they fully recovered.
The etiology of this condition is still a mooted question. DaCosta considered the condition as due to the result of infections and as most likely a functional disorder going on to organic change in the heart and benefited by drugs.
Alfred Cohn considered the condition as essentially a neurosis, depending on fear or anxiety. This deduction was made Ls observation on soldiers in the A.
Lewis uses the term “effort syndrome” to describe this symptom complex inde- pendently of its manner of production, but can not find a definite etiological factor.
Others have looked upon the condition as hypercitation of the sympathetic ner- vous system and Campbell has called at- tention to the great importance of inferior- ity whether physical, intellectual, instruc- tive or emotional.
Sir James Mackenzie considers the con- dition as probably not cardiac in origin and stresses the importance of the central nervous system as a possible causative factor.
Bridgman concludes that there may be a number of factors causing this clinical picture.
Treatment.—This, of course, will vary as to what is considered the underlying etiology of the condition. DaCosta
868 SOUTHERN MEDICAL JOURNAL
thought that drugs had a definite place in the treatment of this condition.
Lewis considers that graded exercises are the method of election in treatment as well as in sorting this class of case. Al- though DaCosta pointed out the great im- portance of graded exercises, he stressed in addition the necessity of drugs, which Lewis considers contraindicated.
Alfred Cohn considers the condition as essentially a neurosis, and _ therefore stresses the importance of doing all possi- ble to increase the morale of these indi- viduals. He doubts the fact that the graded exercises of Lewis are of benefit in the real essential neurosis which under- lies this condition.
Those who consider that hypercitation of the sympathetic nervous system is the basic factor advise such drugs as epine- phrin in its treatment. But a fact which can not be overlooked is that Lewis ob- tained better results with his graded exer- cises than is reported elsewhere.
Briefly, the following points would seem to cover the method of treatment:
(a) Prophylaxis—Place patients who recover from acute infections on graded exercises, before they are allowed to take up their former vocations, for no matter what may be our opinion as to the etiology of this condition, the fact that many cases occur after acute infections is borne out by all studies upon this subject. Be sure of your diagnosis of cardiac damage before telling a patient, as otherwise you may cause chronic invalidism.
(b) Curative—A word of caution as to hospitalization. These patients, from the experience of nearly all observers, do badly if treated in hospitals, and if made bed patients under digitalis treatment as a rule become refractory to any form of treatment. This question is ably taken up by Parkinson.
Graded exercises as outlined by Lewis varied from time to time to prevent mo- notony and investigation of the patient from a neuropsychiatric point of view, full diet and encouragement. At times a change of environment is essential in treatment of these cases.
Drugs of all kinds should be avoided if possible. The question of treatment is
December 1920
given briefly because this subject is al- ready covered in the literature. SUMMARY AND CONCLUSIONS
The effort syndrome is of frequent oc- currence.
It is amenable to treatment in many cases.
Further studies are necessary before its
true significance will be appreciated. BIBLIOGRAPHY Peacock: Mentioned by Hoover in Osler’s Modern
Medicine. DaCosta: On Irritable Heart, a Clinical Study of a Form of Functional Cardiac Disorder, and Its Conse-
quences. Am. Jour. Med. Sc., 1871, 1-82.
Cohn: The Cardiac Phase of War Neuroses. Am. Jour. Med. Sc., October, 1919.
Lewis: The Soldier's Heart and the Effort Syndrome. Paul Hoeber, Publishers.
Connor: Cardiac Diagnosis in the Light of the Experiences with the Army Physical Examinations. Am. Jour. Med. Se., December, 1919.
Campbell: The Role of Instinct, Emotion and Per- sonality in Disorders of the Heart. Jour. A. M. A, 1918, LXXI, 1621-1626.
Parkinson: Digitalis in Soldiers with Cardica Symp- toms and a Frequent Pulse. Heart, 1915, VI, 321-336.
King: Osculatory Phenomena of the Heart in Nor- mal Men and in Soldiers with the Irritable Heart. a of Internal Med., July, 1919, vol. XXIV, pp. 89-97.
Wearn & Sturgis: Studies on —__———-— Effect of Injection of — on Soldiers with Irritable Heart. Archives of Internal Med., September, 1919.
Bridgman: Notes on the Group of Symptoms Desig- nated Effort Syndroms. Johns Hopkins Bulletin, 1919, XXX, 279.
Maskenzie, Sir James: The Soldier’s Heart. British Med. Jour., August, 1917, II, 139-141.
Smith: Teleroentgen Estimations of Heart Size in Effort Syndrome. Archives of Internal Med., May, 1915, 1920.
Peabody, Wearn and Tompkins: The Basial Meta- bolism in Cases of “Irritable Heart of Soldiers.’’ Med- ical Clinics of North America, 1918, 507-515.
DIARRHEA RESULTING FROM BILIARY INSUFFICIENCY
By WILLIAM HOWARD LEwIs, A.B., M.D., Rome, Ga.
During a period of over three years’ clinical service at the Mayo Clinic, the writer encountered one case of extreme diarrhea of the “fatty” type which re- sponded remarkably to the feeding of bile salts. At that time, this had been the only experience of its kind at the Clinic and no rational explanation of its etiology was arrived at.
Since taking charge of the diagnosis department at the Harbin Hospital, four identical instances have been met with in a total of over 700 cases coming under observation. As the original patient above referred to came from Knoxville, Tenn., and since a like proportion of cases was
Vol. XIII No. 12
not met with at the Northern clinic, the question arises as to whether or not this disease may be peculiar to the Southern section of our country.
Briefly summarized, the following facts stand forth. The patients were all adults— in three instances with no antecedent di- gestive nor bowel disturbance of any mo- ment, nor history in any way suggestive of gall-bladder disturbance at any time in their lives; and in four never jaundice nor acute abdominal attacks. With no evi- dent exciting factor they were taken within the course of a few days with abdominal uneasiness, rumbling and gas accompanied by frequent semi-formed or semi-liquid bowel movements. These increased to as many as ten to fifteen in twenty-four hours and were absolutely indifferent to diet, fasting or medication. The stools were grayish and offensive, never a nor- mal color and undigested elements were grossly evident. In spite of the intake of a reasonable amount of food, weakness and emaciation became rapidly marked, in sev- eral months as much as forty to sixty pounds being lost.
The physical examination in these cases elicited very little of note. The procto- scope failed to reveal any ulceration. The abdomens were pliable and no gross pathol- ogy was palpable. Stool examination on the warm stage gave no evidence of para- sites. There was a large amount of undi- gested protein and vegetable matter with corresponding quantities of fat and fatty crystals. The tests for bile indicated its absence or presence in_ insignificant amounts. There was no _ appreciable blood.
Consideration of the intestinal physi- ology in the original instance suggested to the writer that the condition was due to perverted bowel digestion. The pan- creatic secretion is the fundamental agent in this function, but operates in conjunc- tion with the hepatic secretion of which the bile and its salts are the most essential. Without the presence of bile the activity of the pancreatic ferments is greatly re- duced. There is evidence that the prod- ucts of such faulty digestion are irritating to the bowel, resulting in gas formation
LEWIS: DIARRHEA 869
and frequent bowel movements. This is a familiar phenomenon in obstructive jaun- dice.
Operating upon this hypothesis, in the lack of all other reasonable evidence, the patient was given ox gall at regular pe- riods with and after food. The result was immediate and remarkable. The bowel movements within forty-eight hours be- came of almost normal consistency, re- sumed a natural color, were reduced to two or three in twenty-four hours; all abdom- inal distress disappeared ; and, in fact, the entire disturbance ceased. This same ex- perience holds true of the four cases seen recently at our Clinic. One case gained thirty-five pounds in thirty-five days and another ten in eight days. There was no other measure employed; their former mixed diet was unchanged; and no addi- tional medication given. From thirty to sixty grains of ox bile was administered in twenty-four hours. The original case could not for over a year discontinue the bile without the return of the diarrhea, at the end of which time she was lost track of. The recent cases are still upon bile feeding and it is too early to say if it can be discontinued, although two of them have almost dispensed with it.
The question has been broached in re- gard to the relation between these cases and pellagra. Two of them had had a mild sore mouth on previous occasions and a rather dry skin, but no definite eruption nor the other associated features custom- arily attributed to pellagra. They had, however, been regarded by other physi- cians as probable pellagra subjects. If pellagra were related to a faulty intestinal digestion as above indicated, the real pel- lagrin would not improve upon the crowd- ing of proteins and fats (milk) which is their most advantageous treatment. It ap- pears to the writer that these cases repre- sent a distinct clinical entity, due appar- ently to a deficiency in the bile secreting function of the liver.
There does not seem to be any plausible explanation for this deficiency and no other physiological activity appears to be disturbed, as the patients are all returned to complete health by the administration of bile alone.
Soe ame 4
Sowers
—
870 SOUTHERN
The discovery of this group within a period of eight months suggests that it is not an uncommon condition in this section of the country, and this synopsis is pre- sented in the hope that the attention of other observers will be directed toward it. For lack of a better term the writer has referred to it as diarrhea due to biliary
insufficiency. CASE REPORTS
Case No. 1.—Mrs. M. M., Knoxville, Tenn., age 34, was seen January 29, 1912. Family history was negative. She had had two children and one miscarriage. Weight one year before was 178. No previous illness of note.
Eighteen months previously she began a wa- tery diarrhea which had persisted till then. There were eight to ten movements daily. She had been operated upon for hemorrhoids six months previously. Sixty-five pounds below weight. Much abdominal discomfort.
General examination was essentially negative. Proctoscopic examination was negative. Three stools showed no parasites, but a great excess of neutral fats.
The patient was placed upon bile feeding, whereupon the stools became more normal in character and only two or three in twenty-four hours. After a week’s time fats were crowded and a marked diarrhea returned and eight pounds were lost in three days. The patient was re- turned to fat-poor diet and gradually allowed liberal food. In a letter received some months later the patient stated that sne was in normal health and the bowels were normal, but that she could not dispense with the bile.
Case No. 2, 1044.—Mrs. M. B., Rome, Ga., age 43, seamstress, presented herself on November 21, 1919. Family history was irrelevant. She had two children. One miscarriage 13 years before. Twenty-two years previously she had had a year of jaundice (questioned) and malaise; typhoid at 15, and influenza one year previously.
An indefinite chronic indigestion existed for 15 years; not periodically; there was gas and “sour” stomach not related to food or ease. There had been six mild attacks of general abdominal distress for about an hour over that period. She had had some “uncomfortable” feeling about ths entire hepatic area for years. The mouth had felt raw for years. She had had a ravenous appetite. Her normal weight(?) was 120.
There had been a periodic diarrhea for four years; formerly for only a week at a time, but it had become more protracted and the present pe- riod had extended over four months. Much ab- dominal rumbling, pressure and distress had ex- isted. There had been two to six movements a day, consisting of grayish liquid stools with un- digested food.
The patient appeared colorless, emaciated and weighed 121 pounds. Tongue had the appear- ance of beef, but there were no ulcers. Pyorrhea
was present. The chest was negative. The abdo- men was quite distended and tympanitic and not There was a perineal tear, there were
tender.
MEDICAL JOURNAL
December 1920
large hemorrhoids, the vaginal walls were under pressure (fluid?), and there was edema of both legs extending above the knees.
Proctoscopic examination was negative. The stool was a pasty gray; much fat and crystals, and no evidence of parasites on two examina- tions.
November 21.—The patient was given bile with a general diet.
December 1.—The abdominal distress had all gone and the distension was much less, but there were still several bowel movements daily. The amount of bile was increased.
December 26.—Weight 110; edema and fluid all gone for first time in months. No diarrhea for two weeks. Formed, brown stool.
April 12.—Feels fine; weight 125 and eats freely, but still has to use a few tablets a day.
Case No. 3, 1195.—D. L., farmer, age 28, sin- gle, came on February 9, 1920. He was referred by Dr. Floyd. Aside from typhoid at 17 he had been in perfect health. Normal weight, 156.
Seven months previously he began to have a diarrhea which had persisted up to the time he was seen by me. Seven to ten bowel movements occurred in twenty-four hours. Stools were white and pasty. There was much gas and abdominal uneasiness. Rapidly lost weight and strength and had done no work in that time. He had been in bed much of the time. A diet of milk and eggs did not relieve him. Frequent cramp in legs had been complained of.
Examination showed a pale, emaciated man, weight 121 pounds. Tonsils were large, there was pyorrhea, and the tongue was dirty, but not raw. Chest negative, abdomen distended and tympanitic, pelvis negative.
Prostoscopic examination was negative. Ex- amination of several stools showed a pasty, gray, undigested food and fat crystals and no para- sites.
February 12.—Bile feeding; soft diet.
February 17.—Half the number of stools; some color; feels much stronger and no cramps. Bile increased.
March 27.—Has had influenza and been in seri- ous condition. Weight 116. Two to three bowel movements daily.
April 10.—Feels stronger. One to two bowel movements daily, formed, normal color, and no gas nor distress.
May 29.—Back at work; eating heartily; weight 156. Can not get away from bile.
Case No. 4, 1441.—Mrs. A. Q., aged 44, Rome, Ga., referred by Dr. McCall. Lives in country. Family history negative. One child eighteen. No miscarriages. Menopause two years ago. Aside from some chronic throat trouble and influenza fifteen months ago, no illness of note. The pa- tient was very unintelligent and a clear history was not obtainable. There was a history of a chronic indefinite indigestion for twenty years. For five years diarrhea; constant; five to ten bowel movements daily; griping and abdominal uneasiness. Stool colorless. Appetite good. No acute abdominal attacks.
Patient is emaciated and very weak; in bed; pale; false teeth (for years) ; tongue clean; chest
Vol. XIII No. 12
negative; abdomen lax; sigmoid thickened; pelvis clear; weight, 72 pounds.
X-ray of stomach and colon essentially nega- tive. Proctoscopic examination negative. Three stools negative for parasites. Grayish, dirty liquid stool, undigested food and much fat and fatty crystals.
May 13.—Bile feeding; general diet.
May 17.—Abdominal distress gone; one bowel movement in last twenty-four hours; semi-formed and brownish.
May 22.—Formed stool; normal color; one each day; up in chair first time since arrival. Left hospital.
August 25.—No diarrhea since going home. Weight, 110 pounds.
Case No. 5, 1687.—Mrs. D. B. J., age 31, came on July 26, 1920. One child six months old. Family and antecedent history of no moment. Two years previously had two weeks of diarrhea. Has had two operations for cleft palate, in 1911 and 1912.
Immediately after delivery in South Carolina began to have a diarrhea which had persisted up till she came to me. Twelve to fifteen bowel movements daily, watery, clay color and undi- gested stools. Much griping, soreness and dis- tention. Diet no factor. Has had sore mouth all her life, especially during the previous six months. Normal weight, 135 pounds.
Pale; weight 90 pounds; pyorrhea; tongue slightly raw and chest, abdomen and pelvis neg- ative. Prostoscopic examination negative. Stools gray and dirty; semi-liquid; no parasites; much fat and many ¢rystals. Placed on bile and gen- eral diet.
July 29.—Abdominal discomfort all gone; still has six to eight bowel movements daily; color better and stools more formed. Bile increased.
August 10.—Weight, 974% pounds; feels much stronger; distress all gone; one to two bowel movements daily; semi-formed and brown.
HERPETIC SORE THROAT
By JOHN ZAHORSKY, M.D., Professor of Pediatrics, St. Louis University,
St. Louis, Mo.
INTRODUCTION
There is still much clinical and experi- mental work needed to clarify the common and less serious diseases of childhood. For example, the ordinary infections of the mouth are by no means clearly under- stood, with the possible exception of thrush and ulcerative stomatitis. When we con- sider the innumerable diseases of the throat the clinician usually throws up his hands. It is enough to exclude diphtheria and scarlet fever. Everything else re- ceives the appellation of either tonsillitis
ZAHORSKY: HERPETIC SORE THROAT
871
or pharyngitis; or we cover up our ig- norance by the convenient term “grip.’” All will admit, however, that an etiological classification of pharyngeal and tonsillar inflammations is very desirable. But be- fore this can be achieved distinct clinical syndromes must be clearly outlined.
It is with this object in mind that I wish to call attention to a peculiar sore throat, which has not received any attention in recent years, and none at all in American literature. One has to go back many years to find any reference to this disease, and yet it is, at least in St. Louis, a very com- mon affection during the summer months. I refer to herpetic sore throat.
Moro (Pfaundler & Schlossmann) refers to stomato-pharyngitis herpetica in his article on stomatitis macula-fibrinosa as being an affection of the posterior margins of the mouth and pharynx, and evidently refers to this disease. No description is found elsewhere in this work.
ETIOLOGY
The disease occurs-in the summer months. Of 82 cases studied the inci- dence was as follows: June, 11 cases; July, 24 cases; August, 28 cases; September, 13 cases; and October, 6 cases. In different years the disease occurs in different months. Thus, in 1917, most of the cases occurred in June and July, while in 1920 most cases were seen in August and Sep- tember. In some years very many cases are seen, as in 1917 (37 cases).
The disease usually affects children be- tween the ages of 3 and 10 years. The epidemic nature of the disease is very probable since the affection occurs in groups. When one case is encountered in the following weeks many cases will be seen.
The contagiousness of the affection is clearly established in family practice. When several children are in the same family, it is a common experience that sev- eral, if not all, acquire the disease. The stage of incubation was established in a few cases only and varied between 4 and 10 days. We have made several smears from the lesions, stained them, and found only the same bacteriological picture, which is usually obtained from secretions of the mouth and throat.
872 SOUTHERN MEDICAL JOURNAL
SYMPTOMS
The disease begins suddenly with a high fever (102 to 105 degrees). A marked chill was not observed. In one child a severe convulsion ushered in the general symptoms. Vomiting was _ frequently present, but only once did it continue for two days. The children complain of being tired, have headache and backache. Severe prostration did not occur. Diarrhea was observed only a few times and was not severe.
SIGNS
On examining the child nothing is found except the characteristic appearance of the mouth and throat. On superficial in- spection a tonsillitis will be diagnosticated, since the tonsil is always swollen, the pil- lars of the fauces congested, and a slight grayish exudate is often found protruding from the crypts of the tonsils. But on more careful inspection the characteristic vesicles or ulcers will be seen. They are not usually numerous: two to six is the rule. In one case I counted twelve. They are generally situated on the soft palate, most frequently on the free-hanging mar- gin between the tonsils and the uvula, or on the anterior pillar of the fauces; but one or more vesicles or ulcers may be found on the posterior part of the buccal mucous membrane. I have several times found one or more vesicles or ulcers on the surface of the tonsils. Often one or more vesicles are located on the pharyn- geal wall. These vesicles are the size of a small pea or wheat grain. They are marked by a red areola the size of a pea, the center of which has an elevated, gray- ish-appearing blister. Most commonly the larger blister bursts and leaves a punched-out ulcer surrounded by a gray ring of dead epithelial layer and this is surrounded by a dark red areola. The surface of the ulcer often shows a thin grayish deposit.
The course of the disease is uniformly favorable. The child refuses food for a
December 1920
few days on account of the pain on deglu- tition. Salivation is not marked. There is no offensive odor from the breath. The fever, which is irregular, subsides in two to five days and the ulcers in the mouth rapidly heal. Severe exudative tonsillitis has occurred in a few cases as a complica- tion, evidently a secondary infection.
DIAGNOSIS
The diagnosis depends upon the visible ulcers in the posterior part of the mouth and throat. Once I mistook an ulcerative stomatitis, which began with white spots in the posterior part of the mouth, for the herpetic sore throat. But the implication of the margin of the gums and the ap- pearace of a fetid odor on the second day caused me to correct the error. At an- other time a boy, who had his tonsils re- moved, had a severe angina with small grayish spots over the pharynx, which early resembled the disease described, but later it was found that the small gray de- posits were bits of exudate protruding from the hypertrophied pharyngeal lymph granules. One child who had her tonsils completely removed showed several ulcers on the pillars and pharynx.
I have not seen a recurrence in a single child. It is suggested, therefore, that a permanent immunity is produced by one attack.
TREATMENT
Nothing but symptomatic treatment seems necessary. Potassium chlorate was given internally in most cases. It is nec- essary to look after the feeding as in all painful inflammations of the mouth or throat.
I have nothing to suggest as to the na- ture of the disease. It has been suggested that the virus may have its source in milk or ice cream. That it has any relation to the foot-and-mouth disease of cattle is ex- tremely doubtful.
536 N. Taylor Ave.
& 5
Vol. XIII No. 12
GORGAS, CARTER AND LYSTER: YELLOW FEVER
873
TROPICAL DISEASES AND PUBLIC HEALTH
YELLOW FEVER: ITS DISTRIBUTION AND CONTROL IN 1920
By W. C. Gorcas, M.D., H. R. CARTER, M.D., and T. C. LystTerR, M.D., The Yellow Fever Commission of the In- ternational Health Board, Rocke- feller Foundation.
INTRODUCTION
Yellow fever, commonly considered a tropical or semi-tropical disease, has often spread pandemically well beyond these geographical limits. Bolivia is the only country in the Western hemisphere, so far as is known, that has not been visited at least once by yellow fever, and some countries have been visited many times. The reason that Bolivia escaped was due to its having no coast line or low altitudes. Hence, no stegomyia. Western Europe and Africa have had frequent epidemics.' Whether West Africa is an endemic area at the present time is being investigated by a combined British and American com- mission under the auspices of the Rocke- feller Foundation. The question as to why yellow fever has not spread to oriental regions* is one of those epidemiological mysteries which can almost but not quite satisfactorily be explained. Despite the long and indirect sea route from the west to the east coast, then to India, there must have been occasions when the danger of introduction was imminent. So far as we know, Asia is and has always been free. Whether Africa will infect Asia will de- pend upon effective anti-yellow fever work in Africa. The Panama Canal,’ instead of increasing the risk, has on the contrary proved a most effective barrier against American sources.
1. Distribution in the Nineteenth Cen- tury.—The nineteenth century saw yellow fever reach its peak in the Americas. As this period drew to a close and the twen- tieth century dawned, developments oc- curred which spelled the approaching end of a disease that has been one of the most
destructive of life and commercial pros- perity ever known to man. Its rapid spread, high mortality, and the resulting isolation by quarantine enforced by ter- rorized communities, made the disease so dreaded that shotgun dead lines were the rule rather than the exception in the United States.
Two Controlling Factors.—(a) The first of two controlling factors which were des- tined to markedly influence the spread of yellow fever was the change from sail to steam as a motive power for ships. The sailing ship, with its system of deck tanks and barrels for holding a drinking water supply, was well adapted for maintaining on shipboard a constant, liberal and acces- sible supply of a certain species of mos- quito (Stegomyia calopus or fasciata). The introduction of one case of yellow fe- ver was sufficient to insure an epidemic limited only by the number of non-im- munes on board. Since steam vessels re- placed sailing vessels, fresh water has sel- dom been carried except in tanks inacces- sible to mosquitoes. Thus it happened that even before we knew the method of spread the process of elimination had begun.
(b) When in 1900 the Reed Yellow Fe- ver Board,‘ in Havana, proved the cor- rectness of Dr. Carlos Finlay’s® theory of the transmission of yellow fever by the bite of a special kind of mosquito when infected, and greatly amplified the control of the disease by giving us accurate data relative to its etiology, the sanitary organ- ization of Havana, under Gorgas,* was prepared to give practical conclusiveness to the findings. Yellow fever was now practically eliminated from Havana — the great endemic center—and later from other endemic centers, such as Panama, Rio de Janeiro, and Vera Cruz. Our pres- ent methods of elimination’ are but devel- opments along the general lines found ef- fective in Havana. Naturally, advantage has been taken of the fund of information now available, but the original general principles still hold good. Yellow fever campaigns have gradually settled down to an active warfare against the larval and
874 SOUTHERN MEDICAL JOURNAL
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During the nineteenth century epidemics occurred as far south as Buenos Aires and as far north as Montreal.
In 1899 and 1900, due largely to the change from sail to steam, the areas had contracted, especially at the upper and lower limits, leaving the central arens much as of old.
In 1905 and 1906, knowing then the role played by the stegomyia in the distribution of yellow fever, the endemic center of Havana had been freed, resulting in the epidemic areas in Chile, Peru, the United States (Louisiana ex- cepted), and most of the West Indies, either freeing them- selves through natural causes or by the use of sanitary measures.
In 1914 and 1915, the World War largely prevented maritime
commerce, by far the greatest distributor of this disease. Active warfare had been waged against yellow fever by almost every infected country. A second endemic center, namely Panama, had disappeared in 1905, and the Bra- zilian endemic area had been greatly reduced in size. The area around Buenaventura and Caracas had become epi- demic rather than endemic in character. Epidemics had largely been confined to southern Mexico, western Colom- bia, and within some small areas, all coastal, from Caracas to Pernambuco.
Brae
Vol. XIII No. 12
pupal forms of stegomyia fasciata. Other preventive measures are secondary, even the isolation of patients. Reduce the total number of stegomyia to a certain percent- age (below the critical number)§ and yel- low fever automatically disappears. This reduction is best accomplished by prevent- ing the attainment of maturity, and if possible the breeding of stegomyia larvae. Only too often other preventive measures end in delaying the elimination, which will a more fully discussed later in this arti- cle.
2. Maps of Distribution.—The series of maps of the greater part of the Western hemisphere are here included to show by contrast the areas involved —past and present. Different periods have been chosen with a view to bringing out boldly the constantly narrowing limits of the dis- ease, which once roved at will but is now taged in but two endemic and two small epidemic areas. Until these two last Amer- ican endemic areas are freed we can never feel safe as to the probability of occa- sional epidemics of limited distribution in neighboring countries. We use the terms “endemic” and “epidemic” to contrast an area having the disease constantly and indefinitely but never in great numbers, with one having the disease only occasion- ally and then in what is usually an exten- sive form, both as to the number of cases and the area of spread.
3. Methods of Control of Yellow Fever. The difference between theoretical and practical sanitation as applied to the elim- ination of yellow fever has been responsi- ble for much delay and confusion when- ever a country has been invaded by this disease. The great variety of suggested and applied methods, usually impractica- ble and expensive, lessened public confi- dence and aroused opposition. Stress was usually laid upon such procedures as quar- antine,°® isolation of the sick and contacts,'” drainage,'! water supply improvements,'* sewage system,’ fumigation,' — even the evacuation and reconstruction of a city.’ Only recently have all efforts been confined to the prevention of breeding and the de- struction of larval and pupal forms of stegomyia. Until 1900, when we became sure that a species of mosquito, stegomyia fasciata, was responsible for the spread
GORGAS, CARTER AND LYSTER: YELLOW FEVER 875
of yellow fever,'® sanitary advisors were groping in the dark for methods of (a) prevention of introduction, and (b) elim- ination.
(a) Prevention of Introduction."—1. Quarantine. Quarantine, often so rigid as to be ruinous, was the most frequent and favored means of resistance to the spread of yellow fever. With our extended knowledge, quarantine, if intelligently ad- ministered, may with safety be gradually relaxed to the point of detaining only se- lected passengers for limited periods, pro- vided infected stegomyia are not aboard the vessel. Their presence on the vessel can usually be prevented by choosing a proper anchorage. Time spent in a non- infectible port before embarkation, and time spent on board a non-infectible ship, is now counted as part of the usual six-day quarantine period. Thus reduced, a quar- antine of this character interferes but lit- tle with the traveling public and not at all with commerce. Cargo has long since ceased to be considered infectible, so its handling is expedited.
2. Immunity by Lowering Stegomyia Index.—A_ second preventive measure against introduction has been to lower the stegomyia index of the larger cities of a country, especially of its seaports, so that when active cases of yellow fever are introduced no spread of the disease results. This, after all, is the surest and cheapest of all preventive measures.
(b) Elimination.—When, however, yel- low fever has gained admission to a coun- try, the methods of elimination will de- pend upon the efficiency of its sanitary or- ganization.
1. Fumigation.—The first choice has usually fallen upon fumigation, the most unsatisfactory of all. Our experience gained in Havana and Panama convinced us how unreliable fumigation really was. Twice was Panama thoroughly covered, in 1905 and 1906, by house-to-house fumiga- tion, with no apparent effect toward the elimination of yellow fever. Not until the stegomyia index was lowered beyond the critical number, as the result of the intro- duction of a piped water supply, was the disease eradicated. Experience has con- vinced us that fumigation, except in spe- cial cases, despite its theoretical advan-
876 SOUTHERN MEDICAL JOURNAL December 1920 tages, is often of doubtful value in tive use of mosquito bars is beyond the practice. Admitting that infected ste- means of the average resident of an epi-
gomyia are killed in each disinfection, the great cost, the decreased mobility of the organization, and the diverting of men trained in sanitary work when most needed for anti-stegomyia work, to say nothing of public opposition, far over-bal- ance any apparent good. By the liberal use of a yellow fever vaccine now in our
TRINIDAD ow’ Cartagena ®caracas oot s goth
™ Cayenne Paras.
Pernambuco, (Recife
Buenaventura’
Paita
jahia
Rio de Janeiro
1917-1918 MB ENDeEmic
EPIDEMIC
In 1917 and 1918 but three endemic areas remained, although epidemics had spread to Guatemala, Salvador, Honduras, Nicaragua and Peru. One small epidemic area, namely, Coro, was found in Venezuela in 1917.
hands (Noguchi’s), it will not be long be-
fore sanitary organizations having a sup-
ply of this vaccine will much prefer its use to fumigation. General fumigation by inhabitants always does harm.
2. Isolation.—The early isolation of yel- low fever patients has always been and still is most desirable, but it is most diffi- cult to accomplish. Especially in Latin- American countries the early use of a hos- pital for any disease is rare. The critical period of three or four days at the begin- ning of a case of yellow fever has usually passed before the case has been officially seen, much less hospitalized. The use of screening is impracticable except amorg the wealthier classes, and even the effec-
demic or endemic area. These measures are, however, encouraged whenever and wherever practicable, but not at the ex- pense of diverting money and popular support which could otherwise be used effectively to lower the stegomyia index.
3. Vaccines and Serums.'8—The bril- liant work of Noguchi in discovering the
BERMUDA
Buenaventura
Georgetown Paramaribo pe
1919
ee ENDEMIC
V4 EPIDEMIC
In 1919, epidemics continued in Central America and north- ern Peru. Three endemic areas still remained. The dis- ease had disappeared from Venezuela.
organism causing yellow fever (Lepto- spira icteroides) already is having some effect on the control of this disease. In 1919, the Rockefeller Institute kindly lent Dr. Noguchi to the Rockefeller Founda- tion to assist in solving the yellow fever problem in Guayaquil, Ecuador. Dr. No- guchi arrived in Guayaquil in the summer of 1918, and was there successful in dis- covering a spiral organism which he suc- cessfully inoculated into guinea pigs and other animals. On returning to the United States with living specimens both in cul- tures and in guinea pigs, he completed his work and was able to produce both a cura- tive serum and a protective vaccine. Gen- erous use has already been made of this
Vol. XIII No. 12
discovery. Patients have been given anti- yellow fever serum (Noguchi’s) with ap- parently most beneficial results.'® A vac- cine has been made, and while not ab- solute in its protection, it seems reason- able to hope that, as a protective vac- cine, it may be classed among those found useful in infectious diseases. The number of vaccinations performed in man has up to the present been far too limited
JUNE 1920
& ENDEMIC
WY, EPIDEMIC
Rio de Janeiro
In 1920 Guayaquil was free, leaving but two endemic cen- ters, the east coast of Brazil and the Yucatan peninsula. Epidemic areas of northern Peru, Salvador and southern and western Mexico continued.
and has not been governed by controls, so
that definite conclusions can not be drawn.
The protection given animals in the labora-
tory, however, is positive. There seems
little doubt as to the future place that both the serum and vaccine will have in preventive medicine.
4. Anti-Stegomyia Measures.*® — The last twenty years has seen marked changes in the methods used in reducing the pro- duction of stegomyia. Many of us can remember the drainage of swamps and the cutting of grass and foliage on a false suspicion that these activities were of value as preventive measures. Little by little we have learned by experience how
GORGAS, CARTER AND LYSTER: YELLOW FEVER
877
thoroughly domestic and how almost feline in her daintiness is the stegomyia. Her habits, as only the female can feed on man or animals, are now so well known that useless preventive measures are not even considered. We have learned many things which have helped us in lowering the ste- gomyia index of an area. For example: we see that cities differ as regards breed- ing places for stegomyia, depending upon
Van metes \ LEYS Punnee P ¢ BERMUDA wae ° 4% fa) Ont 2 . a iy 4 ~ MS 7 jm Acapulco ‘ / af ~~ ayy 7 — ISLANDS we i os y we. $f — o. Nhe ra Thanacs Pernambuco Recife a®. NOV. 1920 | “ - BB envemic NS EPIDEMIC ,
Nov. 1, 1920.—Since this article was written, in June, 1920, the epidemic area of Central America widened to in- clude Guatemala and Nicaragua and again has contracted to a small area in Salvador which is approaching elimina- tion. The epidemic area in Peru also has about reached the point of elimination. The epidemic area of Mexico has widened to include its total coast line and southern border,
the habits and customs of the people rela-
tive to the use and storage of their drink- ing water, whether it is piped, drawn by hand from river or well, or collected, dur- ing rains, in cisterns, barrels, or other con- tainers of all sorts, shapes and descrip- tions. Stegomyia adjust themselves by adaptation to these conditions, and the recognition and prevention of breeding in the predominant type of container is of
greatest importance, for on it depends im-
mediate success. A rapid survey followed
by an equally rapid elimination of the number of breeding places not only checks the spread of the disease, but recently, to
878 SOUTHERN MEDICAL JOURNAL
our pleasure and surprise, in Central America’ has been sufficient to end an epidemic. The great saving in lives and money, to say nothing of the commerce of an infected community, that results from reaching the controlling factors at once, will be readily appreciated.
It may be of interest to know just where the difference lies in quite a number of cities in which our commission has either directed recent yellow fever campaigns or acted as technical advisors in them. In Guayaquil, Ecuador,” the chief breeding was in storage tanks, usually on the roofs of houses. Properly covering these tanks proved to be the controlling factor in re- ducing the stegomyia index below its crit- ical number, thereby eliminating the dis- ease. In Corinto, Nicaragua,** on the other hand, there were not tanks, but wells instead were usually responsible as breed- ing places. Covering these wells prop- erly and installing hand pumps solved the stegomyia problem in that port. In Leon, Nicaragua, cement tanks called ‘“‘pilas,” usually in the yard and half full of rain water, were found in 6,000 of the 8,000 houses of that city. These “pilas’’ were drained by making an opening near the bottom, and the tenant or owner was al- lowed to use them upon condition that he would remove the stopper from the drain at least once a week. In Recife,”' in the State of Pernambuco, Brazil,’ over 80 % of the breeding of the stegomyia was in stone jars called “jarras.” These ‘“‘jar- ras,” shaped somewhat along the lines of Grecian vases, held from five to forty gal- lons. Frequently emptying these “jarras,” or covering them with a cloth towel, solved the problem here. The list could be extended almost indefinitely. This all goes to show how easy is stegomyia con- trol at times, if an accurate sanitary diag- nosis is made and followed up.
4. Epidemics in Recent Years.—Epi- demics in the seventeenth century, as de- scribed by La Roche, give us a very defi- nite picture of conditions in cities such as New York and Philadelphia when invaded by this disease. Quarantines even in those years were much used, and the peo- ple being in the dark as to the means of spread of the disease, were naturally ter- rorized because of their not knowing when
December 1920
and from what direction the disease would come. Gradually, as years went on, the forces of civilization have prevented the spread of yellow fever, until now epidem- ics, when they do occur, are soon walled off by the activity of neighboring communi- ties. The present epidemic in Peru,'’ as well as the small epidemic now in Salva- dor, is or soon will be under absolute con- trol. Epidemics such as occurred in the last century we feel sure never can occur again unless the disease be introduced into southwest Asia.
5. Endemic Centers, Past and Present. In 1919 there were three well-known en- demic yellow fever areas, namely: (1) Ecuador, (2) East Coast Brazil, and (3) Yucatan Peninsula.
1. Ecuador.**—History shows that yel- low fever was probably introduced from Panama into Guayaquil, Ecuador, in 1848. There may have been times after that when Guayaquil herself was free, but probably her neighborhood was infected. Evidence seems to point to her being so frequently infected as to imply a constant supply from within rather than from with- out Ecuador. Effective anti-stegomyia work has now removed this area from the list of endemic centers. Guayaquil,
’ together with the rest of the republic of
Ecuador, has remained free since June, 1919, or approximately fifteen months.
2. Brazil..—Brazil has probably been an endemic yellow fever center since 1849. Epidemics are thought to have occurred as early as 1689. However, the disease took root in the larger coastal towns, epi- demics gradually ceased, and the area be- came endemic rather from failure of the human host (Carter) than from effective anti-yellow fever measures. So far as we know, only the small coastal zone from Bahia to Recife, Pernambuco, remains in- fected. This area is now being rapidly cleared of the disease by lowering the stegomyia index below its critical number, so that there is good reason for the hope that the present year may end the career of another endemic focus. Should this prove true, there will, in 1921, be but one endemic area to combat, namely, the Yuca- tan Peninsula.
3. Yucatan Peninsula—There seems good reason to believe that the Gulf Coast
f
é bi
Vol. XIII No. 12
of Mexico was probably the original cradle of this disease in man, and that it may also be its last resting place. Just how far back the history of the disease may be traced depends upon interpretations of early writings of Spanish explorers from the time of Columbus to the middle of the seventeenth century. We know that epi- demics of unknown character did occur among the Mayans in Yucatan as far back as the first century of the Christian era. We know that these people moved from Guatemala to their present homes in Yuca- tan for some unknown cause. Explana- tions have been offered by Morley, the well-known anthropologist, that this was because of the exhaustion of the soil around their cities and villages so that corn could not be raised. While this seems the most reasonable explanation, it does not prove that diseases in the area may not have been a contributing cause. However this may be, we feel pretty sure that Co- lumbus found the disease waiting for him on his arrival, and it is believed that the disease was first introduced into white men in Santo Domingo. Epidemics oc- curred all along the coast of the Gulf of Mexico, depending upon the available hu- man host. The supply of stegomyia (Ste- gomyia index) remained almost constantly high. Anti-yellow fever measures were undertaken in Tampico and Vera Cruz. They were successful, and the disease now became confined to the Yucatan Penin- sula. Merida, the capital of Yucatan, like Havana, Panama, Vera Cruz of old, and Guayaquil and Bahia of recent years, has been a reservoir similar to the biblical widow’s cruse. These cities never seem to fail in keeping up a constant supply of yellow fever, often not much but ‘still enough. True to form, epidemics in en- demic centers occur only when there is an addition of a sufficient number of non-im- munes, either by birth or by immigration, the stegomyia index being of course as- sumed as a constant. This is our explana- tion of epidemics such as have occurred in Havana, Panama, Guayaquil, and other places, after these places have passed a period of one or more years with only a limited number of cases.
6. Purpose of the Rockefeller Founda- tion.—In 1916 the Rockefeller Foundation
GORGAS, CARTER AND LYSTER: YELLOW FEVER 879
sent a yellow fever commission, with Gen- eral Gorgas as Chairman, to make a sur- vey of yellow fever wherever it existed and to make such recommendations as they thought proper. As a result of this sur- vey the Rockefeller Foundation deter- mined to use such resources as were avail- able toward the elimination of this disease from the world by assisting sanitary or- ganizations in the various countries. As may be easily seen from the maps of dis- tribution, past and present, the areas in- volved are becoming fewer and smaller. By confining the campaigns strictly. to the prevention of the breeding and production of stegomyia, the problem has been re- duced to much simpler terms, and results in the last three years seem to give good hope of ultimate success.
GENERAL CONCLUSIONS
1. Yellow fever areas have been enor- mously reduced in size; those now exist- ing, with the exception of the Yucatan Peninsula, are well under control; and rea- sonable hope exists of eventual elimina- tion.
2. Epidemics are becoming less and less widespread due to the intelligent methods of combating the disease now in force, which consist of walling off infected areas and lowering the stegomyia index around them.
3. The etiology, pathology and _ treat- ment —both curative and preventive—are being rapidly put into conclusive form.
4. Co-operation of Latin-American coun- tries, with the exception of Mexico, has been brought about, so that the disease is now being combated under unified con- trol, in so far as outlining the plan of warfare is concerned.
5. Our belief is that immunity from yel- low fever is positive, permanent, and ac- quired.
6. We believe that anti-stegomyia cam- paigns alone are sufficient for the elimina- tion of the disease.
BIBLIOGRAPHY
1. La Roche, Rene: Yellow Fever. Phil., Blanchard & Lea, 1855. 2 v.
2. Manson, Patrick: Tropical Medicine, 6th ed. rev., New York, 1918, pp. 272-273.
3. Yellow Fever Bureau Bulletins, Liverpool.
4. Carroll, James: Transmission of Yellow Fever. In yellow fever, a compilation of various publications, 61st Cong., 3rd Sess., Doc. No. 822, Washington, 1911, pp. 175-
880 SOUTHERN
5. Finlay, Carlos: Yellow Fever; Its Tranmission by Means of the Culex Mosquito. Internat. J. M. Sc., n. s. xci: 395-409.
6. Cuba, Governor: Report of the chief sanitary officer of the City of Havana. Washington, 1900-1902.
7. Lyster, T. C.: Journal of trip to Brazil as representa- tive of the Rockefeller Yellow Fever Commission, February 5-April 18, 1920. (Not published.)
8. Ross, Ronald & Edie, E. S.: Larvicides. Ann. Trop. M. & Parasitol., Liverpool. 90.
Some Experiments on v. 385-
9. U. S. Public Health Service, Quarantine Regulations. Washington, 1900-1906.
10. Liceaga, Eduardo: the Mexican republic. 1912, viii: 174-181.
11. Clarac, A.. and Simond, P. L.: Fievre jaune, in Grall and Clarac, Traite pratique de pathologie exotique, Par. iii: 21-176.
12. Gorgas, W. C.: Report to the President of Ecuador relative to Guayaquil. 1908.
13. Ecuador. Director-general
Annual report on yellow fever in Am. J. Pub. Health, New York,
de sanidad publica. In-
forme. 1918, 1919. 14. U. S. Public Health Service, Public Health Regula- tions. Washington, 1900-1906.
15. Carter, H. R.: Report on yellow fever in the district adjacent to Piura. 1920. (Not published.)
16. U. S. Surgeon General's office. Report, Washington, 1901, pp. 176-202.
17. Carter, H. R.: The Mechanism of the Spontaneous Elimination of Yellow Fever from Endemic Centers. Ann. Trop. M. & Parasitol., Liverpool, 1919-1920, xiii: 299-311.
18. Noguchi, Hideyo: Etiology of Yellow Fever. J. Exp. M., New York, 1919, xxix: 547-596; xxx: 1-29, 87-93, 95-107, 401-410.
19. Lyster, T. C.: Yellow Fever Commission Memorandum of Activities in Central America and Mexico, 1919. (Not
published. )
20. U. S. Isthmian Canal Commission. Report of the chief sanitary officer, 1900-1907.
21. Brazil, Directoria geral de Saude publica. Informe. 1919.
M. E.: Yellow Fever Control in Ecuador, a J. Am. M. Ass’n., Chicago, 1920, Ixxiv:
22. Connor, preliminary report. 650-651.
23. Molloy, D. M.: On a reported outbreak of yellow fever in Leon, Nicaragua, and measures to be taken for its control. 1919. (Unpublished letter.)
THE RELATIONSHIP OF ALCOHOL TQ MODERN HEALTH IDEALS*
By EUGENE LYMAN FIsk, M.D., Medical Director, Life Extension Insti- tute,
New York, N. Y.
Man has advanced biologically as far as evolution can carry him — evolution con- noting that complex group of factors apart from self-directed intelligence that moulds and modifies a species. In fact, Professor Conklin, in a recent address at Princeton, submitted evidence in support of the view that biologically man has deteriorated.
While we lack precise and comprehen- sive data as to the physical condition of mankind—say 50,000 years ago—reason- ing by analogy we can at least set up a standard of original physical excellence for
*Delivered before the Fifteenth International Congress Against Alcoholism, Washington, D. C., September 21, 1920.
MEDICAL JOURNAL
December 1920
man comparable to that found in other animals in a state of nature. Measured by such standard, the human animal shows marked physical inferiority and many evi- dences of degeneration and physical insuf- ficiency. This is perhaps best visualized by those having an opportunity critically to examine many thousands of supposedly healthy people, as in the work of the Life Extension Institute, which has covered some 200,000 examinations. Life insur- ance examinations, while more limited in their extent, also offer ample evidence of physical defects, impairments and func- tional insufficiencies among so-called “av- erage people.” A few figures will illus- trate my meaning.
In the examination by the Life Exten- sion Institute of some 10,000 industrial and commercial workers, active at their work and supposedly in good average phys- ical condition, 83 per cent showed evi- dence of nose and throat defects (17 per cent marked or serious); 53 per cent showed faulty vision uncorrected; 21 per cent flat foot; 56 per cent defective teeth; 62 per cent of mouths x-rayed showed root infection; 12 per cent showed well marked cardio-renal-vascular changes; 9 per cent showed marked lung signs, including tu- berculosis.
Among 5,000 individual members exam- ined at the head office of the Life Exten- sion Institute, about 3 per cent showed ev- idence of venereal infections; 30 per cent showed albuminuria ranging from slight to marked; and 50 per cent showed some evidence of arterial change.
It may be stated from our experience that more than half of any body of sup- posedly healthy people will show need for medical, dental or surgical attention, and practically all need some revision of their personal hygiene.
Examinations for war service in this country and other countries has afforded similar testimony. It may be asked: In this present state of war and famine and world misery affecting so many millions of people, why is it necessary to dwell upon these disturbing and apparently dis- couraging facts. I take it, however, that this is a meeting of scientific men inter- ested in securing sound evidence, regard- less of which way it cuts. I am convinced
Vol. XIII No. 12
that, after all, it is the truth that shall make us free and not mere blind optimism. However, for the comfort of those that in- sist that pleasantness must be the touch- stone of truth, I may point out that there is nothing in this evidence pointing to the physical degeneration of man that should assail us with discouragement. Quite the contrary. All thinking men are dissatis- fied with the present state of human so- ciety. They are all agreed that there is too much human suffering and incapacity, but there are few people that have any adequate conception of the degree to which this world misery is due to preventable physical impairment or to faulty mental adjustment that is susceptible to correc- tion. Evidence such as I have quoted re- veals a great basic truth that is in sharp conflict with conventional traditions, even among medica] and other scientific men.
The process termed “ageing” is merely a manifestation of slowly progressing path- ological change, due to definite and, to a considerable degree, controllable physical causes, although in the minds of most men it is ascribed to the influence of time. This conventional picture, however, is wholly changed when we attain a correct perspective and clearly visualize the extent to which bodily changes and even charac- ter and personality are influenced by such factors-as chronic infection, chronic poi- soning, food deficiencies or other faulty conditions in the life or environment of an individual.
I am optimist enough to believe that, regardless of the fact that evolution has done so little for the human race, man is gifted with sufficient intelligence to make him independent to a considerable degree of the evolutionary forces that control the destiny of unreasoning animals. He has already demonstrated his ability to meet and neutralize many unfavorable factors in his environment and even in his hered- ity. It can be truthfully stated that, im- pressive as some of this work has been, it merely represents the first steps of science in controlling human development. Morti- fied and discouraged as we may be when we consider world conditions as they now exist, the lesson is perhaps a wholesome one as bringing out the profound truth that there is no innate tendency in man
FISK: ALCOHOL AND MODERN HEALTH IDEALS 881
to progress; he can not count upon a steady, a gradual progress towards the millennium unless he uses this intelligence efficiently for the direction of the devel- opment of his organism as a whole and the adjustment of it to world conditions. In the midst of present-day afflictions and deplorable tendencies, many of which may well sap our confidence in the title of humanity to occupy this footstool as a dominating organism, there may be dis- cerned some mitigating and distinctly hopeful signs. I feel that there is actually an awakening of the physical conscience of the people. Communities are becoming ashamed of high death rates and morbidity rates. Industrial corporations are recog- nizing their obligation to consider the working condition and the health of the employes. They appreciate the influence of low health standards on industrial ef- ficiency and industrial turn-over and therefore on national prosperity and hap- piness. This entirely apart from the ob- vious obligation that rests upon the com- munity to protect itself from epidemic dis- ease that can be met and defeated by ele- mentary sanitary precautions. Proceeding from the obvious necessity of governing community hygiene and insuring pure food, pure water and protection against epidemic infection, there is coming to be recognized the obligation upon the citizen himself to keep in as good condition as he expects the health department to keep the city in which he lives. There is, I believe, a gradual return among intelligent men who mould the thought of communities to- wards the old Greek ideal of physica! ex- cellence and standards for real manhood. In our complex civilization, mind has out- run the body and the dominance and power that mere mental ability brings has created a certain contempt for so-called brute strength and physical power. But, taking the people as a whole, we have abun- dant evidence of the truth of the Spen- cerian aphorism that “To be a good animal is the first requisite to success in life, and to be a nation of good animals is the first condition to national prosperity.” Be as- sured that no nation can afford to neglect this principle, that no nation can rely upon brains alone for maintaining and carry- ing forward its civilization. There must
882 SOUTHERN be underlying physical and moral excel- lence or evolution will truly operate to obliterate that nation from the map.
How does this discussion touch the al- cohol question? There is, of course, an obvious relationship, but its significance is more profound than may appear at first glance. If man is indeed to free him- self from evolutionary influences alone and mould his destiny toward higher planes of physical and mental existence through the governing power of inte!lect, he must classify and evaluate the menac- ing factors in his environment. Alcohol is obviously one of those menacing factors and is classified as a poison, but how shall we evaluate it? Paradoxical as it may seem, I believe that the prospect of a thoroughly sane and scientific evaluation increases as we come to recognize the fact that alcohol is not the one great underly- ing cause of human misery; that it is only one among a number of major factors that are responsible for human failure. As we approach the consideration of alcohol in this spirit we move away from mere emo- tional propaganda with regard to it, and we enlist the interest of the whole people in a cold-blooded consideration of the scientific evidence that is available with regard to the influence of alcohol on the human race. A striking instance of this changed attitude of mind is afforded by the recent action of the Unitarian Tem- perance Society in announcing the inclu- sion in its program of a broad health prop- aganda and an encouragement of periodic physical examinations so that a search may be made for all conditions that men- ace the health and happiness—and there- fore the moral state of the people.
It is important that these principles be widely disseminated, that the relationship of impaired personality to impaired phys- ical condition be more thoroughly appre- ciated by all who are working to improve the social condition of mankind. There has been a vast amount of wasted effort in working on the surface of conditions rather than attacking those problems fun- damentally.
Placing the consideration of alcohol, therefore, where it belongs in the general program of upbuilding the health and vi- tality and living capacity of all mankind,
MEDICAL JOURNAL
December 1929
we can consider it just as we would con- sider focal infection or a high protein diet, or over-weight, and insufficient exer- cise. There is no question but that a con- siderable number of people are sustaining more damage from _ over-indulgence in food than many people sustain from ob- vious over-indulgence in alcohol. Each form of over-indulgence is important and should be courageously attacked by the hygienist.
Fortunately, over-indulgence in alcohol can be directly attacked by restrictive measures that can not be applied to over- indulgence in food, except during the emer- gencies of war. There was, however, dur- ing the war abundant evidence of the wholesome effect of restriction in meat eating and in sugar consumption. I can not include within the limits of this paper a complete discussion of the evidence that is available as to the harmful effec! of al- cohol. I am not aware that there is any respectable evidence available that its use as a beverage has any direct beneficial effect on the human organism. In such isolated instances where there is a bene- ficial effect I believe this can be classified under its therapeutic influence as a drug. That it has a very limited range of thera- peutic usefulness is the consensus of mod- ern medical opinion. In brief, I may say that there is good ground for assuming that the direct chemical destructive effect of alcohol on the tissues is probably less than many have heretofore supposed. There is, however, an accumulation of evi- dence showing its unfavorable influence upon the organic functions, especially upon the central nervous system and the circulatory apparatus. The elaborate re- searches of Professor Francis G. Benedict at the Nutrition Laboratory cof the Car- negie Institution, which have the merit of demonstrating the influence of alcohol in beverage doses on selected normal indi- viduals, is particularly important as clari- fying and carrying forward the earlier experiments of Rivers, Kraeplin, Aschaf- fenburg, and others. Benedict developed no evidence that alcohol, even in moderate doses, improved the organic efficiency of the circulation. The evidence was in the contrary direction. The disturbing and depressing effect of alcohol on the protec-
Vol. XIII No. 12
tive mechanism of the body was quite plainly revealed by these experiments. Such evidence is far more conclusive as establishing the effect of alcohol than those conducted on the perfused heart or muscle of an animal, such as have been reported by Lee, Burridge, and others. We are concerned with the total effect of alcohol, not with its partial effect under abnormal circumstances. This total effect is one that has a profound influence upon con- duct and upon the responses of the indi- vidual to the menacing factors in his en- vironment. This evidence leads us away from the consideration of the obviously destructive effect of alcohol on the drunk- ard, to its influence on the so-called mod- erate drinker, and here we have the testi- mony of life insurance offices which are entirely consistent with laboratory testi- mony as to the disturbing effect of alcohol on human life. These, briefly summarized, are as follows:
The first important contribution of life insurance offices on this question was that of the United Kingdom and General Provi- dent Institution ef Great Britain, which made a comparison of the mortality among total abstainers and the supposedly mod- erate users during the period 1866 to 1910. This showed an excess mortality of 37 per cent among the users of alcohol, notwith- standing the fact that this was a carefully selected group with a favorable mortality as judged by normal standards, neverthe- less the abstainers showed a far lower mortality. That this was a genuine busi- ness record is evidenced by the fact of the payment of heavy bonuses derived from these mortality savings. Other British and Scottish companies showed similar ex- periences.
Every effort was made by cautious actu- aries and statisticians in this country to pick flaws in this evidence and opinion as to its significance was suspended in many life insurance offices until the report of the medico-actuarial investigation in this country, covering the experience of 43 American life insurance companies, be- came available. This investigation cov- ered the period from 1885 to 1908 and the material was drawn from the records of two million policy-holders. The groups studied were homogeneous, except for
FISK: ALCOHOL AND MODERN HEALTH IDEALS
883
their varying use of alcohol, or their vary- ing exposure to alcohol, as determined by their occupation. All complicating factors, such as physical defects, impaired family history, or personal history, were ex- cluded. The results may be summarized as follows:
“1, Those who were accepted as standard lives, but whose histories showed occasional alcoholic excess in the past. The mortality in this group was 50 per cent in excess of the mortality among insured lives in general, equivalent to a reduc- tion of over four years in the average life time of the group.
“2. Individuals who took two glasses of beer, or a glass of whisky, or their alcoholic equivalent, each day. In this group the mortality was 18 per cent in excess of the average.
“3. Men who indulged more freely than the pre- ceding group, but who were considered accept- able as standard insured ‘risks.’ In this group the mortality was 86 per cent in excess of the average.
STRIKING COMPARISONS
“It should be borne in mind that these com- parisons are made with the general class of in- sured individuals, both users and non-users of al- cohol. Comparison with total abstainers alone would probably show a much greater difference. It is noteworthy that in these drinking groups the death rate from Bright’s disease, pneumonia and suicide was above the normal, and that among the steady so-called moderate drinkers — those using more than two glasses of beer or one glass of whisky daily—the death rate from cirrhosis of the liver was five times the normal.”
It should be understood that this inves- tigation was simply a part of a general investigation of the mortality experience as affected by various factors, such as habits, occupation, over-weight and per- sonal history.
Mr. Arthur Hunter, Actuary of the New York Life Insurance Company, former President of the Actuarial Society of America, and Chairman of the Committee that conducted this investigation, in order to check up this massive result and detect any possible fallacies, had special studies made in his own company of various types of drinkers. The testimony elicited was always consistent as to the influence of increasing alcohol indulgence in produc- ing an increased mortality. It should be borne in mind that the individuals investi- gated in the medico-actuarial study were accepted as standard risks.
In the New York Life Insurance Com- pany, the special investigation covered the experience on a number of sub-standard
884 SOUTHERN
risks in which a lien was placed upon the policy. It was the custom of the Company to rate up or penalize applicants who con- fessed to an indulgence in alcohol equiva- lent to three ounces of whisky or one quart of beer daily. This practice was justified by the final experience on these lives which exhibited an extra mortality of 100 per cent. In other words, a total extra mor- tality risk approximating that in cases of heart disease, syphilis and other impaired states that the average free drinker would regard with considerable terror, although comfortably confident that his own indul- gence is not in any way injuring him. Further figures from the same Com- pany show the following: Approximate Extra Mortality