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Colorado Medicine
The Journal of the Colorado State Medical Society
Editor
FRANK B, STEPHENSON, M. D.
Volume XVII, January to December
1920
Publication Committee
Melville Black, M. D. G. A. Moleen, M. D.
Philip Hillkowitz, M. D.
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3 * PftlEC OF THE WWTJWF NEWSrAfJK uAlOH, OlNVtn
INDEX TO VOLUME XVII
Abscess, Artificial Pneumothorax in Acute Pulmo- nary, 138.
Abstracts of Papers Read Before Colorado State Medical Society, 1920, 201.
Accessory Sinus Disease, With Special Reference to Surgery, The Treatment of Nasal, 156.
Acidosis, 4.
Address to the Graduating' Nurses of Mercy Hos- pital, 314.
Aeroplane, Making Calls by, 109.
Amendment, Educational, 252.
American Society for the Control of Cancer, The Work of the, 145.
Americas Compared, Medical Training in the, 110. Amesse, J. W., 12, 16, 189.
Anesthetist, The Nurse as, 198.
Angina, Vincent’s, 47.
Annual Registration of Physicians, 210. Anti-Narcotic Law, Workings and Improvements of the Harrison, 4.
Antituberculosis Activities in Prance, 132. Antivaccination Again, 107.
Appendicitis, Hereditary, 241.
Army, Tuberculosis in the, 66.
Arneill, James R., 30.
Artificial Menopause Induced by the X-Ray, 84. Artificial Pneumothorax in Acute Pulmonary Ab- scess, 138.
Bailly, Thomas E., 30.
Bane, W. C„ 183.
Baum, H. J., 183.
Beck, Joseph C., 287.
Beggs, Wm. N., 214.
Blickensderfer, G. M., 62, 66, 189.
Bluemel, C. S., 113, 265.
Board of Health, The Work of the Colorado State, 268.
BOOK REVIEWS:
Annual Reprint of the Reports of the Council on Pharmacy and Chemistry of the American Med- ical Association for 1919, 167.
Church, Archibald, Nervous and Mental Diseases,
22.
Crile, George W., Surgical Shock and the Shock- less Operation Through Anoci-Association, 168.
Da Costa, J. C., Modern Surgery: General and Operative, 141.
Da Costa, J. C., Pr inciples and Practice of Physi- cal Diagnosis, 302.
Davis. Edward P., Manual of Obstetrics, 141.
Dorland, W. A Newland, The American Illustrat- ed Medical Dirtionary, 141.
Einhorn, Max, The Duodenal Tube and Its Possi- bilities. 280.
Flint, Austin, Flint’s Physical Diagnosis, 280.
Freud, Sigmund. A General Introduction to Psy- choanalysis, 280.
Griffith, J. P. Crozer, The Diseases of Infants and Children, 168.
Hirsch, I. Seth, The Principles and Practice of Roentgenological Technique, 140.
Hirst, John Cooke, A Manual of Obstetrics, 52.
Levinson, Abraham, Cerebrospinal Fluid in Health and Disease. 75.
Mayo Clinic, 1918 Collected Papers of the, 22.
McFarland. Joseph, Pathogenic Bacteria and Pro- tozoa, 141.
Morelli, Eugenio, The Treatment of Wounds of Lung and Pleura, 303.
Morse, John Lovett, Diseases of Children, 301.
New and Nonofficial Remedies 1920 167.
Ocbsner, Albert J. Practical Medicine Series: General Surgery, 21.
Osnato, Michael, Aphasia and Associated Speech Problems, 140.
Paton, Stewart, Education in War and Peace, 141.
Rivas. Damaso. Human Parasitoioev. 280.
Sternberg, Martha L., George Miller Sternberg: A Biography. 301.
The Medical Clinics of North America, 75, 195,
223. 250. 303.
The Surs-ical Clinics of Chicago, 21, 22, 75, 195,
224, 302.
Veicki. Victor G.. Sexual Impotence, 168.
What Everyone Should Know About Cancer, 302.
White, Wm. A., Thoughts of a Psychiatrist on the War and After. 250.
Boulder Countv Medical Society, 71, 137, 299.
Bovd. Georg e A. 216. 244. r. c 1 c t c
Burnett, C. T„ 70. 132. . ‘ 1 7
Balls, Makine-, hv Aeroplane, 109. c l. .1 < i .< , Cancer, The Control of. 56.
Cancer Problem. The, 230. t t c ( c c V
Banner. Radiation Treatment of, 23,1. \ ‘ <■ c 1 cc c f Barmodv. T. E. 258. J < c t <A c c CC t
Bathartics. Regarding, 24, < c< 'J cB c c Ac G<
Battermole, G. H.. 66, 189.
^Changes in the Colorado Medical Practice Act, Pro- posed, 307.
Childs, S. B„ 36, 221.
Children, Hernias in, 95.
Chiropractic Examiners, The Colorado State Board of, 266.
Chiropractors Define Their Faith, 252.
Clinical Congress in Denver, A, 284.
Clinical Congress of American College of Surgeons, Colorado State Branch, 330.
Colitis, X-Ray Diagnosis of Early Tuberculous, 76. Collection Agency, A State Society as a, 83. Colorado Congress of Ophthalmology and Oto- Laryngology, The, 146.
Colorado’s Educational Problem, 229.
Colorado Ophthalmological Society, 17, 51, 74, 139, 279.
Colorado State Board of Chiropractic Examiners, The, 22 6.
Colorado State Board of Health, The Work of the, 268.
Complete Epispadias With a Review of the Litera- ture, 97.
Congenital Word-Blindness, A Case of. 113. Congress of Ophthalmology and Oto-Laryngology, The Colorado, 146.
Conley, J. F„ 47.
Conservation of Our Greatest Asset, 282. Consumptive in Colorado, The Migratory, 26.
Control of Cancer, The, 56.
Corneal Conditions, The Treatment of by the Gen- eral Practitioner, 44.
Corpus Luteum, A Report of Three Cases Present- ing a Masto-Ovarian Syndrome Relieved by, 128. Cranial Fractures, Indications for Operative Treat- ment in, 9.
Crisp, W. H„ 44, 47, 215.
Dake, Walter M„ 222.
Dean, E. F., 207.
Deer-Fly Fever, 54.
Denver Medical Society of the City and County of, 18, 20, 140, 166, 300.
Denver, Proposed New Hospital, 105.
Differential Diagnosis of Ureteral Obstruction From Lesions of Other Abdominal Organs, 159. Dingley, A. G.. 4, 9.
Diphtheria, Why? Reasons and Remedies, 285. Discrepancies Between the Clinical Symptoms and Laboratory Findings in Syphilitic Diseases of the Nervous System, 147.
Doctors’ Fees and the High Cost of Living, 79. Dogmatism in Medical Writing, 25.
Double Optic Neuritis Associated With Dental and Nasal Focal Infection, A case of, 117.
Douglass, Atwater L., 294.
Drinkwater, R. L„ 268, 271.
Dworzak, Zdenko von, 238.
Education in Colorado, The Future of Medical, 254. Educational Amendment, 252.
Educational Problem, Colorado’s, 229.
Election, A Lesson From the, 281.
Elder, C. S., 213.
El Paso Countv Medical Society, 21, 51, 104, 140, 167, 195, 301.
Empyema: Clinical Diagnosis; X-Ray Diagnosis, 36. Empyema as Seen at Camp Kearney During the Recent Epidemic of Influenza, 30.
Encephalitis, Lethargic, 317.
England Invites American Motorists, 84.
Epispadias, Complete, With a Review of the Lit- erature, 97.
Epler, J. Crum, 44, 193.
Etiological Factors and Treatment of Certain Types of Surgical Infection, 124.
Evans, E. E., 163.
Face A Case of Reconstructive Surgery of the. 60. Federal Board for Vocational Education, Medical Work of the. 177.
Fee Regulation Four Thousand Years Ago, 200.
Fees and the High Cost of Living, Doctors’, 79. Ferris, C. A.. 132.
Filnrer, B. A., 177.
Fowler, O. S„ 159, 163.
Fracture of the Tibial Spine, 217.
Fractures, The Management of Ununited, 173. Freeman, Leonard, 11. 122, 127.
Fremont Corrntv Medical Society, 74, 104..
Freud in 1920. 265.
Friedman, Emanuel, 65.
Function of Your Journal, The, 313.
Gallaher. T. J.. 118, 183.
Gastrostomy for Laryngeal Tuberculosis, 111. Gengenbach I*. Pi 16, 65, 184, 189.
Gibson, .T. D„ 215.
G!f fin, C. D., 84.
G>l^e,rt, 0,;M., :8, Id. 485. ,
Gilenwood Springs Meeting, The, 225.
Gobdlde, Hart. 208.
Graduating Nurses of Mercy Hospital, Address to the. 314.
Granger. Arthur Stanley. 30.
Grant, W. W„ 43, 176, 190, 193.
Group Medicine of the Past, Present and Future, 232.
Hall, J. N„ 36, 44.
Hartwell, John P., 128, 132.
Health Office, An International, 144.
Health, The Far-Reaching Effects of Rectal Dis- eases Upon the General, 294.
Health Work, New, 310.
Hegner, C. F., 177.
Henderson, H. S., 8.
Hereditary Appendicitis, 241.
Hernia, The Relation of, to Military Service, 190. Hernias in Children, 95.
Hickey, C. G., 59, 155.
Hillkowitz, Philip, 43, 56, 59, 154, 270, 285.
Hospital, Denver s Proposed New, 105.
Hospital Service, More About Improvements in, 145.
Hospital Standardization, 109.
Hospital. The State Psychopathic, 53.
House of Delegates, Minutes of the, 272A Ileus, 119.
Infant Feeding, Teaching- Simplified, 184. Infections, Etiological Factors and Treatment of Certain Types of Surgical, 124.
Immunity, Clinical Evidence of Postinfluenzal, 247. Influenza Epidemic Again, The, 23.
Influenza, A Study of the Pulse, Temperature and Respiration in, 244.
Influenza, Symposium on, 71.
Ingraham, C. B., 131.
Inoculation and the Public, Preventive, 54. Improvement in Hospital Service, More About, 145. International Health Office, An, 144.
Jackson. Edward, 46.
Jayne, W. A., 192.
Joints, The Management of Septic, After the Method of Willems of Ghent, 204.
Jones, S. Fosdick, 43, 209. 217, 221.
Journal, The Function of Your, 313.
Jury, Diagnosis by. 1.
Kennelley, F. C., 188.
Kickland, W. A., 97.
Lake County Medical Society, 75.
Laryngeal Tuberculosis, Gastrostomy for, 111. Legislation Which Concerns the Medical Profes- sion, Proposed, 226.
Lethargic Encephalitis, 317.
Libby, George F., 46, 117.
List of Members, Colorado State Medical Society, 323.
Lobelia, Subcutaneous Use of, 164.
Love, T. R„ 163.
Lowen, Charles J., 111.
Lyman, C. B., 176.
Maghee, Thomas G., 60.
Magruder, A. C., 8, 212.
Management of Septic Joints After the Method of Willems of Ghent, The, 204.
Markel, Casper, 244.
Marshack, M. I., 69.
Masto-Ovarian Syndrome, Relieved by Corpus Lu- teum, A Report of Three Cases Presenting a, 128.
Matthews, B. H., 155.
Mayhew, D. P., 42.
McDonald, R. J., 247.
McKinnie, L. H., 41.
Meader, Charles N., 254.
Medical Aids to Surgical Cures, 222.
Medical Education in Colorado, The Future of, 254, 260.
Medical Extension Work Begun, 4.
Medical Practice Act, Proposed Changes in the Colorado, 307.
Medical School and a State Hospital, A Rejuve- nated, 305.
Medical Societies, 17, 51. 71, 104, 137, 166, 195, 223, 279, 299, 330.
Medical Training in the Americas Compared, 110. Medical Writing, Dogmatism in. 25.
Members of Colorado State Medical Society, List of. 323.
Menopause, Artificial, Induced by the X-Ray, 84. Mesa County Medical Society, 51, 167.
Miel, G. W„ 177.
Migratory Consumptive in Colorado, The. 26.
Miller, Lewis I., 97.
Moleen, G. A.. 7, 147, 155, 261, 287.
Morgan. J. W„ 213, 285. 287.
Mortimer, Julius L., 119, 123.
Nasal Accessory Sinus Disease. The Treatment of. With Special Reference to Surgery, 156. Nervous System, Discrepancies Between the Clin- ical Symptoms and Laboratory Findings in Syphilitic Disease of the, 147.
Neuritis Associated With Dental and Nasal Focal Infection. A Case of Double Optic, 117.
Neuhaus, G. E„ 6, 317.
New and Nonofficial Remedies, 52, 62, 141, 166, 196, 224, 280, 304.
Health Work. 310.
News Notes, 17, 49, 70, 103, 136, 193, 223, 249, 279, 298.
Northeast Colorado Medical Society, 52, 104, 301.
Nossaman, A. J., 164, 166.
Nurse as Anesthetist, The, 198.
Nursing Problem, The, 77.
Occult Tuberculosis, 76.
Operative Treatment in Cranial Fractures, Indica- tions for, 9.
Optic Neuritis Associated With Dental and Nasal Focal Infection, A Case of Double, 117. Orendorff, Otis, 47.
Osier, Personal Reminiscences of the Earlier Years of Sir William, 88.
Osier, William, 3.
Otero County Medical Society, 167.
Otitis Media, Misleading- Conditions in Acute Sup- purative, 180.
Packard, G- B-. 208, 221.
Pasteurization, 76.
Pattee, James J., 180, 184.
Personal Reminiscences of the Earlier Years of Sir William Osier, 88.
Pertussis, Vaccine Therapy in, 62.
Physician in Politics, The, 251.
Politics, The Physician in, 251.
Postgraduate Instruction in Colorado, 282. Postgraduate Medical Teaching Demonstrated, 314. Postinfluenzal Immunity, Clinical Evidence of, 247. Powell, Cuthbert, 173, 177.
Powers, C. A., 44, 58, 121, 204, 209.
Practitioner, The Treatment of Corneal Conditions by the General, 44.
Pratt, Elsie S., 189.
Preventive Inoculation and the Public, 54. Preventive Medicine Curriculum at Greeley, 55. Proceedings of the House of Delegates, 272. Psychopathic Hospital Appropriation, 82. Psychopathic Hospital in Colorado, The Need of a. 261.
Psychopathic Hospital, Concerted Effort and the, 77.
Psychopathic Hospital — A Reminder, The, 200. Psychopathic Hospital, The State, 53.
Psychopathic Hospital Victory, The, 197.
Public Health, Popularizing, 143.
Public Health, The Red Cross and, 28.
Public Health Work, A Plea for Coordination in, 309.
Pulmonary Abscess, Artificial Pneumothorax in Acute, 138.
Pulmonary Tuberculosis in an Infant, 137. Radiation Treatment of Cancer, 231.
Radium Therapy in Disease of the Nose, Ear and Throat, 238.
Rawlings, I. D., 286.
Reconstructive Surgery of the Face, A Case of, 60. Rectal Diseases, The Far-Reaching Effects of Upon the General Health, 294.
Red Cross and Public Health, The, 28.
Registration of Physicians, Annual, 210.
Ringle, C. A., 47, 183.
Rogers, Edmund J. A., 88.
San Juan Medical Society, 52, 223, 330.
Scott, Ira D., 47.
Secretaries’ Meeting, Notes on State, 312.
Septic Joints, The Management of, After the Method of Willems of Ghent, 204.
Sewall, Henry, 261.
Shaffer, Mr. John C.. An Open Letter to, 171.
Shere, O. M„ 9, 12, 42, 58, 123, 163.
Shulman, Leon, 30.
Simon, Saling, 69.
Singer, W. F., 66, 132, 165, 184, 209, 243.
Smith. Frank E., 30.
Specialist. The Spurious, 80.
Spencer, F. R„ 8, 156, 216, 232, 259, 261, 287.
Spivak, C. D„ 188, 215.
Spleen, The Mysterious, 2.
Splenic Anemia in Children. 12.
Spurious Specialist, The, 80.
State Hospital, A Rejuvenated Medical School and a, 305.
State Medicine: What Ts It. and in What Directions Should It Be Developed?, 288.
State Society as a Collection Agency A., 83. Standardization. Hospital, 109.
Stephenson. F. B., 183.
Stoddard, T. A.. 43, 58, 244.
Strickler, David A., 210, 217.
Suppurative Otitis Media, Misleading Conditions in Acute. 180.
Surgical Infections. Etiological Factors and Treat- ment of Certain Types of, 124.
Symposium on Influenza, 71.
Syphilitic Disease of the Nervous System. Discrep- ancies Between the Clinical Symptoms and Lab- oratory Findings in, 147.
Swan, W. H.. 216.
Taussig, A. S.. 42. 70, 122.
Teaching Simplified Infant Feeding, 184.
Tennant, C. E.. 123, 124, 127, 209.
Tibial Spine. Fracture of the, 217.
Tremaine, Harmon, 47. 189.
Tuberculosis in the Army, 66.
Tuberculosis in an Infant. Pulmonary, 137. Tuberculosis, Laryngeal, Gastrostomy for. 111. Tuberculous Colitis, X-Ray Diagnosis of Early, 76.
Typhoid Epidemic?, Is Colorado Threatened With a, 228.
Ununited Fractures, The Management of," 173. Ureteral Obstruction, Differential Diagnosis of, From Lesions of Other Abdominal Organs, 159. Vaccination Again on the Defensive, 308.
Vaccine Therapy in Pertussis, G2.
Van Meter, S. D., 241, 244.
Vaughan, Victor C., 259, 271, 287, 288.
Vienna’s Medical Tragedy, 169.
Vincent's Angina, 47.
Vocational Education, Medical Work of the Federal Board for, 177.
Warner, E. R., 118.
Webb, E. C., 154.
Weldon. L. J„ 95.
Wetherill, Horace G.. 171, 173, 314.
Whirligig of Time, The, 147.
Williams, W. W„ 153.
Work, Hubert, 8, 216.
Work, Dr., President-Elect of the A. M. A., 105. Word-Blindness, A Case of Congenital, 113.
Work of the American Society for the Control of Cancer, The, 145.
Writing, Dogmatism in Medical, 25.
X-Ray, Artificial Menopause Induced by the, 84. X-Ray Diagnosis of Early Tuberculous Colitis, 76. X-Ray Diagnosis, Empyema: Clinical Diagnosis, 36
Colorado Medicine
OWNED AND PUBLISHED BY COLORADO 5TATE MEDICAL SOCIETY
PUBLICATION COMMITTEE.
L. B. LOCKARD, M.D., Denver. MELVILLE BLACK, M.D., Denver.
GEORGE A. MOLEEN, M.D., Denver.
EDITOR: Frank B. Stephenson, M.D., Metropolitan Building-, Denver.
Annual Subscription, $2.00 Single Copies, 20 Cents
Yol. 17. JANUARY, 1920 No. 1
tditcrial Comment
DIAGNOSIS BY JURY.
The recent completion of the Blackwood trial compels reflection upon the system at present employed in Colorado of legally de- termining a lunatic’s insanity.
In this trial, as the reader doubtless re- members, Don P. Blackwood, a paranoiac lawyer, was found insane by a lay jury in the Denver county court. During the past five years Blackwood has appeared twice before lunacy commissions and three times before the Denver county court to be tried for insanity. The lunacy commissions, con- sisting of alienists, have found him insane, but till the recent trial the lay juries have failed to uphold the medical diagnosis. Thus Blackwood, although insane, remained at- large, and endangered the lives of unoffend- ing citizens. During the past five years Blackwood’s various trials and mis-trials have constituted a medico-legal fiasco.
The question naturally arises whether a lunatic should exercise the right of appeal from a commission of medical experts to a jury of laymen. What does the layman know about insanity? What does he know about medicine in general? The world would laugh aloud if it should behold a jury of butchers and grocers examining a de- fendant’s lungs, and yet this same world accepts with equanimity the spectacle of a lay jury rendering a diagnosis in the highly specialized field of psychiatry.
Doubtless the lay world has a sneaking idea that it is competent to diagnose a case of insanity, for it feels that as the trial pro- ceeds it can watch for the lunatic to foam at the mouth, or bite the judge, or loop the
loop in open court. But unfortunately for the jury most lunatics are of the 11011-loop- ing order, and the most dangerous lunatics are apt to appear the most rational. And so it happens that the jury’s criteria of in- sanity very often fail.
The diagnosis would be difficult enough for a jury even if a straight-forward inquiry were made into the issues involved. But as a rule no such straight-forward inquiry is held, for in the average trial the clear-cut issues are quickly obfuscated by the expert testimony, erudite physicians being intro- duced to emphasize their points of differ- ence rather than their points of agreement.
Then the difficulties of the jury are further enhanced by the legal formulas and jargon that confuse the procedure. Learned counsel objects to the introduction of evi- dence already introduced. The judge sus- tains the objection and naively tells the jury to unhear what it has already heard. Or the objection is over-ruled, and learned coun- sel takes exception to the ruling and begins jockeying for a re-trial. Or perhaps counsel finds a witness’s evidence to be damning and irrefutable, and so attempts to discredit him on something a little foreign to the evi- dence, such as his wife’s religion. If his wife lias no religion, it is as easy to brow- beat him on some other score. “The wit- ness will tell the jury whether snow is red or green ; he will answer yes or no.”
And thus the trial proceeds.
It would seem better to turn loose a troop of clowns in court to arrive at a diagnosis with their slap-sticks. Their antics would be no more “immaterial, incompetent, and irrelevant” than much of the verbal buf- foonery of the legal procedure. At best the court trial is little more than a personal en- counter between the opposing lawyers, and
Colorado Medicine
in the contest of these wordy gladiators truth and justice may be buffeted from court.
A law court is no place in which a diag- nosis of insanity should be made. Insanity is not a crime, it is a disease; and a case of insanity is one for study by a physician and not for trial before a judge. It is an anomaly that when a man has been found insane by a commission of physicians, he is still legal- ly competent to appeal his diagnosis to a judge and jury. This seems to be an aber- ration of the law.
Fortunately the situation in Colorado may be easily remedied. The state legislature has already authorized the establishment of a psychopathic hospital for the study and treatment of mental diseases, but thus far no appropriation for the purpose has been made. This appropriation should be urged upon the legislature in order that our men- tally sick may be better cared for, and in order that legal diagnoses may lie made by the permanent staff of the hospital. Appeal from such diagnoses should then be possible only to a commission or jury of physicians.
C. S. B.
THE MYSTERIOUS SPLEEN.
There is perhaps no organ of the human body which arouses the curiosity of the in- vestigator of human physiology and pathol- ogy more than does the spleen. Because of its size it is not easily overlooked and by its aggravating tantrums it is continually call- ing attention to itself. Is it an upstart of big outcry and little real importance or does it play a grave role in metabolism, or in re- sistance to infection? Its one macroscopic reaction in disease seems to be enlargement with occasional migration and injury at- tending its increased size and weight. In some of the bacterial infections it waxes large and recedes with the passing of the disease ; in other diseases, as malaria, it may remain permanently enlarged. It may be apparently the seat of primary parasitic in- vasion, or it may react incidentally to in- vasion elsewhere. Microscopically its path- ology is varied.
Its most obscure reactions are those at-
tending the various anemias and leukemias, blood dyscrasias in some of which it Is not yet settled whether the splenic condition is primary or secondary — a problem whose so- lution would have important bearing upon the advisability of splenectomy. In some of these conditions, there is splenomegaly with enormous leueocytosis; in Gaucher’s disease, there is enlargement and a leucopenia, with presence in the spleen of syncytia of large oval cells, peculiar to that condition ; and the classification of splenic diseases in general is still confusing and insecure.
The normal functions of this organ are thought to be concerned with red blood cell formation, at least in the fetus, and red cell disintegration, yet when it is removed other tissues take on that work with apparently lit- tle trouble. It is not a true gland. No “internal secretion” has been authori- tatively attributed to it. It swells with stomach digestion, but does not contribute digestive ferments so far as is known. It has rhythmical contractions of about one per minute during stomach digestion, losing 18 per cent of its volume with each contraction. Histologically, it suggests relationship with the lymphatic system, yet, as stated, it seems to have some functional relation to digestion, and it empties its blood into the portal vein.
Pearce and Pepper in 1914 showed that in spleneetomized dogs the fatty marrow of the femur changed to red marrow in six to twenty months. As regards any protective function, Clifford W. Wells found in 1918 that there was no variation in reaction of the leucocytes to the injection of dead bacteria in spleneetomized and nonsplenectomized rabbits, while Charles H. Frazier states the clinical experience of finding bronchitis and pneumonia common complications of splen- ectomy and affirms that susceptibility to in- fection is to be reckoned with at least until compensatory function is established else- where in the body.
In order to determine definitely whether removal of the spleen lowered an animal’s resistance to infection, Morris and Bullock lately spleneetomized thirty-six rats and re- moved a testicle by the abdominal route in thirty-six control rats, and then let them all be exposed to chance laboratory infection
January, 1920
3
under observation for several months. When an animal of either group died, one of the other group was killed and autoposies per- formed on both. It was then observed that the spleneetomized animals almost invariably died before the controls, and that the death rate among them was 80.5 percent as com- pared with 38.9 percent in the control rats. The tissue changes were characteristic of rat plague and were found nearly always in the animals that died spontaneously, not at all in the controls which were killed.
A second series of two groups of seventy- two rats each was treated similarly, but none was killed. After two months the spontan- eous mortality record was 29.2 percent for the orchidectomized group (normal rate for stock laboratory rats) and 84.7 percent for the spleneetomized. The record in this series at the three weeks period was seven deaths of castrated as against thirty-six deaths (50 percent) of spleneetomized rats.
A third series of young rats, eighty-eight in each group, was operated upon as in tUe previous series and immediately given sub- cutaneous injections of a predetermined sub- lethal dose of a. culture of rat plague bacil- li. In the castrated rats, the death rate tvas 22.7 percent (normal) ; in the splen- ectomized, there was the enormous rate of 87.5 percent with a hastened date of death. The results in a fourth experiment like the third, but with old rats, gave even more striking contrasts.
These experimenters show that under or- dinary laboratory conditions “the spleen” (in rats) “then must in some way help to protect the animals against infection, since removal of another organ of equal size and weight by a similar operative procedure caused no impairment of the defensive mechanism”. They conclude that while rats may get along fairly well without a spleen in the absence of infection, the reverse is the case when bacterial invasion occurs, and “that the spleen normally aids tremendously in resisting in- fectious processes in rats, and that its re- moval temporarily robs the body of its re- sistance until such a time, at least, as com- pensatory processes will have had a chance to reestablish this.”
Inasmuch as the spleen in man is quite a large and active organ and shows no sign of degeneration or rudimentary state, the in- vestigators are probably right in stating that it is not improbable that the human body, deprived of its spleen shows a similar in- creased susceptibility to infection.
In past experiments and observations in splenectomy, it has been difficult to deter- mine how far any subsequent infection was due to the debilitating effect of the opera- tive procedure per se. Morris and Bullock seem to have answered that question rather decisively.
Current 'Comment
WILLIAM OSLER.
A good mind, wide sympathy and interest, industry, thorough training, and the broad- ening and stimulating influence of varied environment united to make William Osier the most prominent physician of his time. Born a dozen miles east of Detroit, July 12, 1849, he took his academic course in Trinity College, Toronto, graduating in 1808 and four years later received his medical degree at McGill University, Montreal. Two years he spent in Vienna, Berlin, and especially London, and returned to Montreal in 1874 to be Professor of Institutes of Medicine in his alma mater. Here he taught physiology for ten years, and studied pathologic anatomy in the post-mortem room.
In 1884 he came to Philadelphia to suc- ceed William Pepper as Professor of Clini- cal Medicine in the University of Pennsyl- vania. Here he extended his acquaintance with the leaders in the medical profession of America; and, probably under the influ- ence of Weir Mitchell, and from his studies in the Orthopedic Hospital, wrote his first important work on the “Cerebral Palsies of Children” in 1889. The same year he left Philadelphia, to become Professor of Prin- ciples and Practice of Medicine in the Johns Hopkins University at Baltimore, and Phy- sician in Chief to the Johns Hopkins Hospi- tal. Here was done his great work in the teaching of medicine, and the international reputation it brought him led to his call
4
Colorado Medicine
to the Regius Professorship of Medicine in the University of Oxford.
His facetious quotation of Trollope’s sug- gestion that men ought to be chloroformed at sixty (he was then fifty-six), seized on by the press, was given world-wide pub- licity, which was so disagreeable that for years afterward any allusion to it was very irritating to him. But it made his name familiar to millions, who never had heard of the solid work he had done in the ad- vancement and teaching of medicine. When, in 1911, he was included in the list of those knighted by King George for distinguished service to the Empire, he became one of the group including Allbutt, Gowers, Johathan Hutchinson, Anderson Critchett, and Lord Lister, that help to keep the English titles of nobility still a real honor in the world, and a source of political strength to the British Empire.
His great books were the “Principles and Practice of Medicine”, first Edition in 1902, and the “System of Medicine”, seven vol- umes, 1907-1910, which he helped to write and edit. But we must not forget his more strictly literary and humanistic writings, such as “Aequanimitas” and “An Alabama Student and Other Essays ’ ’ ; nor his devo- tion to the advance of the profession through the organization and extension of medical li- braries.
It was as a teacher, writer, editor, com- piler, and organizer, that Osier rendered his great services to the medical profession. His broad view of the function of the ^physician and his high ethical ideals made his influ- ence everywhere as wholesome as it was ef- fective. His death, December 29tli, was due to pneumonia and empyema, reported to have folloAved influenza. It will be a mat- ter of deep regret to all familiar with his writings; and more keenly felt by those who had enjoyed his personal friendship.
EDWARD JACKSON.
MEDICAL EXTENSION WORK BEGUN.
As far as can be learned at this early date, the graduate teaching program, to quote the “long-distance” words of Secretary Epler, has “gone off with a bang”. Engagements
seem to have been filled on schedule and much interest shown at the meetings both by attendance and attention.
The . following change in the roster has been announced :
Dr. Saling Simon replaces Dr. J. R.
Arneill.
Dr. W. M. Spitzer replaces Dr. J. G.
Maxwell.
ACIDOSIS.
At a recent meeting of the Medical So- ciety of the City and County of Denver, the scientific program was given over to a dis- cussion of the interesting condition, acidosis, from the laboratory, surgical, general medi- cal, and pediatric standpoints. The papers and discussion have seemed to the editor to be of sufficient general interest to warrant their rather full digest which appears in the Denver society proceedings, this issue.
"Original Articles
WORKINGS AND IMPROVEMENTS OF THE HARRISON ANTI-NARCOTIC LAW.*
A. G. DINGLEY, Denver,
Representing the Collector of Internal Revenue.
I have been requested to present this sub- ject to you briefly in order that we may get a few valuable suggestions which may be transmitted to the Commissioner at Wash- ington in connection with the treatment of drug addicts who will be deprived of the use of morphine, under the Harrison Act, as construed by the Supreme Court. I think, perhaps, the best thing for me to do will be to read a letter from the Commis- sioner addressed to “Collectors of Internal Revenue, Revenue Agents and Others Con- cerned”, which is as f ollows :f
“The enforcement of the Harrison Narcotic Law, as amended by the Revenue Act of 191S, in the light of the recent decisions of the Supreme Court of the United States has produced a condition with regard to the treatment and care of narcotic addicts that calls for exceptionally careful and
♦Address delivered at the annual meeting of the Colorado State Medical Society, October 7, 8, 9, 1919.
fOnly the more essential parts of this letter are here reproduced.
January, 1920
5
rational handling. The vigorous enforcement of this law must be carried out in such a manner as not to produce unwarranted suffering on the part of addicts.
“You have noted that the constitutionality of the Harrison Narcotic Law has been clearly up- held, and that the Supreme Court has held that it is unlawful to furnish a person popularly known as a dope fiend with narcotic drugs for the pur- pose of satisfying his appetite for the drug as an habitual user thereof and not in the course of the regular professional practice of medicine and in the proper treatment of disease. It was also held that an order for narcotics issued by a practi- tioner to an habitual user thereof, but not in the course of professional treatment in an attempted cure of the habit, but for the purpose of provid- ing the user with narcotic drugs sufficient to keep him comfortable by maintaining his customary use, is not a prescription under the law, and that the practitioner who issues an order under such circumstances, as well as the druggist who know- ingly fills such an order, has committed an in- dictable offense.
“The decision of the Circuit Court of Appeals, Eighth Circuit, in the Thompson case, further held that a physician who dispenses nar- cotics not in good faith for the purpose of secur- ing a cure of one suffering from an illness, or to cure him from the narcotic habit, violates the law ; and affirmed the conviction of a physician who was charged with furnishing narcotics to an ad- dict in decreasing quantities, claimed to be in an attempt to cure addiction, but where it was shown that such physician did not personally attend the addict or give him personal attention sufficient to show that he was practicing in good faith.
“The Oliver case involved the sale of a so-called exempt preparation under Section 6 of the Act, to-wit : paregoric, not as a medicine, but for the purpose of evading the intentions and provisions of the Act by supplying addicts with said prepara- tion to satisfy addiction. Judge Woods charged the jury to the effect that whether the paregoric was legitimately sold as a medicine, or was dis- pensed with the intent of evading the purposes for which this Act was passed, was a question of fact to be decided by the jury, and that it made no difference if the officer who bought the pare- goric did not intend to take it himself, provided the defendant sold it for the purpose of adminis- tering to an addict. In brief, if paregoric was sold for that purpose, ‘then the offense was com- plete’ and the defendant ‘would be guilty’.
“You have also been furnished with Treasury Decision 2879, revoking Treasury Decision 2200. The important part of Treasury Decision 2879 is the second paragraph, reading as follows :
“ ‘The Act of December 17, 1914, as amended by the Act of February 24, 1919, permits the furnish- ing of narcotic drugs by means of prescriptions issued by a practitioner for legitimate medical uses, but the Supreme Court has held that an order for morphine issued to an habitual user thereof, not in the course of professional treat- ment in an attempted cure of the habit, but for the purpose of providing the user with morphine sufficient to keep him comfortable by maintaining his customary use, is not a prescription within the meaning and intent of the Act. U. S. v. Dore- mus, No. 367, October Term, 1918, T. D. 2S09.’
“In view of the emergency already precipitated in certain districts the following suggestions, which are subject to modifications through fur- ther interpretation of the law by the courts, are submitted :
1. Use of Narcotics in the Treatment of Incur- able Disease, Other Than Addiction.
“With reference to persons suffering from a proven incurable disease such as cancer, advanced tuberculosis and other diseases well recognized as coming within this class, the reputable physician directly in charge of bona fide patients suffering from such diseases may, in the course of his pro- fessional practice, and strictly for legitimate med- ical purposes, prescribe narcotic drugs for the im- mediate needs of such patients, provided said pa- tients are personally attended by the physician and that he regulates the dosage himself. The prescriptions in such cases should bear the en- dorsement of the attending physician to the ef- fect that the drug is to be dispensed to his pa- tient in the treatment of an incurable disease.
“While the primary responsibility rests upon the physician in charge, a corresponding liability also rests upon the druggist who knowingly fills an improper prescription or order whereby an ad- dict is supplied with narcotics merely for the pur- pose of satisfying his addiction.
2. Aged and Infirm Addicts.
“Cases will come to your attention where aged and infirm addicts suffering from senility, or the infirmities attendant upon old age, and who are confirmed addicts of years standing will, in the opinion of a reputable physician in charge, re- quire a minimum amount of narcotics in order to sustain life. In such cases prescriptions to meet the absolute needs of the patient may be written and filled without involving a criminal intent to violate the law. Even in these cases every rea- sonable precaution should be exercised to prevent the aged and infirm addict becoming the innocent means whereby unauthorized persons may engage in the illicit use and traffic in these habit-forming drugs. Prescriptions in this class of cases should bear the endorsement of a reputable physician to the effect that the patient is aged and infirm, giving age and certifying that the drug is neces- sary to sustain life.
3. The Ordinary Addict.
“One of the principal difficulties in administer- ing this law will arise in the case of the ordinary addict who is neither aged or infirm nor suffer- ing from an incurable disease. Mere addiction alone is not recognized as an incurable disease. It is well established that the ordinary case of ad- diction yields to proper treatment, and that ad- dicts can be taken off the drug and. when other- wise physically restored and strengthened in will power, will remain permanently cured. The aver- age addict does not believe this and it is symp- tomatic with him to have a fear and distrust of any treatment or cure. Wherever the occasion presents itself, the hope of successful treatment should be instilled in the minds of the unfortu- nates addicted to this terrible habit.
“The law as construed by the Supreme Court holds it to be a crime for any person, including practitioners, to furnish an addict with narcotics for the mere purpose of satisfying his cravings for the drug. The enforcement of this law as thus construed presents a problem attended with serious difficulties. The ordinary addict, when suddenly deprived of the drug to which he is ad- dicted, suffers in an extreme manner both phy- sically and mentally. In this condition he may become a menace to life and property and prac- tically a public charge. Therefore, it must be recognized that at present the care and treatment of such unfortunate addicts is primarily a prob- lem to be locally handled by the municipal and
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stute authorities. It is generally recognized that the indigent sick of a community are public- charges therein, and that such immediate care and treatment as is required should be furnished by the local authorities. A project is under consider- ation looking toward the assistance of the United States Public Health Service in the institutional care of these addicts, but no specific appropria- tion for tnis purpose has as yet been provided by Congress.
“Collectors and internal revenue agents should confer with each other and with the United States attorneys in their respective districts and divi- sions regarding the handling of local emergencies as they arise, and should arrange conferences with the local authorities, including boards of health, for the purpose of establishing at the ear- liest practicable date public clinics where relief may be afforded in conformity with the law. Clin- ics of this character have already been established in certain cities, notably New York, New Orleans and Memphis.
“When any of these contemplated steps have been taken the collector should advise the bureau in detail of the plans put in operation in order that in the near future some uniform program may be adopted throughout the United States. It is thought that it will not be difficult under the management of a reputable physician ap- pointed by the local authorities to examine, regis- ter and properly treat ordinary addicts residing in his community by reducing the dosage to the minimum and preparing and encouraging the ad- dict to enter a hospital, sanitarium or institution wherein he can be taken off the drug and prop- erly treated with a view to curing his addiction.
“Care should be exercised by investigating and field officers of this bureau not to interfere with or harass the reputable physician, who in the course of his professional practice and for legiti- mate medical purposes only is in good faith treat- ing a bona fide patient for the cure of addiction, nor the official representative of the local author- ities who is administering narcotics to addicts in a proper manner to meet their immediate needs to prevent collapse. At the same time, it must be understood that the so-called reductive ambu- latory treatment does not meet with the approba- tion of the bureau for the obvious reason that where narcotics are furnished to an addict who controls the dosage himself he will not be bene- fited or cured, and in many cases he may, by de- ceiving or importuning a number of doctors, se- cure a supply for peddling purposes.
“The field officers of this bureau are expected to investigate and report every illicit trafficker in narcotic drugs, including any peddler, smuggler, manufacturer, wholesaler, retailer and practi- tioner, or other person, who wilfully violates the intent and provisions of this law as construed by the courts. In no other way can this menace to the manhood of our country be eliminated. The commercial or so-called “morphine doctor” must be kept under proper surveillance, and in every case where clear evidence of his wilful intent to violate this law is procured no compromise will be made, but his vigorous prosecution will be in- sisted upon.
“DANIEL C. ROPER, Commissioner.” This, in brief, presents the subject ami the principal points. As I understand it, it is desirable to get some valuable views from you gentlemen which can be presented to Washington whereby these addicts may be
treated by you in connection with the loeaL authorities, since a great many of them will be taken care of by you and will yet be a charge upon the city and county.
DISCUSSION.
G. E. Neuhaus, Denver: The question of mor-
phine addiction is a very great one, as all physi- cians know. In the course of our medical work we come in contact with the unfortunate addict and have the opportunity to see the effects, the fearful effects, of his addiction. The legal defini- tion, or laws passed, and the administrative rul- ings of the department with reference to the Har- rison law are clear cut and apparently simple. However, in practice, the subject is not simple, because we cannot decide offhand what we are permitted to do under the law. To illustrate this, I would like to mention an instance that came under my observation about a year ago. A young man came to my office saying that he was an addict, that he had been taking morphine for a number of years, that he was an actor, tempo- rarily in Denver with a troupe of actors who were performing at the local theater, that their engage- ment would end in a few weeks, that they were going only to Salt Lake and then to San Fran- cisco, and that he had the promise of his man- ager that at the termination of his engagement the manager would have him enter an institution for the treatment and cure of his addiction. He was without morphine, had been without the drug for twenty-four hours, and was pretty much on the ragged edge. I felt that to deny him the mor- phine would mean that he would have to give up his engagement, that he probably would lose the support of his manager, who would naturally re- sent his failing him at an important time, and that, from a humanitarian standpoint, and from the standpoint of public policy, it would be best to supply him with morphine. I knew, however, that the ruling of the department was that no addict was to be supplied with morphine in order to satisfy his craving, so I communicated with the office of the internal revenue collector, and was given permission to furnish a prescription for morphine to this man while he was in Denver. Now, the ruling of the Supreme Court says that to attempt to reduce the quantity to patients and addicts gradually from time to time by giving a man a prescription for diminishing amounts when lie comes to the office is unlawful. I believe that is right, that is as it should be, because no ad- dict can be cured by coming to the physician’s office and getting a diminishing amount of mor- phine from time to time. When he gets his stated quantity reduced to such an extent that he feels the pinch, he will go to another physician and enlist his services and get him to prescribe, and in this way he will make up the deficit in his daily allowance ; and as I have been told by the field agents of the department, sometimes ad- dicts go to two or three physicians at a time un- der the pretext of taking a gradual reduction cure.
The only way to cure an addict is to place him in a hospital where he can be fully controlled and where his environment also can be controlled : and I think that would be the ideal plan. Now. however, when an addict comes to us and we tell him that he must go to a hospital he tells -us that he cannot do this without some preparation, and a little reflection will prove that that is true : he cannot go to his employers, or others, and say.
January, 1920
“I am an addict; I have to go to a hospital and get treated”, because that would injure his stand- ing in that community; so lie has to make some preparatory arrangement, and he needs a few days’ time. Now, I think under these conditions, where a man is willing to take a cure for his ad- diction, that we should be permitted to furnish the addict with the- necessary amount of mor- phine to tide him over this period, or this inter- val. I believe, however, with that exception, that we should not have the right to prescribe. I think the right to prescribe morphine to addicts that are not subject to incurable diseases, or infirm, the right to prescribe for relief or for any other purpose, should be reserved for the men who fill a public position, that is to representatives of the Public Health Service, or to county physicians. Only in this way will it be possible to keep track of the addicts and guard against their going from one doctor to the other with the same tale and simply gratifying the appetite. It has been sug- gested that it might be feasible to require them to take their prescriptions to one particular drug- gist in a community and let this one druggist fill all prescriptions that are given to addicts, and that in this way it would be possible to keep track of them and to see that they did not duplicate prescriptions. 1 do not think that is advisable, because, in the first place, it is possible for an addict to go to two or three doctors and get pre- scriptions under assumed names, or to send for a prescription by a friend to this specified drug- gist, and in that way get a much larger supply than he is entitled to have ; furthermore, a great many of these addicts are poor, they are desti- tute, and will neither pay you nor pay the drug- gist for the drug. So, all these cases, I think, should be referred to the Public Health Service representative or to the county physician for treat- ment, and he alone should have the right to pre- scribe for an addict.
The plan that is under consideration by the Public Health Service to provide institutions all over the country for the treatment of addicts is a very good one, but, of course, that is away off in the future. In the meantime, I think it is pos- sible for a community, like ours, for instance, to provide a place somewhere in the county where the appointments could be very simple. Not. much apparatus is necessary ; all that is needed is a man who knows how to treat these addicts and who has the necessary psychiatric knowledge to be able to distinguish between normal and ab- normal individuals ; there is also needed a corps of nurses; and, of course, the place to run the institution. I think a very few thousand dollars would fit out an institution of this kind, and the running expenses need not be excessive. Some such arrangement would provide immediate relief in this very urgent and serious situation. We hear it sometimes said that an addict is not en- titled to relief, that he has gotten into this habit through his own fault, and that he might just as well suffer the consequences of his vice. I cannot take that stand. A great many of the addicts have become addicts, not through viciousness, but through circumstances. Very often they have been to some physician who has been prescribing morphine for them, and they are weak in mind and body and need relief. Anyone who has seen an addict in the throes of the symptoms will be unwilling to leave such a man without relief, and the condition is not always without danger. I remember seeing, during my career, a patient who I think could have been saved if he had been given the necessary dose of morphine to relieve his collapse, that being the only remedy which
will relieve the collapse that comes in the course of the use of the drug. The length of time neces- sary for a patient to stay in a certain institution varies. Some men need a long period of building up, reconstruction ; others are cured in a very short time, and permanently cured. It depends on the incentive the patient has to get well, and on circumstances in general. I remember one case of a woman who had been treated on three different occasions, once in my institution and twice in the county hospital, and who went back to the drug, and when her husband committed suicide, the mental shock she sustained was the means of curing her almost at once, and perma- nently, of her addiction.
G. A. Moleen, Denver: I think if a vote were
taken of the entire medical profession, it would be unanimous in the approval of any plan which is going to make for the relief of these poor un- fortunates, as much as we might feel that it is an imposition on the medical profession to have to pay for the privilege.
Since this discussion has taken the direction of merely the addicts, 1 will speak only from that viewpoint at this time. In the first place, I think we will readily appreciate from the accurate de- scription in general of addicts, or the average ad- dict, given by Dr. Neuhaus — and which I think a person who has seen them will recognize — that the first and most important thing of all is to place within the reach of these addicts an insti- tution or a haven which is easily accessible, that is so situated that it can be reached without notoriety and can be easily entered by those who entertain a serious desire of discontinuing the habit. The second thing, and I think equally im- portant, is the security that such an institution provides. It should not allow the individual pa- role privileges, and should not allow access of the friends or relatives or acquaintances of the individual. It should, in other words, provide for isolation. The reason for this is obvious to every medical man here. And the next point is the hygienic surroundings and comforts that it will provide. Those three conditions should be satis- fied at any place at which the cure of the addic- tion is undertaken.
We have heard a good deal said of the sudden withdrawal of narcotics from those who have been accustomed to them. Most of this comes from the penal institutions and I must say that the most exalted opinions from the heads of these institutions have reached us — they say, “When they come in as prisoners, and are addicts, we put them in a cell and let them fight it out for themselves.” That is all right ; perhaps the head of a penal institution who feels it is his duty to invoke a certain amount of punishment can do this, but in the eyes of the medical profession the human side is uppermost, and I think we will all desire to supply relief. As Dr. Neuhaus has said, this period of time, until they are able to struggle for their own existence, is the important factor to be considered. I am quite sure that we all feel that the institution is an urgent need, like a good many other institutions which we feel the need of in this city, as well as this state and also other states ; but if we are going to grapple with this matter, with people who are unable to control themselves, who cannot be trusted and whose friends cannot be trusted, it requires a place which is inviting, a place easy of access, a place that is secure and that offers something in the nature of a temporary commitment, in order that we shall be legally enabled to keep those
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Colorado Medicine
individuals a sufficient length of time away from their vice.
A. C. Magruder, Colorado Springs: Unfortu-
nately, there are a good many narcotic addicts among the medical profession. This comes to us at almost every meeting of the State Board of Medical Examiners, and it has been necessary on several occasions to revoke the license of physi- cians in this state on account of their use of morphine, heroin, or some other drug. Only yes- terday a physician who was on probation applied to have his license restored, claiming that he was cured. Now, as one feature of this act, if it could be interpreted so that we could allow these phy- sicians to have their licenses back, yet at the same time prevent them from using the blanks to prescribe morphine for themselves — for they come with a long argument of their destitution, of their large family and of the high cost of liv- ing and that they must have their practice in order to maintain their families — now, if we could let them practice, and at the same time not use the blanks, these blanks being withheld from them, we could, in a great many instances, trust them to go ahead with their practice, give them their licenses back ; but with these blanks in their hands by which they may prescribe narcotics for themselves, it is necessary to withhold the license until we feel absolutely sure that the patient is a cure. Now, I should like to ask the speaker if we could get an interpretation of that part of the Harrison Act which would allow us to give the men their licenses back and still withhold the privilege of their prescribing the drug?
F. R. Spencer, Boulder: There is one feature
that has not been sufficiently emphasized, and that is our hearty cooperation with the federal authorities, namely, with the collectors of internal revenue. That is absolutely essential, first, for the benefit of the addicts, and, second, for our own self -protection, because if we do not give them our cooperation in this matter, the addicts will continue to use morphine and will deceive us. They often deceive themselves, which is worse. I was in hopes we might hear from Dr. Strickler on this. One of the big problems before the State Board of Medical Examiners is to take care of these men, and some of them are mem- bers of our own profession. We need to look at this matter from a serious viewpoint. Many of us do not see these addicts often, do not see them often enough to have them firmly impressed on our minds, and we are going to consider it too lightly. Unless this problem can be handled as seriously as it deserves to be, the Harrison law, which has been one of the best laws we have ever had passed, will fall short of its mark.
Hubert Work, Pueblo: This discussion has
wandered a little from the original direction, in- asmuch as two of the speakers have spoken par- ticularly on the treatment of morphine addicts. Both of these eminent men have recommended in- stitutional cure. That, of course, I naturally ap- prove of, yet, on the other hand, I think it is only fair to say to the general practitioners that they can do a great deal themselves in the treatment of morphine addicts. The treatment of a mor- phine or a cocaine or heroin addict is about the simplest thing I know of in medicine. Of course, restraint is necessary, but restraint can be had to an extent without institutional care. If you will allow me to describe the treatment we use, hoping that some of you will derive a little bene- fit from it, I shall do so. We have tried nearly everything that has come up in the last twenty years. So much mystery is thrown about the treatment recommended for this condition, some-
times by ethical men, but largely by unethical men, that it is a sort of relief to us to know that there is something simpler, and that so much of this detail prescribed is unnecessary. The Lam- bert treatment is good ; it is ethical, but it is un- necessarily severe.
To be brief, and to keep within my time, when a morphine addict comes to us we put him prompt- ly to bed and give him a good dose of castor oiL In the course of three or four hours we give him another dose, and continue them for two or three days, small or large, as may be necessary- — it is usually small — and that will furnish all the re- straint that is necessary for the time being. If there is any other treatment that will make a man wish to abandon his habits more quickly than that, I don’t know what it is. After two or three days that man is physically born again ; he has forgotten about his old habits, and be- lieves at the time that if such a course of treat- ment is necessary to restore him, morphine has no longer any attraction for him. Aside from supporting the patient, the castor oil, ordinary common sense and nursing will restore these cases for the time being. After a man has been re- stored, as we call it — we never say “recovered” — - and he appears to be the picture of health, then is the critical time, rather than while he is under treatment. I make these suggestions to the gen- eral practitioner in order that, if lie deems it necessary or better to try the treatment at home he can find the necessary physical restraint in castor oil, and at the same time clear the field for subsequent treatment.
O. M. Gilbert, Boulder: Just one suggestion,
along the line proposed by Dr. Moleen, of some means which are readily accessible by which pa- tients can have themselves committed. I think we might profit by a law of Missouri, although I believe it applies only to the City of St. Louis, by which it is provided that a patient can volun- tarily commit himself. He usually takes a shot of morphine and goes as quickly as he can get there, while the drug keeps his courage up, but once committed he is under restraint and can be held legally for the period of three months. I chanced to be on the staff of the St. Louis Insane Asylum and saw the working of the law, and it is excellent, in that, just as Dr. Moleen has sug- gested, it avoids any idea of publicity in the com- mitment. One does not have to go before a court to be committed — he can commit himself — but once committed he has to remain there. I think that is a provision that should be incorporated in this law.
H. S. Henderson, Grand Junction: I should
like to ask a question. We, living over on the Western Slope, are a long way from any place where there is a hospital to take care of these cases. Oftentimes we are confronted with a very bad local condition, and, unfortunately for me, I happen to be health officer over there, and the rest of them all tell these addicts to go to the health officer for morphine. I should like to ask if there is any provision in the law that will give the local health officer more authority than any other doctor to give these addicts morphine? I have done my best to read through this law, and I cannot find in it any intimation that they have any more authority than anybody else, yet the idea is out, from one cause or another, that we have more authority, and consequently we are the ones that have the grief ; and you tell the patient to go to a hospital, or go to some place where he can be taken care of, and it is four hundred miles — “Well, I have got to have some stuff to get there on, I have got to have so much, I am taking
January, 1920
9
eight grains or ten grains a day. What am I going to do to get there?” And when you give it to him, he may not ever go ; so I would just like to ask if we have any more authority than any other doctor?
Mr. Dingley, closing: As to withholding blanks
from the physician addict, as the law now stands, that would be impossible ; it would be considered, probably, class legislation. There is no exception whatever in the law as to any particular class of doctors, and it gives equal authority to every phy- sician who is registered under the state law. Whether or not that will be feasible, it would be something, of course, the courts would have to decide, and it might be well to recommend some- thing of that sort in our letter to the commis- sioner ; but it is also possible that these prescrip- tions could be checked by some local health offi- cer before the narcotic could be prescribed. That, possibly, would be a good solution of the matter. There is nothing in the discussion here that would prevent any such method of handling cases. It seems evident that there should be some central authority which could decide whether a person was entitled to receive the narcotics under the law, or whether he really needed the narcotic for disease, or to prevent collapse, or something of that kind — that might be a good solution. In re- gard to the other question as to the authority of the health officer, there is a section in the law which says any local or municipal authority can purchase narcotics without official order forms, provided he is a local officer or connected with some local public institution. I. believe that is as far as it goes ; but he cannot prescribe any more than another physician, and I doubt very much whether he could prescribe enough to allow an addict to go any distance, or more than was necessary for immediate use of that patient. The decision of the Supreme Court has been that no one can prescribe for a patient beyond the imme- diate use of such patient. Now, what they would interpret as “immediate use” would be very hard to say, but my opinion would be, it would be what he would need for perhaps twenty-four hours — that is the best I can answer the question at this time.
INDICATIONS FOR OPERATIVE TREAT- MENT IN CRANIAL FRACTURES*
O. M. SHERE, M.D., F.A.C.S., Denver.
While tremendous progress has been made during the past few years in the treatment of fractures in other parts of the human anatomy, very little unanimity of opinion exists regarding the principles of surgical management in injuries of the cranium.
Within the limits of this brief paper I shall endeavor to give the merest outline of the guiding conditions upon which either the operative or non-operative treatment of these serious injuries should be based. To- wards this end a combined study has been made from a series of cases which have
*Read at the annual meeting of the Colorado State Medical Society, October 7, 8, 9, 1919.
come under my personal observation, as well as all the cases of cranial fracture which were admitted to the Denver City and Coun- ty Hospital during the period of fifteen years, from 1904 to date. The balance of the cases were collected from the literature and makes in aggregate with the others a total of one thousand cases.
For our purpose it seems best to tabu- late these fractures in two broad subdivi- sions, namely basal and vault. The former constitute 62%% and the latter 37%% of the entire series. Such a ratio, though con- trary to the teaching of the older and many of the modern surgical text books, which tell us that the vault fractures are exceedingly more common than those of the base, will nevertheless be found to be in conformity with the present day experience of most sur- geons. The figures elicited from the study showing a ratio of nearly two basal frac- tures to one of the vault, will bear some mod- ification, for some of these fractures were not confined to any single region, either the base or vault, but instead were associated in- juries. The larger part of the fracture, how- ever, was in one particular region, and there- fore thus credited. Of these cases, 67% were not operated and 33% were submitted to surgical interference with the following results :
Nonoperated: Relieved 41% ; died 59%.
Operated: Relieved 51.6%; died 48.4%.
The word “ relieved” instead of “cured” is used advisedly in this instance, since a number of patients considered as cured upon leaving the hospital were later found to be afflicted with persistent headache, epilepsy and various forms of mental derangement. These conditions, however, were more pre- valent in the nonoperated than in the oper- ated cases.
The above tabulation would indicate that the percentage of cures is somewhat larger in the operated cases. This is fully in ac- cord with the result of a similar study made by Besley and presented before the Ameri- can Medical Association several years ago.
The general mortality, however, is still ap- palling and certainly no credit to modern surgery. Reasons for this are not far to seek. To quote Cushing: “Anything classi-
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fied as neurological surgery is looked upon by many of us as baffling and difficult and the feeling prevails that the ultimate func- tional results, after recovery from serious cranial injuries are, to say the least, for- lorn.”
Those of us who come in contact with these cases must admit that the tendency to avoid surgical intervention whenever pos- sible is indeed great, because of the small percentage of cures. The percentage of pa- tients who survive operation is, however, no real index of the value of treatment. In a large number of cases injuries are found which no surgery could cure. In others there are minor ones which would not have proved fatal, even if they had been left alone. It would therefore seem to me that the real failures are the cases in which the patient is wrongly classed as hopeless where operation might have saved his life, and also those cases in which the operation, though instituted, is performed too late. It is perfectly obvious that it is easy in this class of patients to operate too much. In many, life is hanging by a mere thread. The shock from the operation added to the al- ready existing one is greatly to be consid- ered. Yet on the other hand it is extremely pathetic to see on the autopsy table that a clot was clearly the direct and chief cause of death. And such instances are by no means rare even in my own series.
The problem then that confronts us is the following: Is it possible to rationalize the perplexing situation to an extent that will determine the question whether or not oper- ative interference should be resorted to in any given case? This, in fact, is the theme and sole object of this paper.
Sharpe says : “If the patient is allowed to develop definite paralysis, a lower pulse rate, Cheyne-Stokes respiration and pulse and that appalling group of extreme intra- cranial pressure, signs, then I agree entirely with the opinion so commonly now held that these patients ‘get along’ just as well with- out operation as with operation at this late stage, the mortality being 50% and over; but the patients with brain injuries should not be allowed to reach this dangerous stage of medullary compression due to the high
intracranial pressure. It should be antici- pated by accurate diagnostic methods new known. ’ ’
In order then to afford these patients pos- sible relief, we must endeavor to decide the following in each individual case : First, the necessity of and, second, the proper time for any surgical procedure. Since the clin- ical symptoms and signs are so varied and frequently so confusing in these patients, it is obviously impossible to lay down ironclad rules. There exist, however, certain prin- ciples which must guide our decision as to operative or non-operative treatment.
For the prompt recognition, as Avell as the proper interpretation of these guiding signs, it is primarily essential that each patient should receive the benefit of a cooperative study and examination made by the neurolo- gist , the roentgenologist and the surgeon. The first must also be well trained in the use of the ophthalmoscope, since this instru- ment plays a very important role in the di- agnosis of cranial injuries.
When we consider that in these patients the subjective symptoms are of no help rvhat- soever, either in making the diagnosis or in- stituting any particular method of treatment, and also bear in mind the fact that no frac- ture of the skull is in itself dangerous to life, it then becomes imperative for the surgeon to consider the seriousness of the most fre- quent complications, whose prompt recogni- tion is so highly essential for the carrying out of timely treatment.
These complications are intracranial pres- sure and hemorrhage. The former can be as- certained with a fair degree of accuracy by the ophthalmoscope, which reveals an ede- matous blurring of the optic discs. This is to be supplemented by the measurement of the pressure of the cerebro-spinal fluid by means of lumbar puncture. Since the spinal mercurial manometer has been brought into use, varying degrees of intracranial pres- sure can lie carefully recorded. Sharpe has estimated the normal pressure to be from five to nine mm. of mercury, so that if a pressure higher than fifteen mm. is ob- tained at the lumbar puncture, we know that the signs of intracranial pressure, as shown in the fundus of the eye, are con-
January, 1920
11
firmed. He states that after a considera- tion of the literature on the subject, and as a result of experience quite extensive, he is of the opinion that the operative treatment for selective cases of fracture of the skull showing signs of intracranial pressure is far superior to the expectant treatment and that the operation most suitable for these cases is the subtemporal decompression.
The clinical symptoms of cerebral hem- orrhage are too well known to need repeti- tion. My plea at this time is simply for its early recognition, so that operative interven- tion may be instituted in time. In every in- stance where fracture is suspected, regard- less of the anatomic location, roentgenogra- phy should be employed, but in such event I would caution against exclusion of fracture because of negative x-ray findings. A few cases have come under the writer’s care in which a fracture was diagnosed clinically and confirmed either on the operative or postmortem table, yet had shown negative radiographs.
As a matter of fact, an operation is indi- cated in every instance where there is a def- inite increase of intracranial pressure, whether or not there is a demonstrable frac- ture of the skull. The two patients which I shall show you presently will serve to il- lustrate this point. The first was discharged from the hospital two days after admission because of negative x-ray findings. On the following day he developed convulsions on the opposite side from the point of injury. These were from fifty to sixty in number during the twenty-four hours preceding the operation, which was performed five days after the occurrence of the trauma. At that time we found a depressed fracture with ac- tive hemorrhage from the middle meningeal artery. The second patient was at a hospital for a number of weeks in a state of mania, coupled with convulsive seizures, these symp- toms following an injury to the skull by an iron ore bucket. No fracture could be dem- onstrated by the x-ray in this case. Upon operation a large degenerated blood clot was found encysted in the frontal lobe, the re- moval of which was followed by prompt re- covery from all symptoms. The result of these operations you may judge for your-
selves when you examine these patients. You will also be impressed with the fact of the probable consequences had the treatment been based upon the negative x-ray find- ings. It is with the idea of accentuating this particular phase, that I bring these pa- tients before you.
What I have said about x-ray is also true of blood pressure, lowered pulse and respira- tion rate and all the other rather crude signs of cerebral injury. While any of them may be of value in correlation with other findings, none is dependable per se.
My conclusions, which some may deem iconoclastic, are nevertheless submitted here as follows:
First: Operate whenever you have defin- ite signs of intracranial pressure, excluding those cases of severe shock and medullary compression.
Second : Every person suffering from a
basal fracture showing definite signs of intracranial pressure should be accorded a chance of recovery by a subtemporal decom- pression.
Regarding the technic I have nothing par- ticularly new to offer, except to emphasize two rather important features in these opera- tions, namely: that the dura should be
opened in all decompression opperations and, again, that I have found muscle tissue to pos- sess powerful coagulating properties, and that therefore its use as a hemostatic in cranial surgery will be found most gratify- ing.
In conclusion I wish to express my best thanks to Dr. Eli Miller, of the resident staff of the Denver City and County Hospital, for his efforts in collecting the cases from the hospital records, thus making the study pos- sible.
610-614 Metropolitan Building.
DISCUSSION.
Leonard Freeman, Denver: Dr. Shore has cov-
ered this subject so completely that it leaves hut little for me to say, and I think I prefer to occupy the few minutes allotted to me by speaking on an- other aspect of the question. The amount of trephining at the present time, together with that which has been done in years past in civilized communities, is trifling compared to the trephin- ing done for fractures in this western hemisphere five hundred to two thousand years ago. When Pizarro invaded Bolivia, Chile and Peru he found a wonderful civilization, with large cities and great
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armies. They fought with spiked clubs, the spikes often being multiple. They were heavy, and not only made single depressed fractures of the skull, but sometimes multiple fractures, and as they fought a great deal the fractures were numerous. It was natural that they should develop the sur- gery of the skull, with trephining. In a large number of skulls that were exhumed from the old graveyards in Bolivia, Peru and Chile, two percent have been trephined for fractures and other things. Our present trephining is nothing at all compared to that. In one specimen, a mummy, preserved in the Smithsonian Institution in Washington, there is a definite paralysis on one side of the face with a trephining at the seat of a fracture on the opposite side of the skull. These trephinings were done in a way peculiar to the South American continent. They sawed out a square piece of bone an inch square, perhaps, or more. This was done with a rough piece of flint, set in a wooden handle and braced against the chest. The operator held the patient’s head between his knees, operating through a crucial incision in the scalp. They may or may not have had an anesthetic. Now, I want to call attention to something which is to me of extreme interest, because it shows that the operation of trephining was sometimes deliberately done for decompres- sion, as Dr. Shere has advocated in his paper to- day. I know this, because there is a skull in the Museum of Anthropology in San Diego, a skull which shows in the cerebellar region the bulge of a tumor. The tumor is very definitely outlined in the skull, about as big as half an orange. A decompression had been done upon the skull. The whole history was written right there. I was per- mitted to take the skull out and examine it, and could read the history as plainly as if it were written in a book. Two surgeons probably worked upon that skull. One started to do a decompres- sion operation and began just back of the left ear. He made an attempt to saw through the skull with a piece of flint, hut unfortunately he got into a large sinus. The patient bled, evident- ly, and he stopped. The patient got well from this operation and the bone smoothed over, so that you could tell that it was some time before the second operation was undertaken. Then, along came another surgeon, in all probability, and pos- sibly he said the first man didn’t know how to get at it, but he could do it. So he started in the center of the cerebellar region and sawed out a square piece of bone, such as I have outlined here. He then pried out the piece of bone, leaving a little portion of the inner table on one side. On all the other skulls that were trephined there was no portion of the inner table left, thus showing that he did not have time to remove this splinter. And it was very evident why he did not have time, because right here he broke into a very large blood sinus which runs along at that point. The groove of the sinus was definitely shown, and just where he broke into it was distinctly shown. The patient died right there — bled to death on the table. I have no doubt that surgeon felt just as bad about it as the modern surgeon would. We know he bled to death because the surgeon did not have time to take out that little splinter of bone, which in every other skull was taken out. That was an operation done for decompression, as Dr. Shere advocates today in his paper. The other operation, as shown by the mummified head in the Smithsonian Institution, was also done for decompression, so that the operation for decom- pression was known and was practiced at that time. If you will permit me, I want to add just a few words. Another preserved skull in the San
Diego museum had a surgical dressing on it which was interesting. It was bound across the top of the head and composed of a roll of cotton in gauze. This “cheese cloth” is made of cotton thread and is exactly the same kind of gauze we use today — and that was fifteen hundred or two thousand years ago. There is not the slightest difference in the gauze, unless it be in favor of the Peruvian gauze over ours, because it is finer. Also there was a heavy string wound repeatedly around the head from the frontal region to the occiput. It was wrapped eight times around the head and was hitched up behind by some kind of a “dia- mond hitch” which I could not quite unravel. One could pull behind on a portion of the cord and tighten up the whole thing — the bandage over the head, the strings around the forehead, and vhe strings over the top of the head. This was evi- dently a method for controlling hemorrhage.
Dr. Shere, closing: I am indeed grateful to
Dr. Freeman for taking up the paleopathology of these cases. There is no subject in the entire history of surgery that equals in interest the tre- phining operation, which, as you know, dates from most ancient times. In the discussion, mention was made of an old skull specimen showing evi- dence of hemorrhage from a sinus. This prompts me to add a few words relative to the subject of hemorrhage during cranial operations. Experi- mentally, at least, I have been able to demonstrate the efficacy of muscle tissue as a hemostatic. About a week ago I deliberately opened the longi- tudinal sinus in a dog and succeeded in stopping the hemorrhage by gently packing the sinus with muscle tissue. The dog has thus far made an un- eventful recovery. If this can be duplicated in the human, then the mortality from these acci- dental operative hemorrhages will be greatly re- duced, if not entirely prevented.
SPLENIC ANEMIA IN CHILDREN*
Report of a case of Banti’s disease in a boy of six years ; splenectomy and recovery.
J. W. AMESSE, M.D., Denver.
Among the numerous problems of internal medicine still awaiting solution, few afford greater interest for the clinician than those associated with disorders of the ductless glands. And with equal truth we may assert that of these peculiar elements of our econ- omy, whose physiological and pathological processes have been the source of such her- culean labor in recent times, none has proven more baffling in its study than the spleen. As Howell fittingly observes, “with all that has been said and written of the spleen, we are yet in the dark as to its distinct func- tion”. Unquestionably concerned with the production of red corpuscles before birth, it is assumed by many that this function ob-
*Read at the annual meeting of the Colorado State Medical Society, October 7, S, 9, 1919.
January, 1920
13
tains throughout life. By others it is sup- posed to destroy red cells and to be con- nected in some way with the production of uric acid. As a matter of fact, about all that is definitely known may be summed up in a brief paragraph. We know that it may be removed from the body without damage ; that it has periods of contraction and relax- ation during digestion and that these move- ments, rhythmical in character and main- tained by the intrinsic musculature of the organ, serve to sustain the circulation inde- pendent of general arterial pressure (Roy).
We may justly assume, too, that from the presence of fatty acids, cholesterin and ni- trogen extractives, active metabolic changes of some kind occur in the spleen (Howell).
If doubt and confusion, however, punctu- ate our slender knowledge of its physiology, how much greater a source of contention and speculation is its pathology! All writers agree that the spleen may be involved in any or all of the acute infections ; that it reacts in varying degrees of enlargement to the toxins of malaria, syphilis and the graver diseases of the blood. It may wander from its normal site into any portion of the abdo- men; may suffer spontaneous or accidental rupture and may occasionally harbor infarcts or abscesses. But these are all secondary dis- orders. Actual primary affections of the spleen are summed up in a brief page or two of our text books, and their consideration in more extensive works is only too frequently dismissed with scant attention. If we elimi- nate such rare conditions as sarcoma and other new growths, among which may be in- cluded the form of chronic endothelioma de- scribed first by Gaucher, our attention is focused on a disease possessing exceptional interest alike for the internist and the sur- geon ; of obscure causation and bizarre man- ifestations, known to the English speaking- profession as Splenic Anemia.
During the twenty years that the syn- drome characterizing this peculiar affection has borne the brunt of repeated investiga- tion, it has been frequently asserted that neither the clinical nor the pathological findings could justify its recognition as a distinct disease entity. In fact we may dis- cern, in the voluminous literature that has
developed about this controversy, two schools of thought; one endorsed by Osier, Lyon, Sippy, Banti and others maintaining that we have, in the condition commonly known as splenic anemia, all the elements of an independent and primary derangement; the other, represented by Wentworth, War- thin and Stengel, contending that it is simp- ly a manifestation of some subtle infectious process. Without recounting the intensive studies and the well sustained arguments which have marked this difference of opin- ion we may infer that most authorities now accept the classification of Osier and recog- nize in splenic anemia an independent dis- ease.
Known under various titles, it may be de- scribed as a disorder marked by extraordin- ary chronicity, showing progressive enlarge- ment of the spleen and further characterized by secondary anemia of extreme grade, re- duction of the white cells, a decided tenden- cy to hematemesis and in the later stages, cirrhotic changes in the liver with ascites, jaundice and pigmentation.
This final involvement completes the pic- ture of Banti ’s disease, which may be termed the last phase of splenic anemia. Sippy finds, in his exhaustive review of the literature, that an accurate description of the disease was made by Woillez in 1856, but that the first case was recognized by Gretzel in a baby ten months old, 1882. Banti re- ported three cases in 1883 and pursued such a searching investigation of the terminal phenomena that the fully developed disease still bears his name.
The factors concerned in its etiology have thus far eluded every search. Cultures and inoculations have been consistently negative and every theory respecting its causation has been proven untenable. It is much more common among males ; it occurs at all ages and in any climate. In all, about one hun- dred cases have been reported.
The pathological anatomy, as discussed by Banti, is most distinctive. The spleen may weigh from 1 to 1.5 kilograms ; the shape is normal and the organ smooth and free from irregularities, although the capsule is thick- ened. There is a general fibrosis of the en- tire gland, involving not only the capsule
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but the reticulum of the pulp and the Mal- pighian bodies. Occasionally endothelial masses are seen in amounts sufficient to sim- ulate neoplasms. In the case reported by Stengel this endothelial proliferation domin- ated the entire pathological survey.
In cases which are far advanced, there is noted an interlobular cirrhosis of the liver resembling the changes produced by chronic alcoholism. Banti observed, in one of his cases, sclerotic changes in the splenic and portal veins. Warthin, in his brilliant mono- graph, describes a chronic thrombophlebitis of these veins, with stenosis and calcification. He believes that the fibroid changes in the spleen were directly due to the congestion thus produced and that the altered portal circulation is responsible for Banti ’s syn- drome in probably every instance. Lossen found a similar condition in a case studied in 1914.
The lymph glands are not especially in- volved in splenic anemia nor does the bone marrow show changes other than those ac- companying severe anemias.
In the blood profound alterations are seen. There is a secondary or chlorotic anemia, the hemoglobin falling to forty or even twenty per cent; the red cells being reduced to one-half or even one-fourth the normal count. There is a pronounced leucopenia, in marked contrast with the findings in practically every other type of splenomegaly, but the differential count is not much disturbed. Normoblasts are infre- quent and poikilocytosis not common.
The symptomatology of splenic anemia is dependent upon the stage of the disease in any given case. It may be summed up in general, however, under its most striking features. (1) Splenomegaly: Practically no other disease save, possibly, leukemia is ac- companied by such enlargement of the spleen. It may extend beyond the median line into the right half of the abdomen and be seen and felt as Ioav down as the spine of the ilium. Through mechanical interfer- ence with the circulation and, thus indirect- ly, with the functions of neighboring organs, we may find hemorrhages, especially from the stomach, ascites — common in advanced cases — digestive disturbances. There is usu-
ally some edema of the ankles; jaundice is common even without recognizable lesions in the liver ; the heart may be dilated and hemic murmurs persist for long periods. An odd feature of many cases has been the pigmenta- tion of the skin, found either on the face or trunk and resembling the discoloration of Addison’s disease. (2) Chronicity: The dis- order may continue for many years, even up to twenty-five, and is not incompatible with a fair amount of work. (3) Anemia, which follows the splenic enlargement instead of preceding it, as in other diseases. In addi- tion, iu considering the symptoms of splenic anemia, we may note that the urine is usual- ly free from gross pathological elements and the temperature normal.
The diagnosis rests upon the general pic- ture above outlined. The clinician has to differentiate splenic anemia from all forms of infection in which an enlarged spleen is accompanied by anemia : from leukemia, Hodgkin’s disease, pernicious anemia and neoplasms. He must exclude the various forms of cirrhosis of the liver and especially eliminate the Von Jaksch syndrome which so greatly resembles it, in infancy. This con- dition, however, may be considered as the re- action of the infantile blood-forming organs to infection. It is always associated with rickets which is believed to be the predispos- ing factor. There is involvement of the lymph glands and an increase in the white cells.
Treatment : Once the diagnosis is estab-
lished the case belongs to the surgeon, as logically and definitely as does one of ap- pendicitis or of exophthalmic goiter. Osier contends that the brilliant results which have followed operative procedure constitute a fi- nal argument in viewing splenic anemia as a clinical entity. Certainly the toxic process must be confined wholly to the spleen for its removal to be followed by such prompt and permanent improvement. In any event, the disease is invariably fatal when treated medically. If splenectomy is done early, the mortality is Ioav ; if the operation is long deferred, many cases succumb, especially among children.
Of eighteen operations at the Mayo Clinic, twelve Avere in excellent health from six months to seven years afterward. In forty-
January, 1920
15
seven cases collected by Graham, the mortal- ity was about ten per cent. The preparatory treatment is important. Transfusion should be employed one or two days before opera- tion, and the hygienic management before and after should embrace all agents tending to conserve the vital functions.
Case history: The following case is sub-
mitted as one presenting the syndrome de- scribed by Banti in the terminal stage of splenic anemia :
A. C., boy, age six years, born in Denver and a resident of this city since birth. His father, an Italian, died of influenzal pneu- monia in February, 1919; his mother died of hemorrhage during childbirth four years ago. This parent was but sixteen years of age when the patient was born, and there is a clear history of an obscure disease, accom- panied by pronounced anemia from her ninth to her twelfth year. She was transfused from the husband at the time of the puer- peral hemorrhage without benefit. There is a second child, a girl, now five years of age, in excellent health.
The patient was a strong, vigorous child at birth weighing nearly twelve pounds, was breast fed for the first year and at that period suffered a severe attack of measles. His next illness was at three, when he was taken to the Children’s Hospital suffering from anemia and great weakness. No spe- cific diagnosis was made at the time but the patient has been continuously ill ever since and it may be fairly presumed that this was the beginning of his present disability. After his mother died, the home was broken up and the boy lived around among relatives and friends, finally coming under the ob- servation of the juvenile court which under- took to provide for him permanently. At the time of my examination at the Children’s Hospital on May 27th, 1919, the child pre- sented a most pitiful appearance. The face, thorax and limbs were greatly emaciated; the skin jaundiced and pigmented; the ex- pression one of pain and exhaustion. In striking contrast with the remainder of the body, the abdomen was markedly distended and in the left flank one could readily make out a smooth mass extending from a hand’s breadth above the pnbes to the left costal
border, and across to the median line. A notch could be easily outlined near the up- per margin. The liver could not be felt. The thorax presented evidences of rickets, in the pigeon breast and the lateral depressions. The apex beat was in the fifth interspace. An anemic murmur, varying in intensity and systolic in time could be heard at the base; the pulse was weak and irregular. Examina- tion of urine, negative except for bile. The blood was pale and watery. Red cells, 1,300,000; hemoglobin, 30%; white cells, 5,300. The W assermann test was negative except at one time in October, 1918, when one test was positive and another negative.
In view of the boy’s extreme weakness, it was considered wise to defer operation until he could profit by careful nursing and the exhibition of iron and arsenic. On June 6th, 1919, transfusion of 300 cc. human blood was performed by Dr. Buchtel and on the follow- ing day he was operated by Dr. J. M. Perkins, who succeeded in removing the spleen very expeditiously and with the loss of little blood. The organ weighed about two pounds and when drained of blood measured 17 cm. in length, 7 cm. in width and 7 cm. in depth. Unfortunately the spleen was not put into fixing fluid for forty-eight hours and when finally examined the structure could not be accurately deter- mined. The patient left the operating table free from shock and made a fairly rapid con- valescence. On June 21st, two weeks after the operation, his red count had tripled and the leucocytes numbered 11,400. The hem- oglobin had risen to 55%.
On discharge from the hospital to the Or- phans’ Home, Denver, the red cells num- berd 4,700,000 with hemoglobin 70%, and on September 25th, 5,200,000 with hemoglo- bin 80%. The leucocytes now run to 13,000, the differential count being as follows : Polynuclears, 47% ; small lymphocytes, 38% ; large mononuclears and transitionals, 8% ; eosinophiles, 5%.
The patient goes to school and enters into all the games eagerly. He has gained twen- ty pounds in weight, eats and sleeps- well and gives every promise of living out the natural span of life.
624 Metropolitan Building.
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Colorado Medicine
DISCUSSION.
O. M. Gilbert, Boulder: Speaking of the func-
tion of the spleen, as Dr. Amesse has done and as our authorities do in general, and in vainly attempting to look it up, one is reminded of the humor of the once-famous anatomist and neurolo- gist, His, who, in quizzing one of his classes, asked a young student what the function of the spleen was. He scratched his head a moment and said, “Oh, I knew it, but I just forgot it.” His said in his droll way, “Just think, you are the one man that ever knew the function of the spleen and now you have forgotten it.” That is the attitude of mind you are left in when you are attempting to discover the function of the spleen. It is still a question, and it does seem now that the spleen, which is apparently such an important organ, in some respects at least, entering so much into our clinical pictures, can be removed without permanent appreciable effect upon the human economy at all. There is just one temporary ef- fect— we have an anemia accompanied by a leuko- cytosis. I think I am at liberty to quote from Dr. James Murphy of the Rockefeller Institute, from a personal communication, that there is a decided lymphocytosis reaching its height at a period three to four weeks afterward ; and inci- dentally, may I remark that Murphy has shown by a large number of charts that along with this curve of increase in leukocytes there is almost a parallel curve in the resistance to tuberculosis. This has a bearing upon another point, which I will not discuss here. My own experience in splenic anemia is limited to one slightly doubtful case, a case which I will report to you very brief- ly. This history was written the twenty-third of January, 1909, nearly eleven years ago : A boy
ten years of age had been pale for about three months. No enlargement of the spleen had been noted. On the twelfth of December he complained of being sick, tired, achy and short of breath, and vomited frequently — in a few instances, vomiting blood. He was confined to bed for a few days and then got up and went out and went to school and to delivering papers. When I saw him on the twenty-third I found the heart dilated, the lungs normal, the liver apparently a little con- tracted, the spleen extending to one inch below the costal margin — a few weeks later, an inch and a half below the costal margin. The hemo- globin was twenty percent ; reds, not recorded ; whites, 2000, 4000. I had in mind typhoid fever when I saw the boy, and noting the absence of leukocytosis I did not follow the leukocytes fur- ther, at that time. The boy vomited bloody ma- terial ; one time he vomited ten ounces of it and he passed some blood in the stool. His tempera- ture was up to 100° on one day, and most of the days it ran 99°, 98° and 98%°. I put the case temporarily on arsenic, and for some reason he recovered ; whether the arsenic did it or not, I do not know, but he recovered ; and I notice his hemoglobin record : 40 percent in one month, two months later 45, and six months later 85. He feels well. A systolic basal murmur still exists.
I made an examination seven years later and I noticed the heart murmurs had disappeared and the spleen was just barely palpable. I believe the case was one of splenic anemia. It is borne out by the enlargement of the spleen, and ab- sence of leukocytosis. I believe I might take is- sue with Dr. Amesse on one point, that death is inevitable without operation. Some cases in child- hood do seem to recover.
F. P. Gengenbach, Denver: I had the pleasure
of seeing this case last fall. These cases are
rather rare, but I have seen in the last two years three cases of what seemed to be, as far as we could determine, true splenic anemia. The clin- ical findings in this case certainly point to a def- inite case of Gaucher’s disease, which is differ- entiated from the ordinary enlargement of the spleen by the fact that in the ordinary enlarge- ment we have a simple hyperplasia. In Gaucher’s disease there is an accumulation of new cells, and these cells are very typical, so it is unfortunate that the specimen was so impaired that it could not be pathologically examined. These cells are definitely characteristic. They are large cells with small eccentrically situated nuclei and with slightly granular cytoplasm. They also appear, according to Holt, in the bone marrow and lymph glands. The lymph glands are not very much en- larged. In Gaucher’s disease we usually have some enlargement of the liver also. The disease is characterized by a peculiar brownish discolora- tion of the skin, and in some cases also by a yellowish brown wedge-shaped discoloration of rlie conjunctiva, just to either side of the cornea. This case I saw first on the twelfth of September in 1918. I also saw it last spring before Dr. Amesse saw it. It was brought to the medical school clinic and the findings were then not materially differ- ent from my first examination, and at that exam- ination just a year ago we noted this peculiar dusky color which the foster mother said had lasted about two years. The eyes were slightly jaundiced. He also at that time gave me a his- tory of hematuria the year before. The blood findings at that time, as my memory serves me, were hemoglobin 50 percent, red cells 2,000,000, and white cells 4.600, a decided leukopenia. The differential count was practically normal, except perhaps a little more increase in the polymor- phonuclears than we ordinarily find at the age of six. The liver as I found it was about one inch, or a good finger breadth, below the costal mar- gin, so it was my impression that the liver was somewhat enlarged. The Wassermann was indef- inite. I referred the child to Dr. Buchtel, advis- ing at that time that the boy should be trans- fused, and that then a splenectomy might be at- tempted. As Dr. Amesse has told you, medicinal treatment promises little or nothing. Most cases have been temporarily improved by splenectomy, but whether they are permanently improved or not is a question, as their resistance to infections seems somewhat lessened by the absence of the spleen.
Dr. Amesse, closing: Dr. Gilbert is to be con-
gratulated upon the recovery of his case, because all the evidence we have at hand points to the failure of medicinal treatment in cases of splenic anemia, which, after all, are borderline diseases. It is an extraordinary disease, and I think where the clinical picture can be studied it is progres- sive. We are justified in resorting to a splenec- tomy where skillful surgery can be secured.
Cancer Control Education in Colorado. In re- viewing Dr. W. T. Mayo’s paper delivered before delegates to the American College of Surgeons at the meeting recently held in New York City, the editor of the Denver Post appends to the article this single sentence :
“It is a matter of pride that Colorado is one of the foremost states in the spreading of knowledge regarding this horrible disease.”
This indicates very clearly the value of the edu- cational work which has been done in this state by the Colorado Committee of the American So- ciety for the Control of Cancel-.
January, 1920
17
Tiews Zdetes
Dr. D. Macdougall King is desirous of finding a purchaser for a Spencer microscope, an elec- trical centrifuge, a Tycos sphygmomanometer, a sinus lamp, some miscellaneous office and surgical supplies, and a small library of medical works. Those who have read the doctor’s work, “The Bat- tle With Tuberculosis and How to Win It”, will be interested in knowing that Dr. King has by no means lost his personal battle with that disease, but is retiring from the limited active practice he has carried on for several years on account of increasing limitations occasioned by progressive muscular atrophy, which first manifested itself a year and a half ago.
Dr. C. D. Spivak of Denver left that city De- cember 28th for New York, where he was to join other members of the joint distributing committee of the Jewish War Sufferers’ Relief Fund. He expected to sail for Europe on January 10th, but did not know of his exact destination further than that he would visit all the devastated regions in Europe with the exception of Russia and Ukraine. Dr. Spivak’s recent appointment to the committee mentioned was announced in the daily press in December.
Dr. E. W. Lazell, formerly of Denver, now of St. Elizabeth’s Hospital, Washington. D. C., has announced a course of twelve free lectures to be given in Washington on “The Analytic Psychology of Human Behavior as Applied to Mental and So- cial Hygiene”. His many warm friends in Denver will welcome this news of his activities.
Dr. Chas. A. Powers is spending the winter at Ormond Beach, Fla. Mail will reach him in care of the Ormond Hotel.
Dr. B. A. Filmer has removed from Colorado Springs to Denver.
The American Congress on Internal Medicine, in conjunction with the American College of Phy- sicians, is to meet at Chicago February 23 to 28, 1920. The sessions will comprise daily clinical and laboratory demonstrations in Chicago’s hos- pitals and teaching institutions, as well as evening- gatherings with addresses by men eminent in American medicine. Hotel accommodations must be spoken for at once. Information about the meeting may be obtained by addressing Dr. Frank Smithies, Secretary-General, 1002 North Dearborn street, Chicago, 111.
The new officers of the Medical Society of the City and County of Denver are A. S. Taussig, president ; W. A. Sedwick, vice president ; Minnie C. T. Love (re-elected), secretary; F. P. Gengen- bach (re-elected), treasurer.
Dr. C. W. Thompson of Pueblo has just com- pleted postgraduate work in neurology in the Neurological Institute, New York, and the Grad- uate School of Medicine, University of Pennsyl- vania, Philadelphia, and has resumed his duties at Woodcroft Hospital, Pueblo.
Woodcroft Hospital, Pueblo, has just completed extensive improvements in the addition of several rooms and suites, with connecting sun porches and private baths. These new apartments have spe- cial service from a modern diet kitchen.
Major J. W. S. Cross of Telluride has ordered his Colorado Medicine sent to Fort Bliss, El Paso, Texas, and states that he has “signed up” to stay until next spring.
El Paso County News.
Dr. H. C. Moses is in Chicago visiting clinics.
Dr. L. H. McKinnie has returned from Kansas
City, Mo., where he read a paper before the West- ern Surgical Association.
Dr. H. R, Shands and Dr. J. R. Haney spent the holidays in their former homes in Mississippi.
Medical deeietiesf
COLORADO OPHTHALMOLOGICAL.
The regular meeting of the Colorado Ophthal- mological Society was held on November 15, 1919, in the assembly hall of the Medical Society of the City and County of Denver, Dr. W. A. Sedwick presiding.
J. M. Shields, Denver, presented for Melville Black, Denver, a boy of eleven years, resident in Colorado, who was suffering from typical vernal conjunctivitis, although after the diagnosis had been correctly made by Dr. Herriman of Alamosa the parents had taken the child to another sur- geon who had been treating the case as one of trachoma. Discussed by W. C. Finnoff, J. W. Patterson and Edward Jackson.
H. R. Stilwill, Denver, again presented a pa- tient shown to this society in December, 1918, on account of traumatic staphyloma of the sclera due to a fall. Discussed by J. R. Robinson, F. R. Spencer, G. F. Libby, Edward Jackson and C. E. Walker.
J. A. McCaw, Denver, again presented a woman of twenty-nine years who had been shown to the society three years previously on account of a syphilitic neuroretinitis. Two months ago she had returned with a defect of the upper half of the left visual field, and the right eye. showed a retin- itis proliferans. Discussed by Edward Jackson.
E. E. McKeown, Denver, presented a boy whose left eye had been penetrated by a pen-knife held in the hand of a schoolmate. The knife had passed through the sclera in the ciliary region. Suppura- tion had rapidly developed in the vitreous, and at the time of demonstration, several weeks after the injury, the pus showed as a yellowish mass behind the lens and bulging in the wound. It was necessary to remove the eye. Discussed by W. H. Crisp, H. R. Stilwill, E. T. Boyd and C. E. Walker.
W. C. Finnoff, Denver, presented a man of twenty-six years who, in February, 1918, while in the United States Army, had been operated upon for pterygium in the right eye. Nine days after the operation solid silver nitrate had been applied by the army surgeon to the operated area, and after this the eye was kept bandaged for twenty- one days. Dr. Finnoff had operated, so far with excellent results, for relief of symblepharon of the lower eyelid to the pterygium. Discussed by E. T. Boyd, .T. A. Patterson, E. L. Strader and W. C. Bane.
W. C. Finnoff, Denver, presented a man of twenty-four years whose left eye had been struck with a baseball in France last March. There was a deep pigmented hole in the center of the macula, and about a half disc diameter to the temporal side of the macula there was a rupture of the choroid running vertically about four disc diam- eters in length.
W. C. Finnoff. Denver, presented a woman fifty- one years of age whose left cornea showed sev- eral deep-seated corneal opacities in the substan- tia propria, and whose right eye had developed a nodule on the pupillary margin of the iris, the condition being suspected to be of a tuberculous character. Discussed by Edward Jackson.
F. R. Spencer and C. L. LaRue, Boulder, pre-
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Colorado Medicine
sented a man of forty-three years who had been operated upon for a very large cholesteatoma of nasal accessory sinus origin which had extended into the orbit. (See Original Articles, Colorado Medicine, December, 1919.)
E. T. Boyd, Denver, showed a case of enuclea- tion in which a Mules vitreous sphere had been inserted in Tenon’s capsule, and described the method which he employed for uniting the wound margins in case of evisceration followed by inser- tion of the vitreous sphere. Discussed by .1. A. Patterson and G. L. Strader.
C. O. Eigler, Denver, presented a woman who, three months previously, had had pain in the left eye and forehead when doing close work, and who said her sight began to fail in the left eye at that time; the case being suspected to be pos- sibly one of pituitary disease. Discussed by G. L. Strader.
J. A. Patterson, Colorado Springs, reported a case of iritis with the formation of granuloma of the iris, in which the diagnosis lay between syph- ilis and a focal infection. Discussed by W. H. Crisp.
J. A. Patterson, Colorado Springs, showed an old ophthalmoscope “nacli Doctor Liebreich”, who had invented the instrument in 1855. Discussed by Edward Jackson, who believed that this instru- ment had been the one most widely sold in Ibis country until the perfection of the Loring Oph- thalmoscope about 1877.
WM. H. CRISP, Secretary.
CITY AND COUNTY OF DENVER.
The regular meeting of the Medical Society of the City and County of Denver was held Tuesday evening, December 2, 1919. President Jackson was in the chair.
Dr. Alpha M. Chase and Dr. Morrow D. Brown were elected to membership in the society.
The scientific program began with an address by Dr. Philip Hillkowitz on the “Nature and De- termination of Acidosis”. Dr. Hillkowitz said for- merly the literature upon the subject was only seen in special journals devoted to biological or physiological chemistry, but at present the litera- ture is very general. He said it has been thought by some that acidosis means that the body fluids become acid. The body fluids never become acid, unless in the very last stages of life, but are al- ways alkaline. The term acidosis refers to the hydrogen ion concentration. In order that this might be understood, he explained that acidity de- pends upon the number of free hydrogen mole- cules or free hydrogen ions or hydrogen concen- tration. It is measured by the concentration of free hydrogen ions in water, which is one gram to ten million liters of water. So, in one liter of water there is 1/10,000,000 of a free hydrogen ion, which is written 10-7, because it is 10 raised to the seventh power and is indicated by C. H., or hy- drogen ion concentration. Later, for convenience, the minus sign was omitted and the sign P. IJ. was substituted for C. H. The body fluids are P. H. 7.45 or 7.40 and are constant either in health or disease. He spoke of the different methods of determining the hydrogen ion concentration of the blood. One method is by the use of indicators as phenolsulphonphthalein. He described other methods and apparatus used for the purpose. He had prepared some test tubes to show the results of the tests by means of an indicator, which were passed around. Dr. Hillkowitz went on to say, when acetone bodies are eliminated by the kid- neys it is not acidosis, hut acetonuria or ketonuria. The alkaline reserve of the body is the sodium
bicarbonate which neutralizes the acid carbon dioxide and the fixed acids. The body resistance to acidosis consists of the bicarbonates, the phos- phates, the proteids and the ammonium salts. These have what is termed a buffer action and furnish what may be called tampons to absorb the acids. If we know the alkaline reserve of bicar- bonate, we know how near the patient is to dan- ger. Thus, by an analysis of the blood we obtain the proper knowledge. When we have improper elimination from the kidneys or retention of car- bon dioxide, the reserve of alkalinity is reduced. One method (Van Slyke’s) to determine the amount of reserve alkalinity is to take a known quantity of blood plasma and obtain the amount of CO, which will combine with it. The normal amount should be about 63 percent per volume and below 50 percent would mean acidosis. An- other method is to determine the amount of alka- linity which remains. In all of these tests where the blood is obtained the patient must have been at rest ; no tourniquet should be applied, or, if applied, should be removed as soon as the needle is in the vein, to prevent any venous congestion, and the blood obtained must not be exposed to the air.
After the meeting was over, Dr. Hillkowitz dem- onstrated the various apparatuses used in these tests.
Dr. Tracy Love next gave a paper upon “The Clinical Aspects of Acidosis”. He said at present we realize that acidosis is an extremely common condition and detecting it in its modified forms may solve many obscure problems. He gave the causes as follows : A diet too rich in fats or too
poor in basic salts; nephritis; chronic cardiac dis- ease : certain stages in diabetes ; anesthetics ; Graves’ disease; extreme fatigue; toxemias of bac- terial or intestinal origin ; sudden deprivation of food as in acute indigestion, acute infections, or starvation resulting from surgical operations. Acidosis is accompanied by persistent vomiting and nausea, due to stimulation of the vomiting center, as well as irritability of the gastric mu- cosa. The vomiting has occasionally been so se- vere as to become fecal in character, simulating intestinal obstruction. There is dyspnea or rather hyperpnea without cyanosis. The respiratory rate has been as high as eighty per minute. There is a dry, coated tongue, with a foul or sweetish acetone odor to the breath. There is extreme thirst, with a parched mouth, sunken eyes and ashy color of the skin, which is also dry. The heart action is not greatly increased, hut the blood pressure is low and the pupils dilated. At first there is excitability; later, drowsiness, followed by stupor. The urine usually contains acetone or diacetic acid. In the chronic variety there is burning in the throat and stomach. These cases have various digestive troubles, constipation or diarrhea, fatigue on slight exertion, fatigue of the eye muscles, nervousness and dry skin. Cases with nausea, vomiting, dry skin and slight dysp- nea, when treated with alkalies, soon show ketone bodies in the urine. These cases usually belong to the class attributed to incomplete combustion of the fatty acids. These patients should be de- prived of all fats and oils, especially before oper- ations. Mild cases of acidosis may be controlled by the use of alkalies by mouth or bowel. The severe or dangerous cases should he given intra- venously a sodium bicarbonate solution with or without glucose. To use too large quantities of the solution is dangerous. The best results are obtained by using frequent injections of 250 to 300 mils of a five percent solution.
“The Relation of Acidosis to Surgical Proced-
January, 1920
19
ure” was given by Dr. C. F. Hegner. He said that acidosis is a very important factor in many acute medical or surgical illnesses, and is little under- stood by the majority of physicians. Acidosis is an impoverishment of the body in bases or their precursors plus an accumulation of the acid prod- ucts of metabolism. The physiological mainte- nance of the normal alkaline balance is main- tained by the complex process of limiting the pro- duction of acid products, conserving the alkaline reserve, and increasing elimination. Acidity in- hibits the functions of the cerebral cortex and stimulates the functions of the medulla in which are situated the centers of respiration and circu- lation. These centers constitute the essential mechanism for the neutralization of acidity. The alkaline reserves of the body are located in the circulating blood and to a far greater extent in the cells, intercellular substance, and the fluids of the tissues. Because of this the blood and tissues of the body are capable of maintaining within wide limits a neutral relation. In acidosis alkalinity is decreased and acidity increased in far greater degree than the usual methods of ex- amination indicate. Laboratory methods may es- timate the alkaline reserve of the blood and the content of alveolar air, but as yet no practical method has been devised whereby the total avail- able alkaline reserve of the tissues can be esti- mated. He thought laboratory reports, since they tell only a part of the truth, are not true indi- cators of the condition present. The factor of safety lies in knowing, then conserving the avail- able alkaline reserve. Since this cannot be known, the alkaline reserve should be conserved by nor- mal supply of fluids, proper food, and sufficient amount of regular sleep. The hydrogen ion con- tent of the blood is increased by all conditions which interfere with the proper oxidation process of metabolism. Some of these are: intense emo- tion, extreme muscular exertion, exhaustion, in- halation anesthesia, asphyxia, surgical shock, in- jury, hemorrhage, anemia, alcoholic intoxication, toxemias and starvation. The available alkaline reserve is diminished by : infections, injections of strychnine, disturbances of the thyroid and ex- cessive oxidation. Physiological restitution of the available alkaline reserve is effected by proper diet and deep, unbroken sleep. It is important to know that the hydrogen ions in the blood are not increased by the narcosis of opium or its de- rivatives. Morphine in large doses disturbs the mechanism of neutralization of acidity to a marked degree. Given before the balance of al- kalinity is lost, it retards the development of acidosis — it is then beneficial. Given after the balance is lost it interferes with the restoration of alkaline balance — it is then detrimental.
He then followed by giving the symptoms of acidosis and explaining their causes. He also called attention to the fact that an unfavorable or even fatal issue may occur in an otherwise successful operation because of the intervention of this condition. As a prophylaxis, in surgical conditions, give plenty of water, citrous fruit juices, sugar (unless contraindicated), honey, avoid starvation, allay anxiety or fear, reduce protein in the diet and give vegetables or their juices; encourage elimination, but do not deplete the patient before or after operation. A careful qualitative and quantitative urinalysis should be made. Sufficient alkali should be administered (particularly in children, the exhausted, or starved) to render the urine alkaline not only to litmus but one of the other indicators. More is not necessary, and by some is considered danger- ous. In pronounced anemia or in severe hemor-
rhage, blood transfusion is a decided advantage. He went on to state, it is not always possible to do all that is necessary to prepare one for the additional burden of a surgical operation, but it is possible to safeguard the patient when the op- eration is begun. He advises morphia prior to anesthesia in cases of great fear or tendency towards acidosis ; gentleness, care and precision in handling the tissues during the operation, and he thinks nerve blocking of advantage. The post- operative care consists in giving adrenalin ; the alkaline, glucose; saline solution per rectum, and water freely by mouth when tolerated ; for vom- iting, alkaline lavage. Keep the patient warm and give pituitary extract if needed to raise the blood pressure. When acidosis has developed give into the circulation the alkaline, saline, dextrose solution.
Dr. F. P. Gengenbach next gave an address upon “Acidosis in Children”. He said it occurred in children as acetonuria, after starvation or an an- esthetic, during infectious diseases and intestinal disorders. In infants it is sometimes found in cases of malnutrition or marasmus and in the later stages of gastrointestinal disturbances. The symptoms are vomiting, air hunger, peculiar color of the skin without cyanosis, irritability which may be followed by stupor and later by coma. The baby will cry as if in pain; there will be sinking in of the eyes and fontanels; mouth and tongue dry with labored respiration ; loose, watery stools ; scanty, highly acid urine, which contains albumen and sugar ; also there is leucocytosis. The fever may be moderate or very high. Acido- sis is more prevalent in neurotic children and more often seen in the winter time. These chil- dren have periodic vomiting spells, highly acid urine, may be constipated and often have been taking an excess of fats or carbohydrates. Dis- eased tonsils are sometimes a cause. In these cases avoid meats in the diet and push fruits and vegetables. In the way of treatment, withdraw food and give glucose and soda. Usually fruit juices, dry toast well chewed, or weak tea are best tolerated at first. The tolerance of alkalies is very high. Fifteen grains of bicarbonate of soda may be given at a time. Glucose and sugar may be given by mouth. In infants a bicarbonate of soda solution can be given into the superior longitudinal sinus through the fontanel or into the external jugular vein. In extreme cases ci- trated blood may be given.
Dr. C. E. Edson opened the discussion. He called attention to the fact that acetonuria and acidosis are not the same, and he also spoke in favor of the old-fashioned gruel as a diet. He said, in the case of acidosis, glucose is given for nutrition and not to neutralize the acids, but to prevent further acidosis from the fatty acids. He divided the causes of acidosis into: first, over- production of acids ; second, pathological produc- tion of acids, and third, improper elimination of acids. Dyspnea, he said, may be either cardiac, renal, or due to beginning acidosis, or extremely high blood pressure.
Dr. O. M. Shere, in his discussion, said that acidosis following an operation was often due to improper care beforehand. One of the elements was too' heavy catharsis. He advocated rather the use of enemas. He called attention particu- larly to the character of the tongue, which, he said, was not only dry, but also red and glossy.
Dr. Emanuel Friedman said when a child is seen with uncontrollable vomiting, with pain and even tenderness in the abdomen, one should think of acidosis, after eliminating acute appendicitis or intestinal obstruction and possibly meningitis.
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Colorado Medicine
He cautioned against too free use of the alkalies in order to render the urine alkaline, as there might be danger of inducing tetany or edema. He thought it better to obtain the carbon dioxide tension of the alveolar air rather than take the urine as a guide. He suggested injecting a bi- carbonate of soda solution into the peritoneum, rather than into a vein. These children, he said, should be given bicarbonate of soda, and the fats and the yolk of the egg be withheld.
Dr. A. M. Moore related an interesting history of three of his patients with diabetes who died rather unexpectedly and suddenly from acidosis.
Dr. G. A. Moleen said the subject of acidosis is not yet thoroughly understood. He spoke of the acidosis caused by high altitudes being due to retained carbon dioxide which stimulates the res- piratory center and causes an increased rate and depth of breathing. He also called attention to the fact that in acidosis the saliva is sometimes acid. He said the question might arise which of the acid bodies were causing the trouble, as car- bonic acid may be replaced by acetic acid. He mentioned some of the obscure causes of acidosis as : faulty digestion with splitting up of the fatty acids, the symptomatic acidosis in disorders of the pituitary, pancreas and suprarenal glands, and the acidosis due to extreme muscular exertion.
Dr. Mary E. Bates spoke of hypothyroidism as a cause of acidosis.
MARY R. STRATTON, Reporter.
The regular meeting of the Medical Society of the City and County of Denver was held Decem- ber 16, 1919, with President Jackson presiding.
Dr. 0. M. Shere exhibited two dogs upon which he had operated in order to demonstrate that the pleural cavity can be opened without collapse of the lung if the air be admitted gradually. In one dog the chest was entered in the usual way, with the result of a collapse of the lung. In the other dog he removed a portion of two ribs by doing a subperiosteal resection in order that the pleural cavity should not be entered. He then introduced a needle into the pleural cavity, making a minute opening which would admit the air gradually. He then waited for seven or eight minutes and intro- duced a little larger instrument, again waiting from five to eight minutes. He continued this process until the opening was large enough for a canula, and later on for a tube. No collapse of the lung resulted. Dr. Shere also showed x-ray plates of the chests of the two dogs.
Drs. William A. Adams and Harold L. Hickey were elected to membership in the society.
The society passed resolutions requesting the city to change the law in regard to venereal dis- eases to conform with the state law. The follow- ing committee was appointed to confer with the mayor and city council : Drs. Davis, Taussig, Sew- all, Moleen, Lyons, Hillkowitz, Meader, Levy, Hall and Jackson.
The scientific program was a symposium on “Focal Infections in Practice”.
Dr. Robert Levy gave the focal infections oc- curring in the tonsils, nose and accessory sinuses. He thought the focal infections of the head were the most important and their importance was in the following order : teeth, tonsils, and the acute and chronic infections of the accessory sinuses. He said there were two ways of definitely prov- ing infections : by bacterial and animal experi- mental study prior to operation, and by the re- sults of operations. He said the systemic in- fections occur as an absorption from a local dis- ease or from an infection of an organ, as in the case of the tonsils. These focal infections are
distributed by means of the blood stream and the lymph stream, and toxemias develop from the foci of infection.
Dr. Wm. H. Crisp gave an interesting paper upon the results of focal infection on the eye. He recited the histories of nine cases, some of which were of long standing (one being thirty years), which were due to focal infection from the teeth. He recounted the remarkable recovery of these cases after the removal of the foci of in- fection.
Dr. S. Fosdick Jones spoke next of the focal infections bearing on the diseases of the bones and joints. He named the focal infections in the order in which he considered they were responsi- ble for diseases of the bones and joints. The order is as follows : tonsils, genitourinary tract, accessory sinuses, syphilis, intestinal tract, and last, the teeth and alveolar processes. He thinks the role of the teeth and alveolar processes in systemic infection has been greatly overvalued. In his practice he has had only one case which he attributed to that cause.
The prostate and adjoining parts were consid- ered by Dr. Oliver Lyons as his part of the sym- posium. He thought the prostate, also the sem- inal vesicles and Cowper’s gland, held an impor- tant place in focal infections. He said that gon- orrhea was not the only cause of focal infection in this region. The infections may come from diseases such as typhoid fever or tonsillitis, and from infections along the urinary tract as from the streptococcus or colon bacillus. He empha- sized the fact that in case of doubt as to the seat of focal infection one should think of the genito- urinary tract.
Dr. Cyrus L. Pershing discussed focal infection as it would affect the nervous system. He thought, in connection with the nervous system, that the teeth were the most important sources of infec- tion, after which came the tonsils and the intes- tinal tract. He mentioned some diseases which are known to be due to infection, as herpes zoster and, often, neuritis. He spoke of some who thought that many of the mental conditions, es- pecially the functional insanities, were due to focal infection. Dr. Pershing thought the extent to which focal infection entered into the cause of mental conditions was greatly overestimated in those cases.
“The Relation of the Appendix and Gall Blad- der to Focal Infections” was Dr. S. D. Van Meter’s subject. His conclusions, from a clinical stand- point, were that the appendix and gall bladder in- fections were usually secondary to a focus else- where, the most likely focus being the teeth or the tonsils. Infections of the gall bladder and appendix may cause neuroses and functional dys- pepsias, play an important role in arteriosclerosis, cirrhosis of the liver, and ulcer of the stomach and duodenum. Also infections of the appendix and gall bladder may hold some relation to mi- graine and epilepsy, as well as arthritis defor- mans.
The last speaker in this symposium was Dr. Chas. N. Meader, who gave “The Importance of Mild Infections”. He called attention to the classes of cases of multiple infections, which pre- sent themselves to the medical man, the difficulty in finding the primary foci and of deciding which focus should be removed first. He spoke of the chronic infections in the lungs which give rise to many mild manifestations of infection. He also spoke of the class of patients who have myalgias, mild joint symptoms, migraine and are nervous, run down and below par, who probably have some subacute focal infection causing this ill health.
January, 1920
21
He suggested that no one had yet mentioned the vaccines.
Dr. Melville Black opened the discussion by saying that no one had mentioned the connection between focal infection and disorders of the in- ternal glandular secretions. He thought that per- sons with disturbance of the internal glandular secretions run along till some focal infection causes an explosion, rather than the focal infec- tion being the cause of the disordered internal glandular secretions. He called attention to uvei- tis, which does not recover quickly after the re- moval of the infection, in which he thought the vaccines were of benefit.
Dr. T. Leon Howard called attention to the many times that focal infection occurs from the prostate, and also stated the infection might be due to many other causes besides gonorrhea.
Dr. Henry Sewall spoke of the interdependence of infections — that one infection starts another, till there is a train of them.
Dr. G. A. Moleen spoke especially of chorea, which develops in the wake of infection and has been attributed to the tonsils. He cautioned against the removal of the tonsils during the ac- tive stage of the disease.
MARY R. STRATTON, Reporter.
EL PASO COUNTY.
The regular monthly meeting of the El Paso County Medical Society was held in the library of the Elks’ Home December 10th. This was the annual meeting for the reports of the Secretary and Treasurer and election of officers.
Forty-three members were present and no vis- itors.
Drs. E. B. Liddle, F. A. Forney and Charles Moore were elected to membership.
Dr. C. R. Arnold was elected president ; Dr. G. B. Gilbert, vice president; Dr. Omar Gillett, treasurer.
Dr. F. T. Stevens and Dr. W. V. Mullin were elected delegates, with Dr. J. J. Mahoney and Dr. E. L. Timmons as alternates.
A letter was read from the Metropolitan Life Insurance Company asking the county society to revoke its rule in regard to the schedule of fees for examination of life insurance applicants. The society instructed the secretary to write the med- ical director of the Metropolitan Life Insurance Company that there would be no change in this rule.
Dr. Magruder moved that the society adopt a resolution to the effect that no member of the El Paso County Medical Society should be allowed to consult with, refer cases to, or operate with an osteopath, or administer anesthetics for an osteopath or chiropractor. The president appoint- ed Drs. Magruder, Shivers and Mahoney to draw up the resolution and to present it at the next meeting.
C. E. RICHMOND, M.D., Secretary.
fleck Reviews
Practical Medicine Series; General Surgery. Ed- ited by Albert -T. Oclisner, M.D., F.R.M.S., L.L.D., F.A.C.S. Series 1919. Chicago, The Year Book Publishers. Price of this volume, $2.50. Price of series, $10.00.
This Year Book of Surgery comes well up to the high standard set by its predecessors and is as the editor says, “especially rich in material
that has been produced by the surgeons who have worked with the Allied Armies.”
Naturally, the Carrel-Dakin management of in- fected wounds comes in for added consideration, and the editor says that two claims of authors have almost disappeared : The first of them, in former years, based conclusions on the inaccurate use of solutions not carefully prepared or tested, while a second class decided adversely on hearsay and without adequate personal experience ; and Ochsner finds results excellent when the method is properly carried out.
Guillotine amputation is argued pro and con. Most surgeons with extensive war experience have doubtless concluded that the operation had a fixed place in selected cases, but that at one time the pendulum swung too far in its favor. V. H. Blake, in describing an amputation shield retractor, has evidently overlooked the fact that this useful in- strument was earlier devised by Monprofit of An- giers.
The terrific occurrence of gas gangrene in France is emphasized and the good work of Tay- lor in this distressing complication properly recog- nized. Tetanus, fortunately very rare, shows noth- ing new. The very important subject of ununited fractures will gain contributions of value as a re- sult of extended war experiences ; so, as well, will the surgery of the peripheral nerves. Cushing, the distinguished brain surgeon, reported in Feb- ruary, 1918, his results in 133 brain wounds of the war : mortality 54 percent in the first forty- four cases, 40 percent in the second forty-four cases, and 28 percent in the remaining forty-five cases. Certainly a splendid piece of work !
Much might be quoted from other fields — the thyroid, the mammary gland, the chest, the abdo- men. Space permits only the statement that the book is a welcome addition to any surgical library.
C. A. P.
The Surgical Clinics of Chicago. August, 1919. Yol. 3, No. 4, with 117 illustrations. Published bi-monthly by W. B. Saunders Company, Phil- adelphia and London. Price per year, $10. The busy surgeon who wishes to know what Chi- cago men are doing will find in this August, 1919, number thirty-three clinics on a wide variety of cases. Several are well presented, cover the sub- ject, and give information of value. Several others bring out no points of value, are quite superficial, and may be skipped with advantage. A few show something new in operative methods.
The opening clinic by Dr. Dean Lewis contains a series of cases illustrating the common results of injury to peripheral nerves and the method of choice for the correction of each condition. R'e presents five cases, each showing a different type of injury. The method of treatment indicated for each type is clearly demonstrated with the help of lucid illustrations so that the reader can not miss understanding Dr. Lewis’ exact technic.
Dr. Arthur Dean Bevan presents three cases in his usual excellent style. Of particular value is his method of excision of epithelioma of the lower lip. His procedure, carefully described and illus- trated, appears to be an excellent rotitine for the average case of this sort. His views on neck dis- section are also given.
Anyone interested in the surgery of the parotid gland will enjoy Dr. A. .T. Ochsner’s contribution, which consists of three cases illustrating certain benign lesions of that organ. Excision, resection and plastic operation of the parotid are explained.
The subject of cranial defects following com- pound injury or operation, especially in war wounds, is discussed by Dr. C. C. Nesselrode. He
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Colorado Medicine
considers the symptoms, the indications for oper- ation, and the prognosis of this condition. This clinic is one of the best in the number giving a clear conception of the proper procedures in this not uncommon lesion. To cover the large defect in the case demonstrated here, Dr. Nesselrode em- ployed osteo-periosteal grafts taken from the tibia.
Chronic dislocation of the outer end of the clavicle, and reconstruction of the acromio-clavi- cular articulation by the aid of a strip of fascia lata is the subject presented by Dr. Edwin W. Iiyerson. His treatment of this obstinate disloca- tion appears of sound principle and may well be considered in any chronic, case. His patient with a history of three years duration completely re- covered in eight weeks after operation.
The operation of Dr. Herman L. Kretsclmer for vesico-vaginal fistula, while presenting no unusual features, is well explained by illustration.
G. R. P., Jr.
Nervous and Mental Diseases: By Archibald
Church, M.D., Professor of Nervous and Mental Diseases in Northwestern University Medical School, Chicago, and Fredrick Peterson, M.D., formerly Professor of Psychiatry, Columbia Uni- versity. Ninth edition, revised. Octavo volume of 949 pages, with 350 illustrations. Philadel- phia and London : W. B. Saunders Company, 1919. Cloth, $7.00 net.
This is a new edition of a work that has already proven its value as a text and reference book, for both the senior medical student and busy practi- tioner. All the salient points and leading symp- toms that will aid in diagnosis are very clearly brought out. Special emphasis is given to those diseases that both the neurologist and general practitioner meet in their daily practice. The di- rections as to treatment are remarkably clear and can easily be followed by the reader. The rarer diseases have been treated more briefly than in most of the text books on neurology, but the most important symptoms and differential points are brought out with sufficient detail, and the student only gains by its brevity.
Though a good many views that have attained considerable popularity among some neurologists have not been discussed, “more time and experi- ence being thought requisite for their unquestion- able establishment”, yet this new edition is, in the best sense of the term, a thoroughly up-to-date text book. As the authors state, “the needs of the student and the wants of the practitioner have had first consideration throughout”, and as such the merits of the work are unchallenged.
Last, but not least, it would be an injustice to the authors not to compliment them upon the very good English employed and the absence of the literary jargon so common in neurologic literature. The style of the book, particularly the section on psychiatry, excels Sir William Osier’s and fully equals that of William James. L. Y. T.
The Surgical Clinics of Chicago. Volume III, No. 5 (October, 1919). Octavo of 25S pages, 91 illus- trations. W. B. Saunders Company, Philadel- phia and London, 1919. Published bi-monthly. Price, per year : Paper, $10.00 ; cloth, $14.00.
A wide variety of interesting cases marks the October, 1919, number of the Chicago Surgical Clinics. There are thirty-three cases covering
every branch of surgery presented by seventeen surgeons.
The opening article by Dr. D. N. Eisendrath is a general consideration of tumors of the kidney introduced by a case of congenital cystic kidney. The subject is covered in a comprehensive man- ner.
Dr. Arthur Dean Bevan presents three subjects, each of particular interest, giving his diagnosis and treatment in his usual lucid manner. The operative procedures for abscess of the pancreas and for an advanced ulcerating carcinoma of the breast set forth many valuable points in the treat- ment of these difficult surgical diseases.
Several genitourinary problems in surgery are treated by Dr. H. L. Kretschmer and Dr. R. H. Herbst. The clinic on carcinoma of the prostate in particular presents some new and valuable fea- tures.
Treatment of fractures varying in location from the mandible to the os calcis, operative and non- operative, is expounded in various clinics. The clinic of Dr. Paul Oliver is' mostly orthopedic, demonstrating four very instructive cases.
Major H. A. Potts and Major A. H. Montgomery present the war problems as they exist today, the plastic treatment of old wounds.
Dr. T. J. Watkins covers the gynecological por- tion of the clinics with a description of one of his perineal operations, while obstetrical technic is discussed by Dr. E. L. Cornell. G. B. P., Jr.
1918 Collected Papers of the Mayo Clinic, Roches- ter, Minn. Octavo of 1,196 pages, 442 illustra- tions. Philadelphia and London : W. B. Saun- ders Company, 1919. Cloth, $8.50 net.
One reads these Collected Papers, always with pleasure and profit. They cover a large number of subjects, both surgical and medical. While one is inclined always to think of the Mayo Clinics as surgical, because of the large amount of surgery done there, these papers show that the medical aspect of cases is well taken care of.
In reading this volume one feels he is getting the latest in all conditions treated, and that withal a marked conservatism is shown. He gets the advantage of the personal experience of the au- thors, who are men actively engaged in the dif- ferent subjects treated, and less of reference to textbooks and of antiquated methods and theories. When references are given they refer you to up- to-date matter.
The editor, Mrs. W. H. Mellish, has arranged the papers so that discussion is given to the ali- mentary canal, genitourinary organs, ductless glands, heart and blood, skin and syphilis, head, trunk, extremities and the nerves, followed by a section on technic and general subjects. Every phase of every condition is thoroughly discussed and brought up to date. In the section on tech- nic we get an idea of surgical improvement.
There are also valuable papers on laboratory diagnosis and subjects, with the technics em- ployed.
One who carefully reads these papers will be helped in matters of diagnosis, as well as in sur- gical procedure and technics. There are over four hundred illustrations.
After reading the book practically from cover to cover, one does not hesitate to say it is well worth while to the general practitioner as well as to the surgeon ; and that one who follows the many discussions cannot help becoming a better diagnostician and operator. H. S. S.
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Our Advertisers.
The Abbott Laboratories of Chicago have been using half-page space in this journal. Their suc- cess warrants them in using a full page at this time, and our readers will find their full-page announcement in this issue. This evidence that the readers of Colorado Medicine are careful to patronize our advertisers is gratifying, and is a tribute to the policy which this journal long since adopted, of publishing in its advertising pages only such medical products as have been accepted by the Council on Pharmacy and Chemistry 'of the American Medical Association.
The readers have come to know that this jour- nal protects them, and as a consequence they may unhesitatingly purchase the products which are advertised in it.
In answering the Abbott advertisement, each reader should use the coupon attached to the page advertisement, in order that Colorado Medicine may receive credit for the inquiry.
Psychotherapy and Tuberculosis.
In observing tuberculosis suspects referred to the neurological clinic Jelliffe and Evans were strongly impressed by the marked notionalism and unreasonableness of many of these patients and their pronounced infantile reactions. They therefore subjected several to psychoanalysis which they report in detail. In every case they
uncovered strong resistances buried in the uncon- scious life, which they believe play no small part in hindering the recovery of tuberculosis patients from their disease. If these resistances are brought to light and removed therapy is thereby greatly aided.
The morale of the tuberculous patients is no- ticeably different from that of the average medi- cal or surgical patient. They are whimsical, irre- sponsible, selfish, irritable, inclined to be irregu- lar in their habits, etc. Although psychotherapy is given such an important place in several sana- toria, the physicians in charge do not know or recognize the unconscious conflict exhausting the patient’s energy ; and they approach the subject from an entirely different point of view, some working with suggestion, others with more physi- cal means. The depressing effect of inhibited emotions upon physiological activity has been well established, and it should be the duty of the phy- sician to improve metabolic changes through psychical control as well as through physical. In a psychoanalysis patients are able to see that these emotional disturbances result in a weak attitude toward life, desiring always their own gratifica- tion and unable to sacrifice the infantile wish. Psychoanalysis cannot change the physical results which are produced by the tuberculous process, but it can greatly improve the functional activities and the physiological processes by relieving the patient of the great drain on his nerve energy through making known to him the unconscious conflict between the heretofore unknown infantile wishes and the demands of conscious life — Ameri- can Review of Tubei-culosis, September, 1919, Vol. Ill, No. 7.
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Colorado Medicine
OWNED AND PUBLISHED BY COLORADO 5TATE MEDICAL SOCIETY
PUBLICATION COMMITTEE.
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EDITOR: Frank B. Stephenson, M.D., Metropolitan Building-, Denver.
Annual Subscription, $2.00 Single Copies, 20 Cents
Vol. 17. FEBRUARY, 1920 No. 2
Editorial 'Comment
THE INFLUENZA EPIDEMIC AGAIN.
During ancl after the overwhelming influ- enza epidemic which occurred principally in the autumn of 1918, it was freely prophesied, on the analogy of the memorable visitation of 1889, that the epidemic would return in succeeding years. In the closing months of 1919 we felt pleasantly disappointed that this did not happen. But now, with the opening of the new year, the prophecy has rapidly been fulfilled, and from every large center, both in this country and on the other side of the Atlantic, comes word of an alarm- ing incidence of what, in the absence of more accurate information, we must assume to be the same disease, although in apparent- ly milder form.
On all hands we are assured that the sit- uation is well in hand and does not threaten a heavy mortality. But general practition- ers are rushed to the limit of their endur- ance, whole families are afflicted with sickness, institutions for the care of the sick are filled to overflowing, some schools and colleges are already closed, and the demand for nurses greatly exceeds the supply. All of which indicates that we are faced, if not with a great many deaths, yet with a serious dislocation of the daily af- fairs of life, and, especially in cases which can not be given the right amount of care, with the probability of very undesirable se- quels related to the ears, nasal sinuses, and other parts of the body.
The city of Denver has very wisely taken time by the forelock in the matter of provi- sion for influenza patients at the city and county hospital, where two complete wards
have been cleaned out and set aside for the purpose. This space may, however, easily prove inadequate, and there will also, in spite of an increasing shortage of nurses, be a great number of people who will insist on staying in their homes rather than accept the hospitality of a city ward. However mis- taken this prejudice may be, it must be reck- oned with and allowed for, and if a real danger exists, it is the duty of every large community, through whatever agency may be available, to provide the accommodations necessary for this and any class of patients. The Public Policy Committee of the Medical Society of the City and County of Denver recently approached the city management with regard to the problem, and was met with the statement that, in the steps that had been taken at the county hospital, the city had done all that was within its power. Pre- sumably the financial difficulty stood in the way.
In the 1918 epidemic, emergency hospitals were established by the Red Cross, and at a recent lunch meeting of the Medical Society of the City and County of Denver Mr. W. V. Hodges, president of the Denver section of the American Red Cross and also president of the Denver Civic and Commercial Associ- ation, stated that the question of similar ac- tion by the Red Cross in the present out- break had been considered, but that in the first place the local Red Cross felt uncertain as to the extent of the emergency, and that in the second place a question had been raised as to the right of the Red Cross or- ganization to spend for this purpose money which it was argued had been contributed by the public simply for relief rendered nec- essary in connection with the war and with the demobilization of the United States Army.
24
Colorado Medicine
It has been difficult for public authorities to establish by figures clear proof of the existence of a serious epidemic, for a great many physicians have been extremely negli- gent in the reporting of influenza cases. But conference between the various medical, charitable, and nursing organizations should be competent to put the facts broadly be- yond cavil ; and upon general agreement that an emergency does exist it would surely be proper for Red Cross funds to be diverted to the provision of such emergency hospital accommodation as may prove advisable. If the public which contributed the funds is satisfied that the work is necessary, that public will hardly quibble greatly over tech- nicalities. It is much to be lamented that in such a public health emergency, civic funds cannot be more readily available than seems practicable at the present time.
(After the preparation of the above, a meeting was called by the Red Cross organ- ization, at which were represented several of the Denver hospitals, the Visiting Nurses’ Association, the Nurses’ Directory, the Wom- en’s Council of National Defence, the Feder- ation of Labor, and the Committee on Public Policy of the Medical Society of the City and County of Denver. The consensus of opinion was that owing to lack of equipment no immediate action could be taken for the provision of an emergency hospital ; but that the private hospitals of the city should be urged to make the best possible use of exist- ing facilities. It was further arranged that the nursing situation would be carefully studied in every part of the city by the Women’s Council of National Defence. Some incidental details, such as economy in the use of available nurses, were to be taken up more fully at a later date.)
W. H. C.
REGARDING CATHARTICS.
The annals of most medical publications contain what may be termed cyclic consid- erations of commonplace subjects. These are often treated in such a manner as to be highly instructive, as is the intention, but unfortunately the teachings sometimes con- flict with the experience of observers in a
way that is quite akin to the impracticality of a culinary receipt from a popular maga- zine or livre de cuisine.
Contributions to such subjects as cathar- tics furnish a case in point, some of them admitting of the gentle criticism that they do not bespeak the results of experience and observation from the broadest point of view.
Our attention was attracted recently to the subject of cathartics, especially with reference to the administration of magne- sium sulphate, which it is stated should be given as a rule with large quantities of wa- ter and not in concentrated form. The facts in the case seem to be that magnesium sul- phate is a purge by reason of its abstraction of water from the intestinal blood vessels, because it stimulates peristalsis directly, and by reason of the fact that solutions of it are not readily absorbed ; and therefore, when a thorough purgative is required— that is when depletion of the intestine or ab- sorption of exudate is to be obtained — the magnesium sulphate should be given in such concentration as to make its solution of as high a percentage as possible.
There was a time when the pendulum had swung so far in the opposite direction with regard to this small point, that it was recog- nized that this valuable salt of magnesium might be given in dry form with advantage, and there were manufactured elastic cap- sules, containing thirty grains of the drug, to facilitate its administration in the dry state. There are many cases in which the use of the salt in dry form has a decided ad- vantage over the nauseous, copious draught of a “well diluted” solution. As taken dry upon the tongue, the amount required is about one-fourth of that ordinarily admin- istered in solution. Owing to the difficulty of solution, there is but little taste when placed upon the tongue and swallowed with cold water; and, in cases where a sustained effect is desired, this means of administra- tion is not as a rule followed by reactionary obstipation as is the case when large vol- umes of water are used in its solution.
It should not be inferred that freely di- luted solutions of Epsom salt are to be con- demned, but it would seem that when the subject of catharsis is ■ discussed omission
February, 1920
25
of matters of provincial experience should be avoided.
Likewise, the statement that acidulous foods or fruits may be taken with impunity along with calomel since the idea that this association was to be avoided has been found to be erroneous, is dangerous; isolated per- sonal experience to the contrary notwith- standing. There are on record instances of individuals falling from great heights and escaping unharmed, but this is no reason or argument for the recommendation of such falls. Both of the chlorin salts of mercury (and more especially the bichloride, into which a portion, often negligible, of the mild chloride is converted in the stomach) are rendered more soluble by the presence of citric acid, of which lemon juice contains about six or seven percent. So well recog- nized is this fact that antiseptic tablets are made with the admixture of citric acid to fa- cilitate the rapidity of solution. At the same time it is conceded that the danger of the mild chloride of mercury arises from the possibility of absorption from the intestinal tract, as a result of a delay in its passage or the coming in contact with substances that facilitate its solubility or its absorbability, and as an example potassium iodide is es- pecially mentioned. The inconsistence here is apparent.
Whether or not it may be demonstrated in vitro that salivation can not be caused by the presence of fruit acids, experience ob- tains that in vivo it very often does occur. And, certainly, the restriction of anything which incurs a liability is preferable to the assumption of risk for no other reason than to advance a dogma.
G. A. M.
DOGMATISM IN MEDICAL WRITING.
It is unquestionably the fault of some medical writers that they are rather dog- matic in their teaching, only to find with ex- perience of later date that they were mis- taken in some one or more of their premises and that the whole structure of theory, given with more or less absolutism, has tum- bled upon the heads of those who may inno- cently have sought shelter under it. In the
foregoing criticism of recent writings upon cathartics, the aim is not so much at any particular fallacy which may be present as the practice of which it is an instance — that of setting forth with the air of absolute finality and under the apparent authority which anonymity gives in a regular depart- ment of an authoratative journal, directions for the guidance of the profession.
This may be illustrated by a statement which has recently appeared that ‘ ‘ One of the chief faults of the cathartic salines is their deficiency in stimulating peristalsis; indeed, intravenous or intramuscular injection has been shown to inhibit bowel movement. The rapid evacuation produced is due to disten- tion of the intestine with fluid ; . . . ” This would hardly lead one to expect, then, that with regular small doses of the salines, such as sodium phosphate, regular soft (not liquid) stools could be secured; yet such is the experience of at least one physician. That parenteral administration of the salines causes certain effects upon bowel peristalsis does not at all signify that their local effect upon the intestinal mucosa when given by the mouth may not produce an opposite re- sult, possibly by reflex action; and it is ad- mitted in the same article that there is no absorption of the drug in case the desired result is obtained, so that inhibitory effects through the circulatory system could hard- ly be looked for.
One rather likes to see statements quali- fied by “if it be true that,” or “it is be- lieved that,” or some such phrase which at once places upon the reader the responsi- bility of using his own brain; otherwise he will be inclined to follow by faith the teach- ing which bears the stamp of unequivocal authority. An author does not lose cast by admitting uncertainty, when uncertainty surely exists, and his opinion is worth even more when it is seen to have encompassed the possibilities of error.
Armour and Company will be pleased to send a reprint of Frederic Fenger’s ai'ticle on “The Seasonal Variation of the Iodin Content in the lodin Gland” to any physician who will ask for it. This paper records work covering more than twelve months, which was done in the research laboratory in organotherapeutics of Armour and Company. Address Armour and Company, Chi- cago.
26
Colorado Medicine
Current 'Comment
RAILROAD RATES FOR A. M. A. MEETING.
The early date of the annual session of the American Medical Association makes it possible to take advantage of the reduced railroad rates effective for winter tourist travel and at the same time have a choice of routes going or returning.
For the guidance of members from Colo- rado who contemplate attending the session, the following communication from the Rail- road Administration was solicited ; it con- veys in brief the possible routings and rates : “Winter tourist fares from Denver to New Orleans are in effect daily up to and including April 30, 1920, with final return limit of to reach original starting point prior to midnight of May 31, 1920. Stopovers will be allowed at all points within final limit of ticket on either going or return trip or both, on application to conductor.
“The round trip fare Denver to New Or-
leans (War tax 8 percent additional) is as follows :
Route No. 1, via St. Louis, (not via L.
& N.) .$74.05
Route No. 2, via Memphis, Shreveport, Alexandria, Farriday, Fort Worth, Dallas, Houston, Beaumont or Lake
Charles 74.05
Route No. 3, via Kansas City and
route Nos. 1 or 2 74.05
Route No. 4, via Omaha or Council Bluffs and Kansas City, St. Louis or
Memphis 79.80
Route No. 5, via Pueblo and route 1,
2 or 3 74.05
Route No. 6, via Chicago (not via Mo- bile) 87.70
Route No. 7, via Chicago and Mobile. . 87.70
Route No. 8, via St. Louis and L. & N. 78.15
“These tickets may be sold via diverse routes at a combination of one-half the fare applying via the route used on the going trip plus one-half the fare applying via the route used on the return trip.
“The standard lower berth rate from Den- ver to New Orleans via Fort Worth or Dal- las or via Kansas City and Memphis is $8.00
plus tax 64c and via St. Louis $8.50 plus tax 68c; via other routes the berth rate would be figured local over the junction point. For example: Via Chicago the lower berth rate would be $6.00 plus 48c tax Denver to Chi- cago, plus $5.50 plus tax 44c, Chicago to New Orleans.”
G. A. M.
SECURE RESERVATIONS FOR A. M. A. MEETING.
We are reliably informed that hotel ac- commodations in New Orleans during the meeting of the A. M. A. are going to be scarce. Reservations should be made now and at a fixed rate, otherwise dissatisfac- tion is likely to result.
THE MIGRATORY CONSUMPTIVE IN COLORADO.
Certain regions in the United States, notably Colorado, California, Arizona, New Mexico, and Texas, are reputed to have cli- matic conditions that will cure tuberculosis. People afflicted with lung and throat affec- tions have migrated thither in large num- bers to receive the advantages of dry air, sunshine, and the other conditions which en- able them to derive the benefits of living out of doors. Colorado has undoubtedly re- ceived its full share of migrating invalids. Many of these have recovered their health, and of this number some have returned to their homes, while others have remained here, engaged in business and are now valu- able citizens to the community. On the other hand, large numbers have died, most of these because their disease was so far ad- vanced that they could not be benefited in any locality, but for the niost part those who died did not have sufficient funds to enable them to live under the proper con- ditions to receive the benefit of the climate. The first group, those that recovered, have spread far and wide the supposed value of the climate in their cure. They have become publicity agents for the climatic resort com- munities; but the other group, those who have died, could not make public the details of the painful struggle that they made, the suffering and homesickness that they had
February, 1920
27
to endure, finally, away from family and friends, having to give up the fight to die. Undoubtedly, if the harrowing tales of these pitiful battles for life could be published broadcast, the desire of poor consumptives to travel to other climes to “ chase the cure” would be greatly checked. Those who come on to form this second group for the most part cannot be regarded as an asset to any community, and Colorado is burdened by a large number of them.
The indigent migratory consumptive is one who has left home for the purpose of regaining health and who has not sufficient funds to properly finance his move. In Col- orado, Denver naturally receives the brunt of the migration of such cases. Colorado Springs, while essentially a health resort, is not the type of city sought by the poorer class. (One hundred and ten nonresident cases visited the Colorado Springs tubercu- losis dispensary in the six months, April to September inclusive, 1919.) The other cities, such as Pueblo and Trinidad, are but stop- ping-off places for those who are traveling to more distant points. It is a difficult mat- ter, however, to determine just how much the problem affects Denver as a community. The public at large is probably totally un- aware that there is such a problem, but the relief organizations and the health depart- ment, coming in actual daily contact with the cases, are seriously and justly con- cerned. The individual cases are themselves distressing and pathetic, and the relief agencies that are obliged to handle them are hampered by the lack of proper facili- ties in Denver and vicinity for sanatorium care, so that these authorities are constantly confronted with the difficult question of their satisfactory disposition.
To get an idea of the size of the problem numerically, we can only estimate from the cases handled by the different relief agen- cies. The municipal dispensary, for exam- ple, during the five months in 1919 from July to November, inclusive, received three hundred and ninety new tuberculosis cases, of which number 57 ^ percent were non- residents, that is had lived in Denver less than one year. The Jewish Aid Society in the same period handled approximately one
hundred cases, of which probably 75 per cent were nonresidents. In addition to this, the Visiting Nurse Association handled ap- proximately fifty cases, and other agencies a considerable number more. This means, making of course a rough estimate, that Denver has between fifteen hundred and two thousand cases of more or less finan- cially dependent nonresident consumptives during a twelve-month period.
Denver has very limited facilities for car- ing for this group of tuberculous patients. Craig Colony can accommodate about seventy men; Sands House, about twelve women; the county hospital, with very unsatisfactory accomodations for approximately thirty-five tuberculous patients, will take no nonresi- dents; and the municipal lodging house is able to furnish temporary quarters for a small number of cases until other disposi- tion can be made of them.
It is an astonishing fact that Denver as a county and a municipality will not accomo- date any emergency case of tuberculosis. The writer investigated the case of an indi- gent migratory consumptive from New Mex- ico, who arrived on a stretcher in Denver at seven o’clock on the morning of September 12th. The authorities would not take this patient to the county hospital, and the poor man remained in the depot — not in the hos- pital room, but in the immigrant waiting room — until one-thirty in the afternoon, when he was taken to Craig Colony, where he died of tuberculous meningitis in three or four days’ time. Other emergency cases that have been refused admission to the county hospital have been reported to the writer, but he lias not personally investigated them. It would seem most unfortunate that a city the size of Denver should refuse admission of emergency cases of tuberculosis to its city hospital unless they are residents of Denver. I know of no other large city in the United States that would take this inhumane atti- tude towards emergency cases of any type.
The problem of tuberculosis among the Jews is handled fairly well by the Jewish organizations. The two large national insti- tutions, the National Jewish Hospital, and the sanatorium of the Jewish Consumptives’ Relief Society, receive cases from all parts
28
Colorado Medicine
of tlie country, mainly from New York and Chicago. These institutions will take a small percentage of Gentile cases. The prob- lem in the relief of the indigent Jewish eases arises from the fact that these two large institutions are in Denver ; as many patients arrive here without having made proper ap- plication for entrance, and hence become a temporary burden upon the Jewish Aid So- ciety. Again, when patients are discharged from either of these institutions and refuse for one reason or another to return to their homes, they are frequently obliged to apply to the Jewish Aid Society for assistance.
If Denver as a community regards the presence of the indigent migratory consump- tive as a menace to its health, precautions nevertheless are not taken to protect it in any way. (That there is a tuberculosis men- ace in Denver is indicated by the death sta- tistics from the city board of health for
1918, showing that out of seven hundred and ninety-eight who died from tuberculosis one hundred and forty-three contracted the disease in Colorado.*) One may go to any drug store or ice cream parlor and drink a glass of coca-cola or eat a plate of ice cream immediately after a person with active tu- berculosis has done the same, the glasses and spoons not having been sterilized. There are few, if any, precautions taken in the poorer class of hotels and rooming houses by cleaning and disinfecting rooms that have been occupied by tuberculous people. There is no attempt to enforce the anti-spitting ordinance, and in many other ways the com- munity as such appears to be blind to the possible dangers that undoubtedly exist.
It would seem very desirable to prevent as far as possible the migration to this com- munity of the indigent consumptive. The only active measures at present being taken to check this migration are those of the lo- cal Anti-Tuberculosis Society, which dis- tributes a small circular entitled “Why Tu- berculous Persons Without Funds Should Not Leave Home”. At the time when these cases are registered at the dispensary or
*Editor’s Note : An article in the November,
1919, issue of Colorado Medicine by Dr. H. B. Whitney gives an analysis of these records which shows them to be faulty, unreliable and adversely misleading as regards the immunity of Coloradoans to tuberculosis.
elsewhere, if they report that they came to Denver on the advice of a physician, the name of this physician is obtained, if pos- sible, and such physician is promptly com- municated with from the office of the Anti- Tuberculosis Society. It is the general opin- ion, expressed by physicians who are coming in contact with these migratory cases, that there are not as many patients being sent out in the advanced stages of the disease as formerly, and probably the actual number of cases is not as large in proportion to the population as it has been in former years. The number of cases, however, will appear greater because of the more complete rec- ords now being furnished through several agencies that have been organized and are tabulating the various cases as they come in contact with them.
The indigent migratory consumptive prob- lem undoubtedly is an acute one in Denver, but in view of the above factors it would not seem to be as great as in former years; and it is the opinion of the writer that if Denver would make proper provision for its resident cases of tuberculosis; would modi- fy its attitude toward the care of nonresi- dent tuberculosis emergency cases ; and would make proper provision for protecting itself from the dangers entailed by the pres- ence in the community of existing active cases of tuberculosis, the problem would not be acute and could be handled with com- parative ease.
SEVERANCE BURRAGE, Secretary, Committee on Indigent Migratory Consumptives, National Tuberculosis As- sociation.
THE RED CROSS AND PUBLIC HEALTH.
Under this same heading, in the June, 1919, issue of Colorado Medicine, editorial comment was made upon the proposed League of Red Cross Societies, and the close relationship between relief work and pre- ventive medicine was pointed out.
The Bureau of Health, which, following the Cannes Conference in April of last year, was recommended as a division of the League, seems now to be assured and a schedule of activities, enormous in scope,
February, 1920
29
has been formulated for it by the General Conference. Since it is expected that there will be important news on this subject grow- ing out of the League conference at Geneva in the coming March, it is worth while to be acquainted with the plans for the Bureau of Health ; an outline of them, with an explana- tory paragraph of the Conference follows :
“Although the Conference does not advise the Bureau of Health of the Red Cross to undertake at once all the activities considered, it submits the following resolutions and memoranda unanimous- ly adopted by the Conference relating to the spe- cial subject of Preventive Medicine, Child Wel- fare, Tuberculosis, Malaria, Venereal Diseases and Nursing, as well as the report on Publication, Ed- ucation and Statistics, for the purpose of indicat- ing in a general way some of the lines of activity which the new organization may wisely follow :
“Resolved : 1. That in view of the wide preva-
lence of Typhus Fever and the extremely grave representations made to the Conference concern- ing it, the control of this disease be at once un- dertaken as an emergency relief measure.
“2. That the promotion of a wide extension and development of Child Welfare Work be selected as of the first important constructive activity.
“3. That wide Public Health Legislation and ef- ficient Public Health Administration be encour- aged everywhere and by all appropriate means, through National Red Cross Societies, and particu- larly that the accurate and full registration of vital statistics be urged as forming the funda- mental basis for definite and permanent improve- ment of health conditions.
“4. That efforts be made to secure a standard- ization of the Vital Statistics of all those coun- tries where adequate registration and notification are not in effect so that comparable data on im- portant subjects may be available, and that stand- ard tables be prepared and submitted for modifi- cation and adoption by the authorities in such countries.
“5. That the Bureau of Health encourage sci- entific investigation in Hygiene and Sanitary Sci- ence, since progress in Public Health depends up- on the advancement and the application of knowl- edge.
“6. That the establishment of Public Health Laboratories or the provision for laboratory serv- ice for every community is an extremely import- ant means of promoting efficient Public Health Administration.
“7. That the extension of the employment of public health nurses or health visitors be fur- thered in every possible manner in all countries, and that standardized educational Centers for training such nurses or visitors be developed.
“8. That the program for the control of Tuber- culosis, Malaria and Venereal Diseases submitted by the Conference be urged for adoption in all countries.
“9. That since educational propaganda has been shown to be the most efficient means for forwarding all forms of health activity, we espe- cially urge the general adoption of scientific pub- licity methods.
“10. That the training by thoroughly qualified teachers of school children in all grades in the subjects of personal and general hygiene, and the inculcation of proper health habits during school life, are essential measures for permanently im-
proving the health and contributing to the wel- fare of the people.
“11. That special attention be directed every- where to the importance of town and city plan- ning and proper housing for working men; and that National Red Cross Societies be advised to prepare plans and designs suitable for use in their respective countries, and proffer the assist- ance and the advice of experts where construc- tion work is under consideration.
“12. That the National Red Cross Societies and their Chapters be urged to promote the erection of buildings to be used as health and community centers in their respective localities, as a most useful, appropriate, and permanent memorial for the soldiers who have lost their lives in the war. That model plans and designs for those be pre- pared and made available to the people of vari- ous communities.
“13. That the general principles underlying successful work in new countries which are de- tailed in the report of Child Welfare be recom- mended for general guidance in all health work in such communities.”
ANNUAL CONFERENCE ON PUBLIC HEALTH AND LEGISLATION.
Never before lias the importance of pub- lic health work been so generally appreci- ated as it is today, and never before have endeavors in that field had the impetus that exists now. The movement is apparently at the threshold of vast accomplishment. The conference referred to in the heading has been called by the Council on Health and Public Instruction for March 4, 1920, at the Auditorium Hotel, Chicago. Incident- ally, this meeting will directly follow the Annual Congress on Medical Education and Licensure, to occur March 1, 2 and 3, 1920, mention of which will be found in the News Items of this issue. The following program is printed at the request of the Council:
PROGRAM.
Morning Program.
1. Call to Order, 9 :30 a. m.
2. Chairman’s Address, Dr. Victor C. Vaughan,
Chairman, Council on Health and Public In- Instruction, American Medical Association.
3. Secretary’s Report, Dr. Frederick R. Green,
Secretary, Council on Health and Public In- struction, American Medical Association.
4. “Standardization of Public Health Activities,”
Dr. George E. Vincent, President, Rockefel- ler Foundation.
5. “Standardization of State Public Health Or-
ganizations,” Dr. Chas. V. Chapin, Commis- sioner of Health, Providence, R. I.
6. “Standardization of Municipal Health Or- ganization,” Dr. Allen McLaughlin, Assistant Surgeon General, United States Public Health Service.
7. General Discussion, opened by Dr. C. St. Clair Drake, Commissioner of Health,
30
Colorado Medicine
Springfield, 111., and Dr. Ennion Williams, Commissioner of Health, Richmond, Va. Afternoon Program, 2 P. M.
Symposium on Health Education of the Public.
1. “Health Education in the Public Schools — -
Thirty Years’ Experience in Michigan,” Dr. Victor C. Vaughan, Ann Arbor, Mich.
2. “Health Education and Activities in Colleges
and Universities,” Dr. John Sundwall, Direc- tor Students’ Health Service. University of Minnesota, Minneapolis, Minn.
3. “Health Education a Function of Municipal
Health Departments,” Dr. Haven Emerson, New York.
4. “Health Education a Function of State Health
Departments,” Dr. W. S. Rankin, Secretary, State Board of Health, Raleigh, N. C.
5. “Health Education a Function of the Federal
Government,” Dr. Chas. V. Bolduan, Direc- tor, Division of Public Health Education, U. S. Public Health Service.
6. General Discussion, opened by Dr. John M.
Dodson, Chicago ; Prof. W. B. Owen, Super- intendent, Chicago Normal College.
"Criminal zirtieles
EMPYEMA AS SEEN AT CAMP KEAR- NEY DURING THE RECENT EPIDEMIC OF INFLUENZA.*
Major Thomas E. Bailly, Captain James R. Arneill, Captain Arthur Stanley Granger, Captain Leon Shulman, Captain Frank E. Smith.
(U. S. Army Empyema Boai’d).
At Camp Kearney the prevailing pan- demic of respiratory disease, called by com- mon consent influenza, began September 23, 1918, with four cases and the crest of its highest wave was reached on October 29, 1918, with a receiving ward record of two hundred and seven cases. On November 17, 1918, the lowest point of the first wave was reached, with a record of nine cases. At this time the authorities thought that the epidemic had spent its force. However, a new crop of susceptibles was discovered by the virus; the cases became more numerous and the crest of the second and smaller wave was reached November 22, 1918, with a record of eighty-three cases on that date. From this time the epidemic gradually sub- sided until] on January 1, 1919, it was called a closed chapter, with a receiving ward record of five cases. Since this date the number of cases has varied from five to ten a day until February 3,
*Read by Di\ Arneill at the annual meeting of the Colorado State Medical Society, October 7, 8, 9, 1919.
1919, on which date the receiving ward re- ported that not a single case of influenza had entered the hospital.
During this period of one hundred days, September 23, 1918, to January 1, 1919, there entered the base hospital four thou- sand, seven hundred and eight cases diag- nosed as influenza. During this same pe- riod, and among these same cases, there were diagnosed seven hundred and twenty- eight cases of pneumonia. Among the four thousand, seven hundred and eight patients entering the hospital with influenza, there were one hundred and forty-nine deaths from pneumonia; and these were practically all cases of bronchopneumonia. Soldiers here did not die from influenza, so often given as the actual cause of death in the mortality records of various cities, but from pneumonia or pneumonia complicated by empyema or lung abscess.
Among our autopsy records of one hun- dred and thirty-five cases of pneumonia during this epidemic, there were one hun- dred and thirty-four cases of bronchopneu- monia and one doubtful case of lobar pneu- monia. We feel absolutely positive that there were several hundred cases of mild influenzal bronchopneumonia unrecognized which recovered under the diagnosis of in- fluenza. The explanation of this fact is this : The pressure of the work during the height of the epidemic was such that ward surgeons found it impossible to examine carefully every .case. As a result, the mild- ly sick influenza cases did not receive a careful chest examination each day, and al- though exact temperature, respiration and pulse records of each case were kept by the nurses, and by this means, together with careful inspection, the mild cases were segregated, they were not given as thor- ough an examination as the severe cases. At the same time, not all ward surgeons at all times recognized the signs of a begin- ning and small bronchopneumonia. We be- lieve that in this base hospital at least one out of every five influenza cases, at some time in its course, had the signs of broncho- pneumonia.
Our records show the presence of twenty- five cases of empyema, recognized either be-
February, 1920
31
fore death by the ward surgeon or at au- topsy by the pathologist, among the seven hundred and twenty-eight cases of pneu- monia (thirty-four percent). By empyema we mean every case showing pleural fluid, no matter how small the quantity, from which a pathogenic organism can be re- covered by culture. We believe it to be quite likely that a definite number of cases of small, mild empyema escaped recogni- tion and that the patient recovered as a result of absorption, encapsulation or organ- ization of the exudate without operation or aspiration. However, an empyema or lung- abscess of much moment has a faculty of making itself known by symptoms and signs which call for recognition or, if these are not recognized, by progressing to a serious or fatal termination, when the diag- nosis is made by the pathologist much to the discomfiture of the clinician.
Etiology : Predisposing factors played but little part in these cases. The severity of the symptoms both of influenza and of the pneumonia following it seemed not to influ- ence in any degree the complication of em- pyema, nor did the time elapsing between the first symptoms of influenza and the pa- tient’s entry into the hospital bear any re- lation to it; eighteen, or seventy-two per- cent, reported to the hospital on the day of or the day following the onset of influenza. Twenty, or eighty percent, gave a negative history of previous disease. Four had had a previous pneumonia (one four years be- fore, and three two years before). One had had typhoid. Ten, or forty percent, used neither alcohol nor tobacco. Fourteen used alcohol to a varying degree. Fifteen, or sixty percent, were between the ages of twenty-one and twenty-three ; five between tAventy-five and twenty-eight ; three be- tween nineteen and twenty; two between thirty-one and thirty-four. Seventeen, or sixty-eight percent, before their entrance into the army were engaged in outdoor oc- cupations. The same number had outdoor duties in the army. There were seventeen Americans by birth, three Mexicans, two Italians, and one each of Swedish, Russian and German descent. Thirteen, or fifty-two percent, had been in the army three months
or less. All were housed in tents. Sixteen, or sixty-four percent, were robust and well developed. The organisms found in the pleural fluid aspirated for diagnosis were as follows: streptococcus hemolyticus, eight; staphylococcus, two ; streptococcus viridans, three; pneumococcus type IV, one; and no growth in three cases. At autopsy the in- fluenza bacillus was found in the pleural fluid in four cases, in the lung in seven cases and in the heart’s blood in one case. Streptococcus hemolyticus was found in the pleural fluid in four cases, in the lung in two, in the heart’s blood in two, and in the spleen once. Pneumoccoccus type III was found in the pleural fluid in three cases, in the lungs in four, in the heart’s blood in three and in the spleen in two. Pneumo- coccus type IY was recovered from the pleural fluid in two cases, from the lung- in four and from the heart’s blood once. Streptococcus viridans was recovered from the pleural fluid in three cases, from the lungs in three, from the heart’s blood in one and from the spleen and pericardial fluid in two cases each. Seventeen cases showed the same organisms in the lung and pleural fluid. The aspirated fluid was in most instances (sixty-eight percent) serous in appearance with varying amounts of floccules present ; in but seven cases did it appear purulent. The amount varied from fifty to fifteen hundred cc. The left side was involved in twelve cases, the right in twelve, and both sides in one.
Pathology: Autopsies were done on nine- teen cases of empyema. The pleura in those in whom the process had progressed for sev- eral days was almost invariably covered by a very thick, shaggy, yellowish exudate, which to a greater or less extent bound the parietal to the visceral layer so that the lung filled the chest without being pushed in any direction. The fluid lay within the interstices of this exudate. Eleven cases, or fifty-eight percent, were so affected. In but three cases was the pleura noted as smooth ; the amount of pus in these was small. Two presented fibrous adhesions; in three the exudate was thin. Two showed distinct pocketing of the fluid. The pleura of the side opposite the affected one was normal in seven cases; in five there were present
32
Colorado Medicine
|
Chart I : Organisms recovered at autopsy. |
|||||
|
Organisms. |
F |
a |
|||
|
►r] CD |
a? |
V |
<X> |
||
|
P |
crq |
O |
2 |
O P |
|
|
CO |
|||||
|
s* |
|||||
|
S |
|||||
|
Influenza bacillus |
6 |
5 |
l |
6 |
0 |
|
Pneumococcus type I |
1 |
0 |
l |
0 |
0 |
|
Pneumococcus type Ha . . . |
0 |
1 |
l |
l |
0 |
|
Pneumococcus type III . . . |
3 |
5 |
3 |
i |
0 |
|
Pneumococcus type IV... |
4 |
4 |
1 |
0 |
0 |
|
Streptococcus hemolyticus |
3 |
2 |
2 |
i |
0 |
|
Streptococcus viridans . . . |
G |
5 |
9 |
2 |
2 |
|
Staphylococcus |
4 |
5 |
4 |
2 |
0 |
fibrous adhesions in varying degree; there was noted a thin fibrinous exudate with serous fluid in three cases; in two a thin exudate without fluid was present ; one showed a small amount of serous fluid with- out an accompanying fibrinous exudate, and in one there was pus.
The lung of the affected side showed a partial collapse in ten cases, or fifty-two percent. This was only apparent in most instances on section, as the thick exudate present closely bound the lung to the chest wall and diaphragm. The color differed ac- cording to the extent of the process. In most instances it was mottled with inter- mixed reddish and grayish nodules which stood out from the surface. The edges of the lobes usually presented a compensatory emphysema. The lungs whose pleural sur- face was not covered by a thick exudate were heavy and voluminous. These last named showed a considerable amount of edema on section. In two cases there were present small areas of necrosis. A massive necrosis was noted once. From the cut sur- face of those which gave a culture of pneu- mococcus type III (three cases) a stringy exudate was noted. Microscopically the alveoli were filled with red blood cells and fibrin or with leucocytes, fibrin and desquamated epithelium, depending upon the location of and the progress of the pneu- monic process in the section cut. The areas of necrosis showed broken down pus cells and debris. The lung of the opposite side presented varying degrees of pneumonic in- volvement in every case. Lung cultures were positive in seventeen cases, or ninety
percent. The interlobar fissures were oblit- erated by fibrinous adhesions in all but three instances.
Complicating pathology except in those organs affected by the toxemia was com- paratively rare. The pericardium was neg- ative in fifteen cases, or seventy-nine per- cent ; one case showed petechial hem- orrhages, one a slight excess of fluid in the sac and in two there was slight roughening of the serous surfaces. The heart was normal in thirteen cases, or sixty-eight per- cent. Ulcerative endocarditis was found once. The right side of the heart was di- lated in four instances, the left side in one of these. Cultures were positive from the heart’s blood in eight cases. The spleen was enlarged in seventeen cases, or eighty- nine percent. In seven instances the cut section was markedly friable and in eight presented scattered grayish nodules of about two mm. diameter; microscopically there was a hyperplasia of the malpighian cor- puscles and a phagocytosis by the endo- thelial cells of the venules ; cultures were positive in seven cases. The liver was
normal in eighteen cases and showed passive congestion once. There were adhesions (old) about the gallbladder in two instances. The kidneys were swollen and congested in seventeen cases, or eiglity-nine percent; in two of these the normal markings were obliterated ; microscopically there was a cloudy swelling of the convoluted tubular epithelium, a thrombosis of the glomerular capillaries and adherence between the glom- eruli and capsule. One case showed petechial hemorrhages beneath the peri- toneum of the abdominal viscera.
Symptoms: There was no preceding
chill. The general symptoms of the pneu- monia gradually changed into those of the complicating empyema. Pain was present in fifteen of the cases, or sixty percent; of these it was noted in the affected side in thirteen, in the opposite side in two ; in ten it was absent or not marked. There was a secondary rise in temperature in twelve cases ; in thirteen it continued high through- out the pneumonia and empyema. The pulse and respiration showed no change in the transition from pneumonia to empyema.
February, 1920
33
Chart II : Combination of organisms found at
autopsy.
Organisms.
|
f |
3 |
|
B B |
wg |
|
CTQ |
o £ o Q. GO |
W
CD
CD
B, Influenza alone 2 1 0
B. Influenza and streptococcus
liemolyticus 1 0 0
B. Influenza and streptococcus
viridans 1 1 0
B. Influenza and pneumococ- cus 11a 0 0 1
B. Influenza and pneumococ- cus III 0 1 0
B. Influenza and pneumococ- cus IV 1 0 0
B. Influenza and staphylococ- cus 0 1 0
B. Influenza, pneumococcus IV
and staphylococcus 1 1 0
Streptococcus hemolyticus alone 0 0 1
Streptococcus hemolyticus and
pneumococcus I 1 0 0
Streptococcus hemolyticus and
staphylococcus 1 2 0
Streptococcus hemolyticus, sta- phylococcus and pneumo- coccus I 0 0 1
Streptococcus viridans alone... 4 0 1
Streptococcus viridans and sta- phylococcus 0 2 1
Streptococcus viridans, pneumo- coccus III and IV 0 1 0
Pneumococcus Ha alone 0 10
Pneumococcus III alone 3 3 3
Pneumococcus IV alone 1 2 1
Pneumococcus IV and staphy- lococcus 1 0 0
Staphylococcus alone 1 0 2
0
0
0
0
0
0
0
0
1
0
0
0
9
0
0
1
1
0
0
Cyanosis was marked in seven cases, mod- erate in three, slight in two and absent in thirteen, or fifty-two percent. Physical signs were in many instances misleading. In fourteen cases, or fifty-six percent, there was no flatness and the breath sounds were bronchial in character. This will be com- mented on later. Dullness and diminished breath sounds were noted in four cases, while but seven showed flatness to percus- sion and absent breath sounds. Leucocy- tosis with high polymorphonuclear per- centage was the rule. Counts done on nine- teen cases showed ten with leucocytes above twenty thousand, three above fifteen thou- sand, while six were under fifteen thousand. The polymorphonuclears were above ninety percent in ten cases, between eighty-five and ninety percent in two, between eighty and eighty-five percent in three, and below
eighty percent in three cases. In general those with low counts were the rapidly fa- tal cases of pneumonia with but little pus found in the pleural cavity at autopsy.
The urine showed albumin and granular casts in twelve cases, albumin alone in two, albumin and pus in five; five were nega- tive and there was no report on one.
Complications were few ; ten cases, or forty percent, showed none. Jaundice was present in four, pleurisy (fibrinous) in sev- en, phlebitis (femoral) in two, while mitral regurgitation, conjunctivitis, otitis media and tonsillitis were each present in one.
The diagnosis was made on: (1) A rise
in leucocytes with high polymorphonuclear count. This was fairly constant; (2) A change in the percussion note from dullness to flatness with diminished or absent breath sounds; (3) Exploratory puncture.
The classical signs of flatness, absent breath sounds and change in level of fluid were absent in many cases because of the fact of the lung being bound to the chest wall by shaggy fibrinous adhesions and the fluid lying in the innumerable interstices so formed. Consequently we learned that dull- ness with tubular breath sounds and bron- chophony were by no means negative signs of empyema. In the eight cases not diag- nosed during life there were no physical signs of fluid, there was a low leucocyte count in six and one died the day positive signs appeared.
Treatments : But seven cases of the
twenty-five received surgical treatment. Thoracotomy with drainage was done on two of these ; one died. Aspiration with in- jection of two percent formalin in glycerine followed later by thoracotomy was done on four. Rib resection was done once, a case complicated by lung abscess. Six of the seven are living. Of the remaining eighteen cases, aspiration with injection of two per- cent formalin in glycerine was done on two ; eight had one or more aspirations ; and eight were not diagnosed during life.
Comments: It will be seen that among
our twenty-five cases of empyema nineteen, or seventy-six percent, died and six, or twenty-four percent, recovered or are still
34
Colorado Medicine
under treatment in the empyema ward of the base hospital.
Of these twenty-five cases : Seventeen
cases were diagnosed by the ward surgeons in charge of the pneumonia wards; eight cases were diagnosed by the pathologist at the autopsy.
Of the nineteen cases of empyema which died: One was operated by thoracotomy
with drainage; ten were aspirated from one to four times ; eight received neither aspira- tion nor thoracotomy but were diagnosed on the autopsy table.
Of the six cases which recovered, one was operated on by resection (lung abscess) and five by thoracotomy with drainage, after they had received from 'one to six prelimin- ary aspirations of from twenty cc. to twelve hundred cc. of fluid.
It might be inferred from the above state- ment and statistics that nearly all of the nineteen fatal cases might have been saved if they had been promptly diagnosed and as promptly operated upon, inasmuch as all of the six cases which are alive were operated — thoracotomy in five and costectomy in one.
Among the nineteen cases which died only one was operated upon (thoracotomy), the patient dying eleven days later, having bled profusely from the wound and having suf- fered severely with hiccough ; while ten were aspirated, a few of these receiving two percent formalin in glycerine in the pleural cavity; and eight received neither aspira- tion nor operation (i. e. thoracotomy or costectomy).
As a matter of fact the vast majority of these cases did not die from empyema but from the extensive bronchopneumonia and the attendant profound toxemia, the empy- ema proving only an incident in the case ; yet, to be sure, it might have proved an im- portant factor, had not the patient so promptly died from his bronchopneumonia.
However, this condoning circumstance did not relieve the ward surgeon of much cha- grin and sorrow when empyema of recog- nizable size was diagnosed in the morgue, rather than in the pneumonia ward. In many of these cases the disease process was so fulminant and the soldier so desperately
ill with extreme weakness, agonizing dys- pnea, marked cyanosis and delirium that the ward surgeon did not feel justified in turning the patient on his side, or causing him to sit up in order to make a careful ex- amination and exploration. Because of these distressing circumstances, the diagnosis was not made in many cases. Had it been made only a small quantity of fluid would have been found in most cases and aspiration or operation would not have saved the pa- tient; the bacteremia, toxemia and mechani- cal involvement from consolidation, not from pleural exudate, were such overpow- ering factors. In the majority of the cases diagnosed as empyema at the autopsy and not recognized before death the quantity of pleuritic exudate was so small and had de- veloped so recently that it could have cut almost no figure in causing the fatal termin- ation. It would not have been called by the majority of surgeons an empyema ne- cessitating operation.
The extreme difficulty of diagnosis of certain types of empyema in this epidemic is generally recognized. The fluid in most cases did not change levels and often had intermingling air-containing lung tissue. The one dependable rule was : when in doubt, use the exploratory needle freely, but with discretion. It is unnecessary to note that the needle should be of good calibre and length. One should not be satisfied with one or two punctures. We have known of the pocket of pus being finally located in the patient of a colleague, in Colorado, af- ter fourteen exploratory punctures. At pres- ent there is in the officers’ ward an aviator who was operated in Colorado Springs, nearly a year ago, because of a post-influ- enzal empyema. This operation did not completely or permanently stop the fever. The patient was transferred to Chicago. Poor drainage or another pocket of pus be- ing suspected, an x-ray plate was taken at the Presbyterian Hospital. Guided by the stereoscopic plates, the surgeon introduced long, large needles a great many times and finally located a lung abscess, the size of an egg, near the pericardium. Costectomy was done, drainage was instituted, and as a result the soldier has for months been
February, 1920
35
without fever and has gained weight up to normal. He still has some drainage, but feels remarkably well. The x-ray was of inestimable value in helping the surgeon to locate this abscess.
In one of our cases the x-ray was alone responsible for the location of a lung ab- scess. This patient, C. G-. S., was admitted to the base hospital December 20, 1918, with influenza. On December 22 bronchopneu- monia of the right lower lobe was diagnosed. On December 25, the right pleural cavity was aspirated and twenty-five cc. of a san- guino-purulent fluid was obtained. On De- cember 26 the right pleural cavity was ex- plored with needles, in five different loca- tions, with negative results. Meantime the soldier developed a double otitis media with excessive discharge of purulent material. He likewise did not complain of any chest symp- toms, stoutly maintaining that his lungs felt perfectly normal. It was thought for some time that the otitis media explained his per- sistent fever and high leucocyte count with high polymorphonuclear percentage. On December 22, whites were 44,500, polymor- phonuclears ninety-one percent ; whites were 18,300, polymorphonuclears ninety-two per cent, December 23, 1918 ; whites were 27,300, polymorphonuclears eighty-nine per cent December 24, 1918.
On January 8, 1919, one of us was called in consultation and advised an x-ray plate. This plate was interpreted as showing a walled off collection of pus, lung abscess, upper right, extending down to the inter- lobar fissure. On January 9, a large needle was inserted between the third and fourth ribs and between the posterior border of the scapula and the spinal column, and pus ob- tained.
On December 25, 1918, the pleural exu- date showed:
Culture, pneumococcus type IV ; smear, gram positive displococcus.
On January 9, 1919, pus from the lung abscess showed, on culture, streptococcus non-hemolyticus and pneumococcus type I. Operation was done in two stages, January 10, 1919, resection of fifth rib was done pos- teriorly, behind the angle of the scapula. The parietal layer of the pleura was sep-
arated from the ribs and packed against the visceral layer by a large amount of gauze to obliterate the pleural cavity over the site of the lung abscess. The gauze was removed two days later. January 12, 1919, an open- ing was made into the abscess of the right lung, which was situated in the apex, pos- teriorly. A large rubber tube was inserted. This protruded from the posterior chest wall beneath the angle of the scapula and afforded excellent drainage. The patient has improved definitely since operation, though he is still draining and has a slight evening rise of temperature.
We are impressed with the lesson to be drawn from these two cases : be suspicious of the presence of pus even after five taps, if the patient is not doing well and con- tinues to run fever; x-ray and explore again, guided by the picture ; also, even though the cavity is apparently draining satisfactorily, if the patient is running fever and not doing well suspect another walled off cavity and explore after x-ray, or sus- pect your tube of not entering the old cav- ity and again take advantage of the assis- tance of the stereoscopic x-ray plate.
Our patients were mostly too desperately ill to transport to the x-ray laboratory from the pneumonia wards without great risk. It is unfortunate that the excellent portable x-ray outfits were not used freely in every suspicious case, in the pneumonia wards. Many incipient and slightly involved cases of pneumonia and empyema would have been recognized with much less strain and suffering to the patient than was imposed Upon him by careful physical examination and exploratory puncture.
In this epidemic with its numerous vari- eties of empyema the old time classical and dependable physical signs were in many in- stances untrustworthy. Formerly we thought that in the adult, high pitched blowing breathing meant a consolidated lung. Now we know from exploratory experience that in many instances it means — pus. Again, we formerly felt that we could depend upon