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THE MISSISSIPPI DOCTOR
OFFICIAL ORGAN
MID-SOUTH POST GRADUATE MEDICAL ASSEMBLY
BOONEVILLE, MISSISSIPPI, JUNE, (1935
DR. HARVEY F. GARRISON
President-Elect of Mississippi State Medical Association
' m
tThe Continental Breakfast
is not suitable for a growing child
In far too many homes, a breakfast of a roll and a cup of coffee is the fare for children as well as adults. Woefully de- ficient in vitamins and minerals, such a meal furnishes little more than a small amount of calories. A dish of Pablum and milk, however, is just as easily prepared as a “continental breakfast,” but furnishes a variety of minerals (calcium, phosphorus, iron, and copper) and vitamins (A, B, G, and E) not found so abundantly in any other cereal or breadstuff.
The addition of a glass of orange juice and one Mead's Capsule of Viosterol in Halibut Liver Oil can easily build up this simple breakfast into a nourishing meal for the children of the family as well as the adult members. It is within the phy- sician’s province to inquire into and ad- vise upon such matters, especially since Mead Products are never advertised to the public. Seruamus Fidem, “We Are Keeping the Faith.”
Pablum (Mead’s Cereal pre-cooked) is a palatable cereal en- riched with vitamin- and mineral-containing foods, consist- ing of wheatineal, oatmeal, cornmeal, wheat embryo, alfalfa leaf, beef bone, brewers’ yeast, iron salt, sodium chloride.
Please send professional card to Mead Johnson & Co., Evansville, Indiana, U.S.A., when requesting samples of Mead Products to cooperate
in preventing their reaching unauthorized persons.
June, 1935
THE MISSISSIPPI DOCTOR
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2
THE MISSISSIPPI DOCTOR
June, 1935
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June, 1935
THE MISSISSIPPI DOCTOR
3
The Mississippi Doctor
The Journal with a vision, the delivery ol modern medicine to the masses at less cost to the individual and more profit to the practition- er. The champion of the small hospital, the hub around which this service must be built.
— Subscription Price, One Dollar A Year —
W. H. ANDERSON, M.D., Editor and Manager MRS. W. H. ANDERSON, Assistant Editor
Official Organ of
NORTHEAST MISSISSIPPI 13-COUNTY MEDICAL SOCIETY
President — Dr. S. R. Deanes West Point. Miss.
Secretary — Dr. A. J. Stacy Tupelo, Miss.
ASSOCIATE EDITORS
V. B. Philpot, M.D
R. B. Caldwell, M.D
G. S. Bryan, M.D
W. A. Johns, M.D
Houston
Baldwyn
Amory
____Corinth
Carl Feemster, Jr., M.D ___.Tupelo
A. H. Little, M.D., Editor for North Mississippi
Medical Society Oxford
Official Organ of
NORTH MISSISSIPPI MEDICAL SOCIETY
President — Dr. W. W. Phillips Secretary — Dr. A. H. Little __
Oxford
Oxford
Official Organ of
MID-SOUTH POST GRADUATE MEDICAI ASSEMBLY
C. R. Crutchfield, M.D.. E. M. Holder, M.D
President — Dr. H. King Wade Hot Springs
President-Elect — Carl R. Crutchfield
Nashville
Vice-Pres., Tennessee — Dr. J. G. Price
. Dyersburg
Vice-Pres., Mississippi — Dr. B. S. Guyton
Oxford
Vice-Pres., Arkansas — Dr. R. B. Robbins
Camden
Secretary-Treasurer — Dr. A. F. Cooper
Memphis
Contributing Editors
C. M. Speck, M.D New Albany
F. M. Acree, M.D Greenville
Nashville, Tenn.
Memphis, Tenn.
H. King Wade, M.D Hot Springs, Ark.
Dewell Gann Jr., M.D Little Rock, Ark.
MISSISSIPPI STATE MEDICAL ASSOCIATION
President — Dr. J. R. Hill Corinth
President-Elect — Dr. H. F. Garrison Jackson
Secretary— Dr. T. M. Dye Clarksdale
Entered as second-class matter, January 18, 1926, at the post-office at Booneville, Miss., under
the Act of March 3, 1870.
EDITORIALS
Dr. Hugh Gamble, of Greenville, is now the active president of the Mississippi State Hospital Association. He is a progressive leader, but safe and cautious. Mis- sissippi is well supplied with hospitals. Greenville, the home of Dr. Gamble, has one of the best. The standards of some of our hospitals needs to be raised to be sure, but even now they are doing good ser- vice. The machine age demands that we have a hos- pital in every county or every two or three counties throughout the nation. The hospitals we have are equipped to take care of a vast majority of our pa- tients. The number of beds does not always count. We need greater financial security for our hospitals. Hospital insurance is right now before us. It is one of our major hospital hopes, we believe. It can be called another name if you like. Dr. Hugh Gamble will weigh all the evidence. He will lead us safely. He will secure action during the year. The medical profession is proud of Dr. Hugh Gamble as is the hospital association.
A hundred thousand go down yearly in this coun- try from accidental death. Accidental death is no re- specter of persons. The most active, the most valu- able, in our human society pay a high toll. If we are to lower this destructive and disgraceful death rate the causes must be studied as we would that of contagious disease. When the survey is made and the truth is known, whiskey will be found to be the major cause it is quite sure. Poor vision and mental deficiency will come in for a share. Ignorance of the simplest safety rules will play a part. The lack of road courtesy will give the minister of the gospel plenty of cause to expatiate. Carelessness, driving without lights, with poor brakes, poor casings and an untrue steering gear must be given due considera- tion. The major portion of this problem is a chal- lenge to the medical profession. We should meet this challenge and step out into the broad field of productive opportunity, productive of good to human society.
The work of Dr. Defoe should give much courage to the general practitioner, the corner stone of the medical profession. Mississippi and every other state have many Dafoes if the truth were known. We be- lieve this. The Mississippi Doctor has preached it for years. His service has not been recognized as it should have been, but he has delivered the service. He shall be rewarded. He will yet come into his own. It is the high batting average of the average doctor treating the average every day disease of the rank and file that will change the sick face of the human earth. Glory and honor and admiration for our practitioners who are ever on the alert in the profession, who count every detail in their great calling of much importance. The American Medical Association should do honor to this class by electing one to the presidency of the association to indicate a long delayed apprecia- tion and recognition.
Dr. E. C. Parker, gentle, kind, refreshing and sys- tematic as the ways of the gulf presided over the Mississippi State Medical Association with ease and efficiency.
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THE MISSISSIPPI DOCTOR
June, 1935
On Tuesday of this week the Dionne babies cele- brated the first anniversary of their birthday. The five little Canadian girl babies are now one year old and going strong, for them. They are cutting teeth and beginning to crawl around. Never before in the history of the world have any five babies attracted so much attention as these. They owe their lives today, no doubt, to the carefule nursing and treatment given them by the doctor and the nurses. Without this medical care the chances are many to one that they would not have lived. They were very small, very frail and were simply kept live by scientific care and treatment. This gives to the world a fine ex- ample of what can be done by careful nursing and constant medical attention. This is not the first time quintuplets have been bom in the world but it is the first time in history that quintuplets have lived more than a few hours after birth.
A special law was enacted in that country making these babies the wards of the King and providing special guardians for their custody. The parents of the babies are allowed to see them but not to have anything whatever to do with them. The mother is not even allowed to take a close relative in to see the babies. One sad thing about this is that they will never know they had a mother, and perhaps will be- come more attached to the nurse than to the mother who gave them birth. They have been commercial- ized and their pictures have been sold to the news- papers and the movie shows until already there is in the bank to their credit a fund of $150,000.00. If they live they should easily be worth a million each be- fore they are grown. As soon as they can appear in person in shows and theaters they will be major at- tractions and reap a rich harvest of money. They are to be taught the French language and raised up in the Catholic church. The latest “argument” about them centers around the plan to have Catholic nuns take charge of them as their constant nurses.
Last week four little sisters, quadruplets, of Lan- sing, Michigan, celebrated their fifth birthday. They are strong, healthy and fine looking little girls. They are longing for next September to come around so they can start to school. They had a birthday party on their fifth anniversary and invited the Quintup- lets to be their guests but the little sisters had to de- cline. In Oakland, Iowa, are three grown girls, sisters, triplets. They are in college at Columbia, Misouri, and will graduate in a few days. They are very much alike, very pretty and said to be very bright. In one school in Atlanta, Georgia, there are 26 sets of twins. And so it goes. Since the birth of the quintuplets thousands of prospective mothers over the country have taken out insurance against the possibility of twins, triplets, quadruplets and quintuplets.
Some one said to be more or less expert m the matter of getting up data along this line says that twins occur, on an average, of once in every 80 births, triplets once in 6,400 births, quadruplets once in 512,- 000 births and the Dionnes are the first quintuplets ever to be born and live.
It is a matter of record, however, that quintuplets have been born but never lived more than a few minutes, or few hours at most. In fact it is claimed that on an average once in every 30 years since history has been written quintuplets have been born. It is claimed that in the entire world every year 337,000
pairs of twins are born, 3,700 triplets and 65 quad- ruplets, and once in 30 years quintuplets come along but none but the Dionnes have ever lived. — Booneville Independent.
Dr. J. R. Hill, of Corinth, is now the full fledged president of the Mississippi State Medical Associa- tion. Dr. Hill will lead the association along safe lines. He will be active and wide awake. He will leave his impress on the society. We do not know just what he will make prominent in his administra- tion, but it will be something worth while, something important. The pages of The Mississippi Doctor are his. We shall be glad for him to use them freely for the good of the association, for the good of organized medicine.
Better be operated for acute appendicitis by a country surgeon in a six bed hospital within six hours of the onset than by a Mayo in a six hundred bed thirty-six hours later which is about the average time for the average appendix. This is true because Dr. Time is the most successful surgeon who has yet op- erated for this the chief of abdominal ailments.
The next meeting of the Mississippi State Med- ical Society goes to Greenville, the capital of the Delta over on the Father of Waters, the home of the Gambles, the Mayos of Mississippi. In entertainment the Delta doctors are big and generous as the waters of the Mississippi are wide and deep.
The leadership of the State Medical Association of Arkansas was placed in safe and efficient hands when George B. Fletcher was selected as President- Elect. He has had plenty of training for this the highest honor in the gift of the society. He is worthy and well qualified in mind and heart.
Dr. C. D. Mitchell is now connected with the Vet- erans Hospital down at Gulfport. He likes his work. He will do it well. This is certain. He has been for many years a corner stone in our state medical so- ciety. Courtly, courteous, grateful and able is Dr. Chas. D. Mitchell.
It Is a Bible principle for the man who stays well to help the man who gets sick.
The Shadows have lengthened, the sun is set; another prince in the medical ranks has fallen. Our friend, associate and adviser, Dr. William Carroll Spencer, departed from us for a while on May 20, 1935, at the ripe age of 81 years, one month and one day.
For 45 years he served his fellowman faithfully and well; for 55 years he walked side by side with the faithful companion whom he leaves behind for a short season; for many years, he steered the barques of sons and daughters whom he leaves to rejoice in the exemplary life he lived before them.
For many years, he wore honorably the magic robe of Esculapius, only now to lay it aside for them who follow to wear it as untarnished as he.
His place will be hard to fill, we shall miss him. Our sympathies are with his bereaved.
BY THE DOCTORS OF TUPELO.
June, 1935
THE MISSISSIPPI DOCTOR
5
The Mississippi Doctor was made the official organ of the Mississippi State Medical Association at its last meeting in Biloxi to be effective January 1, 1936. This, of course, is deeply appreciated by the editor, and we believe by many others in this and adjoining states. This journal has served as a medium of expression of both the practitioner and the specialist. It has car- ried the ideas of many men on our medical problems. As editor, we have tried to pass on these ideas. It Is the champion of the community hospital, the delivery of modern medicine to the masses at a reasonable cost. It has tried to show the importance of affiliation be- tween the small hospital and the large, the general practitioner and the specialist, and closer co-operation between the physician, the nurse, the dentist and the pharmacist. It is also a strong believer in post grad- uate medical courses being brought out to the busy practitioner. We are deeply grateful to our own be- loved society for its confidence in giving us a free hand with the journal. The Northeast Mississippi 13 County Medical Society has led the world we believe in the development of the community hospital. The Mississippi Doctor has tried to carry your ideas over into Macedonia. Friends multiplied over the state and in adjoining states have co-operated with their ideas, their papers, and their encouragement. We have loved the Mid-South Post Graduate Medical Assembly like a big brother and we appreciate the confidence it had in adopting the journal as its official organ even before our own state. We are thankful to and appreciative of the North Mississippi Medical Society. The Mississippi Doctor publishes papers from the busy practitioner out on the commercial firing lines, from the Dafoes of the profession, and it publishes the pa- pers of the Mid-South, the best papers in the United States from the outstanding specialists and authorities. It is free to express medical thought that other journals might not be. It has about twenty-five of the best men in the field of medicine and surgery to be found in the Mid-South as regular contributors, and some men in the North and East. We want every friend to feel that The Mississippi Doctor is his journal, that he is responsible for its success. If we have any ene- mies we hope they will be fair and will be sympathetic. The medical profession can render more service to the nation within the next twenty-five years than any other profession on the earth. To do this it must be big and broad and unselfish. We must study, we must think, we must have courage, we must have brotherly cooperation. Service must be our measure of success. To every reader and to every advertiser we want to express our appreciation and we want to ask you most sincerely to continue to co-operate with the journal in going forward.
Let us all join hands on the level and practice cooperative medicine. Let the big hospital and the little one cooperate one with the other, let the prac- titioner and the specialist hold hands in brotherly cooperation. Give us united effort for the relief of the people and for the good of the profession.
A more thorough application of the known med- ical truths is now a very urgent need.
Some men are so busy preaching medical ethics that they don’t have time to practice much of it.
Charity funds for the indigent sick should be distributed on a per capita basis throughout the state of Mississippi. This is fair and just and right. The man out at the cross roads and down by the old mill stand who has paid taxes all his life is entitled to service in a hospital if he is unfortunate enough to need charity as any one in any city. The idea of carrying a real sick patient two hundred miles to a hospital is out of the question. If he is charity he has no funds to get him to the hospital. If he had this much money he would not be a charity patient in a small hospital. He deserves to be treated at home near his loved ones. His family physician is better prepared often times to take care of him, his home surgeon. There was a time when a few charity hos- pitals in the cities were all right, but now when you can get a first class operation in almost any little town while you wait to get a puncture fixed our pres- ent system is out of date, as much so as a bull ton- gue plow and an ox cart. Modern medicine must be carried out to the commercial firing lines. This ma- chine age of ours is demanding it. The small hos- pital can not carry the burden of charity that is ask- ing for admittance. Charity funds for the actual and urgent indigent should be furnished by the national, state, and municipal governments augmented by church and philanthropy. These funds should be distributed on a per capita basis.
The number of beds in a hospital, the average number of patients may have something to do with the efficiency of a training school theoretically, but as a matter of fact it does not have so much. If there be a difference the twenty-five bed hospital is turning out better nurses than the five hundred bed. Ten patients can furnish more material than almost any nurse can study and learn in three years. We may have too many nurses, but we should find some other way to thin them out than to draw the line on the number of patients. The nurse who is taught to work, has a kind heart, and a generous soul comes more often from the smaller hospital. The number of small hospitals will be increased in the days to come in many states. The nurse who has been trained in the small hospital will better understand. Of course it is fine for her to go to the larger hospital and take post graduate work.
Some form of hospital insurance is most likely the answer to hospital service to the middle class. The principle is all right when practised by honest men. It is a Bible principle.
The medical profession needs to lend its aid to a study of means to reduce our hundred thousand ac- cidental death rate. We need to study the relation of alcohol to automobile wrecks, that of poor eye- sight, and mental deficiency.
/— -1 i
DR. SEALE HARRIS
Gastro-intestinal and Nutritional Disease* Diagnostician 2234 Highland Avenue Birmingham, Alabama
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THE MISSISSIPPI DOCTOR
June, 1935
Syncope and Sudden Death the Result of Disordered Heart Action*
T. K. LEWIS, M.D.
Birmingham, Ala.
To the lay person there are few conditions that portend more immediate danger than those condi- tions or illnesses accompanied by seizures which give as the main presenting symptoms attacks of fainting or syncope, unconsciousness, convulsive movements of certain muscles or groups of muscles or parts of the body or even the entire body, to the lay minds these attacks are best described under the term fits, a word which has come down to us from ancient times to de- scribe all such seizures, the word was originally in- tended to designate the seizures of true Epilepsy, to the medical mind there are many such seizures which are in no way related to true Epilepsy, in the human subject these seizures are manifold. Etiologically there are many general types of these seizures, in a general way there may be said to be three general types.
1st. Those due to Kidney Pathology.
2nd. Those due to defects in the nervous system, the true Etiology of these are poorly known, hidden or even unknown, these are the true Epileptic seizures, and with which the lay mind associates all the related seizures.
3rd. Those due to Cardio-vascular condition. There
*Read before The Birmingham Medico-Surgical Club, March, 1934.
are of course many seizures that do not come within this classification as those due to Pan- creatic dysfunction and those due to various glandular deficiences. In all 3 types both ma- jor and minor seizures occur.
In this discussion we are interested only in those due to Cardio-vascular conditions the performance of the heart is the circulation of the blood, that is its aim and that is its end and as it achieves this purpose suc- cessfully or otherwise, do we get that peculiar prop- erty of life called consciousness.
In the (1) Cardio-vascular system type, the pre- senting symptoms are about as follows according to the length of the attack, pallor, transient giddiness, marked giddiness, dimness of vision, momentary loss of consciousness, convulsive movements of a single muscle, a small group of muscles, a large group of muscles, a single part of the body or even the entire body and if the attack should last long enough death as is seen in status epilepticus, in the cardio-vascular system type these symptoms are the result of a pro- found slowing or even a complete standstill of the entire Heart or the ventricles only.
Webster (2) writing in the Glasgow' Hospital rec- ord 1901, from a study of the condition stated that the preliminary lapse of pulse beats which heralds the attack, the relation between the length of the stand- still of the entire Heart or of the Ventricles and the duration and character of the accompanying nervous symptoms and finally the reappearance of the pulse some time before consciousness is restored teaches us that the unconsciousness is secondary to ventricular slowing or standstill or slowing or standstill of the entire heart, Sir James MacKenzie (3) in his book upon Heart diseases states that there are two kinds of card-
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THE MISSISSIPPI DOCTOR
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iac action which tend to induce loss of consciousness, that in which the ventricles standstill that is Heart Block, and that in which they beat at such a fast rate that the output of the heart is greatly reduced as in Auricular Flutter, he does not mention the type where the entire heart standstill as in A-Systole.
Many authors studying this proDiem have shown thru case reports, that distinct time relations exist between the cardiac events upon the one hand, and the accompanying nervous phenomena upon the other hand. If (4) there is only a slight to moderate slow- ing there will be only a muddling of the consciousness a momentary incoherence possibly a slight dizziness, a dimness of vision, little happens. If the slowing or standstill is for say 4 to 6 seconds there will be usual- ly a slight loss of consciousness, possibly a slight twitching of a small group of muscles respiration be- comes deep, some slight pallor or slight cyanosis if for longer periods say 10 to 20 seconds there will be un- consciousness twitching or convulsive movements of a small group of muscles, respiration deepens becomes sighing in type and a definite cyanosis appears upon the skin surfaces and mucous membranes, if the slow- ing or standstill is from 30 to 50 seconds there will be marked convulsive movements, respiration at first deep and sighing which later becomes rapid and shal- low, the pupils dilate, the mouth falls apart, the cya- nosis of the skin surfaces and mucous membranes become markedly deepened, but recovery can yet oc- cur, however if the heart beat ceases for as long as 90 to 120 seconds or one and a half to two minutes recovery has but rarely been reported, tho we must remember that these figures are variable for cerebral Anemiae like all other things in life is tolerated quite differently by different people. An actual case was reported by Hill (5) in 1900 of a case of Cardiac stand- still in which the standstill lasted for approximately 100 seconds yet the patient recovered only to die later of a more prolonged standstill. Several (6) writers writing upon the subject suggests that the numerous cases which have been reported in Lay literature, and it is interesting to note that none of these cases have been reported in Medical literature, in which a mirror was placed before the mouth and nose and moisture noted on the mirror and which later recovered was some form of standstill of the heart and that possibly weak beats had been coming thru for sometime and a very slight shallow respiration had already been es- tablished— A standstill of the entire Heart is spoken of as A-Systole.
Experimental (7) (8) work and observation has shown that loss of consciousness convulsive move- ments pallor, sighing respiration follow copious bleed- ing whether experimental accidental or therapeutic and the presenting symptoms are pallor, dilatation of the pupils, twitching or convulsive movements, sigh- ing deep respiration and these unquestionably result from an anemiae of the brain.
Kussmaul (9) and Tenner in 1910 showed that if in young adults or children the carotid arteries were firmly compressed over the carotid sheaths at the carotid sinus, thus occluding or stopping the flow of the blood to the brain, there resulted a pallor of the skin, giddiness, dilatation of the pupils, convulsive movements of the muscles, deep and sighing respi- ration later shallow respiration unconsciousness and that these were unquestionably the result of an ane-
miae of the brain, now when we find the same symp- toms associated with cardiac standstill or marked ventricular slowing, the reason for them is clear, that is there has developed an anemiae (10) of the brain, then the syncope or unconsciousness is caused by a deficient flow of blood from the heart to the brain, the defect may be either Cardiac or vascular, in the cardiac the pump fails to do its work adequately, the output of blood from the heart is disordered, in the vascular type the input of blood to the heart being diminished here there is a preliminary fall of general blood pressure if the pressure (11) falls to 60 or 50 MM of mercury the pulse becomes extremely feeble or imperceptible there is then a decreased return of blood to the heart.
An anemiae of the brain may be produced thru the cardio-vascular system in two ways.
1st. By an abruptly reduced inflow, as in the vas- cular type.
2nd. The inflow remaining the same or unchanged by a faulty ejection of blood from the left side of the heart.
In the first group the fainting of severe hemorrhage belongs, also those common fainting attacks, the so called Vaso-vagal (12) attacks, occuring from fright, fear, marked emotional disturbances, or in overheat- ed or over crowded rooms, Hill (5) and Lahr have shown that these cases are the result of an acute dilatation of the Splanchnic arterial system, that Is in these cases they actually bleed into their visceral vessels, the splanchnic arterial system suddenly re- laxes to form a large potential reservoir into which the blood accumulates producing a faulty inflow into the heart, these cases are the result of altered dis- tribution of the blood incident to vascular changes, these are the cases in which there is a slowing of the whole heart accompanied by lowered blood pressure, in so far as these common fainting attacks which are provoked by emotion or by long standing or in over heated or over crowded rooms has been investigated it has been shown that they are vagal in part reflexly so, primarily it is not a cardiac malady but is brought about reflexly, the vagus undoubtedly being involved as an efferent channel, a common exciting cause is the sight of blood the attacks are most frequently con- fined to the erect posture, these attacks are frequent in patients recovering from an acute illness or suf- fering from some chronic wasting diseases, the at- tacks are ushered in by a feeling of unsteadiness, giddiness, dimness of vision, during this period the heart action is becoming gradually slower, at the height of the attack, pallor sweating slow pulse, reduc- ed blood pressure, the slowing of the pulse rate may be very profound even to 20 or 30 beats per minute which accounts for the unconsciousness, twitching of the muscles may be seen, the systolic pressure falls to 50 or 60 and the diastolic to 10 or 15 which also accounts for the syncopal and unconsciousness symp- toms, at this point often the pulse is imperceptible,
N
HARVEY F. GARRISON HARVEY F. GARRISON, JR.
Pediatric Diagnosis,
Diseases of Infants and Children Lamar Life Building Jackson, Miss.
8
THE MISSISSIPPI DOCTOR
June, 1935
nausea or vomiting may precede the loss of conscious- ness, the fact that an intra- venous injection of atro- pine will always immediately cause a recovery of the symptoms stamp the condition as reflexly vagal causing a vaso dilatation of the splanchnic vessels and a decreased inflow of blood to the heart.
In the Second group, that is those due to defective or disordered action of the Heart itself.
1st. In which the entire heart is involved.
(a) Standstill of the entire heart (A-Systole)
(b) Very rapid heart action coming on sud- denly as in the Paroxysmal tachycardiaes and Auricular Flutter.
2nd. In which the ventricles alone are involved.
(a) Standstill of the ventricles only, the auricles beating at the previous rate or greatly accelerated, e.g. Heart Block.
(b) Suddenly developed heart block.
(c) Ventricular standstill in previous existing heart block.
(d) Fibrillation of the ventricles.
Standstill (13) of the entire heart, some years ago
a curious case was reported by Neuberger and Edd- inger (1898) in which standstill of the Heart accom- panied by syncope repeatedly occurred during the act of defication, at autopsy an aneurysm was found upon the basilar artery, so situated as to produce pressure upon the medullary centers during sudden rises of blood pressure, modern methods of record- ing the heart beat were not then available and there is no certain evidence tho there is strong presumptive evidence of a complete standstill of the entire heart. Gerhardt (14) reported a case from pressure upon
the left vagus from a tumor. MacKenzie (15), Wenckeback (16), Laslett (17) and others have re- ported numerous cases of a complete standstill of the entire Heart.
Very (18) rapid Heart action, of the entire Heait coming on suddenly as in the paroxysmal tachycard- iaes, the reserve power of the normal Heart is great, the organ seems to be able to accomodate itself to most any change that it may be called upon to with- stand, but if the muscles of the ventricles are dam- aged or the rate is too greatly exaggerated for some hearts without a known cause the Heart does not seem to accomodate itself quickly and at once as it neces- sary in these types of conditions, the blood pressure falls rapidly and far because the muscles cannot main- tain the pressure head necessary at that new rate and syncope occurs, the most notable form of this type of cardiac syncope is auricular flutter, the accom- panying symptoms suggest an abrupt rise of ventricu- lar rate, usually there is a 2 to 1 block in these pa- tients that is the ventricular rate is one half of that of the auricules, auricular rate 300 ventricular rate 150, the block disappears and the ventricles assume the rate of the auricles or the full rate of 300 per minute, such a rate often is not well tolerated by an adult Human Heart, the arterial blood pressure quick- ly falls and profound syncopal symptoms manifest themselves, several cases of death have been reported in patients of this type possibly due to high ventricular rate or more probably to ventricular fibrillation.
Standstill (19) of the ventricles only, cardiac syncope occurs frequently in patients who exhibit auricular-ventricular block, the ventricles alone ceas-
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June, 1935
THE MISSISSIPPI DOCTOR
9
ing to beat. Sir Thomas Lewis (20) states that there is yet no agreed definition of the term “Adams-Stokes Syndrome.” The precise nature of the fits described by Adams and Stokes is unknown however probable it may be that their patients suffered from A-V-Block, very slow action of the ventricles is not always due to A-V-Block but whatever its cause, it leads to faint- ness or actual loss or consciousness further the pulse rate may be lowered to one half its normal rate by extra-systoles, also it is necessary to remember that cardio-vascular defects may actually be associated with Epilepsy and the seizures be the result of the Epilepsy rather than of the cardio-vascular condition.
Suddenly (21) developed Heart Block, Sir Thomas Lewis reported several cases of this kind in whom repeated attacks of cardiac syncope occurred but in whom at other times the normal Auricular-Ventricular conduction was perfect, without warning the ven- tricular beat would stop while the auricular con- traction continued as normal after a few seconds the patient would lose consciousness, atropine failed to afford relief.
Increase (22) of a pre-existing Heart Block, in those who show high grades of partial block, cardiac syncope is frequent, the ventricular rate decreases while the auricular rate is maintained or accelerated this acceleration causing a more marked slowing of the ventricles thru a change in the refractory period of the A-V node or the ventricular muscles, or there may be a sudden increase in the grade of block say at 3 to 1 or 4 to 1 and suddenly there develops a 10 to 1 or a 20 to 1 block, thus markedly slowing the ventricles thru the lack of conduction thru the A-V node, this increase of block has been explained in numerous ways the more recent explanation is that there occurs a sudden increase of auricular rate and the refractory period of the A-V node is not suf- ficient to pick up this increase and there develops a more marked block at the A-V node.
Ventricular (23) standstill where complete Heart Block already exists, this is less frequent than an in- crease of preexisting block, however cases of complete block seem more prone to enter a state of ‘‘Status- Epilepticus” atropine has little or no effect upon the fits of complete block, thus showing that the vagus is not at fault, it seems from experiments that the Idio-ventricular rhythm of complete block is free from any control of the vagus, and the standstill is due to some unknown cause which effects the idio- ventricular rhythm. It has been shown that a simple lesion of the bundle of His not only suffices to dis- sociate the chambers, but also to cause a profound standstill of the ventricles, the Idio-ventricular rhythm has been shown by many investigators to originate in the junctional tissues and with this change the ventricles alter not only their sequence but also profoundly the rate.
FIBRILLATION OF THE VENTRICLES
If the fibrillation of the auricles is so frequent in the human subject why then is fibrillation of the ventricles not more often noted, the answer is that the fibrillation of the ventricles spells death. Un- less early recognized and correctly treated, which can only be done by the use of the Electrocardiogram. In ventricular fibrillation the ventricles so assaulted ex- hibit very rapid movements of small amplitude the
chambers at first shrink but soon enlarge and no longer expel their contents, the entire wall of the whole chamber is convulsed by minute quiverings. It has been shown by many investigators that the immediate cause of death in coronary thrombosis in ventricular fibrillation and especially does this occur often immediately after the thrombosis t>f a large or anterior vessel the condition often occurs where digitalis is introduced directly into the circulation in fair or large doses, in chloroform anesthesia especially light anesthesia fibrillation of the ventricles is the cause of death. Injections of adrenalin especially when often repeated and given over a long length of time has been shown to be the cause of death in so called asthmatic death.
Sir Thomas Lewis (24) writing of ventricular fib- rillation states that it is difficult or impossible to sum up all the facts about ventricular fibrillation while it is undoubtedly a circus movement as in auricular fibrillation yet the facts seem to show that ventricular fibrillation comprises many different mechanisms and grades of disturbances. Several recent articles have emphasized the danger of too frequent and too large doses of adrenalin in asthmatic cases. Thus cardiac syncope may occur when the heart action is extremely fast, each disorder compromises the blood supply to the brain. The entire heart or only the ventricles may be involved and in the different forms as out- lined, cerebral anemiae is the essential cause of the symptoms.
Case 1. Miss E. T., white female, age 22, nurse. First seen March 25, 1933. Awakened about 1:30 a. m. March 24th with very rapid heart action, with choking sensation in the throat, precordial pain all over the heart area, that morning when patient attempted to go to work as a nurse, the patient became very dyspnoeic and fainted. When seen by me at 4 p. m. the patient was moderately cyanotic, especially the fingers, moderately dyspnoeic, pulse rate 140, BP 90/60. The tracing as you will see is a case of Paroxysmal Tachycardiae. Past history: has had several attacks of rapid heart action with dyspnoea and syncope since about the age of 15, the first attack came on about the age of 15 or 16, had been playing a rather stren- uous game of basket ball for 15 minutes, and then ran about one-half block to high school, when she arrived at the high school the heart action was very rapid, the patient was markedly cyanotic and dys- pnoeic with moderate pain over the heart area. The patient had never had rheumatic fever, tonsilitis,
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10
THE MISSISSIPPI DOCTOR
June, 1935
chorea, scarlet fever, diphtheriae, pneumonia or
Miss E. A. T., W. F., age 22, nurse, 3-25-33.
CD: Acute heart failure with attacks of syncope; Paroxysmal Auricular Tachycardiae.
EKG: Paroxysmal Auricular Tachycardiae.
Rate: 220.
Miss Erie Thomas, 828, 3-27-33; Lead 1, Rate 224; P very low ampter tube pr .04 sec.; R 9 mm high slurred on up stroke and down st.; R T .06 sec.; T is upright rounded 1 mm high .16 sec.
Lead 2, Rate 224. P definitely placed after the R.
Lead 3, Rate 224. The R is slurred on up stroke and down stroke and the P is placed after the R.
typhoid. The family history is negative. The 2nd tracing was taken next day when the heart was per- fectly normal.
155 — Miss Era Thomas — 4-25-33.
Lead 1, Rate 80.
P upright .5 mm high .04 sec. to .08 sec.
P R .12-. 16 sec.
R 8 mm high and is slightly slurred on up and down stroke.
R T .04 sec. T comes off down stroke of R slightly
low on Iso-electric line slightly curved with convexity upward upright rounded 2 mm high .28 sec.
Lead 2, Rate 80.
P upright rounded 1.5 mm high .08 sec.
P R .16 sec.
R 12 mm high.
S 2 mm deep.
R S T .04 sec. T comes off up stroke of S is curved slightly with convexity downward upright rounded 3 mm high .28 sec.
Lead 3, Rt. 80.
P up right sharp slurred 2 mm high .08 sec.
P R .16 sec.
R 8-9 mm high.
S 1 mm deep.
R S T .08 sec. T comes off up stroke of S slightly curved with convexity downward 1.5 mm 1.5 to 2 mm high .28 sec.
Case 2. Mrs. F. L. W., white female, age 23, re- ferred by Dr. J. M. C. June 8, 1933. Symptoms marked irregularity of heart, slight cough, marked edema, slight dyspnoea, first noticed 18 months ago when giving blood for a transfusion to her sister who had been in an automobile accident, the doctors at one of the Birmingham hospitals refused to use the pa- tient as a donor because of the irregularity. Past history: negative except for a suggestive history of rheumatism some 12 years ago. The patient at the time of taking the tracing was 7 months pregnant (Primipara) the history included several attacks of giddiness but no syncope, one tracing was taken and just as the instrument was switched off, the patient complained of marked giddiness, dimness of vision, I switched the instrument back to Lead 1 and in just a short while the patient while not entirely uncon- scious was nearly so, however during the second stand- still there was marked convulsive movements and un- consciousness, marked cyanosis, pupils dilated with peculiar pallor, I believe the peculiar complexes are somewhat the result of the convulsive movements, in as much as the complexes seem rather to be held in systole rather than in diastole later probably because the patient had for several months been taking Dig- italis, rest and sedatives the irregularity was Parox- ymal Auricular Fibrillation seemed somewhat improv- ed tho occasionally occurred the edema dyspnoea and cough much improved, the patient was delivered by Drs. J. M. C. and G. by caesarian section and the rhythm remained somewhat normal, the Etiological condition was found to be Mitral Stenosis with re- gurgiation (Rheumatic Heart disease).
(See cut next page)
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DR. RAYMOND C. TURK, Dentist
A. W. SCHEER, X-ray Technician
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June, 1935
11
THE MISSISSIPPI DOCTOR
12
THE MISSISSIPPI DOCTOR
June, 1935
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Case 3. Mrs. T. H. A., white female, age 49, first seen January 17, 1933. Her complaint was terribly weak spells, often upon slightest exertion faints, has even fainted upon rising up in bed, highly nervous, very quick in her movements, emotional, cries easily, despises summer, very fond of cold weather, has been treated for long years for a very nervous heart, says her heart actually stops when she faints, Doctors have laughed at her about this, but it’s true, all the family have found it true. Examination showed a pulse rate 120, a small adenoma upon left lobe of thyroid, Basal Metabolism 54. There was also intra-pelvic pathology from an old and long standing chronic intra-pelvic inflammatory condition and a marked vaginal lacera- tion, during the physical examination of this patient, the patient had an attack of syncope, the pulse rate became very weak and very slow 36 per minute (Adam-Stokes Syndrome) the tracing (1) was then taken all 3 leads completed and hoping we might be fortunate to record one of the attacks of syncope we left the intrument in lead 2 tho not recording, after a few minutes the patient began to complain of gid- diness, dimness of vision and we immediately threw the recording camera into operation after attempting to standardize the string we took a few seconds of tracing, then re-standardizing to 10 MM note the first part of the standstill is a true A-Systole for 6 sec- onds then (P) or Auricular complexes came in, noting the slight movement of the string I then recorded the standardization knob 3 milli-volts which showed the string to be fairly well standardized, note that at the end of 14 seconds the ventricular beat began to be re- corded (The tautness of the string was not changed in any way, all 5 of the strips are in lead 2). The large wavy up and down movement of the string is due to the movements of the patient while the nurse was trying to resusitate her at the end of the strip 5 you will note that heart began to have the form of com- plexes it did in the first tracing.
June, 1935
THE MISSISSIPPI DOCTOR
13
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14
THE MISSISSIPPI DOCTOR
June, 1935
BIBLIOGRAPHY
1. The Mechanism and Graphic Registration of the Heax-t Beat. Sir Thomas Lewis, 3rd. Edition, London, 1925, page 417, pp s.
2. Webster (A) Cardiac Arrythmiae in Relation to Cerebral Anemiae and Epileptiform Crises; Glas- gow Hospital, rep. 1909.
3. Principles of Diagnosis and Treatment and Heart Affections; Sir James MacKenzie, 4th Edition, 1918, page 61, pp 2.
4. Ibid (Sir Thomas Lewis).
5. Hill (L) Cerebral Anemiae and the Effect which Follow Ligation of Cerebral Arteries; Phil Transaction Royal Society, 1900, B C 111, 69-122.
6. Ibid (Sir Thomas Lewis).
7. Schiff (J. M.) Nervenphysiological Lehrbuch d Muskll, U 1858-108.
8. Ibid (Sir Thomas Lewis).
9. Kussmaul (A) Tenner (A) The Nature and Origin of Epileptiform Conclusion Caused by Profuse Bleeding, New Sydenham Society, 1859-28.
10. Mechanism Graphic Registration Heart Beat, Sir Thomas Lewis, 3rd Edition, London, 1925, 420, pp 2.
11. Diseases of the Heart, Sir Thomas Lewis, 1933, page 97, pp 2.
12. Ibid (Sir Thomas Lewis), page 98, pp 1.
13. Neuberger (Th) Eddinger (L) Berlin Klinic Ochenschrift, 1898, 35-69-71, 100-103.
14. Gerhardt (D) Deutsch Archive and Klin Med- icine, 1912, 462-11.
15. MacKenzie Disease of Hheart, London, 1908.
16. Wenckebach Archives and Anatomy U Physi- ology, 1908, 53-89.
17. Laslett (E. E.) Syncopal Attacks Associated with Prolonged Arrest of the Whole Heart, Quart- Journ of Med., 1908,109, 347-355.
18. Sir Thomas Lewis, Mechanism of Graphic Reg- istration of the Heart Beat, 3rd Edition. London, page 425, pp 1.
19. Ibid, page 420, pp 3.
20. Ibid, page 418, pp 2.
21. Ibid, page 421, pp 21.
22. Ibid, page 421, pp 2.
23. Ibid, page 421, pp 3.
24. Ibid, page 425, pp 2.
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THE SOUL OF THE SURGEON
RUDOLPH MATAS, M.D., LL.D., F.A.C.S., Tulane University, New Orleans, La.
Chief Surgeon, Touro Infirmary.
FIRST INSTALLMENT
Dr. Rudolph Matas, of New Orleans, a citizen of the world. Born in Louisiana Sept. 12, 1860, the only son of Dr. Hereu Matas, a native of Gerona, Spain. At two years of age he was carried to Spain. He was educated at the Ecoles Enfantiles of Paris, primary schools in Barcelona, Spain, and Brownsville, Tex. Soule’s College, New Orleans, and the Literary In- stitute of St. John, Matamoros, Mexico where he was graduated in 1876. He entered Tulane in 1877, grad- uated at the Charity Hospital in 1880. He was med- ical clerk to the yellow fever commission in Havana, medical inspector on national board of health at Vicksburg for some time; editor of New Orleans Medical and Surgical Journal from 1883-85. Held the chair of Sui’gery in Tulane from 1894 to 1927. Presi- dent of the Louisiana State Medical Association in 1894-95; American Medical Association 1920; American College of ' Surgeons 1924-25. He is distinguished for his work on vascular surgery, aneurysm in particular; spinal and regional anesthesia; anatomic dissection^ in surgery; and application of hypodermaclisis and venoclisis. These are a few of the peaks, the high points in the life and the work of Dr. Matas.
These are only a grain of sand in his total assets. His store-house of accurate information on multiplied subjects set him apart as one person. In the art of living, his volume of life, his ability in sustained ef- fort, his good health and mental vigor as he stands upon seventy-five years of such ponderous activity warrant him the Nobel prize over his world contempo- raries in this the greatest of all human accomplish- ments. His radio-active personality emanating de- votion to and dignity in professional duty, human love, sincere friendship, courtly consideration for oth- ers, inspire any who come in contact with him to greater and more noble efforts, and even charge the atmosphere around the earth for any who are attuned to receive such inspiration.
We would not discount the glory and honor mer- ited by Osier, Keen, Deaver, Murphry, Oschner, Gorgas, and Franklin Martin; we would not under- estimate the just distinction that 'is and is to be the Mayos, Erdman, Kelley, Evans et al. But when all the assets are added that fashion a man after the Master of Men we believe that Dr. Rudolph Matas must be accorded the deanship of American medicine. He is really at this time Dean of the Medical world.
In 1915 he delivered an address before the Mis- sissippi State Medical Association. His subject was the “Soul of the Surgeon.” Chairman J. W. Lipscomb of Columbus has the following to say of him at this time.
Chairman Lipscomb, before the Mississippi State Medical Association, in May, 1915, in introducing the orator of that occasion, said feelingly: “The foremost
June, 1935
THE MISSISSIPPI DOCTOR
15
man in the foremost college in this great Southland of ours, the Nestor of our brilliant and gifted pro- fession, he needs no introduction. We have but to mention his name and his contemporaries through- out the United States stand at attention. Someone has said that, to be an ideal doctor, we must possess the wisdom of Solomon, the faith of Abraham, the meekness of Moses, the patience of Job, the charity of Dorcas, the eloquence of St. Paul, the bravery of Joshua, the strength of Samson, the executive ability of a Jezebel, must be a hunter like Nimrod, a fisher like Peter, a climber like Zaccheus, a driver like Jehu. He should be free of Asa’s gout, the melancholy of Saul, the gastric infelicity of Timothy; have all the virtues of the most virtuous and the religion of all saints. All of these are his. And now, Ladies and Gentlemen, I have the distinguished honor, the es- teemed privilege and the great personal pleasure of introducing to you Dr. Rudolph Matas, of New Orleans, who will deliver the oration.”
Mr. President, Members of the Mississippi State Medical Association, Ladies and Gentlemen:
It is my first and most agreeable duty to express my profound appreciation of the honor conferred upon me by the invitation to address the Association on this notable occasion; also my gratification at the opportunity and the privilege of addressing an audience in a city -in which I have the good fortune to count so many personal friends, some of whom I have the joy of recognizing as my contemporaries, many more as my students and fellow-alumni, who have been cradled in the same beloved alma mater; and still others, in the membership of the Association,
who in the course of a long professional life, have honored me with their confidence and good will.
To all these worthy friends and colleagues I am still indebted for the privilege of a large acquaintance with the people of Mississippi — an acquaintance which in the course of many years has been the prolific source of many professional relations, which have ripened into lasting and loyal friendships — friend- ships that have proven one of the greatest rewards and blessings of an arduous professional life. I avail myself, therefore, of the opportunity offered me by your friendship and your goodness, to thank you, and again, through you, to express my admiration, my devotion and my love for the splendid people — the generous, the brave and the chivalrous people — of this great commonwealth, with whom my life has been so closely and delightfully interwoven, from the earl- iest dawn of my professional life to the present time.
It would have been my greatest ambition to have come to you with some scientific offering worthy of the splendid occasion; to have brought some message that would have fitly memorialized the day, and that would have adequately conveyed to you the sentiment of grateful recognition that so many years of close professional intercommunication has fostered and nourished in my heart; but it is not easy for the busy worker in our profession, the man who is eternal- ly at the forge, hammering away at the physical im- perfections of his fellows, shaping, in a manner, their physical destinies, and sweltering over the melting pot of human injury and disease — to suddenly exchange the modest apparel and the grim activities of the operating room for the toga of the orator and the
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THE MISSISSIPPI DOCTOR
June, 1935
graces of the forum.
Fortunately, even though I possessed a single claim to the many virtues that my brilliant friend, your gifted, but too partial chairman, has showered upon me, — the impossible is not expected of me. Even were I capable of oratorical display, any attempt at such an exhibition, — in the land of a Prentiss, a Davis, a Lamar, a Williams, or, in our profession, of a Chaille,— and a host of others, living and dead, who have shed lustre upon the glorious traditions of your State— a State where, seemingly, wit and eloquence spring from the soil as plentifully and spontaneously as the cypress and the pine, — any attempt, I repeat, to contribute to the amenities of this occasion by a display of oratorical power, would not only be “bring- ing coals to Newcastle,” but, in comparison to what you have to offer your guests, would prove an utter failure.
The chief advantage of occasions of this character is that they offer most favorable opportunity for the mutual interchange of thought, opinion, and ex- perience, and, of these, none can be more pertinent or profitable than those which relate to our individual experience in the special fields of labor in which we are engaged.
I will, therefore, permit myself to indulge in some rambling thoughts on a subject with which, from the very nature of my life-work, I am most familiar, if not best qualified to speak — I mean the Surgeon, or,
rather, the Soul of the Surgeon himself.
* * * *
It is now a trite observation, which has become threadbare by continued repetition, that since the advent of the doctrines of Pasteur and Lister, sur- gery has made more progress in the last half century, and especially the last quarter, than had been made in all the past centuries put together. So true is this that there is no longer a horizon to its limitless am- bitions, or a check to its inquisitive enterprises. Mod- ern surgery has knocked down the barriers which, scarcely half a century ago, were deemed insurmount- able. Achievements that would have been regarded as the ravings of a disordered imagination, have be- come stern realities. However we may at times question the audacity of its leaders, no one can fail to admire its indomitable spirit and bow down before its acknowledged triumphs. But if there are, at the present time, a few skeptics who question the power and the possibilities of surgery, there are, on the other hand, a host of others, and perhaps the majority of mankind in general, who have no con- ception of the workings of the surgeon’s mind, of his internal consciousness, or, what might be called, the psychic experience which is peculiar to those who exercise surgery as a science and an art. And none but he can appreciate the enthusiasm, the passion which it inspires and instills, in the one who, whole- heartedly, disinterestedly, unselfishly, and honestly, consecrates his life to 'its ministry.
The surgeon, as a mere practitioner of his art, is known to the masses in his multitudinous and exteri- orized types; but the Soul of the Surgeon — if we may define the soul as “the ethical and emotional part of man’s nature, the seat of the sentiments and feelings, as distinguished from pure intellect” — is a part of his makeup that is unknown to the masses; . and the profound emotions which agitate him and
with which he is rarely credited, can never be appre- ciated or analyzed save by one of the Guild who has lived them.
It is an easy matter for the critic, the dramatist, the novelist, the cynic and the cartoonist, to exercise their talents at the expense of the surgeon. Surgery has furnished, and continues to furnish themes in- exhaustible for humorous dissertations in the comic papers, and cheap diatribes in the yellow journals. This has been so from the days of Aristophanes to Bernard Shaw. Nothing easier than to sneer or rail at surgery by those who are not in need of its good offices. But, in the presence of the cynical and gross- ly material concept of the surgeon’s role in the social fabric, it is only fair that something should be said to prove the baselessness of the charge that he is mercenary, soulless, indifferent to the fate of his fel- lows, greedy of gold, and thirsting for publicity and notoriety.
For the persistence of this opinion in certain quar- ters, the quack, the impostor, and the knave, who thrive in our ranks, are largely responsible. In jus- tice to our calling, however, we must recognize the fact that we are not alone in being cursed with quacks, for they are found in all occupations. “The quack is a loud-mouthed pretender, a person who seeks to gain confidence by unworthy methods or an individual who claims to have a specific for various disorders of manners, morals, finance and politics. There is a quack in statesmanship who would reform every abuse by the iron application of a favorite for- mula; the quack in law, who stimulates litigation and conducts legal procedures with no regard whatever for the interest of the community; and the quack in religion, who claims to have personal influence witn the Creator, invariably speaks as a self-constituted oracle of the Almighty and, to quote a picturesque phrase of Dr. Chalmers Da Costa, ‘would take us to heaven in the private parlor car of a lightning ex- press.’ ”
* * * *
But much of the disrepute, which has come to sur- gery at the present time, has not come through the ordinary coarse, vulgar, ignorant and shameless quack, who advertises undisguisedly in the newspapers, but from those who are regarded as regular practitioners, wolves in sheep’s clothes; these, at bottom, are the most dangerous sort of imposters. There are men who, having been trained in the safe methods of mod- ern surgery, who having learned enough of the rudi- ments of surgical technic to steer clear from the perils of infection and thereby avoid an immediate mortality, and others who have acquired considerable skill from association and training with competent surgeons — sometimes, and I am pained to say it, too often, and with growing frequency — are willing to desecrate their ministry and their art for purely sordid, sinster mo- tives. These are the men who, knowing better, see an operation in any and every complaint made by the
ROSS E. ANDERSON, A.B., M.D. "
Standard Life Bldg. (Suite 515)
Jackson, Miss.
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June, 1935
THE MISSISSIPPI DOCTOR
17
unfortunate victims of their cupidity and soullessness. They are the men who resort to all sorts of subter- fuge to coax their patients to the operating table. They are the men who see in every cramp, an ap- pendix; in every belch, a gallstone; in every heart- burn, gastric or duodenal ulcer; in every uterus, a cancer or a fibroid; in the abdomen of every neuras- thenic young woman, a diseased ovary, an infected tube, an extra-uterine pregnancy; in every neurotic woman’s abdomen, a floating kidney or a prolapsed or displaced organ, that nothing short of an operation, a laparotomy, can cure or relieve, — provided the pa- tient can pay the necessary fee. It is wonderful how sometimes the urgency and perils of a patient’s pa- thology shrivel into a negligible quantity when it is discovered that the pocket-book is empty and that there are no stakes to rake off from the game.
But while tainted money is the most frequent mo- tive for the prostitution of surgery, there are other considerations which often lead a man of the art to sell his birthright and his decency for a mess of pottage. There are others, less base, who are in- sanely ambitious for reputation and prestige as marvel- ous operators; who, possessed of the furor operatorius, allow this vanity to eclipse their reason and their morals. These men will not hesitate to remove nor- mal and inoffensive organs and endanger the lives of their fellows, solely to be quoted as wonderfully successful operators. How easy for a man armed with a diploma, with some appearance, suavity and plausi- bility, to insinuate himself into the graces of a gulli-
ble and impressionable public, if he is the least bit intelligent but unscrupulous. How easy to multiply one’s successes, with even a modest surgical training, by removing healthy organs, or operating upon them in normal individuals when the danger of complica- tions and disastrous consequences are reduced to a minimum by the perfect conditions of resistance that obtain in healthy patients! How easy to swell one’s statistics as a wonderfully successful operator, by shearing the wool of a lot of unsuspecting lambs, while they sleep. How well Zola depicted this con- scienceless type of surgical wolf in his wonderful search into the cause of race suicide, which is summed up in his novel Fecondite.
In this, he introduces us to Gaude, a young hand- some, aggressive, skillful, but unscrupulous gynecolo- gic surgeon, the idol of the smart set and of all the women of the quartier, where he holds his clinics in his private hospital and performs his jugglery before enthusiastic and admiring audiences. He is the Na- poleon of the Pelvis. Every day adds new victories and a new record to his already vast crop of ampu- tated ovaries and hysterectomized women, and his wards are full of sterile and unsexed females. Wheth- er diseased or not, it matters not; his clinics must be provided with material. His appetite is insatiable. It is not so much for his fees and the filthy lucre — to which he is not altogether indifferent — but it is to swell his statistics, and to be reputed as the premier laparotomist of France. And there are many other Gaudes outside of France who hold their sway in
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THE MISSISSIPPI DOCTOR
June, 1935
realms which are not included within the frontiers of the Faculty.
Then there are not only solitary knaves, who hide their nefarious practices in the secrecy of their private sanitariums, but there are combinations, private part- nerships, among equally rapacious and unscrupulous crooks who working in collusion, are ever ready to exploit the unsuspecting, who have been skillfully steered to their operating rooms. In these combina- tions, the internist, disguised as the family physician, as the general practitioner, plays the role of the con- fidence man, who makes the diagnosis, creates the alarm, which leads to an operation, and, then extols and lifts to the skies his secret partner — the surgeon — usually an unknown and obscure recruit from the surgical ranks.
And this traffic goes on, so that the two may di- vide the spoils of the foul partnership in fictitious diagnoses and in unnecessary, and often criminal, operations.
(To be continued next month)
Mississippi Valley Medipal Society
The first annual meeting of the newly formed Mississippi Valley Medical Society will be held at the Lincoln-Douglas Hotel, Quincy, Illinois, on October 2, 3, 4, 1935. A most practical program of intensive post-graduate instruction by eminent clinicians has been arranged. A preliminary program may be ob- tained from the Secretary, Harold Swanberg, M.D., 211-224 W. C. U. Building, Quincy, Illinois.
Book Review
The time has come when we must think in terms of medical problems. How to get medical service over to the people at a cost at which they can utilize it is the challenge. The decentralization of the medical profession, the proper distribution of both doctor and nurse must be considered. The relation of the doctors one to the other, their income, the number of doctors being graduated, and their education are up for con- sideration. How have we traveled this far and where do we go from here all must be considered. The Doc- tor’s Bill by Hugh Cabot is, we are sure, one of the most instructive and one of the most interesting books that has been written along this line. There is much work to be done in solving our medical problems. This book will give you a working basis to think for yourself. Every doctor should have a copy and should study it closely. You need to know how many doctors we have in this country, how many nurses, their incomes, the number of medical schools, the number of nursing schools, the incomes of doctors and nurses; the abil- ity of people to pay their doctor’s bill, how the bill is to be paid in the future. Dr. Hugh Cabot of Rochester gives you facts and at the same time stimulates thought on your part. This wonderful book, this time- ly book, is published by the Columbia University Press 2960 Broadway, New York and the price is only three dollars.
Be sure to get the book on doctor’s bill by Dr. Cabot and read it. It is timely. You will enjoy it and you will profit by it.
Acute Craniocerebral Injuries*
ALTON OCHSNER, M.D. and KIYOSHI HOSOI, M.D. New Orleans, Louisiana
With the introduction of rapid transportation and modern industrialization, injuries of the cranium and its contained cerebrum have become more num- erous and are of a severer type. Whereas automobile accidents are responsible for a very large proportion of head injuries, blows and falls on the head are the most frequent causes. In the authors’ (1) series of 1,099 cases from the Charity Hospital in New Orleans there were 997 in which the type of injury was stated. The most frequent injury was a fall, it being the etiologic factor in 37.9 per cent of all cases. In adults blows on the head were the most frequent causes of cerebral damage (37.2 per cent) and were followed in frequency by falls (27.9 per cent). In children, as might be expected, the most frequent injury was a fall (60.2 per cent), which was followed in frequency by automobile injuries (23.3 per cent). These figures correspond closely with those of Ireland (2), in which in children falls and automobile injuries were ex- citing factors in 62.5 per cent and 25 per cent, respect- ively. The increasing relative importance of the automobile accidents as causes of head injuries is illustrated in our cases. In the decade 1910 to 1920 automobile accidents were responsible for 15 per cent of the injuries, whereas in the periods 1920 to 1930 and 1930 to 1931 the percentages were 30.7 and 38, re- spectively. It is of interest that 4.9 per cent of the injuries in our series of children were birth injuries.
Too frequently physicians consider craniocerebral injuries in the term of fracture of the cranium, whereas in reality injury to the brain substance is of much more importance rather than that of the cran- ium. In spite of the importance of cerebral damage it is surprising how frequently in acute head injuries only fractures of the skull are considered. Although it is unquestionably true that an injury severe enough to produce a disruption of the cranial vault or base usually produces cerebral damage, such is not always the case and certainly the converse is not necessarily true; viz., that in the absence of a cranial fracture, injury to the cerebrum can be disregarded. In 1,000 cases of head injury reported by Wortis and Kennedy (3), x-rays were made in 439 cases, of which 230 were
*Read before the Mid-South Post Graduate Med- ical Assembly, Memphis, Tenn.
/ 1
CHARLES D. BLASSINGAME, M.D.
414 Physicians and Surgeons Bldg. Memphis, Tennessee
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June, 1935
THE MISSISSIPPI DOCTOR
19
negative for fracture, 186 showed fracture of the vault, 63 fracture of the base, and 20 evidence of depressed fracture. Of 441 cases reported by McClure and Crawford (4), 39 per cent were unassociated with skull fracture. Laborers are more frequently sub- jected to head injuries than those in other occupa- tions. In our own series (1), in 43 per cent of the cases in which the occupation was stated the patients were laborers, 13.3 per cent did house work, 10.3 per cent were school children, 2.3 per cent were clerks, and 2 per cent were carpenters.
The greatest age incidence of craniocerebral in- juries varies considerably in the reported cases. This is probably due to the fact that in some series the cases are limited to adults, whereas in others it in- cludes both adults and children. McClure and Craw- ford (4) found the average age in their series to be thirty years. In Connors’ (5), Stewart’s (6), and Vance’s (7) series with cranial fractures the age va- ried considerably. In Vance’s (7) series of 507 cases, the greatest number (22+ per cent) was in the fifth decade. Stewart (6) found that the average age was thirty-six, whereas Connors (5) found that the great- est number (22+ per cent) occurred between one and ten years. In our own series (1) we found the great- est number (27.2 per cent) occurred in the first decade. The incidence of cerebral injuries became progres- sively less with advancing age in our series, decreasing from 27.2 per cent in the first decade to 1.5 per cent in patients above 70 years of age.
In the consideration of craniocerebral injuries it is desirable to determine the type and extent of in- jury to the cerebrum and only exceptionally is dam-
age to the cranium of any importance. Following trauma to the head the degree of cerebral damage varies considerably from simple concussion to ex- tensive laceration and hemorrhage.
Concussion. Many pathologists and clinicians deny the possibility of the occurrence of concussion because in the few fatal cases with concussion, no pathologic change in the cerebrum could be demon- strated. Concussion represents a clinical syndrome which is a physiologic disturbance without anatomic change and in which no pathologic findings can be demonstrated. A number of theories have been ad- vanced to account for the condition. Generalized cerebral edema has been considered to be the cause of the clinical manifestations by Duret (8), Heise (9), and Symonds (10). Separation of the gray and white matter with a difference in their specific gravities has been considered by Tilman (11) to be the cause of con- cussion. Rahm (12) believes that there is a rear- rangement of the lipoids, protein molecules, and electrolytes in the cerebral cells. Miller (13), based on his experimental observations, is also of the opinion that concussion is the result of molecular disturb- ance in the cell, whereas Henschen (14) believes that concussion is produced by interference with, or in- terruption at, the synaptic junctions of the sub- cortical centers within the midbrain. A change in the hydrogen ion concentration has been considered to be the cause of symptoms. Knauer and Enderlen (15) believe that a rapid acidification of the cerebral cor- tex occurs, and Vara-Lopez (16) has shown that in experimentally produced concussion there is a de- crease in the hydrogen ion concentration of the cere-
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THE MISSISSIPPI DOCTOR
June, 1935
brospinal fluid occurring within two minutes after the trauma.
Clinically, concussion is characterized by immedi- ate and temporary unconsciousness usually followed by headache, nausea, and occasionally vomiting. There is a rapid recovery from all symptoms in cases of un- complicated concussion. Russell (17) is of the opin- ion that following a severe head injury the whole nervous system may be paralyzed and that respi- ratory and cardiac movements may cease but they recover quickly and following this, there is return in involuntary movements of the extremities and re- flexes. The higher cerebral or mental functions are the last to recover. Ritter and Strebel (18) believe that concussion of the medulla oblongata occurs more frequently and is more important than that of the cerebrum. In a series of 349 cases, 95 (27.2 per cent of the entire group and 83.3 per cent of the true concussions) showed evidence of medullary involve- ment. They believe that concussion of the medulla results in respiratory and circulatory disturbances, vomiting, blood pressure changes, and unconscious- ness. In all their cases there was immediate uncon- sciousness, which in the majority of cases lasted only a few minutes and never lasted more than five hours. Retrograde amnesia was present in 63.1 per cent of the cases and was associated with unconsciousness. There was an increase in pulse rate in 67.9 per cent. The clinical manifestations are more varied in con- cussions of the medulla oblongata than in that of the cerebrum. The symptoms appear more slowly, and the sequelae occur more frequently. Also, less severe trauma will produce a concussion of the medulla than a similar condition in the cerebrum. Concussion of the cerebrum occurred in only 4.29 per cent of Ritter and Strebel’s (18) entire group of cases and 13.19 per cent of the cases of concussion. Unconsciousness oc- curred less frequently than in concussion of the med- ulla. It was absent in 20 per cent of the cases. In 80 per cent of the cases in which it was present it occurred immediately, was deeper, and lasted defi- nitely longer than in concussion of the medulla. It lasted more than five hours in 60 per cent of the cases. In only 20 per cent of the cases had unconsciousness disappeared within three hours. Retrograde amnesia was present in 66 per cent. The temperature was always increased and vomiting occurred in 26 per cent of the cases.
Edema. Undoubtedly the most important of the anatomic lesions occurring in the brain following a head injury is an edema of the brain substance. Le- Count and Apfelbach (19), in a study of 504 post- mortem examinations of patients with craniocerebral injuries, found that the most frequent lesion was traumatic edema. In these cases they found the cere- bral convolutions were flat, the cerebral veins re- latively empty and flat, and the fluid in the leptomen- inges greatly diminished. Apfelbach (20) states that the edema following craniocerebral injuries is gen- eralized and is not localized about the points of con- tusion. The dura is tense due to the edema and the brain is soft and easily loses its form when laid on a flat surface after removal from the cranium. If the brain is hardened for several days, the lateral ventricles are found to be closed, the brain substance is stippled by small intracerebral blood vessels, and microscopically the perivascular lymph sheaths are
distended with empty spaces between the fibers them- selves, the latter being further apart than normal. Apfelbach (20) found that the water content of the brain was increased above normal from 3 to 45 grams, or as high as 3.7 per cent. That the edema may be due to the changes in the pH is suggested by Fischer’s (21) work, in which it was shown that edema occurs when in the presence of water the tissue colloids are increased and that an increased acidity results in an accumulation of the colloids. Henschen (14) found that in patients recovering from concussion and con- tusion of the brain there was an increased secretion of lactic acid, acetic acid, and phosphoric acid in the urine. Vara-Lopez (16) showed that in concus- sion there is a decrease in hydrogen ion concentra- tion of the cerebrospinal fluid. The edema by in- creasing the intracranial tension may cause obstruc- tion in the venous return which in turn tends to ag- gravate the edema. Eventually as the condition be- comes more progressive a cerebral anemia results.
Contusions and lacerations. Because contusions and lacerations occur concomitantly they should be considered together. The relative degrees of con- tusion and laceration depend upon the severity of the injury, laceration of the cerebrum being more prom- inent in the severer injuries. LeCount and Apfelbach (19), in postmortem studies, found that contusion when present was usually wedge-shaped and that the brain was infiltrated with blood for a depth of from 2 cm. to 4 cm. over an area with an outside diameter of from 4 cm. to 5 cm. They found this type of con- tusion in 49.2 per cent of their series, and in 73.3 per cent it was due to contrecoup injuries. Cerebral contusion was present in 7 per cent of McClure and Crawford’s (4) clinical cases. Trotter ((22) is of the opinion that contusion is most frequently the cause of death in head injuries. Apfelbach (20) believes that the longer a patient lives after the trauma, eve- rything else being equal, the more extensive is the contusion, this being due to continued bleeding during the life of the individual. Laceration, or tearing, of the cerebral cortex is usually associated with con- tusion and represents a more extensive lesion. Ac- cording to Blahd (23), McClure and Crawford (4), laceration is usually associated with fracture of the skull. In 54 of the latters’ cases with laceration of the cerebrum, 5 occurred without skull fracture and 49 were associated with fracture. Bagley (24) is of the opinion, however, that laceration of the brain may occur without cranial fracture and believes that the frontal lobes are the most frequent sites of lac-
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June, 1935
THE MISSISSIPPI DOCTOR
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eration. Contusion and laceration may be direct or contrecoup. In 27 fatal cases of cerebral laceration observed by Vance (7), 6 had unilateral and 11 bilateral contrecoup laceration. Four had direct lacerations and 3 direct and contrecoup lacerations.
Hemorrhage, Hemorrhage associated with acute craniocerebral injury may occur either within or with- out the dura. When it occurs within the dura, it is the result of cerebral contusion or laceration and offers a graver prognosis than when the hemorrhage from the middle meningeal artery or lateral venous sinus occurs extradurally. Hemorrhage aside from that associated with infiltration of the cerebral cortex in contusion and laceration occurs much less fre- quently than the other pathologic lesions. It oc- curred in only 5 of McClure and Crawford’s (4) 441 cases of craniocerebral injuries. In Vance’s (7) 512 necropsy cases, 312 deaths were caused by subdural hemorrhage. Hemorrhage was most frequently asso- ciated with fractures of the posterior and lateral por- tions of the skull. In LeCount and Apfelbach’s (19) series, fractures of the anterior fossa were most often associated with subdural hemorrhage, being found in every instance. Blood in the subarachnoid space is of importance not only because of the danger of cerebral compression, but also because it may become encap- sulated and produce symptoms due to localized com- pression, and when absorbed by pacchionian granu- lations mechanical blocking of these may result. Ab- sorption of the cerebrospinal fluid is interfered with, resulting in accumulation of fluid. Essick (25) show- ed experimentally that the injection of blood in the
subarachnoid space produced a sterile meningitis, whereas Bagley (26) found that the subarachnoid in- jection of blood in puppies caused dilation of the cerebral ventricles. Fay and Winkelman (27 and 28) found that blood in the subarachnoid space caused accumulation of cerebrospinal fluid between the arachnoid and pia and resulted in cerebral atrophy. Extradural hemorrhage occurs even less frequently than intradural, but it is of importance clinically be- cause of the excellent results which can be obtained following the removal of the contained clot. It is us- ually the result of injury of the middle meningeal ar- tery, one of its branches, or the lateral cerebral sinus. It is not infrequently associated with basal fractures, due to the intimate attachment of the dura to the base of the cranium. Extradural hemorrhage was re- corded in 39.4 per cent of LeCount and Apfelbach’s (19) necropsy series. In only 52 per cent, however, was the hemorrhage large enough to produce com- pression of the brain. Fractures of the middle fossa are most frequently associated with extradural hem- orrhage, being found in 70.1 per cent of those cases of fracture of the middle fossa, and occurred in only 2.8 per cent of fractures of the anterior fossa. In Vance’s (7) 507 necropsy cases, extradural hemorrhage was found in 106. The greatest number of extradural hemorrhages occurred between the ages of thirty and forty, which he believes is due to the fact that the dura is adherent just enough to the skull to al- low laceration of the arteries, but not adherent enough to prevent its separation from the bone. The posterior branch of the middle meningeal artery is most fre- quently involved, being found in 25 of Vance’s (7) 61
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THE MISSISSIPPI DOCTOR
June, 1935
cases.
In addition to injuries of the cerebrum, as men- tioned above, injuries of the cranium and its cover- ings are of importance primarily because of the danger of injury or infection of the brain substance. Scalp wounds by permitting the entrance of microorganisms are of significance. Infections of the scalp may ex- tend through the diploic veins into the substance of the bone or even directly into the cranial cavity, being carried as infected emboli through the emissary and diploic veins.
Fractures of the skull are of no importance unless associated with cerebral damage or unless compound- ed and unless there is marked depression of the frag- ment. Fractures of the base occur much more fre- quently than those of the vault, although clinical in- vestigations show the reverse to be true. In Vance’s (7) series of 512 autopsy cases the vault was involved in only 6.7 per cent, whereas the vault and base were involved in 91.9 per cent. In LeCount and Apfelbach’s (19) series the vault was involved in 9.9 per cent and the base in 89.8 per cent. In clinical cases fractures of the vault are diagnosed far more frequently than those of the base. McClure and Crawford (4) in 441 cases found that 85.7 per cent of the fractures were in the vault and only 5.7 per cent were in the base alone. As explained by Vance (7), this difference is undoubtedly due to the fact that it is difficult to dem- onstrate roentgenologically fractures of the base, be- cause of the complicated structure, whereas in rela- tively smooth contour of the bones forming the vault a defect produced by fracture can be readily seen on the roentgenographic films. Fractures of the middle fossa occur more frequently than those of the anterior and posterior fossae. In Vance’s (7) series of cases, the middle fossa was involved in 45.2 per cent, the posterior fossa in 34.8 per cent and the anterior fossa in 11.9 per cent. In LeCount and Apfelbach’s (19) series the anterior, middle, and posterior fossae were involved in 12.1 per cent, 32.9 per cent, and 35.3 per cent, re- spectively. Fractures of the base are especially apt to be compound because they may extend into the nose, the nasal accessory sinuses, the middle ear, the mastoid process, or mouth. Fracture of the base should have a guarded prognosis not only because of the danger of infection, but also because of the pos- sible associated injury to cortical centers. Of 39 cases of fractures of the vault reported by Blahd (23), there was a mortality of 13 per cent, whereas in 20 cases of fracture of the base there was a mortality of 65 per cent. Of all the fractures, those which are compound are of greatest importance because of the possibility of the entrance of micro-organisms into the cerebral substance. Cushing (29) showed during the World War that debridement and primary closure of these wounds largely obviated the danger of cerebral in- fection and possible death. In addition to the com- pound fractures, depressed fractures may be of surg- ical importance, although it is the opinion of most authorities that the danger of depression of the frac- ture has been greatly overemphasized. Bagley (24) is of the opinion that depression is of little significance if the dura remains intact.
Diagnosis. The history is of great importance as regards the diagnosis of acute craniocerebral in- jury and probably of greatest importance is the his- tory of unconsciousness. All extensive cerebral in-
juries are associated with unconsciousness, and the depth and extent of the unconsciousness is usually proportional to the degree of cerebral damage. In simple concussion the unconsciousness occurs imme- diately, but is only temporary, whereas in the more extensive injuries unconsciousness is prolonged. A period of unconsciousness followed by a lucid interval and later followed by unconsciousness is, as first de- scribed by Kocher (30), characteristic of a rapid in- creasing intracranial pressure which is almost invari- ably associated with intracranial hemorrhage, usual- ly from the middle meningeal artery. The pulse rate is of value primarily in cases of shock, the rate usual- ly being increased and the volume poor. In cases of rapidly increasing intracranial tension the pulse rate is decreased due to vagus stimulation and becomes progressively slower as the blood pressure rises. This, however, represents a severe degree of intracranial tension. A slow pulse may also be the result of blood in the cerebrospinal fluid, edema of the cardiac centers, and intracranial tension due either to mid- dle meningeal hemorrhage or edema of the cerebrum. Fay (31) is of the opinion that a thready pulse in pa- tients with head injuries is the result of lack of re- sistance in the capillary bed. This phenomenon he believes is of extreme importance, because of the anoxemia associated with the lowered vascular ten- sion, which predisposes to further edema, because of the increased permeability of the capillaries as shown by Landis (32). The respiratory rate varies consid- erably in cerebral injuries. Fay (31) believes that the respiratory rate is of great importance, especially as regards the prognosis. He states that if above 26, it frequently indicates cerebral irritation, and blood is usually found in the spinal fluid. If the respiratory rate reaches 40 per minute, there is indication of se- vere cerebral damage. Hyperpnea is of importance, because of the hyperventilation with subsequent wash- ing out of the carbon dioxide, and the development of alkalosis and edema. Decreasing respiratory rates, according to Fay (31), are usually the result of in- creased intracranial tension. In severe cerebral dam- age, paralysis of the respiratory centers with cessation of respiration may oecur. The temperature may or may not be increased in cerebral injuries. Early,
n 1 Walter W. Robinson, M.D. Crisler Clinic 1291 Union Avenue Memphis, Tenn.
Specializing in PATHOLOGY ROENTGEN
DIAGNOSIS and THERAPY
-
June, 1935
THE MISSISSIPPI DOCTOR
23
shortly after the injury, the temperature may be sub- normal due to associated shock. Later, especially in cases in which there is severe cerebral damage, the temperature is increased, even a hyperthermia may be present, which always indicates extensive damage and probably the presence of blood in the ventricular system. The blood pressure is markedly lowered dur- ing the stage of shock, in which instance, however, the cerebral damage is not responsible for the hypo- tension. In those cases in which there is rapidly in- creasing intracranial tension, such as that associated with a middle meningeal hemorrhage, there is a pro- gressive rise in blood pressure as first suggested by Kocher (30). This is due to medullary edema and is associated with vasoconstriction of the peripheral vessels. The blood pressure readings, whereas of val- ue in the cases of rapidly increasing intracranial ten- sion, such as seen with hemorrhage, are of little val- ue in the less severe cases of cerebral injury. Hol- brook (33) states that there are many cases in which there is a markedly increased intracranial tension, but in which there is no significant blood pressure change. Gage (34) has shown that blood pressure changes occur relatively later than increases in intra- cranial tension. Fay (31) is of the opinion that the determination of the diastolic blood pressures is of great importance in the diagnosis and prognosis of acute head injuries. The diastolic pressure repre- sents the resistance offered the circulating blood and without sufficient tension (diastolic), there is rapid loss of oxygen so that the blood reaching the capillary bed contains very little of it. As Landis (32) has shown, anoxemia increases the permeability of the vessels with the resulting edema. He believes that in this way a vicious circle is set up and that the diastolic blood pressure must be kept above 40 mm. of mercury. Probably one of the greatest diagnostic and therapeutic aids in acute head injuries is the determination of the cerebrospinal fluid pressure by means of a manometer. Jackson (35), in 1922, re- ported the results in 100 cases of acute craniocerebral injuries in which spinal fluid determinations were made and in which spinal taps were used therapeutic- ally. The cerebrospinal fluid pressure was above 30 mm. of mercury in 14 per cent of the cases, the high- est reading being 60 mm. In 34 per cent the pres- sure was between 20 mm. and 30 mm., and in 44 per cent the pressure varied between 10 mm. and 12 mm. of mercury. Spinal puncture was performed in 414 of McCreary and Berry’s (36) 520 cases of cranial frac- ture. The spinal fluid pressure was increased in 209, normal in 185, decreased in 12, and not noted in 6 of the cases. Munro (37) showed that in cases with fatal head injuries the average intracranial pressure was nearly two and a half times higher than in the non- fatal cases. In 39.9 per cent of the 148 cases in which lumbar puncture was done in McClure and Craw- ford’s (4) series, the spinal fluid was bloody, whereas in 60.1 per cent it was clear. In 83.3 per cent of the cases in which death occurred the spinal fluid was bloody. In 57 of Munro’s (37) series the spinal fluid contained blood, whereas it was clear in 26. In Ste- wart’s (6) series lumbar puncture was performed in 165 cases; bloody fluid was obtained in 90.5 and clear fluid in 10.4. In 414 cases in which lumbar puncture was done in McCleary and Berry’s (36) series the fluid was clear in 13, contained blood in 398, and contained
pus in 3. Lumbar punctures are of value therapeut- ically in that the cerebrospinal fluid pressure can be decreased by the removal of the excessive amount of cerebrospinal fluid and also blood within the sub- arachnoid space can be evacuated. Bagley (26) show- ed that the subarachnoid injection of blood in adult dogs produced cerebral irritation, whereas in puppies it caused hydrocephalus. Fay (28) described a type of cerebral atrophy caused by collections of fluid in the subarachnoid space which is a sequel to sub- arachnoid hemorrhage. In contrast to these authors, there are a number who believe that lumbar puncture is dangerous. McClure and Crawford (14) believe that it should be done only in selected cases and the cere- brospinal fluid should be withdrawn slowly and care- fully. Henschen (14), Besley (38), Sachs (39), and Dandy (40) are opposed to lumbar puncture in head injuries, because they believe the procedure is danger- ous.
Treatment. The treatment of head injuries in recent years has consisted largely of conservatism. Fifteen to twenty years ago many cases of head injury were operated upon, the incidence of opera- tion varying from 20 to 30 per cent (Sharp (41), Wilensky (42), Heuer (43), Naffziger (44)). In recent years the incidence of operation has definitely fallen. McClure and Crawford (14) in their series of 441 cases reported in 1928 operated upon only 4.3 per cent of the cases, and Fay (31) (1930) operated upon only 4.1 per cent. In the Charity Hospital series which we (1) studied, very few operations were performed and the results obtained in this group demonstrated the value of conservative treatment. In the decade from 1910 to 1919, only 5.2 per cent of the cases were op- erated upon, the incidence of operation decreased in the next decade to 1.6 per cent, and in the two years 1930-1931, the incidence of operation was 0.5 per cent. In the entire series of 1099 cases only 31 op- erations were done, an incidence of 2.8 per cent. The value of this ultraconservative treatment is shown by the results obtained in our series. In the entire group of 1099 cases there were only 92 deaths, 8.4 per cent. If one excludes those cases dying within the first twenty-four hours in which probably relatively lit- tle could be done, because of the extensive injury, there were only 43 deaths (a mortality rate of 3.9 per cent). The mortality rate in the operative cases was 25.8 per cent, whereas that in the non-operative cases was 7.8 per cent.
Patients with craniocerebral injury and in shock should be treated first for shock. The patient should be put to bed immediately, external heat applied, and hot fluid administered. The intravenous administra- tion of hypertonic dextrose solution is valuable, be- cause not only does it combat shock by filling the vascular tree with fluid, but also tends to prevent and combat the cerebral edema. Fifty cc. of 50 per cent dextrose solution are given intravenously and may be repeated in six to eight hours. Fay (31) warns against the use of adrenalin and caffeine in the treat-
",r ■ ■ ""
R. W. HALL, M.D.
215-216 Standard Life Bldg.
Jackson, Miss.
Specialty: Dermatology, X-Ray and Radium Laboratory
V
24
THE MISSISSIPPI DOCTOR
June, 1935
ment of those cases with shock, because frequently, although there is temporary improvement in the pa- tient’s condition, later there may be a depression of the circulatory and respiratory system. While the patient is still in shock he should not be subjected to an extensive physical examination because of the danger of increasing the shock. As soon, however, as recovery from the shock occurs, a complete, especial- ly a neurological, examination should be made, especial care being paid to the cranial nerves, pupillary re- flexes, evidences of discharge of blood and spinal fluid from the ears, nose, and mouth, and evidences of weakness or paralysis. A lumbar puncture with the determination of the cerebrospinal manometric pres- sure should be done as soon as the patient recovers from shock. In all cases of severe craniocerebral in- jury a pressure above 10 mm. of mercury is abnormal and enough fluid should be removed cautiously to de- crease the pressure above 10 mm. of mercury by one- half; i.e., if the cerebrospinal fluid pressure is 20 mm. of mercury, enough fluid should be withdrawn to re- duce the pressure to 15 mm. of mercury. Roentgeno- grams should be made because of their medico-legal value and also because they may show the presence of a depressed fracture. In cases in which there is a discharge of cerebrospinal fluid or blood from the ears, the external auditory meatus should be lightly plugged with sterile cotton saturated with alcohol. No attempt should be made to irrigate the auditory canal, because, as emphasized by Weaver (45) and Davis (46), there is danger of introducing the organisms into the meninges. Compound fracture should be treated by mechanical sterilization (debridement) as soon as the patient recovers from shock. The con- taminated skin edges and brain tissue are removed by excision and suction, respectively, as suggested by Cushing (29) during the World War. Debridement of the scalp, as suggested by Weaver (45), is of ut- most importance in head injuries, because infections of the scalp are potential brain abscesses. This is particularly true if there is a compound fracture. Morphine should not be used because it masks the patient’s symptoms by depressing the respiratory center and producing somnolence. Another distinct disadvantage of morphine is that it increases the cerebrospinal fluid pressure. The subcutaneous ad- ministration of caffeine, because it is known to de- crease the cerebrospinal fluid pressure, is of value as are other diuretics, such as diuretin. Probably both caffeine and diuretin act because of the diuresis which they produce.
Quincke (47), in 1905, suggested the use of re- peated spinal taps in order to reduce the increased in- tracranial tension associated with acute craniocere- bral injuries. Jackson (34) and Munro (37) have been recent champions of therapeutic lumbar drainage in cases of head injuries. Jackson (34), in 1922, reported 100 cases of acute craniocerebral injuries which were treated by repeated lumbar punctures, performed at intervals of from six to twenty-four hours. Fay (31) is of the opinion that lumbar punctures should be performed as often as a rise in pulse pressure and respiratory changes may indicate. Spinal tap is of value in acute head injuries not only because it per- mits a decrease in the cerebrospinal fluid pressure by withdrawal of excessive amounts, but also because blood in the cerebrospinal fluid may be removed. As
mentioned above, blood if allowed to remain in the subarachnoid space results in cerebral atrophy and occasional internal hydrocephalus. In cases with blood in the cerebrospinal fluid, relatively small amount of fluid should be removed in the first three to four days after injury in order not to rapidly de- crease the intracranial tension, which might aggra- vate the hemorrhage. Dandy (40) warns against lum- bar puncture at any time, because of the danger of increasing hemorrhage in cases of cerebral bleeding. Fay (31) believes that repeated lumbar punctures are necessary for a period of ten days when blood is pres- ent in the spinal fluid, because it takes this time be- fore all the red cells are hemolyzed.
The intravenous injections of hypertonic solu- tions are of great value in decreasing the intracranial tensions. In 1919 Weed and McKibben (48) demon- strated that cerebrospinal fluid pressure and brain bulk could be influenced by the intravenous admin- istrations of hypertonic and hypotonic solutions. Whereas the original solutions employed were hyper- tonic sodium chloride solutions, at the present time one is agreed that sodium chloride should not be used because frequently a subsequent edema developed which is more marked than the original. This is due to the fact that the injected sodium chloride Decomes fixed in the tissues, resulting in subsequent -retention of fluid. The intravenous administration of 50 per cent dextrose, because of its hypertonicity, is valuable in decreasing cerebral edema and in contrast to hy- pertonic sodium chloride solutions subsequent edema is not apt to occur because the dextrose is rapidly excreted in the urine and produces a diuresis. A sec- ondary cerebral edema is less apt to occur than if sodium chloride solutions are used. Fifty to 100 c c. of 50 per cent dextrose may be given every six to eight hours. Fay (49), in 1923, advocated the use of magnesium sulphate by rectum and stated that the effect became pronounced within an hour. Magnesium sulphate administered either by mouth or by rectum is a valuable agent in dehydrating a patient with cere- bral edema. It should not be used until the patient has completely recovered from shock because the loss of fluid is poorly tolerated by a patient in shock. One to three ounces of 50 per cent magnesium sulphate solution may be given by rectum without injury to the patient. Fay (49) found that magnesium sul- phate was preferable to sodium chloride because the latter is dialyzable and an increased chloride content of the blood leads to a secondary tissue retention with a rapid return of symptoms after its administration. Magnesium sulphate, however, being non-dialyzable produces a rapid dehydration of the blood plasma by excretion of fluid into the intestinal lumen. Fay (49) found experimentally that magnesium sulphate was twice as efficient as a dehydrating agent in the intestine as the sodium chloride.
Operative treatment is seldom indicated in acute craniocerebral injuries. As mentioned above in the paper, the incidence of operations has definitely de-
-
DRS. O. S. McCOWN — O. S. McCOWN, JR.
GYNECOLOGY— UROLOGY— SURGERY 899 Madison Memphis, Tennessee
* /
June, 1935
THE MISSISSIPPI DOCTOR
25
creased. It is now quite generally accepted that de- compression accomplishes little and is seldom neces- sary in cases of increased intracranial tension. The principal indications for operations are scalp wounds and compound fractures in which debridement should be done, large extradural hemorrhage in which op- eration permits the evacuation of the clot and the control of the hemorrhage, and infrequently the ele- vation of a depressed fracture. Depressed fracture is of significance only when there is actual compression of the brain substance and should not be done until the patient has recovered from the original shock.
Prognosis. The prognosis in acute craniocerebral injuries is bad. Munro (37) collected 2,908 cases from the literature with a mortality rate of 37.8 per cent. In the Boston City Hospital there is a mortality rate of 19.6 per cent in the cases of head injuries. In Fay’s (31) series of 48 cases the mortality rate of those patients who survived the sixth hour after admission was 10.4 per cent, whereas in the entire group the mortality rate was 20.8 per cent. The value of con- servative therapy is indicated in our own series in which a total mortality rate of 8.4 per cent was ob- tained and if those cases which died in the first twen- ty-four hours are excluded, the mortality rate was 3.9 per cent.
SUMMARY AND CONCLUSIONS
1. Head injuries are becoming more frequent and more severe.
2. The most frequent causes of head injuries are falls and blows on the head (37.9 per cent and 28 per cent, respectively).
3. Automobile accidents are relatively two and one-half times as frequent causes of head injuries in 1930-1931 as in 1910-1920.
4. The highest incidence of head injuries is in the first decade of life and with each succeeding decade there is a progressive decrease in incidence.
5. Injury to the cerebrum is the important factor in craniocerebral traumas. Cranial fracture is of no significance unless compounded and extensively de- pressed.
6. Cerebral lesions consist of concussion, edema, contusion, laceration, and hemorrhage.
7. History of injury, unconsciousness, and neu- rologic physical examination are of importance diag- nostically. Diagnostic lumbar puncture is best indi- cation of degree of cerebrospinal fluid pressure.
8. Treatment of head injuries should consist of conservatism; i.e., bed rest, repeated spinal taps, and dehydration by intravenous injections of 50 per cent dextrose solutions.
9. Operative procedure is indicated only in scalp wounds, compound fractures, massive hemorrhage, and depressed fractures.
REFERENCES
1. Ochsner, Alton and Hosoi, Kiyoshi: Acute
head injuries: Analysis of 1099 cases (In Press).
2. Ireland. J.: Fracture of the skull in children, Arch. Surg., 24:23, 1932.
3. Wortis, S. B. and Kennedy, F.: Acute head injury: Study of 1,000 cases, Surg., Gynec., and Obst., 53:365, 1932.
4. McClure, R. D. and Crawford, A. S.: Manage- ment of craniocerebral injuries, Arch. Surg., 16:451, 1928.
5. Connors, J. F.: Treatment of fractures of the skull, Tr. Am. Surg. Assn., 45:427, 1927.
6. Stewart, J. W.: Fractures of the skull, J.A.M.A.,
77:2030, 1921.
7. Vance, B. M.: Fractures of die skull, Arch. Surg., 14:1023, 1927.
8. Duret: Arch, de physiol., p. 320, 1874. (Quoted by Tilmann, Arch. f. klin. Chir., 59:239, 1899).
9. Heise, K.: Pathology and therapy of cerebral commotion (concussion of the brain), Monatsch. f. Unfallh., 36:120, 1929.
10. Symonds, C. P.: Cerebral states and head in- juries, Brit. M. J., 2:302, 1928.
11. Tilmann: Arch. f. klin. Chir., 59:239, 1899.
12. Rahm. H.: Mechanics of concussion of the brain, Zentralbl. f. Chir., 47:146, 1920.
13. Miller, G. G.: Cerebral concussion, Arch. Surg., 14:891, 1927.
14. Henschen, C.: Ueber die Ursachen des post- kommotionellen und postkontusionellen Hirkdruckes, insbesondere uber Hirnodem, Hirnschwellung und Hirnverkleinerung nach Schadelverletzungen, Zen- tralbl. f. Chir., 54:3169, 1927.
15. Knauer, A. and Enderlen, E.: Die pathologische Physiologie der Hirnersehutterung nebst Bemerkun- gen uber verwandte Zustande, J. f. Psychol, u. Neurol., 29:1, 1922.
16. Vera-Lopez, R.: Change in pH in cerebral fluid in experimental concussion of brain, Arch. f. klin. Chir., 150:111, 1925.
17. Russel, R.: Discussion on the diagnosis and treatment of acute head injuries, Proc. Roy. Soc. Med. (Section on Neurology and Surgery), 25:751, 1932.
18. Ritter, A. and Strebel, K.: Concussion of the brain and medulla oblongata, Monatsch. f. Unfallh., 35:369,1928.
19. Le Count, E. R. and Apfelbach, C. W.: Patho- logic anatomy of traumatic fractures of the cranial bones and concomitant brain injuries, J.A.M.A., 74:501, 1920.
20. Apfelbach, C. W.: Studies in traumatic frac- tures of the cranial bones, Arch. Surg., 4:434, 1922.
21. Fischer, M. H.: Edema and nephritis, J. Indi- ana M. A., 18:247, 1925.
22. Trotter, W.: Evolution of surgery of head in- juries, Lancet, 1:169, 1930.
23. Blahd, M. E.: Fracture of the skull and its complications, Am. J. Surg., 37:33, 1923.
24. Bagley, C.: Grouping and treatment of acute cerebral traumas, Arch. Surg., 18:1078, 1929.
25. Essick, C. R.: Formation of macrophages by the cells lining the arachnoid cavity in response to the stimulus of particulate matter. Contributions to Embryology, No. 42, Carnegie Institute of Washington, 272:377, 1920.
26. Bagley, C.: Blood in the cerebrospinal fluid: resultant functional and organic alterations in the central nervous system, Arch. Surg., 17:18, 1928.
27. Fay, T. and Winkelman, N. W.: Widespread pressure atrophy of the brain and its probable relation to the function of the pacchionian bodies and the cere- brospinal circulation, Am. J. Psychiat., 9:667, 1930.
28. Fay, T.: Generalized pressure atrophy of brain secondary to traumatic and pathologic involvement of pacchionian bodies, J. A. M. A., 94:245, 1930.
29. Cushing, H.: Notes on penetrating wounds of the brain, Brit. M. J., 1:221, 1928.
30. Kocher, T.: Hirnersehutterung, Hirndruck und chirurgische Eingriffe bei Hirnkrangungen, Nath- nagels System, Vol. 9, 1901.
31. Fay, T.: Head injuries: The results obtained with dehydration in 48 consecutive cases, J. Iowa M. Soc., 20:447, 1930.
32. Landis, E. M.: Micro-injection studies of capil- lary permeability of the capillary wall to fluid and to the plasma proteins, Am. J. Physiol., 83:528, 1929.
33. Holbrook, F. R.: The diagnosis and manage-
EUGENE ROSAMOND Pediatric Diagnosis Rosamond Clinic for Children Madison Avenue at Somerville Memphis, Tenn.
26
THE MISSISSIPPI DOCTOR
June, 1935
ment of head injuries, J. A. M. A., 83:489, 1924.
34. Gage, I. M.: Acute traumatic craniocerebral injuries, Am. J. Surg., 6:64, 1929.
35. Jackson, H.: The management of acute cran- ial injuries by the early exact determination of intra- cranial pressure and its relief by lumbar puncture, Surg., Gynec., and Obst., 34:494, 1922.
36. McCreery, J. A. and Berry, F. B.: Study of 520 cases of cranial fracture, Ann. Surg., 88:890, 1928.
37. Munro, D.: Therapeutic value of lumbar punc- ture in the treatment of cranial and intracranial injury, Boston M. and S. J., 193:1187, 1925.
38. Besley, F. A.: A contribution to the subject of skull fractures, J. A. M. A., 66:245, 1916.
39. Cushing, H.: Notes on penetrating wounds of the brain, Brit. M. J., 1:221, 1918.
40. Dandy, W.: Diagnosis and treatment of head injuries, J. A. M. A., 101:772, 1933.
41. Sharp, W.: Observations in the diagnosis and
treatment of brain injuries in adults, J. A. M. A., 66: 1536, 1916. „ „ ...
42. Wilensky, A. O.: Fracture of the skull with special reference to its neurological manifestations, Ann. Surg., 70:404, 1919.
43. Heuer, G. J.: Fracture of the skull, J. A. M. A., 82:1467, 1924.
44. Naffziger, H. C.: Head injuries: Indications for surgical treatments, S. Clin. North America, 3:699, 1923.
45. Weaver, J. C.: The anthropology of the negro: Its bearing on mortality in head injuries; review of 600 cases, Surg., Gynec., and Obst., 50:499, 1930.
46. Davis, E. D. D.: Injuries of the ear arising from fractures of the skull, Brit. M. J., 2:741, 1928.
47. Quincke, E.: Diagnosis and therapeutics of lumbar puncture, Deutsche med. Wchnschr., 31:1825, 1905.
48. Weed, L. H. and McKibben, P. S.: Pressure changes in cerebrospinal fluid following intravenous injection of solutions of varicose concentrauon, Am. J. Physiol., 48:512, 1919.
49. Fay, T.: The administration of hypertonic salt solutions for the relief of intracranial pressure, J. A. M. A., 80:1445, 1923.
Fraternal Recipe
A pinch or two of pleasantness,
A brimming cup of smile;
Another pinch of thoughtfulness —
Keep stirring all the while.
The spice of love to mingle through The mixture as you go;
And laughter of a singing heart To give the wonder glow.
A little dash of gratitude,
Another of good will;
A measure of the fortitude That overcomes the ill.
In loveliness it creams.
A spoonful, stirring all the time,
Of romance and of dreams —
Then watch it as to some old rhyme
What are you making this strange way You ask, and I reply;
A perfect life, a perfect day,
A sort of magic pie.
All spiced with tenderness, you see,
And sweetened with desire —
And some for you and some for me To taste and never tire.
— Baltimore Sun.
Ocular Headaches*
EDLEY H. JONES, M.D., F.A.C.S. Vicksburg, Miss.
This subject was chosen for presentation to this group for the reason that headache is the symptom that most frequently leads a patient to seek medical advice and that eye strain and other eye conditions rank second only to constipation as the most fre- quent cause of headaches.
Ocular headaches must be differentiated from pseudo-ocular headaches from sinusitis, migraine, syphilis, etc. True ocular headaches are readily di- visible in four classes, due to:
1. Disease.
2. Errors of Accommodation (ametropia, astig- matism, etc.).
3. Muscular anomalies.
4. Asthenopia (weak eyes).
I. HEADACHES DUE TO DISEASE OF THE EYE
Headaches due to ocular disease are readily rec- ognized as a symptom of the obvious pathology pres- ent. They accompany severe attacks of conjuncti- vitis and the majority of cases of keratitis, iritis and pan-ophthalmitis. These headaches are usually dull, occasionally throbbing, but never lancinating: they may be constant or intermittent; they are usually located in the eye and the frontal and temporal re- gions.
Headaches are present in all types of glaucoma except the chronic non-congestive type. In early simple glaucoma they are intermittent with irregular onset ana usually dull; the pain is located in the eye. As the disease progresses the attacks become more frequent and more severe with periods of very severe lancinating pains shooting thru the eye. In acute glaucoma the pains are frequently terrific.
These headaches are relieved when the under- lying pathology is corrected.
Another type of headache occasionally encounter- ed is that due to photophthalmia, resulting from over- exposure to light, ultra-violet or infra-red rays. In the moving picture industry this condition is known as “Klieg’s eyes,” taking its name from the Klieg mer- cury lights. The cases we see are usually due to pa- tients using electric or acetylene welding torches with- out goggles, or with faulty goggles. I have had one case due to looking steadfastly at a partial eclipse of the sun and several due to the flash of light accom- panying the blowing out of electric fuses on a switch- board. This type is not always easily recognized. There may be no diagnostic signs present and the patient may consider exposure to light unimportant and
^Presented before the Issaquena-Sharkey and Warren Counties Medical Society, Vicksburg, Miss., April 9, 1935.
HENRY G. HILL, M.D.
Clinic, 847 Madison Avenue Memphis, Tennessee Practice Limited, Braces
Diseases and Injuries
Bones and Joints .
Cripples and Deformities Appliances
and Orthopedic
June, 1935
THE MISSISSIPPI DOCTOR
27
forget to mention it. A careful history will make the diagnosis. This headache is relieved when the re- action to the light rays subside. Butyn and opiates may be used palliatively.
II. HEADCHES DUE TO ERRORS OF ACCOMODATION
Headaches due to. eyestrain are comparatively common and usually easily recognized. The head- aches are usually located in the frontal region but occasionally in the occipital region. They are usually dull, occasionally throbbing but never lancinating and become more severe with continued use of the eyes. There is usually a definite history of their onset fol- lowing use of the eyes — particularly after knitting, sewing, reading, clerical work, moving pictures and long auto drives, as a rule the onset is during the aft- ernoon or evening. After a night’s rest the eyes feel good in the morning but with continued use, they tire and headache follows. These headaches are never constant, except in advanced cases. If a patient re- tires without a headache but arises with one, it can- not be due to eyestrain; this is obvious but of differ- ential diagnostic importance. Of course, it is possible for a patient to have headaches from more than one cause; such a patient may be suffering with eyestrain and also with some other condition causing morning headaches. Another point is that headaches due to eyestrain are not usually relieved by aspirin. Relief follows rest of the eyes.
In most of these cases, the vision is impaired, but not always. It is a point of importance that a pa- tient may be suffering with headaches due to eye- strain and still have normal vision for distance. Tak- ing the near vision reveals a loss of accommodation, altho very occasionally this will also be normal. These cases are usually suffering with astigmatism. There is frequently an accompanying irritation of the eyes and the patient may complain of sensitivity to glare.
Examination will reveal whether the patient’s refractive error is far-sighted (hyperopic), near-sight- ed (myopic), astigmatic, or a combination of these conditions. Relief is obtained by the use of proper glasses.
III. HEADACHES DUE TO MUSCULAR ANOMALIES OR DEFECTS
This type of ocular headache is so frequently over- looked or disregarded that I wish to especially em- phasize it. You are all familiar with divergent and convergent strabismus. These cases are muscular anomalies but do not cause headaches because the visual image of one eye is suppressed by the brain. When a patient has such a muscular imbalance but of lesser degree, binocular vision is maintained by the fusion centre, but the strain on the muscles is suf- ficient to cause severe headaches.
This imbalance without double vision (diplopia) is called a phoria. Phorias may be vertical (hyper- phoria) or horizontal (esophoria and exophoria). The vertical phorias are the more important because the symptoms are so severe and because they are usual- ly relieved only by including a prism in the correction.
Despite the fact that these cases are of common occurrence and easily diagnosed, they are frequently overlooked. Optometrists do not usually include mus- cular tests in their examinations and inasmuch as
they are not supposed to treat pathology, this is con- sidered correct practice. This means that any case of phoria who consults an optometrist for glasses will not have the benefit of proper ocular examination and will fail to obtain eye comfort. On the other hand, every oculist should include muscle tests with every refraction, tho this appears to be frequently over- looked.
In order to determine the frequency of these conditions, I reviewed my last 500 (consecutive) re- fractions. I found 21 (4.2%) cases of vertical phorias that needed prisms included in their correction and 26 (5.2%) cases of lateral phorias. The surprising thing is that of these 47 cases, only 3 gave a history that would suggest any muscular anomaly, yet 21 had to have special glasses and 6 others had to have special types of exercises in order to obtain relief — a total of 5.4% patients who would not have received relief by simply “being fitted with glasses.”
The phorias are due to convergence excess, con- vergence insufficiency, divergence excess, divergence insufficienty, or combinations of these conditions. They may be influenced by toxin or foci of infection. The onset is usually gradual but occasionally quite sudden.
Of course there are other types of muscular an- omalies but it is the phorias that usually cause head- aches. These headaches are similar in onset, loca- tion, character and frequency to those caused by er- rors of accommodation (ametropia, astigmatism, etc.) but may have normal vision. They are at times ac- companied by. double vision (diplopia) or vertigo.
A diagnostic point in considering such cases is that by closing one eye for a sufficiently long period, the headache is relieved. One of my cases, a young lady of 20, found that the only way she could enjoy a moving picture show was to sit with one eye closed. Another suggestive point is that, on inquiry, a patient may recall that when the vision blurs while reading, at the exact moment of blurring the print appears to “double.”
There are several tests but the Maddox rod is most commonly used. The examination can be quick- ly made. It is also of importance to determine the duction power in horizontal phorias; this can be quick- ly done with the Keystone Stereoscope, the Wootring Rotoscope and other apparatuses.
As inferred above, the vertcial phorias are re- lieved by including a prism of sufficient strength in the correction. The horizontal phorias can usually be benefitted by proper muscular exercises, prism glasses, stereoscopic training sets, Orthopters, the Wootring Rotoscope and many other appliances that may be used.
IV. HEADACHES DUE TO ASTHENOPIA
This paper would not be complete without men- tioning asthenopia or “weak eyes.” This condition may be due either to errors of accommodation or to muscular anomalies. It may also be due to ncuras-
DRS. HENDERSON & HALL
Dermatology & Syphilology Radium and X-Ray as applied in this field
1403-1407 Exchange Bldg.
Memphis, Tenn.
28
THE MISSISSIPPI DOCTOR
June, 1935
thenia, hysteria, improper illumination or to foci of infection. When due to errors of accommodation or muscular imbalance, it may be relieved by proper glasses or exercises but when due to other causes, glasses are usually unsatisfactory and the patient is relieved only when the causative factors are corrected or eliminated.
Herewith I present three cases of muscular anom- alies that may be interesting.
CASE REPORTS
Case 1. M. G. M., 16 years, white school girl of Florence, Miss., came in Sept. 19, 1934, complaining of constant headache.unrelieved by aspirin, BC powd- ers or purgatives, and of vision blurring after eyes had been used a very few minutes. At the age of 3 the eyes “crossed” and her mother took her to an “Eye Doctor” (really an optometrist) in Jackson. Altho her condition suggested pathology, he did not refer the case to an Oculist, but fitted her with glasses. The convergent strabismus was corrected and from time to time they returned to the same optometrist who re-examined her and fitted her. Three months before I saw her, she began suffering with headaches, blurred vision and irritated eyes. They returned to him but the glasses he prescribed failed to give her comfort. Examination revealed, beside the error of refraction, a 4 degree right hyperphoria. Including the proper prism in her new correction gave immediate relief. A letter received three months later stated she was getting along nicely.
Case 2. Mrs. E. W. P., 60 year old white housewife was out riding Nov. 4, 1934 and suddenly noted that when they passed another car, it appeared double. Examination revealed 14 degree exophoria for dis- tance and 1 degree for near. This is unusual in that the near finding was within normal limits, while the distance finding was markedly abnormal. She was given muscular exercises, training with a stereoscopic set and later prism glasses for exercise only. On Feb. 14, 1935 examination revealed normal muscular bal- ance. She was refracted, her lenses changed and has gotten along splendidly, tho she has continued to take muscular exercises at less frequent intervals.
Case 3. P. M., 6 year old girl came in Nov. 3, 1934. Mother had noted that if she looked at magazine pictures or cut out paper dolls when tired, the eyes crossed. Examination revealed marked esophoria. She was refracted under atropine and a full correc- tion given. This controlled the condition until three months ago when the eyes would occasionally “cross” even while wearing the glasses. Since that time she has been given treatments with a stereoscopic train- ing set and now has a hand stereoscope and cards for home exercise. Shortly I expect to give her rotary muscular exercises. She is getting along very nicely at present and I am in hopes of achieving permanent results without resorting to surgery.
Many other cases, some even more interesting, could be presented but these are fairly typical and I do not care to impose on your time.
CONCLUSION
In conclusion, I would like to remind you that headaches may be caused by errors of accommodation, muscular anomalies or weak eyes, even when the patient has normal vision. A careful history will in- dicate ocular examination. Proper ocular examina- tion will include tests for muscular anomalies.
Appreciated Letters
Dr. W. H. Anderson, Editor,
Mississippi Doctor,
Dear Doctor Anderson:
I wish to take this occasion to congratulate you on receiving the contract with the Mississippi State Medical Association for publishing their proceedings beginning in 1936. I hope you all of success in this new undertaking.
From what I can gather, it appears that the doctors of Mississippi have no particular objections to our Journal, but that they were in favor of patron- izing their home Journal. The praise and compli- mentary remarks that we received from the Mississippi physicians about our Journal leads me to the opinion that a great many of them will continue to subscribe to our Journal. We hope in this regard we may have your cooperation.
Again wishing you all a success, and with very best regards, I am,
Yours very fraternally,
P. T. TALBOT, M.D.,
General-Manager.
May 17, 1935.
Dr. W. H. Anderson,
Booneville, Mississippi,
My dear Doctor;
It is indeed gratifying to me, to know that the Mississippi Doctor, has been made the official Journal of Mississippi Medicine.
You already know that I have advocated this forward step, for several years. I believe it will do much to place Mississippi Medicine, where it right- fully belongs.
Mississippi, is probably the leading state in Com- munity Hospital Service. These hospitals are ade- quately meeting a need in our social order, and with a Journal, sponsoring these institutions in an official capacity, they should do much to raise the standard of medical practice in the state, by serving as centers of medical education in the communities in which they operate.
If these hospitals could be correlated, and co- ordinated, and could become affiliated with a larger teaching hospital, Mississippi Medicine, would ad- vance to the front ranks, in things medical.
Let me congratulate you, in seeing a dream come true.
Sincerely yours,
J. A. RAYBURN, M.D.
May 24, 1935.
Dr. Wm. Henry Anderson,
Booneville, Miss.
My dear Dr. Anderson:
While I am greatly disappointed of course that the Mississippi Medical Association did not continue with their contract with the New Orleans Medical and Surgical Journal, nevertheless I understand fully why they did not do so, and as long as they desired to give up this contract I cannot think of any better person to have than you. I congratulate you most heartily and wish you all success in your new undertaking. Very cordially,
May 17, 1935. J. H. MUSSER, M.D.
June, 1935
THE MISSISSIPPI DOCTOR
29
THE WALLACE SANITARIUM
MEMPHIS, TENN
HUGH W. PRIDDY, M. D.
WALTER R. WALLACE, M. D
For the treatment of Drug Addiction, Alcoholism, Mental and Nervous Diseases.
Fully equipped for the care of patients admitted Sixteen acres beautiful grounds.
Located in the eastern suburbs of the city at South- ern Ave., and Cherry Road.
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30
THE MISSISSIPPI DOCTOR
June, 1935
Sterility*
W. H. BRANDON, A.B., M.D., F.A.C.S. Clarksdale, Miss.
Sterility is one of the most important problems facing the gynecologist today. The study of sterility in the female requires a more thorough understanding of the physiology and pathology of the generative and associated organs than any other gynecological con- dition. However, the study of infertility and sterility has undergone great changes in the last decade. The tendency of the medical profession to attribute con- jugal sterility solely to the abnormal conditions found in the female generative organs and to ignore the potentialities of the male, is rapidly disappearing. Due to the notable work of such men as Huhner, Meaker, Anspach, Rubin, Reynolds, and Macomber, and many others, the problem is approached by studying the couple rather than the individual.
Involuntary sterility is on the increase in all civil- ized countries. Reynolds and Macomber place the figure in this country at approximately ten percent. Many place the figures much higher. A condition so prevalent deserves our earnest consideration. A bar- ren marriage is one of nature’s tragedies; seldom is a childless union an entirely happy one. The longing for a child is especially felt by the woman. The ma- ternal instinct in the human species is one of the most powerful of biological urges, the lack of an out- let of which not only portends monotony and longing, but a tragedy words cannot depict.
The following requisites of fertility as outlined by Mazer must, of course, be present: (1) Normal spermatazoa must be produced. (2) The spermatazoa must be undamaged after passing the male tract. (3) Insemination of cervix at ejaculation must take place, except in rare instances. (4) The endocervical secretions must be favorable to the life and activity of the spermatazoa. (5) The tubes must allow the descent of the ovum and ascent of the spermatazoa. (6) The ovaries must produce normal ova. The en- dometrium must be in a receptive condition — normal premenstrual endometrium.
A greatly increased knowledge of the causative factors underlying human infertility has pointed the way to a more adequate diagnostic study and more efficient treatment. Such procedures as dilation and curettage, the use of the intra-uterine stem, ampu- tation of the cervix, plastic operations on the cervix, etc., have been replaced by more logical and simple investigative tests, such as Rubins, Huhners, and by conservative surgery where indicated. Meaker’s plan of investigation is generally followed, with some mod- ifications, as follows:
Male Female History
(a) Past (venereal)
(b) Present
(c) Sexual
II. Female
Physical Examination
*Read before Memphis Obstetrical and Gynecolog- ical Society, Memphis, Tenn., Sept. 21, 1934.
(a) General
(b) Local Gynecological
1. Vagina
(a) Trichomonas vaginalis
2. Cervix
(a) Normal (mucous clear)
(1) Normal viscosity
(2) Tenacious
(b) Lacerated (1) Ectopian
(c) Endocervicitis (1) With erosion
| (2) With mucopurulent discharge
3. Uterus
4. Adnexa
(c) Laboratory
1. Complete blood count; Wassermann test; Kahn test.
2. Sedimentation; Urinalysis; blood pres- sure
3. Cervical smears
(a) Fresh hanging-drop
(b) Stained
III. Female
Postcoital Examination (Huhner test)
(a) Vaginal pool (l-2y2 hours after coitus)
1. Amount (1) Number
2. Consistency (2) Morphology
3. Spermatazoa (3) Motility
(b) Aspirated Cervical Mucus
1. Spermatazoa (1) Number
2. Pus cells (2) Morphology
3. Tenacity of Mucus (3) Motility
IV. Male
Physical Examination
(a) General
(b) Urologic
(c) Condom or ejaculate
V. Female
Tubal Patency (Rubin test)
(a) Carbon dioxide gas (or air)
1. Antispasmodic drugs
2. Repeated patency tests
(b) Iodized oil instillation
1. Fluoroscopic examination
2. Roentgenographic examination
3. Roentgenographic examination with combined oil and pneumoperitoneum.
VI. Female
Endocrine
(a) Basal metabolic rate
(b) Frank’s test for female sex hormone in blood
VII. Male
Endocrine
(a) Basal Metabolic rate.
These routine procedures, outlined above, are of course, interrupted at any point where the exami-
■ '
MRS. S. A. CARNS Rt. 1 Biloxi
HOME OF JUGTOWN POTTERY AND HAND WEAVING
On the beach between Gulfport and Biloxi
June, 1935
THE MISSISSIPPI DOCTOR
31
nation reveals a definite cause for sterility. After removal of the cause, further tests may be made. Modern research has illuminated particularly four aspects of the causation of sterility: (1) the true sig- nificance of local genital abnormalities; (2) The in- fluence of constitutional depressions; (3) the multi- ple incidence of aetiological factors; (4) the division of responsibility between male and female.
LOCAL GENITAL ABNORMALITIES
Major obstacles to fertility, in the male, are those conditions which interfere with spermatogenesis, such as atrophy or hypo-plasia of the testicles and inflam- matory and other conditions which produce an epid- idymal blockade. Chronic prostato-vesiculitis may exert a very depressing effect on fertility, probably not by the direct action of hostile secretions upon sper- matozoa in the vesicles and prostate, but rather by an interference with spermatogenesis in the testicles by blood borne toxins from the chronic focal infection. Other genital lesions appear to be of little importance with reference to sperm production. Broadly speak- ing, we may then say that local genital factors play a very small part in the male in the causation of steril- ity. Necro-spermia and oligo-spermia are far more frequently the result of constitutional depression than of lesions in male genital organs.
Various female genital factors are noted in cases of sterility. Many of these deviations from the strict genital normality affect fertility little, if at all. Fa- miliar examples of conditions which in the past have been considered to effect sterility but which are known now to have but occasional importance in their affect on sterility are uterine displacements, fibromyo- mata, and acidity of the secretions. We find four causative factors occurring with marked frequency, namely (1) tubal blockade, (2) hostility of the en- docervical mucus, (3) developmental arrest, (4) me- chanical interference with ovulation.
Tubal occlusions may be partial or complete. Partial obstructions may be due to strictures, kinks, adhesions, plugs, or spasm. In any case, their pres- ence is of importance as a cause of sterility. There may be a partial agglutination of the folds of the tubal mucosa or adhesions and angulations with so little thickening as not to be palpable. Uterotubal insuf- flation with the use of the kymograph, as popularized by Rubin or hysterosalpingography, with the use of a radio-opaque oil, such as Lipiodol, or Diodrast are the methods that we prefer to determine thd patency of the tubes. Being cognizant of several reports in the literature of various minor or major accidents following the injection of Lipiodol, we began the use of Diodrast. We have found that this media gives us excellent results without the danger of Lipiodol.
If Diodrast penetrates the uterine mucosa or enters a permeable uterine or ovarian vessel, no harm will be done. Where the Rubin test is unsatisfactory or inconclusive, or where a permanent record is desired, we use radio-opaque oil and x-ray. In fact, we pre- fer this method in a great many types of cases, such as locating the level of the occlusion, or determining whether the occlusion is unilateral or bilateral. An- other advantage following the use of radio-opaque oil for salpingography is the not infrequent finding of patent tubes following one or more injections of radio-opaque oil. Jarcho reports a case of bilateral
tubal occlusion which ten months later showed a normal picture. Pregnancy, following the opening of the tubes by insufflation or oil injection, is a not in- frequent occurrence.
Excessive viscosity, with the formation of an in- spissated plug, frequently may entangle and kill the spermatazoa.
Some degree of female genital hypo-plasia may be seen in a large number of cases. The real significance of this condition lies, not in the genital hypo-plasia, but in the concomitant failure to develop of the ovaries and their consequent defective ovulation.
Amenorrheic and irregularly menstruating wo- men are invariably of low fertility, since infrequent menstruation implies an associated infrequency of ovulation with a relative reduction in the changes of fertilization. Pregnancy can and does occur, how- ever, in the course of amenorrhoea and menstrual disorders are sometimes permanently cured by chance pregnancies. Regularity of the menstrual cycle can not be taken as conclusive evidence of normal ovaries and extragenital glands. Regularly menstruating sterile women, in whom we can find no constitutional or local condition to account for their sterilities and whose mates are known to be fertile, must be classed as cases of endocrine origin, even when they show no definite stigmas of existing endocrinopathies.
A thick tunica albuginea interferes mechanically with ovulation. Prolapse of the ovary and adhesions .around the ovary may prevent the ovum reaching the mouth of the Fallopian tube.
CONSTITUTIONAL DEPRESSIONS Recent experimental work has shown that many types of constitutional disturbances produce an im- pairment of the reproductive capacity and a high in- cidence of certain constitutional abnormalities has been found in many sterile human matings. It has been found that these disturbances produce a de- pression of the vital functions, as shown objectively by laboratory measurements and metabolism determ- inations. Again, such disturbances cause a deficiency, in the male patient, in the quantitative evaluation of the semen in regard to number, morphology, bio- metrics, motility, and endurance of the spermatazoa, and improvement is shown when these deficiencies are corrected. It is also a matter of clinical experience that the treatment of these constitutional faults in one or both partners often results in a cure of steril- ity. These constitutional factors which thus depress fertility are endocrine disorders, chronic intoxications, metabolic faults of extrinsic origin, and conditions of general debility.
The most common endocrine disorder is an un- derfunction of the pituitary gland, with the thyroid gland following close behind. Only a small number of primary ovarian endocrine failures are seen, as is the case of testicular endocrinopathies. Rowe believes that the testicle ceases to function as an endocrine gland after adolescence.
Focal infections, of the chronic intoxications,
r
DR. E. M. HOLDER General Surgery and Gynecology Suite 302 Physicians and Surgeons Building Baptist Hospital Annex - 899 Madison Avenue Telephones: Office 6-2184; Res. 8-1640 Memphis, Term.
32
THE MISSISSIPPI DOCTOR
June, 1935
are easily the most common. Such other causes as colonic stasis, hepatic toxaemia, poisons, as lead, alcohol, etc., and such diseases as malaria and syphilis lead to infertility.
Errors in diet and lack of sufficient exercise to insure proper assimilation are the source of metabolic fault of extrinsic origin. Negative nitrogen balance, with protein intake below the maintenace level, leads to subnormal metabolism, which is a source of im- perfect gameto-genesis. There is no true causative relation between obesity and sterility, although the obese are frequently found in the infertile column.
General debility lowers fertility frequently. Poor hygiene is a frequent factor. The strain of the pre- sent day life, with its excessive demands on the re- serve energy, is particularly seen among the better classes.
MULTIPLE INCIDENCE OR CAUSATIVE FACTORS
In the above conditions conducive to infertility just enumerated, there are more than forty different factors which will affect the fertility of a couple. Frequently one or two such factors will be revealed in the thorough study of a fertile couple, whereas the sterile couple will show from four to eight such con- ditions. It is a well known fact that the human is a poor breeder, as compared with other species. Ab- solute sterility may be caused by only one factor, such as the complete blockade of the genital passages or a complete gametogenetic failure. There are usually, however, more than one such definite cause. The spermatazoa may be produced, but the abnormal heads may be more than 20 percent and the number may be below normal, although the sperm may be actively motile. Thus some pathology in the passages, while not completely blocking the sperm, may cause a state of relative fertility.
A graded scale of relative fertility-sterility is con- ceivable, with the lowest limit one of absolute sterility and the upper limit one of absolute fertility. A fer- tility level lies midway between these Utopian and Stygian conditions, with the fertility or barrenness of the couple depending on how far above or below this level they may chance to be. The number and character of inhibiting factors present determine the position in this scale that any given mating may oc- cupy with respect to their fertility-sterility. A single impediment to fertility may be overcome, but four or five such factors is usually sufficient to depress the fertility of a mating below the threshold of concep- tion. It is of basic importance to appreciate that in the ordinary clinical case, sterility is due, not to some one abnormal condition, but to a summation or totali- ty of several causative factors. Too often, the first discovered abnormality is accepted as the sole cause of the sterility, with a resulting inadequate treatment and unsatisfactory results.
DIVISION OF RESPONSIBILITY BETWEEN SEXES
It is an exceedingly complex problem to allocate the individual responsibility for infertility to one in- dividual. In the majority of the cases, about one third of all demonstrable causative factors may be conceded to the male and two-thirds to the female. But the story is not told here. In many instances, either member of the pair would be able to reproduce if mated with a highly fertile mate. Therefore, it is a virtual impossibility to say absolutely that the fer-
tility level of one individual is such as will or will not allow procreation, unless such an individual is ab- solutely sterile. A considerable degree of relative sterility in one partner may be overcome by high re- lative fertility in the other; or a moderate relative fer- tility may be counteracted by a somewhat more than moderate degree of relative sterility. The usual clin- ical problem is a sterile mating due to the combined action of several causative factors, an aetiological sum total to which both partners in some way con- tribute.
METHODS OF DETERMINING THE DEGREE OF MALE STERILITY
There are two methods generally used, the study of the condom specimen and the search for spermata- zoa in the postcoital cervical secretion. These should be studied jointly, as the condom specimen will show the presence of actively motile sperms, their mor- phology, and biometrics, but will not show the effect of the cervical mucus on the sperm. Kurzrok and Miller found that the normal specimen of semen will dissolve the cervical mucus. However, they found that one sample of cervical mucus might be dissolved, while a sample of cervical mucus from another wo- man might remain unaffected, thus showing that an otherwise normal spermatazoa might not have an universal lytic action, and thus might explain an otherwise unexplainable case of sterility. Where a condom specimen shows an abnormality of the sperm, the repeated finding of dead spermatazoa in the postcoital cervical secretions of a woman who is free of cervical infection, indicates a biochemical incom- patibility between the cervical secretions and sper- matazoa.
Dysfunction of the thyroid gland, as evidenced by clinical signs and basal metabolic disturbances in both male and female, is known to reduce fertility. When a subnormal function is suspected, it is better to take the average of several metabolic determina- tions. In the absence of subnormal findings, but with a clinical evidence of lowered thyroid activity, small doses of thyroid gland, under close supervision, is recommended. This type of organo-therapy has been most successful.
BIBLIOGRAPHY
Rubin, I. C.: Am. J. Obst. & Gynec. Vol. 24, p. 561, 1932.
Campbell, A. M.: Am. J. Obst. & Gynec. Val. 24, p. 542, 1933.
Anspach, B. M.: & Hoffman, J.: Am. J. Obst. & Gynec. Vol. 24, p. 3, July, 1932.
Rubin, I. C.: Am. J. Obst. £r Gynec. Vol. 24, p. 729, November, 1932.
Keen, F. E.: & Payne, F. L.: Am. J. Obst. & Gynec. Vol. 23, p. 857, June, 1932.
Cary, W. H.: Am. J. Obst. & Gynec. Vol. 25, p. 335, March, 1933.
Moench, G. L.: Am. J. Obst. & Gynec. Vol. 25, p. 410, March, 1933.
Sturgis, M. C.: Am. J. Obst. & Gynec. Vol. 24, p.
/ '
HENRY G. RUDNER, M.D.
Clinic — Internal Medicine 1108 Madison Avenue Memphis, Tenn.
June, 1935
THE MISSISSIPPI DOCTOR
33
335, September, 1932.
Reynolds, E. & Macomber, D.: Fertility & Steril- ity in Human Marriages, W. B. Saunders, Co.
Mazer, C. & Goldstein, L.: Clinical Endocrinology of the Female, W. B. Saunders Co.
Mazer, C. & Goldstein, L.: Med. J. & Rec. p. 137, March 1932
Mazer, C. & Goldstein, L.: Radiology V. 20, p. 146, February, 1933.
Mazer, C. & Goldstein, L.: Radiology V. 20, p. 86, February, 1933.
Mazer, C. & Goldstein, L.: Human Biology, V. 4, p. 525, December, 1932.
Mazer, C. & Goldstein, L.: N. O. M. & S. J., V. 85, p. 227, October, 1932.
Mazer, C. & Goldstein, L.: Nutrition Abs. and Rev., V. 2, p. 451, January, 1933.
Mazer, C. & Goldstein, L.: Penn. Med. J., V. 36, p. 414, March, 1933.
Mazer, C. & Goldstein, L.: N. O. M. & A. J., V. 85, p. 817, May, 1933.
Lotka, A.: Proc. Nat. Acad. Sc., V. 14, p. 99, 1928.
Kurzrok, R. & Miller, E. G.: Am. J. Obs. & Gynec., V. 15, p. 56, 1928.
Huhner, M.: N. Y. Med. J., V. 113, p. 678, 1921.
Kilroe, J. C. & Heilman, A. M.: Am. J. Obst. & Gynec. Vol. 25, p. 152, January, 1933.
150 Yazoo Avenue.
Ward Rounds
ISIDORE COHN, M.D., F.A.C.S.* New Orleans, La.
In the operating room the visitor expects to see at times spectacular procedures, unusual operations and technical details.
Many visitors are not concerned with the follow- ing important factors: whether the operation is well planned, based upon adequate pre-operative study, nor does he concern himself with what happens after the operation, particularly with reference to the post- operative treatment and the course of the patient.
The ward rounds before and after operation are largely the measure of the surgeon. They may not, however, give an estimate of the operator. It is the surgeon and his work which concerns us in this pres- entation and we will, without further ado, proceed with an ordinary ward round at Charity Hospital.
The particular ward under consideration is a negro female surgical service. At this time there are in the ward several varieties of diseases of the breast, thyroid disease, tumors of the mandible, two cases of purpura, several varieties of the ever present ap- pendix and masses in the neck.
This bird’s eye view gives one some idea of what is to be gained by more than a routine look in on the ward.
Let us take for example the thyroid cases first for study.
A few years ago thyroid disease in any strata of our southern, more particularly Louisiana popula- tion, was rare. At the present time we are seeing a comparatively large number of thyroids in this service of nineteen “colored beds.” The cases seen belong to almost every type of thyroid disease described.
During the past two years there have been in the service cases of acute suppurative thyroiditis, adoles-
*Professor and Head of the Department of Sur- gery Graduate School of Medicine, Tulane University Associate Senior Surgeon, Touro Infirmary.
cent goitre, nodular toxic and nodular non-toxic goitre, diffuse non-toxic and diffuse toxic goitre as well as malignant diseases of the thyroid.
Each case which presents for study has in addi- tion to the routine physical examination an X-ray of the chest, one or more basal meiaooiic readings, dependent on the type, a blood examination, includ- ing blood chemistry, a cardiogram and a consulta- tion with the laryngologist. This routine is not merely done as a means of compiling scientific data, but each procedure is intended to throw a distinct light on the future handling of the case.
The X-ray is of particular significance in that it will throw light on the size of the heart and it should also indicate whether there is a substernal enlarge- ment of the thyroid. The knowledge of the presence of a substernal goitre is ol gieat importance before operation, especially if the goitre has existed for a long period. If a substernal enlargement has existed for a long time there is one thing which should be known and that is the amount of deviation of the trachea. It is well to remember that substernal en- largements usually result from a noduiar goitre (adenoma of the lower pole of one lobe). The devia- tion of the trachea will be to the opposite side. Furth- ermore if a goitre has been present for some time it is possible that absorption of tracheal rings may have taken place. If these facts are not accounted for be- fore hand great distress may be experienced at the operating table, such as sudden release of the firm hold which the thyroid tumor had on the trachea may allow a sudden collapse of the trachea and a conse- quent asphyxial death if precautions to avoid this are not taken pre-operatively.
The precautions necessary to avoid this disaster
are:
1. X-ray of neck and chest.
2. Lipiodol instillation into trachea to outline deviation of it.
3. Intra-tracheal anesthesia.
4. In operating one should adopt the suggestions of Frank Lahey with reference to lifting the sub- sternal mass out of the mediastinum.
The value of an intra-tracheal anesthesia can hardly be estimated for two reasons, first, there is no danger of tracheal collapse and, secondly, there is no respiratory distress experienced during the pro- cedure. The pressure of and the pull on the thyroid tumor does not interfere with free inspiration and expiration through the intra-tracheal air way.
The basal metabolic reading indicates in a meas- ure the need for pre-operative medication.
The usefulness of iodine in the preparation for operation cannot be exaggerated. Iodine, either in the form of Lugol’s solution, sodium iodide intra- vaneously or iodostarine by mouth, given over a period of ten days reduces the metabolism in most cases to a safe level.
There is one controversial point in reference to the administration of iodine. Goetch and many others
GILBERT J. LEVY, M.D.
Practice Limited to Diseases of Children and Communicable Diseases.
20 S. Dunlap St.
Memphis, Tenn.
34
THE MISSISSIPPI DOCTOR
June, 1935
state that iodine is unnecessary in nodular toxic goitre, the so-called toxic adenoma. On this point it is my practice to give Lugol’s solution to these patients because it is our belief that the same sub- stance is responsible for the stimulation of the sympa- thetic system in all types of toxic goitre, and it is certain that the regressive changes produced by iodine are the same in all forms of thyroid hyperplasia.
It should be emphasized that iodine should not be given over long periods of time, and under no circumstances should it be considered except as a means of preparation for operation.
One last word about iodine in thyroid disease- - there are a certain number of patients who are un- able to retain Lugol’s solution by mouth, and a small group who are delirious. These patients can be stabil- ized best by the administration of sodium iodide in- travenously, in doses of 7% to 15 grains, once daily for several days.
The cardiogram indicates in a measure the amount of heart muscle damage.
Within recent years the effect of thyroidectomy in decompensated heart cases has been appreciated and therefore the inter-relationship more clearly in- dicated.
Last, but not least, one should not operate on a thyroid without first having a laryngeal examination. Pressure on the recurrent laryngeal nerve may have caused a paralysis of one of the vocal cords. Failure to obtain this information pre-operatively may cause embarrassment and necessitate needless post-opera- tive explanations.
To obtain the above data requires no extra time, but can be arrived at while the patient is resting and being prepared for operation. Every safeguard thrown around the patient before operation combined with an anatomic operation which is gently and expeditiously done diminshes the post-operative worries.
The post-operative treatment as observed in our service consists in the maintenance of the fluid balance (with intravenous drip and fluid by mouth as soon as the patient can take it without vomiting). Morphine in adequate amounts to favor rest and diminsh psychic disturbances, as well as Lugol’s solu- tion during the first forty-eight hours at least by rec- tum.
The morbidity and mortality in thyroid disease will diminish in proportion to the attention to details of management on the part of the surgeon and his associates.
As we proceed with our ward rounds we see sev- eral cases of carcinoma of the breast. Cases which have been operated recently, those waiting to be op- erated and then we see the unfortunate who has come under observation too late with extensive metastases or the recurrent case with metastases in the skin as well as distant skeletal or pulmonary metastases.
Everywhere in the literature one finds such splen- did phrases as “cancer is curable in the early stages,” “educate the public,” and lastly the one which strikes home so forcibly, “early diagnosis leads to greater percentages of cures.”
Before I forget it is necessary to say that unless statistics are made up from vast numbers of cases, impartially selected, they are of no value.
As we see these patients in all stages we are forci- bly impressed with the fact that the necessary edu-
cation of the public has not permeated to the negro population, and I might add from some personal ob- servations from private practice that the same may be said in lesser degree of the white population.
Education must permeate our own ranks if we are to educate the public.
Education not only to the need for operating when the disease cannot be mistaken, but education to a fuller appreciation of the necessity of more care- ful histories and methods of examination. If this is accomplished only those patients who may be offered some hope of an ultimate increase in life expectancy will be operated.
The early diagnosis about which so much is writ- ten is dependent on the impression which we can make in our communities through our advice and the care which is taken in trying to do more than merely palpate the breast and advise operation.
Examination of a patient is more than palpation.
Inspection may disclose in many cases informa- tion of the utmost value. The breast may be slightly asymmetric, one nipple being on a slightly higher level, there may be a very slight elevation in one quadrant of the breast and the skin changes, if pres- ent at all, may be so slight as to escape notice except by a careful observer. The “pig-skin” appearance is not always evident. Elevation of the arms may show a greater lifting of the affected breast. The nipple is not always retracted, elevated or deformed when a small lesion exists.
Palpation of the breast with the palm pressing the breast against the chest wall has the effect of ironing out the normal breast and enables one to palpate tumors much more effectively than picking the breast up between the fingers. It is true that when some cases present themselves a large mass is already present, the skin may be of the “pig-skin” variety, glossiness and telangiectases, as well as fixa- tion of the tumor firmly to the skin, are present. In some of these unfortunate patients ulceration has also taken place when they first present for examination.
Palpation of the axilla for enlarged glands does not always reveal their presence even though at operation a definite chain of glands is found.
The finding of supraclavicular glands places the case in the category of inoperables.
No case should be operated on without at least an X-ray of the chest. Here many surprises are in store for the surgeon. Physical examination may and often does fail to reveal mediastinal and pulmonary me- tastases which are shown by X-ray.
It is wise to note carefully on the X-ray the ap- pearance of the ribs and vertebrae as metastases may be present in the skeleton when the lungs are not in- volved.
If a patient with a breast tumor has complained of lumbar pains be sure to investigate for possible metastases to the dorso-lumbar vertebrae and the
*
D. H. ANTHONY, M.D., F.A.C.S.
Eye, Ear, Nose & Throat 1720 Exchange Bldg.
Memphis. Tenn.
/
June, 1935
THE MISSISSIPPI DOCTOR
3"
pelvic bones.
Emphasis is laid on the need for X-ray investi- gations pre-operatively because of the number of patients who return a few months following so-called radical operations with metastases in the lungs, liver and skeleton. It is probably that some of these pa- tients would not have been subjected to surgery if the condition had been known prior to operation.
When one comes to select an operation for the radical removal of breast cancer he should be guided by certain well accepted principles. The primary con- sideration must not be given to the immediate closure, but an adequate amount of skin must be sacrificed in the vicinity of the growth.
An effort should be made to avoid placing an incision on the arm because contractures of the scar tissue will limit movement of the arm.
Adequate exposure of the axillary vessels is es- sential.
Dissection should be sharp and not of the dry sponging type.
The two types of removal of the axillary content are different as wielding a violin bow and scrubbing a floor.
Avoid hemorrhage by clamping vessels, tributaries to the axillary vein and branches of the artery, before sectioning them.
Ligation of the vessels and removal of clamps will avoid having many clamps cluttering the field and will also avoid the accidental tearing of an axillary vein with a consequent hemorrhage.
At all times keep the chest wall protected with hot moist towels.
If one has not had to sacrifice too much skin a closure can be accomplished.
Freedom of motion of the arm should be en- couraged after operation.
The above requirements for a useful operation are met with by the Stewart type of transverse incision which I have been using for twenty years.
Post-operatively these patients must be given fluids by the most effective methods.
It is important that post-operative radiation should be instituted as soon after the operation as possible. One need not wait for complete healing of the wound. This holds true particularly in cases in which complete closure has not been possible.
Deep therapy is instituted first and skin grafting done at a later date if the wound has not entirely healed by that time.
Interest in this type of case cannot help being heightened when one sees skin metastasis, pulmonary and mediastinal involvement and almost generalized skeletal involvement which comes under observation in a large institution which draws its population from a widely disseminated area.
* * *
As we proceed on our ward rounds we next see the patient bleeding from the gums, rectum and vagina, whose skin is peppered by petechial hemor- rhages, whose pulse is rapid, weak and the patient looking anxious.
Immediately you are impressed with the need for action. The question arises is there other evidence on which one can arrive at a diagnosis and what can be done for the patient.
What does the blood picture tell us? Looking at
the chart one sees that the platelet count is greatly reduced. The bleeding time is prolonged, The coagu- lation time is normal and the clot does not retract. There is a marked secondary anemia.
Here we have a typical picture of purpura hem- orrhagica, true thrombocytolytic purpura. This dis- ease is sometimes called essential thrombopenia on the false assumption that the platelets are not formed in normal number. They must be formed in normal amount and destroyed by a hyperactive reticulo-en- dothelial system otherwise they would not appear so early after operation.
With the above clinical and hemotological pic- ture before us operation is indicated at once. At present nothing else effectively cures these patients. Transfusions of whole blood give temporary relief, but sustained improvement comes only from sple- nectomy.
The development of our present therapy of pur- pura hemorrhagica is the natural outcome of in- creasing information with reference to the formed elements of the blood and the functional relationship of the spleen and other members of the reticulo- endothelial system to the formed elements of the blood.
Splenectomy has within the past fifteen years become the specific therapeutic measure for purpura hemorrhagica.
My first case was done in 1923 on a boy five and one-half years. This child had had repeated sub- cutaneous hemorrhages which were controlled tempo- rarily by transfusions. Just about this time Brill and Rosenthal made their first contribution on sple- nectomy. At once I investigated the work of Katznelson and Frank. The arguments for the op- eration were so convincing that we decided to give this child the benefit of the method of treatment. From the date of the operation to the present time he has never had a recurrence of his bleeding. He has developed physically in a remarkable manner.
Since that time our enthusiasm has ripened into a conviction based on added experience. In some instances the results have been most spectacular. On several previous occasions I have cited my experiences with splenectomy and now I want to add one of my most convincing cases.
Case M. T., colored, female, age 26 years. This patient had been on a medical service for one month. She had received repeated citrated transfusions, in spite of which she continued to bleed profusely from the gums, the stomach, rec- tum, vagina and into the subcutaneous tissues. She was running a septic temperature, the pulse was weak and thready, the skin was parchment-like and there was a large decubitus ulcer. To add to the bad outlook the patient was in a semi comatose condition.
When I saw the above clinical picture I ad-
■ \
J. M. DORRIS, M.D., F.A.C.S.
General Surgery Traumatic Neurosurgery 402 Physicians and Surgeons Bldg. Telephone 6-3288
899 Madison Ave. Memphis, Tenn.
v
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THE MISSISSIPPI DOCTOR
June, 1935
vised an immediate splenectomy as a last resort.
The operation was done one year ago. The patient had a long tedious convalescence but she has had no further bleeding.
Just here it is only fair to state that the post- operative care given this patient by the Nursing Staff headed by Mrs. Godchaux and the attention to details by Dr. Carroll, our intern, aided ma- terially I believe in the recovery of this patient.
While splenectomy removes an agent which has been destroying platelets, the maintenance of the fluid balance and the feeding of the patient are important factors. The continuous intraven- ous drip as first proposed by Professor Matas and feeding with an indwelling nasal catheter are the means which were utilized so effectively in this and similar cases.
When considering the indications for splenectomy in purpura hemorrhagica one must not feel it es- sential to find a large palpable spleen. It must be remembered that the spleen has to be one and one- half tir es its normal size in order to be palpated.
It is essential, however, to be certain that one is dealing with true purpura and not purpura simplex or hemophilia. The findings are so definite that there should be no mistake.
There are other diseases for which splenectomy is equally as spectacular, hemolytic jaundice and splenic anemia On previous occasions I have dis- cussed the diffejt-ntial diagnosis and indications for operation in these diseases.
Recovery of purpura hemorrhagica patients fol- lowing splenectomy is the source of gratification when one considers the almost hopeless outlook prior to the last fifteen years.
(To be continued)
Dr. W. C. Spencer
Dr. W. C. Spencer, 81, of Verona, who had long been recognized as one of North Mississippi’s leading physicians, died at his home May 20, after an illness of several weeks.
Dr. Spencer was. educated in Memphis and New Orleans more than 50 years ago, and up until a few years ago, had been active in his practice.
He is survived by his wife and six children, Mrs. B. White, Corinth; Mrs. Nina Boyette, Jackson; Luth- er Spencer, Verona; Dr. C. E. Spencer, Verona; Dr. Shelby Spencer, Waco, Texas, and Sidney Spencer, Bogue Chitto.
Dr. W. C. Spencer was a choice spirit in the pro- fession. For about half a century he was active in serving the people and relieving suffering. He was a man of fine judgment. He had poise. He was dignified, but kind and courtly with a professional air always. He labored that others might have life and have it more abundantly and with less pain. He practiced the art as evidenced by eighty-one years of activity. Kind thoughts of his noble work, eternal rest to his soul, sympathy to the bereaved ones.
Post Graduate work, much of it, must and will be carried out to the busy practitioner. We are hav- ing some fine courses in our state at this time. It is a great step forward.
Some General Remarks Concerning Anesthesia With Particular Ref- erence to the Use of Evipal*
W. H. PARSONS, M.D., F.A.C.S.
Vicksburg, Miss.
The history of anesthesia is quite ancient, in age approximating that of surgery itself. In the time of Nero poppy syrup was employed to lessen the pain of burns and Hippocrates was acquainted with the use of opium, mandrake and Indian hemp. Such crude agents, administered purely empirically, obviously were not ideal, and for that matter, despite the vo- luminous literature that has developed with the peri- odic crowning of some new agent or technic, the ideal anesthetic still eludes us.
Davy, in the latter part of the 18th century, noted the anesthetic properties of nitrous oxide, but the brilliant lead of this chemist was allowed to lie dor- mant until finally, in 1842, Crawford Long performed the first operation under general anesthesia. Con- siderable controversy arose as to whether Long or Morton was entitled to priority, but it has been well established that Long, a modest and unpretentious practitioner of Georgia, antedated Morton by three years.
Chloroform was developed later and while gradual- ly it came to be regarded as an exceedingly dangerous anesthetic agent, it continues to be used relatively often in certain localities with seemingly reasonable safety. I hold no brief for this particular agent, but I doubt if it is as dangerous as one would be led to believe and it is possessed of certain merit not gen- erally accredited to it.
In 1879 cocaine was discovered and in 1884 the first premeditated use of cocaine for nerve blocking was done by Halsted and Hall (1). Neuro-regional anesthesia had its inception, and in all its modifica- tions is based upon, the principle of blocking formu- lated by Halsted. Matas sufficiently perfected the technic of regional anesthesia and so generously trained and greatly stimulated his younger associates in the use of the method, that for many years (1895 to 1915) the majority of operations performed at the Charity Hospital in New Orleans were performed with the aid of regional block.
Corning in 1886 announced his discovery of epi- dural and spinal anesthesia. The wave of unbridled enthusiasm for the method which followed has al- ternated with periods of depression to this very time. Matas (2) regards spinal anesthesia as “the supreme attainment of regional anesthesia,” but he objects “to the routine, indiscriminate and wholesale use to
*Read before the Issaquena-Sharkey- Warren Counties Medical Society, Vicksburg, Miss., October 9, 1934.
> ■' <
THE THREE MUSKETEERS BOOK SHOP Peabody Hotel Building Phone 8-2009 Memphis, Tenn.
Mail orders filled promptly
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June, 1935
THE MISSISSIPPI DOCTOR
27
which it has been put in many quarters.” Those in- terested in the whole subject of anesthesia, both local and regional, are referred to the very compre- hensive presentation of this matter by Matas (1).
Not content with any of the agents previously mentioned, the search continued so that during the past 10 years other agents, notably Avertin, to be ad- ministered per rectum (and by some intravenously) and the Barbiturates, the latter employed both by mouth and intravenously, were developed. These drugs have been largely employed, in addition to serving their purpose alone, as a basic or synergistic anesthesia. Today their greatest field is probably as an adjunct to ether, the gases, or regional block.
I wish to discuss briefly and to report our ex- perience with the drug Evipal. This preparation, in- troduced largely to American surgery within the past eighteen months, developed during the year 1933, in the German periodicals, a rather voluminous liter- ature.
It must be admitted at the outset that intraven- ous anesthesia, and it is by this route alone, if at all, that this drug has unusual merit, possesses the ob- jectionable feature incident to spinal block or rectal injection, of non-controllability. Evipal, however, is very quickly eliminated and it does not seemingly produce permanent or irreparable damage to any organ or tissue. The drug is decomposed in the liver and its destruction and elimination does not affect the kidneys. White and Collins (3) state that “re- peated doses failed to damage the liver, but excessive doses were marked by arrest of metabolism and fall of body temperature.” No significant changes have been noted in the alkali reserve or blood sugar follow- ing its administration either by other observers or by me. Experimental studies have shown that the lethal doses is four times that required for anesthesia, it would seem a reasonable margin of safety.
White and Collins (3), without discussion of the biochemical action of the drug, relate its clinical behavior in a series of 100 patients subjected, under Evipal anesthesia, to surgery. Various types of surg- ical procedures were performed. Anesthesia was satisfactory in all cases and in none did untoward reactions occur. Their cases were carefully studied and accurate observations were made in each instance regarding the effect of this drug on the circulation, the respiration, and the chemistry of the blood. No significant or undesirable effects were noted.
Our own experience has coincided with the ob- servations of White and his associates. Anesthesia has been induced in each instance within sixty sec- onds of beginning the injection and patients have, with one exception, reacted within twenty minutes. The exception was in the case of a young negro male who, according to the story, had not slept for a pro- longed period prior to the administration of the anesthetic and may well have been suffering natural fatigue. No alarming symptoms developed in this case and it was not necessary to hospitalize the pa- tient.
The blood pressure generally falls, the depression averaging ten points and returning by the termina- tion of the anesthetic to the normal level. The action of Evipal in this respect differs sharply from spinal block or amytal intravenously. It is unnecessary to administer ephedrin or similar drugs to guard against
excessive vascular depression, for the cardiovascular system seems not at all affected by Evipal. Patients affected with hypertension, likewise, are suitable can- didates for Evipal — a condition eminently untrue if spinal anesthesia is contemplated. However, Evipal is not and will never be a rival of spinal anesthesia. Its action is too brief, except in the occasional case, to compete with this drug.
The pulse rate is usually moderately depressed; the respirations become slightly retarded and full, approximately those noted in deep natural sleep. The induction in each instance has been perfectly smooth; two patients only have reacted noisily and few have suffered nausea. There have been no undersirable sequelae encountered.
My associates and I have employed Evipal as the anesthetic agent in a total of 100 cases, embracing the following procedures:
Dilatation of the rectum.
Sigmoidoscopic studies.
Incision of acute abscesses.
Extraction of teeth.
Tonsillectomy.
Diagnostic curettage.
Appendectomy.
Pelvic procedures, such as salpingectomy.
Hernioplasties, both inguinal and epigastric.
Release of intestinal obstruction.
Amputation of tongue.
Enucleation of eye.
Major amputation.
Reduction of fractures.
There have been no deaths and no severe reactions.
The administration of Evipal is exceedingly simple. The solution is freshly prepared by dissolving one gram of Evipal in 10 cubic centimeters of sterile water. The injection is best given at the rate of one cubic centimeter per ten seconds. The drug, as indicated previously, is rapidly elmiinated and if injected more slowly, an unsatisfactory result may be anticipated. If injected much more rapidly, artificial respiration for a few minutes may be required. On one occasion I have had this experience. The heart action re- mained perfectly normal; the blood pressure was not unduly depressed and after about one minute, normal breathing was resumed. There were no undesirable sequelae.
The injection should not be made until the opera- tive field has been prepared and draped. Anesthesia is complete by the time the injection is finished.
Any agent incapable of inducing anesthesia of longer than twenty minutes duration must occupy at best a very restricted field. And certainly any drug of service mainly, if not exclusively, in the perform- ance of minor or relatively simple major procedures, must offer almost absolute safety if it is to be of value. It appears from a study of available literature that Evipal may be able to meet the requirement of safety. If such proves to be the case, a valuable ad-
WM. MILTON ADAMS, M.D.
Practice Limited to Plastic and Reparative Surgery Suite 410-414
Physicians and Surgeons Building 899 Madison Avenue Memphis, Tenn.
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THE MISSISSIPPI DOCTOR
June, 1935
dition to our armamentarium has been made.
SUMMARY
(1) A brief historical survey of the more com- mon anesthetic agents is offered, together with cer- tain comments concerning their use.
(2) Particular attention is called to a relatively new drug, “Evipal.”
(3) Especial significance is attached to the ap- parent safety of Evipal, the prime requisite for any proposed anesthetic agent.
(4) It is suggested that the drug not be em- ployed if extensive hepatic damage exists.
BIBLIOGRAPHY
1. Quoted by R. Matas, Journal American Surgery. August, 1934, page 362.
2. Matas, R., Local Anesthesia, American Journal of Surgery, August, 1934, page 372.
3. White, Charles S., and Collins, Lloyd J., South- ern Medicine and Surgery, Vol. 96, No. 7, July, 1934.
Program — Northeast Mississippi 13 Counties Medical Society
Dr. W. H. Anderson,
Booneville, Miss.
Dear Dr. Anderson:
Our program for our 13 County runs about like this: Dr. Morris, of Macon will have a paper on Empye- ma, Dr. Lilly of Tupelo will have a paper on Transfu- sions, Dr. Davis of Corinth will have an interesting case of the elbow. Dr. J. B. McElroy of Memphis will be our visiting essayist and Dr. McGahey of Calhoun City, will have a paper on Toxemia of Pregnancy.
There will be entertainment with a banquet giv- en by the Houston Doctors following the scientific program.
Dr. G. H. Boyles pastor of First Methodist churcn will render the invocation.
Very sincerely,
A. J. STACY, Secretary.
Deaths of Mississippi Physicians
Dr. Willis Cabe Weathersby, Coahoma, February. Dr. William Daniel Potter, Clinton, May.
Dr. W. W. McRae, Corinth, May.
Dr. C. G. McEachern, Moss Point, April.
Dr. W. C. Spencer, Verona, May.
Dr. J. W. Price, Booneville, March.
Dr. James Henry Slaughter, formerly of Green- wood, Miss., died at Kilgore, Texas.
The profit in the practice of medicine in the fu- ture will have to come in the main on volume of business rather than such a long price to the indi- vidual.
D. W. Jones, of Jackson, and J. W. D. Dicks, of Natchez, are the associate editors of the Mississippi State Medical Association. They will do their part exceedingly well.
Better be on the look out for the chain store medical journal. It will come in the name of service, but its God will be money.
Affiliation, What It Means to the School, the Student, and the Future Graduate Nurse*
SISTER CELESTINE,
Director of School of Nursing, Hotel Dieu New Orleans, La.
DEFINITION
In considering “Affiliation, What it Means to the School, the Student, and the Future Graduate Nurse,” let us first decide what “affiliation” means in nursing terms. Susan Francis had defined it as “the asso- ciation of one hospital or school of nursing with an- other for the purpose of complementing the educa- tion of the student nurse.” Now, the word “comple- ment” implies two things which mutually complete each other and together constitute a whole.
As we progress in this discussion, we hope to bring out the dual nature of affiliation, that is, the re- ciprocal assistance rendered by the home school and the receiving school, resulting in the complemented oi complete education of the student nurse.
TYPES OF AFFILIATION Let us consider the three types of affiliation need- ed and offered. First, there is affiliation for the school which lacks a major service. Secondly, there is affiliation for the school possessing limited or in- adequate facilities in the major service. And third- ly, there is affiliation for the school which offers its students elective in addition to full time in the main services, and seeks broader experiences for specially interested students.
POLICIES GOVERNING AFFILIATION Having decided the need for any type of affilia- tion, the school contemplating affiliation must now study the available centers with regard to their pro- fessional standing, the theoretical and practical work given, the living conditions and health supervision offered. After selection of and acceptance by the affiliation center, the term of contract must be agreed on — this contract to be a formal, written one, signed by both schools. It will include such stipulations as the number of students, entrance date, length of affiliation, requirements as to previous general edu- cation, theory and practice, immunization, transpo:- tation, health certificate and health protection, theo- ry and practice offered, records and reports kept and given to home school, condition causing elimination of affiliating students, and terms of abrogation of contract by either school.
TRIPLE VIEW OF AFFILIATION The three types of affiliation described offer many
*Read before the Mississippi State Nurses Asso- ciation, Hattiesburg, Nov. 1, 1934.
Offices of
WILLIAM CALVERT CHANEY, M.D.
20 S. Dunlap Street Memphis, Tennessee
Internal Medicine and Allergic Diseases
-
June, 1935
THE MISSISSIPPI DOCTOR
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advantages; but, as life goes, we do not have advan- tages without difficulties. We shall consider these advantages and difficulties from a triple standpoint: that of the student going for affiliation; that of the hospital sending the affiliate; and that of the hospital receiving the affiliate.
STUDENT’S ADVANTAGES AND DIFFICULTIES Primarily, there is the occasional student who fails to recognize the value of affiliation, who fails to see what it will give her, and who fails to appreciate what it will mean to her as a graduate. Then, there are some students who have much difficulty in adapt- ing themselves to the new environment. As we consider what affiliation will give the student, we realize that the biggest advantage she receives from this arrangement is the development of her profes- sional spirit and the enlargement of her vision as to the possibilities of her profession. She enjoys stimu- lating associations and has opportunity for compara- tive study of the two schools. In addition, her life in the new school frequently results in the establish- ment of desirable and lasting friendships.
OBSTACLES TO BE SURMOUNTED BY HOSPITAL SENDING AFFILIATES
Naturally, the hospital sending its students for affiliation faces some difficulties — some dark clouds. The darkest of these is the problem of supplying nurs- ing care to its sick without increasing the student intake. Apparently, the solution is simple — just em- ploy graduates on general duty. It is true that the hospital must stretch its purse to some extent. But, even with the utmost good will and co-operation on the part of the hospital’s finance committee, there is a limit to which the hospital’s purse can be stretched, and only too frequently this limit is reached before the student nurse reduction, due to affiliation has been fully compensated by graduate nursing. However, all life is a series of compromises. So, the school having its students’ welfare at heart, rests cofitent with a middle ground relinquishing, though reluctantly, the full measure of affiliation envisioned as ideal.
In accepting students, the director, with a view to affiliation, must have in mind the requirements of the receiving school as to educational background. Notwithstanding that she may be busy about many things, she must carefully plan courses of lectures around the schedule of prospective afiliates so that they may not miss out on any theory during their absence. Nor must she fail to have always a clear perception of the basic theory and practice that must precede each affiliate’s entrance to the receiving school. Those of us who are familiar with rotation of students readily see how constantly alert the di- rector must be to foresee all these points. Again, there are such problems as the obligation to send the agreed quota of affiliates at the set date, regardless of such home conflicts as unexpected increase in occupied hospital beds, minor epidemics among the students, and even at the appointed time, illness on the part of the affiliate herself.
It goes without saying, that the director must have her eyes, too, on the physical condition of the prospective affiliate as the date for affiliation ap- proaches, so as to eliminate undue fatigue and strain, thus ensuring the student having all possible aids for a successful adjustment to the working condition. One
very practical way to help this situation is the sched- uling of the affiliate’s vacation to immediately pre- cede her entrance to the receiving school.
Having landed the student safely in the affil- iating school, let us not imagine that the director’s responsibility is ended. It is her duty, as an edu- cator, to keep in touch with the student’s progress in her new surroundings. In the multiplicity of obliga- tions on the part of the director are further included such things as seeing that a transcript of the stud- ent’s report precedes her entrance to the affiliating school, and that her affiliation reports are incorporat- ed in her regular school report.
ADVANTAGES OF THE SCHOOL SENDING THE AFFILIATE
Is this of affiliation all difficulties and dark clouds'? By no means! There is the proverbial silver lining! Let us dwell on advantages and benefits of affiliation. Every nursing educator feels that the effort affiliation involves is decidely worth-while when she considers the well-rounded course she is able to give her stud- ents— when she views with satisfaction the improved standards of the nursing school — when she realizes that she is making a definite contribution to effective nursing of the sick — and when she appreciates that, she is adding her bit to the advance of nursing edu- cation. Then indeed is she recompensed with the sense of fulfillment of duty — with the sense of living up to the ideals and principles of the conscientious educator.
Of course, you understand that reference to the director and the satisfaction she experiences implies the satisfaction whch is felt by the hospital board of managers that has, through its sanction and co-op- eration, made possible the good work. More and more do our hospital boards recognize their responsibility in this regard; they see that in thus rendering justice to the student nurse by giving her a well-rounded course, they are inevitably improving the nursing of the sick confined to their care.
DIFFICULTIES OF THE RECEIVING SCHOOL
The receiving school faces the very serious prob- lem of supplying adequate supervision to insure uni- formity of technique and reliability of affilation pre- formance. The receiving school is responsible for initiating and maintaining proper relations between the regular students and the affiliates. It must handle the sickness situation; students who have adapted themselves to strenuous work under a given set of circumstances, frequently have unexpected physical reactions when transfered to different working con- ditions. There is often the problem of the affiliate who regardless of the formality of physical exami- nation preceding affiliation, begins, shortly after her entrance, a record of frequent small indispositions, making many adjustments necessary. Then, too, the director of the receiving school must deal with the student who averaged fairly well in theory and prac
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J. A. HUGHES, M.D., F.A.C.S.
Eye, Ear, Nose and Throat Suite 1805-6 Sterick Bldg.
Memphis, Tennessee
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THE MISSISSIPPI DOCTOR
June, 1935
tice in her home school but who, in a larger school and more confusing environment proves inefficient or ranks in that puzzling borderline of students who are not really incapable and yet are not truly efficient. Not the simplest of the receiving school’s difficulties is the planning of its regular student’s theory and practice so as not to conflict with the theory and practice pledged to the affiliate.
ADVANTAGES OF THE RECEIVING SCHOOL
Despite these numerous adjustments which the receiving school director must supervise and provide for, she comes out victorious in that she has achieved the necessary nursing care of the patient confided to her; she has procured for her students valuable interchange of ideas and enlargement of professional outlook by the reception of suitable affiliates; she has spurred her regular students to improved perform- ance by the stimulating presence of the affiliating students; she has 1;he satisfaction of knowing that she is accomplishing definite educational work for her profession — raising the standards of large numbers of its members; and last, but best of all for the true nurse, she knows that she has contributed to the bet- ter nursing care of the sick — and this over a wide area.
AFFILIATION IN PSYCHIATRIC NURSING
In speaking of affiliation, we have put but little stress so far, on affiliation for electives. All over the country, the mental hygiene movement is steadily gaining momentum. Therefore, it seems to me that the outstanding affiliation elective at present is that in psychiatric hospitals. This will elevate the level of nursing given mental patients, now cared for chiefly by attendants. It gives the student insight into the working of the mind; it gives her tolerance and keen- ness of observation. Most important, it gives her ap- preciation of mental illness as the cumulative effect of repeated unhealthy reactions of the individual to the demands of his environment. All this prepares the nurse to teach mental hygiene.
AFFILIATION WITH PUBLIC HEALTH ORGANIZATION
We have been talking of affiliation strictly in terms of hospital — hospital. Viewing nursing in the light of the increasing emphasis on its teaching pre- ventive, and social, aspects, there is another affilia- tion essential to student nurses’ education. Needless to say, we have reference to affiliation with public health organizations. These organizations cover the services found inadequate or actually non-existent in many hospitals — pediatrics, communicable diseases, and obstetrics. Public affiliation offers, under super- vision, knowledge of childhood and opportunity to adapt nursing to home conditions; it offers definitely a view of the patient in relation to his family and community; a comprehension of social problems and how they affect the patient; a knowledge of the health and social resources of the community.
The advantages to the public health organization from affiliation are practically identical with those which the receiving hospital obtains from its affiliates.
It was our aim, in this discussion of “Affiliation, What it Means to the School, the Student, and the Future Graduate Nurse,” to demonstrate the comple- mental nature of affiliation — that is, the reciprocal assistance rendered and received by all parties to
the affiliation.
Do we all agree? Affiliation brings undoubted advantages to the school sending the affiliate, to the hospital or organization receiving the affiliate, and to the student going on affiliation; consequently af- filiation brings marked advantage to the future grad- uate nurse.
BIBLIOGRAPHY
Nutting, Mary Adelaide. R.N.. M.A., “A Sound Economic Basis for Schools of Nursing.”
Hodgman, Gertrude E., R.N., ‘Affiliation with Public Health Nursing Association,” A.J.N., April, 1924.
Francis, Susan C., R.N., “The Value of Affiliation,” A.J.N., May, 1924.
Clayton, S. Lillian, R.N., “Affiliation for Schools of Nursing with Public Heatlh Nursing Associations,” A.J.N., November 1924.
Jamme, Anna C.. R.N., Affiliation,” A.J.N., Sep- tember 1928.
Sherman, Marjorie (Student, Knapp College of Nursing, California.), “The Value of Affiliation,” A.J.N., September, 1928.
Sauer, Audry (Student, Riverside Community Hos- pital, California.), “The Value of Affiliation,” A.J.N., September, 1928, and others.
Tuberculosis Abstracts
Only about one out of each six cases admitted to tuberculosis sanatoria is an incipient case. Years of public education and of urging people to consult the doctor at the first appearance of symptoms have not succeeded in materially increasing the ratio of early cases to moderately and far advanced cases. One reason why both the specialist and the general prac- titioner seldom see tuberculosis in its incipiency is probably because the disease often begins as an acute subapical lesion. Such lesions develop rapidly into far advanced disease before they are recognized. The authors of a paper on this subject published six years ago, have accumulated additional data and these sub- stantiate their original views.
SUBAPICAL TUBERCULOSIS
In earlier communications attention was called to subapical tuberculosis based on a study of 200 cases. Now that the series has been brought up to 1,000 cases the conclusion that progressive and destructive pul- monary tuberculosis usually begins suddenly with exudative subapical lesions seems justified. While later statistical material shows some change over that of the 200 original cases, the conclusions drawn from the original report are restated with additional support.
The older concept of pulmonary tuberculosis is that it usually begins quite incipiently with a small lesion in the apex of the lung and spreads caudal- ward, and that the symptoms and physical findings are so elusive as to escape all but the keenest diag- nostician. The majority of patients present them- selves first with far advanced disease; incipiency, as seen in the apical lesion is seldom found. The
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JOHN W. RAGSDALE, M.D.
CHESTER D. ALLEN, M.D.
327 Medical Arts Bldg.
Memphis, Tenn.
Urology and Urological Surgery
June, 1935
THE MISSISSIPPI DOCTOR
4l
authors believe the acute subapical lesion is the more frequent as the truly incipient lesion and that such lesions often develop into far advanced disease before they are recognized for the reason that they increase rapidly in extent.
The study is not to be construed as an attempt to classify pulmonary tuberculosis into confusing sub-
groups, but rather as a means of throwing light on the diagnosis, treatment and prognosis through a proper appreciation or the history of onset and course, and the location and nature of the disease.
The picture of the case with a typical subapical lesion, with its acute manifestations, as against the one with apical involvements, is as follows:
Onset:
1. Clinically
2. Anatomically
3. Localization
Course:
1. Clinically
2. Anatomically
3. Direction of progression
4. Extent of lesion
5. Cavitation
6. Duration
7. Healing
SUBAPICAL
Sudden
Acute bronchopneumonic infiltration Subapical
In acute exacerbations
Rapidly progressive or retrogressive changes interrupting chronic course Toward apices and caudalward Large extent already in “incipient stage”
Early occurrence and frequent Relatively short
Absorption and/or massive fibrosis
APICAL
Insidious
Discrete, productive tubercles Apical
Slow progression or long period of standstill
Very slow changes Apicocaudal
Incipient stage identical with min- imal stage
Late occurrence and relatively in- frequent Very long
Localized fibrotie scars
SUMMARY
1. Progressive and destructive pulmonary tuber- culosis usually begins suddenly with exudative sub- apical lesions.
2. Lesions, far advanced, and excavations fre- quently develop within less than six months.
3. Processes leading to active progression and to excavation are most frequently associated with acute symptoms.
4. Physical signs and symptomatology (tradi- tionally described as characteristic for “incipient tu- berculosis”) are misleading for the detection of truly incipient subapical acute processes.
Acute Subapical Versus Insidious Apical Tuber- culosis, Douglas, Nalbant and Pinner, Am. Rev. of Tuber., Feb., 1935.
Most articles on pregnancy and tuberculosis pre- sent a pessimistic outlook. A study of the cases at Sea View Hospital, New York at first gave a similar point of view but on careful investigation is appeared that pregnancy had very little effect on the course of the disease and that the character of the pulmonary form of tuberculosis determined the destiny of the patient.
PREGNANCY AND TUBERCULOSIS
The records of 85 patients who had tuberculosis and who were delivered at Sea View Hospital during the past ten years were studied. The average dura- tion of stay before confinement was 2.1 months; and the average after delivery was 3 months. Of the 85 cases, 36 per cent died, 18 per cent were unimproved or progressed and 46 per cent improved. This cor- responds with statistics of other writers. But when these figures were compared with a control group of non-pregnant females with pulmonary tuberculosis it appeared that the pregnant woman stands as good a chance as her non-pregnant sister, if not a better one.
The cases were divided into groups, classfied
according to the character of the pulmonary path- ological processes. This qualitative classification di- vides pulmonary tuberculosis into two main groups: Exudative and Productive.
Exudative reactions are characterized by high tissue sensitivity and are immediate and explosive. The greater the mass or dosage of tubercle bacilli the more likely the opportunity for over irritation and resultant cell death. The exudative type is subdivided into the Benign Exudative, the Exudative-productive and the Caseous-pneumonic. The Productive form results when tissue sensitivity is low and dosage of bacilli is small. The reaction is cellular with a ten- dency toward fibroid tissue formation.
In the regrouping of the 85 pregnancy-tubercu- losis cases, 51 cases were classified as caseous-pneu- monic, 9 as resolving-exudative and 25 as productive. There were 31 deaths and all were in the caseous- pneumonic group. The prognosis of caseous-pneu- monic tuberculosis is bad; the majority of cases end fatally.
To determine whether the high toll in the group classified as caseous-pneumonic was due to the com- plication of pregnancy or to the disease itself a com- parison was made with 51 non-pregnant females having caseous-pneumonic tuberculosis. In the preg- nancy group, 41 cases (80.37 per cent) died or pro-