™ MEDICAL .SCHOOL LI ISMAM.1T Digitized by the Internet Archive in 2016 https://archive.org/details/journalofmedical28unse THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY PUBLISHED MONTHLY UNDER THE DIRECTION OF THE BOARD OF TRUSTEES Volume XXVIII. January, 1931— December, 1931 Publication Committee : Drs. Henry C. Barkhorn, Edward J. Ill, Linn Emerson J. Bennett Morrison 14 South Day Street, Orange, N. J. ; ; , ’ ; Editor:,*,- » TP/ Henry G. Reik, M.D.v'F.A.C.S, INDEX Address, President’s Annual 539 President’s to House of Delegates Aug. Sup. 1 Advertising, False and Misleading Aug. Sup. 8 Aug. Sup. 47 American College of Physicians, Report of Meeting 51.3 American Federation of Hard of Hearing 953 American Medical Association Convention 666 Delegates’ Report of Aug. Sup. 36 American Physiotherapy Association; Letter from Dr. Harold D. Corbusier 63 Annual Conference, Secretaries and Reporters of County Societies 956 ANNEAL MEETING— Assessment of Dues Aug. Sup. 18 House of Delegates Report Aug. Sup. 1-59 Preliminary Program of 435-441 Scientific Sessions, Report of Aug. Sup. 56 Section of Ophthalmology, Otology and Rhinolaryn- gology , Aug. Sup. 59 Section on Pediatrics Aug. Sup. 61 Section on School Physicians Aug. Sup. 62 Transactions of Aug. Sup. 1-86 Woman’s Auxiliary Aug. Sup. 63-86 Annual Report of Editor and Executive Secretary .Aug. Sup. 6 Asbury Park Convention 579 AUTHORS OF ORIGINAL ARTICLES— Adams, J. K.: Discussion of Fractures 12 What Is Wrong with the Fracture Situation? 3 Aitken, Frank J. T. : A Group of Endocrine Cases 470 Altschul, F. J. : Fusospirochetal Disease of the Lung.. 834 Arlitz, William J. : Discussion of Fractures 10 Asher, Maurice: Discussion of Duodenal Tube Drainage of the Biliary System 814 Avidan, Maurice S.: Discussion of Fractures 11 Baker, Charles Frederick: Duodenal Stasis 1 Bancroft, Frederic W. : Thrombosis and Embolism 619 Barbarito, William N. : Discussion of Duodenal Tube Drainage of the Biliary System 814 Barkhorn, Henry C. : Discussion of Acute Mastoid Dis- ease 26 Our County, Presidential Address to Essex County Medical Society 900 Report of Publication Committee Aug. Sup. 2 Beling, C. C. : Report of Judicial Council Aug. Sup. 17 Belk. William P. : Discussion of Fusospirochetal Dis- ease of the Lung 849 Blanchard, Kenneth: Discussion of Changes in Human Rickets After Viosterol Therapy 22 Discussion of Clinical Evaluation of a Concentrate of Vitamins A and D 853 Bland, P. Brooke: Leukorrhea 489 Bowen, D. C. : Health Department Growth in New Jersey j 196 State Health Laws 59 Bowers, Anna Mae: The Future of Freud 52 Bowles, Harry IT. : Medical Ethics 35 Bradshaw, John Hammond: A Visit to the Royal Vic- toria Hospital, Montreal 715 C’est Formidable L’ Opinion Publique 717 Hurry, Hurry, Hurry! 952 Lowering of the Standard of Ethics 53 Medical Societies 581 More Health Ethics 143 Patients Must Not Be Neglected 432 Recent Visit to the Grenfell Mission on the Labrador 864 Success 867 The Physicians in Holy Writ 252 Uphold Honor of the Profession 494 “Who Steals My Purse Steals Trash” 359 Bronner, Augusta F. : The Future of Freud 52 Brown. Harvey: Discussion of Pedographic Impressions in School Children 930 Burton, Opitz R. : Clinical Significance of High and Low Blood Pressure 302 Caffey, John: Changes in Human Rickets After Vios- terol Therapy 21 Discussion of Changes in Human Rickets After Vios- terol Therapy 22 Campbell, William: Advantages of General Anesthesia in Tonsillectomy < « , « *..., 29 Church, Franklin H.: Forcible Extension in an Anky- losed Joint ! . i '. .. 9‘l4 Cone, Ralph S.: Requiem to the Unknown Soldier ... 142 The Bell Buoy ^ ^ . 577 1 The War Nurse’s Story 1 ... .^. 14± Corbusier, Harold D : American Physiotherapy Asso- ciation , 6^* Corson, E. S. : Phlebitis 1*2 Corwin, Theodore W. : Discussion of Tonsillectomy 30 Cosgrove, Samuel A.: The General Practitioner and Obstetrics 545 Coughlan. Ella: Discussion of Pedographic Impressions in School Children 930 Craster, Charles V.: A Skin Test for Whooping Cough 236 Danzis, Max: Discussion of Biliary Tract Disease _ 797 Discussion of Duodenal Tube Drainage of the Biliary System 815 Honor to Max Danzis • • 276 Darlington, E. P. : Discussion of Symposium on Public Health Work 207 Davidson, Harold S. : Diabetes Mellitus and Throm- bo- angiitis Obliterans in the Same Patient 570 Recurring Postoperative Parotitis 85 Deaver, J. Montgomery: Discussion of Biliary Tract Disease 299 Deaver, John B.: Surgical Aspects of Biliary Tract Disease 295 De Meritt, C. L. : Medical Possibilities of Sea Water.. 706 The Acute Abdomen ;• 407 Doane, Joseph C. : What the Present Day Public Thinks of the Medical Profession 648 Donaldson, Walter F. : A Romance of Paternalism 587 Doody, William: Child Guidance 595 Downs, R. I. : Publicity, a Remedy for Many Society Problems 959 Dublin George J. : Common Conditions in Industrial Ophthalmology 704 Dunnington. John Hughes: Clinical Management of Heterophoria 919 Discussion of Ocular Muscle Abnormalities 927 Eagleton, Wells P. : A Doctor’s Confession of Faith. . 237 Ellis, William J. : Development of Public Welfare Work 187 Ely, Lancelot: Report of Committee on Scientific Work Aug. Sup. 2 Emerson, Linn: Combined Orthoptic and Operative Treatment of Convergent Squint in Young Children 923 Discussion of Acute Mastoid Disease 27 Discussion of Ocular Muscle Abnormalities 926-7 Ewing, Harvey M. : Discussion of Cardiac Irregulari- ties and Silent Mitral Stenosis 912 Fanburg. S. J. : Fungus Infections of the Skin 92 Finkelstein, A. S. : Discussion of Whooping Cough 100 Treatment of Whooping Cough 96 Finkler. Rita S. : The Female Sex Hormone 766 Fish, Clyde M.: New Method of Outlining the Heart, Its Chambers and Great Vessels 817 Floyd, Rolfe: Treatment of Bright’s Disease 552 Fowler, Robert H. : Discussion of Acute Mastoid Dis- ease 26 Discussion of Tonsillectomy 31 Tonsillectomy Under Local Anesthesia 27 Gamon. Robert S. : Is Group Medical Publicity Ethical? 961 Gardam, Joseph William: Statistical Study of Diph- theria in Newark 626 Gerber, Louis J. : Radiographic Diagnosis of Gall-Blad- der Pathology 829 Gerendasy, J. : Practical Gastro-Enterology 768 Giglio, A. S. V.: Tonsillectomy by Diathermy 77 1 Goldstein, H. H. : Foreign Body in the Urinary Blad- der 709 Useful Irrigating Fluid for Septic Wounds 492 Goldstein, Hyman I.: Discussion of Cardiac Irregu- larities and .Silent Mitral Stenosis 913 Hereditary Epistaxis 309 Gowen, Cecil H. : Bacteriologic Study of Chronic In- fectious Arthritis 38 Gray, John W. : Bacteriologic Study of Chronic Infec- tious Arthritis 38 Griffin, Guy B.: Liver Cysts 337 Gross, Max: Review of Recent Literature on Thrombo- angiitis Obliterans 571 Hagertv, John F. : A Case of Pseudo-Hermaphroditism 899 Discussion of Fractures 9 Discussion of Symposium on Public Health Work 208 Memorial Tablet to Dr. O. H. Sproul 110 Haigh, G. W. : Medical Service of the Future 115 Hallinger, E. S. : Sinusitis 475 Hartman. J. C. : Obstetric Mortality 31 ^Ifij’twpll, Johiji Continued Education of the « . I)bc\or . i 639 HeM>\ WillWn : . Tb’e! Jrufure of Freud 52 Heller,' George: ‘ PreVerftton of Measles 617 Heller. N. B . : Alc^ojic^ fse^do- Pellagra 467 Hermnntt/ Jonf\ «H*. : -Liver. \Gy?ts 337 ; IJerrn?an, W. 4«G- i $is£fts&it>ij[ of Fusospirochetal Dis- * ' base of* the *Ltmg •*.•.*... .* 849 INDEX Fusospirochetal Disease of the Lung 834 Uterine Hemorrhages Radiologically Considered 819 Heyd. Charles Gordon: The Physician’s Economic Con- tribution to the Community 258 Heyman, Arthur: Discussion of Malnutrition in Chil- dren 211 Hubbard, H. V. : Discussion of Ocular Muscle Abnor- malities 926 Discussion of Tonsillectomy 30 Overlapping the Rectus Muscles for Correction of Strabismus 915 Huberman, John H. : Value of Blood Sedimentation Test in Gynecology 403 Hull, Donald B. : Discussion of Pedographic Impres- sions in School Children 930-931 Pedographic Impressions in School Children 928 Hummel, E. G. : Discussion of Whooping Cough 100 Hyman, Albert S. : Myocardosis; the Failing Heart of Middle Life 831 Treatment of Acute Coronary Thrombosis 296 111, Edward J. : Society for Relief of Widows and Or- phans of Medical Men of New Jersey 69 Ireland, Allen G. : Discussion of Pedographic Impres- sions in School Children 930-931 Discussion of the Physician’s Part in the Training Irvin, John S. : Public Relations as a Specific 959 Jack, H. Wesley: Factors in the Early Diagnosis and .. Treatment of Fractured Skulls 603 Jaffin, A. E.: Discussion of Cardiac Irregularities and Silent Mitral Stenosis 912 Discussion of Duodenal Tube Drainage of the Biliary System 814 James, Bart M. : Common Diseases of the Oral Mucosa 563 Johnson, F. C. : Discussion of Diet in Eczema of In- fants 223 Discussion of Non-Pathologic Heart Murmurs in Children 103 Johnson, V. Earl: Modern Treatment of Varicose Veins 229 Kahrs, Grace M. : The Physician’s Part in the Train- ing of Teachers 932 Kelley, Charles B. : Discussion of Symposium on Pub- lic Health Work 206 Kerley, Charles Gilmore: Discussion of Gastro-Intes- tinal Disorders 20 Gastro-Intestinal Disorders 14 Kessler, Henry H. : Discussion of Fractures 11 State Department of Labor in Relation to the Public and Medical Profession 200 Kildufle, Robert A.: The Anemia of Pregnancy 341 Kiley, John E. : Occupational Dermatitis 613 Kinch, Frederick A.: Discussion of Pedographic Im- pressions in School Children 931 Discussion of the Physician's Part in the Training of Teachers 936 Kipp, Charles J. : Memorial Tribute to Dr. Charles J. Kipp 275 Klein, Edward C., Jr.: Ruptured Gastric Ulcer 412 Kramer, David W. : Circulatory Disturbances in the Extremities of Diabetics 560 Krauss, F. I. : Diet in Eczema of Infants 217 Discussion of Eczema in Infancy 228 Discussion of Essentials in Infant Feeding 216 Discussion of Gastro-Intestinal Disorders 20 Discussion of Integration of the Child 109 Discussion of Malnutrition in Children 211 Discussion of Whooping Cough 99 The Practitioner’s View of Medical Economics 743 Kuder, Joseph M. : Local County Medical Society Publicity %2 Kummel, Max: Medicolegal Aspects of Disability in Industrial Lead Poisoning 327 Lamson. William J. : Discussion of Pedographic Im- pressions in School Children 931 Lathrope, George H. : Discussion of Value of Duodenal Tube Drainage of the Biliary System 813 Etiology, Diagnosis and Treatment of Peptic Ulcer.. 344 Some Difficulties of the Asthma Problem 684 Levy, Julius: Child Hygiene 694 Discussion of Integration of the Child 109 Discussion of Whooping Cough 99 Influence of Public Health Activities on Medical Practice 193 Lippincott, A. Haines: Presessional Report of the Wel- fare Committee 438 Regular Report of the Welfare Committee. .Aug. Sup. 27 Littwin, Charles: Discussion of Ocular Muscle Abnor- malities 926 Lyon, B. B. Vincent: Discussion of Duodenal Tube Drainage of the Biliary System 815 Value of Duodenal Tube Drainage of the Biliary Sys- tem in the Treatment oi Disease and Disorders of the Liver 799 McBride, Andrew F. : Discussion of Fractures 14 Discussion of Symposium on Public Health Work... 206 McCauley, F- J. : Discussion of Eczema in Infancy 228 Eczema in Infancy 223 McGuire, James J. : Annual Report ol Board of Medical Examiners Aug. Sup. 29 Violations of Medical Practice Act 63 McKiernan, R. L. : Foreign Body in the Urinary Blad- der 709 McLean, Stafford: Discussion of Changes in Human Rickets After Viosterol Therapy 21 Maliniak, Jacques W. : Plastic Surgery 679 Marsh, Elias J. : Abell Commission Report 62 Discussion of Ocular Muscle Abnormalities 926 Treasurer’s Annual Report Aug. Sup. 19 Treasurer’s Presessional Report 496 Martin, J. W. : Discussion of Fractures 13-14 Relation of Traumatic Surgery to Industry 6 Marcus, Joseph H. : Clinical Evaluation of a Concen- trate of Vitamins A and D S50 Discussion of Clinical Evaluation of a Concentrate of Vitamins A and D 853 Marcus, Joseph M. : The Gastro-Intestinal Patient 90 Mark, Joseph S. : Differential Diagnosis of Lead Poi- soning 334 Prevention and Control of Lead Poisoning in In- dustry 773 Marvel, Philip, Jr.: Cardiac Irregularities 903 Discussion of Cardiac Irregularities and Silent Mitral Stenosis 913 Mengel, Willard G. : Squint in Childhood and Its Ef- fect in Later Life 700 Miller, D. J. M. : Discussion of Non-Pathologic Heart Murmurs in Children 103 Morrison, J. Bennett: An Historical Sketch of Develop- ment of Preventive Medicine in New Jersey 731 Discussion of Fractures 10 Discussion of Symposium on Public Health Work.. 206 Newcomb, M. W. : Discussion of Pedographic Impres- sions in School Children 931 Nichols. Stanley H. : Discussion of Clinical Evaluation of a Concentrate of Vitamins A and D 853 Discussion of Integration of the Child 109 Discussion of Non-Pathologic Heart Murmurs in Children 102 Nicholson, Percival: Discussion of Eczema in Infancy 227 Discussion of Essentials in Infant Feeding 217 Discussion of Gastro-Intestinal Disorders 20 Essentials in Infant Feeding 212 North, Harry R.: Finance and Budget Committee Re- Okin, Irving: Discussion of Nipn- Pathologic Heart Murmurs in Children 103 Non-Pathologic or Functional Heart Murmurs in Children 100 Orr, Thomas G. : Culture 581 Osmun, L. Cook: Councilor District Meeting 63 Paddock, Royce: The Dust and Bacterial Factors in Asthma 687 Pannell, W. L. : Some Oddities in Acute Mastoid Dis- ease 22 Parsonnet, Aaron E. : Myocardosis; The Failing Heart of Middle Life 831 Treatment of Acute Coronary Thrombosis 296 Parsons, William Barclay: Indications for Surgery in Diseases of the Thyroid 431 Patterson, Ross V.: Our Responsibility for Public Edu- cation Regarding Comparative Costs of Sickness... 585 Peacock, Robert: Discussion of Symposium on Pub.ic Health Work 207 The Doctor and the Law 203 Peer, Lyndon A.: Asthma from the Standpoint of the Rhinologist 692 Tube Flaps in Reconstructive -Surgery of the Face.. 86 Perlberg, Harry J. : A Few Thoughts in Therapy for Ailing Medical Practice Neither New Nor Official.. 960 Filler, Jacob: Treatment of Active Measles by Intra- muscular Injection of Recent Convalescent Whole Blood 340 Pinneo, Frank W. : Discussion of Fractures 10 Discussion of Symposium on Public Health Work... 206 Preliminary Report of Health and Accident and Automobile Insurance Committee 438 Regular Report of Health and Accident and Automo- bile Insurance Committee Aug. Sup. 34 Polevski, Jacob: Discussion of Cardiac Irregularities and Silent Mitral Stenosis 913 Discussion of Duodenal Tube Drainage of the Biliary System 815 Relation of Arteriosclerosis to Cardiac Pathology.... 762 Significance and Diagnosis of Silent Mitral Stenosis 910 Some Sources of Information and Misinformation in Cardiac Diagnosis 121 Pons, C. A. : Discussion of Fusospirochetal Disease of the Lung 849 Fusospirochetal Disease of the Lung 834 Quigley, F. J. : Discussion of Symposium on Public Health Work 207 INDEX Read, Hilton S. : Constipation 755 Danger Ahead in the Cathartic Habit 660 Reik, Henry O. : Automobiles More Deadly Than War 148 Discussion of Symposium on Public Health Work.... 207 Editorials (see list) Lighthouse Observations (see list) Presessional Report of Editor and Executive Secre- tary 439 Regular Annual Report of Editor and Executive Sec- retary Aug. Sup. 6 Reports to Welfare Committee 64, 65, 363 Reviews of Books for Collateral Reading: Biologic Basis of Human Nature — H. S. Jennings 145 Clinical Interpretations of Blood Examinations — Robert A. Kilduffe 433 Doctor and Patient — F. W. Peabody 360 Easier Motherhood — Constance L. Todd 433 Noguchi — Gustav Eckstein 778 Our New Progress — James Bayard Clark 361 Paris and All the World Besides — Robert M. Keeley 433 .Soviet Russia — William Henry Chamberlin 361 Women and Monks— Joseph Kalinikov ... . 361 State Medicine in England 246 State Medicine in France 354 State Medicine in Other Countries 427 Travel Talks, with Medical Observations 42. 135. ?16, 354, 427 Reissman, Erwin: Looking at the Facts in the High Cost of Medical Care 854 Rodman, E. W. : Consideration of the Causes of Diar- rhea 548 Rosenberg, L. Charles: Discussion of Essentials in In- fant Feeding 217 Discussion of Malnutrition in Children 212 Malnutrition in Children 208 Ross, William H.: Obligations of Professional Medical Service 159 Report of Governor Roosevelt’s Commission to De- vise a Public Health Program 508 The Open Hospital 51 Rothschild, Karl A.: One Year of Neurologic Service.. 47S Rubinow, S. : Some Thoughts on Medical Economics and Medical Practice 238 SchafF, Royal A.: Acute Perforation of Peptic Ulcers 417 Schapiro, Joseph: Discussion of Pedographic Impres- sions in School Children 931 Schiffmann. S. : Moses Maimonides — Physician and Philosopher 750 Schulte. Herbert A.: Treatment of Perforated Peptic Ulcer 421 Schwarz, Berthold T. D.: Short History of Diphtheria Eradication 529 Scott, James Ralph: Practical Management of Dia- betes 304 Sherman, A. Russell- Observations in the Vienna Eye Clinics 485 Sherman, E. S. : Discussion of Ocular Muscle Abnor- malities 926 Shope, Pierce: Refraction and Health 69 7 Silver, H. B. : Discussion of Clinical Evaluation of a Concentrate of Vitamins A and D 853 Smith, Ellis: A Skin Test for Whooping Cough 236 Snedecor. S. T. : Discussion of Pedographic Impressions in School Children 930-931 Discussion of the Physician’s Part in the Training of Teachers 935-936 Sommer, George N. J. : Discussion of Symposium on Public Health Work 207 Impressions of Annual Conference of Secretaries of Constituent State Medical Associations, 1930 60 New Year Greetings 49 Presidential Address 539 Presidential Address to House of Delegates. . Aug. Sup. 1 Spencer, G. T. : Intradural Caudal Anesthesia 235 Sproul, O. IL: Memorial Tablet to Dr. O. H. Sproul... 110 Stalberg, Samuel: Discussion of Integration of the Child ! 109 Stern, Arthur: Discussion of Diet in Eczema of Infants 222 Discussion of Whooping Cough 99 Stewart, Walter B.: The Cult of Asklepios 603 Stewart, W. Blair: Report of American College of Physicians Meeting 513 Stokes, John II. : Preventing the Transmission of Syphilis 391 Stokes, S. Emlen: The County Society 114 Subin, Harry: High Lights in the Life of Robert Koch 342 Sullivan, George F. : Discussion of Ocular Muscle Ab- normalities 926 Talleson, H. M. : Are We Underpaid? 578 Taneyhill, Mrs. E. C. : Report of Field Secretary Aug. Sup. 24 Teeter, Charles E.: Cardiac Failure of the Congestive Type 823 Toye. John E. : Discussion of Fractures 8 Wade, S. F. : Discussion of Duodenal Tube Drainage of the Biliary System 814 Wallhauser, H. J. F. : Discussion of Eczema in Infancy 226 Warren, C. B. : Discussion of Pedographic Impressions in School Children 930 Waters, Edward G.: pUn for Control of Special- ism Aug. Sup. 41 Plan for County Society Control of Periodic Health Examinations 956 Weber, F. C. : Bacterial Heart Failure 760 Weigel, Elmer P. : Discussion of Fractures 9-13-14 Wells. Walter A.: The Noises of Civilization and Their Evil Effects 653 Wherry, E. G. : Discussion of Eczema in Infancy 227 Wile, Ira S. : Integration of the Child 103 Williams, F. E. : Mental Hygiene 60 Wolf, I. J. : Recent Advances in Acute Poliomyelitis. . 936 Wright. Harold Edwin: Pre-School and School Physi- cal Examinations 61 Yaguda, Asher: Development cf a Postmortem Service 636 Yazujian, Dikran M.: Discussion of Tonsillectomy 30 Zehnder. Charles: Discussion of Ocular Muscle Abnor- malities . ... 926 B Board of Medical Examiners: Annual Report Aug. Sup. 29 Reported Prosecutions 63, 516 Board of Trustees, Report Aug. Sup. 20-51 Budget Committee Report Aug. Sup. 20 Business Committee: Appointment of Aug. Sup. 14 Report of Aug. Sup. 45 C Charter, Committee Report on Aug. Sup. 21 Child Health and Protection Aug. Sup. 12-48 COLLATERAL READING— How’s Your Blood Pressure? 951 Noguchi i 778 On an Anthology of Chestnuts 254 Real and Unreal 712 Review of Some Medical Books 433 Santa Claus and New Books 145 Some New Books 360 The Future of Freud — William Healy, Augusta F. Bronner, Anna Mae Bowers 52 The Immortal Lydia 664 Will Other Worlds Affect Our Health ? 870 COMMITTEE REPORTS— Board of Trustees Aug. Sup. 20, 51 Business •> Aug. Sup. 45 Charter Aug. Sup. 21 Constitution and By-Laws Aug. Sup. 3-35 Defense and Indemnity Insurance Aug. Sup. 33 Delegates to American Medical Association .. Aug. Sup. 36 Editor and Executive Secretary Aug. Sup. 6 Field Secretary Aug. Sup. 24 Finance and Budget Aug. Sup. 20 Health, Accident and Automobile Insurance. .Aug. Sup. 34 Honorary Membership Aug. Sup. 28 Hospitals and Medical Education Aug. Sup. 33 Judicial Council Aug. Sup. 17 Nominations Aug. Sup. 49 Post-Graduate Education Aug. Sup. 30 Program and Arrangements Aug. Sup. 3-19 Publication Aug. Sup. 2 Scientific Work Aug. Sup. 2 Secretary , Aug. Sup. 4-14 State Board Medical Examiners .. Aug. Sup. 29 Treasurer Aug. Sup. 19 Welfare Committee Aug. Sup. 27 COMMUNICATIONS— Abell Commission Report; Letter from Dr. Elias J. Marsh 62 Active Immunization Against Measles 447 Additional District Health Officers 596 American Association for the Study of Goiter 172 American College of Physicians 517, 879 American College of Physicians Clinical Session 171 American Physiotherapy Association; Letter from Dr. Harold D. Corbusier 63 An Interesting Item of History 675 Another Question of Ethics 675 Arc We Facing Social Control of Medical Practice?.. 674 Child Guidance — William Doody 595 Concerning Salt- Free Diet and Focal Infection 724 Councilor District Meeting; Letter from L. Cook Osmun 63 Crippled Children’s Commission 975 Defense Against Malpractice Suits 596, 725 Errors in Official List 447 First Councilor District Meeting 447 Gorgas Prize to New Jersey Girl 596 How French Dentists Met the Insurance Question 723 How Practipedists Are Made 976 Important Notice Concerning Health and Accident In- surance 976 INDEX Impressions of Annual Conference of Secretaries of Constituent State Medical Associations, 1930 — George N. J. Sommer 60 Mental Hygiene; Letter from Dr. F. E. Williams 60 New Jersey Conference of Social Work 974 One Reason Why Patent Medicine Venders Thrive.. 445 Pre-School and School Physical Examinations; Letter from Dr. Harold Edwin Wright 61 Society for the Relief of Widows and Orphans of Medi- cal Men in New Jersey; Forty-ninth Annual Report 674 Survey of Chronic Illness in New Jersey 974 Violations of Medical Practice Act 63, 516 Walt Whitman Hotel 64 CONFERENCES— Secretaries and Reporters of County Societies 956 Tristate Medical .. ,...148, 497, 585 Constitution and By-Laws Committee Report. .Aug. Sup. 3-35 Corrections 245 Errors in Official List 390, 447 Errors in The Journal 943 CURRENT EVENTS— American College of Physicians 513 American Medical Association Convention 666 Dr. R. D. Freeman Lauded at Dinner 875 Fifth Councilor District Meeting 261 New Jersey Conference on Child Health and Protection 511 New' Jersey Tuberculosis League 874 Present Status State Society — Rutgers Post-Graduate Course 259 Seventh Annual Conference of County Society Secre- taries and Reporters 956 The Physician’s Economic Contribution to the Com- munity—Charles Gordon Heyd 258 Urges Development of Posture Practice. Finds Cure for Old Age 875 Welfare Committee Minutes 64, 65, 363 Would Elevate Chiropractic 875 D Deafness— American Federation of Hard of Hearing 953 DEATHS— Beatty, Henry Moore 990 Benjamin, Dowling 84 Blair, James A 602 Blake, Duncan Williamson 286 Colhoun, Charles 390 Commorato, John 84 Craythorn, Charles J 538 Davis, Lester R 730 De Grofft, Eugene E 286 Demarest, Frederick F. C < 465 Donges, John W 390 Dowling, Charles E 898 Frazer, Thompson 898 Garrison, Biddle H 730, 794 Hedges, Benjamin Van Doren 83 Hunter, James J 601 Kitchen, J. M. W 286 Koch, Louis A ; 678 Lamson, William J 990 Lawrence, George W 465 Lindley, Charles L 538 Lockwood, Frank Wesley 730 McCormick, Daniel L 84 Madden, Walter 466 Mercer, Archibald 990 Moore, John H 186 Morse, George Vane 84 Osmun, Louis Cook 466 Paczkowski, Thaddeus . 898 Savoye, Richard G 186 Schureman. James Percy 538 Scott, George 466 Seibert, Raymond S 538 Simpsen, Maxwell S 990 Stratton, William N 538 Taggart, Thomas Dartnell 794 Van Mater, John H 730 Voorhees, Nathaniel Whitaker 602 Webster, D. King 466 Wilson, Norton L 950 Defense and Indemnity Insurance Aug. Sup. 33 DISCUSSION OF PAPERS— A Case of Pseudo-Hermaphroditism 899 A Few Thoughts in Therapy for Ailing Medical Prac- tice Neither New Nor Official 960 A Plan for County Society Control of Periodic Health Examinations 956 Cardiac Irregularities 903 Cardiac Irregularities and Silent Mitral Stenosis 912 Changes in Human Rickets After Viosterol Therapy.. 21 Clinical Evaluation of a Concentrate of Vitamins A and D 853 Clinical Management of Heterophoria 919 Combined Orthoptic and Operative Treatment of Con- vergent Squint in Young Children 923 Diet in Eczema of Infants 222 Eczema in Infancy 226 Essentials in Infant Feeding 216 Forcible Extension in an Ankylosed Joint 914 Fractures 8 Fusospirochetal Disease of the Lung 849 Gastro-Intestinal Disorders 20 Integration of the Child 109 Is Group Medical Publicity Ethical? 1. 961 Local County Medical Society Publicity 962 Malnutrition in Children 211 Non- Pathologic or Functional Heart Murmurs in Chil- dren 102 Ocular Muscle Abnormalities 926 Overlapping the Rectus Muscles for Correction of Stra- bismus 915 Pedographic Impresions in School Children 930 Some Oddities in Acute Mastoid Disease 26 Symposium on Public Health Work 206 Surgical Aspects of Biliary Tract Disease 797 The Physician’s Part in the Training of Teachers 935 Tonsillectomy 30 Treatment of Whooping Cough 99 Value of Duodenal Tube Drainage of the Biliary Sys- tem in the Treatment of Various Diseases of the Liver 813 E ECONOMICS— Are We Underpaid? — H. M. Tolleson 578 Family Doctor’s Income in Relation to Preventive Medicine 578 The Open Hospital — William H. Ross 51 Editor: Presessional Report of 439 Regular Annual Report of Aug. Sup. 6 EDITORIALS— Adding Insult to Injury 133 Advance Notice of Annual Meeting 425 An Apt Phrasing of Medical Ethics 781 Asbury Park Convention 579 Automobiles More Deadly Than War 861 Control of Specialism 243 County Society Advertising 131 County Society and Hospital Reports 426 Crippled Children’s Commission 779 Doctors Are “Easy Marks’’! 351 Entering Upon a New Fiscal Year 580 Errors in the Journal 943 Fractures and the Compensation Law 49 Growing Importance of Mental Hygiene 780 In This Issue 245 Interesting Information Concerning Old Golds 493 Iowa Plan of Securing Payment for Services to the Community's Indigent Sick 49 Legislation in the Making 245 Medical Service of the Future 132 Necessity for Vacations 661 Negotiating Loans for Medical Expenses 244 New Year Greetings — George N. J. Sommer 49 Newspaper Publicity j 713 Parlous Times 941 Personal Interest and Activity 353 Preliminary Announcement Regarding Post-Graduate Medical Courses 863 Revision of Public Health Laws 714 State Medicine 352 Status of State Medicine 426 Study of State Medicine 662 The Official Transactions 661 The Passing Westward of Osmun and Lawrence 425 The Physician an Idealist 352 What Price Football! 942 Workman’s Compensation Law 713, 863 Election of Officers Aug. Sup. 49 ESTHETICS— Appreciation of Good Music 254 Consider the Dreamer 360 Culture — Thomas G. Orr 581 Make Your Own Murals 494 Music in Relation to Art and Life 54 Musical Matters of Interest to Physicians 868 Phlebitis — E. S. Corson 142 Recognition of Home Talent 141 INDEX Requiem to the Unknown Soldier — Ralph S. Cone 142 Roadside Esthetics ~8J The War Nurse’s Story — Ralph S. Cone 141 The Windmill Orchestra Conductor , .... 717 ETHICS— C’est Formidable L'Opiniou Publique 717 Character — Decent Conduct 782 Hurry, Hurry, Hurry! -. 952 Lowering of the Standard of Ethics 53 Medical Societies 581 More Health Ethics 143 Patients Must Not Be Neglected 432 Success 867 The Law Is an Ass .t., 663 The Physicians in Holy Writ 252 Times Square Has a Summer Visitor 663 Uphold Honor of the Profession 494 “Who Steals My Purse Steals Trash" 359 Executive Secretary: Presessional Report of 439 Regular Annual Report of Aug. Sup. 6 Reports to the Welfare Committee 64, 65, 363 F Field Secretary, Report of Aug. Sup. 24 G Group Defense and Indenmnity Insurance Aug. Sup 33 Group Health and Accident and Automobile Insur- ance Aug. Sup. 34 H Hard of Hearing, American Federation of 953 House of Delegates, Transactions of Aug. Sup. 1-56 I INSURANCE— Defense and Indemnity Aug. Sup. 33 Health and Accident and Automobile — ..438, Aug. Sup 34 Important Notice Concerning Health and Accident In- surance 976 J Judicial Councilors, Reports of Aug. Sup. 17 L Lighthouse Observations 55, 147, 148, 257, 441, 497, 583, 665, 666, 719, 720, 784, 872, 953 M Maternal Welfare, Resolutions on . ,..Aug. Sup. 42 Medical Defense and Indemnity Insurance ...... Aug. Sup. 33 Medical Examiners, Report of Prosecutions Aug. Sup. 9, 63, 516 Membership. Official List April Sup. 1-48 Mental Hygiene, Committee Report ....Aug. Sup. 48 N New Jersey Conference on Child Health and Protection 511 Nominating Committee Report Aug. Sup. 49 O OBSERVATIONS FROM THE LIGHTHOUSE— Acute Hemorrhage from Corpus Luteum and Graafian Follicle 665 American Federation of Organizations for the Hard of Hearing 953 Combination Anesthesia 583 Diagnostic Relationship of Physician and Dentist...... 872 Head Injuries 441 Management of Angina Pectoris 597 Massage in Rehabilitation Work 148 Mental Hygiene and Industry . 720 Mental Hygiene and the Child 666 Practical Use of Spinal Anesthesia 719 Public Relations Committee 55 Rehabilitation of the Disabled 147 The Patient with Heart Disease 257 Vocal Cords of Metal 257 Why We Reach for That Sweet 784 Officers, Election of Aug. Sup. 49 Official Transactions, Annual Meeting ........ Aug. Sup. 1-86 ORIGINAL ARTICLES— Acute Abdomen — John B. Deaver 407 Acute Perforation of Peptic Ulcers — Royal A. Schaff.. 417 A Doctor's Confession of Faith — Wells P. Eagleton 2S7 Advantages of General Anesthesia in Tonsillectomy — William Campbell 29 A Group of Endocrine Cases — Frank J. T. Aitken 470 Alcoholic Pseudo- Pellagra — N. B. Heller 467 Anemia of Pregnancy — Robert A. Kilduffe 341 An Historical Sketch of Development of Preventive Medicine in New Jersey— J. Bennett Morrison 731 Are We Underpaid? — H. M. Tolleson 578 A Romance of Paternalism — Walter F. Donaldson 587 A Skin Test for Whooping Cough — Charles V. Craster, Ellis Smith 236 Asthma from the Standpoint of the Rhinologist — Lyn- don A. Peer 692 Automobiles More Deadly Than War — Henry O. Reik 148 Bacterial Heart Failure — F. C. Weber 760 Bacteriologic Study of Chronic Infectious Arthritis — John W. Gray, Cecil H. Gowen 38 Cardiac Failure of the Congestive Type — Charles E. Teeter ■ 823 Changes in Human Rickets After Viosterol Therapy — John Caffey 21 Child Guidance— William Doody 595 Child Hygiene — Julius Levy 694 Circulatory Disturbances in the Extremities of Dia- betics— David W. Kramer 560 Clinical Evaluation of a Concentrate of Vitamins A and D — Joseph H. Marcus 850 Clinical Significance of High and Low Blood Pressure — R. Burton Opitz 302 Common Conditions in Industrial Ophthalmology — George J. Dublin 7C4 Common Diseases of the Oral Mucosa — Bart M. James 563 Consideration of the Causes of Diarrhea — E. W. Rod- man 548 Constipation — Hilton S. Read 755 Continued Education of the Doctor — John A. Hartwell. 639 Councilor District Meetings — Dr. Snedecor 506 County Society — S. Emlen Stokes 114 Cult of Askiepios — Walter B. Stewart 603 Culture — Thomas G. Orr 581 Danger Ahead in the Cathartic Habit — Hilton S. Read 660 Development of a Postmortem Service— Asher Yaguda 636 Development of Public Welfare Work — William J. Ellis 187 Diabetes Mcllitus and Thrombo angiitis Obliteians in the Same Patient — Harold S. Davidson 570 Diet in Eczema of Infants — F. I. Krauss 217 Differential Diagnosis of Lead Poisoning — Joseph S. Mark 334 Doctor and the Law — Robert Peacock 203 Duodenal Stasis — Charles Frederick Baker 1 Dust and Bacterial Factors in Asthma — Royce Paddock 687 Eczema in Infancy — F. J. McCauley 223 Essentials in Infant Feeding — Percival Nicholson 212 Etiology, Diagnosis and Treatment of Peptic Ulcer — George H. Lathrope 344 Factors in the Early Diagnosis and Treatment of Frac- tured Skulls — H. Wesley Jack 608 Female Sex Hormone — Rita S. Finkler 766 Foreign Body in the Urinary Bladder — R. L. McKier- nan, H. H. Goldstein 709 Fungus Infection of the Skin — S. J. Fanburg 92 Fusospirochetal Disease of the Lung — F- J- Altschul, C. A. Pons, W. G. Herrman 834 Gastro-Intestinal Disorders — Charles Gilmore Kerley.. 14 Gastro-Intestinal Patient — Joseph M. Marcus 90 Generla Practitioner and Obstetrics — Samuel A. Cos- grove 545 Health Department Growth in New Jersey — D. C. Bowen 196 Hereditary Epistaxis — Hyman I. Goldstein 309 High Lights in the Life of Robert Koch — Harry Subin 342 Indications for Surgery in Diseases of the Thyroid- William Barclay Parsons 481 Influence of Public Health Activities on Medical Prac- tice— Julius Levy 193 Integration of the Child — Ira S. Wile 103 Intradural Caudal Anesthesia — G. T. Spencer 235 Leukorrhea- P. Brooke Bland 489 Liver Cysts— John II. Hermann, Guy B. Griffin 337 Looking at the F'acts in the High Cost of Medical Care — Erwin Reissman 854 Malnutrition in Children— L. Charles Rosenberg 208 Medical Ethics — Harry H. Bowles 35 Medical Possibilities of Sea Water — C. L. DeMeritt... 706 Medical Service of the Future — G. W. Haigh 115 Medicolegal Aspects of Disability in Industrial Lead Poisoning — Max Kumme! 327 Memorial Tablet to Dr. O. H. Sproul — John F. Hagerty 110 Modern Treatment of Varicose Veins — V. Earl Johnson 229 Moses Maimonides — Physician and Philosopher — S. Schiffmann 750 Myocardosis; The Failing Heart of Middle Life — Aaron E. Parsonnet, Albert S. Hyman 831 New Method of Outlining the Heart, Its Chambers and Great Vessels — Clyde M. Fish 817 Noises of Civilization and Their Evil Effects — Walter A. Wells 653 Non -Pathologic or Functional Heart Murmurs in Chil- dren— Irving Okin 100 Obligations of Professional Medical Service — William H. Ross 159 INDEX Obstetric Mortality — J. C. Hartman 31 Observations in the Vienna Eye Clinics— A. Russell Sherman 485 Occupational Dermatitis — John E. Kiley 613 One Year of Neurologic Service — Karl Rothschild 478 Our Responsibility for Public Education Regarding Comparative Costs of Sickness— Ross V. Patterson.. 585 Pedographic Impressions in School Children — Donald B. Hull 928 Physicians’ Economic Contribution to the Commun- ity— Charles Gordon Heyd 258 Physician's Part in the Training of Teachers — Grace M. Kahrs 932 Plastic Surgery— Tacques W. Maliniak 679 Practical Gastro-Enterology — J. Gerendasy 768 Practical Management of Diabetes— James Ralph Scott 304 Practitioner’s View of Medical Economics — F. I. Krauss 743 Presidential Address — George N. J. Sommer 539 Prevention and Control of Lead Poisoning in Industry— Joseph S. Mark 773 Preventing the Transmission of Syphilis— John H. Stokes 39J Prevention of Measles — George Heller 617 Public Relations as a Specific — John S. Irvin 959 Publicity, A Remedy for Many Society Froblems— R. I. Downs 959 Radiographic Diagnosis of Gall-Biadder Pathology— Louis J. Gelber 829 Recent Advances in Acute Poliomyelitis — I. J. Wolf. . 936 Recurring Postoperative Parotitis— Harold S.‘ Davidson 85 Refraction and Health — Pierce Shope ,. 697 Relation of Arteriosclerosis to Cardiac Pathology— Jacob Polevski 753 Relation of Traumatic Surgery to Industry— J. W. Martin ‘ g Report of Governor Roosevelt’s Commission to De- vise a Public Health Program— William H. Ross 508 Review of Recent Literature on Thrombo-angiitis Ob- literans— Max Gross 57] Rupture of Gastric Ulcer— Edward C. Klein, jr. 412 Short History of Diphtheria Eradication— BeHhold T. D. Schwarz 539 Significance and Diagnosis of Silent Mitral Stenosis— J. Polevski 910 Sinusitis — E. S. Hallinger 475 Some Difficulties of the Asthma Problem— George H7 Lathrope ^84 Some Oddities in Acute Mastoid Disease— W. L. Pan- nell 22 Sciir,e s . Information and Misinformation in Cardiac Diagnosis — Jacob Polevski 121 Some Thoughts on Medical Economics and Medical Practice — S. Rubinow 218 Squint in Childhood and Its Effect in Later Life— Wii- lard G. Mengel 700 State Department of Labor in Relation to the Public and Medical Profession — Henry H. Kessler 200 Statistical Study of Diphtheria in Newark— Joseph William Gardam ‘ g3g Surgical Aspects of Biliary Tract Disease-^- John B Deav« 795 Thrombosis and Embolism — Frederic W. Bancroft 619 Tonsillectomy bv Diathermy— A. S. V. Giglio 771 Tonsillectomy Under Local Anesthesia— Robert H Fowler 27 Treatment of Active Measles by Intramuscular Injec- tion of Recent Convalescent Whole Blood— Jacob Filler 340 Treatment of Acute Coronary Thrombosis— Albert S. Hyman, Aaron E. Parsonnet 396 Treatment of Bight’s Disease— Rolfo Floyd 55? Treatment of Perforated Peptic Ulcer— Herbert A. Schulte 40J Treatment of_ Whooping Cough— A.' ' S.' ’ Fi’n’keistein .' 96 Tube Flaps in Reconstructive Surgery of the Face— Lyndon A. Peer gg Useful Irrigating Fluid for Septic Wounds— H. h! Gold- 492 819 Uterine Hemorrhage Radiologically Considered— W. G Iierrman Value of Blood Sedimentation Test in Gynecology John Huberman 403 Value of Duodenal Tube Drainage of the Biliary Sys- tem in the Treatment of Diseases and Disorders of the Liver — B. B. Vincent Lyon 799 What Are State Departments of Labor Doing to Ad- vance Industrial Surgery ?— Round Table Discussion. 498 What Is Wrong with the Fracture Situation ?— J. K. Adams j What the Present Day Public Thinks’ ' of' 'the ' Medical PERSONAL ITEMS— POEMS— De Profundis 242 Don’t Quit ; 777 Phlebitis — E. S. Corson 142 Requiem to the Unknown Soldier— Ralph S. Cone ..... 142 September 712 The Bell Buoy — Ralph S. Cone 577 The Love of Books 859 The War Nurse’s Story — Ralph S. Cone 1 141 Today 41 POST-GRADUATE EDUCATION— Preliminary Announcement Regarding Post-Graduate Medical Courses 863 Committee Report • Aug. Sup. 30 Preliminary Program of. Annual Meeting 435-441 Pre-School Child, Medical Care of . ...Aug. Sup, 50 President: Annual Address of 539 Opening Address to House of Delegates Aug. Sup. 1 PRESESSIONAL REPORTS— Committee on Health and Accident and Automobile Insurance 438 Editor and Executive Secretary 439 Treasurer 496 Welfare Committee , 438 PROGRAM AND ARRANGEMENTS— Annual Report : ..-. .Aug. Sup. 3-19 Preliminary Report 435-441 PUBLIC RELATIONS— Agree Not to Publish Doubtful Advertising . 876 Announcement of the First Award Under the Thomas W. Salmon Memorial 263 A “White Collar” Hospital That Is Proving the Case 514 Bill No. 304 Abell’s 57 Consultation Service at Mt. Sinai Hospital for People of Moderate Means 721 Control of Proprietary Medicine 514 : Copyright Glasses ;..... 972 Disclosure of Diseases Under Prohibition Act Abolished 261 Doctor’s Dilemma 878 Future of Surgery 723 Generosity Runs Riot 722 Governor Looks at Chiropractic 442 Hold Free Foot Clinic in Resort This Week 878 How Science Nipped an Epidemic 169 “In a Heluva Fix” .-... 972 Infant Mortality Lowest in History 57 Leadership in Medicine 878 Legal Voluntary Euthanasia 972 Male Prostitute Convicted 720 Measurement of Noise 784 Medical Cowards 722 More Persons in Mental Than in General Hospitals.. 671 New Jersey Pharmaceutical Convention 671 Newark Tops Class in Health Rating 442 Noisy Ambulances 970 Report to the Commissioner , of Labor by the Work- man’s Compensation Advisory Commission .... 442 Smith Urges Clinics or Health Insurance , 877 Staging a Health Drive Among Pre-School Children.. 672 State Medicine and Control of Specialism 168 Surgeons Reduce Fees 57 The Hoe, a Cure for Crime 971 The New England Medical Center 262 The Supertrained Nurse 672 Tobacco 875 Vaccination Favored to Prevent -Diphtheria 877 Warning to Physicians 261 White House Conference on Child Health and Protec- tion 58 PUBLICATION COMMITTEE— Annual Report of Aug. Sup. 2 R RESOLUTIONS— Committee to Study Status iof State Medicine .Aug. Sup. 47 False and Misleading Advertisements Aug. Sup. 47 Maternal Welfare Aug. Sup. 42 Medical Care of Pre-School Child Aug. Sup. 50 Medical Care of School Children Aug. Sup. 43 Mental Hygiene Aug. Sup. 48 Motor Vehicle Accidents Aug. Sup. 48 Prohibition ; Aug. Sup. 5 Specialists and Specialism Aug. Sup. 37 Jan., xxiii. ; Feb., xxviii.; Mar., xxi.; Apr., xxi.; May, XXI.; June xxi.; July, xxi.; Aug., xxi.; Sept., xiv.; Oct., xiv.; Nov. xiv. S SCHOOL CHILDREN— Medical Care of Aug. Sup. 43 INDEX SCHOOL HEALTH DEPARTMENT— Cafeteria and Luncheon 785 Clippings 723 Minimum Bibliography for School' Physicians 515 Notes from Los Angeles 444 Notes of General Interest 365 Physician’s Part in Hygiene and Sanitation of the School Building 879 Pupil Supervision 673 School Physician’s Part in Health Education 973 Special Meeting of School Physicians 263 Standards for Prevention and Control of Contagious Diseases 169 Suggested List of Activities for School Physicians 597 School Health Work — Request of Dr. Ireland. .Aug. Sup. 35 School Physicians, Section of ! Aug. Sup. 62 Scientific Work, Report of Committee Aug. Sup. 2 Secretary: Annual Report Aug. Sup. 4-14 Secretaries and Reporters of County Societies. Annual Conference 956 SOCIETY REPORTS— Councilor District Meetings: Councilor District Meeting 63 First Councilor District Meeting 276 Second Councilor District 522 Third Councilor District 894 Fifth Councilor District 450 Round Table Discussion of 506 County Medical Societies: Atlantic 71, 175, 268, 370, 450, 519. 883, 978 Bergen 73, 178, 271, 375, 450, 522, 791, 885, 979 Burlington 271, 376, 523 , 782, 980 Camden 73, 178 , 272, 377 , 451, 524, 886, 982 Cape May 982 Cumberland 179, 451, 678, 886 Essex 73, 179, 272, 377, 451, 524, 886, 982 Gloucester 74, 179. 277 , 382 , 454 , 526, 793 . 888 , 983 Hudson 74. 180. 277, 382, 454, 526, 888 Hunterdon 184. 462, 987 Mercer 81, 184, 284 , 388, 462. 534 , 599. 893 , 988 Middlesex- 81, 184, 388, 463, 599, 895, 988 Monmouth 82, 285, 389, 463, 535, 599, 896 Morris :82, 185 , 389. 536, 600, 793 , 988 Ocean 163, 537, 988 Passaic 83, 185 , 285 , 390. 463 , 537 , 794, 896, 989 Salem 285, 464, 897 Somerset 285, 464, 600, 897 Sussex 286, 989 Union 185,464,678,897 Warren ...186, 537, 989 Local Societies: Academy of Medicine of Northern New Tersey 381, 526, 888, 983 Eye, Ear. Nose and Throat Section 74, 179, 272, 379, 453, 525, 888, 983 Atlantic City Hospital Staff 71, 176, 268, 374, 520. 598, 677, 728, 788, 885, 979 Bayonne Hospital Clinical Conference. . 180, 283 , 461, 890, 987 Jersey City Medical Center 80, 460 North Hudson Hospital Clinical Society 77, 182, 383, 458, 531, 891, 984 Pine Rest Sanatorium 72 Rutgers Medical Club 82, 185, 388, 535, 599, 895 Summit Medical Society 185, 464, 537, 897 Westfield Medical Society 83, 898, 989 SPECIAL ARTICLES— Medical Travel Talk — Henry O. Reik...42, 135, 246, 354, 427 Recent Visit to the Grenfell Mission on the Labrador- Travel. Visit to Royal Victoria Hospital, Montreal— John Hammond Bradshaw 715 John Hammond Bradshaw 864 Some Observations Upon Health Matters in England— Henry O. Reik 944 SPECIALISTS AND SPECIAL1SM- Plan for Control of Aug. Sup. 41 Resolutions on Aug. Sup. 37 STATE HEALTH DEPARTMENT— District Health Officers 597 Laboratory Tests in Undulant Fever 366 Narcotic Control 516 Pasteurization of Milk 170 Spotted Fever 673 State Health Laws 59 State Medicine, Committee to Study Aug. Sup. 47 T Transactions, Annual Meeting Aug. Sup. 1-86 Travel Article: A Visit to the Royal Victoria Hospital, Montreal 715 Treasurer, Annual Report Aug. Sup. 19 Presessional Report 496 Tristate Medical Conferences 148, 497, 585 Trustees: Annual Report Aug. Sup. 20-51 W WELFARE COMMITTEE— Annual Report Aug. Sup. 27 Minutes of November Meeting 64 Minutes of December Meeting 65 Minutes of March Meeting 363 Presessional Report of 438 WOMAN’S AUXILIARY— Adulteration of Foods 879 Annual Meeting, Minutes of Aug. Sup. 63-86 Annual Meeting, Transactions of Aug. Sup. 63-86 A Task Proposed for the Auxiliary 726 Attention Ladies 172 Executive Board Meeting 448, 881, 976 Note from the Editor 367 Panoramic View of the Woman’s Auxiliary to the American Medical Association 172, 367, 598, 676 Preliminary Program Woman’s Auxiliary to the Ameri- can Medical Association 173 Society for Relief of Widows and Orphans of Medical Men of New Jersey — Edward J. Ill 69 State Society Auxiliary 70, 173 Winning Them Over 70 Woman’s Auxiliary A. M. A. Ninth Annual Conven- tion 517 Woman’s Auxiliary to the American Medical Asso- ciation 786, 977 Woman’s Part in Medical History. Jane Todd Craw- ford— The Model Patient 264 Women at the A. M. A. Philadelphia June Meeting.. 448 County Reports: Atlantic 174, 266, 369, 518 Bergen 70, 369 Burlington 881 Camden 174 Essex 174, 266, 369, 881, 977 Gloucester 70, 266, 369 , 449, 519, 881, 977 Hudson 70, 267, 370, 449, 787, 882, 978 Hunterdon 449, 978 Mercer 267, 519, 978 Ocean 267, 882 Passaic 174 Somerset 175, 370, 882 Union 175, 267, 370, 449, 727, 882 Workman’s Compensation and Contract Practice, Com- mittee on Aug. Sup. 45 Journal of The M edical Society of New J ersey Published on die First Day of Every Month Under the Direction of the Committee on Publication Vol. XXVIII., No. 1 ORANGE, N. J„ JANUARY, 1930 Y“r DUODENAL STASIS* Charles Frederick Baker, M.D., Newark, N. J. Duodenal stasis is undoubtedly much more frequent than was formerly recognized. That it may be the cause of symptoms which we have been prone to lay to diseases of the ap- pendix and gall-bladder is a possibility with which we must reckon, for operations upon those organs do give relief, unless coincidently the factors producing duodenal stasis are rec- ognized and, so far as possible, corrected. The causes of duodenal stasis may produce continuous or intermittent effects. Those producing continuous mechanical obstruction and interference with normal duodenal mo- tility may be extrinsic or intrinsic. The ex- trinsic are peritoneal bands resulting from cholecystitis ; anomalies of the pancreas in- cluding tumors or annular pancreas ; compres- sion by the superior mesenteric or other ar- teries in the mesenteric root, behind which lies the horizontal portion of the duodenum ; gas- troptosis and ptosis of the colon and small in- testine. The intrinsic causes include anom- alies of duodenum, size and position; ulcer; tumors ; etc. Those producing intermittent or temporary stenosis are attributed by some to neuromuscular derangement ; by others to su- perior mesenteric artery compression accom- panying right-sided ptosis or ptosis of the small intestine. Conceivably, a drag upon the ♦(Read at the 164th Annual Meeting of the Medical Society of New Jersey, Atlantic City, June 13, 1930.) mesentery, producing intermittent stasis, may follow periods of atonicity during severe physical and nervous depression, particularly with overloading of a low cecum and conse- quent increased dragging upon its support ; whereas, when, following rest or general re- laxation a better tone develops, an improve- ment would occur. Ptosis of the stomach, by a dragging down- ward of the upper portion of the duodenum, causes an unusual angulation of the upper- third of the descending portion, with stenosis and dilatation. Inflammatory bands, result- ing from cholecystitis and periduodenitis fol- lowing ulcer, as well as anomalous develop- ment of the peritoneum or failure of absorp- tion of embryonal peritoneum, affect the lower angle or junction of descending and horizontal portions. Pressure by the superior mesenteric or other branches which leave it or the aorta at about the same level, gener- ally produce dilatation and stenosis in the horizontal portion. Inflammatory bands be- tween the duodenum and jejunum at the duo- denojejunal angle are generally the causative factor in stenosis of the ascending portion. The superior mesenteric artery leaves the aorta above the horizontal portion of the duo- denum, which it crosses, and gives off the midcolic, right colic, ileocolic and terminal branches to the small intestine. Many anom- alies occur in this as in other anatomic structures. As stated by Kellogg: “The arterial walls possess little elasticity as compared to the tis- sues which surround them and when the or- gans to which the arteries are distributed be- 2 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 come prolapsed, the latter become their chief support and may compress the duodenum. For this reason, prolapse of the small intes- tine compresses the third duodenal segment, by a direct pull upon the superior mesenteric artery, providing the prolapse is not sufficient to permit the intestines to rest upon the pelvic floor. Prolapse of the cecum drags upon the ileocolic, and through it on the superior mes- enteric, causing compression at the same point. With descent of the hepatic flexure, the right colic, when it crosses the duodenum, compresses the second or third segments proximal to the mesenteric root. More than one artery may be involved and (this is im- portant) a combination of arterial compres- sion and congenital or acquired bands is com- mon.” Symptomatology. The symptoms are due to the mechanism of obstruction and to the tox- emia, which is severe in direct proportion to its proximity to the pylorus. From the ob- struction we find nausea or vomiting. The latter may be either spontaneous or forced, to obtain relief, and occurring or produced after a relatively short period following reception of food into the stomach; pain in the upper abdomen, either to the right or left of the median line, and often deep and referred to the back as in cholecystic disease; it may also radiate to the shoulders. The pain may be very severe or there may be complete absence of this symptom. It may be relieved by pos- ture, particularly if a change of position re- lieves a drag of the prolapsed intestine. These symptoms may be worse when the cecum is over-full and constipation is present. If the compression affects the region of the ampulla of Vater, secondary effects may be present in the liver, with enlargement and increased sensitivity of both liver and gall-bladder. I he toxic effects are more or less of a mi- graine character: so-called bilious attacks which may have originated in childhood, ushered in by marked constipation and head- aches ; disturbance of mental processes ; severe physical depression ; disturbed heart action ; poor peripheral circulation ; hyper and paresthesias ; skin eruptions ; subnormal tem- peratures and blood pressure, most of which arc typical of toxemias in general. Physical examination may reveal unusual tenderness along the course of the duodenum, ;f it is distended, and a tympanitic note may be found behind the right rectus muscle to the right of and below the pylorus between the liver and transverse colon. Duodenal succes- sion may be elicited. Pressure may sometimes empty the duodenum and the gas may be heard as it rushes into the jejunum; follow- ing which the area of tympany disappears. The Roentgen-ray examination may easily settle the diagnosis but when the cause lies chief!} in mesenteric compression a negative report is common. The reason for this is that the mechanism may not always operate to produce partial obstruction, with delay in the passage of the barium content through the duodenum, and peristalsis may at the time of the examination be excellent. Improved peri- stalsis may result from a rest period of a few days or weeks preceding the x-ray ex- amination ; or a cathartic the day before may so improve peristalsis that stasis is overcome. 1 he radiograph may reveal varying degrees of stasis from simple lagging in the flow of the intestinal contents to complete stoppage. The normal current through this organ is so rapid that a true intestinal outline of the duo- denum is never seen, unless delay exists. The barium shadows appear as mere flecks dis- seminated along its course. As the barium mixture distends the dilated duodenum, valvulae conniventes appear, which under or- dinary circumstances are generally first recog- nized in the upper jejunum. Hence, any films showing a distinct intestinal outline, in the regions of the descending or horizontal portions, should at once intrigue us into care- ful analysis of Roentgen and physical find- ings and symptomatology, to see if we can- not unravel the mysterious cause of a chronic dyspepsia which may have bothered the pa- tient for a considerable time and for which he may have already been operated upon with- out relief. In cases showing greater dilation in the more obstructive lesions, the signs are so ap- parent that literally one who runs may read Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 3 the findings. The duodenum may be 2 or 3 times its normal diameter, and the stomach also dilated. Under the fluoroscope, the duo- denum may be seen to writhe in spasm, and waves of reverse peristalsis may be demon- strated. It is held by some that fluoroscopy is the method of choice in detection of this con- dition. If it is not used many pictures should be made with the patient in different postures, at least the prone, oblique, lateral and vertical. Treatment. Many cases are amenable to the usual measures employed to relieve en- teroptosis and intestinal stasis. Surgical measures are indicated when medical fail to relieve. Some are plainly surgical in the be- ginning, notably those in which the duodenum is greatly dilated or is causing frequent cop- ious regurgitation of bile. Personally, I do not feel that it is pertinent for the roentgen- ologist to discuss the various surgical meas- ures and will leave that to others. WHAT IS WRONG WITH THE FRACTURE SITUATION* J. K. Adams, M.D.. East Orange, N. J. Some well meaning persons suggested that I read a paper on fractures in 15 minutes. This seemed to me a good deal of a contract, and I wrote the Secretary that 1 really did not think I could do that, but that instead I might make a few remarks on the fracture situation in general, which perhaps might promote a discussion. At any rate, I will promise you one of the shortest papers that was ever read before this society, if you want to call it a paper. It seems to me that there is something wrong with the fracture situation, and that the great- est trouble lies in the present arrangement of services in our hospitals. I am assuming that it is the earnest desire of each and every one of us who treat these conditions to have the hospital services so arranged that the patients *(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Atlantic City, June 14, 1930.) will get the greatest benefit possible. It seems to me that “rotating” services, where from 2 to 4 different men handle a case, do not give the best results. The responsibility is divided. The problems facing each man as he goes on duty are not as clear cut and well defined as they would be had he handled the case from the beginning. This creates a situation that is distressing to the patient and his relatives, not to mention some of the doctors. A frac- ture occurring the latter part of the month is often delayed in receiving the attention it should, in order that the man coming on duty the first of the next month can handle it from the beginning; and patients who should have their casts or apparatus removed near the end of a month are often left over to the first of the next month for the man who originally put the cast on to take over the case again. It occurs to me that there is nothing stimulating about such a service. It lacks interest and, frequently, the functional results suffer. The medical profession created this type of ser- vice ; we created it, and it is up to us to get rid of it. No one else is responsible. It seems time for a change, and it has been changed in many hospitals with very gratifying results. As I see the problem, there are 3 things that can be done : (1) Have a service called a “Fracture Service”, to be under the charge of one man with as many assistants as the work requires. The entire responsibility will be his and all due credit will be his. He cannot pass the buck to anyone. The compensation income from such cases might be divided between the Fracture Service Staff and hospital; that is, if they want to divide it. What you do with the money so derived does not matter much because it amounts to an extremely small sum to any one person. It could very well be spent on equipment, which is not very ex- pensive. The head of such service should spend at least 2 weeks each year in visiting first class bone clinics, actively studying the manner in which they are treating these cases, and should upon returning read a written report to the staff of his hospital. (2) If the first method is not cared for, I 4 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 siiggcst the following : Let everyone treat the fractures in the old way, but at the end of the month, when a man goes off duty on everything else, let him continue to treat the fracture patients that he has been treating, and to treat them continuously until they are discharged. This method has the advantage of No. 1 in placing responsibility where it belongs, and it also prevents buck-passing. Further, it prevents men saying their fractures were taken from them. (3) A “Traumatic Surgery Service” ab- solutely continuous like No. 1 might be es- tablished. This would prevent any quibbling in a case where there is a minor fracture but decided nerve, ligament or muscle injury. There could be no misunderstanding as to whose service the case belonged, and who was to control treatment. It may interest you to know that when the new Physicians’ and Surgeons’ Hospital was started in New York it was decided to have a fracture ser- vice, but that anyone of the staff who wished could, by saying so, treat his proportion of fractures, but he was required to finish every case he started. I am told by the head of the service that since that rule was made only 1 man has asked to treat such a case, and he only asked once. Is there anyone here who does not believe that a properly organized fracture service by men interested in the subject, and who are con- tinuously working on it, will produce better results than the old rotating type where everyone tries to do everything? The fracture equipment in many of our hospitals is insufficient or poorly kept. This chaotic state of affairs is often due to the fact that the equipment is not under somebody’s special supervision. There may be a closet into which all fracture equipment is thrown; a few old Thomas’ splints, some rope and per- haps a few splints bought from some clever salesman by the superintendent but which no one would ever use. Such an assortment and a few very poor Balkan frames may con- stitute the entire equipment. The reason for this is that no one was really interested in the subject. A physiotherapy department does not ex- ist in some hospitals; massage and such trifles are not used, and there is no gymnasium with simple apparatus for restoring function. Much of the required apparatus is very in- expensive and could be made by a hospital carpenter. The following recommendations, then, oc- cur to me: First, put the fracture service on a sound basis, like the operating room. Make some one absolutely responsible for its proper functioning. Second, put in charge of the equipment some one who will keep it under lock and key, in a place where the apparatus can be properly arranged and where it can be found when needed. There is an extraordinary impression all over this country, and I guess wherever peo- ple have fractures, that the one thing to be accomplished is to get the two ends of a broken bone to grow together. That is not the most important point in treating frac- tures. I will admit that getting union is a very important detail in treatment of a frac- ture, there is no question about that, but the patient did not come to you because he had a broken leg — that is not why he came — he came to you because he had pain and loss of the use of his leg. Now, when you' have a man with, we will say, a very simple fracture of the tibia, and you have put it in a cast after it has been nicely aligned, and he is lying in bed, you are not treating him, he is treating himself. His fragments are in perfect align- ment. he gets nice union, radiograph shows that there is an excellent formation of callus ; then you are going to begin to treat him, if you do the right thing. You are ready to go ahead and treat him after he has been lying in bed for 3, 4 or 5 weeks. But in most cases this does not happen. He is discharged after the cast has been removed, and no further treatment is given him. The follow-up service in most hospitals is imper- fect. There are a few hospitals of the better class that have a good follow-up service and know what these patients are doing. From one hospital that boasts of its follow-up ser- vice I have treated 6 fracture patients who came out within the last 6 weeks, and none of them ever saw the follow-up attendant. Jan , 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 5 Put the fracture service on a sound basis, gentlemen, like the operating room. Why have you a decent operating room in your hospitals? The Board of Governors did not come to you, nor the Board of Trustees, nor the Executive Committee and say, “we insist on your having the most magnificent equip- ment that we can force upon you”. They did not say that ! Oh, no, they did not ! You went to them and said, “We can’t do the kind of work that has to be done in the hospital unless we have something to do it with”. There are no records in your staff minutes in 99% of the hospitals in this country, showing that you have ever intimated to the Board of Trustees that you wanted anything special with which to treat fractures. Go back and read over the books and see when you requested them to furnish you with apparatus that you really -could do something with. It is not there. Now, equipment is a very broad word as applied to treatment of fractures. What do I mean by equipment? I don’t mean that your hospital should be supplied with a perfectly stupendous collection of complicated me- chanical splints, the last word in the brace- maker’s art. That is not what I mean at all. If you have any such collection as that, it is -an admission by your staff that they don’t know how to treat fractures, and that they are going to use the brains of the brace- maker instead of using their own. The best fracture men that I know have no such ap- paratus. The other day a bracemaker came into my office with such a perfectly mag- nificent splint, I mean it was such a perfectly magnificent piece of mechanical excellence for the forearm and wrist, including every joint of the entire hand, wrist and elbow, that it was a mechanical masterpiece. It cost, I think, $35 or something like that. It was such a splendid and perfect piece of mechanism that, although I have no use for such a thing at all, I almost bought it just to study its mechanics. However, the great trouble with all that kind of thing is that you are fitting the patient to a mechanical appliance. That is not what you want to do. It is the greatest mistake under the sun to do this. When a fellow practices medicine way out in the coun- try and has no drug-store convenient, he has to keep some medicines on hand, and it is highly proper that he should; but for a man in a big city, that has a large drug-store near the office, it is another thing, It is foolish, when a patient comes to his office, for him to go to his closet saying, “Why, yes, I have just the thing for you”. There is no splint, I don’t care how expensive it is, how perfectly mag- nificent from a mechanical standpoint, that cannot be improved upon by a very few dol- lars worth of plaster of Paris, a little wire and a pruning knife. You can put it in any desired position and make it fit. What I mean, when I say equipment, is : You do want some Balkan frames, whether metal or wood is up to you ; the wooden frames have one very decided objection — they are a perfect nest for vermin. After you have used one for a very long time, destroy it. Make them out of cheap stuff. The vast majority of them don’t have to be very heavily con- structed. You don’t need a Balkan frame made of 2x2 lumber if you are going to treat a fracture of the little finger. One of the very best Balkan frames I ever had was an old bamboo fishing rod that I had used quite often. It was 25 feet long, and it could be tied to the head of the bed, pulled down and tied in the desired position. If you are going to do something in regard to lining up a pelvis and getting the patient’s weight off the bed, that is another thing; but you should have in your hospital some type of bed or beds on which the patient’s bowels can move without moving the patient in any way. I am not a salesman for the Zimmer Company, but I have not seen any other bed like it for treating fractured hips, pelves or spines. You should have a good fracture table in your hospital, and you want somebody in charge of it who knows enough to oil it every day ; and you want someone to sharpen the plaster knives every day ; and someone who understands the making of plaster bandages, for they are very simply made, and it is a frightful waste of money to buy them. A nurse that knows how to do these things, who has been brought up in the business, and knows how to handle herself in a fracture 6 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 room, is an asset. We have one at the hospi- tal for Crippled Children in Newark. She will do a 5 yd. bandage in a minute, and she will do it for ah hour without the slightest trouble. You need Balkan frames. If you are going to use the metal ones, let me caution you against having an electrocution. They are splendid frames, they are absolutely vermin- proof, but there are situations — unless you keep the point in mind — where you may get your high-tension line a little too near the metal, and cause trouble. That is all the equipment you need. It does not cost much. Of course, you should have physiotherapy, but don't have to have any gorgeous display. Massage is necessary. You want some diathermy. Those are the 2 main things you need, and if you have them you can go a very long, way. RELATION OF TRAUMATIC SURGERY TO INDUSTRY* J. W. Martin, M.D., Baltimore, Md. Many interesting problems are arising be- tween industry and our profession ; especially is this true with traumatic surgery. These problems are interesting because they deal with facts facing our profession today and which we must solve. The date of conception of “industrial sur- gery” is unknown ; its birth was unheralded and its growth unnoticed, until the compensa- tion laws went into effect. The British Par- liament passed its Workmen’s Compensation Act in 1897. This attracted the attention of men in the United States who were interested in labor problems ; and while several acts were passed here which did not meet constitutional requirements, it was not until 1911 that the legislatures of Wisconsin and New Jersey passed compensative laws of an effective form. Since that time all the states except * (Delivered at the I64th Annual Meeting of the Medical Society of New Jersey, held at Atlantic City, June 13, 1930.) South Carolina, Florida, Mississippi and Arkansas have adopted compensation laws; and while there is a great variance in their interpretation, it is the intention of all of these laws to protect injured workmen and in- dustry as well. Since the various compensation laws went into effect, the attention of the medical pro- fession has been aroused because the laws provide for the collection of accounts for services rendered. This caused a competition among doctors for the business and has had a tendency to commercialize this branch of surgery, with the result that the greater part of this work has been thrown into the hands of medical men who possess more business sense than professional ability ; and industry has found that for the interests of all con- cerned it is necessary to endeavor to place in- jured employees under the care of competent surgeons and to establish control of all mat- ters of a medical and surgical nature. Con- sequently, there must come a complete and definite understanding of this economic prob- lem by industry, by commissioners of labor, by labor organizations, and by the medical pro- fession. Our profession is faced with the responsibility of giving to injured workmen efficient service at a reasonable price, and has for its reward the saving of human wastage and the avoidance of unnecessary deformities, which mean so much to the injured, to say nothing of the time saved and the large per- centage of disability avoided. The indis- criminate use of doctors means not only poor end-results or prolonged disabilities for the injured, but it is costly to industry. The general handling of industrial surgery requires more than surgical knowledge ; it re- quires an interest in the work from the stand- point of the employer, the employee and the insurance carrier. The surgeon should be able to make to the insurance carrier and to the Commissioner of Labor true and firm state- ments of a disability, without fear or favor. A man might be a foremost surgeon in his com- munity but if he does not cooperate in the proper handling of compensation cases, he will be practically worthless as a surgeon for industry. Tt is a very hopeful sign that the- Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 7 best surgeons are beginning to give more of their attention to surgery of the injured, which means of course that the claimants under com- pensation laws will receive a superior class of service in the future. There are still many weak points in the surgical treatment of com- pensation cases. Our profession is going through a very close investigation by industry because our end-results in the treatment of injured work- men have not been satisfactory from an eco- nomic standpoint; and if they have not been satisfactory from an economic standpoint, they have not been satisfactory from a humane one, because these go hand in hand. Good surgical results produce good economic re- sults. Our profession is on the witness stand, as it were, and industry is asking : “Why does the same kind of a case show good results and small expense in the hands of one physician, and poor results and great expense in the hands of another?” “Why do some cases re- quire many office treatments and a great amount of physiotherapy, while the same kind of cases respond to fewer treatments and no physiotherapy in the hands of another?” Thousands of dollars are being paid for hernias which, as the result of accident during the course of employment, have' never ex- isted. To illustrate, a man was acting as a watchman and was being heckled by some children. The history of the case states that he jumped from behind a shed and said “Boo”, causing him to have a double hernia; and our organization was ordered to pay out more than ,$300 in hospital and surgical charges. The tendency to do open operations when not indicated, cases of so-called trau- matic appendicitis, and most interesting ex- amples of sacro-iliac subluxation which have Smith-Peterson or other fixation operations performed, would fill a book and take all day to talk about. Hospitals are authorized to put injured employees in private rooms when not necessary, to assign special nurses, and to take x-ray pictures out of all reason. To illustrate, a case was sent to a hospital with a clinical history of a possible fracture of a rib ; radiographs were taken of skull, spine, and chest, the cost amounting to $75. Much of the chaos found in the field of traumatic surgery is due to the wide variance of opinion ; and industry is asking why. When a person is given to several physicians to be examined, so that a true statement of the man’s condition can be obtained, the re- ports will show variations anywhere from practically no disability to almost total disa- bility. No wonder Commissions of Labor have a tendency to ignore our recommenda- tions and form opinions of their own ! I firmly believe that every injured workman should be given a liberal allowance for a dis- abling injury; at the same time, if we are to be responsible for the proper interpreta- tions of those disabilities, our decisions should lie made with a fair mind and a mature judg- ment. The term “aggravation of a preexisting condition" is not thoroughly understood by the laity and is capable of many interpreta- tions. Shrewd lawyers have taken advantage of this fact, and as a result this term is fre- quently encountered in the trial of cases which cannot stand on their own merits. For ex- ample, instead of syphilis causing delayed union of a fracture, it is claimed the accident aggravated the syphilitic condition; instead of rest in bed, following a back injury, improv- ing the heart in a mitral insufficiency, it is frequently argued that the general devitaliza- tion of the body tissue as a result of the acci- dent has aggravated the heart condition which existed prior to the accident. This phrase also benefits the malingerer; we may be mor- ally certain that the patient is not as disabled as he claims, but the Court says the burden of proof rests upon us. Unfortunately, the mal- ingerer is usually able to find some physician who is willing to support his claim; as a re- sult there is the usual difference in profes- sional opinion, the Court becomes bewildered when it finds 2 exactly opposite interpreta- tions of the issue, and the general public be- comes convinced that the medical profession wears its dignity merely to camouflage its ig- norance; for disagreement is always inter- preted as ignorance. Unless our profession confines itself to facts and accepted principles rather than the competitive juggling of s JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 theories and possibilities, our opinions will be little heeded and we will lose the respect of the public. However, the poor end-results being ob- tained for the injured workmen present our greatest problem. Much of this is due to the carelessness and indifference with which a large part of our profession regards compensa- tion cases. Men who lack special training will attempt to handle injuries coming under the compensation law which they would be afraid to treat in their own private practice. A doc- tor should know his limitations and should be conscientious enough to immediately call a con- sultant, specially trained, just as he would in his own private work; for we all know what procrastination means. As Scudder said in his oration on fractures: “By treating a frac- ture instantly, you treat the fracture; by treating the fracture after delay you treat complications. Early treatment is easy, de- layed treatment is difficult and dangerous, late treatment is lamentable.’’ During the past year we have also found many cases in which there has been improper treatment of simple wounds. The principles of proper dressings have been neglected. Oint- ments have been used on clean lacerations, making a clean wound infected. Suppurating wounds have been sealed by tight, dry, band- ages. Anti-tetanus serum has been neglected. Indifferent treatment has been given fractured fingers and toes, causing unnecessary disa- bilities and deformities. Injuries to soft parts, such as nerve injuries and the cardinal symptoms of acute abdominal conditions, have not been recognized. During the past year we have had several cases in which proper diagnosis of a severed median or ulnar nerve was not made. To my knowledge there have been 4. cases of “acute abdomen” where the patient’s life might have been saved if proper diagnosis had been made and immediate ac- tion taken. We cannot help but realize that the chief failure in our treatment of industrial injuries comes from indifference, incompetence, and delay ; and the solution lies in doing honest, efficient work. It is no longer considered •economy to organize a staff of surgeons on a basis of low fees. There is a sincere desire to give to the industrially injured the highest grade of surgical care that can be secured. Personally, I am not interested in fee sched- ides ; but I am interested in seeing that proper and efficient work is being done. For if we are doing honest work, then that work should be paid for by industry in proportion to what the injured workman could pay if he were a private patient. Industry should and will pay for such service, regardless of fee schedules or limits of compensation laws ; for naturally if good work is done for the injured, the amount of disability is lessened and in- dustry and insurance carriers profit by it. I will welcome the day when every state in the union will provide for unlimited medi- cal attention in its compensation law, with proper surgical supervision, and when there will be appointed to every Commission of Labor outstanding medical men to act in an advisory capacity without fear or favor in connection with the care of the injured, the estimating of disabilities, and the disposition of controverted bills. 1 am happy to state that the best men of our profession are inter- ested in the solution of this problem. None of us wants to see future medicine controlled by state laws ; and as our profession in the past has been respected and honored for its high ideals, I am sure that industry, Com- missions of Labor and the public will not be mistaken in the confidence placed in us to solve this economic problem. Discussion Dr. John E. Toye (Arlington): It strikes me that fracture work has become a highly specialized specialty and calls for a great deal of time. It calls for more time and more patience than the average general surgeon has to put into it. The average general surgeon looks for results and wants them quickly. He has been trained to action. He has not been trained to wait. The average fracture man, or bone surgeon, or ortho- pedist is trained to wait and take an abundance of time. For that reason I think the hospital’s fracture service should be a distinct and separate service, not because the rotating service is all wrong, but because of the time a man may be willing to put into it. As Dr. Adams has said, when you have put the bones to something near apposition, you have still done practically nothing to rehabilitate that man, and the object of frac- ture treatment is to get that man back on a wage- earning basis as nearly as possible to that which he enjoyed before. There is where time comes in. It is easy enough to put fixation on and wait for Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 9 the bone to heal; but then your time, your patience and your ingenuity are called upon to put that man back on a wage-earning basis. Just a word about physiotherapy: Until the general surgeon, who is doing fracture work, or doing industrial surgery or traumatic surgery, as you choose, follows it up as a thing worth while, physiotherapy is in danger of coming into disre- pute and falling into the hands of charlatans. It is in disrepute now; there is no question about that. Many people will say, “I have a lamp, I can take care of that at home”, which is utter rot. Of course, use of heat is a means to an end, but your massage and your constant follow-up are the means of rehabilitation of the injured man. I would like to follow Dr. Martin with a word. This is apparently going to be a “panning” party anyhow, and just now I am going to “pan” in- dustry, or the insurance companies through in- dustry. Dr. Martin said that industry is willing to pay. In my observation industry has not been willing to pay. It has delegated responsibility for the injured workman to the insurance companies, and the insurance companies have, by hook or by crook, gotten rid of doing the best possible be- cause they won’t pay the price. It is axiomatic that you cannot get something for nothing. A man who is doing special work, good conscientious work, and attempting to rehabilitate injured work- men, is not going to work for the fees which they attempt to dictate. It is not at all unusual for me to have a letter back from an insurance company, after I have presented a bill, stating that “our fee is — thus and so for this type of treatment”, but that fee isn’t my fee; I can’t do that type of work at that price, and until the insurance com- pany is willing to recognize that it has to pay for competent men — and it has to have competent men to rehabilitate the injured workmen — it is my contention that industry is not willing to pay. Dr. E. P. Weigel (Plainfield) : I think both Dr. Adams and Dr. Martin have opened for discussion a subject which is rapidly becoming more acute to all of us who engage from time to time in the treatment of orthopedic or traumatic cases. As Dr. Adams stated, the assignment of fracture cases in a general hospital service has been a matter of considerable concern to all of us. From the very nature of the case, it is inconsistent to expect that the general surgeon shall be equally adept and interested in fracture work. The frac- ture problem is becoming entirely different from the straight surgical service. I think in many hospitals it has been assigned to the orthopedic service because it more closely fits into the work than it does into the general surgeon’s work. Many of the smaller hospitals throughout the country have been unable in the past to support an ortho- pedic service because there were not enough cases of a straight orthopedic nature to warrant such a service. The usual orthopedic deformities were not in themselves large enough in number to en- list the services of a man who did orthopedic work. However, many of our smaller hospitals are today adopting a wise policy by putting the fracture service along with the orthopedic service, which enables them to maintain an adequate staff for this kind of work. I know in several of the hos- pitals in which I do the fracture work, we fre- quently have as many patients, particulai'ly on the male ward, as the general surgeons do. We have in 2 of these institutions now adopted the prin- ciple which the doctor has suggested here of the man who first starts the treatment of a fracture case seeing that case through. I do not think it is at all fair to turn it over at the end of 1 month or 3 months to another man, who possibly entirely disagrees with the treatment the first man started. I was impressed recently by a Fracture Symposium, which I attended at one of the Ameri- can College of Surgeons' meetings, to see how few of the most prominent authorities agreed on the methods of treatment of ordinary fracture cases. I think this brings out just one point: It is im- possible to standardize the type of treatment of any given fracture. Frequently hospital superin- tendents buy fracture equipment because it has been advertised as the type used by some promi- nent man, and then attempt to fit their cases to it. This is never entirely satisfactory. Every man has to use the type of treatment which in his hands has proved most successful. We all know that certain surgeons throughout the country have brought out operative methods for treatment of conditions which in their hands are successful, but it is impossible always to teach those methods to men of lesser experience and lesser surgical skill, probably with equipment they do not know how to use. I distinctly remember a position 1 held at the Post-Graduate Hospital in New York where I taught operative orthopedics on the cadaver. One of the instruments that we used was the motor saw that Dr. Albee devised, and the doctors who had come from all over the coun- try to take a 6 weeks’ course were taught the use of that motor saw. Some of the men used it well; they were mechanical by nature. But I also re- member the difficulty encountered by others. I don’t believe we are ever going to be able to standardize the treatment of fractures. A man has to use that method which in his hands gives the best results, providing he has been well trained and takes the opportunity to acquaint himself with the new ideas and new methods of men of repu- tation. I don’t think it is ever fair for that reason to turn a case, the treatment of which has been started by one man, over to another before that treatment has been finished. In reference to Dr. Martin's remarks about in- surance companies being willing to pay for good treatment, I think there are 2 sides to it. I have been told from time to time by some of the respon- sible men in insurance companies: “Doctor, we want good work. We are willing to pay for good work, and if good work is rendered we will see that you are amply compensated for it.” I be- lieve this is the attitude of the better companies. However, there are many claim agents who feel they must “shop” in medicine as they would for ordinary commodities and are still looking for cheap treatment regardless of quality. I do work for some companies that never question the bills; they want good service and -seem to think we are giving them good service, and are satisfied with our bills. However, we are constantly receiving letters from some companies requesting reductions of bills, objecting to the charge which we have made, when that charge is what we have adopted as standard for the same type of treatment. My experience has been that some companies, as Dr. Toye brought out, still want cheap work. They do not realize that they are paying a great deal more in the end than they would be by hiring a man who makes it his business to render better service, even though at an increased initial cost. I believe most companies, sooner or later, find out the men who are competent, and are willing to pay them a fair price for their services. Dr. John F. Hagerty (Newark) : I think if any argument were needed to prove the truth of what 10 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Dr. Adams has said, it lias been supplied by the pictures shown by Dr. Martin, that fractures or- dinarily are not properly cared for. In St. Michael’s Hospital until 7 years ago the fractures were taken care of by the general sur- geon, and, as has been well expressed here today, the general surgeon has not the temperament for taking care of fractures. Accustomed as he is to dealing with acute illnesses and acute infections, the general surgeon has not the temperament to care for patients whose care lasts over a very long time, nor has the average surgeon the me- chanical skill required. I think it requires a peculiar type of ability to care properly for frac- tures, and that ordinarily is not possessed by the general surgeon. We decided, therefore, in St. Michael’s 7 years ago, to set up a special fracture service, and there all of the fractures that are ad- mitted to the hospital are admitted to the care of one man, Dr. Fort, who has a group of assistants, and who cares for them properly. As has been well pointed out, in the old days sometimes* a fracture would be admitted at the close of the morning, after the surgeon had spent an arduous period operating, and he would direct somebody to see that the patient received tempor- ary care and he would look after it later; whereas, quoting from Dr. Martin, when a fracture is cared for immediately it becomes a very simple thing and easy to take care of. Dr. Frank W. Pinneo (Newark) : Dr. Adams has shown that fractures for treatment, form one, distinct, group in medicine. That brings out 2 things; the fundamental principle of undivided re- sponsibility, and yet, at the same time, the need of cooperation. Now the fear that many doctors have of fractures should not result in inadequate care of the patient nor, on the other hand, in the mistakes of the patient’s care shifting from one to another service. The demonstration that Dr. Martin has given follows up Dr. Adams admirably, and some of his remarks recall to mind what Sir Robert Jones told us in the armies, that the orthopedist must “work for function from the start”. This is con- trary to the conception that all a patient needs at First is treatment for his infection, and, after that, he can be made over again, to improve, or save from further, deformity, it being rather implied that his fracture, or other injuries, must neces- sarily involve some deformity, whereas proper treatment from the start would prevent deformity. As to the relation between industry and our pro- fession, I do not see why there should be a dis- agreement when both parties are aiming for the same end-result. We must admit that frequently the operation of the law is very faulty in substi- tuting the interest of the insurance company for the professional skill necessary. Dr. William J. Arlitz (Hoboken) : I don't know that I can add anything to what has already been said. The remarks of the gentleman “that insur- ance companies are not willing to pay” is, I think, far-fetched. There are a number of men in the room who are specializing, and whom I have called upon on various occasions to offer their best judgment and treatment in cases. The insurance companies were always willing to pay for proper services. They do want capable men to treat and examine their cases. In the Compensation Bureaus we see the end- results of fractures that have been treated by the ordinary surgeon and by the orthopedist. I do not consider the orthopedist more capable than the general surgeon. When 1 say “general surgeon”, I mean a man who is a recognized visiting surgeon at a good hospital and who is experienced. Such surgeons usually get good results. Poor results are those where the fractures are treated by men who have had little surgical experience. They all have a method of their own. Most of their methods are not good; but in the final analysis, the visiting surgeon at a hospital gets as good a result as the orthopedist. They both get good results. I know that the railroad companies — and I rep- resent quite a number of them — are always willing to pay for good service. The insurance companies, likewise, are always willing to pay for good ser- vice. They do object to huge bills for the treat- ment of minor injuries — large bills are not un- usual. We have been criticizing the results in trau- matic surgery for a great many years. I don’t think that our criticism has brought about any great improvement in methods. I don’t know how you are going to bring these about. Dr. Martin was talking about the "aggravation of a preexisting condition”, after trauma. The majority of you would be amazed if you went into a Compensation Bureau and heard these various alleged accentuations. There are a number of men here now, who have been associated with me in the defense of such cases. A man will have a small burn of the foot, and a troupe of doctors will come in, and they will allege that this man is now suffering with advanced tuberculosis as a result of that burn of the foot. Another man will have a troupe of doctors come in and say that the man is suffering with a gastric ulcer as a result of a contusion of the foot. They claim all types of aggravations and accentuations after minor injuries. I don’t know how you are going to put a stop to it. I know many members of the County Societies and members of the State So- cieties, who make these allegations. It would not be good judgment to say that all doctors who make these allegations ,are liars, because some- times trauma does produce aggravation of a pre- existing condition. A frank expression of opinion in many of these cases would not look good in the record of the case. Aggravation is so fre- quently claimed that I usually request that a specialist examine such cases in consultation. The specialist is. of course, one who has a special knowledge of the particular allegation. These ag- gravations are alleged year in and year out. I have devoted many years to these problems, but I am frank to say that with all of my experience I am unable to offer any solution for these per- plexing problems. Dr. J. Bennett Morrison (Newark): At this time I am going to ask you to recall the paper I read to you on Wednesday morning — on industrial medi- cine. I ask you to recall the plea that was made for an extended cooperation between the medical profession and the carriers in a effort to produce better results, better after-results in the treatment of the laborers in the state of New Jersey. I told you that some of the carriers were anxious to clean house and were coming to us begging for our assistance to raise the standard of surgical ability of the men who are treating those cases. I told you that some of the carriers were willing to pay your bills as rendered if it be proved that you are reputable men; that they reserved to them- selves only the privilege of referring bills which they thought excessive to those committees in the state of New Jersey which we have provided Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 11 to pass upon questionable bills; and I told you that they stated that they always paid the bill after our committee passed upon it. I can tell you instances in the state of New Jersey where in- surance companies have paid single bills up to $1000 for surgical procedures, one bill of $1200. TVe have taken this opportunity to bring to you this morning the Medical Director of one of the largest carriers in the United States. Bring him upon the floor here, treat him as you would any other speaker. Here is your opportunity to find out about the relation of your work to the com- pensation work. Let us ask him if the carriers have an association where the better class of car- riers can induce the poorer class of carriers to try and elevate their work? I am very glad indeed that the doctor showed us that series of pictures. I have been practicing medicine and surgery for the past 30 years. I do not believe there is a man in this audience, be he specialist or general practitioner, who ever had the results that were shown to us this morning. Those results are a condemnation of the class of men that the carriers pay to take care of indus- trial medicine. That is the class of work that is a reflection of the very men who are discrediting industrial medicine. That is the class of men who do the cheap work that some of the carriers want to get away from. Those pictures show in them- selves that the carriers have paid on that series of cases alone probably $100,000 more in prolonged disability and total disability than they would have paid had they employed the average competent surgeon to take care of their work. Here is an opportunity for the carriers to tell us what class of work they want, ask our co- operation in securing that better class of work, and assure us that they are interested in it and are going to pay for it when the time comes. We all know that industrial medicine is here to stay. We all know the type of men who are engaged in it. We all know the better class surgeons have been discouraged because of the number of times they are called to court, because of the ques- tion of their bills, and because of the unsatisfactory relations between them and the carriers. Now, for the next 100 years we must keep push- ing our attempts to get a closer cooperation be- tween the medical profession and the carriers. There may be faults on both sides, but the greater portion of the fault, as we can see it, is from the carriers' side. Here is an opportunity to question this man, and here is an opportunity for him to lay his cards on the table and tell us what he wants us to do in order to better this condition. Dr. Maurice S. Avidan (Newark) : I have been associated with the State Department o'f Labor for several years and, having had the opportunity to review a large volume of this work, I should like to present certain facts. In the first place, the type of fracture and other industrial work that is being done in this state at the present time is far better than it has ever been before. This includes the work from the general profession at large. One reason why the work has made such an improvement is because of the fact that there has been created a very important depart- ment relative to industry, which is a sort of clear- ing house for all industrial work, called the Com- pensation Bureau, through which medium a check- up can be made of the character of work of each man engaged in the practice of industrial surgery. Each case of any importance must pass through this Bureau and its functional end-results are made a record and evaluated. This is done by careful studying of each case from purely a medi- cal and surgical standpoint, including clinical, pathologic, x-ray findings and prognosis as to function. Consultations and conferences in the more serious cases have been of great value in determining this factor. A public record is made of each case. I have always felt that the fracture work should not be taken away from the general surgeon. I have seen some very good results among the gen- eral practitioners and have also seen some very poor results among the industrial and bone spe- cialists. I think that the general practitioner who is conscientious and who knows his limitations is very capable of handling this class of work. I also think that some of our bone specialists are at times a little over zealous and often too radical, especially in the open operative field. After all, industry demands good functional re- sults with the least amount of lost time. Dr. Martin demonstrated some very poor results in fracture work. I do not think that is the type of work that is found in New Jersey; and if some of these poor results should be found, then indus- try and the insurance carriers should have no complaint, because they have full control of the medical situation, as to choice of doctor in each particular case. They have taken advantage of that right under the Act and have been given full sway in making their choice. Dr. Martin stated that in his opinion there should be . no question about the payment of medical bills if the work is properly done. Dr. Martin represents one of. the largest1 insurance companies in the country and it is very gratifying to the medical profession to know this. From my experience I believe 90% of the insurance companies have co- operated and have done fairly well, everything be- ing taken into consideration. They frequently come to the State Department for suggestions and advice concerning special treatment. Therefore, I don’t think that they ought to be unnecessarily criticized. However, a few of the companies in the last few years have tried to take advantage of some of the doctors; but in the long run they have not succeeded. Quite often the doctors have had grounds for criticism, but in the large ma- jority of instances it was due to misunderstanding. One of the greatest problems we have to deal with in this state, and one which cannot so easily be solved, is the question of expert medical testi- mony in compensation cases. As Dr. Martin stated, one expert will state that a man has 10% loss of function of a limb and another will state he has 80% loss of function. In these instances we are compelled to resort to courts and to have laymen decide questions that are purely medical in nature. It has become a serious problem because it puts the medical profession on the defensive and very often in a very embarrassing position. There are members of the medical profession who make a specialty and have no other form of prac- tice than giving expert opinions on disabilities in courts. There has been an attempt to overcome part of this perplexing problem by urging medical conferences and consultations; which in many in- stances have proved successful, especially where there was wide difference of. opinion. Dr. Henry II. Kessler : I just want to add a little note of optimism and sort of second the statement just made by Dr. Avidan. About 10 years ago we used to see those same results which you saw on the screen a fe’jv moments ago; but fortunately we do not see them now. I am quite 12 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 sure there has been a marked improvement in the end-results of the treatment of fractures, both by the orthopedist and by the general surgeon. How- ever, I do think we should aim toward a definite goal regarding the general relationship between the cax-riers, industry and the medical profession. I feel there has always been a spirit of conciliation between the various groups. Today, at least in the northern part of this state, we do not see indus- trial surgery or traumatic surgery in the hands of a very few. There has been a tendency on the part of carriers and industry as a whole to dis- tribute the work rather evenly among the general practitioners and surgeons. As a general rule, the bills that come from com- petent men, men who are on the surgical staffs of recognized hospitals, are rarely questioned. Then, of course, we have a different set-up, of which I will tell you this afternoon which helps in the adjustment of medical differences. I would like to see a special fracture service in hospitals. I am in accord with the previous speakers on the subject. At the same time there is still room and still an opportunity for the gen- eral surgeon who is interested in fracture work to get aboard the bandwagon. No better instance can be pointed out than the fracture service at the Massachusetts General Hospital. There you see orthopedic surgeons and general surgeons co- operating in performing some of the finest frac- ture work in the country. Dr. J. K. Adams: First, Mr. President, I did not mean to state — I don’t think I did state — that I wished any differentiation whatever in the treat- ment of fractures by general surgeons or by or- thopedists. If Dr. Arlitz understood me to say that, if he thought I said the fracture services were not properly handled by general surgeons, he is mistaken. What I stated was that there should be a fracture service established, that is, that the rotating- type of service should be abol- ished. Yrou could call it a “traumatic service”, or a “fracture service”, or you could call it any kind of service you wanted to; but I have made no •differentiation whatever between general surgeons and orthopedists. I even went further, I said let anybody treat the fractures who wants to treat them, but make someone responsible. When Dr. Hitchcock presented his paper on this subject, which was the most illuminating I have ever heard or expect ever to hear, he distinctly ended his argument by stating that if he had a severe, compound, infected fracture of the femur, or any other long bone, he would rather be treated by a good, earnest conscientious man who under- stood the principles of what he was doing than by the 3 greatest stars who ever lived; and what he was referring to was the rotating- service. That is my point. In this fracture business we go through fads. We do things because it is the style. You will remember that about 20 years ago we were going along in the same old routine way when Arbuthnot Lane, of England, made a visit to America. He was the master of a per- fectly extraordinary technic in the application of medical plates to bones; the result of years and years of extensive study and splendid concentra- tion: a technic that was impossible for the aver- age man ever to approach. Within 6 weeks after he arrived, the steel mills were busy turning out plates to put on broken bones; and some of the results were perfectly frightful. Not only were these plates put on patients who did not in any sense require them, and who could have been treated by a closed method perfectly well, but it was the style to use steel plates — and the Lord knows they were used in America, there is no question about that. Now, as to what Dr. Toye said about the general surgeon being unwilling to wait, or not being trained to wait, and what he said about the or- thopedist being more or less trained to wait is, I think, true in a certain sense. The orthopedist has naturally been forced into a waiting attitude as the result of a great deal of bone pathology that has come under his attention, such as tuberculous spines, and tendon transplantations followed by long periods of muscular education. I think that is true. It is natural for a man who has been brought up to play cricket in England to spend 3 days playing a game; while in America we want to see a ball game in an hour and a half. We are not accustomed to have a man go to the bat and take 3, 4 or 5 hours to make 150 runs; we expect him to do something right away, either strike out or get on first base. In regard to this insurance company proposition: we all have had our experiences from which to form our opinions. Naturally, the opinion we have is the result of our experiences. If you have sent 150 bills to insurance companies in a certain length of time, and every insurance com- pany has sat down and sent you a check promptly, you do not feel that there is anything to com- plain about.; but when a great many insurance companies on a great many different occasions refuse to pay your bills, why then you don’t feel that insurance companies have exactly rushed for- ward with money. That is the point. I have had some of those experiences, I must admit. I even had an instance where an insur- ance company wrote me that my bill was too low, and sent me a check for a higher figure. But that was only one instance! (Laughter.) I think 1 sent them a bill for $25, and they thought the result was very nice indeed, and that I had under- charged, and sent me a check for $50; but that isn’t a daily occurrence. That is what I want to bring out. Now, these are exact facts, and there are men here who can back me up on them. My experience has been somewhat like the experience of Dr. Toye. A man was struck on the back by a heavy hoist that was lifting a large stone. He was com- pletely paralyzed below the waist. He was brought into the hospital. A careful examination was made and it was found that he was totally paralyzed be- low the point of fracture, which roughly was somewhere around the first lumbar vertebra. He had absolutely no control of the bladder and no rectal control ; no sensation whatever below the waist. He was in very decided pain. I was asked to see him by the physician for the company for which this man had worked. He told me that he wanted me to see the man, and he wanted me to suggest a treatment to have carried out, that he would be prepared to assist in carrying it out, and if he was not able to do it alone would get some one to assist him, and that he had au- thority from his company to ask me to see the man. I saw the man. We made the examinations, we x-rayed him, and found he had a fractured spine, naturally. It was not quite so bad as we had thought. This man was put up with a head apparatus with traction on it, and -with traction on his feet also. He did not do well. I saw the representative of the company, who was an ex- ecutive of that company, in that hospital with a great many of this man’s relatives and friends within a few days, and they wanted to know what I thought about his condition, and I told them very plainly that I thought the man was very Jan., 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 13 seriously injured, that I did not think that he would ever walk again, and I questioned whether he would live. Well, that was discouraging, of course. Now, this accident, while I will not say that it was absolutely the fault of this company, I know that the company felt that it was a little to blame because the representative told me so, or intimated that it had not taken the safe- guards that it should have taken to prevent that accident. The representative asked me if I would mind having someone else see this man in con- sultation with me. I said: “Certainly not. Have you anybody in mind? You can have anybody that you want see this man, anybody that you think can be of service or of the slightest assist- ance.” In the course of the conversation the name of Dr. Albee, of New York, was suggested as a proper person to come and see this man in re- gard to what the probable outcome of the case would be and as to what the treatment should be, the subsequent treatment. Dr. Albee said he would be very glad to come, and he did. Fie made a very thorough and careful examination of the man, and said he had nothing whatever to sug- gest in regard to the future treatment. He said he would come again in 6 weeks and see the man and ascertain whether he was doing well, and that the advisability of what should be done would, of couse, depend on what the examination revealed at that time. Now, I saw this man 5 or 6 times, went a considerable distance from where I live to see him, and he was being taken care of daily by the physician of this company and another physi- cian had been called in to assist him. He had a number of radiographs, and his board was being paid in the hospital by this company. At the end of about 3 weeks the man died, and the physician who treated this man sent in his bill. It was a larger bill than mine, very much. It was paid. The other physician who assisted him sent in his bill. That was paid. The x-rays were paid for. The hospital was paid. Dr. Albee was said to have been paid, and I think he was; at least this man said so. I sent this representative a bill for $100. As I said, the patient was seen by me 5 or 6 times, and I went an appreciable distance to see him. I did see other cases when I was there on most occasions, but on 1 or 2 occasions I went up there just to see him. I got a letter back from the insurance company saying: “We don’t see why we should pay your bill. We would like you to write a letter in explanation of your bill and send it to the State Department of Labor and explain why you have sent us this bill.” The executive of this company who saw this patient with me, and who saw him in the presence of his relatives, stated in the presence of these relatives that there was no expense whatever that this company would not pay to put the patient on his feet again if it was humanly possible. I wrote Dr. Avidan a letter about this matter and asked him what to do about it. He replied that he would be very glad to take it up, that he would write to the insurance company, but he said, “We have no authority to make them pay, but I will be very glad to write a letter for you and see what can be done in the matter”. Flave they paid? No, they have not, and I don’t suppose they ever will un- less I sue them. Now, when you tell me that in- surance companies are always glad to pay, do you wonder why I disagree with you? Dr. J. W. Martin : I did not know I was going to get into a commercial argument here today. I am not going to hold any brief for insurance companies. Up until a year ago I had the pleas- ure of being a doctor myself. It is true that in- surance companies do have claim departments which try to get you down to the last cent. I did this work until a year ago, and I was tremen- dously interested in traumatic surgery. I will have to tell a little about myself. I know how the medical men do not get together as a unit, but act as individuals, and the one fellow fights the other, and how the Claim Departments, if they can, will whip you down a dollar. So, when I went into this Department, I said, “We are not going to have any fee schedule, and the Medical Depart- ment is going to run as a separate unit, not con- nected with the organization”. And that is true as far as this company is concerned, and that is all I am interested in. If men will charge a reasonable fee, or charge the insurance companies what they would charge in that case were it a private patient, insurance companies would pay for it, and they would pay for it without any trouble, and they would pay a whole lot more than would a private individual because a private individual could not afford to pay the economic value that the insurance com- pany could. They are dealing in dollars and cents; but it so happens if they deal in dollars and cents, we are dealing with the human side of it, and the two go hand in hand, as I tried to bring out in my paper. Now, these end-results — they were not from New Jersey, but they were from different states in the Union. I do not think, Gentlemen, from looking over the files and records in the United States, we are doing good work. It is not because we do not know better; we are indifferent to it. It is up to you to get behind this thing and say to the insurance companies: “We are going to give you the best there is, and you are going to pay for it.” Dr. Weigel (Plainfield) : May I ask Dr. Martin just one question? He has said in his rebuttal, as it were, that if the doctors would charge the in- surance company for the treatment of cases what they would charge ordinarily to individuals if the individual was to pay the bill himself, the insur- ance company would very gladly pay that much or possibly more. Now, it is my understanding of the average compensation law that it was put into effect for the very reason of giving that man some compensation and paying for his treatment because he was injured while in the employ of whoever happened to have hired him. I think everyone of us feel that if these men were in- jured When not working for the company employ- ing them, they would all be charity patients on the ward service. Invariably, these laborers are the heads of large families, who can’t pay a sin- gle thing for their treatment. The same man if he is injured after his work on his way home, for instance, by an automobile, pays the doctor ab- solutely nothing for his services; and it seems to me that if the insurance companies are going to tell us that we should charge for these services just as we would charge him as a private indi- vidual, we would have to treat every case for nothing. Dr. J. W. Martin : I don’t know how to make myself clear, but I don’t see how I can make it any plainer than this: What is going to be the ordinary charge for a broken femur for a man who is working at $4.50 per day; and, we will say, who has a family to support? You say he goes into the ward and you don’t get anything. Well, I imagine that $150 or $200 would be a good price under those circumstances. 14 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY •Ian., 1931 Ur. Weigel (Plainfield) : Yres, but the man could not pay that. Ur. ■] . W. Martin : But the insurance company would pay you. Now, as far as the compensation law is con- cerned, I tried to bring out in my remarks that I would welcome the day when a universal com- pensation law was adopted. Down in some of the Southern States, for instance, a man has a broken leg. The compensation law says $100. Well, how long does that last? As long as a snowball in some place. The fellow has still the fractured leg, and it must be taken care of. Industry must be philanthropic, because if they let that leg go im- properly cared for. then they are going to have a tremendous amount of disability; therefore, they cannot recognize your compensation law, they have to pay several hundreds of dollars for the care of the case, and willingly do it because if they get a good result it is cheaper for them. However, our troubles are we don’t know what charges we are to make. 1 think that is the trouble. One of us might think that our time is worth a whole lot of money. Well, if it is, then don't fool around with this sort of work; but if you can take it in along with your practice in a general way, and get a general fee for it, all well and good. I will say frankly, from a commercial stand- point, for every dollar that this company takes in — and I believe it is the same way with all com- panies— they are spending $1.50, so they are not making any money on it. My Department alone spent $2,000,000 to the medical profession of the United States, anu, therefore, I believe that the insurance companies are giving a little money to the profession. Fig. 1. Chairman McBride : We have had a very splen- did morning. These papers have all been very worth wrhile, and I want to thank at this time the speakers who presented them, also the discus- sants. It has been very illuminating, and I be- lieve we have gained knowledge by their presenta- tion and discussion. GASTRO-INTESTINAL DISORDERS IN RELATION TO DEFECTIVE GASTRO-INTESTINAL MECHANICS* Charles Gilmore Kerley, M.D., New York City That gastro-intestinal disorders of widely varying types may be occasioned by faulty structural gastro-intestinal relations in the adult has been known for years. It has been known that displacements, dilatations, angu- lations and peritoneal bands have a pro- nounced effect upon function; that similar * (Lantern Demonstration at the lG4th Annual Meeting of the Medical Society of New Jersey, Sec- tion on Pediatrics, Atlantic City. June 14, 1930.) 1. Iliac Crest. 2. Stomach erect lower margin. 3. Transverse colon erect lower margin. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 15 conditions might exist in a child has received but scant attention. The child is given the credit, without investi- gation, of being structurally normal except in such strikingly apparent conditions as pyloric disturbed physiologic function in which the matter of food and chemistry is emphasized. Further, the young child, because of lack of development, is prone to nerve imbalance — a systemic failure of coordination. This ap- Fig. 2 -A. stenosis, imperforate anus or other gross anomalies. It has been, and is, largely the medical habit to attribute all types of gastro- intestinal disorder in infants and children, from vomiting to constipation, primarily to plies particularly to that part of the baby which comprises the gastro-intestinal tract, where function is entirely under the control of nerve impulses. Imbalance and incoordi- nation of the independent parts of the gastro- JOURNAL OF THE MEDICAL SOCIETY OF NEW JH RSEY Jan., 1931 ] G intestinal mechanism explain many of the functional gastro-intestinal disorders of early life. During the past 20 years I have in different contributions called attention to the depen- dence of many gastro-intestinal ailments in children on defective gastro-intestinal mechan- ics. The nature and some of the results of a loss of appetite in the infant or young child? The answer — presence of food in the stomach; food retention beyond the time when it should have passed into the intestine. Hunger pains do not occur in a partially filled stomach. I have investigated a vast number of these loss of ap- petite cases through giving a test normal breakfast, consisting of milk, cereal, perhaps Fig:. 2-B. poorly functionating gastro-intestinal ma- chine comprise the aim of this contribution. General practitioners and pediatrists are con- sulted daily by parents concerning children in whom the chief complaint is habitual loss of appetite ; often with associated symptoms of eructations of gas, stomach pain and, in many, habitual vomiting. What is the outstanding cause of habitual an egg or bacon and a breadstuff, and then by means of a stomach tube determined the pres- ence or absence of retained food, 4 hours or more after completion of the meal — repeat- edly finding food residue 5-6 hours after the meal. Fig. 1 demonstrates a girl, Sl/2 years of age, who had persistent loss of appetite with food retention 5 hours or longer after Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 17 a meal. In nearly all of such children there is a mucous gastritis which can be demon- strated by the thick mucus removed from the stomach — shown in the illustration suspended on wood applicators. This child’s food re- Fig. 3. tention after 5 hours varied from 1-3 oz. I feel that the retention is caused by pyloric spasm, due largely to gastric hyperacidity, i Hyperacidity of the gastric contents in chil- Fig. 4. clren — Jour. A. M. A. Nov. 25, 1922 — by Kerley and Lorenze.) The thick mucus possibly acts as a plug to the pyloric opening of the stomach. The management in a case of this sort is re- peated stomach lavage at least 5 hr. after eat- ing. An ordinary 3 meal a day diet is allowed, with the exclusion of fat and bananas; these substances are invariably a part of the reten- tion if given to children in whom this feature is prominent. Fig. 5. In Fig. 2 is shown a girl, 11 yr. of age, who came to us because of a persistently poor ap- petite and habitual constipation ; eructations Fig. 6 -A. of gas and food were of daily occur- rence and vomiting was fairly frequent. The relative positions of the stomach and colon in the erect posture are shown. The lower bor- 18 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 der of the stomach in a child of this age should be 1 in. above the umbilicus. The ptosed stomach is mechanically inefficient, a slow working organ. Cases of this type also show high stomach acidity and usually mucous gastritis. In Fig. 2-A, the position of the stomach is indicated, according to the x-ray findings. The constipation can in this instance be ac- counted for by the ptosis of transverse and descending colon and sigmoid ; demonstrated in Fig. 2-B. Management. The first step in treatment of a case of this sort is to prevent a stomach over-load ; but small amounts of fluid can be given with a meal, and after a meal the child should remain recumbent for 2 hours. Water Fig. G-B. is given sparingly, and not over a pint of milk is allowed in 24 hours. Soups are excluded from the diet. A powder composed of atropin sulphate gr. 1/300, magnesium carbonate gr. 1. bismuth sub. carb. and sodium bicarb, each gr. 2. is given 10 minutes before meals. Parents are instructed to avoid condiments, cold drinks and iced foods. A 5 hr. interval feeding plan is invariably followed, with no food between meals. Cases of ptosis in- variably make a more rapid recovery if a belt (Fig. 9) is worn during the time the pa- tient is up and about. For the constipation a dessertspoonful of mineral oil is given at bedtime and aromatic fluid extract of cascara Yz teaspoonful after each meal. Fig. 3. Chronic appendicitis may also in- fluence stomach emptying. In these cases we find food retention, lack of appetite, recur- rent vomiting, periodic pain and frequently malnutrition ; constipation alternating with diarrhea is frequently present. The illustra- tion demonstrates bismuth in the appendix 96 hr. after the bismuth meal. The appendix in this patient was removed a few weeks after the x-ray study and was found badly diseased. Recurrent vomiting is frequently due prim- arily to defective mechanics. A boy, 4 yr. of age, came to us because of repeated vomiting attacks which had occurred about every 3 months for a period of 2 years. The Fig. 7. attacks were very severe, producing much loss in weight and dehydration to the degree of necessitating glucose solution intravenously and subcutaneously. In Fig. 4 is shown the spastic colon of this patient 72 hr. after the bismuth meal; the bismuth meal being held for this period of time by the spastic colon. The child suffered from obstinate constipation, and daily enemas were required in addition to co- pious doses of mineral oil. This child repre- sents the extremely neurotic type of individual, manifested in the intestinal tract by exagger- ated nerve impulses associated with imbalance Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 19 and incoordination. In this patient, under diet and hygienic measures, atropin to the point of physiologic effect, together with mineral oil and the aromatic fluid extract of cascara ad- ministered 3 times a day in doses of ^ dram, relief of constipation and recurrent vomiting- seizures was effected. Intestinal stasis of this type invariably produces food retention in the stomach beyond the 5 hr. period. Fig. 5 demonstrates the stomach of a boy, 6 yr. of age, who suffered from violent stom- ach colic. The illustration shows the stomach in active hyperstalsis with spasm at both the Fig. 8. pyloric and the cardiac orifices. Because of the double spasm, particularly at the cardiac end, the child could not secure relief' by vomiting. Localized circular fiber spasm may occur at any point between, and including, the esophagus and anal sphincter. Fig. 6 A-B. This patient was an infant, 3 months of age, of the spasmophilic type who was brought because of severe colic. The illus- tration A shows marked muscle incoordina- tion and circular fiber spasm. Illustration B demonstrates complete coordination both longitudinal and circular fibers in violent action with immediate forcible evacuation. Nerve imbalance and defective coordination of the independent parts of the gastro- intestinal mechanism explain the colic in this case, and colic in general in infants and children. An important point to remember is that pain ( col- ic) due to nerve imbalance and muscle inco- ordination is apt to be much more severe than pain due to pathologic states — more tempor- ary in character, and is further indicated by acute paroxysms of pain and sudden relief. In our radiographic studies we have demon- strated 2 types of colic — stomach colic and that of intestinal origin. There may be var- ious remote causes but the immediate cause Fig. 9. ot the pain is the formation of gas block due to muscle cramp, localized circular fiber spasm with hyperstalsis of the blocked gut areas. This infant had been carefully fed and no change was made in the food formula. Atro- pin. 1/1000 gr., was given immediately before each feeding ; with an immediate cessation of the colic. Ordinarily, these colicky infants re- quire food adjustment, stomach lavage and often-times dilatation of the anal sphincter. Constipation and delayed bowel evacuation can be readily understood by study of the constipation group which follows: , Fig. 7 represents what may be looked upon as a normal colon in a child 2 yr. of age. 20 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Fig. 8 compared with Fig. 7 demonstrates at once the cause of the obstinate constipa- tion from which this child suffered. In cases of this sort, evacuations are invariably de- layed. An elongated redundant colon ex- plains the delayed evacuation in the great ma- jority of children studied by means of x-rays. Any factor that causes delay in emptying of the colon is very apt to postpone the emptying time of the stomach, with consequent loss of appetite. The management of cases of this type comprises the use of the abdominal belt, mineral oil, aromatic fluid extract cascara in sufficient dosage, usually jA dram or more 3 times daily after meals, to produce 1 or 2 free evacuations daily. X-ray studies of ptosis cases demonstrates that a decided support is sup- plied to the gastro- intestinal structure by the use of the abdominal belt (Fig. IX). In about 75% of the gastro-intestinal dis- orders of infants and children are found due to defective gastro-intestinal mechanism. There- fore, every patient with a gastro-intestinal disorder, with a history of chronicity, who re- sists the usual common sense dietetic manage- ment and properly directed medical measures, is given the advantage of a complete gas- tro-intestinal study by means of radiography. Discussion Dr. Percival Nicholson (Philadelphia) : I have been interested in this subject for many years. Dr. Kerley brought out some very important points. One was in regard to chronic appendicitis, which was very interesting. I have seen in the last 18 months about 7 cases of appendicitis that only showed spasticity of the colon. They all showed very definite and distinct changes in the appendix. Some had adhesions with complete obstruction at the end, and the children had a very uneventful convalescence. I should like to ask if he has taken any blood calcium analysis in the spastic types to determine whether these patients had any low blood calcium, with regard to administration of calcium as a means of lessening spasticity. Dr. F. I. Krauss (Chatham) : I feel that a pupil requires a great deal of temerity to discuss the paper of his teacher. Some thoughts occurred to me as Dr. Kerley was reading this paper and show- ing his radiographs, and I wish to ask him for further discussion. First of all, the question of loss of appetite in children, or poor appetite, which usually begins after they are 1 yr. of age, is due to 2 factors: first, the physical factor which Dr. Kerley has portrayed, and secondly a mental one, the influence of the mother on the child, that is, her influence in trying to force too much and too frequent feedings. We are hearing so much to- day of mental hygiene that we must be careful not to lay too much emphasis on this mental side, but must remember the physical side which is also very important. I believe that many cases of poor appetite are due to the frequent feeding of infants, especially with sweet milk. I have noticed in keeping chil- dren on lactic acid and lemon juice milk for the first year that, when put on sweet milk, they very frequently begin to lose appetite or to have such symptoms as the doctor has spoken of. In several of these cases I have gone back to lactic acid or lemon juice milk and have kept it up even during the second year, with relief of symptoms. The second cause is rickets and the loss of muscular tone, particularly the lordosis due to rickets in the first year. A third cause might be due to the general ptosis because of the upright posture assumed. There is a tendency to forget that the child must rest after meals. It leaves the table and runs about, and immediately there is a drag and weight on the stomach and intestines to which it was not formerly accustomed. I have found that having these children rest after each meal is a very im- portant factor in correcting the conditions. Dr. Kerley has brought out that these cases are due to too much sweet milk in the second year of life. We cannot go back to acid milk until we have relieved the fermentative condition if it is at all severe. In treating cyclic vomiting I thought at one time that it was due to too much fat and my routine was to put them on skimmed milk, take away butter, etc. I found a certain proportion of these children went on with their attacks. I had not taken into account the fact that these children had ptosis, and had a great deal of heavy mucus in the stomach; it was often more im- portant than the amount of fat that was being consumed. Another point is that pylorospasm does not stop in infancy. We think of it as occurring in the first 6 months of life, but, as the doctor has brought out, many of these children up to 6 and 7 years of age have a tendency to pylorospasm. If we treat them as we do in infancy there is re- lief. My greatest friend in the practice of medi- cine for children is atropin. I have it made up in tablets of 1-.1000 gr. and dispense it rather than send a prescription to the druggist because I do not know where the druggist buys his atropin. and so many times if prescribed in solution it is kept too long and has deteriorated; I make a prac- tice to give it at the office as long as I want the child to have it. We should take more radiographs. It is remark- able how few x-ray pictures of the gastro-intes- tinal tract are taken; and it is not a difficult thing. They bring out just these points that Dr. Kerley has mentioned and I feel as he does that if we do not do this we are practicing the medicine of 30 years ago. Dr. Charles G. Kerley (closing) : It is quite im- possible in a contribution of this kind to go greatly into detail. My time allowance only permitted of referring to essential points. Retention of food in the stomach may be due to causes relating imme- diately to the stomach, such as spasm at the pylorus, mucous plugs and malposition, and to re- mote influences such as delayed emptying of the intestine or inflammatory conditions in any part of the intestinal structure. The most frequent remote cause is constipation, regardless of whether it is due to the spastic gut, to ptosis, elongations or angulations of the descending colon and sig- moid. An important feature, therefore, in reten- Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 21 tion cases is free bowel evacuation. I see to it that 2 evacuations occur daily, when bowel in- activity is the apparent cause of loss of appetite due to stomach retention. Among- the food substances that are slow in leaving the stomach, fats of all sorts and ba- nanas stand out prominently. Atropin is of great value in all cases of gastro- intestinal spasm re- gardless of the location. It must be used in full dosage, to the point of physiologic effect often- times. Probably three-fourths of the digestive ailments of infants and young children are due primarily or remotely to defective gastro-intestinal me- chanics. This applies equally to the acute as well as habitual derangements. CHANGES IN HUMAN RICKETS AFTER VIOSTEROL THERAPY* John Caffey, M.D., New York City Fourteen cases of severe and moderately severe rickets were studied clinically, chemi- cally and roentgenologically, before and after administration of viosterol therapy. The be- havior of these rachitic patients varied con- siderably and the group studied is not large enough to warrant general conclusions, but 16 lantern slides were shown depicting the changes after viosterol in individual cases. One or more examples of the following types of reaction to viosterol were demonstrated in each picture. (1) Appearance of the “line test” for healed rickets, in x-ray films, after 14 to 21 days in the usual care of rickets on adequate viosterol dosage (20-30 minims daily). (2) The increase of lowered serum phos- phorus concentration to normal after 7-14 days of viosterol therapy in the usual care on adequate dosage. (3) In high calcium rickets, a depression of the abnormally increased calcium to normal concentration before increase in the depressed phosphorus concentration began. (4) Rapid increase in the lowered calcium concentration, and rapid disappearance of clin- ical symptoms of rachitic spasmophilia, after adequate viosterol dosage. Calcium concentra- *(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Section on Pediatrics, Atlantic City, June 14, 1930.) tion became normal after 48 hr. Laryngo- spasm in 1 case disappeared after 24 hr., and Chvostek’s sign subsided after approximately 96 hr. in a second case. (5) Persistence of craniotabes for 30-40 days after adequate viosterol therapy and many days (10-20) after the “line test” for healing had become positive in x-ray films of the long bones, and after serum phosphorus- concentration had increased to normal and the product of the calcium plus the phosphorus exceeded 40. (6) Marked clinical improvement occur- red in all cases which showed chemical and roentgenologic healing after viosterol. The clinical improvement was manifested chiefly by increased activity and gain in muscle power, improved disposition and appetite, and gain in weight. None of the patients was definitely anemic, nor did any of them show enlarged spleens previous to viosterol therapy. (7) A few patients treated with inade- quate amounts of viosterol (5-10 minims daily) showed a greatly retarded response to viosterol and 1 showed no signs of healing after 40 days. (8) The results with viosterol in this group of rachitic infants approximate those previously reported with cod-liver oil and ultraviolet light therapy. Discussion Dr. Stafford McLean (New York) : I quite agree with Dr. Caffey’s statement regarding the favor- able effects of viosterol therapy in rickets as shown by x-rays. It is a helpful piece of academic work. That rickets is a very important disease needs no argument and any accurate observations on the results of new therapy are of value to all of us. Dr. Caffey has asked me to show some x-ray pictures of healing with cod-liver oil, for in spite of the favorable changes in chemistry, and healing as shown by the x-ray with viosterol, we are both very cautious When teaching medical students about the use of viosterol. YVe stress that suffi- cient evidence has thus far not been obtained re- garding indications for the use of viosterol except possibly in certain types of cases, and that for general use either for prevention or cure it is not a substitute for cod-liver oil. It was formerly thought that rickets was present only at certain age period. I have a radiograph in m'y possession of an infant taken on the first day of life by Dr. Maxwell of Pekin. The mother had osteomalacia and this infant showed definite x-ray evidence of rickets at birth. This child was cured roentgenologically by giving the mother, who was nursing the infant, viosterol. At the end of a month there was marked evidence of healing. We have seen x-ray evidence of rickets at 6 weeks 22 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 of age in New York, and I have seen autopsies on infants 2 months of age who showed microscopic evidence of rickets. Rickets in our experience may occur in the second and third and fourth and oven fifth year of life but in decreasing frequency. (Slides shown.) Dr. Blanchard : Do you feel as the result of your observation that it is better to give some cod- liver oil routinely with viosterol? Dr. Oaffey: Yes, I think it is better to give cod- liver oil with viosterol. If you want another sub- stitute for the vitamin A content, egg yolk con- tains vitamin A in high concentration. We have given viosterol in large dosage with no signs of lack of appetite. Large dosage in our experience does not seem to have any untoward effect. SOME ODDITIES IN ACUTE MASTOID DISEASE* W. L. Pannell, M.D., East Orange, N. J. To a body of men so widely experienced in clinical and operative otology, it is scarcely possible to introduce a single oddity that has not previously been met. Nevertheless, this Section might care to consider, by way of diversion, any little oddities incident to aural practice, and which go to make up the larger horizon for the otologist. Dwelling on the peculiarities of a disease, however, a grave danger lurks in the possible habit of missing the bigger issue. It is on this score that we feel some reluctance in appearing to capitalize items of important but often of wayside in- terest. Perusal of literature on the atypical reveals interesting points of view, and one could not do better than quote the words of 3 recog- nized workers in our specialty : Benjamin Schuster, discussing Ersner’s paper on aty- pical mastoiditis, stated that were he to write a book on otology he would endeavor to teach the student even more about the atypical than the typical mastoid. The late S. Macuen Smith, in a paper read before the Southern Medical Association, emphasized the tragedy resulting from unrecognized or atypical forms of mastoid disease. Frank Allport, being ♦(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Section on Ophthal- mology, and Otorhinolaryngology, Atlantic City, •Tune 13, 1930.) asked to discuss T. H. Harris’ paper on aty- pical mastoiditis, demurred somewhat on the ground that he had met so many atypical cases that it had become hard for him to know what constituted the typical. Apparently, we are brought up on the ortho- dox mastoiditis of text-book writers, only to be asked to bolt to some extent time-honored points of diagnosis. A friend practicing otology said that in his intern days all was definite and clear to him, whereas after 20 years of experience in a busy clinic he had learned that practice was a great amender of early ideas. The mastoid appears to intrigue one with the simplicity of its signs of disorder. As time goes on, however, the student is slowly but surely undeceived. The first recorded mastoid operation was performed in 1740; Jean Louis Petit, a gen- eral bone surgeon, having that distinction. Nearly 100 years elapsed before any treatise on otology appeared — that by Itard — and peculiarly enough, the first clear description of mastoiditis did not appear for 2 more gen- erations, waiting on Friedrich Bezold to chart the signs of that disease. After nearly 200 years of mastoid surgery it is noteworthy that there is still discussion as to the relative value of symptoms calling for surgical intervention. Of the many odd things that are informally talked about by our associates in an ear clinic, it is a jolt to me to discover that a thing that is important enough to make conversation be- tween friends falls far short of the require- ment for such an occasion as this. To sift out the experiences that might be of most interest to you is indeed difficult, and pre- sumes your indulgence. Mackenzie has hinted that unusual anatomy may be responsible for atypical disease, while G. E. Roberts states that strange anatomy is sometimes baffling to the surgeon. Accordingly, it may not be amiss to consider for a moment the anatomic side of acute mastoiditis. Of the structures in close relation to the operative area, the facial nerve may, by a rare chance, prove of importance both symptom- atically and surgically. Alderton, in his series of specimens, found that the facial canal varied in depth from the suprameatal spine Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 23 11-20 mm. Likewise, variation of nerve posi- tion in the region of the oval window was marked, considering the small size of the sul- cus through which it passes. Toward the stylomastoid foramen the path may vary suffi- ciently from the normal to invite trouble, es- pecially if the surgeon follows the sigmoid too far toward the jugular bulb. Byrd speaks of noticing the facial in an anomalous position while making the primary groove in a simple mastoid operation. A study of the bony canal in Alderton’s opinion does not reveal de- hiscences in many instances. Early palsy in acute otitis media may come from the sur- rounding cells or through a breach in the canal itself ; the latter statement is disputed by Politzer. A boy aged 16 came to the clinic with a strange facial expression, voluble type of speech, and history of double acute mas- toiditis 6 months previously. Double facial palsy comes under one’s notice rarely, and reference to this case may .be appropriate under the title of odd things that may be met. On the anatomic side of our oddities by far the most interesting seem to relate to the lateral sinus. Seymour Oppenheimer gave some interesting data on this venous channel in connection with his research, on the venous system of the temporal bone. He cited an in- stance where the emissary vein was quite as large as the lateral sinus. This recalls the dis- secting room experience of J. C. Beck; find- ing 2 sinuses on the same side. Allison T. Wanamaker, in his recent article on sinus thrombosis before the “Triological” society, incidentally mentioned that the right sinus was usually larger than the left and more sus- ceptible to involvement. While the position of the sinus is a problem in chronic mastoid disease it may also occupy an unusually for- ward position in acute cases even where there has been no preexisting inflammation to re- tard development of the mastoid cells. Throm- bosis might be expected to occur unusually early in such an instance. A case comes to mind where I found the sinus crossing the mastoid at a very high level, as if to connect the lateral sinus and jugular bulb by the short- est possible route ; there were more cells be- low and behind than above and in front of the sinus ; the antrum seemed especially deep in a small triangular cavity and was canted at a peculiar angle, and the nerve, though not uncovered, must have occupied a high level in the posterior canal wall to permit the sinus to go under it to the bulb. The vein, how- ever, was not thrombosed. Philip Kerrison has reported such a case. Familial sinus thrombosis probably has no place in otologic nomenclature. Yet, I had a case where throm- bosis of the sinus seemed to be a family dis- ease, for 2 older children had been operated on in another city for this complication, and while the mastoid in my case, the third in the family, was not especially suggestive of sinus involvement, the family history impelled me to explore, and the vein was found to be thickened and discolored but still patent. By the extra bone work, customary in such cases, I was able to avoid in this instance the sinus and jugular operation. The local bony find- ings did not emphasize extension by necrosis. Cheatle, as quoted by Oppenheimer, spoke of a vein connecting the middle ear and sinus. Its caliber was sufficient to admit passage of a No. 1 lachrymal probe. Could this have been a family anomaly responsible for the unusual frequency of sinus thrombosis? In forecasting the position of a sinus, whether unduly close to or away from the posterior canal wall, Whiting, it is recalled, stated that if the mastoid was round and convex, the sinus was probably close to the wall ; if a flat mastoid process, it was probably well back. Hetrick places some reliance on the posi- tion of the posterior perforated space as indicative of the downward turn of the under- lying lateral sinus. In spite of helpful sur- face markings, most of us by way of reassur- ance, seem to tip-toe in our operation until deeper landmarks are revealed. In closing the anatomic aspect of our sub- ject, it may be said that in acute otitis media the center of expansion would seem to be in the posterior superior region of the tympanic cavity, from which part cells diverge in al- most every possible direction. While com- munication with the mastoid antrum is easiest in the vast majority of cases, it is conceivable. 24 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 in freak formations, that free intercellular communication may tend in unusual direc- tions. Pressure is equal in all directions if we may apply here the Pascal principle. It is a matter of resistance to expansion. Cellular connections may take the process far afield of the original focus, and at a very early stage of invasion. A boy about 12 yr. old came to me with the story that swelling of the cheek occurred almost coincident with his ear-ache and ear discharge. While his ear canal and mastoid tenderness were not significant of severe mas- toid involvement, his temperature and face pain compelled action. Relief was immediate and lasting in spite of the fact that there was no unusual pathology in the zygoma. It is much in the same way that resolution occurs in Gradenigo syndrome cases after the simple mastoid operation. Trouble is relieved by retrogression in many cases if the operation is carried close to the supposed center of maximum pressure. Bowers, at a recent meeting of the New York Academy of Medi- cine, reported a case of extension in probably the same manner, because he was able to in- sinuate a fine probe in the path of the sinus that extended to the nasopharynx. A post- pharyngeal abscess was the ultimate thing in this case, as in one of my own, in a much younger patient however. The venous plexus connecting the middle ear and the orifice of the eustachian tube probably explains the pathway of infection in some instances (Op- penheimer). Max M. Kulvin reported a true case of subtemporal abscess, explaining that pus determined itself in the zygomatic fossa because the anterior fibers of the temporal muscle are loosely attached while the posterior ones are firmly adherent to the skull. Many years ago I saw a case that presented pus in the cheek. Trauma of the mastoid process that affects • the underlying cells to the extent of requiring operation is illustrated by a case I saw oper- ated on by Elliott Shipman, during my hos- pital internship. A young adult had been shot and the bullet flattened out on the mas- toid process near the tip. The destruction was extensive enough to justify the simple mas- toid operation. Imperatori recorded the case of a baby that developed an operative mas- toiditis from a fall, the impact being behind the ear; a sinus thrombosis complicating be- cause the sinus plate had been fractured. Many excellent articles, too numerous to recite, have appeared on the peculiar nature of the Streptococcus mucosus infection of the middle ear and mastoid. Guggenheim and Ferris recently contributed an illuminat- ing article on this type of infection, entitled “dry necrosis of the mastoid”, in consonance with the title chosen by Oscar Wilkinson. Cases are recorded by others where middle ear symptoms were lacking, suggesting the descriptive title of mastoiditis without tym- panic involvement. Also, under the title of “atypical mastoiditis”, the odd ways of the Streptococcus mucosus have been described. Guggenheim and Ferris introduced their cases as representing a peculiar form of mastoiditis characterized by an infection of long duration, few symptoms and an extensive dry necrosis. New, I think it was, found that these cases occur with an infrequency of 1 :500, and it lias not been my privilege to meet a case with positively no antecedent middle ear involve- ment. Some years ago a woman aged 30 came under notice with indifferent tympanic and mastoid symptoms, but a low grade headache on the suspected side, a slight fever and a hemorrhagic nephritis. Operation disclosed a mastoid that appeared to be undergoing reso- lution— not a drop of pus or other secretion was found — simply a little redness; yet, threatened chagrin faded as all symptoms promptly subsided. A 7 yr. old boy, answer- ing the same type as to symptoms, except renal irritation, showed the self-same condi- tion of the mastoid and the same satisfactory postoperative course. In another instance, in a girl of 20, the operative findings were totally different, yet the healing process, though rapid enough, was almost alarming in its dry- ness. No cultures were taken and it is un- fortunate that the organism was not isolated in any of the foregoing cases. Dry healing seems not to be mentioned in the reported cases of dry necrosis and may be quite an- other infection. Kopetsky thinks that the Jan , X&31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 25 Klebs-Loeffler bacillus may be the organism in some of these atypical cases. J. G. Dwyer, in a personal conversation, stated that the Streptococcus mucosus may give trouble even after the ear and wound have healed, the hypothesis being that trouble starts anew when the capsule of the organism is dissolved, possibly a matter of months longer; since the outlet for the new discharge has been shut off, intracranial complications threaten. With a dry ear, a normal canal wall, and all in all a dearth of local symptoms, the diag- nostic ability' of the clinician is surely put to the test. With regard to children an observ- ant mother may save the day. An ear his- tory, however remote, may provide the single clue. Altered appetite of the child, failure to gain in body weight, morning moisture of the night clothing, have, singly or in combination, prompted me to make an investigation of the mastoid where constitutional reasons seemed lacking. A night’s sleep that is disturbed, if only for a little while, may be tell-tale, as pointed out by Ewing Day, of Pittsburgh. Misbehavior of peristalsis has been alluded to very much in recent years and some of the members of this Section may wish to elabor- ate on this symptom. As regards adults, Mac- Kenzie says that most local symptoms may be absent, but least frequently of all, some drooping of the posterior canal wall. Many writers seem to concur in this opinion. With a dry middle ear, but a suspected mastoiditis, Hetrick thinks that the Weber-Schwabach paradox test is of assistance in arriving at a diagnosis. Again, easily induced fatigue may suggest the undertow of a long standing but latent infection. W. S. Tomlin reported a case of 10 yr. of invalidism and the prompt gain in weight of 20 lb. after a mastoidectomy. According to many, audition may be unaffect- ed, but should always be tested for possible loss. In these obscure cases it is the indi- vidual as much as the ear that might disclose etiology of the illness, bearing in mind that a systemic something may be found to act as a herring across the scent and delay the cor- rect diagnosis of mastoiditis. It is not the many symptoms in the early phase of the disease that should concern us, but the lone and persistent symptom that too often finds us complacent. As, between the meaning of white cell and red cell count, each has its adherents. Latent mastoiditis, in Hetrick’s analysis of reports, occurs anywhere between babyhood and senescence. The period of latency may ex- tend. as in Bar's case, up to 2 years, perhaps more. As already quoted from Macuen Smith, serious pathology is not a surprise. The radiograph seems to serve its best use in • symptomless mastoiditis. Granger, in a re- cent contribution to radiology, described a technic and interpretation that proved useful with infants. It would be superfluous to report some of mv own experiences when the literature abounds in illustrative cases. The lack of tympanic symptoms in these odd cases of mastoiditis gives rise to the conjecture as to whether or not they may be of hematogenous origin. Glogau believes that primary mas- toiditis is a clinical entity. Taylor, of Jack- sonville, as quoted by Mallison, cites a case of mastoiditis developing secondarily to a bacteriemia, while T. E. Carmody, in connec- tion with Hempstead’s paper, recalled that a blood-borne mastoiditis seemed to occur in an ear opposite to the one he had operated upon. Classified as atypical and sometimes leading to operation is the type of case described as mastoidalgia. My Chief of Clinic was im- plored by a neurologist to operate on such a case. In his final letter of refusal he ex- plained that the best result he could possibly get would be to restore the ear to the condi- 1 tion it was then in. Byrd, in the course of conversation, cited a case where there was, however, a high degree of deafness, actual pain and occasional watery discharge, and on operating he found hyperostosis in the region of the attic and aditus, cramping the ossicles. After creating room where needed the pa- tient regained her hearing and enjoyed com- plete comfort. Harris related an instance where simply a skin incision yielded a splendid psychic result. If the maxillary antrum has now its back against the wall as to normality, the mastoid antrum, likewise, is seldom a nor- mal part in the eyes of critical observers. 26 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 i ime and again a radiograph of an unsuspect- ed mastoid antrum yields evidence of trouble. When is this antrum well, is a pertinent ques- tion. In viewing our middle ears and mastoids irom another angle, it almost appears that these parts are susceptible to vasomotor changes. A young man called at the office on different occasions with an acutely in- flamed middle ear and apparently a mastoid • inflammation. His attacks, while of sudden on- set, generally disappeared just as suddenly in a few hours, suggesting an analogy with the mucous membrane of the nose and maxillary antrum that balloons and then collapses with rapidity. Ilaskin, with others, believes that an abscessed tooth, even without sinus in- volvement, may alter the course of a mastoid inflammation. Two cases have come under my care where extractions seemed to cause an abrupt turn of events for the better. Robert H. Fowler believes that there are carriers of mastoid disease, and I hope he will explain, while here, his scientific example of cherchez la femme. Meanwhile, it is hoped that these scattered remarks on the mastoid and some of its peculiarities may lead you to tell of bigger things. Discussion Dr. Henry C. Barkhorn (Newark) : It is always a pleasure to discuss a paper of Dr. Pannell’s. He has a message, and he gets it across. Atypical mastoids are the bane of our lives. It develops that the more mastoids you see, the more mastoids you do, the fewer are typical if you get back to your fundamentals. In the infant, the antrum is at 12 o’clock; at 1 year it is at 1 o’clock; at 3 years it is at 3 o’clock. Naturally, the child has prolapse of the canal without mas- toiditis because the antrum is right over the canal. When a child has a funnel-shaped canal it has a mastoid; these are the cases that don’t get well without operation. Of children who have a pro- lapse of the canal, the vast majority get well on conservative treatment. If you follow along anatomic instead of pathologic lines in your operative procedure, you will make fewer mistakes. Take out all the cells that may be diseased, not only the cells that are visibly dis- eased. Consider the ear that is apparently normal but has a history of earache, that has half-headache, has pain behind the eye; this brings us to the work that Dr. Eagleton has recently done, and, by the way, there is an article in the March Archives of Surgery — not of Otology but of Sur- gery— by Dr. Eagleton that is of outstanding im- portance. There are 2 ways that you can get an apex involvement. One is through the extensive cellularization of the petrous pyramid. The other is bv an embolic process. The one is sick from the very beginning, has a headache out of proportion to his mastoid findings, may or may not have Gradenigo’s syndrome, but he gets well in the vast majority of cases without any further operative procedure because his is the cellular mastoid. The other patient has a mastoid, is doing moderately well, and suddenly has a shot of temperature, chill, rigor, convulsion if a child, and then has a pain behind the eye, middle and posterior fossa syndromes; he has something in the apex of his pyramid which doesn’t get well. No matter how extensive your mastoidectomy is, you can’t drain an osteomyelitis, embolic in nature, in the bone marrow of the apex. There is where Dr. Eagle- ton’s operation, of unlocking the deepest portion of the petrous pyramid, comes into its best field. He takes away the dural plate, takes away the sinus plate, takes away the angle of the petrosa, unlocking the posterior and the middle fossa, he separates the dura in as far as the apex in the middle fossa, separates the dura in as far as the internal auditory meatus in the posterior fossa, and if there is anything there finds it. That is the real reason for such success as we have had, this operation of unlocking the petrous pj ramid. Dr. Robert H. Fowler (New York): Dr. Pannell and I worked together in Dr. Rae’s ear clinic at Manhattan, and in talking over his paper I told him the following story about a child 4-5 years old who had a mysterious mastoid infection which repeated operations failed to clear up. Talking about affinities — the child’s family was French, the child could not talk English, and they had a French nurse who must always be present. It was not possible for the surgeon to handle the case and still get rid of the French nurse, so she was always present with that child. The French woman and the child were so passionately fond of one another that it was pathetic to see when Madamoiselle had to take an occasional hour away from the bed side. The trained nurses who had the professional responsibility kept objecting to the presence of someone who would disturb the diet and who brought in irregularities and innovations. The operation had to be repeated more than once, and the best consultants in town had no sugges- tion as to why this child should be singled out more than others for recurrent infections, until one day Madamoiselle herself came into the office with a running ear, developed an acute mastoid and then for the first time acknowledged that she had been suffering for weeks with earache. As soon as she was definitely off the case the child’s mastoid cleared up. The professional nurses thought that Madamoiselle had been kissing the child, contrary to orders, and that she was a carrier. Instead of. a “Typhoid Mary” this was a case of “Mastoid Madamoiselle”. There was a curious sequel to that story; 3 months after the nurse recovered from her own mastoid operation the question came up as to whether I would be willing to recommend her to another family as a child's nurse. T liked this Madamoiselle. She had been very loyal, she had every virtue that a human being can have, and had showed a remark- able affection for the children. But 2 of the chil- dren in the first family had endured mastoid operations, and though she was a good children’s nurse it was a matter of professional judgment as to whether there was not a risk of her carrying infection into a new family. There was so much doubt about this that I found it better not to recom- mend her. She didn’t get the job but went to work somewhere else, and now you will be surprised when I tell you that the child that she did not take Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 27 care of came down with an acute mastoid. So, perhaps it was just as well for the French nurse that she had not taken that job and incurred any question of blame. This story if it stood alone would mean nothing, but it does not stand alone. Perhaps you will re- member that Oliver Wendell Holmes was a doc- tor, and that he discovered by making observa- tions in ward work that puerperal infections, post- partum infections were contagious. That was 60 years ago, and we now take full precautions against the spread of such infections, but are we justified in assuming that otitis and mastoid in- fections are never contagious? I think not, for in my own practice there have been not less than half a dozen cases where a patient seemed to get the mastoid infection from someone near by who themselves suffered from acute or chronic ear trouble. In a ward of 40 mastoid cases in the army 2 things happened that would be surprising if it were not admitted that certain germs have definite affinities. It isn’t on the cards, it isn’t in the books, but the orderly whose job it was to pick up the cotton in that ward came down himself with an acute mastoid, and two weeks later 1 of the doctors, a general medical man who had his quarters directly across the hall from my own, came down with an acute mastoiditis and had to be operated on. From then on, screens were placed between the beds in the ward and other steps taken as though the streptococcus was con- tagious. This thing doesn’t happen often, but when you have recurrent mastoids to handle let me advise you to look with suspicion at those who are in closest contact with your patient, remembering my story- — cherchez la femme! Chairman Emerson : This subject that Dr. Fowler speaks of is new to me, but it certainly is something more than coincidence. Last Monday night, I asked my associate to do a mastoid oper- ation on a dentist’s son. This dentist has 2 boys. His other boy has had 2 mastoids, and this was the second this boy has had. They are the only children in the family. Incidentally my 2 daugh- ters had mastoiditis and were operated on 4 days apart, several years ago, during an epidemic of measles. We have often remarked in our work that it was remarkable that there seemed to be certain families with 1 to 6 children, in which we have done in the last 10 years anywhere from 3 to 8 mastoid operations. There are some families in which all their children, 3 or 4 children, have had mastoiditis. I have in mind 1 girl, a very strong, healthy, well-developed, handsome girl, of 12 who had 7 mastoid operations; 4 were done by sur- geons in New York before I saw her, and 3 were done by me in 3 successive years. This child had an excellent nose and throat,, yet every time she got a cold, one or the other of her mastoids blew up. What Dr. Fowler has said certainly gives us food for thought. It does mean, as I look back over our practice of the last 20 years and recall the numerous families in which we have had multiple mastoid operations, running as high as 8 in some families, that it merits serious con- sideration. People have said to me: “Is mastoid disease catching, or can this child which has had mas- toiditis once have it again, or is it more liable to have it than one who has never had it?” My answer has nearly always been to all those ques- tion, “No”, but I believe that I have been mis- taken, and I believe there is a certain kernel of truth in what Dr. Fowler has had to say on this subject. TONSILLECTOMY UNDER LOCAL ANESTHESIA* Robert H. Fowler, M.D., New York City The modern tonsil operation under local anesthesia is a far, far better thing than those that preceded it. Bleeding is controlled; there is no pain, and only slight discomfort ; the operation is an open one with full visi- bility at every step, and it is complete, remov- ing tonsil and infratonsillar nodules to the very base of the tongue; and, in the most successful cases the slight trauma leaves the muscles of the tonsil bed intact. To obtain these desirable results it is neces- sary to pay attention to the details of technic. Not any particular man’s technic nor any one set of instruments. The improvements I am about to speak of have been instituted by many surgeons in different parts of the coun- try. It will simplify matters to take them up under the following 14 points : .( 1 ) Spraying the throat with parasthesin powder. (2) Injection of novocain; floating the tonsil. (3) Incision. (4) Grasping the capsule. (5) Cleaning the white layer of the cap- sule. (6) Fibrous attachments freed. (7) Mucous glands saved. (8) Upper lobe cleared. (9) Differentiating and injecting mus- cular belt. (10) Sponge placed in fossa. (11) Shaving off muscles. (12) Snaring lower pole. (13) Removal infratonsillar nodules. *(Read at the 164th Annual Meeting of the Medical Society of New Jersey, Section of Oph- thalmology and Rhinolaryngology, Atlantic City, June 13, 1930.) 2 S JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 ( 14) Powder fossa. Tie vessels. Examine removed tonsils. The time is short arid it is better to illus- trate with pictures and speak briefly than to read any lengthy discussion. (The technic hereafter described was illustrated by lantern slides.) Parasthesin powder full strength is sprayed on the throat twice with a 2 minute interval. The surface of 'the tonsil and pillars, and per- haps the whole pharynx, is included if there is a persistent reflex. Then 10% solution of novocain on an applicator wound tightly with cotton is rubbed over the surface of the pil- lars and plica triangularis. This is done 3 times at 3 minute intervals, the applicator being turned or spun in the fingers each time. Ten minutes later an angular needle is used to make injections of 1% novocain with a few drops oi adrenalin added. The object is to float the tonsil, introducing the needle pre- cisely where the incision is to be made. The point of the needle must always be placed close to the capsule in the theoretic space be- tween it and the surrounding muscles of the tonsil so that the solution cannot be absorbed but will come out at once when the tonsil is removed. The fluid starts to run out the moment the incision is made. The initial prick of the needle can be made barely per- ceptible, if the point is sharp and the needle fine, arid the novocain is projected *4 in- al- ways in advance from there on. It is not sufficient to flood the upper lobe, that is the upper pole, of the tonsil, but even greater care must be exercised in flooding the lower lobe; and this is, for anatomic reasons, a more diffi- cult procedure. Posterior pillar flap. It is difficult to run the incision straight down the posterior pillar without tearing the mucous membrane. It can be accomplished better with a sharp knife and it is often found possible to shape a flap to cover in with mucous membrane the upper quarter of the posterior pillar. Fixation of posterior pillar is helpful. Anterior pillar. The incision is carried dowward over the plica triangularis, saving a flap of mucous membrane from its surface, and terminates at junction of the anterior pil- lar with the base of the tongue. If the whole of the mucous membrane from the plica tri- angularis be left in the throat it is often found to contain lymphoid tissue, infratonsillar nodules, at the lower third. These can be seen and the incision can be patterned to skirt them before reaching the base of the tongue. Grasping the capsule with forceps is an im- provement that has lately been introduced. It has an advantage over the established custom of seizing the lymphoid mass of the tonsil tissue, in that it keeps the capsule taut and gives a higher degree of visibility. The for- ceps used for this purpose is an Aliys clamp with box lock and extra grasping teeth. The white layer of the capsule is the final single layer of pharyngeal fascia on the north pole of the tonsil. The more professional certi- tude displayed in denuding this thin layer, known as the capsule of the tonsil, without breaking it, the better chance there is of es- caping hemorrhage and leaving a protected wound ; one with enough fascia covering the muscle's to prevent their becoming infected. The fibrous attachments are cleared from the upper pole by meticulous sharp dissection and the mucous glands with their blood supply are separated from the tonsil. The lilliputian attachments are shaved from the tonsil bit by bit till the pink layer to be left in the fossa is clearly contrasted with the white dry sur- face of the upper lobe of the tonsil. When the upper lobe has been altogether freed the muscular attachments appear attached to the equator. It is well to inject these with novo- cain to cut off a branch from the ninth nerve. A sponge, half the size of your thumb, is placed above the tonsil at this time and the upper lobe of the second tonsil is freed. When the sponge is removed the muscular attach- ments at the belt and lower lobe can be shaved from the surface of the tonsil with a razor edged knife. By shaving I mean a process of freeing bit by bit the firm attachments be- tween the capsule and the tonsillopharyngeus muscle. There is an old saying — “beware the snare-'. That phrase, when I use it, means use your snare not to dissect muscles but to sever the lower pole from the base of the Jan.. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 29 tongue and to clear away irifratonsillar nodules, if any are present, from the lowest portion of the plica triangularis where it at- taches to the base of the tongue. These nodules have come in for a great deal of dis- cussion lately. When left in the throat they prevent the clearing up of cervical adenitis. When the tonsil with the infratonsillar nodules has been removed, the operation may be finished by powdering the fossa with bismuth and tying 1 or 2 of the larger vessels. The most important one is at the center of the fossa where the posterior pillar joins the lateral wall. Instead of a slip knot, a needle may he used to place a suture under these vessels. ADVANTAGES OF GENERAL ANES- THESIA IN TONSILLECTOMY* William Campbell, M.D., East Orange, New Jersey Although I am speaking on the advantages of general anesthesia, I do local anesthetiza- tion on suitable cases. Looking over my rec- ords of patients over 16 years of age, I found that 65% were done under general anesthesia, but I do not mean to infer that a greater per- centage could not have been done under local hut that general was the anesthesia of choice in those cases. In neurotic people where apprehension is apt to be present, there is considerable .mental shock during local anesthesia. In one case I know of, a highly strung woman was in bed for several months following a nervous break- down that occurred a week or two after the operation. Where bleeding may be expected, or where you have an excessive amount of fibrous tissue, from repeated peritonsillar ab- scesses, I feel that general anesthesia is easier on the patient and certainly much easier for the operator ; and I do not know of anything more trying than a tonsillectomy under local anesthesia on a panipky patient. *(Read at the 164th Annual Meeting of the Medical Society of New Jersey, Section on Oph- thalmology and Otorhinolaryngology, Atlantic City, June 13, 1930.) In arteriosclerosis and high blood pressure the use of adrenalin and novocain will some- times raise the pressure 20 points. In such types I decide by judging the individual and have not had any trying experiences either way. A few months ago I had a 9 year old girl, referred to me by an internist, with the history of a congenital pulmonary stenosis and a rheumatic condition. He did not con- sider the heart competent for general anes- thesia, and considered the case a poor risk. The urine was normal, also the bleeding and clotting time. I removed the tonsils under local anesthesia and with very good co- operation from the child. She had an ex- cessive amount of adenoid tissue, which was removed under first stage ether anesthesia. The child did not have any postoperative- bleeding from the tonsils, but 10 hr. later had a uterine hemorrhage of 500 c.c. which was repeated twice, making 1500 c.c. in all, and did not stop until after a small transfusion. After the hemorrhage, cyanosis was gone and the child never was in shock. A blood count taken later showed 6,500,000 red cells without any abnormal findings. I do not know to what we should attribute the cause of the hemorrhage. In children, I prefer general anesthesia. I have seen, several times, uvulectomy and in- jury to the soft palate result from intract- ability of the patient under local anesthesia. Adhesions of the pharynx need only be under one’s care for relief to make us sufficiently appreciate the necessity of prevention. A competent anesthetist and assistant are essential, and I have not had any complica- tions, such as lung abscess, etc. Hemor- rhage, under general anesthesia, will be greater at the time of operation but you are in a bet- ter position to control it and in all cases the throat should lie dry before the patient leaves the table. I believe you are more liable to get postoperative bleeding 5 or 6 hours later after local than after general anesthesia. I do not see any reason why the actual me- chanical work, using the dissection and snare method, should not leave just as good an after-result whether it be . done under local or general anesthesia. I think the outstanding advantage of gen- 30 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 eral anesthesia is the convenience to the oper- ator. Discussion Dr. Theodore W. Corwin (Newark): I think we have listened to a wonderful description of the tonsil and tonsil operation, by Dr. Fowler. I am sorry that our discussion must be limited at all. One hates to be limited when he has such an op- portunity for speaking of this wonderful subject. The demonstrations by Dr. Fowler really very much simplify the subject. You know from your own observation and experience that the relation of the tonsil to the outer wall of the throat is comparatively little understood. In fact, so far as we have had to depend on text-books for the anatomy of the throat, very little has been said of the external relations of the tonsil, and yet they are what we are up against. It is to be remem- bered that the operation of tonsillectomy is really an operation that is extratonsillar in character. We don’t operate on the tonsil. It is very important, therefore, that we should know the external re- lations of the tonsil. I have tried to keep up with the methods of doing the operation. My preference has always been for the dissection and snare method, using the snare method a little more freely than we used to do or than Dr. Fowler suggests. As compared with other methods, I think the dissection snare method has very great advantages. The ad- vantage Dr. Fowler speaks of is notable, in that you can follow the course of the operation very carefully. The great point, of course, that Dr. Fowler has demonstrated, is the existence of mus- cular tissue which enters from the muscles of the throat wall into this fibrous capsule or into that layer of pharyngeal fascia which coinstitutes a capsule for the tonsil. I know very well that we encounter difficulty in clearing the tonsil cap- sule at the equator of the organ, but the ex- planation before has not been very explicit. Now. we can go out with an understanding that will aid us greatly and save us very many compli- cations. The question of hemorrhage always comes up. I don’t want to enlarge upon that except to say that entry of the blood vessels into the tonsil occurs through this equatorial region which con- tains muscle fibers. In approaching the tonsils, the arterial vessels keep subdividing and attain small caliber perhaps When right in contact with the tonsillar tissue of the capsule. If you cut through the muscular attachment, you encounter large vessels, comparatively, and you are more liable to have bleeding. If you are careful to fol- low the actual surface of the tonsil, as near as can be, you cut across these vessels when they are down to a comparatively small size, owijng to rapid subdivision. The subject of anesthesia has been demonstrat- ed beautifully by Dr. Fowler. I notice that he makes more insertions of novocain solution than I have been accustomed to, and notably the direct in- jection to the glossopharyngeal nerve opposite the lower lobe of the tonsil. That is an important point to be remembered as even at best under local anesthesia there are some people who feel a little pain when the glossopharyngeal nerve is approached. I have always been accustomed to giving my patients morphin and hyoscin in such doses as to make them stuporous an hour before the operation, and generally patients have no pain if they attain that condition. The pain is more apt to develop when the snares are used. That is a violent process and not only cuts but it also draws upon the tissues of the throat all around at some distance from the cutting wire. 1 will say that local anesthesia can be made very complete in- deed. I do it for nearly all my operations where the patient is able to sit up and control himself. 1 think the main part of control is psychic. If the operator is nervous and fidgety he doesn't have team-work, and if he shows any apprehension or awkwardness himself that is sure to be imparted to the patient. But if an operator approaches with confidence, the patient will be assured. Things to be avoided are those which excite the patient. I think that depression of the tongue is one of the things you have got to be careful of. I depress it very little and turn it to one side. If you bring the tongue in contact with the posterior wall of the throat you are sure to have some difficulty of breathing, and that is a thing which is bound to excite the patient, in the same way, the posterior wall of the throat must not be touched by the in- strument. Never swab the posterior wall of the throat if you want to get along comfortably. Dr. IT. V. Hubbard (Plainfield) : I have been rather surprised that there has been no mention of the toxicology of local anesthesia. Since novo- cain has come into use there hasn’t been much question about the toxic effect, although there have been some cases of mistake in solution used, and in my experience at the Post-Graudate Hos- pital in New Y'ork I have seen some instances of toxic effect. The method of operation may vary with the operator. One man gets accustomed to using a certain form of modified Sluder, and does it very well, producing good results; and another man gets accustomed to the dissection and snare, and he also does the operation very well. So that in the hands of different men different operations and good results may be obtained. Dr. Dikran M. Yazujian (Trenton) : In the mat- ter of anesthesia I think we should be careful in lubcrculous cases. I remember seeing at least . 2 such patients who had their tonsils removed un- der general anesthesia which aggravated their dis- ease and death followed in a short time. I think it is a great mistake to operate, on people with tuberculosis under general anesthesia. We must draw the line there, I believe: We must always operate on them with local anesthesia, and I pre- fer. like Dr. Fowler and others, novocain with adrenalin in it. Injecting the tonsil, I find that only 3 points along the anterior pillar are all we need, because, the fewer points we inject the less edema we will get and the less obscuring of outlines of the pos- terior pillars. I go through the anterior pillar and inject behind the tonsil in 3 places. The lower pole of the tonsil we must thoroughly anesthetize because in my experience it is the most sensitive part. There is where the patient will have pain if it is not anesthetized well. The kind of tonsil syringe is a very small mat- ter, but I experimented with several different kinds and the one I found most satisfactory was the Cook syringe. It is nothing but the frame of a syringe, as you know, and the novocain carpules come all ready to be slipped in to take the place of the barrel. Yrou just take out the used carpule and slip another one in and it is ready again. Another advantage of it is that there is no danger of get- ting your solutions mixed. For instance, if you have been using cocain for surface anesthesia be- fore you inject the tonsil, there have been cases where cocain and novocain have been confused Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 31 and the patient has died from the injection of cocain. This method avoids all that, because the carpule comes with the right solution in it and labeled. I think we all agree that patients who have had attacks of quinsy should be given general anes- thesia instead of local, because there is so much scar tissue that the local anesthetic will not pene- trate enough to make the operation painless. As to the technic of tonsillectomy, after using dissection, snare and Sluder methods, each for sev- eral years. I have adopted the La Force technic, which I have now used for 6-7 years. I prefer it to the other methods because it removes the ton- sils, and only the tonsils, cleanly and with much less bleeding and with much less reaction in the throat. Dr. Fowler (closing) : It has been a great honor to come down here and talk to you and show these movies to your society. I like to meet men who are on the frontier of our work, who are themselves doing the operating day by day and who are willing to listen to something which may help them. There is no subject that is numerically so important as the tonsil operation; it constituted one-third of all surgery in the United States dur- ing the last 10 years, and there is no operation we owe more to in the way of study. The suggestions that were made in the discus- sion can be very quickly answered. I have here something which I think covers 2 at 1 shot. This is an x-ray film of the lungs of a child 5 % yr. old whose operation had to be done under local because, as you will see, the tuberculous process had destroyed one lung. The doctor who sent the child into us said that to give ether was out of the question, the tonsils were very bad and the oper- ation under local would be. a life saver if it could be done. The operation was successfully per- formed, thanks to using the kind of psychology that Dr. Corwin has suggested. The boy was given a promise of a boat as a present from his mother if the first tonsil came out all right. A tear trickled down his cheek, then he was told that he could have his choice of another present if he let the other tonsil come out, and he sent out word to his mother, after thinking a minute that he would like a radio on the boat. The mother said he could have that, and then gently and slowly the novocain was introduced. I don’t know whe- ther you have ever seen an operation on a child well under 10 yr. old of that type, but it was re- markable with what ease physical removal of the tonsil took place, and it is remarkable sometimes to see how these children react to the proper en- couragement, undergoing what used to be thought a, very difficult procedure. Dr. Hubbard, I think it was, spoke of the toxi- cology. I apologize to you for not having taken that matter up. It is, I think, the one serious danger to be thought of and must be considered by everyone doing local work. Everyone who has done any of this work has seen either fatalities from that or dangers of fatalities through the accidental substitution of a drug, because the 2 clear fluids are on the table in similar glasses, and the doctor, thinking of his work, gets the syringe in the wrong glass. This can be definitely pre- vented by coloring the stronger solution. Chairman Emerson: How about adrenalin'; Dr. Fowler: Adrenalin I think is very much less apt to cause fatalities, because the adrenalin is added by the nurse, say, the 6 drops or whatever you order beforehand, to the solution, and the doc- tor isn’t apt to put his syringe into a brown bottle marked adrenalin. But he is apt to take a strong solution (10% cocain) that is clear white and is on the table there next to a weak solution (1% novocain) that is clear white and also on the table. These may get mixed at the pharmacy, they may be mistaken by the nurse, they may be substituted by the doctor. You have got to prevent in your local work absolutely any such thing as that happening or you will have accidents. I have seen in New Y’ork 2 actual fatalities in the hands of doctors of high repute through their making that mistake, and it is easy to prevent. You just put a fence around it, if you know what it is. One of the doctors suggested that a Cook syringe is the answer. Well, that is one answer, a syringe with an ampule, where the solution is made up beforehand. Or, if you prefer to have another syringe with perhaps a finer needle than the Cook— it has a rather heavy needle — you can use the solution fresh from the ampule put into an open glass at the time. There is another way, and that is if you have novocain 10% on your table, or perhaps you choose to have 10% cocain there, then have it a different color and you won’t mix them. I always have my strong solutions on the table blue or red and so well marked there is no danger. It is known nowadays that there is no danger in adding a couple of drops of gentian violet, and that pre- vents you from substituting the stronger solution for the weaker injection fluid. That certainly should have been mentioned in this paper. A STUDY OF OBSTETRIC MORTALITY J. C. Hartman, M.D., Germantown, Pa. As an introduction let me state that some people say obstetrics has become a surgical specialty. To this we cannot subscribe, for the majorit)^ of all deliveries always have been and always will be conducted by the general practitioner. The advance that has been im- parted to surgery through the perfection of technic, bacteriologic studies and practice of asepsis, has placed at our disposal a means of opening the birth canal that was not dreamed of heretofore. That this weapon has been used with indiscretion is only too apparent. Let us for the moment glance at some inter- esting statistics, concerning the maternal and infant mortality and morbidity. First is a report of the New Orleans Gynecologic and Obstetric Society, which covers the cesarean sections performed in 6 hospitals of that city over a period of 6 years. 32 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 During- the years covered by this report. 291 cesarean sections were performed and the in- cidence based on 16,000 deliveries in the same period was about 2%. More than j/j of those operations were done by 3 men, 1 an obste- trician and 2 general surgeons. Only 12% were done by the transperitoneal low cervical technic. An analysis of the maternal mortality from the standpoint of indications for opera- tion shows that out of 41 eclamptics in the series 17 were lost, a mortality of 41.5%. The operation for other toxemic conditions gave a mortality of 25%. Glancing at the fetal mortality, one is impressed first by the fact that out of 55 deaths, 20 occurred in prema- ture children. Immediately the question arises whether cesarean section is justified for pre- mature babies. As a direct result of placenta p'rbvia 13 children were lost, which is more than 39%. In this series of 291 cases, 47 mothers were lost, a mortality of 16.1%; 55 babies, a mortality of 18.9% ; and the fatality was a dual one in 16 cases. Since the above report, 31 cases were operated upon by the low cervical technic with no mortalities. Now let us look at a survey of cesarean sec- tions in the Borough of Brooklyn during the same years. In this group there were 934 cases with a maternal mortality of 54, or 5.8%. In 104 cases that were operated on for eclampsia there were 27 deaths, a mor- tality of 26%. A fetal mortality of 25.6%. Among 273 classical operations in which no vaginal operations had been made there were 16 deaths, a mortality of 5.9%. Among 199 classical operations where vaginal examina- tions had been made there were 27 deaths, a mortality of 13.6%, Among 66 lower seg- ment operations without vaginal operations there was 1 death, a mortality of 1.5%, and among 57 of these operations performed after vaginal examinations there were 6 deaths, a mortality of 10.5%. The latest report comes from the city of Los Angeles, over the years 1923 to 1928 in- clusive, with a series of 1322 sections, 1060 classic and 262 low cervical, performed in 12 hospitals, with a mortality of 4.2%. In the series of 1322 cases there were 107 fetal deaths, or a mortality of 7.9% ; 37 of these deaths were in premature infants, 6 were monsters and 5 were still-births. This is a much better report, but leaves much to be desired. I wish to give you the indications for this group of 1322 sections: Pelvic disproportion . . 488 Eclampsia 46 Premature separation .... 25 Previous abdominal operations 30 No progress ... 112 Cardiac disease „• 38 History of difficulties 29 No cause found 42 Prolapsed cord . . 4 Prolapsed cervix 1 Fetal distress 2 ■ Contraction ring 3 Ruptured uterus 4 Intrapartum infection 1 Intestinal obstruction 1 Recent laparotomy 1 Strangulated hemorrhoids . . 1 Hydrocephalic baby 1 Previous cesarean 197 Preeclampsia 187 Placenta previa 68 Fetal malposition . . 61 Old primiparas . 55 Fibroids 28 Sterilization 27 Insanity 1 Epilepsy 1 Anemia 2 Pernicious anemia 1 Request 4 Thyroid . . . . 1 Diabetes 1 Pyelitis 2 Gain in weight 1 Nervousness 2 Doubled uterus P Dysmenorrhea 1 Dead fetus 2 Now let us look at the mortality records of the United States in the past 10 years. In 1915, the maternal mortality rate in the reg- istered area was 6.1%. In 1920 it was 8%; in 1927 it was 6.7% per thousand births, and of this number 40% of all maternal deaths were due to infection, supposedly a preventable cause, while 27% are chargeable to eclampsia and the toxemias. Of the remaining 33% about 10% may be allotted to dystocia and operative labor. The remainder may be credited to the accidents of pregnancy and labor. To substantiate the belief that operative inter- vention increases maternal mortality, listen to the mortality rate in Massachusetts. In 1901 the rate of deaths per thousand live births was 3.8% ; in 1905 it was 4.2% ; in 1910 — 4.8% ; in 1915—5%; in 1918—8%; in 1920—7.5%; in Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 33 l°24 — 6%. In an analysis of 1000 fatalities, death occurred in 225 from puerperal infec- tion, 217 from toxemia, 140 died from acute infections, 129 from hemorrhage, 97 died of embolism, and 49.5% died of heart disease. Therefore, septicemia, toxemia and hemor- rhage— causes which are preventable — were re- sponsible for 58% of the deaths. In 58% of the cases operative procedures had been re- sorted to. With the above statistics before us, that speak for themselves, let us seek for measures to brighten the situation: (1) Better funda- mental obstetric teaching in our universities. (2) More careful supervision of our residents, Leaching them how to observe the normal. How many instances do you see where the resident physician is only called just in time to put on his gloves and tie the cord. He, in his youth and enthusiasm, feels that to get anything out of his hospital training he must do forceps, version, episiotomies and all the operative procedures connected with the ser- vice. Unfortunately, in many institutions he is aided and abetted in his desire by careless- ness of his superiors, either on the staff of the hospital, who are not doing special obstetric work, or by the courtesy staff if it happens to be an open hospital. He should be taught, first, the dangers of operative interference and made to observe the normal physiologic me- chanism of labor, so as to appreciate when the normal is at fault, and to expect help when this mechanism is abnormal. The more he is made to appreciate the dangers of operative interference the better will be our maternal mortality, when he joins our midst as a prac- titioner. Prenatal care. Here I wish to consider principally eclampsia and preeclampsia. From the foregoing statistics I am sure you are all convinced that cesarean section has no place whatsoever in the treatment of eclampsia. In most of these cases the child is dead from the toxemia or is premature and death occurs soon afterward. These cases are treated with greater safety to mother and child by early hospitalization, complete rest, dietetic and -eliminative measures with induction of labor in the preeclamptic stages. If eclamptic, the recognized procedures, such as morphin in massive doses, elimination by bowel and stomach, glucose, magnesium sulphate, and as normal a delivery as possible. Since 27% of our maternal mortality is charged to toxemia we would do well to increase our carefulness in prenatal care. Insist on the patient follow- ing directions as to diet, amount of water in- gested, keeping the avenues of elimination open and strict attendance at your office as often as necessary to check the blood pressure and urinalysis. In your prenatal study be careful to eliminate all possible sources of focal infection. Remember we do not know the cause of eclampsia, and that all our ef- forts must be toward elimination and lighten- ing the burden of the kidney and liver. In hospitals with well regulated out-patient departments eclampsia is almost entirely eradi- cated ; it is rare to see such a case but the in- cidence is just as great as ever. Therefore, this 27% of our mortality must be placed at the door of careless prenatal care and un- sound surgical judgment. Unnecessary cesarean section. As you listened to the indication for cesarean section in the Los Angeles statistics, did it not sound like a High School farce ; picking out some of the high lights — fetal malpositions, old primi- paras, sterilization, request, pyelitis, nervous- ness, dysmenorrhea, dead fetus, history of difficulties, no cause, no progress, cardiac dis- ease, etc.? I am sure that out of 1322 sections more than one-half of them were not justified. When you realize that clinical experience has taught us that 60 to 80% of the labors in relatively, contracted pelves terminate spon- taneously, you can lop off in a stroke 288 of the 488 done for contracted pelvis. Eliminate 233 done for eclampsia and preeclampsia, and about 400 for foolish causes, and the ever present desire to operate, and you will agree that my estimate of one-half is low. With reference to complicating disease in pregnancy, the pregnancy in most instances can be disregarded and attention given to the treatment of the disease. Here again let me reiterate that cesarean section has no place in the treatment of eclampsia. Cesarean section in the treatment of pla- 34 JOURNAL OF THK MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 centa previa has a definite place. In central placenta previa it is indicated in all cases, primipara and multipara. In the marginal and lateral types the method of treatment is one of choice, especially in the multipara where we expect less difficulty in opening the birth canal. The condition of the cervix always guides our choice, if it is a long, hard snout- like affair and the baby alive, cesarean may show the best judgment. The condition of your patient is not the guide for your proced- ure. If she is in shock, treat her for that by intravenous injection of salt solution, glu- cose acacia or blood transfusion, before any operative procedure is undertaken. Simple rupture of the membranes with the jamming of the presenting part into the cervix is often sufficient to control the hemorrhage and labor terminates spontaneously. Statistics show that where cesarean is done in routine for all previas, fetal mortality is markedly raised, as so many of these infants are anemic from loss of blood and unless immediately transfused die within a few hours, whereas you have subjected the mother to more serious danger, from infection, especially if she has been ex- amined vaginally or, as often is the case, has been packed with any and everything in the emergency. All cases of placenta previa should be hospitalized as soon as the diagnosis is verified, so as to treat the woman asepti- callv and guard against loss of blood, which in turn lowers resistance and favors develop- ment of infection. Malpositions. The incidence of cesarean section is steadily increasing for this compli- cation and is very unjustifiable. It is done for occiput posterior, breech, brow, face, trans- verse and every possible presentation. This incidence is due in great measure to the gen- eral surgeon, called in consultation, not being trained in obstetrics, who does the thing that he can do best — a surgical operation, ces- arean section. In these cases it is better to consult the obstetrician who is trained in the mechanism of labor and who realizes that malposition is only one chapter in the patient’s obstetric career. Cesarean section relieves the present situation but places the mother’s life in jeopardy for all future pregnancies, as she has a 14% chance of the scar rupturing. I am not blaming the surgeons, as he extricated himself with the best weapon at his disposal, but if fear of the patient being removed from possible hospital care or receiving inadequate medical attention was present in our conscience we would seek another way out, because a cesarean predicates future demands for the highest type of attention and skill. Here again the finger of accusation points to lack of pre- natal care, for in a good prenatal clinic with examinations and palpation 2 or 3 weeks prior to delivery, you will detect the abnormalities when correction can be made, or if not cor- rected you know what you have to deal with and are prepared to carefully guide. labor from the onset. Elderly primiparas. The dangers and diffi- culties of labor in elderly primiparas have been greatly exaggerated, for statistics show that neither fetal nor maternal mortality is increas- ed above levels generally accepted as normal and the average duration of labor is only slightly prolonged, while 20% of the women have strikingly rapid and easy labors. Dys- tocia may be expected in about 15% of cases, and in most instances it is not a true dystocia but a weak uterine contraction that fails to dilate the cervix. These cases are helped tremendously by Gwathmey analgesia where the painful inefficient contractions are relieved long enough to allow the real expulsive second stage pains to begin. Development of the low cervical cesarean should lower this cesarean incidence by allow- ing patients to have a test of labor. If this is practiced most of these cases will deliver spontaneously. Many think that a test of labor is just so many hours. My idea carries with it, the condition of the patient, frequency and duration of the pains, their impression on the cervix, and whether they are of the ex- pulsive or the hugging type. No definite length of time, 4 to 18 hours, but a careful personal observance of the patient during the test period, controlling nervousness and ap- prehension of the patient with sedatives and trying to ascertain her obstetric ability; plac- ing no weight on the patient’s outcry. A certain percentage of cesarean sections Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 35 will always be done in these elderly primiparas. due to long standing sterility and the increased value placed on the child. The foregoing shows that too many sections are being done. It carries a greater mortality and morbidity than any other clean abdominal operation. The mortality ranges from 1.8% in clean cases in which operation has been per- formed before the beginning of labor to 27% in cases in which forceps have failed and the membranes have been ruptured for any considerable length of time; while the mor- bidity ranges from 33 to 70%. Now let us pass on to another cause of ma- ternal mortality and morbidity and a high fetal morbidity — use and abuse of forceps and the abuse of pituitrin. The application of forceps still goes on. without any definite idea as to presentation or position of the pre- senting part to the vaginal canal. High, med- ium or low forceps, with utter disregard to the efifacement and dilatation of the cervical -canal, and a lack of any sense of disproportion between the presenting part and pelvic inlet. Only the other night I was called in consulta- tion where forceps had been applied and slip- ped off 3 times, on an R. O. P. above the in- let, with the cervix uneffaced and only par- tially dilated ; entire pelvic diaphragm eviscer- ated out of the vagina, bladder not catheter- ized, the cervix cut in 8 different places, and the fetal skull crushed. This in a young primipara, with a normal pelvis, in labor only 12 hours. Forceps should never be applied above the pelvic brim and only in extreme cases when the head is in the mid-pelvis. Low forceps as your judgment and ability direct. All should be used with great aseptic care and emulating nattire as much as possible. The arrested high heads should be converted into the an- terior positions and allowed to descend. In the minor degrees of contracted pelvis the in- duction of labor 10 days or 2 weeks early gives excellent results, especially in multiparas. Pituitrin is still given in massive doses — -1, 2 or 3 ampules at a time in one labor; given when the cervix is undilated, when the uterus is already undergoing strong contraction ; given without reference to fetal and pelvic disproportion, causing ruptured uteri, cervical tears and hemorrhage, and increasing the fetal mortality by intracranial hemorrhage. Pituitrin should be used with great care and in minute doses, and only when labor ceases to advance because of uterine dystocia. After rupture of the membranes it should be used with extreme caution; never in disproportion of head and pelvis or in thick rigid cervices. In conclusion, let me say that statistics show 90 to 95% of all labors terminate spontan- eously, and that the higher the incidence of operative interference, whether done by the expert or the general man, the greater the in- crease in both maternal and fetal mortalities. Therefore, let us increase our prenatal care, be sure of our knowledge of the physiologic mechanism of labor, practice rigid aseptic technic, keep our conscience ever present, de- crease our interference with normal labor by such instruments as forceps, version and pituitrin, and only use cesarean section after good obstetric consultation. A FEW PROBLEMS IN MEDICAL ETHICS* Harry H. Bowles, Summit, N. J. I wish to express my sincere thanks to the members of this society for the kindness and cooperation they have extended to me during the past year. I know that I have not been so efficient as I should have been, yet you have all been so helpful and considerate that the cares of office have seemed more like a pleas- ure than a burden. One must be bold indeed to dare a dis- cussion of medical ethics. It has been worn so threadbare by repeated handlings that everyone raises an eyebrow when it is men- tioned.- Hence, lest your patience be too sorely tried, I shall make this reading very brief. In the first place it has been, and can still be, said that the right sort of medical man needs very few rules of conduct, while the * (Presidential Address at the Annual Meeting of the Summit Medical Society.) 36 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 wrong sort will be bound by no rules, how- ever rigid they may be. In the last 35 years there has been tremendous progress in the practice of medicine, also in governmental structure and industry, so that many import- ant things have happened to affect the rela- tions of physicians to each other and to the public. One important phase to be mentioned is the employment of doctors by societies, which undoubtedly has a cheapening influence on the practice of medicine. Insurance and fraternal organizations frequently employ physicians to do family practice in a whole- sale way. Corporations made up of laymen employ physicians, and advertise in a com- mercial- manner to attract patrons. Many practitioners are listening to the siren voice of quick money, obtained with little expendi- ture of energy; thus presenting some new problems for medical societies to solve. Where strictly mercenary organizations are concerned, we know the old rule of ethics ap- plies directly. The problem is chiefly con- cerned with borderline cases, where, for ex- ample, a corporation employs physicians on salaries, supposedly to treat indigent cases yet not excluding those which should pay a physi- cian’s regular fee. The question which pre- sents itself here is — can a physician aiming to be ethical become identified with such organi- zations ? Another problem is that of friction which sometimes occurs between physicians of health departments and the family physician. Neith- er is at fault, but trouble is caused as a rule by introduction of the newer methods of pro- phylaxis, vaccine therapy, and so on. Cer- tainly there is some cause for debate as to where the duty of the Health Department ends and that of the family doctor begins. The problem requires tolerance and under- standing for its remedy and no rule of ethics can govern it entirely. To speak frankly it is common knowledge that a considerable portion of the people are not getting the highest type of medical ser- vice. And this is not because of a lack of kindness or altruism on the part of the pro- fession. Medical men still retain the whole- - souled generosity and charitable feelings they have always had, and I think always will have to the end of time. The difficulty appears to lie in the fact that there is a lack of coordina- tion between practitioners and health organi- zations. In the complex civilization in which we now live, individualism has given way to coordinated effort in other lines of community endeavor. The administration of public schools, the building of roads, the regulation of transportation, the regulation of food and drugs, by governmental agencies must meet with our approval. The interest of the gov- ernment in prevention of the spread of com- municable diseases, the control of water sup- plies and sanitary movements, is certainly to be commended. Thus it would seem the government takes care of preventive medicine, the private physi- cians of curative medicine, and it is hard to draw a definite line between them. This small rift or lack of coordination of practicing physicians with health boards and other gov- ernmental agencies, some fear may be an ex- citing cause of ill-advised agitation for state medicine. We have all witnessed the spectacle of state medicine in Europe threatening to demoralize the whole practice of medicine. Some thinkers fear it may seep in here, though we hope not. I believe that state medi- cine would be disastrous for the profession in America and that we should be on the alert to nip it in the bud, should that become neces- sary. We should endeavor to cooperate with all local and state health organizations for the advantage of both sides. I am sure that the profession, so carefully trained as it is to- day, can cope with the situation. We have eaten of the fruit of the tree of knowledge. It remains for the present and succeeding generations to demonstrate that knowledge has been wisely used for the healing of peoples. We must cease to be individualists and must work in splendid cooperation for our fellow- men. Before passing on from this phase of the subject, I merely wish to add that credit must be given to health boards for popularizing, through publicity, the periodic health examin- ations of children and adults. These examin- ations, incidentally, eventually add to the in- Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW TERSEY 37 come of private physicians. One state, to my certain knowledge, is trying to institute a system through its health boards, whereby the examination of children of preschool age may be gradually transferred from the domain of the school physician to the family physician. The radio is now being used a great deal for broadcasting important news items to the world. Of course, it is employed in giving to the public' many important fact's regarding scientific medicine and the prevention of dis- ease epidemics: It is perfectly proper for health officers to use the radio in broadcast- ing such news but what about the private physician in a similar situation ? When the latter’s name appears upon broadcasting pro- grams, even if' Inis "meaning is good, he is subject to criticism in the medical family. However, if the occasion were to arise, so that it would seem necessary for one or more mem- bers of the practicing fraternity to broadcast, it might seem more fitting for the local medi- cal organization to select the speaker or speak- ers,' thus avoiding any embarrassment. Another point to be mentioned, we have among the fraternity a few men (fortunately few) who seem to us to be rather heavily in- clined toward the commercial side of medi- cine. These are often the gentlemen with the grand autos, the brilliant plumage, the well- curtained waiting rooms— in short all the “window dressing”. These are the gentry who call every abdominal pain appendicitis, every belch a gall-stone, every heart-burn, an ulcer. Their practice is large, their income huge, their cures miraculous, in the minds of their grate- ful patients. Again, we have the men, and often able men they are, who are endowed with multi-cylindered egos, flavored with avarice, and who exact the ultimate farthing from their patients. These fellows pretend to justify such practices by saying they have rendered unusual service, and that large charges impress the patient with the prestige of the physician. Such acts, of course, vio- late the ethics of practice as much as secret fee-splitting and reflect on the profession as a whole. A little aside from or indirectly related to ethics, yet a phase which medical men should be interested in, is the experiment which is being made to reduce the cost of medical care and hospital expense to the' people of mod- erate means, who do not wish charity, whd wish to pay a moderate fee but who cannot pay the regular fees of hospitals and high priced specialists. Of course, all fair minded medical men would charge but nominal fees to such patients, but what about the hospitals ?' In some of the larger centers efforts are being made to furnish such moderate wage earners with reasonable care, such as combined hos- pital and medical care at $4 to $6.50 per day. Recently there has Ijeen added the Baker Me- morial wing of the Massachusetts' General Hospital to take care of such cases. Presi- dent Embree, of the Rosenwald Foundation,, at the dedication of the Baker wing spoke as follows: “Under conditions of poverty and dependence, charity was a virtue, a human necessity. Today the citizen of America does not require alms, he does not want charity. He wants and rightfully demands that in medical treatment, as in the other necessities of life, agencies be so organized that service will be good and efficient and costs correspondingly low. lie demands this service be not doled out to him as charity but that he be allowed to paV a reasonable and proper cost. Under new con- ditions hospitals should cease to boast of their medical charity, they should take increased pride in striving to have all their services so organized that each patient, even the low wage- earner pays as he goes for what he gets.” These words, bear in mind, were spoken before the great slump in business and vast unemployment came. And the Baker Me- morial started with $1,000,000 endowment and during the first 3 years the deficit will be one-half underwritten by the Rosenwald fund. It will be interesting to watch this and similar experiments. In conclusion, I wish to say that medical men follow a code of ethics which originated in olden times. This code was constructed on the principle of fair dealing of doctor to doctor and doctor to patient. By holding to this code of ethics we can maintain the humanitarian standard on a high plane. In this talk I have meant to be entirely imper- 38 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 sonal and have not meant to infer that the ten- dency of modern medicine is as a rule mercen- ary. Perish the thought. The vast majority of the fraternity are splendid, ethical men ; the ex- ceptional ones are to be considered in some way, I don’t know how. That will be the problem of the societies in the future. In the rapid progress made of late years in all lines of business and the professions it is strange that the adjustments have been so smooth as they have been. It is the duty of such societies as this to help in ironing out the rough spots and paving the way for a broader understanding of physicians to each other, to the profession as a whole, and to the public in general. A BACTERIOLOGIC STUDY OF CHRONIC INFECTIOUS ARTHRITIS John W. Gray, M.D., and Cecil H. Gowen, Newark, N. J. During the past year certain clinical and laboratory observations have been made in the Arthritis Clinic at the Hospital of St. Barna- bas and in private practice, which seem of sufficient importance for at least a preliminary report. The clinic was started primarily for the study and treatment of chronic infectious arthritis (arthritis deformans). Cecil, Nicholls and Stainsby1 did extensive work on this subject. They isolated a strep- tococcus from the circulating blood of pa- tients with chronic infectious arthritis in 61.5% in a series of 7S cases, which organ- ism they considered a specific strain in 83.3%. They also found that streptococcus, culturally and biologically identical with the strain iso- lated from the blood, could sometimes be iso- lated from a focus of infection and in affected joints in the same patient. Cecil’s technic was duplicated and results similar to his were obtained in our laboratory. It was very difficult to get the organism started in primary cultures, as shown by the fact that an average of 17 days’ incubation was required in his series. One of our posi- tives developed on the twenty-eighth day. There was always the suggestion on the part of critics that because the containers had to be opened so many times for subculturing we might be dealing with contaminations. Such a conclusion was highly improbable because we were getting a fair percentage of strep- tococcus growth of uniform type, only an occasional culture showed staphylococcus and diphtheroid organisms, and normal controls showed the same number of contaminants but no streptococcus. Furthermore, Cecil had thoroughly checked his work by animal in- oculation and cross agglutination. However, when tve hit upon a modification of the media about 3 months ago zvhich produced positives in the form of diffuse clouding of the media in 1 to 4 days without opening the bottles, the criticism above mentioned was eliminated. This method which consistently showed more positives than any we had tried, and all in a comparatively short time, presented numerous other advantages from both research and clin- ical standpoints. Cecil’s Plan of Culturing The patient’s arm is prepared by 2 coats of iodin and washed off with alcohol and 20 c.c. of blood is drawn from a vein in the arm and placed in 2 sterile dry test tubes ( 10 c.c. in each). These are placed in the ice box over night. The serum is removed, clot broken up, and the pieces of clot placed in each of two 100 c.c. bottles containing 50 c.c. of media. The bottles are incubated for 30 days and sub- cultures are made on blood agar every 5 days. The media is prepared as follows: Fresh beef heart is freed from fat and fibers, ground finely in a meat chopper and infused at ice box temperature over night, using 500 gm. ground meat and 500 c.c. tap water. Next morning the infusion is warmed to 20-25° and squeezed through a flannel bag. The filtrate is then boiled slowly for 1 hour and filtered through paper. It is then made up to volume and 1.5% peptone and 0.5% NaCl added. This is then placed in the Arnold, for 20-25 minutes to dissolve the peptone and salt. It is then titrated to pH 7.8 and placed in the Arnold for 1 hour. It is filtered through Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 39 paper and retitrated. If the pH has dropped it should be retitrated to 7.8 and put back into the Arnold for another hour. Then 50 e.c. of the media is placed in 3 oz. bottles and sterilized 34 hour in the Arnold for 3 suc- cessive days. It is titrated again and, if it has a pH of 7.6 or slightly above, it is satisfactory for use; if below 7.6, it is unsatisfactory. The finished product should be incubated several days for sterility. Modified Method Preparation of the infusion is exactly the same as above. At the end of the boiling and filtering, 0.5% NaCl, 1% gelatin (Bacto), 1% glucose (c.p.) and 1.5% peptone (Wittes) are added. This is placed in the Arnold for 20 minutes and titrated to pH 8. It is then placed in the Arnold for 1 hour and retitrated. If below 7.8 it is adjusted to that figure and placed in the Arnold for an hour. It is filter- ed through paper. It should not be below a pH of 7.8 before placing in bottles. The bot- tles are prepared beforehand by placing about a teaspoonful of calcium carbonate (c.p. pow- dered) in each of them, plugging with cotton, or cheese cloth and cotton, and sterilizing in the dry sterilizer for 1 hour. In these sterile bottles 50 c.c. of the media are placed and ster- ilized in the Arnold for 30 minutes on 3 suc- cessive days. At the end of 3 days it is titrated and if the pH is 7.6 to 7.8 it is satis- factory. It usually shows a pH of 7.7 to 7.8. The calcium carbonate helps to keep the media from becoming more acid while being steril- ized. If the pH is correct it is placed in the incubator for several days and if sterile is then ready for use. Description of the Organism While the growth is young, long chains are formed which cloud the whole medium. As the culture gets older this clears and the or- ganism breaks up into small chains or even diplococci and settles to the bottom of the con- tainer. Initial transfers into brain broth (Difco) or blood brain broth show the same characteristics. Transfers into a meat in- fusion medium (plain broth) form sand-like flakes which adhere to the side of the tube or settle to the bottom leaving the medium per- fectly clear. After several transfers in this plain broth the organism diffuses through the medium, producing a uniform cloudiness. Long chains which appear in cultures of an enriched medium, such as brain broth or gela- tin dextrose broth, each chain sometimes con- taining as many as 30 to 50 cocci, break up after 24 to 48 hours. The chains are much shorter (6-12 cocci) in plain broth but do not break up until 60 to 72 hours have elapsed. After several transplants the organism tends to grow uniformly in chains of 6 to 12 cocci. On blood agar there is a very delicate growth which shows a definite production of methem- oglobin. This is a very pale green and does not diffuse into the medium but is beneath and immediately surrounding the colony. The colony itself is a dirty grayish color. There is also a small zone of partial hemolysis sur- rounding the colony after 48 hours incuba- tion which is much more pronounced around the colonies deep in the medium. Blood Cultures for Streptococci No. No. No. No. Clinical diagnosis Cases Cultures Neg. Pos. Normal individuals 5 5 5 0 Chronic ulcerative colitis 2 2 2 0 Acute appendicitis 1 1 1 0 Hypertension 1 1 1 0 Purpura hemorrhagica 1 1 1 0 Carcinomatosis 2 8 8 0 Diffuse peritonitis 1 1 1 0 Septic abortion 2 2 2 0 Typhoid fever 1 3 3 0 Cavernous sinus thrombosis 1 2 1 1 Malignant endocarditis 1 4 2 2 Acute peritonsillar abscess 1 1 0 1 Agranulocytic angina 1 3 2 1 Myositis 1 1 1 0 Sciatica 1 1 1 0 Gonococcal arthritis 2 3 3 0 Hypertrophic arthritis 5 13 13 0 Subacute osteitis 1 , 1 0 1 Chronic infectious arthritis 2 2 1 1 (Fluid from knee joint) Chronic infectious arthritis 37 59 34 25 (blood) The above table includes febrile and non- febrile conditions as controls. The malignant endocarditis and quinsy cases showed positive growths of streptococcus which could not be culturally differentiated from the “arthritic” strain. The positive culture in the case of cavernous sinus thrombosis was a typical Streptococcus viridans. The patient suffer- ing with agranulocytic angina had a septic throat and pyemic abscesses. Hemolytic streptococcus was found in the blood culture. 40 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 The subacute osteitis case was of unusual in- terest because of its close clinical and bac- teriologic relationship to the infectious ar- thritic group. The patient complained of moderate pain in the lower thigh for about 4 months, had a low grade tempera- ture and radiograph showed thickening of the bone. Three diseased teeth were extracted soon after the onset. Vaccine was prepared from the “arthritic” type streptococcus iso- lated from the blood. The streptococcus re- covered from the knee fluid was identical, cul- turally and morphologically, with that re- covered from the blood stream and occurred in one of the cases listed under chronic in- fectious arthritis, a woman of 56 years who gave a history of arthritis for 15 years and was badly deformed. The chronic infectious arthritic group of 37 cases in which 59 blood cultures were taken showed a positive growth of the “arthritic” streptococcus in 67.6% of the cases and 42% of the cultures. The cases placed in the above group showed many variations but were sufficiently typical clinically to be so classified. They all had multiple arthritis, most of them typical fusi- form swelling of the smaller joints and many had deformities. The youngest was 14 and and had suffered involvement of the joints of the hands and feet for 4 years (Still’s dis- ease). The oldest was 75, the average age 44. The duration of illness was from 3 months to 25 years ; the average duration being 5 years 2 months; 29 were females, 8 were males. Several cases classified as chronic in- fectious arthritis showed interesting varia- tions. Two patients, a woman of 40 and a man of 60, had severe bilateral rheumatic iritis which developed prior to onset of arthritis. Both gave histories of severe sinusitis. One patient of 29 first noticed pain in one finger, developed tenosynovitis with a “trigger” finger and subsequently typical arthritis. Three gave histories of rheumatic fever or allied condi- tions in childhood; 2 of these had definite at- tacks of rheumatic fever, 1 had chorea and myositis. All had rheumatic cardiac signs. In 1 . interphalangeal joints of the hands showed fusiform swelling typical of early deforming arthritis, while the other 2 had multiple de- formities. Two showed “arthritic” strep- tococcus in blood cultures. We are not in a position to determine whether the rheumatic fever infections or secondary infections were the etiologic factors in these cases. Of the chronic infectious group, 30% showed definite foci in teeth, tonsils or sinuses. In the hypertrophic group no his- tory or evidence of foci were found. Cecil recently stated that patients with typi- cal chronic infectious arthritis show high agglutination for the typical arthritic strains in 94% of cases. This would be important not only in proving the specificity of the or- ganism for this type of arthritis but also in differentiating border-line infectious and non- infectious types. We have examined most of our cases for agglutination of these organisms and find that many of the bloods show a posi- tive result to a high titre. However, no fur- ther report of this phase of the work can be made until proper controls are carried out. Chronic infectious arthritis is undoubtedly due to a streptococcus infection of the joint tissues caused by a blood stream infection from a primary focus such as the sinuses, teeth and tonsils. Probably some patients control foci in the joints without any treament, others apparently recover when the primary focus is removed, but the great majority do not con- trol the secondary foci in the joints and stead- ily or intermittently progress toward deform- ity and invalidism. Vaccine therapy has been persistently used in the belief that it would have a specific action on the joint infection. The vaccine was pre- pared from the “arthritic” streptococcus iso- lated from the patient’s blood or from prim- ary foci, or both, or from typical strains in case an autogenous vaccine could not be ob- tained. A primary dose of 200 million was given, increasing that amount each week until 2000 million was given as a maximum dose and that amount was continued indefinitely unless a reaction occurred. Because of re- current attacks in 2 patients while on this regimen, focal or general reactions were con- sidered indications for reducing the dose. The most important single observation regarding Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 41 vaccine therapy was that it must be used for a long period of time. One must have a great deal of confidence in this method of treat- ment to encourage patients to continue injec- tions for months with little or no apparent change in the joint picture. But we have been repaid for persistence in many instances by a sudden improvement which progressed to an apparent cure. However, one should not expect too much from vaccine alone. Some patients are acute- ly ill and require hospitalization. A large number are poorly nourished and require a high caloric diet. Two patients who had in- sufficient vitality to respond to vaccine or any- thing else were given initial transfusions. Many patients find it necessary to continue work, using up every ounce of their reserve, when they deserve long continued rest. Fa- tigue should always be avoided. A warm, dry, equable climate is ideal. Although we are par- ticularly interested in prevention of deformi- ties through early and possibly specific treat- ment, there are thousands of crippled people who could be infinitely improved through proper physiotherapeutic and orthopedic treat- ment. They cannot receive adequate treat- ment at home and there are few hospitals for the care of such patients as cannot afford a private sanatorium. It is obvious that because the group of cases treated was small and because of the short time they have been observed no final con- clusion can be made until a later date. Nor would we venture too far in making con- clusions regarding: the cultural study, but we do feel that the method above described for the quick growth of organisms from the blood of patients suffering from chronic infectious arthritis is of sufficient importance to be brought to the attention of other workers at this time. References • 1. Cecil, R. L., Nicholls, E. E., and Stainsby, W. T.: Bacteriology of the Blood and Joints in Chronic Infectious Arthritis, Arch. Int. Med., 43: 571, 1929. 2. Cecil, R. L. : A Modern Conception of Arth- ritis, Jour. Lab. and Clin. Med., 15:1177 1930. TODAY Yesterday, I know not how, I slipped out from Then to Now. Such a world before me lay, Growing fairer every day, ’Til this morn I pause to count All my wealth — a vast amount : Friends, the love that round me lies, Flowers and birds and sunset skies, Memories of what hath been, Hope for days that wait unseen; But the best in every way Is the gift of each new day ! Every morn for me it waits, When I drift through sleep’s dim gates. None may hasten, none delay, None may spend it — My Today. So this little prayer I raise For today and all the days : Joyfully may I fare forth, Make each swift day full of worth, Work and love and pray and live And myself for others give. So may life be richer when I am sped from Now to Then. Frances, C. Hamlet. 42 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Special Article MEDICAL TRAVEL TALK A Physician’s Vacation in Ireland, England and France Henry O. Reik, M.D., Atlantic City Physicians find it more difficult than any other class of workers to take a real vacation, if by that word one means putting aside thought of the daily occupation, for the prac- tice of medicine is not only a noble profession but a very exacting one, and when one becomes wedded to it he finds himself bound to a jeal- ous mistress who demands constant attention. and explorations. A short post-graduate course of study may be made to serve the purpose of vacation, as may also attendance upon some national or international medical convention. Or, inasmuch as travel has both a vacational and educational value, even an informal trip into distant states or other coun- tries may prove profitable if combined merely with observation, from a medical point of view, of the habits and customs of other peo- ples. It was with some such vague idea in mind that we planned this summer’s vaca- tion ; we had no desire to listen to the reading of scientific papers, nor to attend clinics, but we believed it might be possible to pick up some information concerning the working of national health insurance laws — sometimes referred to as State Medicine — while at the same time enjoying the delights of travel, and, *!* : sfsaasB'.v-'sr : .. . m ilia ■■ fmm* r : i gsiiti ' v *»K m win ii 81 IS Fig. 1. Village Dispensary. District medical service to the poor: under a very old law. On the other hand, no group of workers de- serves more than physicians or is in greater need of periodic vacations, if by that term we mean a surcease from routine labor and substi- tution of new scenes and thoughts. Properly speaking, vacation should embrace change of climate and variation of mental activity, rather than complete cessation of labor, for it is from changes that one procures that bodily rest and cerebral stimulus which tend to re- store healthy vigor. Thus we may find a happy medium, between complete loafing and constant work, fitted to the conditions that affect most medical practitioners. The physi- cian can take a rest from his usual routine of labor and yet continue in touch with some of his vital interests ; can do this perhaps better than other workmen because there are so many fields into which he may extend his studies .further, to secure some interesting pictures of foreign medical institutions. So, we took along a “Filmo” and proceeded to record some moving events. In the beginning let us say that the often heard excuse — “I can’t afford it” — is not a sound reason for not taking an annual va- cation. No man who is doing or wishes to do high class professional work, and that should apply to all physicians, can afford not to take an occasional vacation. Few better invest- ments exist, for the profits — renewal of en- ergy and preservation of health — are certain and immediate. Nor need the cash investment be very large. True, travel is more expensive now than in former times, just as the cost of everything else has increased, but it is not sufficiently high to be out of reach of the average practicing physician provided he is Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 43 willing to travel on a moderate basis. Con- sider, for instance, a European trip embracing visits to great medical centers, whether for clinical study or simple observation of insti- tutions and passing events ; a vacation of 2 months duration can be financed on less than $1000, with due allowance for living in first class style; a single month of absence from home, which covers 2 weeks on the ocean and 2 weeks abroad need not cost more than $600. Of course, if one feels it necessary to travel on the “ocean greyhounds” and to command all the luxuries of the most fashionable liners, more money can be expended ; but such a course of action is by no means necessary to a beneficial vacation. We have crossed the Atlantic many times, and have tried all types of boats, and experience has resulted in the jumping off from Baltimore, in the County of Cork, the southernmost point of Irish land, and landing in Baltimore, Maryland. It happen- ed that our ship landed us not far from the northern extremity of Ireland, i.e. in Belfast, so we had to traverse the entire length of the country. We are not inclined to recommend booking to Belfast unless you have some very special reason for so doing. However, the fact that we sailed around the northern coast and close enough to procure a good view of the land in the late afternoon and early evening hours, compensated in some measure for the discomforts of landing ; for the ship was an- chored in the Irish sea and we were sent ashore on a ferry-boat which consumed 2 hours passing up the bay and river, to put us on the dock at 3 a. m. Sunday. It is far more Fig. 2. Merrion Square. Specimens of doorways. American Consulate at right. conviction that the greatest comfort and satis- faction are obtained from the modern “cabin” boats; such ships as the Samaria, Carmania or Aurania, of the Cunard Line, and the De Grasse or Lafayette, of the French Line, offer all the necessary conveniences, perfect comfort and excellent food, and are in some respects preferable to the larger boats of the same companies. The round trip can be made on any of the boats named for $300 to $500, according to size and location of room, and, $10 per day is ample allowance for the time to be spent on shore. Remember this when preparing next year’s budget. Having on previous voyages neglected Ire- land, we determined to commence this time with that country ; partly because we had a desire for new sensations, and partly because our maternal great-great-grandfather migrat- ed from the Emerald Isle 150 years ago — comfortable to enter Ireland by way of Queenstown (Cobh), where facilities for landing are much better. Belfast has few attractions for the tourist; in fact, we can think of none except that it con- stitutes a good approach to the Giant’s Cause- way, if you care to visit that freak of nature, and that a side trip can be made by auto-bus over a beautiful driveway which follows the northeastern coastline for a considerable dis- tance through County Antrim — a road running along the edge of the cliffs much as our own Hudson and Bergen County Boulevards fol- low the course of the Hudson River along the Palisades. Belfast is essentially a commer- cial city, in the midst of a manufacturing district, and except in the newer residential portion has a drab appearance, though the public park and suburban area redeem this to some extent. The surrounding country is 44 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 charming, but that can be said of practically every square mile of Ireland. From the first glimpse of green behind the rocky coastline, to the farewell view as we crossed to Wales, we were conscious that the sobriquet— Em- erald Isle— is most fittingly applied. No green we have ever seen has been greener, and no land we have yet seen offers anything superior to the fertility of Ireland’s soil. Everywhere, from north to south, from east to west coast, the land is a rolling terrain, and everywhere it is covered with a luscious growth of plant life ; a sight to please anyone with a countryman’s soul and a farmer’s eye. Across the boundary line into the Irish Free State and we entered Dublin. The austere, sombre appearance of Belfast gave way to the contrasting brighter and gayer modern American cities ; and we were soon to discover that in Ireland it is the general custom. On our first car ride, we requested the conductor to tell us when we should be arriving at the point nearest to Dublin Castle. After some little time, a gentleman leaned across the aisle and said: “I heard you asking for Dublin Castle. If you will get off at the next corner, where the car will turn, walk one square farther on this street, and then turn to your left, you will be facing the Castle.”i This was kindly intervention, for the conductor would probably have forgotten us because of other demands upon his time. On other occasions, when asking for informa- tion, people put themselves to considerable trouble to render assistance. Such experiences naturally led to conversations from which we Fig. 3. Ruins of the Castle from whence came the Donohoes. capital city of the recently organized Irish Re- public. The fact w'as brought strikingly to our attention by the coincidence of making our ad- vent at the same time as the first French Am- bassador to Ireland. An American Ambassa- dor was installed some time ago, and while watching the procession attendant upon the French Ambassador’s reception, a kindly Irish gentleman gave us an interesting discourse on the local political situation, and, also, a lessoi in Gaelic. And right here let us take advantage of the opportunity to say that nowhere else in the world have we met such uniform cour- tesy as we found throughout Ireland. Our first surprise came upon entering a crowded street car, and observing that the passen- gers moved to make room for us to sit down ; such a delightful contrast to conditions in gleaned valuable knowledge in addition to what we had originally sought. Also, some of these experiences were amusing as well as interesting, for the Irish wit found abundant chance for display. Our Gaelic friend, while watching the am- bassadorial parade and discussing various sub- jects, drew for us a comparison with relation to the Irish Free State's desire to take life easily, saying: “We are not inclined to rush and hurry, but prefer to take things slowly. I had a friend, of about my own age, who was always urging me to be more ener- getic and do more business. He was not satis- fied with business life in Dublin, and so he went to Belfast and then to London, and he worked hard, and he succeeded in making money and building up a large business, but — he has been Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 45 living in a cemetery for 10 years, and I am still hale and hearty.” And he was a remark- ably well-preserved, patently successful man considerably beyond the allotted three score and ten years of age. From the medical point of view our inter- est in Dublin centered in Trinity College and we spent most of our first day inspecting that institution. Trinity is, as you probably know, one of the world’s notable universities, and dates from December 29, 1591, when it was established by royal permission of Queen Elizabeth. One of the chief points in esti- mating the success of any form of govern- ment is found in the attention paid to the sub- ject of education, and we were interested to learn the plans of the Irish Free State in this respect. The Irish Times of Saturday, Aug- (generally spoken of as Trinity College), is of recent birth — only about 20 years old — and has not yet attained any particular renown. It is the present policy of the government to in- sist upon the study of Gaelic in all the public schools ; an order that seems to have greater sentimental than practical value. Trinity, with its 340 years of growth, has become an institution of imposing appearance and great national importance. The grounds form a lovely park and the buildings are pleasing from an architectural aspect, but the Library is the center of attraction to anyone at all interested in educational affairs. Like Oxford and Cambridge, this University has always received under British law a copy of each' book published in the United Kingdom, so that its library contains today more than Fig. 4. Lake ICillarney at twilight. ust'9, carried an explanation of the public school system : compulsory school attendance up to the age of 14, when a “Primary School Leaving Certificate” may be obtained upon satisfactory passage of an examination; sec- ondary educational curriculum providing for “Intermediate Certificates” after 2 years’ fur- ther study (showing ability to take up ad- vanced work or to enter technical schools) and final “Leaving Certificate” at the close of an- other 2-year period; and, “Honors Certi- ficates” when pupils’ marks justify the award. The leaving certificates have a definite value inasmuch as they are accepted for matricula- tion in the National University of Ireland, and accepted with certain qualifications for en- trance to Trinity College. The National Uni- versity, which, by the way, must be dis- tinguished from the University of Dublin 300,000 volumes of exceptional value for ref- erence purposes. Then, claim is made locally that the most valuable book in the world is in the possession of this library ; that is, the famous Book of Kells, a marvelous piece of illuminated text of the gospels, the life work of one monastic scribe in the eighth century. This book is carefully preserved and is under supervision of a special caretaker; each even- ing it is placed inside a steel vault, and each morning is opened at a new page and placed in a glass case for the inspection of visitors during the day — the opening at a different page daily being designed to avoid too pro- longed exposure of any given page to the ef- fects of daylight. Trinity is located in the very heart of the city, the entrance being directly opposite the old Parliament House, which is now used as 46 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Tan., 1D31 the head office of the National Bank of Ire- land, and the chief buildings are ranged along the 4 sides of an immense quad the center of which constitutes a small park containing many beautiful old trees. There is an inner court, containing dormitory buildings, and at the distant end of the outer quadrangle stands the Medical School with its anatomic and physiologic laboratories. In 1654 the College of Physicians was established in connection with Trinity College, and this connection is still maintained in the choice of professors for this medical school. The medical school buildings are not very ancient but they were undergoing reconstruction during the period of our visit and the Sunday paper contained the following interesting and witty news item : structure to the sister association buildings in London. It might be mentioned, too, that the British Medical Association has a separate branch for Ireland, with a resident secretary and office in Dublin ; but of our visit to that institution we will speak later. The region between Trinity and St. Ste- phen's Green, embracing both Kildare Street and Merrion Street, is rather fashionable and contains many fine old houses that intrigued us because of their beautiful front doors. Perhaps the greatest mark of distinction about the external appearance of an Irish home is the portal of entrance; the architectural beauty of the facade hangs particularly upon this feature of the plans and many of these houses have doorways of striking character. The doors are made of fine woods, mahogany Fig. 5. Typical Irish Village Market Day. A Warm Time Cominc “For some time now workmen have been busy at the medical school, putting in new heating ap- paratus. A new boiler of formidable proportions was taken in through the front door — various walls and windows having to be demolished to permit its passage — and duly lowered into the depths. In connection with the complicated arrangement of engines of torsion and leverage, which were rig- ged up to get the boiler into its new home, a curious incident occurred. A steel cable stretched some 6 ft. above the path smashed the windscreen of the car of Dr. E. J. Watson. Had Dr. Watson been decapitated, as he so nearly was, the Rugby Club would also have lost its head; for he is its President.” We were interested also in visiting the very, old homes of the Royal College of Physicians, on Kildare Street, and the Royal College of Surgeons, on St. Stephen’s Green, 2 of the fin- est buildings in Ireland and quite similar in predominating, and the woodwork, as well as the brass knocker, is kept in a state of high polish. Furthermore, they are protected from the effects of inclement weather and the sun’s heat by canvas covers that may be adjusted as seems necessary. The fan-shaped tran- soms, behind which in some instances one ob- serves a marble statuette of some animal or the bust of some distinguished man, add to the interest as well as the beauty of these entrances. Leinster House, once the residence of Lord Edward Fitzgerald, is now used as the meet- ing place for the Irish Parliament. It is flanked on either side by the National Library and the National Museum ; the 3 buildings forming 3 sides of a hollow square. Old Dublin Castle, for many centuries the center of political authority, is now being used as a Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 47 temporary home for the High Courts and as offices for other divisions of the government pending reconstruction of the buildings par- tially destroyed during the revolution. On the occasion of our visit to Dublin Cas- tle. we had an unique experience. After hav- ing been shown through most of the galleries and some of the rooms that are not ordinarily opened to visitors, our guide took us into the court chamber where a case was being tried and extended the courtesy of following the proceedings so long as we might be interested. The most impressive feature to us was the manner in which the trial judge endeavored to dispense justice ; a striking contrast to some court scenes we have witnessed in this grand and glorious United States. The case under concerned.” Here was a judge ready to push aside technicalities, in order to effect a full measure of justice. Certainly a pleasing sight in these days. Our wish to photograph many interesting and historic spots in Dublin was interfered with by weather conditions. During the first morning of our stay in the city we started out with camera in hand but found a shower of rain and returned to the hotel room for an umbrella. As the elevator descended with us for the second time within a few minutes we apologized to the operator for not having properly prepared ourselves at first, and then asked whether it rained often in Dublin. His answer was : “An umbrella is a useful thing to have, sir, in Dublin, for you will Pig. 6. View of Blarney Castle; indicating location of the famous charmed stone. consideration concerned the disposal of prop- erty left by some one’s Last Will and Testa- ment, and the administrator, some fiduciary company, was trying to force all of the lega- tees to comply with orders of his own. The attorney for the plaintiff had explained the situation and requested an order of the court to compel obedience. The judge listened at- tentively and then said, in effect, something like this: “Before calling upon the defense to reply, I think I should say to you, sir, that I realize you are trying to take advantage of a technicality of the law, and that while you may have a legal right so to do, I am not in- clined to grant your request, for the simple reason that such a decision would possibly work great injustice to some of the parties meet another shower about every second street crossing.” His words proved to be quite true not only for Dublin but for all of Ireland during the 2 weeks we spent there. If we can feel that it is a beautiful, charming coun- try, in face of the continuous wet and cold weather of this past summer, it must be some- thing wonderful to see during a sunshiny period. The Killarney lake region seemed to us deserving of all that Tom Moore wrote and that John McCormack sings about it; veritably, “a little bit of heaven”. The nearest comparable thing in America, in so far as we can recall, is Lake George, but much as we love this favorite spot, we are compelled to admit that Killarney possesses even greater charm. There is a bewitching beauty, a poetic 48 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 softness and delicacy, about Killarney that is all its own, and we earnestly recommend it to you for a short visit, or a prolonged so- journ, according as you can afford the time ; but do go there sometime during your life if only for a fleeting glimpse. One can make, as we did, a very delightful circular tour from Dublin to Killarney, thence to Glengariff and other points on the south coast, across to Cork and up through Tipperary to the capi- tol city again, and every mile of the way will be enchanting. In the cities, and in every town through which we passed, generally close to the town hall or to the church, we observed Public Dis- pensaries, and our first thought was that these its application to the 3 northern counties that remain a part of Great Britain. This infor- mation, with much more of interest, was ob- tained through 2 very pleasant hours spent with the Commissioner of Health of Dublin, Dr. Russell, and the Secretary of the Irish Section of the British Medical Association, Dr. Hennessy. Dr. Russell had visited the United States 2 years ago when the Rocke- feller Institute conducted a tour of foreign public health officers to study American meth- ods, and Dr. Hennessy had practiced medicine in England before and for a time after adop- tion of the National Insurance Act, so we were able to secure considerable authentic informa- tion concerning medical conditions ; facts Fig. 7 Kissing the Blarney Stone consists in hanging head downward into the opening and placing the lips against the under surface of the basic stone in that portion of the outer wall at the end of the iron bars. One has to hold firmly to those bars, and it is advisable to have a friend hold the kisser’s feet, to prevent an accidental fall resulting from dizziness. were part of a national health insurance plan, but upon inquiry we discovered that under a very old law of the country free medical service is provided for the poor, and each district of a certain size has its own dis- pensary, the attending physician being a paid, part-time, official with the privilege of private practice. The British Health Insurance Act was meant to cover Ireland along with the rest of the United Kingdom but in Ireland it met with even less recognition than our national prohibition law has been accorded in some of the states ; in fact, throughout Ire- land, it was simply ignored until 1928 when action by the League of Nations resulted in which will be utilized for discussion at a later date. While we were in Dublin, however, the i Irish Times published the following item: Medical Benefits The Irish Medical Committee has passed a reso- lution drawing the attention of the Saorstat (Irish Free State) Executive Council to the establishment of a system of medical benefits in Northern Ire- 1 land, and suggesting steps be taken to provide medical treatment for insured persons in the Free State, preferably by the establishment of a na- tional medical service on the terms suggested in the Majority Report of the Committee of inquiry on the National Health Insurance and Medical Services. (To be continued) Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 49 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J. Entered at the post office at Orange, N. J.t as second-class matter PUBLICATION COMMITTEE HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J. EDITOR: HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J. Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact. NOTE. — The transaction of business will be expedited, and prompt attention secured if: All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to The Editor, Atlantic City, N. J. _ . All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements, or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication Committee, (address above), Newark, N. J. THE PRESIDENT’S NEW YEAR GREETING The President of the Medical society of New fersey takes pleasure in greeting the membership in the New Year. He extends his best wishes for a yrear filled wfith the joy of work well done. He hopes the Great Physician will shower blessings upon the mem- bership and give them wisdom to cope with the serious problems with which they are faced. To the Womans’ Auxiliary he pledges his interest and support in its noble and unselfish efforts to aid in promoting the aims and ob- jects of the Medical Society of New Jersey and to serve as an ally to that organization in developing its program of health education and public welfare. George N. J. Sommer. FRACTURES AND THE COMPENSA- TION LAW In the December Journal we published an interesting discussion of the practical working of the Workman’s Compensation Law, started by Dr. Sherman’s paper on Eye Injuries. This month we present an excellent corollary to that review, in the papers by Drs. Adams and Martin, on Fractures and Traumatic Surgery, and the accompanying discussion. Taken to- gether, these contributions pretty nearly cover the complications and difficulties that inter- fere with a smooth working of that law. You will profit by reading the matter in its en- tirety. We may at the same time report that a spe- cial subcommittee of the Welfare Committee is now engaged in studying a plan for smooth- ing out all the disagreements that so common- ly arise between physicians and compensation insurance companies. A PROBLEM SOLVED. IOWA PLAN OF SECURING PAYMENT FOR SERVICE TO THE COMMUN- ITY’S INDIGENT SICK The Annual Conference of State Society Secretaries and Editors, held at Chicago in November, provided this year some discus- sions of exceptional interest. President Som- mer accompanied your regular representatives, and in the Department of Communications you will find a letter from him relating his impressions. The Department of Lighthouse Observations is also being utilized this month for presentation of a summary of one of the most important papers read at that confer- ence ; a paper dealing with the relations of the medical profession to the public, and especially to the much talked about problem of state medicine. It remains for us to direct your attention to a paper presented by Dr. Robert L. Parker, Secretary of the Iowa State Medi- cal Society, under the title, “The Best Method of Caring for the Indigent Sick”. During a visit to one of our county societies recently we heard a somewhat heated dis- cussion concerning the relationship between the local physicians and the Board of Free- holders, with special reference, apparently, to 50 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 the disinclination of county authorities prop- erly to compensate physicians for services ren- dered to the indigent sick. Furthermore, a situation was reported last month by the Essex County Medical Society, indicating that the Newark City authorities and the county society are endeavoring to reach an agreement whereby the city’s indigent sick will be prop- erly cared for and the physicians will be paid for services rendered. The Iowa plan for providing adecjuate medical services to im- poverished citizens, securing to physicians payment for services rendered, and avoiding disputes, seems to us peculiarly applicable to some of our own county conditions. Briefly stated, the Iowa plan provides that the county medical society shall make a blanket contract with the county authorities, under which the latter will pay annually a fixed sum to the society in return for proper medical care, by members of the society, of all the in- digent sick in that community. Such medical attention is to be supplied upon orders of the freeholders (or whatever may be the official name of the county authority) ; and such ser- vice is divided among members of the society on as nearly an equable basis as possible. The total annual payment goes into the society treasury, to be disposed of as may be deter- mined by the organization : members may be paid out of this fund for services actually ren- dered ; the unexpended balance may* be used as the society sees fit ; or, members may con- tribute their services without pay and permit the society to utilize the entire fund for the benefit, in some other form, of all its mem- bers. Consonant with the last mentioned de- vice, some of the Iowa counties have found this money sufficient to relieve members of the entire burden of dues to county, state and national societies ; some propose using the growing fund to establish an endowment; some purchase insurance and indemnity poli- cies for all members, on the group basis ; and some use all or part of the fund for bringing speakers from a distance, thus relieving the program committee of a burden, or for con- ducting post-graduate courses. The income of the county society, from this plan, varies in accord with the population of the countv ; and the sick demand varies with its percentage of indigent citizens. In Iowa, the plan has been tried for a few years in 1 1 counties. The population ranged in these counties from 16,000 to 63.000, and the con- tractual payments ranged from $1600 to $12,- 600. In general, the obligation was to furnish full medical service, including major surgery when necessary, and medicines and supplies except serums, antitoxins and salvarsans. It will be noticed from the above figures that the smallest county paid on the basis of 10c for each member of the total population, while the larger county paid upon the basis of 20c. The total population of the 11 counties being 316,201, and the total amount of money paid into the 11 county medical societies $36,530, you will observe that the average payment was upon the basis of a trifle over 1 lc per citizen. The membership of the smallest county so- ciety numbered 10; of the largest county, 86; the average being 36. As the total registered membership was 370, and the total fund $36,- 530, the average allotment for each physician might have been a little less than $100. In some of the counties the work was per- formed by assigning patients to the nearest physician ; in some instances arrangements were made whereby members of the county society rotated in service; in some counties the pa- tient was permitted freely to select his own physician from the county society member- ship. As indicated, the plan worked admirably in so far as it has been tried in the state of Iowa. It has resulted in physicians being paid for services rendered to the indigent sick* just as other services and supplies to such citizens are paid for by the community ; thus eliminat- ing the injustice of placing upon physicians alone the burden of caring for the sick poor. It has further resulted in a general satisfac- tion of the community with its physicians through this supplying of effective medical service to the needy, and it has also resulted in the removal of friction between physicians and local boards of supervisors and social workers. Finally, it has served to provide the county society with much needed funds to carry on scientific or educational work. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 51 Economics THE OPEN HOSPITAL William H. Ross, M.D., President of the New York State Medical Society, Brentwood, Long Island, N. Y. There is no other practical way of bridg- ing the gap between the time of a doctor's graduation in medicine and the present day knowledge, than by experience in a hospital. Practically, this is possible for all of the pro- fession in an open hospital. Much has been written about the merits of an open or closed hospital but considering the educational in- fluences on the profession, an open hospital is of greater community value. In no other way can the profession be kept in the proper state of education regarding modern medicine than by continuous education in its own environ- ment. It is not the primary obligation of hospitals to undertake to make specialists and it is the obligation to train the 80% of the profession who are general practitioners and who attend to that percentage of care of dis- ease. If those who manage hospitals do not make them available in some way to the entire pro- fession for practice therein, so as to benefit by the education that flows from them, we are not protecting the public, by making good doctors, from that ever present tendency of the human mind to credulity and the unusual nor are we developing availability of the science of prevention and cure of disease — an ideal that came to the front in the initial meet- ing, in 1807, of the Medical Society of New York State when it offered a prize greater in value than its then entire financial resources for the best method of prevention and cure of Typhus Mitior. I believe that with the 1,000,000 hospital beds in 9000 hospitals and the increase of 127% in hospital facilities in the last 20 years, the time has come when every doc- tor should have a hospital connection un- der some plan. A hospital does much for a community. It sets up an advanced standard of practice. In addition to making better doc- tors it becomes a real source of education to the public and steadily breaks down medical ignorance, the greatest foe of public health advance. Medicine has done much for human wel- fare and for civilization, and the education that flows from a modern hospital can con- tinue this and make it the greatest modern factor in advancing these age-old functions of the profession of medicine. In New York City and its metropolitan area, the educational advantage offered physicians seems consider- able when we realize that 51% of doctors have hospital or out-patient service, 16% of the remaining are either retired or engaged in other phases of medical work, leaving 34% who are without institutional appointment, but since there are in New York City 10,877 physicians, 3698 are by the present system of hospital service largely deprived of the oppor- tunity of continued education. The only im- portant difference that I know of in the medi- cal situation in New York City is that there is 1 physician for 550 people and in the rest of the state the average is 1 for 793 people. You may draw your own inferences regarding professional attitudes toward clinics, health centers, and the economic situation, and efforts to improve it. The question arises — is organized medicine meeting its obligation to provide the best kind of physicians that it can ; and right here I would like to say that which I have said on several occasions this year, that it is time for organized medicine to self-appraise its own organization and offer proposals for the solu- tion of problems that government has taken on in 23 other countries, if the profession is going to avert more state medicine. The rural hospitals of New York State are generally open hospitals and their standards of practice are good. Human nature is about the same in rural as in urban sections. If an open hospital brings about arising of the level of professional ability of practicing physicians and prevents a loss of professional prestige, and gives the patient the right to select his own physician, insuring personal interest and responsibility' for his welfare, then it is worth trying in cities and the few remaining places in the country under the guidance of medical statesmanship with rules, regulations, and penalties for enforcement of standards to see if it does not work out as well as it now works in many small communities in New York State doing work equal in results to the av- erage city hospital. My experience in hos- pital organizations makes me believe that the essential control is compulsory staff confer- ences to review the catastrophies and to record the story of diagnosis and treatment, so that a strange doctor reading it would understand the case, and, then to file the record so as to be easily accessible for study. Sometimes I think that perhaps our own profession is dividing itself into 2 classes — one the conservative, guided by tradition ; the other the liberal, interested in human progress. 5.2 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE\ Jan., 1931 Collateral Reading THE FUTURE OF FREUD The Structure and Meaning of Psycho-analysis By William Healy, Augusta F. Bronner and Anna Mae Bowers {Reviewed by Joseph Jastrow in Saturday Review of Literature, June 28, 1930.) Despite the increasing numbers to whom the ideas underlying psycho-analysis have be- come familiar, the recent restatement of “Freud” by Freud is relatively unknown. His disciples have , carried on a campaign of ex- position of the clinical phases and their bear- ing on life problems and the interpretation and organization of human motives. The di- vergent views of Jung and Adler, of Adler notably, continued the same emphasis with more liberal interpretations. Yet through it all the starred feature is the origin of the neurotic trends and the technic for their con- trol. Dr. Freud shows the characteristic tendency, as thinkers approach three-score-and-ten, to lose interest in the collection of data and focus upon the fundamentals which now, as of old. implies a philosophy. This is equally true of William James and Wilhelm Wundt, two other master minds. Freud’s interest in clin- ical psycho-analysis has given way to its theoretic formulation, which in truth is not “psycho-anal ysis’Jat all ; Freud calls it “meta- psychology”, which supplies in the apt title of Dr. Healy ’s notable book “the structure and meaning of psycho-analysis”. A correctly perspective view of the Freu- dian psychology is not likely to arise in the clinical camp of Freudians. They are too closely absorbed in the intricate psycho-analyz- ing of “cases,” whose complexity they tend to exaggerate, and whose diagnosis they coerce into conformity with accepted doctrines. There is in all a marked cultist streak which is not conducive to reflective clarity or ob- jective sanity. The contribution of Dr. Healy, Dr. Bron- ner, and Miss Bowers may be accepted as a long anticipated recognition of the develop- ment of Freud’s views as a theory of psychic motivation. Dr. Healy is not a psycho-analy- tic practitioner; he holds no brief for any school or cult. He utilizes the psycho-analytic approach in the handling of personality and be- havior problems of a far more varied and directive character than appear in a neuro- logic clientele seeking relief from oppressive conflicts. He is a broader type of clinician; and it is fortunate that he has included among his interests that of setting the Freudian house in order. While I expected such a book to appear in due course, it was my further anticipation that it would be devoted to the clinical phase of psycho-analysis. This is still an urgent de- sideratum and would form volume 1 of the magnum opus of which Dr. llealy and his associates have given us volume 2. The method adopted in this book is well adapted to the purpose in hand. It consists of a large- type text on the left hand pages, stating Freud’s own formulations, with a commen- tary on the right- hand pages in smaller type, setting forth the variant views of followers and dissenters — a psycho-analytic Talmud. It requires a close knowledge of the subject to follow this exposition, a far more sustained interest than even the well versed student of psychology is likely to command. lo the serious student of the subject it is an indis- pensable guide. So much for the right hand text indicating the purpose and temper of the volume; and now for my left hand comment which, I fear, will in some circles be regarded as a left hand- ed compliment. For the fundamental ques- tion that readers of reviews of books-to-be- read will ask, relates not quite to the structure or the meaning, but to the significance and value, and the ever persistent truth of it all. Freud is weak, whether by temperament or training in the architectural sense; he erected his edifice as a series of facades and additions, with a ground-plan supplied as he built. Now, retrospectively, he makes good his deficit, yet never with the skill of Dr. Healy’s penetrat- ing pragmatic gift. The “cardinal formula- tions” are libido, cathexis, polarities, ambival- ence, the unconscious, preconscious, and con- scious, the “id”, the ego, and the super-ego, the fundamental principles; pleasure and reality, Nirvana and compulsion, the Eros or life instinct, the death or destructive instinct. All of these have their developmental stages ; a life is a genesis and a growth. They have their constitutional patterns strongly influ- enced by early experience. They disclose me- chanisms, here better called dynamisms ; and they end in character and personality, and there find their consummation and justifica- tion. Therapy is but an application and ap- pears in the concluding chapter alone, how- ever closely theory follows, the clues of clini- cal findings. This bare enumeration and its unintelligi- bilitv until elucidated, make it clear that the Freudian metapsychology is a new science, or shall we say speculation? It requires a new Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 53 vocabulary, a new approach, a new set of concepts. This story of the lify of the mind is completely different from ithat of the stand- ard psychologic versions of whatever origin that occupy academically and practically the great body of contemporary psychologists. If Freud holds the clue, they are pursuing false trails. Has Freud made good? is the question. For what all this means for the understanding or management of a human life can but be hinted at in a review. If lives and personalities are but Freudian exhibits, then for the great majority life is lived with a minimum of un- derstanding. It means that we are fearfully and wonderfully, sexualized, not merely the lower centers of our protozoic past, now sur- viving as the “id”, but equally the higher cere- bral areas where ego rules' and the super-ego soars, starting, like an airplane, with wheels on earth, but winging its way to the altitudes of human aspiration. We are victims all of the Oedipus fate and the emasculating dread called the castration complex. Our urges- hover between life and death; we are victims of birth traumas and sex shocks. Our genital origin imposes, a genital consciousness that never leaves us, and all we can do to live the life industrial, social, or intellectual is to con- vert and sublimate and transfer and symbolize dn'd project and rationalize arid idealize the original and persistent libido. Sex thou art, to sex returnest, was first (and last) spoken •of the soul. Is this really the truth of life? Is there no alternative except that of being glandular marionettes or Freudian fobots of most fear- ful and wonderful construction? Must we ever appease our “id”, consult our sub- and pre-conscious, make terms with ego and super-ego, before we can hope to understand ourselves or meet our' fellow men? Is a nor- mal man realty made in the image of a Freu- dian neurosis? Will the momentous decision of the future be Freud or anti-Freud? When we are told that the fear of small Tying or crawling insects derives from the tear of the father who also makes a sudden appearance and excites the idea of getting rid of him; that smoking derives from a fixation on the nipple, and eating sweets from the mother’s milk; that “later interests in paint- ing, sculpture, cooking, metal molding, and carpentry are believed to be traceable to cop- fophilic pleasure in smearing and molding” ; that characters . divide according to anal and oral persistences, we seem to be justified in consigning the entire system that sponsors such conclusions to the nearest wastepipe, and then ask wherein “psyching” is more scientific than other pretentious and marketable sys- tems of reading character. For there is the crux of the Freudian con- troversy. Viewed in one aspect it seems to offer a penetrating illumination into the motives of life; viewed in another, it becomes a gro- tesque and degrading caricature. What is wrong : the structure or the details, the archi- tecture or the plans and specifications ? Im- portant as it is to see the movement through, will the verdict of science declare it all in- genious futility and error, or a revelation of an unpleasant but vdrolesome truth? The re- flection can hardly be avoided: if this is Freud, is Freud -worth it? Dr. Healv has furnished the protocol for a fair trial, and has done so in terms of Freud’s, matures! convictions. Among the recent contributions of Freud is a temperate but definite essay, “The Future of an Illusion", describing the fate of religion as it emerges from the psycho-analytic mill. Will some future critic consider Freudianism under the same title? Medical Ethics LOWERING OF THE STANDARD OF ETHICS ]ohn Hammond Bradshaw, M.D., F.A.C.S., Orange, New Jersey “We have, lived from the time when public ad- vertising of doctors was considered an ethical sin; and into the time when the most , flagrant adver- tising of very prominent doctors in the lay press has been considered a remarkably virtuous per- formance.”— Parker Syms. I quote the above rather ironic words of a celebrated surgeon, the son of a most cele- brated father, which were recently received in a personal communication, and I give the pass- age with the kind permission of the author. Now, allowing for all altered conditions of this changing world, is the profession advanc- ing or retreating? The standard of so many things is under- going transition. Doctors are not the only ones on whom the spot-light can be thrown. Many of the practices of the present day, when viewed by the light of years ago, might not only bring ostracism to the perpetrators thereof,, but could even land these individuals behind bars. (But, ialas, the bars of those days were different from the bars of today!) Even the Church is having the spot-light of criticism thrown in its direction.. And this is not entirely the fault of the laity! 54 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Business by its very nature and require- ments is always changing its standards. An optimist naturally thinks things are always like Cone's little rhyme. Unfortunately, the other persuasions are vocal. If the writer should begin to write on the ethics of sex relationship, he might get him- self in deep waters, but here there are also many shallows — also many rocks! It is even a debatable question if the lower- ing of the present strict ethical standard of National Prohibition would not elevate the righteous cause of Temperance (spelled, with intent, with a big T). After all, “to err is human’’ ! A straight thinker is, generally speaking, also a “straight shooter”. What is the matter with the Golden Rule? Esthetics MUSIC IN RELATION TO ART AND LIFE PADEREWSKI’S PESSIMISM (From the Literary Digest, Nov. 15, 1930.) Paderewski sat on the edge of his chair as if playing the piano. The great shock of auburn hair, made famous in Burne-Jones’ drawing, is now thin and silvered. “His high but sloping forehead is his most characteristic feature, and, dome-like, it dominates the remainder of his head, and in comparison with the lower part of his face seems small.” “There is nothing of the far-away musician about him.” These bits of personal character, observed by S. J. Woolf, during his interview with Paderewski for the New York World, com- port with the thoughtfulness and vigor of the musician’s talk about the situation where our mechanistic age has placed all the arts, not simply music. Finding music is only a little behind the trend followed by pictorial art, he asserts that “art has been on an orgy”. Thus: Some few years ago it went wild for color. Line was forgotten in mad desire for vivid hues. Today music is still in the state that painting was in some years back. Color is the god before which all modern com- posers are worshiping, but they forget there are other gods than that. They have blinded their eyes, if I may so express it, to the beauty of the simple lines of the classicist, and endeavor by ef- fects of color to attain beauty without line. Light and shadow and the glow of color are wonderful, but they must have outlines to bound them, otherwise they are formless masses. And then, too, while I have been speaking of painting and music in similar terms, after all color is not music. Next he was asked what he thought was back of these tendencies in the arts, and Pad- erewski, who was once Premier of Poland, showed he has reverted to the artist, when he said : We are living in a strange age. Economics and inventions and discoveries have held the public attention for some years. I do not underestimate the value of these things. They, may make for physical comforts, but with them they bring attendant evils that kill creative genius in art. For genius is a tender plant which will not thrive in all soils or surroundings, and the quiet and peace that are essential to it have been driven out by the mad haste and constant desire for change and challenge that mark this era. Individuality and originality are being killed by the increasing necessity, I might almost call it, for collectivism. The day of the lonely craftsman has passed. One man rarely produces any finished product today. It is the result of many hands, and while better automobiles may perhaps be produced in this way, surely better poems or paintings or sonatas can not. And it is this spirit which is pervading everything. For great art, though it is the creation of one man, is the product and the result of the time in which he lives. Bach could not have written his works in a sky-scrapper any more than Michelangelo could have decorated one of the modern temples of in- dustry. Men are not happy today, he thinks, and, throughout the world, in politics as well as in all the arts, is “a constant desire to get away from existing conditions". He continues: In art there is a striving for originality. Men are endeavoring to create something new. Nothing new was ever created consciously. True originality has its foundations in the soul, not in the mind, and when there is an effort to create something different, it is usually a failure. Beetho- ven or Schumann or Chopin did not try to be original. They were original. However, this craving for originality, this desire to get away from old forms, this pulling down of the old-time gods, is typical of this period of the world’s history. Men feel the same dissatisfaction in regard to politics. Throughout the world there is an undercurrent of unrest. For years the so-called parliamentary system in government had been looked upon as a panacea for all ills. It was felt that when the man in the street was represented in a legislative body, then that man had something to do with the making of the laws and management of his country. But ideas in regard to this are changing. People are beginning to feel that this system is not altogether what it promised. Indeed, it has been my experience that in most bodies of this kind a tremendous amount of time is wasted in useless and futile talk. Jan., 1931 55 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Hours are used up in listening' to speeches of no import or value. In times of economic distress long discussions in parliaments only irritate. A hungry man’s appetite is not appeased by words. What he wants is food. And when he sees that the words do not give him food, he be- comes dissatisfied with that system of represen- tation which does not provide him with necessities, let alone comforts. It is this spirit of dissatisfaction with things as they are that has caused both the artistic and political restlessness throughout the world today. In Lighter Vein Fact-Finding Stuff A committee of 5 usually consists of the man who does the work, 3 others to pat him on the back, and 1 to bring in a minority report. — Royal Arcanum Bulletin. Banking On Wiley’s Nerves Jinks — “My wife thought she heard burglars last night, and I went straight downstairs to in- vestigate.” Binks — “Gosh, how could you be so positive she was mistaken?” — Chicago News. On the Sunny Side of the Grass “My brother is working with 5000 men under him.” “Where?” “Mowing lawns in a cemetery.” — Log. Concern advertises the perfect bridge lamp. Must be light enough to see by and too heavy to throw. — Dallas News. Scientists have achieved some wonderful re- sults, and maybe in time one of them will succeed in producing a cigarette the ashes of which will match the color of the rug. — Louisville Times. Answered at Last She (in poetic mood) — “What are the wild waves saying?” He — “Sounds like ’splash.’ ” — Panther. It now appears that the coffee situation is the chief cause for the revolution in Brazil. We’ve tasted coffee like that, too. — Judge. An insane-hospital up in New Jersey has in- stalled a miniature golf course for use of its pa- tients. Try to laugh that off. — Jackson News. As Good as a Lip-stick Martha, aged 4%, had been ill. Protruding her tongue, she asked : “Mother, how does my tongue look?” “Oh, it’s all coated white.” “You buy me a red lollypop and I’ll fix it.” In Dire Need of Strength The following message, pencilled on a scrap of wrapping paper, was recently delivered to a physician, member of this society: “Pleas give this boy strong medcin as I didn’t adminstrate reglar for 2 months so send some- thing strong.” Lighthouse Observations THE PUBLIC RELATIONS COMMITTEE It has been our custom to carry in this de- partment a resum.6 of recent scientific develop- ments in regard to some particular disease prob- lem but this month we are devoting the space to a problem of equally great concern to the profes- sion: i.e., to the best means of dealing with some problems that affect the health of the medical profession itself. At the moment there is so much discussion of economic problems, general and spe- cific, that we cannot find sufficient space for publi- cation of all that seems pertinent to our needs or relevant to our daily occupations. In consequence, we shall present for your information, through use of this column, an, abstract of views expressed at- the recent annual Conference of State Society Secre- taries and Editors, held under the auspices of the American Medical Association, by Dr. William H. Ross, President of the Medical Society of New York State. The meeting in Chicago this year, attended by the President of the Medical Society of New Jersey, Dr. George N. J. Sommer, as well as by your Secretary and Editor, Drs. Morrison and Reik, was an exceptionally interesting event; as you may learn from a special letter in this issue of the Journal, wherein President Sommer records his impressions. At each of these annual meetings, the Secre- taries of all the State Medical Societies — and such officers are in closer touch with and make per- haps the best possible representatives of gener- alized state professional opinion— confer upon one ‘ or more vitally important organization problems. On the recent occasion. Dr. Ross presented an elaborate paper upon the subject of “The Public Relations Committee” as developed in the medical society of his state during the past 3 years. We may be permitted to say at this point that the functions of that committee are embraced, in New Jersey, in the program of our Welfare Commit- tee; in other words, we have the same thing un- der a different name. In New Jersey, too, during the last 2 years, practically every county medical society has provided for a local welfare, or public relations, committee of its own, to function locally and to cooperate with the similar state society committee. So, we have, already set up, the ma- chinery for consideration of and action upon such problems as Dr. Ross , was discussing. Dr. Ross’ paper will in due time be published in full in the American Medical Association Bulletin, so we shall attempt here to present only a con- densed report upon the more important features of his address, as follows: There is an economic disturbance in the medical profession greater even than the general economic disturbance in industry. The medical profession has for some time blamed health organizations, and even departments of government, for public health activities, on the ground that they have in- terfered with the private practice of medicine. The profession has seemed to believe that inter- ference with private practice is solely due to ac- tivities of these agencies, and has seemed to for- get that medical research and discoveries, to- gether with changed social conditions and in- crease in public knowledge, are the real causes of such activities. Times are changing. The gen- eral public, has become interested, and industry and civic organizations are at work, in response to public demand and supported by public opinion, trying to advance health service with a view to 56 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., J931 saving as much as possible of the $100,000,000 an- nual wastage through preventable illness. There is an oncoming tide of public sentiment for the advancement of public health, with the object of limiting illness and lengthening life, and providing adequate medical care in sickness;-. No one could sit through , the recent. 4-day meeting of the Ameri- can Public Health Association, with its 10 sections going on concurrently, its 16S speakers listed, and the largest number of practicing physicians ever in attendance, without realizing that times are indeed . changing. The effort of organized medicine to meet its own professional problems has up to The present time been along , the line of creating committees and bureaus for study of economic problems and in argument against the health ef- forts of various agencies and the paternalistic tendencies of government. Organized medicine has not undertaken an impartial appraisal of its own organization to see whether its own public medical relationships are such as to make it most efficient in the distribution of preventive measures and provision for medical care. . Organized medicine must realize that the day of isolation is over and that it must go through the throes of adjustment to new conditions and prepare to go along with the irresistible force of public opinion. Our Public Relations Committee in 'New York has during the1 past 2 years ar- rived at a more comprehensive conception of . the obligations resting upon the medical profession — to render satisfactory public service as well as to attend to its own private business. We recognize that scientific medicine has develojied much faster and traveled further than has the application of scientific discoveries to the limiting of unnecessary illness and the provision for adequate care of all classes of sick people. This committee believes that it, is, proper to secure aid from other sources, when funds are not available from general taxation, for administrative organization of mass or semi-mass health service, and for health education; that the profession is responsible for guidance of all efforts to advance preventive medicine; and that the pro-, fession should be the major factor in proposals for solution of the great problem of adequate medi- cal care. Organized medicine will not overcome its diffi- culties until it has made a proper self-appraisal and determined whether it is meeting all of its obligations to render public service. If it does not meet these obligations, some other agency will; and possibly in a manner that will be unsatisfac- tory to the profession. The organized profession of Great Britain has just made a proposal for ex- tension of the National Health Insurance Act; a proposal that might better have been made 20 years ago, although it is to the credit of the Brit- ish Medical Association that it is now properly meeting the situation. There is a lesson in this for the medical profession of America. Will we heecl it? Medicine has come to have a public character ; knowledge of what can be had in the way of health service is rapidly expanding; the broad- casting of unsolved health and medical problems is increasing. The social trends of the time ir- resistibly insist upon better health service; as is reflected in public welfare laws, old age pensions, etc. The profession is confronted by a new state of affairs. Heretofore, medicine lias spent its effort largely in studying the effects of public health service upon its own material rewards and has given a minimum of consideration to the causes under- lying social changes. We might well consider some of these social changes: the increased pur- chasing power of the public, due to better wages- and shorter hours of labor; increased education; tripling of the per capita wealth during the past 25 years; the increase in man productivity by 40% within 12 years; the present mechanized state of,, industry, resulting in unemployment because of the lessened need for men. Emerson tells us that society is always taken by surprise at any new example of common sense. Let us see if we can apply common sense to our problems. There are 2 methods of procedure open to the medical profession. One is to fight public opinion and retreat as slowly as we can; you can find examples of that expressed quite fre- quently in medical meetings. The other is to ac- cept the practical philosophy of self-appraisal, and if the result of such self-examination warrants it, to make proposals for meeting public health needs by the prevention of illness and the jn’ovision for proper care of the people when sickness combs. The second method may be successfully followed if our relationships be changed so as to cooperate with other agencies under the expert guidance of the medical profession. Are we equal to this responsibility? The Public Relations Committee of the- New York State Society, as a preliminary step, under- took to have organized in every county society a Public Relations Committee. Then, it undertook to have each county committee make a survey of the health activities of the county and the relation of the local profession to them. If the principle of conference between the various health agencies was not in use in reaching conclusions, and if there was not a cooperative relationship, then the State Committee undertook to bring about such a conference with the object of cooperation on the fundamental basis that the medical profession was the only body that could give expert guidance to methods of distribution of health services and that it was willing to be consulted. Notwithstanding the almost complete transfor- mation of medicine within the recollection of many of us, because of laboratory aids and the use of instruments of precision in diagnosis and treat- ment. there may come another revolution in medi- cal practice, as it has come in the past, as the re- sult of great social needs, and who knows that it is not beginning. We may be nearer than we know to such things as unlimited old age pensions, provision for adequate medical care by the state, and the inclusion of sickness benefit in Workmen’s Compensation and compulsory health insurance laws as in other countries. It should make us think. The work that the Public Relations Committee undertakes to do is to establish by conference a conclusion as to plan and then a cooperative re- lationship between official and unofficial health agencies and the medical profession. It under- takes to arouse medical interest in present day social trends and the need of providing plans for the distribution of preventive service, i. e. the establishment of a county health department with a full-time and trained personnel. Another is the support of the work of Parent-Teacher Associa- tions and the value of the family physician in pre- school work. Another is the proper relation of the medical profession to the movement on the part of the state to aid in the establishment of county hospitals so that the entire profession may have the educational opportunity arising from service in a hospital and in formulating rules and regu- lations to control standards of practice. The Public Relations Committee undertakes to Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 57 adjust differences of opinion between the medical profession and the health activities of other or- ganizations by use of the principle of conference while the proposals are in the formative stage. It undertakes to visualize the medical future; to see as far as possible what is ahead in medicine and plan such relationships as are necessary for medi- cal leadership. The medical profession can never cure the ills that it complains of by fighting the present social trends. It can no longer afford, in more senses than one, to hold a hostile attitude to- ward any health agency supported by public opinion. It will suffer if it does not have a re- ceptive rather than a hostile attitude. I have been a part of a movement in my county medical society that has resulted in as desirable a relationship of the profession and health agencies as one could conceive of — a movement that has given the profession leadership with the support of lay organizations. A county medical society that does not modernize its relationship into har- mony wtih new conditions is not meeting its pro- fessional obligations nor laying a foundation to prevent economic disturbance of the private prac- tice of medicine. No amount of resistance to the present social trends will make any final difference. Continuation of present methods to cure our ills will amount to nothing. To consider medicine under seige, and the tendencies of government as paternalistic, will avail nothing; but self-appraisal of ourselves and proposals from the organized profession regarding medical problems will succeed and will put the profession of medicine in the position that it should be in and the position that public opinion expects it to occupy. Public Relations SURGEONS REDUCE FEES (From N. Y. Times, Nov. 18, 1930.) A plan to reduce the cost of medical attention for the so-called white-collar workers, under which 2 hospitals will reduce their rates and prominent physicians and surgeons will give their services at decreased 'fees, was announced last night at a dinner in the Hotel Commodore. The hospitals are the Park West at 170 West Seventy-sixth Street and the Park East at Park Avenue and Eighty-third Street, both built origin- ally by the same stock company to care for wealthy patients. The plan was described to 200 members of the staff of the 2 institutions by Thomas F. Dawkins, executive manager of both hospitals. If the reduced rate program proves successful, both institutions will be turned over to the doctors and nurses of their staffs for operation as co- operative enterprises, according to Mr. Dawkins. Although the plan was not announced as in any way connected with the recent statements of Health Commissioner Wynne, that doctors are faced with the alternatives of lower fees or State Medicine, it agrees with Dr. Wynne in its em- phasis on the need for placing hospital care with- in reach of persons with moderate incomes. The Park West Hospital, opened in 1926, has 75 beds and represents an investment of $750,000. The Park East Hospital has 130 beds. It was opened in September 1928, at a cost of approxi- mately $1,000,000. Since these institutions were designed at first only to serve wealthy patients, the cost for a room was fixed at from $13 to $40 a day, Mr. Dawkins said. Under the new plan it will be pos- sible to obtain a room for $6.50 a day. For those who desire better accommodations there will be a maximum of $30 a day. The practitioners who have already agreed to reduce their fees include some of the best known medical men in the city. The practice of basing fees for operations on the patient’s apparent ability to pay would be curtailed to a great extent, Mr. Dawkins indicated. Medical men connected with these institutions include Dr. Thomas Darlington, former health commissioner, who is on the advisory board, and Dr. Howard M. Hayes, president of the board of both institutions. INFANT MORTALITY LOWEST IN HISTORY (Newark Evening News, Oct. 24, 1930.) New Jersey’s infant mortality rate for 1929 is the lowest ever recorded for this state, according to statistics of the bureau of census and division of vital statistics of the United States Department of Commerce. The rate was 60 deaths under 1 year of age per 1000 births. New Jersey is 1 of 11 states whose rates are lower than at any time since their admission to the registration area. The infant mortality rate throughout the regis- tered area, which comprises 46 states and the Dis- trict of Columbia, is 68 per 1000, the second lowest since the establishment of the birth registration area in 1915. For the sixth consecutive year, Ore- gon leads the states with the lowest rate, 48. While the infant mortality rate throughout the country was lower than usual last year, statistics show that the birth rate for 1929 was 18.9, the lowest for any year since establishment of the birth registration area. Oregon had the lowest rate, 14.1, of any state. New Jersey’s rate was 17.2. PENDING LEGISLATION ON ABELL COMMISSION REPORT In the Welfare Committee Minutes (page 65) you will find a review of the 3 Bills now under consideration in the Senate of the General Assem- bly, and will note the decision to oppose passage of those Acts. It seemed necessary to oppose S. 262 and S. 304 in toto because of their glaring defects. Inasmuch as the medical profession is not opposed to a proper budget system honestly constructed and applied alike to all governmental departments and boards, without discrimination, it was suggested that these Bills could be made acceptable by amendment, and the changes pro- posed were designed: to clarify the question of authority; to guarantee that the boards would be allowed appropriations as large at least as their own receipts — to carry on law enforcement; to place the new “bureau” under the Board of Regents instead of a state officer whose appoint- ment and tenure of office are subject to political control; and, to “cover in” the lawyers and realtors along with other examining and licensing boards. These points are all excellently well expressed and approved by an editorial in the Camden Courier-Post of December 16, as follows: Bill 304 Carries the Spirit of Reform but not the Substance! New Jersey has 14 separate professional boards. Each has its own secretary, maintains its own in- specting staff, operates its own office and collects and disburses its own funds. 58 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Bill 304, sponsored by the Abell Commission, would consolidate 12 of these boards under a Bureau of Professional Registration. Hearing on that measure takes place today, and vigorous pro- tests are being lodged against it, especially by the medical profession. The principle embodied in this bill is one for which this newspaper has long stood — economy in state administration through consolidation of ac- tivities and centralized financing. No private business permits each of its departments to handle its own financial affairs and, to all effects, operate as an independent concern. There are, however, serious defects in Bill 304. The medical profession, not without reason, asks why the legal profession should be exempted from the measure along with the State Real Estate Board? If it is good business to consolidate 12 of the 14 State boards should it not be even better business to consolidate the whole 14? Lawyers, however, drew up the measure. And by exempting themselves they expressed exactly the same opposition to the bill that the physicians and other protesters are to make at today’s hear- ing. That is, they don’t object to the principle of this bill — only they don’t want to be subject to it. ****** More serious than that seeming discrimination, however, is the fact that Bill 304 will tend to limit the professional authority of the various boards, although they will still be continued in existence. There is a justification for the fears of physi- cians that the proposal to place all the boards under the authority of the Commissioner of Edu- cation— a political appointee — will tend to bring politics into the various boards and lower their standards. Especially is this important where the boards concerned are charged with safeguarding the pub- lic health. Most important of all, in the medical profession! New Jersey has high standards which should be maintained free from political influence. Bill 304 does not guarantee that, even though the Abell report clearly states “the regulatory work of these boards would in no manner be interfered with.” Moreover, the purposes of the scheme as out- lined in the Abell report do not seem fully real- ized in the proposed legislation. In the report it is stated: “We recommend that a Bureau of Profes- sional Registration be created in the Depart ~ ment of Education which will consolidate these twelve examining and licensing boards into one unit, with one Secretary instead of the dozen now drawing pay. Great economies in rents would likewise be effected.” But the bill itself reads: “The Commissioner of Education shall . . . appoint a secretary of said bureau and such clerical, technical and other assistants as may be necessary, fix their compensation and pre- scribe their duties . . In short, while there will be one secretary, there xoill be a lot of other jobs, under other names. Insofar as Bill 304 covers the consolidation of the financial functions of these professional boards it has our hearty approval. But we do believe the measure is weak in that it is not emphatic enough in assuring the public that their regulatory functions will not be mo- lested; and that it is far too vague as to how the promised economies in operation are to be effected. In brief the measure should be redrafted along these 3 lines: To consolidate the boards in matters of finance; To preserve their standards of qualification, notably in the professions which concern the pub- lic health; And lastly, to make definite, in the bill itself, a guarantee that there will be real economy and not sham economy! THE WHITE HOUSE CONFERENCE ON CHILD HEALTH AND PROTECTION Reported by William G. Schauffler, M.D., Princeton, N. J. The Conference on Child Health and Protection called by President Hoover met in Washington, D. C., on November 19, 1930, and continued through November 22. The sessions were held in the group of buildings centering around the Red Cross Build- ing and the Hall of the Daughters of the American Revolution. Conference headquarters was at the Interior Department Building, and the general meetings were held in Constitution Hall, which holds about 5000 people, and which was filled at the opening session on Wednesday evening, when President Hoover made the opening address after Secretary Ray Lyman Wilbur, M. D., Chairman of the Conference, had welcomed the delegates. Over 3000 delegates attended this meeting, com- ing from more than 20 states. They represented the tremendous interest shown in all parts of our country for, child welfare, and were a remarkably fine body of men and women. The work of the conference was divided into 4 Sections as follows: Section 1. Medical Service, subdivided into (a) Growth and Development. (b) Prenatal and Maternal Care. (c) Medical Care for Children. Section 2. Public Health Service and Adminis- tration. (a) Public Health Organization. (b) Communicable Disease Control. (c) Milk Production and Control. Section 3. Education and Training. (a) The Family and Parent Education. (b) The Infant and Pre-School Child. (c) The School Child. (d) Vocational Guidance and Child Labor. (e) Recreation and Physical Education. (f y Special Classes. (g) Growth Outside of Home and School. Section 4. The Handicapped. (a) State and Local Organizations for the Handicapped. (b) Physically and Mentally Handicapped. (c) Socially Handicapped, Dependency and Neglect. (d) Socially Handicapped, Delinquency. In preparation for this conference more than 150 committees and subcommittees had been gath- ering material and collating it for consideration during the past year, and the facts were stated in a most intelligent and comprehensible manner. Breakfast, luncheon and dinner groups were held during the 3 days of the meetings, at which the subjects could be talked over more informally than in large group meetings. On Saturday morning the 4 Section chairmen presented consolidated reports, and the conference was concluded with the “Consideration of Reports Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 59 by the Conference”, presented by the Chairman- Secretary Hon. Ray Lyman Wilbur, M. D. These conclusions, which will form the basis of work in all parts of the country, were as fol- lows: Every American child has the right to the following services in its development and protec- tion. Every child should he understood. (1) Every prospective mother should have suit- able information, medical ■supervision during the prenatal period, competent care at confinement. Every mother should have postnatal medical super- vision for herself and child. (2) Every child should receive periodic health •examinations before and during the school period, including adolescense, by the family physician, or the school or other public physician, and such ex- amination by specialists and such hospital care as its special needs may require. (3) Every child should have regular dental ex- amination and care. (4) Every child should have instruction in the school in health and in safety from accidents, and every teacher should be trained in health programs. (5) Every child should be protected from com- municable diseases to which he might be exposed at home, in school or at play, and protected from impure milk and food. (6) Every child should have proper sleeping rooms, diet, hours of sleep and play, and parents should receive expert information as to the needs of children of various ages as to these questions. (7) Every child should attend a school which has proper seating, lighting, ventilation and sani- tation. For younger children, kindergartens and nursery schools should be provided to supplement home care. (8) The school should be so organized as to discover and develop the special abilities of each child, and should assist in vocational guidance; for children, like men, succeed by the use of their strongest qualities and special interest. (9) Every child should have some form of re- ligious, moral and character training. (10) Every child has a right to a place to play, with adequate facilities therefor. (11) With the expanding domain of the com- munity’s responsibilities for children, there should be proper provision for and supervision of re- creation and entertainment (12) Every child should be protected against labor that stunts growth, either physical or men- tal, that limits education, that deprives children of the right of comradeship, of joy and play. (13) Every child who is blind, deaf, crippled or otherwise' physically handicapped should be given expert study and corrective treatment where there is a possibility of relief, and appropriate develop- ment or training. Children with subnormal or ab- normal mental conditions should receive adequate study, protection, training and care. (14) Every waif and orphan in need must be supported. (15) Every child is entitled to the feeling that he has a home. The extension of services in the community should supplement and not supplant parents. (16) Children who habitually fail to meet nor- mal standards of human behavior should be pro- vided special care under guidance of the school, the community health or welfare center, or other agency for continued supervision, or, if necessary, control. (17) Where the child does not have these ser- vices, due to inadequate income of the family, then such services must be provided for him by the community. (18) The rural child should have as satisfac- tory schooling, health protection and welfare facilities as the city child. (19) In order that these minimum protections of the health and welfare of children may be every- where available, there should be a district, county or community organization for health, education and welfare, with full-time officials coordinating with a state-wide program which will be respon- sive to a nation-wide service of general informa- tion, statistics and scientific research. This should include: (a) Trained, full-time public health officials with public health nurses, sanitary inspection and laboratory workers. (b) Available hospital beds. (c) Full-time public welfare services for the relief and aid of children in special need from poverty or misfortune, for the protection of chil- dren from abuse, neglect, exploitation or moral hazard. (d) The development of voluntary organizations for children, for purposes of instruction, health and recreation through private effort and benefaction. When possible existing agencies should be co- ordinated, to avoid overlapping. It is the purpose of this Conference to establish the standards by which the efficiency of such services may be tested in the community, and to develop the creation of such services. These standards are defined in many particulars in the reports of the committees of the conference. The Conference recommends that the continuing committee, to be appointed by the President from the conference, shall study points upon which agreement has not been reached, shall develop further standards, shall encourage the establishment of services for children, and re- port to the members of the Congress through the President. New Jersey was well represented at the Con- ference by members of the State Medical Society and laymen and women. Commissioner William J. Ellis, of the Department of Institutions and Agen- cies, was prominent in the work of Section 4. State Health Department STATE HEALTH LAWS (A communication from D. C. Bowen, Director New Jersey State Department of Health.) Wide commendation is meeting the ‘‘Physicians’ Handbook”, prepared and distributed by the State Department of Health. Simplicity and conciseness of the new booklet of vest-pocket size for handy reference are the characterizations of one of its en- dorsers. Copies are available to physicians of the state without cost and may be obtained by com- municating with the department, at the State House, Trenton. Do you find it hard to keep in mind just what matters you should report to boards of health and when and how these reports should be made? It is not surprising if you do. Regulations on the subject are long and appear in several different laws which are not easy to read nor to remember. The Physicians’ Handbook lists under separate headings subjects on which you are expected to re- port, in accordance with various laws and regu- lations, state-wide in effect. The booklet is ar- ranged in a manner convenient for ready refer- 60 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 ence. Legal terms are avoided. It is concise, and I believe it will be helpful to you. Will you not look over the booklet now and note what it con- tains. It will fit your pocket. Acknowledgements have been most gratifying to the department for the work involved. Dr. James J. McGuire, of Trenton, Secretary of the State Board of Medical Examiners, plans to give each successful candidate qualifying in the board’s examinations a copy of the booklet, which the State Department of Health will supply. The reportable communicable diseases, dog bites of persons, epilepsy and mental deficiency, and drug addicts under treatment are dealt with under a uniform arrangement of sub-heads which in- clude: (1) what diseases to report, (2) what facts to report, (3) to whom to report, and (4) when and how to report. Reporting of diseases ' which occur on dairy premises, and of venereal diseases, is discussed under appropriate headings. Physicians’ duties with respect to recording births and deaths are explained in a concise way. The busy physcian will find in the 12 pages of this booklet information he frequently needs in a form convenient for ready refei-ence. In a foreword to the booklet, the department said : Physicians are usually the first who see cases of communicable diseases in a community and are able to give authoritative warning of their presence. Local health departments have been empowered to enforce measures to prevent the spread of these diseases, but no health department, however well organized, can plan nor apply effective measures to prevent their spread without a knowledge of when and where cases occur. Responsibility has also been placed upon health departments to collect records of births and deaths, and to preserve these records, so important to the people of the state. Again it is the physician who has knowledge of facts and conditions essential to such records. For the public welfare, therefore, state laws and regulations have placed upon physicians the duty of reporting cases of communicable diseases and certain other ailments, and of filing or supplying facts for certificates of births and deaths. A digest of these state-wide, legal requirements, for the reference of physicians, is given in this booklet. Communications IMPRESSIONS OF THE ANNUAL CONFER- ENCE OF SECRETARIES OF CONSTITU- ENT STATE MEDICAL ASSOCIA- TIONS, 1930 Dr. George N. J. Sommer, M.D., Trenton, N. J. This meeting was held at the American Medi- cal Association Headquarters in Chicago, Novem- ber 14-15, 1930. On the invitation of Drs. Mor- rison and Reik, I attended this meeting and was cordially received by the President, Dr. William Gerry Morgan, Secretary Olin West, and various members of the Board of Trustees, one of whom, Dr. J. H. J. Upham, of Ohio, happened to be an old class-mate. The papers presented were quite notable and quite to the point, dealing largely with present day problems of the profession in its relations with the general public. The paper of Dr. R. L. Parker, of Des Moines, on “Service for the Indigent Through Contract with the County Medical Society’’, described a plan which has been put into practice by 11 of the county societies in Iowa and apparently is working out satisfactorily. A close study of this plan would solve this problem to the satisfaction of physicians and public in rural counties at least. (See editorial, this issue.) Dr. F. C. Warnshuis, of Grand Rapids, Michi- gan, read a paper on “The Relations of State Boards of Medical Examiners to State Medical Associations”; which seemed to be similar to what we have in New Jersey, but which ar- rangement for us seems to be in grave danger from the Abell Report recommendations. Dr. W. C. Rappelye spoke on the general sub- ject of “Health Insurance’’ and gave some facts relating to the systems in vogue in England, Germany and other countries of Europe. No solution for our country was advanced but the data gathered by him will need to be considered by us to solve our problem in this regard. “Co- operation Between Medical, Public Health and Educational Organizations” was discussed by Dr. E. A. Myerding, of St. Paul, in a lengthy descrip- tion of the method now in use in Minnesota. It is an expensive, thorough program financed by the State Medical Society and Social Service Or- ganizations, under one head, and is working well; an example of a good way to do a necessary work under control, as it should be, of medical men. Dr. F. C. Hammond, of Philadelphia, Editor of the official organ of the Pennsylvania State Medi- cal Society, presented his ideas on “What a State Medical Society Journal Should Mean to the So- ciety Membership”. This paper will bear inten- sive study by medical men of any state. Our Journal measures up to all of the standards he established and is serving our membership ex- ceptionally well. The last, but not least, was a paper by Dr. William H. Ross, President of the State Society of New York, on “The Public Relations Com- mittee”. This is the coming bulwark of the pro- fession against the encroachments of State Medi- cine and the problem was discussed in scholarly manner by one who has given much of life and time to study of professional relations with the public. No doubt this paper will have a great influence on this perplexing problem and its solution. After hearing all these papers on.' was struck with the grasp of the various authors on the great problems of the profession of our times, and no doubt the papers will be of use to us in New Jersey in solving our own problems. I was personally much impressed with the re- markable executive talents of Drs. Olin West, Secretary, and Morris Fishbein, Editor, in their sane attitudes toward the problems which confront the medical profession. MENTAL HYGIENE (A letter from Dr. F. E. Williams, Medical Di- rector, National Committee for Mental Hygiene, New York City.) The phenomenally rapid growth of interest in all aspects of extramural psychiatry in recent years has created several situations of consider- able gravity, of which the shortage of adequate- ly trained personnel is by far the most pressing. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 61 The mounting interest of communities in child guidance and other types of mental hygiene clinics has already exhausted the never-suflicient supply of specially trained psychiatrists for this work, and unless physicians with the requisite training and aptitude can be secured in greater numbers, either the establishment of many new clinic projects will be delayed, or, worse, their functioning will be attempted by unprepared or poorly prepared staffs. To assist in lessening some of this shortage of properly trained psychiatrists The National Com- mittee for Mental Hygiene offers fellowships toward acquisition of the special preparation required. Details of these fellowships are con- tained in the enclosed announcement, a repro- duction of which in the columns of an early is- sue of your periodical will be deeply appre- ciated in the interests of modern medical edu- cation. Minimum Requirements for Applicants These fellowships are designed to provide spe- cial training for physicians who have had pre- vious hospital training in psychiatry but who wish to prepare themselves for extramural work in the fields of child guidance, delinquency, edu- cation, dependency, and industry. Fellowships are open to physicians who are: (1) Under 3 5 years of age. (2) Graduates of Class A medical schools. (3) Who have had at least 1 year of training in a hospital for mental disease maintaining sat- isfactory standards of clinical work and instruc- tion. A longer period of hospital training is de- sirable. Applicants able to meet these requirements will not be required to take competitive written or oral examinations. Selections will be made on the basis of length and type of previous train- ing in formal psychiatry; on general fitness for the work contemplated; and (in most cases) on the results of a personal interview. General Details of Fellowships (1) These fellowships cover a period of train- ing approximately 1 year in length. (2) During this training period, trainees usu- ally are assigned for 3 to 4 months’ periods at such places as the Boston Psychopathic Hos- pital; Judge Baker Foundation, Boston; Insti- tute for Juvenile Research, Chicago and other places of a similar nature, as well as to various child guidance clinics located in Cleveland, Phila- delphia and other cities. Assignments to these training centers are not definite, however, and as- signment to any given place will depend upon the availability of instruction at such place, as well as the special needs of the individual trainee. Assignments are not made for more than 3 months in advance, and adheience for the year’s training period to a fixed program in advance is impossible. (3) These fellowships carry stipends at the rate of $2000 to $2500 for the 12 months’ period. (4) Applications need not be filed within stated periods but will be received at any time. In the case of successful applicants, arrange- ments will be made to begin work whenever mutually convenient to the applicant and to the director of the training center to which the ap- plicant is first assigned. Applications or inquiries for further informa- tion should be sent to Dr. Frankwood E. Will- iams, Medical Director, National Committee for Mental Hygiene, 37 0 Seventh Avenue, New York, N. Y. PRE-SCHOOL AND SCHOOL PIIYSICAD EXAMINATIONS Harold Edwin Wright, M.D., Princeton, N. J. (A letter to the Journal, under date of Novem- ber 11, 1930) In the issue of the Journal for October 1930, under School Health Department, was an article entitled, “Preliminaries to the School Doctors Examination’’. It appears much like a harmless little article and hardly worth commenting upon but its prac- tical worth, while of little value should be dis- cussed. Some writers on questions relating to school matters always seem to think the teacher has plenty of spare time on her hands, and thoughtlessly suggest some new idea to consume some part of her day in helping to carry out some suggestion; very often a foolish one. After about 20 years experience as a school medical inspector, connected with a school sys- tem of very high standing, I feel I am compe- tent to express myself with some judgment of experience. Where can there be any improve- ment in the mental attitude of a. child who re- ceives a physical examination the first week of school or the third week? What can a teacher do to prepare a child to meet a school medical inspector, if the inspector does not understand how to meet and handle children? Also1, how does a child’s mental status improve a physical defect? If the examination consists of a psych- ologic laboratory test, then the mental prepara- tion could be appreciated, but the examination of eyes, throat, ears, posture, heart, lungs, etc., needs no mental preparation; such organs have either a defect or no defect, which is readily as- certained. A child to be examined physically in school is in a very different class from a child who approaches a physician for some ailment. Delaying the examination for a few weeks is a small matter, very true, but what have you ac- complished by such a delay? Observation in the class room by the teacher, to ascertain any peculiar traits of a child, such as likes, dislikes, habits, etc., will be of value pos- sibly to the teacher but not to the doctor. The efficient school inspector does not need assist- ance of the teacher to discover whether a child is undernourished. In comprehensive school sys- tems the children are weighed each month by the nurse and records are kept, which enables the school physician to bring influence to bear at home. While the duties of the nurse are multi- plying and her responsibilities are greater, yet she should always be at the disposal of the medi- cal inspector to assist him both in conducting physical examinations and follow-up work on detected defects. Just how much progress and thoroughness is made in other places, the writer does not know. However, we do feel that in Princeton every side of the question of school medical inspection is practiced. For many years we have been very particular concerning health of the teachers and a physical examination of each one is made an- nually. We are laying particular stress upon the pre-school examinations of children. These ex- 62 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 animations are only conducted in the presence of the parent. They are by far the most important examinations made. They enable the child to enter school with all defects corrected, and the parent of the child is taug-ht to appreciate the value of such corrections and how to care for a child that is not normally developed. In Prince- ton these examinations are conducted every spring and are becoming each year more popu- lar. Place the child in school with 100% physical condition and the teacher will have much less trouble with the mental development. To do this, we do not need any foolish training of a child’s mind to meet the doctor. Also, such ex- aminations of pre-school ages conducted in the presence of the parent can be done with the clothing removed. We sincerely hope the remov- al of all clothing of each school child, as has been suggested, will never be practiced. It would create, and justly, a storm of criticism, and in the opinion of the writer would require possibly 2 examiners, a man and a woman. This is unnecessary expense to the taxpayer for ques- tionable results. It is a procedure which is not required if pre-school age examinations are em- phasized. It is very hard for the writer to un- derstand why so great a weight is placed upon a foundation the strength of which has not been estimated. If we have knowledge of the child’s physical condition when it commences its school career, we know what to expect and what can be done. This view , certainly is a practical one; it is an inexpensive one; and it eliminates a great deal of the so-called gallery play or ideal- istic impracticabilities. The rural districts can afford thorough pre-school physical methods when they can see the results, but cannot afford the many useless methods advocated for the school child after it has entered upon its career. It seems strange that more common sense and not so much theory does not prevail. Another point that must be borne in mind is the difference in methods used in the larger com- munities and those used in the rural districts. It is very possible for the larger towns, where enrollment is very large, to practice what is be- ing done in New York; i.e. for the teachers in each grade to set aside 1 day for gross inspection of the pupils for enlarged tonsils, eye-readings, hearing tests, and detecting any unusual abnor- mality; I do not mention teeth because they should come under the dental department. This procedure may have its valuable side in places where thousands of pupils are to be examined, but it would not fulfill the law in New Jersey where it is specified that examinations must be made of each pupil, each year, by a medical in- spector. Should there be a change in the pres- ent system, the writer sincerely hopes it will be the development of a system in regard to the pre-school medical attention. Also, if a child enters school pronounced free from defects, an- nual physical examinations would be super- fluous. Examinations upon entrance to school and subsequent ones about the third and sixth years would cover the requirements. While the duties of the school nurse are in- creasing each year, so are the duties of the medical inspector. Communicable diseases re- quire his daily attention, and should never be diagnosed by any one except a physician. Con- trol of them requires close cooperation of the Health Officer of the community. Preventive methods now so widely used for immunization against these diseases requires much more time of the medical inspector. In addition to all this the medical inspector is at the disposal of the athletic de_partment for any injuries or opinion in matters pertaining to the medical side of that department. There is plenty for the nurse and doctor to do and do thoroughly without the ad- dition of questionable ideas. ABELL COMMISSION REPORT (A letter, advising caution with regard to legis- lative matters, from Dr. Elias J. Marsh, Treas- urer of the Medical Society of New Jersey.) I have received from the State Board of Medi- cal Examiners a copy of the proposed law to con- solidate the administrative work of various pro- fessional examining boards, together with notes on the experiences of other states where similar plans have been tried. From these it appears that the results have not been altogether satis- factory, and our Board seems to fear that the proposed plan would hinder them in some of the work they are now doing. S. 304 is one of a series of acts offered by the so-called Abell Commission for the general re- organization nad simplification of the state govern- ment. The great need 'of such a reorganization is generally recognized, and I think there is little question among our people that in its main lines the plan outlined by the Commission is wisely and soundly conceived. Perfection in all details is hardly to be expected in a work of this character, and opinions will differ; there are always minor defects which are subject to just criticism. Unfor- tunately, opposition, even when just in itself, on account of what are really minor points, im- portant though they may seem to those inter- ested, often strengthens the resistance to great and necessary reforms offered by interested per- sons for selfish reasons. It would be a great mis- fortune for the state, and a heavy charge against those responsible, if this great opportunity to re- form our government should be lost by the aid of objections raised against details, however valid the objections in themselves. I am not sufficiently familiar with the opera- tions of the Board of Medical Examiners to pass an opinion, but most of the mentioned difficulties appear to me incidental, and remediable by amendment, rather than inherent. But even granting them as serious as the members of the Board seem to regard them, we should remember that we are citizens before we are physicians, and the state is entitled to priority of consideration even before our profession — supposing there is any conflict, which I did not admit. After all, the work of the Board of Medical Examiners, like all other boards, is for the welfare of the people, not of the profession, and if the best advantage of the state demands some sacrifice on our part — mind, I say if — it ill becomes that profession which is justly proud of its self-sacrifice and pub- lic spirit to refuse it now. By all means let us strive for such changes in the bill as will con- serve the advantages for the public service en- joyed by the present board, without lessening the main puropse of the reform, but I sincerely trust that our Welfare Committee and the leaders of our society, as well as the members of the Board themselves, will not place the society and the pro- fession in the position of hindering in any way the most hopeful promise of civic reform seen in New Jersey in a generation. (Signed) — Elias J. Marsh. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 63 AMERICAN PHYSIOTHERAPY ASSOCIATION (A letter transmitted to us by Dr. Harold D. Corbusier, with approval for publication.) The New Jersey Chapter of the American Phy- siotherapy Association, a national association of physical therapy technicians organized shortly after the war, has established a registry and ap- pointment bureau for its members in this state. Requirements for membership in this associa- tion are as follows and are approved by the Council on Physical Therapy of the American Medical Association. Active members are those having had 1 year of practice in physical therapy within 2 years of graduation from: (1) An approved School of Physical Therapy. (2) An approved School of Physical Education and satisfactory completion of an approved course of physical therapy. (3) An approved School of Nursing and satis- factory completion of an approved course of physical therapy. Junior members shall be persons fulfilling the requirements of active members, except 1 year of practice shall not be necessary; nor shall they have the power to vote. The standards of ethics of the American Phy- siotherapy Association shall be as far as possible those of the American Medical Association. All members shall practice only under the prescription and direction of a licensed physician. . Therefore, only persons having the best possible training may register in this bureau. It is the place to which the physicians may apply when in need of well trained physical therapy technicians either in their private offices or in hospitals. The registry is under the direction of Miss Jean Smith, Beth Israel Hospital, Lyons Avenue, Newark, N. J. Telephone — Terrace 3-5700. VIOLATIONS OF MEDICAL PRACTICE ACT (A letter from Dr. J. J. McGuire, Secretary of the State Board of Medical Examiners.) Schuyler C. Pew, of Perth Amboy, was found guilty of practicing medicine without a license, on September 8, by the Judge of the New Bruns- wick District Court. Mr. Pew held himself out as a masseur and also gave electric treatments. Theodore DeDragic, of Atlantic City, who held himself out as a Vienna physician and physio- therapist, was found guilty of practicing medicine without a license on September 10, and on failure to pay the penalty was committed to jail for 30 days. Emma L. Garwood, of Beverly, who advertised as a masseuse and electrotherapist, pleaded guilty in the Court of Common Pleas of Burlington Coun- ty, on September 11, to a charge of practicing medicine without a license. Frank Weber, of Burlington, pleaded guilty in the Court of Common Pleas, of Burlington Coun- ty, on September 11, to a charge of practicing medicine without a license. Mary A. Wilson, a psycho-analysist, of Newark, on September 18, paid the penalty for practicing medicine without a license. Thomas Parusis, of Jersey City was found guilty in the First District Court of Jersey City, of prac- ticing medicine without a license. On failure to pay the penalty, he was committed to jail for 30 days. Daniel S. Priest, druggist, of Toms River, in September 1930 paid the penalty for practicing medicine without a license. Ernest M. Bick, of South Orange, who pre- scribed medicine to be taken internally, was tried in the Second District Court, Newark, on Octo- ber 3, on a charge of practicing medicine without a license, and was convicted. He had previously been convicted on January 28. Lillian Kallila, of Jersey City, on October 7, pleaded guilty in the First District Court of Jer- sey City to a charge of practicing medicine with- out a license and paid the penalty. Aino S. Mateinheimo, of Jersey City, on October 7, pleaded guilty in the First District Court of Jersey City to a charge of practicing medicine without a license and paid the penalty. Eugene Gebauer, of Newark, who was prac- ticing electrotherapy and hydrotherapy, was found guilty of practicing medicine without a license, by the Judge of the First District Court of New- ark, on October 8. He refused to pay the penalty and was committed to jail for 5 days. Nicklos N. Barron, of Newark, who prescribed medicine to be used both externally and internally, was found guilty on October 20, by the Judge of the Second District Court of Newark, of practicing medicine without a license and paid the penalty. Abram Taub, druggist, of Pompton Plains, was found guilty of practicing medicine without a li- cense on October 21, by the Judge of the Paterson District Court. William Miles, of Atlantic City, on October 24, paid the penalty for practicing medicine without a license. Solomon Boxer, druggist, of Ventnor, was found guilty on October 29, by the Judge of the Atlantic City District Court, of practicing medicine with- out a license. The defendant had a dffiloma in his drug store showing that he was a graduate of a college of naturopathy, but prescribed drugs for his patients. Frieda Korte, of Atlantic City, who was giving elec- tric treatments and colonic irrigations, was found guilty by the Judge of the Atlantic City District Court, on a charge of practicing medicine without a license. This was the third time that Mrs. Korte had been convicted and as she was unable to pay the penalty, she was committed for 60 days. George Lezenby, Jr., of Atlantic City, a naturo- path, was found guilty on October 29, of practic- ing medicine without a license, by the Judge of the Atlantic City District Court. He failed to ap- pear in Court and the Judge ordered him com- mitted to jail for 60 days, but when the commit- ment was served he paid the penalty. Charles Schaefer, Sr., of Oaklyn, in October, paid the penalty for practicing medicine without a li- cense. Charles Schaefer, Jr., of Oaklyn, in October, paid the penalty for practicing medicine without a li- cense. Charles S. Newell, of Merchantville, a naturo- path, paid the penalty on November 5, for prac- ticing medicine without a license. Ehrgott W. Gebhardt, of Merchantville, a drug- gist, paid the penalty on November 5, for practic- ing medicine without a license. COUNCILLOR DISTRICT MEETING (A letter from L. Cook Osmun, M.D.) The first Councillor District Meeting of the First Councillor District will be held on Thurs- day evening, February 12, 1931, in the Academy of Medicine, Newark. The main address will be €4 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 by Dr. W. H. Ross, of Brentwood, L. I., and we are planning to make this a large affair. THE WAI/I WHITMAN To the Editor: The American Medical Associa- tion will hold its annual meeting in Philadelphia June 8-12, 1931, and I am writing that you may announce throughout the state the convenience and desirability of stopping at THE WALT WHITMAN during the period of that meeting. As you know, we are but 10 minutes from the center of Philadelphia — busses stopping at our doors at all times. ‘A New Jersey hotel for New Jerseymen”. Sincereley yours, Chas. F, Krapp, Manager. Current Events MINUTES OF THE WELFARE COMMITTEE Trenton, New Jersey, November 9, 1930. Pursuant to call, regularly issued under author- ization of the President of the Medical Society of New Jersey. Dr. George N. J. Sommer, the first meeting of the newly appointed Welfare Commit- tee of the State Medical Society was held at the Stacy-Trent Hotel, Sunday, November 9, 1930. The meeting was called to order by President Sommer, who anounced that the objects of the meeting would be, first, to organize by election of a chairman, and then to transact any business pertaining to the winter’s program. Roll call disclosed the following members pres- ent: Coleman, A. H.; Conaway, Costill, Dandois, Davis, Ely, Green, Haussling, Hunter, Lippincott, McBride, McMahon, Morrison, Morrow, Nafey, North, Schauffler, Schlichter, Sewall, Sherman, Sommer, Tracy. Excuses were received from Drs. Clayton, Donohoe, D. Leo Haggerty, Londrigan and Ward. Vice-Presidents John F. Hagerty, and Quigley were present by invitation, and Drs. Kel- ley and McGuire were present from the State Board of Medical Examiners. The President called for nominations for the chairmanship and Dr. A. H. Lippincott was nom- inated and elected by unanimous vote. The Presi- dent thereupon called Dr. Lippincott to the chair. The Executive Secretary presented the following report: Report of the Executive Secretary to the Wel- fare Committee The Executive Secretary has at the moment only a short report to submit. The work of his office has proceeded in routine manner during the sum- mer, and at present everything is progressing smoothly and satisfactorily. The public educa- tional program will be continued this winter as heretofore, and we have reason to believe that ra- dio broadcasting will be conducted under the aus- pices of 5 county medical societies in whose ter- ritory proper facilities exist; to wit: Atlantic, Ber- gen, Essex, Hudson and Monmouth. The Field Secretary, Mrs. Taneyhill, is carrying a program this year that is even heavier than through pre- vious seasons. With the kindly assistance of the State Board of Education, she has arranged to ad- dress nearly all the school organizations of the state, stressing particularly the importance of mental hygiene, but presenting also on occasion the other lectures of her series. It is early to predict anything about the ap- proaching General Assembly of New Jersey, but the election returns and certain information that has leaked out from political headquarters per- mit us to draw some inferences. In all proba- bility, the next State Senate will be in the hands of our friends; that is to say, that Senator Wol- ber, who has always been cooperative, is said to be slated for the post of President of the Senate; Senator McAllister, of Cumberland, is to be the Re- publican Senate Floor Leader; and our very good and reliable friend, Dr. Blase Cole, is to be the Democratic Senate Floor Leader. If those selec- tions are confirmed we may feel reasonably safe as regards the Senate attitude toward public health legislation. In the House of Assembly, the situa- tion is less favorable. The Republican slate is said to be — Wise, of Passaic County, for Speaker, and Otto, of Union County, for Floor Leader; the first named is a cultist of variegated hue and we need expect no favors at his hands. At the Annual Meeting of the State Society, a resolution was adopted upon motion of Dr. Mor- rison, seconded by Dr. Quigley, that the Welfare Committee be requested to consider the necessity ior or advisability of securing legislation to con- trol or prevent the employment of unlicensed physicians by municipal, county and state institu- tions. That request is hereby respectfully directed to your attention. We have not as yet, of course, any specific knowledge of bills to be introduced into the Gen- eral Assembly but experience leads us to expect the usual crop of objectionable medical bills. The Surgery Control Bill that was under consideration at the Legislatures of 1929 and 1930 is more than likely to make a reappearance. The Welfare Com- mittee of last year left further consideration of that question in the hands of a special committee composed of Drs. John Hagerty, W. G. Schauffler, and Joseph G. Coleman. The special committee on the Hospital Lien Law, under the chairman- ship of Dr. Londrigan, accomplished the greater part of its task last year but was held over to con- sider whether further action in the future is de- sirable. There is no other unfinished business. Respectfuly submitted, Henry O. Reik, M.D., Secretary, Welfare Committee. At the suggestion of the Chairman, the report was accepted and ordered to be placed on file. At the request of the President, Dr. Sommer, the Executive Secretary presented a communica- tion from the Mercantile Finance Corporation of New Jersey, with offices at 32 E. Hanover Street, Trenton, which, in effect, set forth a plan for the collection of physicians’ bad accounts, and for the loan of money to patients for the payment of medi- cal bills or for the payment of prospective sur- gical procedures. Dr. Reik called attention to the fact that a sim- ilar proposition, offered by the Gilbert Acceptance Corporation, of Newark, had been rejected last year by the Welfare Committee after a very thorough investigation by the Secretary and, later, by a special committee. Dr. Sommer stated that he knew nothing about the proposition and presented it only because it had come to him officially. Dr. North remarked that he had seen a copy of the offer, had read it carefully, and did not con- Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY sider it worthy of endorsement by the medical pro- fession. Upon motion of Dr. McBride, the committee voted unanimously to decline further considera- tion of the proposition. At the request of Dr. Morrison, the Executive Secretary read a letter z’eceived from Dr. Law- rence Greeley Brown, of Elizabeth, N. J., complain- ing about the manner in which the Medical Bill Adjustment Committee of Essex County had acted in reference to settlement of a professional ac- count rendered to the Aetna Insurance Company for services to an injured man. After some discussion, it was decided that this matter should be referred to the Essex County Medical Society because the complaint dealt with the acts of a, committee in that district. Quoting from the Transactions of the Medical Society of New Jersey in annual session at Atlantic City June 1930, the Executive Secretary called at- tention to action taken by the House of Delegates, upon motion of Dr Morrison, seconded by Dr. Quigley (Transactions, page 42), .calling upon the Welfare Committee to consider what action should be taken with reference to the employment of un- licensed physicians by municipal, county and state institutions. After discussion, participated in by Drs. Kelley, Coleman, Costill, McGuire, Nafey and Morrow, Dr. Morrison moved that this matter be referred to a special subcommittee, to act in cooperation with Drs. McGuire and Kelley, of the State Board of Medical Examiners, for investigation of this ques- tion and later report to the Welfare Committee. The motion was adopted and the Chairman ap- pointed the committee as follows: J. Bennett Mor- rison, Chairman; R. H. M. Davis and Herbert W. Nafey. Dr. McBride called attention to the fact that during his presidency of the State Society he had forwarded to the Governor of the state of New Jersey the names of 3 physicians from whom the Governor might select an appointee for the State Board of Medical Examiners to fill the vacancy which would occur at the expiration of Dr. Char- les B. Kelley’s term, and stated that up to the present time the Governor has failed to act. He felt that the Medical Society is not being accorded proper respect and that the Governor is failing to perform his duty. Upon motion of Dr. Schauffler, it was decided to request the Chairman of the Board of Trustees to call Governor Larson’s attention to this ques- tion again, and to support Dr. McBride in his ef- forts to secure official action. Both the Executive Secretary, and the Secretary of the Board of Medical Examiners, called the Welfare Committee’s attention to newspaper re- ports of the Abell Legislative Committee’s pro- posal to transfer the work of the Medical Exam- ining Board, and other similar bodies, to the State Board of Education. After discussion by Drs. McGuire, Schauffler, North, Morrison and Schlichter, a motion was of- fered by Dr. Schlichter that a committee of 5 be appointed to consider the Abell Committee’s report and to later advise the Welfare Committee what action might be advisable. Dr. McGuire offered as an amendment that the proposed committee be instructed to confer with the Board of Medical Examiners and other sim- ilar groups concerned in the proposed change. Dr. Schlichter accepted the amendment and the amended motion was duly adopted. The Chairman appointed the following commit- tee: Andrew F. McBride, Chairman; Charles H. 65 Schlichter, Henry B. Costill, W. G. Schauffler, and T. B. Lee. Dr. Kelley reported upon the present status of osteopathy and chiropractic in New Jersey, say- ing that he did not believe either of these groups would attempt to secure special legislation this year but that he anticipated an effort on the part of the naturopaths to procure special' privileges. Dr. John Hager ty, as Chairman of the subcom- mittee on the Surgery Bill, stated that his com- mittee would report at a later meeting. The Executive Secretary presented a document prepared by Dr. Morrison in explanation of the State Society work and the manner in which the Society’s funds are expended, and recommended that this be printed in the form of booklet pre- viously used with reference to auxiliary matters and in explanation of cultism, and that these book- lets be distributed for the edification of members of the State Society and for the use of officers of county societies in collecting dues and in pro- curing new members. A motion was duly passed authorizing publica- tion and distribution as recommended. The meeting then adjourned. Henry O. Reik, M.D , Secretary, Welfare Committee. SPECIAL MEETING A special meeting of the Welfare Committee was held at the 'Stacy -Trent Hotel, Sunday, De- cember 14, at 3 p. m., with the Chairman. Dr. A. Haines Lippincott, presiding. The following members answered to roll call: Bloom, Clayton, A. H. Coleman, J. G. Coleman, Conaway, Dandois, Davis, Donohoe, Ely, Green, D. Leo Haggerty, Hunter, Larkey, Lippincott, Londri- gan, McBride, McMahon, Morrill, Morrison, Mul- ford, Nafey, North, Schauffler, Schlichter, Sewall, Sherman, Sommer and Tracy. The following sent excuses: Brown, Haussling and Lee. The following invited guests were present: John F. Hagerty, Paul M. Mecray and James J. McGuire. The Chairman called for the report of the Ex- ecutive Secretary, and Dr. Reik asked permission to present his report in sections in order that the first section might be acted upon as promptly as possible because some members interested in that portion of his report would want to be excused at 3.30 p. m. to attend another meeting. Report of the Executive Secretary (Section 1) There are several matters of interest to be pre- sented to the committee today, but inasmuch as there is to be another meeting at 3.30 p. m„ which must be attended by some of our members, a con- ference of representatives of organizations affected by proposed legislation growing out of the Abell Commission’s report, it seems best to list that subject first. Since the last meeting of the Welfare Committee, on November 9, the Abell report has been made public and several legisative acts designed to con- vert that commission’s recommendations into law have been introduced into the General Assembly. On Saturday, November 29, Dr. McBride and the Executive Secretary traveled to Morristown for an interview with Senator Abell, the results of which were quite satisfactory. On December 1, Senate Bill 304 was introduced, and the 3 bills which affect the State Board of Medical Examin- ers have since been made available for study. S. 260 provides for establishment of a centralized 66 JOURNAL OK THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 control and uniform system of accounting for the money received and expended by the state. S. 262 provides for an improved budgeting plan to take the place of the existing unsatisfactory method. S. 304 is a special act designed to bring all of the Boards of professional examination and licen- sure under a central bureau in the State Depart- ment of Education. It is the last named bill which has caused most public discussion, though objec- tion has also been made to S. 262. On Sunday, De- cember 7, representatives from several of the pro- fessions and Boards met in Trenton to confer with our own subcommittee under the chairmanship of Dr. McBride; the other groups present including particularly the dentists, pharmacists, and under- takers and embalmers. On Thursday, December 11, at a public hearing on S. 262, we were represented by President Sommer. Announcement has been made that a public hearing will be given Tuesday, December 16, on S. 304. At this point I wish to ask your consideration of 2 or 3 possible danger spots in the manner of dealing with this proposed legislation. First, per- mit me to warn against a too intimate alliance with the organizations that are opposing this legisla- tion. That phrase may sound queer, coming from me, in view of my previous efforts in the direc- tion of cooperation. It was I, for instance, who 3 years ago brought about the cooperative re- lationship with the pharmacists. But, please keep this in mind — that while I have always advocated cooperation, I have never recommended amalga- mation. We may, indeed we should, confer with the other organizations, but we should be ex- tremely careful to avoid responsibility for actions they may take, and extremely cautious about entering into any conference that may in- volve us in an obligation to support a ma- jority decision. That is a very important point to keep in mind. Already, newspaper articles have appeared from one of those groups that our so- ciety certainly could not endorse. I am informed that at the public hearing last Thursday some of those groups were represented by special agents, attorneys, and ex-members of the legislature. I trust this society will not be led into joining in such a procedure or into fol- lowing that example. It would be derogatory to the dignity of our profession and it would be in- jurious to the standing we have acquired through 6 years of following a different policy. Incidentally, such methods rarely, if ever, accomplish the in- tended purpose, and they do constitute a waste of money. Members of this group present today can better represent you and accomplish more satisfactory results than can any attorney or paid lobbyist in the United States. Further, permit me to express the opinion that we are in grave danger of being swept into a false position through the influence of mob psy- chology. The appearance of these legislative bills, indeed the preceding newspaper stories about what the Abell report would contain, planted in our minds a fear that something terrible was going to happen. That fear has grown to the point where we are in danger of acting unreasonably. I have heard much talk about these bills but most of it has been irrelevant, based upon fear rather than study of the bills, and some of it has en- tirely misrepresented the apparent intent and the actual wording of the bill. I have heard it argued that these bills propose abolition of the Boards of Examiners, substitution of examinations by per- sons incapable of conducting appropriate ex- aminations, the employment of an immense force of adjunct employees to carry on the work, and the application of funds properly received by the Boards to State work other than that heretofore carried on by the Boards. There is not a word in either of the laws to justify any of those criticisms. I am not a prophet and I cannot predict with cer- tainty what will happen if those laws are enacted, but that is not the question before us at the moment; the question calling for our first con- sideration is — what do these bills propose? I do not see how the medical profession can consistently oppose bills 260 and 262, for they offer to the state exactly what all good citizens have been demanding whenever the wastefulness or the dishonesty of state government has been under discussion. S. 262, to which exception has been noted, proposes for the state exactly what this society has had for years and what it held so precious as to rewrite into its new Constitution and By-Laws. The budget system and central control of all monies is one of the cardinal prin- ciples of the business conduct of this society. What does S. 304 say? Stripped of all excess verbiage, which for some inexplicable reason is made a part of all legislative acts, it provides: (1) For creation of a bureau within the De- partment of Education “for the centralization of records’’ and “for the administration of the financial operations of the several examining and licensing Boards”, at the same time “preserving the entity and identity” of such Boards, and that all monies received by such Boards “shall be paid into the State Treasury” and that all expenditures of said Boards shall be in accord with the state budgeting system. (2) Authority is conferred upon the new bureau, specificially, “to manage and regulate the financial operations of the several Boards”; to “receive and pay over to the State Treasury all monies col- lected by the Boards”; and to issue licenses and certificates of registration when and as approved by the said Boards”. (3) “Requests for appropriations shall be sub- mitted by said Boards to the bureau”, and the bureau shall pass approved requests to the Budget Committee, which in turn submits a report to the Legislature as a basis for the appropriation of funds, “to the end that expenses for maintenance, operation and administration of said Boards shall be appropriated from the funds collected by the Boards or from the free treasury funds of the state”. (4) “Nothing contained in this act shall be construed to conflict with the examining, regu- lating and general supervisory functions of the State Boards.” I am unable to detect anything very alarming in those provisions. I would suggest 3 slight change?, in the form of amendments: 1 believe that administration of the bureau might better rest with the Board of Regents than with the Commissioner of Education; that is, something comparable to the New Y'ork plan. Secondly, a verbal change in the provision for appropriations might be made so as to assure annual appropria- tion of a sum not less than that of the receipts of the Board. At a meeting of the Tristate Medical Conference one week ago, I reported our concern over this pending legislation, and the President of the Pennsylvania Society, Dr. Ross V. Patter- son, Dean of Jefferson Medical College, and who is better informed than most of us concerning medical education and Medical Licensing Boards, stated that Pennsylvania now has practically the same legal provisions and that he would advise us to accept the proposed laws because he believes they will work out to our advantage. The ex- periences of New York and Pennsylvania consti- tute the answer to some of the protests that this J-n„ 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY G 7 proposed legislation is unique and impracticable. Thirdly, I would insist that the State Bar Exam- ining Board and the Realtors’ Board be included in the law. The most pronounced criticisms of the Abell Commission plan seem not to be based upon the proposed laws themselves but upon suspicion and fear of how' such laws may be enforced. That is a criticism of the American political system rather than of these special acts, and I think we should study these acts carefully before assuming a pub- lic stand in opposition. The Chairman: The first section of Dr. Reik’s report is before you for action. Dr. McBride: I am opposed to the transfer of these licensing Boards to the Department of Edu- cation for the reason that I am afraid such trans- fer wTill enable, or will result in, bringing these matters under control of politicians. As to sub- stituting the Board of Regents for the Commis- sioner of Education, I would like first to know something more than I do now about the Board of Regents. As to S. 262, I think we should insist upon a re- turn to our Board of all the monies turned into the Treasury by the Board. That amendment, sug- gested by Dr. Reik, is a good one. Dr. Schauffler: I wonder if Dr. Sommer would like to tell us something about the hearing on 262 last Thursday. Dr. Sommer: A hearing was held on that bill last Thursday and I attended along with repre- sentatives of the dental and pharmaceutical asso- ciations, as arranged at the conference last Sun- day. It seems that there is to be another hear- ing on that bill, for I have received a message stating that S. 262 and S. 304 will be considered further at the hearing announced for Tuesday, December 16. The main opposition to 262, as developed last Thursday, was on the score of “dedicated funds” Everybody wanted to know what dedicated funds meant. The school teachers, for instance, feared that might interfere vrith their pension fund, and I noticed that their attorney, Mr. McCarter, wanted an assurance written into the bill to make it clear that such fund would not be interfered with. Dr. Liva spoke for the Medical Examining Board and the medical profession and Dr. Forsythe, of this city, spoke for the dentists. The conference committee, of which I am a part, came to the con- clusion that it would be wise to have an attorney’s opinion on some parts of these bills and has asked - Mr. McCarter to interpret those bills in so far as they relate to the medical profession. Senator Richards, who did most of the , cross questioning, tried to keep away from any promise guaranteeing a return to the Boards of their own funds. Dr. McBride: We had a meeting of the Passaic County Medical Society last week and passed reso- lutions opposing S. 262 and I will ask Dr. Reik to read those resolutions. Dr. Reik: Several of the county societies have passed such resolutions and I have been informed of such action by the Atlantic, Monmouth and Passaic County Societies and by the Physicians’ Association of Woodbury. The Passaic County resolutions, asked for by Dr. McBride, are as fol- lows : “We the members of the Passaic County Medi- cal Society, respectfully request that you oppose Senate Bill number 262 in its present form. We contend that unless the bill is amended to make mandatory an annual appropriation equal to the amount of money collected by the State Board of Medical Examiners during the year the cause of public health will be endangered. This money is necessary for the proper execu- tion of the work engaged in by the State Board of Medical Examiners in the interest of public health. We feel that this money should be avail- able to the Board without any uncertainty of ap- propriation. We know that it has always been the desire and wish of the State Board of Medical Examin- ers to have its accounts audited by the proper au- thorities and we heartily endorse this principle.” Dr. Morrison: I move that we endorse and adopt the resolutions sent by the Passaic County Medi- cal Society. This motion was seconded and unanimously adopted. Dr. Morrill: I understand that action applies only to S. 262. Dr. Morrison: Yes. Now as to S. 304, I feel that we have perhaps not sufficiently studied that bill to justify flat opposition. I have read the act carefully and it seems to me to guarantee keeping the examining and licensing in the hands of the respective Boards; it doesn’t propose to do any- thing to such Boards except to govern their money affairs. I am inclined to think it would be a good thing to approve this legislation if we can secure the amendments that have been suggested. Dr. Hunter: I would like to ask how the Board of Regents is constructed, whether by appointment or by election, and whether anybody here knows the members of that Board? Dr. Schauffler: I know the President of that Board very well indeed, and am sure that Mr. Jeffers is a thoroughly trustworthy individual. Dr. Morrison: I would like to say that our limit- ed experience with the Board fully justifies that recommendation. When the Chairman of our Post-Graduate Instruction Committee and the Ex- ecutive Secretary had occasion to confer with the Board of Regents regarding plans of the State Medical Society and Rutgers University, Mr. Jef- fers treated them with the utmost courtesy, showed great interest in our educational work, and prom- ised his hearty support. I have thought for sev- eral years that this society should endeavor to secure an association with the Board of Regents similar to that existing in New York. Dr. Morrill: I think that Dr. Reik and Dr. Mor- rison have hit the nail pretty squarely on the head in regard to these bills, namely, that the greatest objection is to placing the Boards under the con- trol of the Commissioner of Education. Such a change as is proposed would bring these Boards under the control of one individual, and that indi- vidual filling a position by political appointment. If the Board of Regents could be substituted, for the Commissioner of Education, the bill would be vastly improved. In fact, the bill does not other- wise read badly. Dr. Schlicter: I also think this substitute would be a good one and for the reasons just expressed by Dr. Morrill. I am skeptical about giving too much power to the State Board of Education, and I say that because there seems to have been lately 68 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 a movement all over the country, on the part of these Boards, seeking for more power. Dr. Morrison : I move that the suggested amend- ment, providing that the Board of Regents shall be substituted for the Commissioner of Education, in S. 304, be endorsed. The motion was seconded, but was defeated by vote of the committee, after lengthy discussion of the bill and its possible effects by Drs. McGuire, Reik, North, Hagerty, Lippincott, Hunter and Davis. Dr. Londrigan moved that the Welfare Committee express its opposition to the entire bill — S. 304. The motion was seconded and carried. Report of the Executive Secretary (Section 2) Next, Mr. Chairman, I would like to report that in response to a call from the Legislative Bureau of the American Medical Association, I have filed with each of the Senators and Congressional Rep- resentatives from New Jersey protests against 2 bills now under consideration by Congress (1) An Antivivisection Bill applicable to the District of Columbia but announcedly intended as an enter- ing wedge for similar legislation relating to the states; (2) the Jones-Cooper Bill which consti- tutes an attempt to reenact the old Sheppard- Towner law. As indicating our relationship with legislators, resulting from the plan of direct per- sonal appeal in the name of the State Society, it will interest you to know that out of our delegation of 14 members written to, we received prompt an- swers from 10 ; 1 of them replying by telegram, and all of them expressing thanks for the infor- mation supplied. Dr. Dippincott: I think we should endorse the the Secretary’s action in this matter, and trust somebody will so move. Dr. Conaway offered a motion endorsing the Secretary’s action and instructing him to continue opposition to the Antivivisection and the Jones- Cooper Bills. The motion was seconded and unanimously adopted. Executive Secretary’s Report (Section 3) At one of our sessions last year, we had under consideration a form of health department blank to be used by physicians in recording information required by law to be made available to the Crippled Children’s Division of the State Rehabil- itation Commission at that time objections were made to the several forms under consideration. On December 4, Mr. Buch, the Chairman of that Commission, called to see me for the purpose of submitting a new record form. He has endeavored to reduce the requirements to the lowest limit, and the present proposition is to utilize the customary Health Department blanks for births and still-births, adding to such books of blanks, in the front portion, several blank forms to be used when necessary. On the regular blanks would be printed a line directing attention to the necessity for filling the special blanks whenever there exist deformities that should be reported. The special blank provides for recording the name, address, date of birth, type of deformity, whether under treatment or referred to other physicians or surgeons, and the signature of the attending physician. The Commission and the Health De- partment would like to have immediate considera- tion of this matter so that if approved the certi- ficates can be prepared for new blanks about to be ordered by the Department. Dr. Ely: As Dr. Reik has stated, this matter was before us a year or more ago and it seemed impos- sible then to agree upon a satisfactory method of making these records. I move that we approve of the plan he has submitted today. The motion was seconded and adopted. Report of Executive Secretary (Section 4) The National Bureau of Economic Research, in letters dated December 2, appealed to Drs. Sommer and Morrison for information regarding medical care on an insurance or contract basis, in New Jersey. The Bureau asks: “(1) Do you know of any hospitals or group clinics in your state that are offering medical service to individuals or to employers (for the benefit of their employees) on a contract basis? The essence of the contract is of course an agreement on the part of the hospi- tal or clinic to furnish a certain type of service during a stipulated period of time in return for a fixed fee paid by the contract holder. (2) Do you know of any corporations or associations of- fering such service and arranging with medical practitioners and hospitals to give the medical service?” A proper response to this request would neces- sitate an investigation that would involve consider- able time and labor for some person or committee, and we submit the proposition for consideration. Dr. Haggerty: I move the appoinment of a sub- committee to consider this question and report later to the Welfare Committee. The motion was seconded and adopted. The chair appointed Drs. D. Leo Haggerty, Chairman ; Francis R. Haussling and Samuel A. Cosgrove. Report of Executive Secretary (Section 5) At the last annual meeting of the State Medical Society a great deal of time was devoted in the general sessions and in sessions of the Section on Ophthalmology, to discussion of the Workmen’s Compensation Laws. The December issue of the Journal carries one of the most instructive dis- cussions of that subject that we have seen, and the January issue will carry the papers and dis- cussions that were associated with the appear- ance at our convention of the medical represen- tative of one of the large insurance carriers. Our neighbor states, with compensation laws more or less like our own, and with problems of similar character to those that have arisen in this state, have also been giving attention to this mat- ter. The New York State Journal of Medicine of November 15, 1930, presents us with an agreement that has been made between the Medical Society and the Compensation Carriers — an agreement which seems to offer a solution for most of the difficulties complained of. I have a copy of that agreement at hand, but I would not claim to be competent to say that it is applicable in all re- spects to conditions in New Jersey. I would like to suggest that it be immediately taken under consideration by some one or some committee competent to advise the Welfare Committee and the State Society with reference to this matter. Dr. Morrison: This is a matter that deeply con- cerns the Medical Society of New Jersey and I move the appointment of a subcommittee of 5 to study the documents that Dr. Reik is prepared Jan., 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 69 to present, and to advise us as to their application to New Jersey conditions. Dr. John Hagerty: In seconding that motion I want to say that I attended a meeting in New- ark recently at which this same matter was dis- cussed and I think that the New York agreement is applicable to most of the conditions existing here with reference to our Workmen’s Compensa- tion Act. I will be glad to serve on that committee if you think I can be of any assistance. Dr. Lippincott: It is so unusual to have anyone volunteer for work that I think we can assure you, Dr. Hagerty, your offer will be accepted. The motion was then unanimously adopted. The chair appointed Drs. J. Bennett Morrison, Chair- man; John F. Hagerty, H. B. Costill, Millard F. Sewall and B. C. McMahon. Dr.Reik: During the last 2 legislative sessions, Dr. Leo Haggerty has looked after certain affairs for the Welfare Committee, particularly by keep- ing us informed of the exact status of legislation pending in the General Assembly. Being required to subscribe to the New Jersey Legislative News, he has expended for such information the sum of $25, for which amount he should be reimbursed. A motion duly made and seconded authorizing payment of this bill. Dr. Morrison: I would like the Welfare Com- mittee to submit to the House of Delegates of the Medical Society of New Jersey, at its meeting in June next, a request that this committee be given permission to draft an amendment to the Medical Practice Act giving us power similar to the Griev- ance Committee, provided for in the New York law. Dr. Morrison’s motion was seconded and unani- mously adopted. The meeting then adjourned. Respectfully submitted, Henry O. Reik, M.D., Secretary. Woman’s Auxiliary THE SOCIETY FOR THE RELIEF OP WIDOWS AND ORPHANS OF MEDICAL MEN OF NEW JERSEY Edward J. Ill, M.D. (An address delivered before the Woman’s Aux- iliary of the New Jersey State Medical Society at the Annual Meeting June 12, 1930.) I am thankful to be able to present to you some facts which should of necessity interest you. If it is not for your personal benefit, you should be aware how many doctors leave their families in a destitute condition and how our society has been able to relieve much real distress. The Society for the Relief of Widows and Or- phans of Medical Men of New Jersey has been in existence for 40 years. It has 500 members. At the annual meeting on May 14, the Treasurer re- ported a Permanent Fund of $44,930. The income from the Fund amounted to $2316.63. This in- come may be distributed to such widows and or- phans as in the opinion of the trustees is thought wise. The trustees wish to help such as are in need. It is not considered a charity by the trus- tees but a right to which such widows and or- phans are entitled. I am asking you now to present to me the names of such widows and orphans of members, who are in need, so that the trustees may take such ac- tion as they think wise to give some relief. It has been most difficult to get the names of such as are in need. A false modesty, or let us call it pride, may be at the bottom. Let us remember that the needy have a right to request aid. During the past year we have distributed $850 to such widows. No doubt we could do better if we knew to whom to send help. It may interest you to know of a few instances of which the trustees have been able to learn and where they have given relief. There is Mrs. S., the widow of a very active former member of the State Society. He left her with an income of less than $15 a week, and a hopeful son of grammar school age. With the little help we could give her, being an energetic woman, she got along. Suddenly her son, after leaving college, got sick with an incurable disease. Then there is Mrs. W., left with 3 little children and no help. Mrs. N. was an old lady when she became a widow. We helped to get her into an old ladies home. Mrs. V. was left with 6 children ranging from 2 to 15 years of age, after her husband had died from pulmonary phthisis of some years standing and during which time their little savings had dwindled to almost nothing. Mrs. T. had a husband, who had been sick and helpless with chronic arthritis. For years he earn- ed nothing, and we were glad to make him a loan while he was living and then helped the widow until such time as she could look out for herself. Mrs. G. retired to the country. Two of her half -grown-up children got sick with phthisis. We were glad to help her. Mrs. H. was left with 5 little children after Doc- tor H. died from a long illness of heart trouble. She certainly needed our help. Dr. E. left a widow, well advanced in years. He was an old man when he died. He had lost all during his declining years when sickness prevented following his occupation. I might go on relating many more deplorable instances. In 9 years we have distributed but $4400. During this time we have also made loans to sick doctors to the amount of $720. This, of course, came back to us from the death benefits but was soon returned to the widows as a gift. You will be surprised to learn how many widows are in immediate need of funds after the doctor’s death. With the usual poor business ability of our profession, no provision has been made for any immediate help. Thus, a very busy surgeon died within the year. There was not enough money to pay the grocer. Our check came as a great relief and we were glad to be able to send it within a few days of the doctor’s death. I am showing you what amount we have paid out annually during the past 11 years. Amount paid heirs of members each fiscal year ending May 1: 1920, $4250.25; 1921, $1197.75; 1922, $3856.50; 1923, $2430.50; 1924, $3956.00; 1925, $4317.25; 1926, $5467.75; 1927, $2126.75; 1928, $3617.25; 1929, $5633.75; 1930, $5307.75. If your husband is not a member please pre- vail on his becoming one. Please correspond with me or the Secretary, Dr. Wm. D. Minningham, 18 Hedden Terrace, Newark, N. J. I want to thank you for giving me a hearing 70 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 and am open to any questions you may want to put before us. I also want to express my appreciation to your President, Mrs. Hunter, as well as Mrs. Clark, Chairman of your Program Committee for their kindness to me. WINNING THEM OVER At a meeting of the Secretaries of County Branches of the Wisconsin Medical Society, held at Milwaukee, March 1, 1930, the President of the State Society, Dr. F. J. Gaenslen, said: “I am glad to see that one of the subjects on the program is that of the Woman’s Auxiliary. While I was not keen about that some months ago, the more I think of it, the more I feel it is going to be a powerful influence in the formation of public opinion regarding matters pertaining to medicine and to public health in general.” STATE AUXILIARY The Woman's Auxiliary to the Medical Society of New .Jersey will hold a luncheon meeting at the Stacy-Trent Hotel, in Trenton, on Monday, Jan- uary 12, at 1 p. m. Mrs. Walter Jackson Free- man, of Philadelphia, will be the guest of honor and there will be guests from the neighboring states of Pennsylvania and Delaware. Mrs. Free- man will outline plans for the meeting of the National Auxiliary to be held during the session of the American Medical Association in Phila- delphia from June 8 to June 12. She will tell the State Auxiliary how much depends upon it in the line of hospitality. Mrs. John Nevin, the President, will preside and she will help formulate a program for our activities during the meeting of our State Society at Asbury Park the first week in June. Please send acceptances promptly to Mrs. George N. J. Sommer, 120 West State Street, Trenton, New Jersey. Bergen County Reported by Mrs. Michael Sarla The regular monthly meeting of the Woman’s Auxiliary to the Bergen County Medical Society was held in the form of a luncheon on December 9, at ‘‘Ye Chestnut Tea House” in Bogota with 23 members present. Mr. and Mrs. B. C. Wooster, of the County Board of Education, were our guest speakers. Bridge was played during the remainder of the afternoon. Gloucester County Reported by Mrs. Henry B. Diverty The Woman’s Auxiliary to the Gloucester County Medical Society had luncheon at the Wood- bury Country Club November 17 at 1 p. m., under the auspices of the American Homes Department of the Women’s Clubs, to hear Dr. Ellen Potter, Director of Medicine in the State Department of Institutions of New Jersey. On November 20 the Auxiliary met at the Wood- bury Country Club at the same hour of the doc- tor’s meeting, the president, Mrs. E. Downs, in the chair: 14 members and guests were present. Following the business meeting Mrs. James Hun- 1 ter, Jr., of Westville, ex-president of the State j Auxiliary, gave a detailed report of her trip to the Johnstown, Pa., Convention the week of Oc- j tober G and stressed the efficiency with which it 3 was conducted. She also reported as 1 of 4 vice- chairmen on the State Program Committee for entertainment of the guests of A. M. A. Conven- J tion to be held June 8 to 12, 1931, in Philadelphia. Plans are well under way, under the very effi- cient leadership of Mrs. Freeman, of Philadelphia. After adjournment the doctors and Auxiliary were I ushered into the dining room where a wonderful | repast was served by our new chef at the Wood- 1 bury Country Club. Hudson County Reported by Anne Hetherington The regular meeting of the Woman’s Auxiliary I to the Hudson County Medical Society was held on I November 14 in the Jersey City Y. W. C. A. Announcement was made that on January 21, 1 in the Stacy-Trent Hotel at Trenton, an open 1 executive meeting will be held, followed by a t luncheon at which the president, Mrs. John Nevin, 1 hopes to see a large representation from Hudson I County. The event of the day was a lecture on “Adult- I Child Psychology” by Miss Flack, member of the I Child Development Institute of Columbia Uni- | versity. Miss Flack commended those present for their interest in her subject, which is engaging - almost universal attention. She explained the urg- I ent need of a new psychology to solve the prob- I lems of the modern parent and child since the whole fabric of living has changed in the last 10 I years. Instead of the old-fashioned home with its I garden and attic play-grounds, we have the small I apartment where the mother has a 24 hour con- fl tact with the child. Irritability is the natural re- 1 suit of such emotional strain. Perhaps George I Bernard Shaw had an over-burdened mother in mind when he made the statement that the only autocracy left in the world today is the home, I where the worst tempered member always rules. 1 It is the purpose of the newer methods to lessen difficulties of that hardest but most important job in the world — raising a family. Psychologists are opening the way to a better understanding of child behaviorism and many believe environment to be the strongest influence in human training. Scien- tists differ on this score, some declaring the adult to be 80% the result of heredity and only . 20% of environment, but since not much can be done with heredity any way, the more plastic fac- tor, environment, remains the hope of the race. A social hour was enjoyed after the lecture. The following new members wei'e welcomed: Mrs. O. R. Blanchard and Mrs. E. J. Daly, of Jersey City; Mrs. Joseph Londrigan, Mrs. H. Broesner, Mrs.. J. Rosenkranz and Mrs. W. W. Farr, of Hoboken; Mrs. H. Schwartz, North Ber- gen; Mrs. William Eckert, Union City; Mrs. E. Bailyn, West New York; and Mrs. Charles Larkey* of Bayonne. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 71 County Society Reports ATLANTIC COUNTY John Irvin, M.D., Reporter The regular monthly meeting of the Atlantic County Medical Society was held in the Blue Room of the Chalfonte Hotel on Friday evening, December 12, at 8.30 p. m., with 95 in attendance, including Dr. George N. J. Sommer, President of the State Society, and Dr. J. B. Morrison, Secre- tary of the State 'Society. The minutes of the previous meeting were read by Dr. Joseph IT. Marcus, secretary. Dr. Homer I. Silvers, president, called for re- ports of the various committees. Board of Censors by Dr. Clarence Andrews: The applications of doctors who have just graduated or Who have not been practicing for 12 months will be held over for 12 months. This is no re- flection upon the man himself, but is merely a custom. Public Health and Sanitation by Dr. W. Blair Stewart: The matter of broadcasting was brought up at the last meeting. Dr. Reik has been in- vestigating that subject. A motion was passed that the incoming president appoint a committee to arrange for broadcasting of health talks over WPG. Dr. Stewart spoke of the Abell Bills now before the state legislature to reorganize the state busi- ness and the state budget. Dr. Stewart stated ob- jections of the Board of Medical Examiners and said he would like to see the society vote unani- mously against these bills. Dr. Sommer spoke about S. 262 which pro- vides for putting all state funds in a budget sys- tem, including all funds received from licensing candidates. While the proponents of this bill as- sure us that there will be no difficulty about allowing funds for the prosecution of illegal prac- titioners, there is nothing definite in the bill about this matter. When one deals with politicians one must not take anything for granted. Dr. Darnall also spoke against these bills and urged all who could to be present at a hearing on the bills in Trenton. A motion was unanimously carried that the so- ciety go on record as opposed to Senate bills 262 and 304 and that a copy of the motion be sent to our senator and assemblymen. Dr. Morrison read a paper on the menace of state medicine, explaining its present status and asking all to concern themselves in order that we may find a relation satisfactory to the public and to the profession. Dr. W. P. Conaway spoke about a notice he had received from the Narcotic Department of the Government. This notice stated that if the nar- cotic tax is not paid medical men are subject to a fine of $2000 or jail for 5 years. Previously the fine was 75% of the amount of the tax. He sug- gested that steps be taken to find out what this means. Dr. Stewart replied that he has already written to the authorities for an explanation. Dr. J. H. Marcus read a letter from another col- lection agency which desires to enter into rela- tions with the society. The communication was laid upon the table. A letter of appreciation was received from the Atlantic Visiting Nurses’ Association. Dr. Marcus also spoke about the collection of dues. Out of 130 members, only 35 have paid their dues. The official list closes January 25, and those who are not paid up before that time will not have their names listed and will not re- ceive their Journal. Dr. Silvers introduced the speaker of the even- ing, Dr. John Deaver, who read an interesting paper on “The Acute Abdomen”. Discussion fol- lowed by Drs. Stewart, Senseman, Scanlan, All- man and Deaver. Atlantic City Hospital Staff Joseph H. Marcus, M. D., Secretary The stated monthly meeting of the Atlantic City Hospital Staff was held November 2 8 in the Nurses’ Auditorium, with Dr. David B. Allman presiding. The program presented was that of the Medi- cal Service, Dr. Clarence D. Andrews, Chief, and Dr. Hilton S. Read. Dr. Read presented a survey of the months of August, September and October; 169 patients being admitted, of whom 90 were males and 79 females. Dr. J. V. Reeves, resident physician, reported an interesting case of “Ruptured Abdominal An- eurysm”. C. P., aged 32, male, colored, was ad- mitted complaining of pain in the epigastrium, coughing and vomiting of blood (?). Father died of carcinoma, 5 yr. before, but further than this no hereditary taint discoverable. Onset of trouble 3 days before admission. Went on a “drunk’1’ and stayed under the influence of alcohol for 2 days; then began to feel weak and this weakness was accompanied by distress in the epigastrium. This tormina increased in severity, giving a severe burning sensation in the region of the stomach. On the same day he commenced to vomit, which continued until his death. His appetite remained good but he could retain no food. On the day of admission vomited about a pint of dark red blood, which gave him great relief. He thought that he passed some blood in his stools on several occasions before admission. Pulse rapid, irregu- lar and weak; B. P. 105/70; temperature 102.5°; heart, slight enlargement to left; aortic area of dullness slightly widened; no bruit, thrill or murmur heard. Patient had a hacking cough productive of a slight blood-tinged expectoration. The lungs were negative except for roughened breath sounds and a few moist crackling rales at the left base posteriorly. Distinct tenderness and slight distention in the upper abdomen. Blood count 4,200,000 red cells and 9 000 leukocytes of normal differentiation. Wassermann and Kahn tests negative. Urine of no significance, and deep reflexes normal. Condition grew progressively worse; cough more annoying; pain more severe in the epigas- trium; vomited several times during the first day and pulse rate dropped from 124 on admission to 60; temperature remained 102°. On the second day vomiting continued and he had what was ap- parently a pulmonary hemorrhage of about 3 oz. blood. There developed both a pericardial and pleura] friction sound in the left axilla, with con- siderable bogginess of the left base posteriorly but no evidence of fluid or consolidation. The patient was being treated for a probable alcoholic gastritis and pneumonitis. On his third and last day after admission he had apparently 3 pulmonary hemorrhages of 3 oz. each following severe attacks of coughing and vomiting. His symptoms grew worse from 3 p. m. to 2 a. m. when he died rather suddenly, remaining con- 2 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 scious to the end; temperature fell gradually from 102° to 97°, and pulse jumped from 75 to 155, and interceptability in his last hours. Autopsy. The left pleural cavity was literally filled with clotted blood and the lung greatly com- presed. Tracing the descending aorta a clot about the size of a baseball was found just above the diaphragmatic hiatus, removal of which dis- closed a hole in the aorta about 2 cm. in diameter. The stomach was entirely normal. Anatomic diag- nosis— ruptured aneurysm of descending thoracic aorta. The chief mistake in diagnosis was brought about by paying too much attention to his recent history. With the knowledge of gastric insult from excessive use of alcohol in the preceding few days, and the main symptoms abdominal on ad- mission, it was hard to lose sight of this possi- bility when the signs and symptoms persisted in the epigastrium and became more acute even as new signs made their appearance in the thorax. It is sufficient lesson that although a history is indispensible in making many diagnoses it may be at other times very misleading. Dr. Moore presented the following case of “Tetanus”. C. D., colored female, aged 58, ad- mitted because of stiffness involving her jaws, legs and back and twitchings of her arms. Re- called no childhood diseases. In 1904, sustained a dog bite on her left ankle and has been subject to intermittent periods of ulceration of that area since that time. She last felt very well August 4, after which time she was subject to stiffness of her neck, back and extremities. On August 5 she worked at home ironing clothes all day but that evening became somewhat worse and called in a physician. She noticed on August 6 that her jaws were becoming stiff and she had some diffi- culty in eating, and so remained at home in bed until August 10, at which time, being subject to more marked rigidity of the jaws, legs and back and associated muscular contractions in her upper extremities, she was admitted to this hos- had been active at the beginning of the illness pital. The ulceration on her left ankle be- came swollen and inflamed at the time she noted the stiffness. On admission she suffered from urinary incontinence but often before she had been subject to this condition. Her bowels were normal and her mentality unimpaired. Observation revealed sudden contractions, tonic in type, involving the flexor muscles of the upper extremities, occurring at irregular intervals and seemingly painful. Tetanus was the diagnosis made upon admission and immediate admin- istration of tetanus antitoxin was begun. It became necessary to relax this patient before in- traspinal administration was possible. Intra- venus sodium amytal (9 c.c.) was given and re- laxation obtained except for the legs and spine. A cisterna puncture was successful and 10,000 units antitoxin were administered. The next day an order was written for 10,000 units every 6 hours day and night, to be given intravenously, and the following day we gave in addition 20,000 units into the cisterna. Because of impending dehydration, 500 c.c. of 5% glucose in normal saline were given intravenously. August 14 she was able to open jaws somewhat further and liquids by mouth were given. This was the first day, 4 days after admission that any appreciable improvement was evident. From day to day fol- lowing the improvement in the muscles of the jaws there was a gradual general improvement and on August 30 toxin therapy was discon- tinued. Dr. Lucas, resident physician, detailed the fol- lowing case of “Pernicious Malaria”. Mr. and Mrs. J. R., aged 53 and 48 respectively, died from a malignant infection of malaria, within 24 hours after admission to the hospital. Family history was negative, and the personal histories had no bearing on the present conditions except for the fact that they never previously had malaria and were never in the South until this fall. At onset of present illness they were just completing a motor trip through the South. Just 11 days before onset they spent a night in a mosquito in- fested community in the Everglades. Onset of illness occurred 5 days before entering hospital and was ushered in by malaise, head- ache chilliness and coryza anorexia. Within 2 days they were suffering from chills and sweats at irregular intervals. By the fourth day the man developed jaundice of rather marked degree. He complained more of headache and generalized muscular pains especially of the back and neck muscles. The woman had more gastro-intestinal symptoms; abdominal cramps, nausea, vomiting and diarrhea. On admittance they were prac- tically moribund. The man was in medical shock; delirious, skin cold and clammy, pulse rapid and irregular, and it was impossible to measure blood pressure. He was markedly jaundiced, and ex- amination revealed an enlarged spleen, the lower border of which could be palpated 2 finger- breadths below costal margin on anterior axil- lary line. Liver not palpable. The woman was extremely toxic, and assumed the position in bed of one suffering from severe abdominal pain; legs flexed on the abdomen and she made continuous pressure over the epigas- trium with her hands. She was rather obese. It was impossible to palpate any mass in her abdo- men. She was not jaundiced. The man had a leukocyte count of 21,000 with 77% polymorphonuclears. The woman -also had 21,000 white cells with 92% polys in differential count. Signet-shaped malaria parasites were present in enormous numbers in blood smears from both patients. Treatment of the man consisted in measures to combat shock and provide cardiac stimulation. The woman was given quinin hydrochloride in- tramuscularly every 6 hours, and the same amount by mouth every 3 hours. The man died 14 hours after admittance; never reacted com- pletely from shock. The woman died 22 hours after admittance. Necropsy was performed on the man and the spleen was 3 times normal size. Dr. Robert A. Kilduffe demonstrated the pres- sence of malaria parasites by microscopic photo- graphy in the case reported by Dr. Lucas. Dr. Clarence L. Andrews, chief of the Medical Service, presented the report of the Medical Ser- vice, commenting on each of the 32 deaths during his service period, and comparing autopsy records with ward diagnoses. Dr.- Theodore Senseman presented a case of “Spina Bifida” in an infant upon whom he had operated some weeks before. The progress of the baby and the site of operation were both highly satisfactory, and there were no signs of increased intracranial tension. The prognosis was indeed excellent. Pine Rest Sanatorium Harry Subin, M.D., Reporter The regular monthly meeting of the Staff of the ine Rest Sanatorium was held at the insti- tution on Thursday evening, December 11. The Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 73 minutes of the previous meeting were read by the recording secretary, and accepted without correction. The scientific portion of the meeting was open- ed by Dr. Fish, who demonstrated the method of outlining Kronig’s Isthmus by palpation, percus- sion and auscultatory percussion. He pointed out that the narrowing of the field of resonance is due to limitation of movement of the diaphragm on that side. The paper was opened for discussion by Dr. Hudson, who believed that Kronig’s Isthmus is not narrowed until scar tissue forms, and is of no value as a sign in incipient phthisis. Doubt as to reliability of the palpatory method of outlining the limits of Kronig’s Isthmus was expressed by Drs. Kaighn anc. Allman. Those present were Drs. Hudson, Kilduffe, Mar- cus, Allman, McGeehen, Fish, Pennington, Subin, Nickman and Mr. Conover. BERGEN COUNTY C. H. Dittwin, M.D., Reporter The regular meting of the Bergen County Medi- ical Society was held at Englewood Hospital on the evening of December 9. Dr. Edward W. Clarke presided. In addition to about 6 0 mem- bers of the society there were a great many stu- dent nurses of the hospital present. The minutes of the last meeting and also of the Executive Committee meeting were read and approved. A motion was regularly passed recommending that the physicians of the society charge a flat rate of $6 for diphtheria immunization. Dr. Huff reported for the Educational Com- mittee, which consists of Drs. Wolowitz, chair- man, Huff and Black, appointed in the interim since the last meeting. Rutgers College courses are again being offered, and after a quick survey the committee believes the most popular course to be in obstetrics and office gynecology. The secretary mentioned a meeting of the State Compensation Committee in Newark to consider different phases of the compensation laws; Dr. G. W. Finke represented Bergen County. The question concerning Dr. F. Haagen was presented to the society. The Executive Com- mittee at one of its previous meetings requested an investigation of this man by the federal au- thorities. A week ago the announcement came out on the front page of the Bergen Evening Record that he admitted being a drug addict and would go away for treatment. Dr. A. Liva, Presi- dent of the State Board of Medical Examiners, suggested that the society write a letter stating these facts, to serve as a complaint, so that the Board might hold a hearing on the revocation of his license. After some discussion Dr. Littwin’s motion was passed that this matter be referred to the committee on Public Relations, for a report at the next meeting. Then followed a long and excellent scientific program prepared by Dr. Dittwin as follows: Immunization of Measles with Convalescent Serum, Dr. George Heller, of Englewood. Squint in Children, Dr. Raymond Meek, of New York. The School Physician and the School Health Program, Dr. A. G. Ireland, of Trenton. Pneumonia in Children, Dr. Charles H. Smith, of New York. CAMDEN COUNTY Robert Gamon, M.D., Reporter The regular monthly meeting of the Camden County Medical Society was held in the Camden City Dispensary Building, December 2, with Dr. E. G. Hummell, Vice-President, in the chair. The society was honored by attendance of the President of the State Society, George N. J. Sommer, of Trenton, and (Secretary J. B. Mor- rison. Dr. Sommer spoke briefly, emphasizing the importance of a strong Woman's Auxiliary and its relationship to the county society. He also emphasized the importance of our society taking part in the Post-Graduate Courses offered by Rutgers University and the Medical Society of New Jersey. Dr. Morrison read a very timely paper on the much talked of subject of state medicine. Both speakers were most cordially received. The regular Scientific Program followed . “Sinusitis'’, Earl S. Hallinger (by invitation.) Discussion opened by O. R. Kline. “Status of Present Day Treatment of Pneu- monia”, T. K. Bewis. Discussion opened by E. B. Rogers. “The Management of the Asthma Patient ” Geo. P. Meyer. Dr. D. F. Bentley, Jr., historian of the society, was given a rising vote of thanks for his contri- bution in the form of an “Historical Sketch of the Camden County Medical Society” and its members which is appended to the newly pub- lished Constitution and By-Laws of the Society. Communication from the President of the So- ciety, Dr. W. J. Barrett, indicated he would be present at the January meeting of the Society. Dr. Wilmer Kruzen, Jr., Assistant Dean of Temple University Medical College, was a guest at the meeting, and by invitation discussed the papers of Drs. Hallinger and Lewis. Dr. A. G. Kinney, 249 Woodlawn Terrace, Col- lingswood, N. J., was elected to active member- ship. Drs. H. P. Coxon, of Stratford, N. J., and Samuel Rosen, 109 N. 27th Street, Camden, were pro- posed for membership. A special committee was appointed by the president to consider advisability of the Camden County Society taking part in the annual Post- Graduate Courses. The discussion and interest in the meeting was active. ESSEX COUTY Frank W. Pinneo, M.D., Secretary The plans of our Maternal Welfare Commission are complete for the course in obstetrics. Here- with please find their announcement. You are offered a special course of lectures, with manikin demonstrations, conducted by the teaching staff of Obstetrics and Gynecology of Columbia University land Sloane Hospital for Women. We believe this course offers an unusual opportunity in obstetrics for our members. Tickets will be issued to those who subscribe, remitting $10, for the course of 6 lectures, to be held at the Academy of Medicine, 91 Lincoln Park, Newark, 4.3 0 to 6 p. m„ scheduled as fol- lows: Wednesday, January 14, Pre-natal Care and Management of First Stage, Dr. B. P. Watson. 74 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Wednesday, January 21. Forceps Delivery, Dr. W. E. Caldwell. Wednesday, January 28, Breech Delivery: Version, Dr. W. E. Studdiford. Wednesday, February 4, Fetal Injuries and Neonatal Pathology, Dr. E. S. Coler. Wednesday, February 11, Antepartum Hemor- rhages, Dr. H. Halstead. Wednesday, February 18, Pelvic Floor Injuries: Their Prevention and Repair. Management of Puerperium, Dr. C. E. Caverly. Eye, Ear, Nose and Throat Section Academy of Medicine ol' Northern New Jersey E. LeRoy Wood, M.D., Secretary A very interesting meeting of the Eye, Ear, Nose and Throat Section of the Academy of Medi- cine of Northern New Jersey was held on Monday evening, November 10, under Chairman J. Wal- lace Hurff. The paper of the evening was on “Detachments of the Retina and the Gonin Operation1’, read by Dr. Mark J. Schoenberg, of New York City. He related that up to advent of the Gonin operation nothing promising was known about detachments of the retina, while at the present time there is a definite favorable prospect in a number of cases. He estimated that of all cases of detachment of the retina, only 40% are suitable for operation, and of those operated on the results are good in 50% of the cases. The operation resulted from the fact that in the study of beginning detach- ments a hole or tear in the retina could often be seen, and the thought occurred that perhaps if that hole or tear could be closed with a cautery the process might be arrested. Local anesthetic is used, holocainbutyn, but never cocain, because a clear cornea allowing fundus inspection is essential. An incision is made in the cornea at a point located over the retinal hole. Expose sclera, dry and clean sclera, stop oozing to avoid blood in the vitreous. Incise medially with Grade knife, pass cherry-red cautery through incision, and through retina into vitreous. Then the cau- tery is withdrawn, catching the retina, pulling it out and anchoring it to the wound. The after- treatment is atropin, bandaging of both eyes, and bed for 8 days. Have the patient rest so that the operated area is in a dependent position and the vitreous lies upon it. Do not look at the eye for 6 days unless the patient has pain. Conjunc- tival sutures are removed the eighth day and a cathartic given; then diet for 8 days more. There is danger of hemorrhage from the sixth to ninth day; greatest when walking around. Dr. Elbert S. Sherman reported the absorption of a large traumatic opacity of the lens. When he first saw the patient, a slender grass wire had perforated the eye 4 days previously and vision was only fingers at 1 foot. There was a large opacity in the posterior part of the lens cortex. One month later vision was 20/30 and the opacity thinner; 5'A months later the vision was 20/20 without correction and the opacity had completely disappeared and was not visible even through the slit lamp. Dr. Sherman said that small opaci- ties may absorb but he had never seen such a large one disappear. He pointed out the lesson that one should not be hasty in giving on opinion as to the percentage of disability, until sufficient time has elapsed. Dr. Wallace Pyle, of Jersey City, made a fur- ther report of a case he first presented in 1924. The patient first seen by him in November, 1923, and then 4 months old, had a profuse discharge of pus from each eye and a false membrane on both lids which presented a diagnostic problem after diphtheria, gonorrhea and Vincent’s angina were ruled out. Opinions of eminent consultants were secured and the diagnosis of the rare con- dition— “Recurrent Membranous Conjunctivitis” — finally agreed upon. In February 1926 the eyes were quiet, the lower lids free, with a marked growth from the upper lids. On November 1, 19 30, neither eyeball was inflamed, there was no membrane and the lids looked like an old trach- oma. There were marked polypoid, peduncu- lated growths from both upper lids, which ap- peared to be easily removable but surgical assist- ance was refused. Dr. Linn Emerson, of Orange, reported seeing a patient with “Double Symmetric Ring-like Catar- act with Clear Central and Outer Portions and Preservation of Good Vision”. Thirty-two members were present. The meet- ing adjourned at 10.50 p.m. GLOUCESTER COUNTY Henry B. Diverty, M.D., Reporter A most interesting meeting of the Gloucester County Medical Society was held December 18 at the Oak Valley Country Club, near Woodbury Heights, entertained capably by Carterer McGar- rity. The following members were present: Drs. S. F. Ashcraft, of Mullic.a Hill; M. F. Lummis, of Pitman; James Hunter, Jr., R. K. I-Iollinshed, Edwin R. Ristine, of Westville; C. F. Fisler, of Clayton; E. E. Downs, J. Harris Underwood, Harry Nelson, C. A. Bowersox, of Woodbury; A B. Black, of Mickleton; William and Charles Ped- rick, of Glassboro; B. A. Livingood, of Swedes- boro; O. R. Wood, of Paulsboro; H. W. Stout, of Wenonah and I. W. Knight, of Pitman. Guests wer Dr. Masineo, of Philadelphia; Dr. James L. Gray, of Pitman; Professor Clovis, of Rutgers University; Dr. J. Claude Foster, of Westville, and Dr. Amos Underwood. Dr. Corson, of Bridgeton, and Dr. Church, of Salem County, were present as delegates. The essayist of the evening was Professor John H. Gunther, M.D., D. D. S., assistant professor of anatomy at the University of Pennsylvania Den- tal School, and whose subject was “The Relation of Mouth Infections to the Manifestation of Gen- eral Disease.” This important subject was finely illustrated by lantern slides. HUDSON COUNTY Harry J. Perlberg, Secretary The Hudson County Medical Society held its monthly meeting December 12 with Dr. J. M. Cassidy presiding. The minutes of the last meeting were accepted as published in the bulletin. The Board of Censors reported favorably upon the following applicants: Herman M. Jaffe, Con- rad M. Bahnson. J. L. Mathesheimer, and Otto H. Mustermann, and all were elected. Dr. Cassidy spoke of the passing away of Dr. J. H. Commorato, and requested that a large dele- gation of members attend the services as a last tribute of respect to his memory. The following Committee on Post-Graduate In- struction was appointed by the president: L. C. Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 75 Lange, Chairman; Thos. White, R. L. Ballinger, George Gingsberg and A. E. Jaffin. In reference to the Antidiphtheria Campaign, the president stated that he had a conference with Dr. Salmon, who had assured him of close cooperation between the Board of Health and the Hudson County Medical Society. Dr. Cassidy stressed the laxity of members of the various committees and called upon them to fulfill their obligations. A symposium on Genito-Urinary Disease was then held. Dr. C. L. DeMerritt, whose subject was “Ure- thral Conditions in their Relation to Sexual Dis- turbances”. Sex failure is defined as an involun- tary failure to perform the sexual act. It is to • be sharply defined from sterility, as the latter is a failure to discharge live spermatozoa, and in no way denotes importance. Among the causes of sterility are; (1) urethral causes, as after pros- tatectomy or with a tight stricture, where it is conceivable that the seminal discharge might be- come reflux into the bladder; (2) central nervous system lesions, with involvement of the nervi eri- gentes; (3) hypofunctiOn of the testicular cells; (4) asthenia and debility; (5) psychic causes. Dr. DeMerritt then proceeded to give a brief but adequate review of the anatomy of the male generative organs, with special reference to the urethra, and a description of the sex lesions of the urethra. (1) Anterior urethral canal, (a) Malformations. Epispadias is so rare as to warrant no attention. Hypospadias — the opening is usually in the un- dersurface of the gland, and the lesion per se seldom if ever causes impotence or sterility, (b) Urethritis. In the acute stages, the condition causes impotence. In the chronic stages, the pa- tient is potent and desirous of sexual intercourse long before being cured, unfortunately, (c) Stric- ture of itself causes no change, but when associat- ed with urethritis, as is usual, impotence is the rule, (d) Chordee if sufficiently great may inter- fere with the sexual act and require surgical re- lief. (2) Posterior urethral canal. Here is the usual site of trouble in impotence, and here the vast majority of causes are to be found in dis- ease and dysfunction of the verumontanum or crest. Dr. DeMerritt here outlined the anatomy and known physiology of the crest. It ’S a highly glandular, non-erectile mound of tissue on the posterior aspect of the prostatic portion of the urethra, which changes slightly on erection. It is regarded by some as the trigger of the sexual gun, timing the moment of discharge. Diseases of the Crest (1) The congested crest. Common causes are urethritis and coitus interruptus. Masturbation becomes of concern only where clerical cure has been attempted, with usual severe psychic results. The crest in this type is red, congested, bleeds easily and may have polypoid changes or excres- cences. The complaint is usually early ejacula- tion, before or immediately upon intromission. It is especially common in middle-aged bachelors or widowers who are continent before remarrying. Treatment consists in the urethroscopic applica- tion of caustics, and gives excellent results. The procedure is to first clean up the field, apply car- bolic to the entire crest; 5-10 treatments are given once or twice a week, with fine results. Carbolic is better than silver nitrate. While not so good for diagnosis, the open instrument is better than the air or water distention instruments for treat- ment. In addition to local treatment, moderate exercise, especially walking, is prescribed, with attention to general hygienic measures. (2) The anemic crest. With this type the out- look is poor. Local treatment gives poor results and attention to general hygienic measures seems to offer the best chance. It is probably true that the anemic crest does not follow the congested. Its etiology is indefinite. Dr. E. J. Daly talked on “Injuries to the Urinary Tract Through Outside Violence”. The urinary tract, except the urethra, although quite well pro- tected by the bony skeleton and heavy muscula- ture, is nevertheless subject to injury from out- side forces, the result of falls, kicks, or squeezing, which produce contusions and lacerations; or pointed objects such as knives and bullets, which produce penetrating wounds. The damage done is not always in proportion to the force applied and may be limited to the urinary tract, or com- plicated by injury to other organs. Most cases we have seen have been of the contused and lacer- ated type. For convenience, we will divide our field into upper and lower urinary tract. In the upper portion we have the kidneys, renal vessels, and upper ureters. Fortunately for the patient, and also for the surgeon, we usually find only one side involved. The kidney is injured by being forcibly thrown against the spine or ribs, or the blow being transmitted to it through the muscle wall. In penetrating wounds, the object passes directly into or through the kidney. The resulting trauma may vary from a slight sub- capsular contusion to multiple lacerations or com- plete maceration of the organ. Where only a slight contusion is present, there is an oozing of blood which remains beneath the true capsule, but, if the capsule is torn, will spread out into the perinephritic tissue. The bleeding is usually slight, ceases spontaneously, and healing is ac- complished by absorption, or formation of fibrous tissue. Where the injury is more severe and the parenchyma is lacerated, with considerable hemorrhage into the perinephritic fat, the same process of healing may take place; but it is in this type of case where secondary infection is prone to occur, either hematogenous or directly from the kidney or nearby bowel. Then we are confronted with a perinephritis which develops in the ensuing few weeks, or a destroyed kidney, the result of a diffuse pyelonephritis, which mani- fests itself some weeks or months later. If the injury extends into a calyx, it permits escape of urine and the above conditions develop more readily. Extravasation of blood and urine al- though somewhat limited by attachment of the peritoneum to the posterior abdominal wall, tends to burrow downward, and may extend into the true pelvis. If the peritoneum has been torn, it will enter the peritoneal cavity. These cases are serious, not always because of hemorrhage, but because of the devastating effect of the ex- travasated urine. Injuries to the upper ureter occur with in- juries to the kidney; the major portion is so well protected and fixed that it is rarely injured by external forces; penetrating objects have caused complete division and lacerations have resulted from falls. Where the patient's condition is not too alarm- ing there is much to be gained by expectant treat- ment, for when operation is indicated, nephrec- tomy is either necessary or seems the most rational procedure. I feel that a kidney that can be left in will be a better kidney if left undisturbed. 76 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 During the period of observation, shock is com- bated with heat, clysis and morphin. Pulse and temperature should be recorded at hourly inter- vals. Frequent palpation will reveal any in- creasing tumor or evidence of intraperitoneal irri- tation. These are all guides as to the necessity of surgical intervention. When operation is in- dicated, it is usually within 48 hours. As to the future of these kidneys avoiding op- eration, many of them seem to go along without further trouble. Others develop a pyelonephritis, or hydronephrosis, and are prone to be the seat of calculus formation. Lower tract. The bladder is more susceptible to injury if distended, because in the collapsed state or containing only a small amount of urine it is well protected by the bony pelvis, while, if distended, a portion of it is only protected by the less rigid abdominal wall, and is also more sub- ject to a greater hydrostatic pressure. Injuries may be classified as contusions, lacerations and perforations. Lacerations and perforations may be either intraperitoneal or extraperitoneal, and both conditions are serious, one because of the escape of urine into the peritoneal cavity, and the other because of extravasation into the pelvic tissues, perineum, and abdominal wall. In our own cases, most of the bladder injuries have been extraperitoneal and associated with fracture of the pelvis; damage to the bladder being longi- tudinal tears or perforations by bone fragments. Injuries of the bladder should be diagnosed and proper treatment instituted as quickly as possible. Here, we cannot carry out expectant treatment with the same degree of safety as in injury to the kidney. The symptoms of rupture or perforation of the bladder are: History of in- jury with sudden pain in the bladder region, blood in the urine, desire to urinate but inability to do so. Shock is .present; more so in cases accom- panying fracture of the pelvis. In the intra- peritoneal type, seen early, palpation may not dis- close any particular evidence. This is very im- portant in intoxicated persons, with intraperi- toneal rupture. When seen late there is evidence of peritonitis. In extraperitoneal rupture, there is rigidity, fullness and tenderness over the supra- pubic region extending laterally and into the peri- neum. Catheterization as an aid to diagnosis is valuable, but dangerous, and is not infallible. It should be carried out under most careful asepsis and one should be prepared to follow with opera- tion in a very short time, if such procedure is found necessary. The same may be said for cys- toscopy. The diagnosis having been made, operation should not be delayed. Where intraperitoneal rupture is suspected, the peritoneal cavity should be opened through a low midline incision. The wounds in the bladder, if jagged, should be trim- med, and closed with at least a double row of sutures. The escaped urine is mopped out, and the abdominal wound closed in layers. A large catheter is then passed through the urethra and anchored in place. For extraperitoneal ruptures, the usual supra- pubic approach is made, and the bladder ex- posed. Considerable bleeding is sometimes en- countered, springing from torn pelvic bladder vessels. The rupture or perforation is usually found on the anterior aspect of the bladder, and frequently extends into the roof of the posterior urethra. The wound should be closed with a double layer of plain catgut, and the bladder drained through a suprapublic tube. The pre- vesical bleeding can be controlled by gauze pack- ing. Where the posterior or bulbous urethra has been crushed, it is advisable, while the bladder is open, to do a retrograde catheterization, leaving the catheter in situ. As to the care of a fractured pelvis, the appli- cation of casts or slings does not seem very prac- tical. Osteomyelitis, invariably develops and sequestra of bone either work their way through the skin or are removed. Bone healing, although slow, is usually in the end quite satisfactory. Urethra. The urethra may be injured by falls, crushing the bulbous or membranous portions against the pubic arch, cutting objects, gunshot or bullet wounds, or circular pressure applied to the penis. The most common cause is falling a- stride some firm object such as a rail or beam; this results in a contused laceration of the bul- bous or membranous urethra. Gunshot wounds usually involve the rectum or bladder, and may carry away a considerable portion of the ure- thra. Cutting objects cause wounds ranging from lacerations of the urethra .and corpus spongeosum to amputation of the penis. Circular pressure from rings, rubber bands and iron bolt nuts, cause interference with the circulation. The result de- pends on the length of time the constriction is present, and varies from a contusion to gangrene of the distal portion. Treatment of wounds of the urethra consists of approximating the divided ends and diverting the urine from the wound. In the less severe cases this is readily accomplished by an indwelling catheter over which the ends of the urethra are approximated. When there is only slight injury an indwelling catheter may be the only treat- ment necessary. In cases of contused lacerations of the perineal urethra, external urethrotomy should be done. If the proximal end of the urethra cannot be located, a suprapubic cystot- omy and retrograde catheterization is necessary. Dr. 8. R. Woodruff. “Radiographic Delineation of the Urinary Tract by Means of the Intravenous Injection of Uroselectan; A study of its Relative Value as Compared to Retrograde Urography”. Delineation of the urinary tract by utilizing the secretory power of the kidney through the intra- venous injection of a substance that would be excreted in sufficient volume and be of sufficient radiographic value, has long been sought as the ultimate in urographic diagnosis. In 1923, the first attempt was made by Osborne, Sutherland Scholl and Rowntree who injected solutions of sodium iodide of various strengths. The results were not particularly noteworthy. There is at present considerable discussion as to priority in the application of the present uroselectan, and as practically all the preliminary work has been done in Europe, we do not feel that our knowl- edge of conditions allows us to criticize or extol in any particular direction. From our observa- tions of such an important matter as this we would draw attention to the splendid work done by Professors von Lichtenberg and Binz and Drs. Rath and Swick. At the Post-Graduate we have been particularly fortunate in obtaining uroselec- tan through the courtesy of von Lichtenberg and this chapter is devoted solely to a consideration of our results. Uroselectan is an organic iodin combination and its formula is still under observation and likely to change, so that its exact chemical com- position makes little difference at this time. It is very soluble in water, neutral in reaction, and practically 90% will be excreted (by the kidneys within 8 hours. Some of the historians say that it is non-toxic and that absolutely no reactions Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 77' fallow its use. Our experience leads us to be- lieve that this is not always true for we have noted urticaria, generalized erythema of the skin, and in 1 case, nystagmus, incoherence of speech, and temporary unconsciousness. We view, with considerable alarm the expect- ancy of the general surgeon and internist who believe that they will now be able to diagnose all genito-urinary diseases, particularly those of the kidney, without use of the cystoscope or urolo- gist, and we feel that a crop of unfortunate, sur- gical mistakes is about to be harvested. The value of intravenous pyelography is tremendous and unmistakable but its use should be limited to those with experience in evaluating the results obtained. Not the least of its value lies in the fact that it is practically a most excellent test of renal function, for in the normal kidney it is quite usually to be found in the renal pelvis if a roentgenogram is taken in 5 minutes after the injection, while in those kidneys diseased or al- tered in their functional capacity in any way, delay or positive non-appearance of the material is the result. Patients with moderate destruc- tion of renal function in 1 kidney will show a corresponding lengthening of appearance time and insufficient filling of the renal pelvis. Where both kidneys are damaged, one might even hesi- tate in using the material unless it be desired to do so from a functional standpoint. Some of our cases were especially fitted for this type of diag- nosis while others were done simply as a routine procedure. It is in some peculiar conditions found in urology that . intravenous pyelography will be of its greatest value. Where one or more ureters have been transplanted and ureteral ori- fices are not available to catheterization we have no other diagnostic means. In children a fertile field will no doubt be found for this type of diag- nostic procedure. In those cases where some physical, mental or anatomic condition makes cystoscopy either impossible or not advantageous, delineation by this type of procedure will be of immense -value. One of our chief criticisms has been that one has absolutely no control over the result after giv- ing uroselectan. The radiographic exposure may or may not contain anything of a diagnostic value. Our principal objection is that the results are by no means uniform. One may go through the en- tire procedure of injecting uroselectan and the subsequent roentgenographic exposures, without obtaining anything of a diagnostic nature; that is, for the exact condition for which one might be using the substance. The non-secretion of the material naturally means a kidney which at that particular time is not functioning. In some cases, as of reflex anuria, this may be only temporary, while in other conditions of actual renal destruc- tion, the exact type of pathology cannot be fore- told, as such conditions may be present in any of the destructive changes taking place in the kid- ney. If the material comes through delayed and in small amounts, only a cursory knowledge of the pathology can be foretold, for the renal pelvis under these conditions will probably not be well delineated. If the material comes through in good quantity there is probably a normal kidney anyway; this latter knowledge at least being im- portant many times. Retrograde pyelography at the Post-Graduate has been particularly of value to us from a diag- nostic and prognostic standpoint. While we feel that intravenous pyelography is one of the most outstanding procedures brought out in urology in a number of years, yet we cannot believe that it will supplant cystoscopy nor retrograde ure- teropyelography. This latter procedure we have found to be positive in 96% of its usage, and while we greet intraveneous pyelography with open arms, we will probably still keep one hand on the cystoscope. The dosage and method of administration of uroselectan has not yet been , absolutely stand- dardized. We have usually given 30 to 40 gm. dissolved in double distilled water in a volume of 120 c.c. The solution is filtered thoroughly and sterilized in a water bath or autoclave for half an hour. The dose for children is graduated, as in all medication. It is quite necessary that no rubber tubing come in contact with the ma- terial and therefore it must be given by the syringe method. If 30 gm. are given, the entire amount may be injected at once, while if 40 gm. are used it is better to inject one-half of the ma- terial and then wait for an interval of 5 minutes- before repeating. This latter procedure probably brings out a better resultant shadow. Investigating this work, we followed a set schedule: Taking the pulse, a sample of blood from the vein and a preliminary roentgenogram. During the injection of the material and for a few minutes afterward, the pulse was counted con- tinually and its variations noted. The blood was used as a check-up against blood taken from the vein one-half hour after the injection, and the iodin content noted. Radiographic exposures were made at 5 minutes, 15 minutes, 30 minutes, 1% hours, and 3 hours. We found quite usually the maximum intensity of radiographic result was at the 15 minute exposure, although this would naturally apply to normal kidneys. Not the least value of uroselectan is the fact that it intensifies the shadow of the kidney itself, thereby being of remarkable value in delineating its size and posi- tion. We were much chargrined to find it of no value in interpreting the shadow in 3 cases of ureteral stbne. In none did the ureter fill and in 1 there was no shadow of the calculus at all.. These 3 were later easily checked up by the or- dinary cystoscopic and radiographic means. The comparative poor filling of the renal pelvis and ureter, when considered in relation to that of a good ureteropyelogram will be sadly felt by the urologist. Clinical Society North Hudson Hospital J. Africano, M.D., Reporter The regular monthly meeting of the Clinical Society was held Tuesday, December 9, with Dr.. William Sweeney acting as chairman; 5 2 mem- bers and guests present. Dr. Tannert read the report for November: 246 admissions; 317 dis- charges; 15 deaths, of which 10 were surgical, 4 medical, and 1 new-born; 4 autopsies were per- formed; clinic cases 394, emergency cases 474, ambulance calls 9 9. Several of the deaths were briefly discussed. The following case presentations were made by members of the Staff: Dr. Lawsing. Interesting Case of Duodenal Ul- cer. J. C., male, aged 2 8, admitted complaining of pain in the upper abdomen, gaseous eructa- tions, slight loss of weight and headaches. In- fluenza and tonsillectomy 7 yr. previously. Gonor- rheal urethritis in 1921. About 6 years ago the patient first noticed a mildly sharp pain in the epigastrium, which would come about % hr. after meals, last 2 hr. and be relieved by eating. 78 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 A meat meal would make the pain worse. Some meals would not be followed by pain. He has had 3 recurrences of such attacks in the past G years. Two years ago when he had his second attack, radiographs were taken and he was told he had an ulcer. He responded to treatment and was free from pain until the present attack which, ‘besides the pain, is accompanied by a gnawing sensation and a fullness in the upper abdomen. The pain comes 2 hr. after eating and is relieved by food and sod. bicarb. Abdomen soft: no masses; slight tenderness 2 in. above umbilicus in the midline and extending 2 in. to the right. Slight tenderness in both lower quadrants. X-ray. G-I series was reported as showing a normal pylorus and duodenum with no defects in the gas- tric outline. The 6 hr. plate showed no gastric retention; head of the meal was in the transverse colon and the tail in the coils of the terminal ileum. The patient was put on a milk and cream diet with alkalis and this was gradually increased; a modified Sippy diet. He improved and was dis- charged. In this case we have a clinical diagnosis of duodenal ulcer which is not supported by the gastric analyses nor by the x-ray examination. Peptic ulcer is common; approximately 5% of all adults dying from various causes show open or healed peptic ulcer. Clinical history frequently shows that ulcer has been present for many years continuously or recurrent, but not recog- nized. The most conclusive evidence of unhealed peptic ulcer is derived from careful study of dis- tress symptoms. In peptic ulcer 50% of cases show hyperchlorhydria; 40% are within normal limits; in less than 10% there is hypo-acidity. A combination of burning, fullness and pronounced hunger pain relieved by food or alkalis, occurring periodically and rhythmically, is almost con- clusive of duodenal ulcer. Dr. Miller. Unusual Fibroid Tumor of the Ovary. Mrs. A. C., aged 32, complained of a mass in lower abdomen. Appendectomy at age 17. Nulli- parous. Menstruation regular, non-painful, mod- erate in amount, excepting for being scanty for the past 3 months. She had noticed a mass in the lower mid-abdomen, more toward the left, and assumed she was pregnant, and this was confirmed by a physician. When seen at my office the patient was in excellent health, having no complaints, desiring only prenatal care because of the fact that she felt fetal movements. No confirming examination was made outside of the routine measurements, blood pressure and urin- alysis. ■ She returned 2 months later, presenting herself with a generalized edema, which proved to be an anasarca. Bimanual examination reveal- ed a globular mass in the midlower abdomen, cor- responding to a 6 months' pregnancy. No fetal heart heard. Blood pressure and urinalysis nor- mal. The lower extremities were about 3 times nor- mal size, and abdominal cavity gave evidence of free fluid. There was no colostrum of the breasts, nor were there any other prevailing signs of preg- nancy. Under diet and symptomatic treatment there was no recession of the generalized ana- sarca. The patient was prepared for laparotomy by removing 1500 c.c. fluid from the chest. The abdominal cavity was filled with several liters of straw-colored fluid, which was slowly aspirated, and a tumor weighing 7 lb. and measuring 20 cm. in diameter, on the left ovary, was found and removed. The patient made an uneventful recovery. The pathologic report was fibroma with myxomatous degeneration. The interesting fea- ture is the unusual generalized anasarca accom- panying this not uncommon type of tumor. Dr. Pearlstein considered the feature of edema: This is supposed to be caused by a change in the movement of water of the tissues incident to dis- turbances of the electrolytes, as in inflammation; or it may be due to a lesion of the “water-regu- lator” center in the hypothalamus; or finally, it must be explained on the basis of an endocrine disturbance, as in cases of diabetes insipidus. In the case presented it could not be ascribed to congestive heart failure, the measurements of the heart being normal, nor to portal stasis from obstruction, nor to nephrosis; tuberculosis of the peritoneum, and malignancy were ruled out at the operation. Dr. D’Acierno thought it likely that the tumor was a coincidence along with polyserositis. Dr. Tannert disagreed, as the patient improved remarkably after the operation, but Dr. Schul- man pointed out that in tuberculosis effusion due to Concato's disease even simple exploratory lapa- rotomy often causes marked clinical improvement. Dr. Tataryan. Pyeltis Complicating Pregnancy. Pyelitis is the most frequent complication of preg- nancy. It was first mentioned in 1841, by Pierre Rayer, with the statement that the pregnant uterus was the cause of inflammation of the ureters and kidney pelvis. After a silence of 50 years, Heblaut made some careful observations on the course of pyelitis in pregnancy. In the etiology, 2 component factors must be recognized: urinary infection, and urinary obstruction and stasis. Only where both obstruction and bacteri- uria exists conjointly does an infection of the kidney pelvis take place. M. M., aged 17, admitted to hospital June 14. Chief complaints were chills, fever, generalized aches, pain in the right loin, vomiting, constipa- tion, cough and expectoration and loss of weight, and slight hemoptysis 1 week before. The provis- ional diagnosis was pulmonary miliary tuber- culosis and pregnancy. The positive findings were a few bad teeth in the upper jaw, moist scattered rales on both sides of the chest; fundus uteri 1 cm. below the umbilicus; fetal movements felt, fetal heart sounds not audible. Urinalysis showed many pus cells, clumped; smear showed B. coli. Cystoscopic report was: trigone and post-urethra congested, both ureteral orifices small and con- gested. Pyelography of the right side showed dilated ureter, distorted, and enlarged pelvis and calyces. On July 14, an indwelling catheter was in- troduced and on July 19 she gave birth to a live premature baby who expired in a few hours. After this the patient began to improve; tempera- ture came down to normal and she was dis- charged as improved. This was primarily a severe case of acute pyelitis of pregnancy, the physical findings of the chest misled us and prompt urologic examination and treatment were not instituted. We believe that introduction of indwelling ureteral catheters and continuous drainage and irrigation of the renal pelvis would favorably change the progress and outcome of the case. Many cases of pyelitis of pregnancy are recurrences of old childhood in- fections, therefore the pediatricians should not be satisfied with apparent cure of pyelitis in children, but urologic examination should be made before they are pronounced cured; for, in pyelitis, as in syphilis, the residue is appalling. After the patient is discharged, a follow-up system should be instituted, as delivery does not Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 79 cure the urinary infection; postpartem pyelo- ureterograms demonstrate that distention of the kidney pelvis and ureters and obstructions have been found months, even years, after delivery. Dr. HekimJan stated that failure to diagnose pyelitis may be due to neglect of a careful urin- alysis or to the fact that few symptoms refer- able to the pelvis of the kidney become manifest; in using indwelling catheters, their size must be gradually increased in order to give continued drainage. Dr. Schulman has noted that in most cases the the pyelitis clears up after the patient gives birth, as shown by pyelograms. Dr. Luippold. A Case of Congestive Heart Fail- ure with Thyrotoxicosis. Patient, a housewife, aged 29, entered the hospital October 9 com- plaining of extreme dyspnea, orthopnea, restless- ness, anxiety and agitation. She was. made aware she had a heart disorder 11 yr. ago following an injury to the chest. No further trouble with her heart, however, until 6 % yr. ago when she be- came pregnant; in addition to her cardiac dis- tress at this time, there developed a marked edema of the lower extremities. A spontaneous abortion occurred at 2 months and it was neces- sary to dilate and curette, for- it was incomplete. There ensued a period of cardiac tranquility for 2%yr., after which there was another pregnancy, this time carried to full term. During this period there was no edema, but her heart gave more trouble than ever before and it was necessary to take medicine to relieve the dyspnea. After de- livery. which was normal except for some diffi- culty with a retained placenta and loss of much blood, the patient was invalided for months; in fact she never did recover former strength. Bight months after delivery, she had a “heart attack” lasting a few days, which was very sim- ilar to her present symptoms. Three months later she once more became pregnant; this term- inated in a miscarriage at 6 months in January, 1928. Following this the patient was weaker than ever. There was marked dyspnea, orthopnea, cyanosis, extreme restlessness, gasping for air, and a tense and anxious expression. Eyes prominent, mod- erate exophthalmos, but the other signs of ex- ophthalmic goiter not in evidence; pupils con- stricted but equal, reacting normally. The neck showed visible pulsations on either side and dis- closed a systolic, carotid thrill and murmur on the right side, with right jugular dilated and en- gorged. There was no thyroid enlargement. The chest showed a wildly tumultuous apex beat and heart action — visible beating over the entire chest. The tachycardia was extreme — 160-200. No murmurs could be made out. Systolic sound weak, diastolic accentuated and snappy. Pulse scarcely perceptible. Lungs normal. The ab- domen was not enlarged, but the liver was palp- able to about 3 finger-breadths below the R. C. M. and disclosed pulsations. There was slight edema about the ankles and hands. Laboratory findings: Blood count and urinalysis showed nothing abnormal. Wassermann negative. Icteric index 30. Van der Berg immediate direct reaction — moderate. Basal metabolism 1-48. Patient was given morph, sulph. and powdered ■digitalis leaf; initial dose of the digitalis was 9 gr. Within 4 hr. the pulse became more distinct and slowed down to about 90. Next day the pa- tient was in great distress with nausea and vomit- ing and a choking tightness in the chest, but the heart rate had come down to 72, and pulse was of good quality but irregular, with premature contractions. A systolic murmur was now easily heard; most marked at the apex. The excellent response to treatment was also evidenced by a urinary output of 103 oz. during the first 24 hr. Because of the pronounced susceptibility to digi- talis, its dosage was cut at first to 3, then 2 gr. per day, and this seemed to be all that was neces- sary as a maintenance dose during the rest of the hospitalization. The response to morphin was also excessive, as shown by the undue somnolence. Patient gradually rallied in strength and about 3 weeks after admission she was allowed out of bed and limited exercise, and was content and in- sisted upon going home. Adopting the classification of the American Heart Association, this case was diagnosed as: (a) Etiologically, probably rheumatic but super- imposed upon which there is undoubtedly a thyrotoxicosis. There is here probably a long standing chronic exophthalmic goiter so mild that it is not recognizable, in which there are acute exacerbations, induced by pregnacies and other severe strains, (b) Anatomically: Enlarged heart with a mitral and tricuspid insufficiency, (c) Physiologic: Normal sinus rhythm with a sys- tolic murmur most marked at apex, (d) Func- tional: Class 2-B, that is, a patient having organic heart disease, unable to carry on in less than or- dinary activity without discomfort. Dr. S. Africano. Diabetic Coma Complicated by Acute Suppurative Nephritis. Mrs. L. T-, Swiss, aged 5 2, occupation mender, admitted on Novem- ber 25, at 11 a. m. in coma and died at 11.14 p. m. same day. Five years ago the patient was told she had diabetes. "Was never in coma before. She had polyuria, polydypsia and headaches. Patient was gradually becoming drowsy since noon of November 24; by midnight she was unable to answer when called and lapsed into coma; in coma approximately 13 hr. before receiving treat- ment. She had been given 25 units of insulin by a physician Yz hr. before admission. Autopsy findings: Both kidneys of average size and on section the surfaces presented many nodu- lar protrusions which upon stripping the capsule were found to contain purulent material. On section both cortices and medulla presented fre- quent scattered areas of hemorrhages and puru- lent exudate. The pelvis of the kidneys injected but not enlarged. Sections showed marked de- generative changes of both tubules and glom- eruli with localizations of columnar cells in abscess formation. Section of the pancreas showed fatty infiltration and here and there fibrosis of the islands of Langerhans. In this case we have 2 reasons for the failure of insulin. One is that the patient was in coma for several hours before receiving treatment. The other is the complication of suppurative neph- ritis, which undoubtedly was the main factor. It is well known that any infection in a diabetic is a serious matter. It frequently precipitates the coma even in mild cases, and is particularly dan- gerous in a neglected or undiagnosed case. The infection lowers the tolerance of a diabetic pa- tient for glucose. Among the serious complications which may produce fatal coma are hypertension, arterio- sclerosis, nephritis, gangrene, septicemia, furuncu- losis aind tuberculosis. Dr. Dalven. Study of 3 Cases of Nephritis. Dr. Dalven discussed at length the various classifications of neuphritis, their symptoms and signs, and the laboratory findings, and reported 3 case histories. 80 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 JERSEY CITY MEDICAL CENTER Joseph Binder, M.D., Secretary The regular monthly meeting of the Medical Staff of tlie Medical Center of Jersey City was held on Thursday evening, December 11, at 8:45 p. m., in the Out-Patient Department. Dr. Charles B. Kelly, presiding. Present : Drs. O’Hanlon, Kelly, Binder, Burke, Jaffin, Houghton, Harter, Sprague, Winter, Friele, Hall, Schneckendorf, B. Kelly, Rundlett, De Fuccio, White, Siegler, Fineberg, Brophy, Perkel, Faison, Street, Cohen, Sullivan, J. Connell, Christian, Yaehnin, Hasking, Daly, Residents and Interns. Motion made and seconded that all rise and stand in silent prayer for one minute in respect to our departed colleague, Dr. J. R. Commorato. The Commorato Memorial Committee read its report, which was accepted and ordered be spread in full upon the minutes. (See Obituaries) Scientific Session Dr. Jaffin. Abdominal Angina. Tissier, of Lyons, France, in 1924, noted intestinal symptoms due to peri-aortitis. These symptoms were colicky pains, associated with diarrhea or constipation. Others noted that this pain was increased on ex- ertion or after eating. These symptoms very fre- quently simulate those seen in the ■ surgical abdo- men, and patients are therefore not infrequently operated upon for gall-stones, with nothing being found at operation. One must always bear in mind that abdominal pain in the old may have a medi- cal basis, i. e. anginal in character. The general regimen in these cases is to instruct patients they are to avoid any physical exertion, and not to over-eat. To prevent or relieve anginal pain, nov- atropin has been used, and has served to relieve the arterial spasm during attack. Drs. White and Macchi presented a case of Chronic Intestinal Obstruction for further diagno- sis. The points of interest here were dilatation of the stomach, and visible peristalsis. Dr. Perkel studied the radiograph of the G. I. tract and stated that he felt that there was a chronic partial obstruction about the duodenum, and also a spastic rectum. Dr. Jaffin felt that this case should receive fur- ther medical study because this might be a func- tional condition. Dr. Burlce stated that this patient gave him a definite ulcer history, and he believes that the ob- struction is due to an organic lesion, i. e. ulcer. The marked loss in weight, down to 93 lb., is im- portant. This patient also presents a spinal de- formity, and gives history of previous laparotomy for adhesions following a cesarian section a few years ago. Dr. Burke and Dr. Shanik. Acute Pancreatitis. E. W., white, male, 42, foreman, admitted August 2. About 3 hr. before admission, patient was seized with severe sharp colicky pain in R.V.Q., well lo- calized, non-radiating, accompanied by nausea and forced vomiting. Pain had persisted since onset without any relief. Previous attacks for past 10 years, at intervals of 6 months to a year, but never as severe or of such persistency. During the in- terval between attacks, patient was entirely free of pain. No G. I. disturbances, no epigastric dis- comfort, no eructations or flatulence, bowels reg- ular. Abdomen scaphoid, no palpable masses; rigidity of upper right rectus muscle with marked tenderness on superficial pressure; spasticity and rebound tenderness present. Provisional diagnosis was perforated peptic ulcer; cholelithiasis with cholecystitis. Operation disclosed a good number of stones, black in color and varying from the size of a grain of hemp seed to that of a cherry stone; a stone of small cherry size impacted in the cystic duct. The glands about the common duct were as large as hazel nuts. The serous covering of the gall-bladder was not much changed in appearance, but the mucosa was greatly swollen and extremely friable. Nine days later, both drains removed. Dakin tube inserted, shortened 2 days later, and finally removed in G days. Patient had unevent- ful course and was discharged after 20 days. Patient readmitted after 3 months. Began to be troubled with a dull pain in the epigastrium, 4 days before admission, and had been getting pro- gressively worse until now it felt like the “pres- sure of a foot in the abdomen"; pain constant, radiating to the back, not to the shoulders, asso- ciated with vomiting; had vomited 4-5 times before admission. Provisional diagnosis of acute pancreatitis. At this operation found dense adhesions between the liver and the parietal peritoneum, fibrinous ad- hesions between the liver, stomach and duodenum. There was a greenish edema about bile-ducts and duodenum, and a similar edema at the base of the membrane over the pancreas. Adhesions between stomach and duodenum divided by sharp dissec- tion— adhesions about duodenum separated with finger. Edematous tissue about head of pancreas opened bluntly and 1 rubber tube drain placed to lateral side of duodenum. Gastrocolic membrane opened and edematous tissue over pancreas broken open. Patient relieved, feels fine; 12 days postoperative. Slight spasticity of lower abdomen with exquisite tenderness on slightest pressure over abdomen, especially on lower quadrant. Tympanitic, no demonstrable fluid. Operation — Dr. Burke. Fibrin deposits over vis- cera in R. L. Q. Perforation closed by 2 layers Lembert sutures, and a curtain of omentum was stitched over the repair for additional security be- cause of friability of the tissues. Two rubber tube drains inserted, one in pelvis and one in ileo-cecal region. Patient on strict regimen. Temperature dropped to normal the following day, and has remained normal since. Pulse 100. Dr. Doran gave a brief resume of 6 cases of Acute Pancreatitis. There were 2 females and 4 males; 3 deaths, 2 females and 1 male. Two gave gall-bladder his- tory; 2 no gall-bladder history; 2 had gall-bladder removed previously. In 1 case findings showed a bloody fluid; 2 had turbid fluid free in abdomen; 3 had fluid, bile-stained, localized about the pan- creas. There were 2 autopsies; 1 showing a large hemorrhage in head of pancreas, and 1 necrosis of the tail of the pancreas. Dr. De Fuccio showed the pathologic specimen from a child of 6 months, who died with history of persistent cyanosis without physical signs. Path- ology of heart showed persistent, patent foramen ovale. Drs. Burke and Perkel presented a case of Gas- trojejunal Ulcer. Male, 22 years old, chronic drinker, admitted 2 years ago with duodenal perforation after beer drinking fest. Operation at that time was an- terior gastro-enterostomy. Patient did well until May 1930, when he experienced sharp sudden pain. Admitted to ward, treated medically, and discharged improved. Readmitted July 17 and again treated medically. Finally, patient was admitted to sur- gical service. Radiograph by Dr. Perkel showed a marginal ulcer at site of original gastro-enteros- Jan., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 81 tomy. Operation by Dr. Burke. Gastro-enteros- tomy unhitched and closed, ulcer sutured and re- inforced with piece of omentum. The enterostomy portion of the tube was closed and dropped back into abdomen. Thus far patient doing nicely. A lively discussion ensued on this case as to the type of original operation. Meeting adjourned at 11.30 p. m. to collation in hospital dining room. MERCER COUNTY A. Dunbar Hutchinson, M.D., Reporter The Mercer County Medical Society held its annual meeting in the Carteret Club on Decem- ber 10, Dr. J. S. Vanneman presiding. The minutes of October and November meet- ings were read and approved, after which Mr. Woodruff, of Rutgers University Extension Course was granted the privilege of the floor, and an- nounced the continuation, under previous ar- rangements, of the Post-Graduate Lectures. The Treasurer submitted his yearly report, which, after being audited by the Committee, Drs. Connelly, Yazujian and Weisler-, was certified as correct, and the Treasurer highly commended for his efficiency, sagacity and judicious manage- ment of the finances of the society. Motion was carried that on and after Decem- ber 10, 1930, all applicants elected to member- ship, shall be elected as associate members, and at the expiration of 1 year they may become eli- gible to active membership. Drs. Applestein, Cohen, ITaney, McGuigan and Blanton were regularly elected. The following applications were read and will take the usual course: Drs. Harry R. Aronis, Her- man Cohen, Morton Reese-Cohen, Thomas V. Murto, Joseph Ragany and Peter J. Warter. The request of Dr. G. M. Frank for transfer to Essex County was granted. The following officers were elected: President, Nathan Swern; Vice-President, Wm. L. Wilbur; Treasurer, H. R. North; Secretary-Reporter, A. D. Plutchinson; Board of Censors, Wm. G. Schauf- fler; Member of Nominating Committee, James J. McGuire; alternate, H. R. North. Delegates: J. S. Vanneman, IT. R. North, A. D. Hutchinson, B. D. Lavine, Nathan Swern, IT. D. Beilis, W. E. D’Arcy ; Alternates, C. R. Sista, N- B. Oliphant, J. M. Schildkraut. A communication from the Executive Secretary relative to the Merchantile Finance Corporation of New Jersey was received and filed. A communication from Health Officer Dr. Alton S. Fell, with reference to Infant Mortality in the City of Trenton, was read and following discus- sion, the President appointed the following com- mittee to confer with the Health Officer on this vital subject: Drs. J. J. McGuire, H. M. Rowan, A. W. Atkinson, Wm. J. Harman, Wm. R. Little and L. L. Friedmann. The President, Dr. Swern, appointed Drs. Sica, Scammell and J. H. McCullough, Sr., to draw reso- lutions relative to the Compensation Bureau. Following a very thorough discussion of Senate Bills 304 and 262, by Dr. McGuire, the Society voted to go on record as opposed to these bills, and that the Senator and Assembly Representa- tives from this District be so notified. The President appointed Drs. Scammell, Mitchell, Wilbur, Purcell and Vanneman as a Legislative Committee to act in conjunction with the State Welfare Committee on Legislation. MIDDLESEX COUNTY William C. Wilentz, M.D., Reporter The Annual Meeting of the Middlesex County Medical Society was held on Wednesday night, December 17, at Pfaff’s Restaurant, Metuchen, with an excellent attendance. The membership committee reported favorably on the application of Dr. Smith, of New Bruns- wick. On motion of Dr. McKiernan, seconded by Dr. Spencer, this application was passed by the society. Dr. Johnson read the Treasurer’s Report for the year and showed our society in very good financial condition. He stated, however, that there were several members who were not paid up in their dues and warned them that they would be dropped from the roll if the matter was not taken care of immediately. A motion was made and seconded that the so- ciety pay for the expenses of this dinner and the entertainment. The motion was passed. The application of Drs. Toy, of Milltown, and Fishkoff, of Perth Amboy, were read and refer- red to the Membership Committee. A communication was read from the Red Cross asking the society to purchase a Health Bond and in that way give a donation. On vote, the society decided not to buy the bond. A motion was passed to the effect that the Pro- gram Committee investigate the feasibility of holding all of the county meetings in one place, and of having the meetings in the evening, as well as combining social events with the meeting. The Nominating Committee forwarded the names of the following as officers and delegates: President, William McCormick, Perth Amboy; Vice-President, Robert McKiernan, New Bruns- wick; Secretary, Samuel Berkow, Perth Amboy; Treasurer, Frank C. Johnson, New Brunswick. Delegates: Joseph Mark, Woodbridge; Frank C. Johnson, New Brunswick. Nominating Delegate: F. C. Johnson; Alternate, J. Mark. Dr. Brown, the retiring President, gave a short talk in which he thanked all the members for their support during the year and also thanked the officers for their great assistance in making the past year a very successful one. Dr. McCormick then occupied the chair and asked Dr. J. V. Smith to introduce Dr. Grattan who was the speaker of the evening. Dr. Grattan, who is Chief Consultant Plastic Surgeon to the Allied Hospitals in New York City, delivered a splendid and most interesting talk on treatment of old scars and deformities of the nose. His talk was illustrated by lantern slides. The society gave Dr. Grattan a rising vote of thanks for his most interesting talk. Professional entertainment and a delicious sup- per were catered to the society. S2 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 Medical Section Rutgers Club J. H. Rowland, M.D., Secretary The regular monthly meeting of the Medical Section of the Rutgers Club was held on Friday evening, December 19, at the Elks’ Club, New Brunswick, Dr. Klein presiding. There were 30 members, friends and guests present. There being no business to transact, the speaker of the evening was immediately introduced. Dr. Harry Koster, of Brooklyn, spoke on "'Spinal An- esthesia”. Dr. Koster emphasized contraindica- tions for spinal anesthesia, which are: cerebellar tumor, infection along the site of spinal injection, and types of fractures of the skull with pressure symptoms. He mentioned many reasons why spinal anesthesia was of choice in any operation and spoke of the more complete and normal re- laxation, lessening of complications, and safety of its use with particular relation to paralysis of the respiratory center. Dr. Koster, who is very en- thusiastic about the use of spinal anesthesia, bases his opinion on experience in 7000 cases. Spinal anesthesia was illustrated, together with various types of operations, by moving pictures. After the meeting the , members adjourned to the dining room, where they were entertained by the hosts of the evening — ‘Doctors Gruessner, Gutmann, Haight and Haywood. MONMOUTH COUNTY Wiliam Von Oelisen, M.D., Reporter The annual meeting of the Monmouth County Medical Society was held at the Country Inn, Freehold, December 9, with the President, Dr! James A. Fisher, in the chair. Minutes of the previous meeting were read and accepted with minor corrections. The applications of Drs. Douglas, Haines and Levine were presented and on motion of Dr. O. K. Parry, seconded .by Dr. W. W. Beveridge, it was voted that these applications would have' to take the course as laid down in the new state by-laws; that is, that the secretary must, write to the Biographical Department of the American Medical Society for any material they may have relating to the applicants. The application 'of Dr. Millard B. Ervin, of Matawan, for permission to join the Middlesex County Medical Society was granted. On motion of Dr. J. C. Clayton, seconded by Dr. Brown, it was voted that the secretary be em- powered to have copies printed of the “Code of Ethics” and a fee schedule, to be sent to all present members and to all new applicants. The resignation of Dr. H. B. Slocum, as of June 3, 193 0, as a Delegate to the State Society was read and on motion of Dr. W. K. Campbell, sec- onded by Dr. Warner, it was voted to accept this i esignation and that Dr. "W. G. Herrman be ap- pointed in his place, the appointment to be en- acted as of the date of Dr. Slocum's resignation. The Nominating Committee reported as fol- lows: President, William K. Campbell, Long- Branch; Vice-President, Stanley Nichols, Long Branch; Secretary, Daniel F. Featherston, As"- bury Park; Treasurer, Robert E. Watkins, Bel- mar; Reporter,. William Von Oehsen, Bradley Beach; Board of Censors, John C. Clayton, Free- hold; Samuel Hausman, Red Bank; and William G. Herrman, Asbury Park. Delegate to State Society for 3 years, W. G Herrman, Asbury Park; Alternate, J. C. Clayton. Dr W. G. Herrman was also designated as member of the Nominating Committee from Mon- mouth County. I J he Secretary was instructed to cast one bal- lot for election of the entire ticket. Dis. Warner, Bryan and Beveridge spoke at length on objections to the Abell Committee Re- port and Senate Bill 304, and on motion of Dr. James A. Fisher, seconded by Dr. W. H. Fair- banks, the secretary was ordered to write to the State Senator, Assemblmen and others, stating their objections. Dr W. K. Campbell appointed as an Educa- tional Committee to act on the Post-Graduate ourse of Instruction, arranged by the State .Medical Society and Rutgers University, Altschul 1 To ut, and Featherston. The treasurer reported for the year of 1930 as follows: Bank Balance from previous year .... $ 213 14 Total received in dues for 1930 1 6 3 o!oo •total funds .... .... $1843 14 Expenditures for 1930 ! !!!! 1706 34 Balance on deposit Dec. 9, 1930 ITTmlso A turkey dinner was served to the 35 members present. Marcus A. Curry, M.D., Reporter A regular quarterly meeting of the Morris rwl ynMe?iCal Society was held the evening ol Decembei 18, in the recreation hall of the cafe- teria building at the New Jersey State Hospital at Greystone Park; the society enjoying the privil- ege extended by the Board of Managers and Chief Executive Officer Dr. Curry. President Sutphen presided over a gathering of more than GO in- < hiding members of the Summit Medical Society also Dr. VanBuren, of New York, and various newer members of the medical staff of the in- stitution. Routine business included the reading and ap- proval ot minutes of the annual meeting in Sep- tember, a special meeting in November, the pro- ceedings of meetings of the executive committee- a floial tribute to late member Noble PI. Adsit ol Succasunna, who passed away November 22’ and the appointment of a committee on me- morial resolutions; also conferences with the county Board of Chosen Freeholders in reference o the coroner situation and indicating their willingness to cooperate with the society. The resignation of Percy L. Smith, now prac- hemg ip Utica, New York, was received, and the secretary also reported Dr. Weisenhoffer, recently resigned of Schenectady, New York, now eligible for membership in that county society. Dr. J Henry Harrington, of Rockaway, was proposed for membership; this being duly re- fened to the credentials committee. Dr. Young reported having audited the Treas- 111 ers books and found them correct. Dr. Sher- JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Jan., 1931 man, for the Committee on Public -Relations, re- ported progress. Dr. Lathrope reported that the Committee on Revision of Constitution and By- Laws had completed the work, a copy of the adopted revision being' in the hands of the mem- bers, and suggested that the committee be now discharged. The event of the evening was a paper by Dr. William Barclay Parsons, of the Presbyterian Hospital Medical Center, New Y'ork, the topic being “Indications for Surgery in Diseases of the Thyroid". Dr. Parsons presented his subject in a manner that immediately invited and held the interest of his audience. The introductory was that in the treatment of the various diseases of the thyroid gland, various methods are in use; involving doing nothing, the use of iodin, gland- ular extract, radiotherapy, and operation; sur- gery probably has the wider application than any other single form of treatment, being called upon in the infections, tumors, and some of the dis- turbances in physiologic function. Dr. Parsons covered in an able and detailed way, infections, neoplasms, adenomas, and indicated surgery to drain an abscess of the thyroid gland; to remove localized tuberculosis; to relieve pressure from an adenoma or Reidel’s struma; in carcinoma and other malignancies; in adenoma without hyper- thyroidism, to improve the appearance, to aid or prevent pressure, and to avoid the development of hyperthyroidism and carcinoma; also in cases with hyperthyroidism as a method with a high percentage of cure and a low element of risk, particularly as a safeguard before cardiac damage has occurred, or in the presence of cardiac dam- age, to effect improvement in symptoms and in- terrupt the vicious cycle. The paper was enthusiastically received and the discussion was extensive; those taking part being Drs. VanBuren, Curry, Larson, Pickney, Frost, Glazebrook, Lathrope, McMahon, Rice, Ward, Tiedeback, Collins, Young, Rubin, Thomas, Emory and Abell. PASSAIC COUNTY Wayne W. Hall, M.D., Reporter The December meeting of the Passaic County Medical Society was held at the Health Center, Paterson, December 10, at 8.30 p. m., Dr. Joseph Morrill presiding, with 70 members present. The minutes of the November meeting were approved as read. The Censors’ report approved the applications of the following doctors: S. Rosa Frank, 365 Park Ave., Paterson, and Jacob Warren 666 Broadway, Paterson. The following applications were re- ceived and referred to the Board of Censors foi investigation; Morris S. Joelson, 122 Paterson St., Paterson, and F. R. Palmer, 27 Monroe St., Passaic. Bills S. 262 and 304, proposing to place all Boards of Examiners under control of the State Board of Education, was discussed. As the passing of this law would require the turning over of all monies to the State Treasury, the State Medical Society should oppose it because of the loss of funds with which to combat illegal practice. It was moved and seconded that a letter protesting this be sent to our legislators. Prof. John H. Stokes, head of the Department of Syphilology and Dermatology at the University of Pennsylvania Medical School, and formerly connected with the Mayo Clinic in a similai capacity, and author of “Modern Clinical Syphil- ology’', one of the best written authoritative texts in the English language, spoke on “Preventing the Transmission of Syphilis by Control of In- fectiousness”. Dr. H. H. Lucas, of Paterson, reported on the establishment of a Psychiatric Clinic in the Gen- eral Hospital. After much interesting discussion of these highly appreciated papers the meeting adjourned. UNION COUNTY Westfield Medical Society Frederick Adrian Kinck, M.D., Reporter The December meeting of this society was held at the home of Dr. George S. Daird on December 9. A full representation of members was present. As President iSalvate was ill, Vice-President Lowell presided. After the regular routine business, Dr. Louis G. Newman read a very interesting paper on “Heart Lesions”. The discussion was very spirited as to how much should be told the patient, whether he could take better care of himself and cooperate with his physician, or whether he would be so frightened his condition would become much worse. Refreshments were served and the meeting ad- journed after a vote of thanks to Dr. and Mrs. Laird for their hospitality. Obituaries HEDGES, Benjamin Van Doren, of Plainfield, died at his home November 2, 1930, after an ill- ness of 2 weeks’ duration. Dr. Hedges was 65 years of age and had been suffering from a cardiac affection for several years. He was born in Trenton, the son of Joseph E. Hedges and his wife Ann Elizabeth Van Doren. He was graduated from Princeton University in 1888 and from the College of Physicians and Surgeons of New York in 1892, and began his practice here in 1894. He was a member of the American College of Surgeons, American Medical Association, New Jersey State Medical Society, consulting surgeon of Muhlenberg Hospital, Plainfield, and Bonnie Burns Sana- torium, of Union County; former president of the Society of Surgeons of New Jersey, the New Jersey 1 State Sanitary Association, the New Jersey State Pediatric Society, the Plainfield Board of Health, former member for 17 years of the Plainfield Board of Education and former member of the Plainfield Public Library Board. Resolutions of the Union County Medical So- ciety : In the passing of Dr. Benjamin Van Doren Hedges, the Union County Medical Society has lost a loyal and valuable member. For a quarter of a century he has been one of the outstanding members of this society. His scientific contributions were always of the highest order and he stood for the highest ideals in medicine. 84 Journal of the medical society of new jersey Jan., 1931 Therefore, be it resolved: that our sincere sym- pathy be extended to his bereaved family, and that the society attend his obsequies. Be it further resolved, that these resolutions be spread upon the minutes of the society, that a copy be sent to his family and to the press. Signed: Norton L. Wilson Harry V. Hubbard Watson B. Morris COMMORATO, John, of Jersey City, the per- sonal physician to Mayor Frank Hague, and a member of the Staff of Jersey City Hospital and of St. Francis’ Hospital, died in the last named institution on November 30, at the age of 45 years. Resolutions on Death of Dr. Conumorato At a special meeting of the Director and Medi- cal Staff of the Medical Center of Jersey City, held December 2, 1930, the following resolutions were unanimously adopted: Whereas, in memory of the loss suffered by the death of our associate, John R. Commorato, M.D., we recognize again the uncertainty of human af- fairs and desiring to express our appreciation of the faithful and able manner in which he has at- tended the sick as Visiting Physician during the many years he has been connected with our in- stitution ; be it Resolved, that in the death of Dr. John R. Com- morato the Medical Center of Jersey City mourns the loss of skilfull and conscientious colleague. Desiring to convey to his family this testimony of our regard and appreciation, it is directed that a copy of these proceedings be sent to them and also that they be entered in full on the records, as a perpetual Memorial of the love and esteem in which he was held by the Director and Medical Staff. Committee: Drs. Rundlett, DeFuccio and Von der Leith. McCORMICK, Daniel L., of 9 Tichenor Street, Newark, was killed in an automobile accident on the highway between Trenton and Princeton, No- vember 27, as he was returning home from a Thanksgiving Day family reunion. Dr. McCormick was born in Elizabeth in 1874 the son of the late Judge Thomas F. and Elizabeth McCormick. He was educated in Seton Hall Col- lege, and was graduated by the College of Physi- cians and Surgeons in New York about 35 years ago. He practiced medicine in Jersey City 6 years and 28 years ago came to Newark and opened an office in Mulberry Street. Later he moved to West Kinney Street and for the last 15 years his home and office have been at 9 Tichenor Street. D* • McCormick was appointed a member of the Newark Board of Health by the late Mayor Ray- mond when he took office January 1, 1915 and was reappointed 2 years later. He was one of the Mayor's .physicians and also was the physician of The Newark Evening News for its employees During Dr. McCormick’s service on the Board of Health, between January 1915, and November J917, he was chairman of the sanitary committee. Dr. McCormick was a member of the Academy of Medicine, Essex County Medical Society, the Medical Society of New Jersey and the American Medical Association. Resolution ol’ Camden County Medical Society on the Death of Dr. Dowling Benjamin “Whereas: Dr. Dowling Benjamin who has honored the Medical Profession with unswerving allegiance to its high ideals, and with tireless ef- forts for the afflicted under his care, as well as with citizenship that was unselfish and thought- ful, has been called from this earthly life; there- loie be it Resolved that we, his fellow practition- ers in Camden do hereby give expression of sor- row in his passing. 1 he notable career of Dr. Benjamin is worthy of our sincere commendation; and a few of the High Spots or activities may be properly refer- red to herein. As an original member of the Cooper Hospital staff, he is credited with the first introduction of surgical asepsis in said institution. In 1882 he was responsible for the rejuvenation of the Camden City Medical Society, which fact led to the many years of prolific charity through the present Camden City Dispensary; as well as fur- nished the medical profession with a permanent hall for our meetings. He was a prominent factor m obtaining an artesian water supply for Cam- den which literally stamped out typhoid fever. His personal influence with Mr. Andrew Car- negie was responsible for the erection of the Main Library of our city. water, also a Lecturer in th- Medico- Chirurgical College of Philadelphia; an. was very conspicuous as a medical expert in ou local Courts, as well as the Philadelphia Courts and by local practitioners he was considered to b. the best read man in our professional circle. Be it further Resolved: That a copy of thes. lesolutions shall be entered upon the minutes oi . . society, and a copy of the same be forwarder to the family of our deceased member. Signed, H. F. Palm, M.D. A. Haines Lippincott, M.D. Alexander MacAlister, M.D.” MORbE, George Vane, of 70 Watsessing Avenue Bloomfield died December 12 at the Homeopathic Hospital, East Orange, after an illness of a month He was 42 years old and had practiced medicine in Bloomfield 15 years. Dr. Morse began his practice in Bloomfield after graduation from the University of Michigan and the New York Homeopathic Medical College and Hospital. He served during the World War in the Medical Corps of the American Expeditionary Forces in France. Upon his return he specialized in surgery. As a surgeon he became well known in Essex C ounty He was a member of the Essex County . ledical Society, the New Jersey State Medi- cal Society an the American Medical Associa- tion, and was a former president of the Associated i nysicians of Montclair and vicinty. He served on the senior surgical staff of the Homeopathic Hospital, in the out-patient depart- ment of the Mountainside Hospital, as consulting obstetrician to the Community Hospital, Mont- clair, and as an honorary member of the staff at St. Vincent’s Hospital, Montclair. 85 Journal of The Medical Society of New J ersey Under the Direction of the Committee on Publication Vol. XXVIII., No. 2 ORANGE, N. J., FEBRUARY, 1930 RECURRING POSTOPERATIVE PAROTITIS Harold S. Davidson, M.D., Associate in Medicine, Atlantic City Hospital, Atlantic City, N. J. Parotitis as a postoperative complication is not unusual but its occurrence twice in the same patient after 2 clean abdominal operations is unusual enough to warrant a report. The pa- tient was operated upon by cesarean section for contracted pelvis 5 years previous to the second operation. Immediately after the first operation left parotitis, developed, and went on to suppuration, necessitating incision and drain- age. She was so extremely ill that her sur- geon advised her not to conceive again, but 5 years later she consulted me because she had missed a menstrual period and feared she was pregnant. Examination confirmed her sus- picion. Acting upon the advice of her sur- geon, she was referred to Dr. D. B. Allman, at the Atlantic City Hospital, who, under gas and ether anesthesia, performed a therapeutic abortion, removed a right cystic ovary, tied off both fallopian tubes and removed a normal- looking appendix. The patient reacted very well from the operation, having but little dis- comfort, taking liquids and being free of fever. During the night of the second day after operation she developed a chill, fever of 103° F., and pain and swelling of the left parotid gland. Ice was applied. The gland continued to swell, became red, and dysphagia appeared ; due to the encroachment of the mass on the lateral wall of the pharynx. The leukocyte count was 13,500. After 5 days, pointing appeared, and the gland was incised but only a few drops of serosanguineous material were expressed. Un- fortunately, a culture was not made. She made an uneventful recovery. Most writers on this subject believe that the infection occurs as either an ascending infec- tion of Stenson’s duct, or from pyemia or em- bolism. Hanan and Pilliet, in 1899, first advanced the idea of ascending ductal infection. They, however, pointed out that inflammation around the mouth of the duct occurred, which was not the case in my patient, nor was pyemia a fea- ture of this case. Paget, quoted by Lynn (Surg. Gyn. & Obs., 34:367, 1922), believed that secondary parotitis was sympathetic, basing his opinion on the occurrence of changes in the gen- erative organs during epidemic mumps. This, as an etiologic factor, has largely been discarded, however, since it now is known that parotitis is not any more common a complication of pelvic than of intraabdominal conditions. Deav- er suggested that traumatism during anesthesia might be a factor, but Lynn points out that many cases in which forcible manipulation of the jaw is necessary do not develop parotitis. Again, this complication occurs in abdominal operations performed under local anesthesia. Jones reported a case occurring in a patient with recurring appendicitis; in the first attack the abscess was opened and drained and bila- teral parotitis occurred ; 1 year later the abscess was again opened and drained and again the bilateral parotitis occurred ; the following year there was another attack of appendicitis and this time the abscess was drained and the ap- pendix removed, and again there followed a bilateral parotitis. 80 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1331 Predisposing factors are said to be chronic oral infection and decreased resistance to in- fection due to debilitating diseases. Neither of these factors could be considered in my case; oral hygiene here was excellent and there was no debilitating condition ; in fact, she went to each operation in excellent health. Fecal vomiting has been advanced as a cause (Kaiser: Munchener, Med. Wochsch., 68: 1385, 1921) whereby the bacterial flora of the mouth would be increased. There was no vomiting of any sort by this patient. The high mortality of this complication would speak for the hematogenous route of in- fection, but in pyemic processes with secondary abscesses in various organs the parotid gland is rarely involved. 1 he onset is that of an acute suppurative process. There is usually a chill, abrupt rise of temperature to 103 F. or more and always pain over 1 or both parotid glands. In children there may be delirium. The leukocyte count will reveal a polymorphonuclear leukocytosis ; then swelling and redness appear with trismus and dysphagia. The condition may resolve spontaneously or fluctuation may develop and demand incision. Humphrey and Sherwood (Minn. Med., 11:722, 1928) point out that, because of the very thick gland capsule, fluctua- tion is difficult to elicit and that the surgeon should not wait longer than 48 hours if there is not subsidence of symptoms (Peightal Am. J. Obs. & Gyn., 10:88, 1928). Gangrene of the gland is a possibility. The treatment is preventive, symptomatic or surgical. Collins (Surg. Gyn. & Obs., 10:404, 1919) states that the best preventive measure is to keep the gland actively discharging a current of secretion down Stenson’s duct into the mouth. After trying several methods, he finally concluded that the best was to give the patient an old fashioned lemon candy stick to suck, as acids excite the parotid gland to secrete There apparently is not enough secretion swal- lowed to excite active peristalsis of the stomach or bowels. This precautionary measure was neglected in my case. Since she once before had a complicating parotitis, such precaution might have been a means of preventing recur- rence of the complication. TUBE FLAPS IN RECONSTRUCTIVE SURGERY OF THE FACE Lyndon A. Peer, M.D., Newark, N. J. (From the Plastic Surgery Department, Newark Bye and Ear Infirmary) While the principles involved in making and using pedunculated skin flaps have long been known, it was not until the World War that definite rules for their preparation were formu- lated ; based upon a large amount of surgical experience. In the first operations during the war, trial was made of the then known meth- ods, many of which had been based on 1 case only, the procedures being thereafter assid- uously copied from older books to new with- out test of merit. The main weaknesses of these earlier methods were lack of understand- ing of the necessity for a lining in all mucous lined cavities and the tendency to hurry the operation. To Major IT D. Gillies and his associates belongs the credit of perfecting the tube flaps. This paper explains their prepara- tion and use in practice at the Newark Eye and Ear Infirmary. The photographs show each step in the restoration of a partial loss of the ear. Knowledge of the anatomy and physiology of the skin will aid in selection of .the appro- priate graft to cover any given defect. Most problems of reconstructive work are surgical in character, and a knowledge of asepsis and of the correct handling of tissues is essential. Association with an active plastic surgery clinic is helpful, but the basic principles which under- lie the technical application of plastic pro- cedures are those of general surgery. Thiersch grafts are thin shavings of the epi- dermis including a portion of the germinal layer. Under proper conditions they always grow because the epidermis is normally nourish- ed by lymph from the coriutn, and when cut away and placed on a denuded surface, it again, in the absence of corium, has an abundant lymph supply from the severed vessels of the surface. The Thiersch graft is indicated where a thin covering is desired which is almost sure to “take”. Because it tends to assume a prune-juice color, it is often used to replace superficial loss of skin in burned areas, the Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY S 7 graft blending well with the surrounding dis- colored skin. It is not suitable where deep scars have been removed because scar tissue will again form beneath the graft. Full-thickness grafts include the epidermis and corium, but not the subcutaneous fat. These do not “take” as often as the Thiersch graft because the corium is transferred to a new surface where it must obtain nourishment from lymph until new vessels have grown into its substance. It may be used to repair any skin loss of the face where there is not deep scarring or distortion of the lips or nose. Tissue loss from one eyelid can be replaced by a full- thickness graft from the uninjured one. Tube flaps may be formed on any surface where the skin is loose. They consist of a tube of skin containing its subcutaneous fat layer. The skin is connected at either end with the ad- jacent skin surface, much as the handle is con- nected with the suit case, and the handle, or tube, receives nourishment through each of these attachments. The end which is later to be severed and attached in a new area is called the distal end, and the connection which is left in place to furnish nourishment until the distal portion can support itself, is called the central end. The procedure whereby one end is incompletely divided, and later completely de- tached, is called delaying the tube flap. This is always advisable as it causes the other at- tachment to play a larger part in the tube’s circulation and prepares it for the more radical change when the incompletely divided end is severed. Tube flaps are necessary in the repair of deep scars involving distortion of the lips, nose and ears ; and for actual loss of the lips, nose or ears. Complete loss of the nose is best con- structed from a forehead flap. One should exercise great care in matching the color, hair-bearing character, and texture of the graft with the skin in the area of defect. A white patch of skin from an arm would ap- pear grotesque on the face of a dark skinned individual; in such a case a tube flap from the neck, migrated up into position, would be pre- ferable. Upon these facts the surgeon studies each case, and if the condition is extensive, as with burns of the face, he wisely utilizes a variety of skin grafts. Generally speaking, the sim- plest method of repair is the best, since one may later use a more extensive procedure in case the first fails. Narrow scars not causing distortion are excised and the skin edges brought together. A depression is filled in with fat or muscle rotated in from the sides, with a portion of their blood and nerve supplies attached ; or, where these are not available, a fat transplant from the leg is used. A muscle flap which has lost its nerve supply will atrophy. Cartilage also may be used to fill in defects; clinical evidence of its permanence when buried beneath the skin has been shown experiment- ally by Davis. Flat, thin, burn scars may be replaced by a Thiersch graft and the ectropion corrected by means of a full-thickness graft from the uninjured eyelid. A distortion of the lips and nose or partial loss of an ear must, however, be corrected by a tube flap, taken from the neck, if it is not badly burned, or from a distant part, such as the arm. Technic for Making Tube Flap Preparation. After a suitable location has been determined, keeping in mind the matching of the tube skin with the skin in the area of defect, and the absence of hair where hair is not desired, the surface is scrubbed well with tincture of green soap, washed with alcohol, and then with a mixture of alcohol and ether. Strong antiseptics are contraindicated. Anesthesia. Local anesthesia is used except- ing with children; we prefer 1% novocain with alcohol, and give the injection deep into the buttocks, alternating sites of injection. No other medication was allowed. Tt was noted that in the colored children treated the substance injected remained for 48 98 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 to 72 hours; in some cases as a circumscribed hard area. In white children, the material was absorbed within 24 hours. Among the improved cases, 68 patients re- ceived not less than 4 nor more than 7 injec- tions. Among the unimproved, the 23 pa- tients received from 4 to 11 injections. We were unable through the Dispensary to follow up our patients to see if the improve- ment was lasting. The mothers failed to re- turn as directed ; only 16 returning to state that no relapse occurred. All the children bore the injections well. The age of the patient did not seem to enter into the matter of improve- ment or dosage. In reviewing our experience with this method of treatment, we naturally pause at our failures and try to account for them. Why one case of severe whooping-cough should respond to treatment while an apparently milder case does not, is a problem that still confronts us. To attempt to explain the success or failure of any treatment in any given disease one must turn to the pathology of the disease and to the method of attack by the treatment on that dis- ease. Of the pathologic anatomy in whooping- cough, Osier said — “whooping cough itself has no special pathologic changes”. Holt and How- land say that the only constant lesion of per- tussis consists in a catarrhal inflammation of varying intensity which affects the mucous membrane of the larynx, trachea, bronchi, and sometimes that of the nose and pharynx. The seat of the irritation which produces the cough has been variously located by different ob- servers. The weight of evidence seems to be that in a great majority of cases the source of irritation is in the larynx or trachea. Von Herf, by laryngoscopic examination, found the mu- cous membrane of the larynx to be swollen and congested, and that a paroxysm could al- ways be excited by irritating the mucous mem- brane between the arytenoid cartilages. Removal of mucus from the posterior laryngeal wall shortened the paroxysm. Rossbach reported negative laryngoscopic findings but found a plug of mucus in the trachea which he quali- fied as the cause of the paroxysm. There has been much discussion as to the role of the enlarged tracheobronchial lymph- nodes in the pathology7 of whooping-cough. Laurence W. Smith, reviewing 3000 case his- tories, found that in about 80% of cases there is a demonstrable peribronchial thickening in- volving chiefly the lower branches of the bron- chial tree. During the course of the disease, within 7 to 10 days, there was a demonstrable diminution in the peribronchial shadow7, as shown by Roentgen rays. Concomitant with the peribronchial thickening is an enlargement of the tracheobronchial lymph-nodes. Smith reported recovery of the pertussis bacillus cul- turally in 7 out of 8 fatal cases. He believes that action of the bacillus is a mechanical one, interfering with the normal action of the cilia and possibly leading to their destruction. This might prevent the normal removal of secretion, resulting in a continuous irritation and the characteristic cough. In addition, Smith states the evidence of a mild toxin, as shown by pres- ence of a slight inflammatory exudate, by a lymphocytosis, and by formation of a specific antibody which produces fixation of the com- plement. It seems, therefore, that the accepted patho- logico-anatomic findings in whooping-cough consist of a catarrhal inflammation of the mucous membrane of the upper respiratory7 tract — nose, pharynx, larynx, trachea, and bronchi with a peribronchial thickening that results in tracheobronchial adenopathy. Ether may exert any 1 of 5 actions: (1) an antispasmodic action on the bronchial spasm ; (2) it may act as a sedative on the striated muscle; (3) as an anesthetic to the larynx, thus diminishing irritability of the mucosa; (4) as a sedative or anesthetic to the respiratory center; (5) as an antiseptic and bactericidal agent. In our work in the clinic, on a few7 occasions we noted a distinct ether odor on the child’s breath 15-30 minutes after the injection. Mason reported a similar experience with a few7 of his patients and noted in 1 case that the ether odor persisted for almost 6 hours. It seems plausible that the ether when injected intra- muscularly is absorbed and eliminated or ex- creted in ether vapor through the lungs. Audrain in his original report thought ether by inhalation or by injection exerted an anti- septic and bactericidal effect. Magni thought ether exerted its effect by a combination of its Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 99 antispasmodic, febrifugal, and antitoxic ef- fect ; that elimination of ether through the lungs allowed the drug to reach the most minute recesses, attack the bacteria lodged be- tween the cilia, and affect some moderate de- struction of the bacteria. Magni also thought the ether might stimulate phagocytosis or raise the antibody content of the blood, thus attack- ing the toxin of the bacteria. Genoese believed that ether injected has a specific action on the organisms causing pertussis, as well as relieving the paroxysm and breaking up a tenacious sputum. Ether has been used as an antiseptic to the skin in gynecologic work and Genoese believed that by its elimination through the lungs it acted as an antiseptic to the entire respiratory tract. In summarising, we wish to bring out the fact that our results in a moderately large series of cases seem to bear out the work- done by other investigators abroad and in this country. We feel that with this manner of treatment, ether in oil intramuscularly, there is no danger of abscess or necrosis at the site of injection. We feel, that this treatment offers a definite means of aiding the child with whooping-cough. We offer no explanation for our failures other than the fact that since the treatment was so well tolerated, perhaps larger dosage should be used. We suggest a further study with double the dosage or even larger doses, since it may be that a larger dose will bring even better results. We further feel that in a disease as distressing as whooping- cough, especially in very young infants, any form of treatment which can be easily admin- istered and which gives encouraging results in a fair percentage of cases should be given a trial. Discussion Dr. Arthur Stern (Elizabeth) : About 6 years ago one of my colleagues asked me whether there was anything known that would give his child, and the whole household, some rest at night from the child's incessant whooping-cough spells. I spoke to him about injections of ether intra- muscularly, which I had used in connection with vaccine treatment with good results but warned him of possible skin necrosis. When I met the physician some time afterward he thanked me for my advice and told me that the relief had been instantaneous. In another very severe case o.f, b/.'onchopneu ■ monia, in connection with whooping-cough, treated by another colleague, the improvement was rapid. I have since used the injections in bac) cases and I want to congratulate Dr. Levy on' bis .improve- ment in bringing to us a staple form in his new ampules. I have used them a few times in hospi- tal practice and shall use them again if necessary. Anything as effective as this remedy is a great blessing to suffering children and to their parents, in such a miserable disease as whooping-cough. Dr. Julius Levy (Newark) : In the first place I want to congratulate Dr. Finkelstein for the very fine way in which he has presented this subject, and to make clear that this work has been en- tirely done by him. In appraising the value of this report, an important thing is to be sure of its reliability because, particularly with whooping- cough, we have previously heard of a thousand sure remedies and doctors are justified in being very skeptical of all new suggestions. I would emphasize that we should not become enthusiastic just because we see 1 or 2 children apparently get- ting better, because whooping-cough itself varies a great deal in severity and duration, and it is very easy to believe that the improvement is due to your treatment rather than to the passing of time. I think care has been exercised in estimating improvements and cures, yet I think this skepti- cism is entirely wholesome. It is, therefore, de- sirable to collect as many series, and as large series as possible, in different seasons because all infectious diseases vary a great deal in intensity, severity and duration. It is not uncommon to see several cases of whooping-cough in the same family, one lasting 3 months and another only 3 weeks, so I think we should be very guarded in our estimates of any therapeutic measure. I think it is worthwhile mentioning, on the other hand, the slowness with which we take on new methods. Treatment of whooping-cough by ether injections has been written about considerably for the past 10 years, and it is still not used very ex- tensively in America. While I think it is proper that we should be skeptical, yet, on the other hand, it should not take 25 years for a new idea to be accepted by the medical profession. I think the effect of making a report like this on a very large series of cases is at least to hasten a trial of this remedy. Necrosis is important. We reported 100 cases and indicated that we thought the treatment should be given up because about 25% of them presented necrosis. I discussed this question with a laboratory worker and he suggested putting the ether in oil, in ampules, and since then we have had absolutely no necrosis and no difficulty. Dr. Finkelstein referred to this peculiarity, that it does help some patients and not others. Appar- ently he thinks we have no answer. But Chat does naturally raise a question in our minds as to the direct efficacy of ether in the treatment. After all, it does seem strange that it should be effective apparently in some cases and not effective at all in others. There is no question that in some of the cases it does act almost miraculously, especially — and this is very important — in some of the very small infants. Whooping-cough, of course, is a very grave disease in infants under 1 year. Whoop- ing-cough and measles cause more deaths under 1 year of age than all the other contagious diseases combined. It does seem that in these young pa- tients it is particularly effective. I think that is one of the most encouraging things about it and I feel that all of the men who have an opportunity to try it should 'do so and then report their results. Dr. F. I. Krauss (Chatham) : I wonder if the •va.fyfng -reswi>s that. Dr. Finkelstein shows might not be due to his dosage given intramuscularly be- 100 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1.931 ing too small for the occasional patient. I have not used ether in this way, but use it continually in whooping-cough cases, by intrarectal injection in olive oil, and I find that I can vary the dose from 2 to 10 c.c. once or twice a day according to the severity of the case. Some require 2 "c.c. and others 10 c.c., and I find that my results have depended on the size of dose. That, of course, would be a distinct drawback for the intramuscular injection. It seems to me it would be difficult to give larger doses, for it is a painful method of treatment. I have never used it because I have no public health work. My treatment of whooping-cough is con- fined entirely to private practice and there would be objection by the parents. I would object to giving it every day or so because of the pain, and we know how difficult it is to have mothers agree to a treat- ment that is painful. Dr. A. 8. Finkelstein (Closing) : I have never had any experience using ether by rectum. As far as the dosage is concerned, that is a great problem in treating whooping-cough by injections of ether intramusculai ly. As to its being a painful proced- ure, all patients that were old enough to walk got off the table a few minutes after the injection and walked off. The material is absorbed in 24 hours or sooner. The following day it is entirely absorb- ed, just the skin prick being noticeable. As to giving larger doses, in 10 of our cases I gave 4 c.c.; 5 were improved and 5 unimproved. In a very small series of cases now going on at the City Dispensary I have given as much as 6 c.c., which consists of 3 c.c. ether and 3 c.c. oil. Some showed improvement with 6 c.c., and some with 4 c.c. did not show improvement. There is one point that may be of practical help. In getting the ether out of the ampules it is neces- sary for the syringe and needle to be cold. It does not come out of the ampule easily if the syringe is hot and it is difficult to handle but if the syringe and needle are cold there is no difficulty what- ever. Dr. Hummel : May I ask what preparation you use; and are the ampules on the market? Dr. Finkelstein: They are on the market and are prepared by the Lozier Laboratory. The ether is put up in a bland vegetable oil similar to peanut oil; 12 ampules to the box. NON-PATHOLOGIC OR FUNCTIONAL HEART MURMURS IN CHILDREN* Irving Okin, M.D., Passaic, N. J. (From Pediatric Department N. Y. Post-Graduate Medical School and Hospital, New York City.) There is a large group of children with heart murmurs who are not suffering with cardiac disease. Because this fact is not always kept in mind some of these children are unneces- sarily invalided, their activities are restricted pH — : - ■ V ; ; *(Read at the 164th Annual Meeting of the Medical Society of New Jersey, Sectioji mi ;Pfdiw-. tries, Atlantic City, June 13, 1930.) “ -‘l . •„*’ and they become the objects of undue anxiety. Aside from harmful neurotic tendencies ac- quired by a child stigmatized as a victim of “heart trouble” parents are needlessly alarmed. The ratio of noil-organic to organic murmurs is 3:2, based on the study of many thousands of school children. Many authorities state that noil-pathologic or functional murmurs are rare under 3 years of age. This is not true, for frequently infants I during an acute infection or a septic blood con- dition present cardiac murmurs ; usually soft systolics at the base or apex, which disappear upon improvement of the child’s general con- dition. In the septic cases, autopsies have shown no heart pathology. Peer reports a case of a baby 10 weeks old with sepsis, who before death had a very loud systolic murmur in the pulmonary area and at autopsy no ab- normalities were found in the heart. Jacob- I solin reports the case of an infant in whom a soft systolic murmur was heard over the base ' of the heart at the pulmonic area on the fourth day of life following a severe intestinal hemor- rhage on day of birth; with improvement in the blood picture after treatment the murmur dis- appeared and remained absent after the eighth day. This is the earliest case I have found re- ported in the literature. I have had the opportunity of observing over a period of 3 years 50 children with non- pathologic heart murmurs, in the cardiac clinic for children at the N. Y. Post-Graduate Medical School and Hospital. This study is not yet completed. A recent study at Bellevue Hospital showed that 4 out of 100 cases of non-pathologic murmurs became definite or- ganics after 1 year. None of our series has shown organic changes, but observation over several years is necessary in determining the final outcome of these children. Three of the children in this series have lost their murmurs during periods of 6 months to 1 year. One girl under observation for 2 years with a faint sys- tolic murmur at the apex and no enlargement of the heart has been allowed normal activities ; 6 jpouths ago, .with onset of menses, body G antes'.. ‘ofi tpuUeptv, increase in weight and height, np mynwr \vas heard and there has •’beeji/nvne tijp. tp the present time. Feb.. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 101 Types of Murmurs As a general rule the murmur is a short, soft, systolic heard over the base of the heart in the pulmonic area or at the apex. There are 3 main types : (1) The cardiopulmonary, or so-called res- piratory murmurs. These are heard over the pulmonic area or third to fourth left inter- spaces along the sternum. They vary with respiration, being usually loudest at end of in- spiration and faintest with expiration. These murmurs, changing with position, become louder when the child is lying on its back. Even pres- sure with the stethoscope causes increase or decrease in intensity. This type is very com- mon, comprising 20 to 40% of the non-patho- logic group. (2) Atonic murmurs are heard best at the apex and pulmonic areas and have a soft blow- ing character. They are found especially in asthenic children and have been attributed to a vagus atonia. Dioxades has pointed out that x-ray pictures of these children show a broadening of the heart shadow to the right. There may be loss of tone of the heart muscle, and thereby a relative insufficiency of the mitral valves is caused. In fevers such as scarlet, typhoid, grippe, influenza, tonsillitis and pneu- monia, or almost any acute febrile disturbance, this murmur is not infrequently found. It may suggest endocarditis but with convalescence it disappears. The pulmonic second is never accentuated in the presence of this murmur. These comprise the largest group, 60 to 80%. Hemic murmurs are usually of the same char- acter as these atonic murmurs and are present in anemic children. (3) Venous humming murmurs at the base of the heart, which Palmer and White have recently described in detail, are continuous humming murmurs heard in the supra and in- fraclavicular regions especially on the right side and transmitted to the vessels of the neck — best heard on raising the chin and turning head to the left. The murmur is similar to the one of patent ductus arteriosus and must not be confused with it. Symptoms. The symptoms are seldom car- diac, unless the parent, knowing that the child has a murmur, stresses such symptoms as fa- tigue, pallor and precordial pain. Practically all of our cases were discovered in routine physica’. examinations for other conditions ; mostly pre- liminary to tonsillectomies, or referred bv school authorities with note saying that child has a murmur. Diagnosis. The diagnosis is established by : (1) absence of rheumatic history, chorea, growing pains, repeated acute tonsillitis; (2) consideration of the general condition of the child — malnutrition or anemia or an acute fe- brile condition; (3) size of the heart — no en- largement demonstrable by physical examina- tion radiograph, but shape of the heart in the radiograph is important for if it is of mitral shape or indicates ventricular hypertrophy ac- quired heart disease must be considered; (4) the murmur — its character, time location vari- ability; (5) absence of accentuation of second pulmonic sound, which is always present in acquired or congenital heart conditions; (6) electrocardiographic studies. When the electrocardiograph shows a pre- ponderance of the right ventricle it is assumed the case is one of pulmonary stenosis, which is a frequent congenital defect. Also, left sided defects like patent interventricular defects and patent ductus arteriosus cause a preponderance of the left ventricle. Neither sign is found in non-pathologic hearts. Differential diagnosis. In congenital heart disease, besides the electrocardiographic evi- dence, cyanosis with clubbing of the fingers is almost a regular clinical finding. The mur- murs are louder, rougher and longer (extend- ing into diastole) than the non-pathologic ones. They are found early in life and are persistent. A marked thrill over the heart is frequent and also a chest deformity with ac- companying general lack of development will be present. The acquired murmurs usually have a rheu- matic history, cardiac enlargement accentua- tion of second pulmonic sound and a murmur of definite character, viz : the rumbling, rough or low pitched murmur of mitral stenosis. However, the murmur of mitral insufficiency may be the same as a non-pathologic one. Treatment ( 1 ) Impress the parents that the child is not a cardiac but should be kept under ob- servation for at least 1-2 years; examinations 102 JOURNAL OK THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 at the hospital once a month for a year, then once every 2-3 months. (2) Do not make a mental invalid of the child and do not limit physical activities ex- cept for the active over-tired child. (3) Remove any foci of infection; carious teeth, diseased tonsils and sinuses. (4) Treat for malnutrition with increased diet, and tonics to improve appetite; Tr. nux vomica 5-10 drops before meals. (5) Treat anemia by removing cause, it possible ; focal infection, intestinal parasites, lack of fresh air and sunshine. Saccharrated carbonate of iron, 10-30 gr. 3 times a day, and high protein diet have corrected the anemia. (6) Regulate the child’s life; to bed early at night, daily baths which tone up the cn dilation, ample nutritious diet with attention to the vitamins. Two illustrative cases and their progress follow : Case 1. G. I., girl, aged 4 yr., has a sister aged 6 who is a cardiac. One year ago she had grippe. For the past 2 weeks has had bilateral discharging ears and tender, enlarged cervical glands on both sides. Temperature normal. The tonsils were enlarged, inflamed and cryptic, and the cervical glands bilaterally enlarged but discrete and slightly tender. The heart was not enlarged; the rate was normal. The apex was localized in the fourth space within the nipple line. A short systolic mur- mur was heard in the fourth left interspace — not transmitted. There was no change in the murmur after exercise, position or respiration. Her weight was 29% lb. Tonsillectomy was performed and 9 months later weight was 33l/2 lb. ; glands were not enlarged ; no murmur heard. Case 2. E. B., boy aged 12, had pneu- monia at \]/2 years; pertussis 3y>, measles at 5, and was subject to frequent sore throats. Tonsils were removed at 18 months; again at 10 years of age. Three years ago complained of slight fatigue. He was referred from gen- eral clinic as possible cardiac, as a murmur had been discovered on examination. His weight was 121 y2 lb. General appearance and color good. Marked dental caries with gum infec- tion. The heart was not enlarged; rate and rhythm normal. At the apex a faint blowing systolic murmur was heard. Advised removal of carious teeth and no restrictions in activi- ties. Ten months later his weight was 123 lb. The carious teeth had been removed. No mur- mur was heard. Discussion Dr. Stanley Nichols (Long Branch): I am sure we are all very thankful to Dr. Okin for this very comprehensive paper on a very much neglected subject. To me, this is the greatest problem we have in the field of children's heart disease. There is no question that thousands of children in this country are unnecessarily made, not only physical, but mental, invalids by some one pronouncing a heart murmur to mean heart disease. The men- tal part of it is the worst because the physical part may disappear. The proportion of these functional to organic cases is so large that it justifies the doctor hearing a heart murmur in calling it non-pathologic, if he has any doubt. If he is not sure in his own mind the first time he sees the case, after taking the history and listening to the heart, that it is a definite acquired or congenital murmur, he may wait 6 months or a year before deciding this point — making repeated examinations meanwhile. He is thus easing the mother's mind and at the same time making sure. 1 would say, roughly, that 60% of heart murmurs can be classified at the first visit, but certainly 20 to 30% will take 6 months or a year to prove. A mental fear may be very serious. It does not bother the child very much unless he becomes a mental invalid, but a mother immediately takes fright. You can say to her that her child has some tuberculous con- dition, or nephritis, and while she will be mod- erately alarmed, she will not be half as frightened as by the report of a heart murmur. The reason for this is the impression that heart disease has made 6n the human mind. For instance, she reads that some friend dropped dead in her home last week, or someone in a prominent position is well today and gone with heart disease tomorrow. So, while perhaps 90% of heart cases die of a lin- gering illness, heart disease to the public means death and probably sudden death. Mothers gen- erally have that idea firmly in mind, and so is created a mental invalidism, something that is difficult to get rid of. We should be absolutely negative on heart murmurs being organic until we are absolutely sure of our ground. Dr. Okin has covered that point and has emphasized that these children should be followed for a period of 5 years. How long should a non-pathologic murmur be fol- lowed? If in 6 months to a year you have de- cided that it is a non-pathologic condition, you should say to the mother — “This shows no evi- dence of being organic.” It should be remem- bered that you have to treat the child and the mother, 'and the mother is really more important. After you have studied the scientific problem, then study the mother. If she is well balanced and not inclined to take alarm, you can tell her that if the child develops any symptoms she must bring it back. Unfortunately, many mothers are not so well balanced. The very words “heart murmur” cause them so much mental fright, that it is bet- ter to say to the majority of mothers that they had better return with the child every 3 to 6 months so that you can watch the condition and keep their fears allayed. This may have to con- tinue throughout childhood. You will be accused of wanting to fill up your office at the public ex- Feb.. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 103 pense, of course, but you will be doing justice to the patient and keep this child out of the hands of some one who may invalidize it and give unneces- sary treatment. If you discharge a nervous mother and child and say that the condition is not organic, in 3 months to a year some other doctor will hear this heart murmur and start the ball rolling again. The routine treatment unfortunately given to many children with heart murmurs is simply to administer digitalis, and not let the child do very much. There is only too often no careful study made to find out whether it is a congenital, ac- quired, or non-pathologic murmur. 'The pediatricians are peculiarly equipped to han- dle these heart problems, more so than some car- diologists, because they often have more interest in the child heart and see it from a different view- point. Far too many cardiologists think that the child is a small replica of an adult, and treat its heart accordingly. If we follow the treatment Dr. Okin has outlined, we will be doing a very satis- factory service, and perhaps cure what might cause a mental invalidism to the mother and some- times to the child. While you may say that is a part of the art of medicine rather than the science, you can first practice the science, making sure the murmur is not pathologic, and then practice the art, which is to keep the patient’s mind free of mental invalidism. Dr. D. J. M. Miller (Atlantic City) : I did not hear the essayist’s paper and heard only part of the discussion, but I did hear the doctor say, and I would like to endorse the fact, that there is a great amount of unhappiness caused by the knowl- edge that a child has a cardiac murmur. You pediatricians have seen cases sent in, particularly by school doctors, and the mother in a great state of apprehension because a murmur has been dis- covered. I only want to say this, that in my own experience the most common so-called functional or non-pathogenic heart murmur heard in chil- dren is the pulmonary systolic murmur which is heard at the base of the heart, usually on the left side, sometimes on the right and sometimes even down as far as the apex. I think it can be safely said that if the child has a heart murmur, par- ticularly in that situation, and there is no other sign of heart disease, the child can be dismissed without further examination and without further following up of the case. The mother's fears can be allayed and the child can be allowed to go on with its ordinary amusements and exercises. Too many children are hampered because they have a heart murmur. There is another functional murmur heard which is generated in the lung, the so-called car- dio-pulmonarv murmur: definitely connected with respiration, I think. If that feature is noted I think those murmurs also can be dismissed with perfect confidence that they are not organic. Dr. F. C. Johnson (New Brunswick): I would like to second very strongly what Dr. Nichols said about these cases, and what Dr. Okin probably believes about the treatment of the family, but I would like to go even further; I wonder if very often, with certain people, it would not be legitimate to say nothing at all about these heart murmurs which you are convinced are non-pathologic? It may be that the patient will go to some one else who will bring the condition home forcibly and want to treat it as a heart disease, but why not let some of these murmurs go until they are perhaps outgrown, the patient being seen regularly several times a year, as many of our patients are coming to be observed? There might be a great deal of nervous strain saved if func- tional murmurs were not mentioned. As to the classification of these cases which are called non-pathologic: is the condition of the heart in which the ring is dilated and the murmur pro- duced by relaxed muscle or ring strictly non- pathologic? It is not a normal heart but it is not the function of the cardiologist to treat it. The treatment is not heart treatment, at all, but general treatment of the patient; so that this condition should be, 1 think, distinct from those cardio- respiratory and other non-pathologic functional murmurs which do not amount to anything. Has there ever been anything gained by taking an electrocardiogram of the cases which were clinically thought to be non-pathologic? Dr. Irving Okin (Closing); In this group, these electrocardiographic studies were made more from a scientific than a clinical viewpoint and certainly we do not do them in private practice. I have never seen a case where the electrocardiographic study alone made the diagnosis.; it was made clinically every time. As to considering them as a pathologic group, that was the point I tried to bring out, that it was not heart disease or rheumatic disease. We consider the rheumatic heart as a part of the rheumatic disease. We do not feel that these cases are definite organic cardiacs. The valves are not sclerosed, there are no inflammatory changes in the valve, and at autopsy, where the patients have died of other conditions, there was no cardiac pathology. Do not treat the heart but treat the general con- dition and by building up the whole system and bringing the child into the best possible state of health you will probably bring the heart muscle into the best possible state of health at the same time. Dr. Miller said we should dismiss these children once we have made the diagnosis, and Dr. Johnson suggests that we should say nothing to the parent about the condition. I have had one unhappy ex- perience. One day, while I was away, another doctor was called to one of my patients and the family was very much worried because he found this murmur and told them about it, and of course the whole cycle about which we have been talking was started. I assured them that I had heard the murmur and that it did not amount to very much. I think you should mention it to the mother to protect yourself. INTEGRATION OF THE CHILD* Ira S. Wile, M.D.. Mew York City The practice of pediatrics has altered ma- terially during the past generation. A consid- eration of the various types of work now in- volved in the care of the young demonstrates the tremendous variety of interests and func- tional organizations. One need but enumerate *(Read at the 164th Annual Meeting of the Medical Society of New Jersey, Section on Pedi- atrics, Atlantic City, .Tune 13, 1930.) 104 JOURNAL OF THL MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 such problems as are involved in child hygiene, prevention of blindness, growth of boarding homes, development of pre-natal work, pre- school examinations, medical inspection of school children and the inception of various types of clinics for mental hygiene and for meeting the problems of exceptional children. One notes the existence of a large variety of lay organizations dealing with juvenile problems or, indeed, with specific phases of work with chil- dren. Under this head are found, for exam- ple, groups organized for fostering clinical ser- vices in settlements and schools, for promoting welfare during infancy, urging diphtheria and tuberculosis prevention in communities, as well as lay groups interested in the moral status of dance halls, pool rooms and theatres ; and those who are specially cognizant of the needs of industrial hygiene, limitation of child labor, special classes for handicapped children and who propose various modes of elevating child- hood from the education of parents to their abolition. This variety of interest in juvenile Avelfare has developed without serious partici- pation of pediatricians. Today one finds a shift of emphasis from specifically physical problems to those that in- volve intellectual activities, emotional adjust- ments and social adaptations. It still remains common to have the child considered in terms of specific phenomena. As in a previous gen- eration there was stress upon excessive cigarette smoking, today there is a fear of too great fondness for liquor or for movies. There is, however, a larger degree of attention given to juvenile habits that are deemed undesirable. The viewpoint has altered in that today many habits are viewed as subversive of the finest growth of the personality of the young, and not merely as unpleasant for the family or the community. One need but enumerate such difficulties as sleeplessness, worry, excitement, lack of concentration, school failure, mental de- pression, fear and anxiety, irritability and tan- trums, sex delinquencies, disobedience and cruelty, to appreciate some of the new ele- ments entering into consideration of child be- havior. Fidgetiness, lying, stealing, vagrancy, fantasy, frequent change of occupation, men- tal retardation, drug addiction, the epilepsies, have become as significant in the welfare of children as the more readily noted difficulties of speech, sight and hearing or even such seem- ingly physical behavior as scoliosis, enuresis, pavor nocturnus, chorea or syncope. The layman no longer regards behavior as accountable on the theory of original sin or in- heritance from ancestors who cannot voice their own defense. Pediatricians are inade- quate in their medical service if they dwell en- tirely in the seclusion of somatic diseases. They must take cognizance of all behavior — asocial, social or antisocial. They should treat all aberrant forms of reaction — and all diseases are reactions in and through living. All human behavior, particularly in its juvenile phases, represents a totality of reaction. Is the pedia- trician to treat the child who reacts or merely some of his reactions? This leads me to ask: what is a child? From the common viewpoint it is merely an offspring in relation to his parents. On the other hand, a child even as a physical entity has primary relationships in terms of physical activity, in- tellectual life and social adjustment construed as community values. Is a child merely to be viewed in terms of his body? Is he an agglom- eration of muscles, viscera, glands and nerves? Is he merely an anatomic organization? Patently, anatomy, in itself, does not consti- tute the essence of the child or there would be no distinction between the cadaver and the functioning organism. The child may be definitely viewed in terms of his anatomy but his physiology is of far greater significance. Is he, however, merely a congery of physiologic systems organized to sustain the vital processes ? The distinction between hypothyroidism and hyperthyroidism indicates the significant dif- ference between the physiologic activity and the mere anatomic presence of an organ. Ab- sence of the thyroid gland, with its resultant cretinism, evidences one phase of physiologic dependence upon anatomic presence. Func- tional stability of the heart is vital to the total welfare of the child but the presence of a con- genital cardiac anomaly that necessitates a com- pensatory modification of function does not al- ways disturb the total equilibrium of childhood. Consciousness of the cardiac dysfunction may be more devastating than the lesion and its Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 105 physiologic deviations. The child obviously is more than his basic somatic structure. Is the child to be viewed entirely as mind? Are the primal instincts, his emotions, intelli- gence and imagination, his capacity for mental activity, whether in learning or adaptation, to be regarded as his totality? Patently, instinc- tive activity is inherent in child biology but his social existence involves regulation of the in- stincts for practical living. Mere knowledge of the intelligence of a child does not give a picture of him any more than knowledge of the size of his hand gives sufficient informa- tion concerning his capacity to hold a job. No one can gainsay, however, the important part that mind plays in the total configuration of child life. Psychic life involves the instinctive, emotional, intellectual components, but as in- teracting rather than mutually exclusive fac- tors. Laying aside for a moment the biologic manifestations of a child in terms of anatomy, physiology and mental activity, there are very definite social values which constitute an es- sential part of child reactions in health and in illness. Some people refer to the soul of the child as though it were a thing apart from his mundane life. No one would assume that religion, social sentiment and spiritual values represent the summation of child life, even though they cannot be disregarded as vital facr tors in his living. The social bases of his per- sonal welfare are deeply founded in the physi- ology and psychology of the child. Pie is what lie is by virtue of the totality of factors enter- ing into his unitary completeness. His entire personality is created by the internal interaction of all that he is in response to all that he touches in his environment and to all of the environment that impinges upon him. The child is a unit in function. His activity! is the expression of his total reaction as a biologic social being. The child, as an ab- straction, has very little practical value to physicians save for the purpose of establising theoretic norms of height, weight, metabolic activity and the like. Each child is a unit in his own constitution, in his inheritance, in his en- vironment. His life depends upon the unified reaction of all the endogenous and exogenous factors that affect him. There is an inter- relationship between a large variety of seem- ingly unrelated elements. Whatever behavior he manifests represents the integration of all his functions. One cannot differentiate his physical and mental systems as though they were acting in parallel or possessed independ- ent activity. They are only phases of his total personality. Walking, talking, dreaming, creat- ing are not phenomena isolated from respon- sive social living. One may consider the large variety of behavior patterns of childhood from any one of several angles but their meaning depends upon their relation to the possibility of securing harmony in environment. Abnormal behavior represents disharmony whether from causes primarily somatic, psychic, or social. Abnormality in structure or jn function car- ries with it no certainty of type reaction. The behavior response is unpredictable because neither structure nor function constitutes the sole dominance of the being. The vital or- ganism is not essentially behavioristic and so a definite stimulus does not always determine the identical response. I may illustrate this by considering myopia. There are, of course, varying degrees of myopia but one cannot pre- dict the behavior reaction of a child even when the degree of myopia is known. One child, for example, , with a moderate degree of myopia, will complain of headaches, fatigue, refuse to study and perhaps play truant. Another child, with the same degree of visual difficulty, will apply himself more assiduously, strive to at- tain high standing and regret school vacations. A third child thus handicapped will do more school work than is necessary, but will seek an outlet for his activities by recourse to stealing, or by day dreaming or creative work along lines involving little visual application. The behavior variations of these children depend upon elements of personality that are not bound up in the myopia. Amputation of a thumb takes from a child something more than 2 phalanges. Who can prophesy his response to this mutilation? It may totally disorganize the harmony of living for a child, particularly if he has aspirations to be a baseball pitcher. Re- moval of tonsils is not to be regarded as a slight physical operation without effects upon the total reactive organism of childhood. One need but think of the unexpected and unpredictable post- io<; JCH RXAL or THE MEDICAL SOCIETY OE NEW JERSEY Feb., 193T tonsillectomy neuroses, phobias, choreas and the like as evidence that the operative proce- dure involves more than a physical trauma. One cannot even state what a child will do it his foot is stepped on ; much depends upon when, where and by whom. 'Hie interaction is very observable in the re- actions of children to psychic distress. The physical reactions of fear, rage, love and the like are manifest in a vast variety of somatic expressions which greatly disturb normal adaptation. The hysterias of childhood, the psychogenetic epilepsies and the psychoneuroses bear witness to the involvement of the somatic systems as an expression of diminished har- mony in the total psycho-physical life. Fear produces disturbances of muscular and glandu- lar function, and functional disorders of the heart or gastro-intestinal system cause fear reactions. The adrenal gland affects and is affected by psychic reactions of frustration and anger. I have stated that intelligence is not the main factor in the organization of child life. No one denies that the possession of a high or low intelligence quotient is a matter, of importance. The intelligence quotient, however, does not reveal qualities of leadership, persistency, in- dustry, artistry, humor or social adaptability which are vital constituents of personality. The behavior reactions of a moron, an imbecile or a superior-minded child are not to he evaluat- ed entirely in terms of their intelligence levels. One cannot predict immediate reactions nor later success in life with certainty, utilizing the intelligence quotient as the sole basis for judg ment. Intelligence is hound up to no small degree with many physical states. The absence of a thyroid gland, for example, makes the intelli- gence level exceedingly low. Presence of deaf- ness or mutism appear to lower intellectual potentials. Hemiplegia, mongolism, chorea, encephalitis affect mental potentials. Fear of injury or personal harm may interfere with the adequate employment of existent intellec- tual potentialities. The relation between social adjustment and intelligence involves more than a definite level of intellectual capacity. Social harmony in contacts is not assured by keen mental powers of learning. The relation be- tween character and intelligence involves the consideration of non-intellectual components. In the last analysis, intelligence is relative. A child may be intellectually capable in one school and intellectually incapable in another school having a much higher level of pupil selection. Intellectual adequacy or inadequacy, however in so far as it is a part of the total expression of juvenile behavior, is definitely less import- ant than emotional stability. The emotional life of a child is conditioned by inherent mechanisms upon which I need not dwell at this particular moment. It is suffi- cient to say : “The motor trend of the emotion dominates conduct.’’ The child is a reacting organism. Doing is more important than think- ing. I shall not discuss motivation or life goals because it would require too much time to explain the psychodynamics of Freud, Jung, Adler and others who dwell upon the psy- chogenetic domination of human activity. Nor shall I stress the conditioning theories popular- ized by Watson or the foundations of an ap- proach through the social psychology of Mc- Dougall or Trotter. I wish to be more generic in my approach to the emotional drives, regard- less of their nature. To put one’s self across in the community and to gain personal satisfaction is especially significant for child life. One may recognize potent emotional factors entering into person- ality as they grow out of definite instinctual qualities of life. There are the emotions that grow out of the ego, the herd and the sex in- stincts. The feeling tones, whether in terms of pleasure or pain, sinlessness or sinful guilt, in so far as they affect the person as a unit and as they affect his relations to the groups with which he must live, deeply affect his total re- actions. The sexual instincts affect both the ego and the herd trends and are inherent in the somatic and psychic organizations of the child. These emotional components vary in their activating forces in accordance with their dominating presence in the conscious and un- conscious life. In childhood, the pressures upon the ego are most severe. The entire scheme of habit formation for social living involves a modifica- tion of the ego trends and the restriction of native biologic impulses in order to attain a Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 107 social harmony without too great a sacrifice of the ego. The entire training period of child- hood therefore involves tremendous molecular readjustments of the personality. There are involved coordination of the brain and muscles, the cerebrospinal, sympathetic and parasympa- thetic systems, the intelligence and emotions, out of which grow the variety of attitudes and powers, including the ability to make adapta- tions, the willingness to do so, and finally, the determination to secure the harmony most pro- ductive of satisfaction in every realm of action. The child seeks security and love, companion- ship and harmony in terms of an internal sense of success and achievement with an increasing amount of independence and power in external relations. I am emphasizing that the child as a unit possesses a physical life, an emotional life, and an intellectual life but that these are thoroughly interacting and merge finally in an expression of social life through which self-realization must be secured. Child behavior always has meaning ; it is symptomatic ; it has purpose. The feeling of inferiority, as stressed by Adler, may arise because of somatic inferiority or by rea- son of some failure of adjustment in the home, school, on the playground or in the factory. The reaction to inferiority may be theft, bully- ing, emesis, truancy, etc. Conflicts within the individual child, due to clashes of personal and social demands and desires, are bound up in innumerable reactions that are at one time dominantly physical, intellectual or emotional. Only for purposes of discussion may one focus attention upon some specific phases of the child, because in evaluating and interpreting child behavior it is essential to synthesize what- ever has been analyzed in order to grasp the behavior as total reaction. Multiple causation must not be ignored as the outgrowth of life patterns and reactions. The child is born a biologic unit and his biology involves, of course, psychology. The very facts of conception, parturition and lacta- tion indicate that the child is likewise ab origine a social unit and his social adjustments are inherent in every phase of his physical well- being. The physical animal depends for sur- vival upon social existence. The declining in- fant mortality rate demonstrates this fact. If one discusses moral well-being, one patently is viewing the child as a social unit. This requires the consideration of the child in terms of his efficiency, human compatability and general adaptability in a dynamic environment. This involves recognition of the individual per- sonality of the child. Consideration of juvenile morals, however, involves judgments concern- ing his behavior in relation to the ideas, opin- ions, judgments, sentiments and mores of a community. Right and wrong are not inherent in biology. They are not patterned in cere- bral structure nor in endocrine function. They are outgrowths of organized social life. Ab- normal behavior is therefore only a reaction type that is not accepted by communal judg- ment. Judgments, therefore, concerning the goodness or badness of childhood, or of specific activities, habits or conduct trends, are in terms of socially determined scales and these are relative rather than absolute. The efforts of the child to make adjustments in terms of his physical capacities, his intellectual potentials and his emotional systems, bring about be- havior that is viewed as asocial, social or anti- social according to time and place considera- tions. Society by mandate, regulation, tradi- tion or taboo creates its code by which it seeks to preserve the mass with little thought of the individual. An adult world attempts to secure juvenile conformity by pressures of education, government, and religion. Each age produces new conflicts of the older and younger genera- tions and, as a result, codes of morals are changed. Childhood is subject to the flux of its age. It is obvious that social and economic status, general and familial, plays a definite part in the integrated functions of a child. One views the child as a whole only when his wholeness involves himself in his setting. Even here the integration of his functions include what he is seeking to do to his environment and what his environment is seeking to do to him. And in- deed one may add that his integrations involve also his reactions to the communal estimations of himself and his responses to the reactions of various communal groups to his efforts at special social participation. The inherent bi- ology of a child varies as an instrument of stimulation and response under conditions as 108 JOURNAL OF THE 'MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 found at home, at school, at church, at play and at work. I have said sufficient to indicate that the pediatrician must learn to view the child as a whole rather than to pass quick judgment upon his behavior. One recognizes the effect of fatigue upon behavior as well as the modifica- tions of conduct due to the prodromes of con- tagious diseases. The physician appreciates that profound alterations of behavior may re- sult from a large variety of physical causes. I need but refer to club feet, birth traumas, blindness, convulsive seizures, poliomyelitis and encephalitis. There is a vast distinction between causation and concomitance. A syphil- itic child may steal but that does not prove etiologic relations any more than the coexist- ence of diabetes and wanderlust, tuberculosis and masturbation, flat feet and tantrums or endocarditis and lying. Where one thinks in terms of the possible causes of school failure, delinquency, homosexual practices, mental dis- eases or physical inadequacies, the pediatrician must shift his viewpoint so that he views the child as an integrated personality. The physical sequels of diseases are not limited in their effects to the specific organs that they may in- volve. Faucial diphtheria may damage the kidneys; intestinal typhoid produces delirium and even psychoses ; encephalitis may com- pletely transform a personality from a socially acceptable type to one that is so dangerous as to require permanent institutional care. The symptomatology of numerous diseases involves more than the somatic manifestations of the underlying physical processes. Why, for ex- ample, does one child respond to a mild fever with headache, malaise, disobedience and tan- trums, while another child evidences increased activity, marked volubility, together with sub- missiveness and a general acquiesence to paren- tal and medical requests. These differences in behavior are determined by the total functions of the children. The countless deviations of children from a theoretic norm depend upon their totally integrated reactions. The whole child, for example, has a disease even though the main systomatology appears to be localized. Treat the child, is almost a pediatric slogan. Health in children has wide connotations. It is not to be regarded merely as the absence of defect or disease. Physical perfection in itself is not a rational goal of life and the full at- tainment of remedial work on children does not guarantee completeness of living. Fulness of life is a positive characteristic and is more than being full of life. I have shown that anatomy is subordinate to physiology; that physiology conditions psychology ; that psychology fash- ions social reaction and that social reaction de- termines morals. This does not mean that these elements are segregated in the personality of children. To the contrary, they constitute such an interconnecting mechanism that the child can be considered as a unitary being only by recognizing the continuous interweaving of these factors in and upon his personality. The whole child is more than the sum o'f his con- stituent parts. The health of the body, mind and spirit is resolved into what Williams de- fines as “the quality of life that renders the individual fit to live most and serve best”. The integration of the child calls for a larger degree of attention by the pediatrician because it enables him to interpret the child as a bi- ologic-social unit. He cannot practice modern pediatrics intelligently ^without an appreciation of his part in guiding and forming juvenile characteristics. He is not a dispenser of drugs nor only an adviser of sunlight, fresh air and an adequate dietary ; he is a source of ideas of child training, a guide to useful habit forma- tion, a counsellor on human relationships, an authority on mental hygiene, and preventive medicine. As a scientist he reveals the art of living and reconciles it with the theoretic scien- tific basis of life. His contact with homes, with children, with parents, with school and with the community give him a tremendous ad- vantage in approaching the problems of the juvenile population. His major medicosocial service is attainable, however, only when he sees children as individuals and as parts of a communal organization. He should grasp the idea that the child oft-times is in conflict with the regulations and the adult rules of life, but ever is seeking to find satisfaction in the en- joyment of his inherent biologic demands and urges, while endeavoring to function in his world with the least internal conflict. The pediatrician has a prominent role as physi- cian and specialist, friend, guide and conn- Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 109 sellor in influencing the integrations of the child. To interpret the protean world to a child and to interpret the child to his many- sided world is a social pediatric function whose integrative value is paramount for fostering a socially adjusted life with a harmonious growth of personality and an effective individuality. Discussion Dr. Julius Levy (Newark): We cannot let this very brilliant and philosophic talk go by without some comment. For many years, those of us who have known Dr. Wile have known him as a genius for bringing together the many thoughts and ideas that are brought out from time to time and giv- ing them a logical basis, a sequence, and an orien- tation which is often lost in this busy world. I think one of the great contributions Dr. Wile is making today to pediatrics, and particularly in the field of mental hygiene and psychology, is this insistence that the ideas that are brought out from time to time, and the emphasis placed on certain statements or viewpoints, are merely single re- flections of some general idea. One of the great dangers in medicine has been that in every gen- sration we act as if somebody had rediscovered the sause of all things, and we wildly follow one idea, forgetting everything that has been said for the previous hundred shears only to be brought up short by a thorough student and shown that there is no need of neglecting all that has gone before. I think there is a particularly important lesson in Dr. Wile’s approach to this question. One hesi- tates to use the word practical after Dr. Wile’s profound elaboration of this problem, but those of us who are more simple in our work adopt very fully Dr. Wile’s idea that when children are brought to us for anything at all there is a mag- nificient opportunity to try to understand fully the child and the family environment. I know that the pediatrician who has permitted himself to grow into something more than an infant feeder has found his greatest encouragement, his great- est influence, in trying to help children to adjust themselves better to their environment and to help mothers to make this adjustment easier by under- standing their children. Another important point is Dr. Wile’s casual reference to the great number of lay organizations that have developed an interest in the child. There is a group that is very well intentioned but whose familiarity with children is only from yesterday and they make one phase of child life dominate the whole field of child care. You know it is very easy for a Viennese to come here and, by tickling the intellectual palates of our women, to be readily invited into the homes of America, and by prop- erly engineering newspaper publicity made to ap- pear that he has discovered the whole secret of child management and child care. Child care has another duty: that of giving the proper place to many of these new ideas. Dr. Wile has made a brilliant contribution and we are certainly very much honored in having him here. Dr. Stanley Nichols (Long Branch): I have al- ways said that men who understand children should lead in this field of work and Dr. Wile, as any one will confirm who has sat at his feet, lias gone into the child mind and outdone the psy- chologists. Anyone who can should go up to Mt. Sinai Hospital at 3 o’clock on Wednesday after- noons and see his work in progress. You will never do so without learning something that will be of value in your practice. The subject is so large that we pediatrists stand in much the same relation to it as the general physician does to the pediatrists. We are as the blind leading the blind, but perhaps we can get one eye open if we apply ourselves. The simpler adjustments in family life we can carry out. I sincerely hope that the com- mittee’s recommendation, of having a course in this state, will be carried out so that all practi- tioners may take a course in children’s mental ad- justments. In the matter of keeping this subject in the hands of medical men, the question immediately arises — How many men can we furnish in this state to keep the child guidance clinics going? At the present time there are not enough such doctors. We have psychiatrists running child guidance clinics and they often approach the prob- lems, not as Dr. Wile does, to integrate the child, but as a neurologic or mental problem. When we refer the child to such a clinic we are likely to get a neurologic report rather than some definite rec- ommendation as to how we shall solve the family difficulty. If we had more pediatrists interested in this field, such as the members of the commit- tee that Dr. Levy is serving upon, who would give more time and attention to that subject, we could have a system of state family adjustment clinics to make such studies and recommendations, as well as men who, in private practice, would solve the more difficult problems as Dr. Wile does in his private practice in New York. We all know that it is a question of educating the mother after we have first studied the situation. We often wish that we could do what they do in unhappy mar- riages, and put another mother in her place, be- cause that sometimes seems to be the only solu- tion. Dr. Samuel StaXberg (Atlantic City) : Dr. Wile’s work appeals to me as a general practitioner, es- pecially as he approaches the subject, not so much from the philosophic or psychologic standpoint as from that of the general health of the child, and the general diseases which may assail it. Dr. Wile’s work is especially valuable because of the fact that child delinquency and crime have been on the increase, and I think no greater work has been done in the realm of pediatrics than that of Dr. Wile in the last few years. Dr. F. I. Krauss (Chatham) : I might quote my views in the form of a paradox, in saying that this question is harder than it seems and yet not so hard as it seems. When one listens to Dr. Wile, one feels very inadequate at first in his ap- proach to the : subject, but on second thought it is not so hard because 99% of it is common sense and the other 1% for the general man is technical knowledge. Our greatest difficulty in private prac- tice is to teach the mothers that children are en- titled to a certain amount of liberty. From the m,oment the child is able to toddle around, after the first year has passed during which the child is the tyrant of the family, this child must conform to what the parents want it to do, and as soon as it begins to interfere with their liberties and de- sires, discipline begins; whereas, discipline should have begun in the first few weeks of life. It is usually delayed until the damage is done and then the conflict arises in the child’s mind as to how to adjust itself to the social status. I always em- phasize to parents that they shall give the child 110 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 such liberty as is compatible without interfering too much with social adjustments, and when the child must be disciplined or corrected in any way let the punishment lit the crime; consider it from the child’s viewpoint, how the child reacts, and whether the correction is justified from the child’s standpoint. Usually that helps a great deal in giving the mother an idea how to handle the child. Our greatest trouble, of course, is with the first child or only child of the family. By far the best thing is to have several children in the family so that the children can work out their social adjust- ments as they go along. I am glad that Dr. Wile brought up the sub- ject of fear — fear following operations, particu- larly tonsil operations. We speak of these as minor operations. I regard them as major opera- tions. A description of the way the anesthetic is given, the approach to the hospital, etc., are very important factors in the history. How many times have we seen a child refuse to eat after an opera- tion for weeks and weeks; or a child who is fear- ful of going to a doctor or to a hospital, fear of the ordinary hygienic things which must be done. I think these fears carry over into adult life and turn many people away from the legitimate medi- cal profession. There are people who still remem- ber the fears they acquired of doctors and hospi- tals when they were children. I feel that doctors as a whole do not need to know all the various technical treatments which psychology evolves Let us approach it from a common sense standpoint, remembering our own childhood, our own complexes and fears. Most of us have had some experience in bringing up our own children, and by putting yourself in the child’s place you can help the mother, and the child in- directly in its whole future life. MEMORIAL TABLET TO DR O. H. SPROUL ERECTED BY THE HUNTER- DON COUNTY MEDICAL SOCIETY AT GLEN GARDNER Address at the Unveiling Exercises John F. Hagerty, M.D., Newark, N. J. It is a great pleasure to take part in a meet- ing of the Hunterdon County Medical Society in this lovely section of New Jersey. I am not a stranger in these parts, having become familiar with this and surrounding country during my apprenticeship with the late Dr. Donohue, of New Brunswick, whom many of you remember. He had occasion to come out this way frequently on professional work, and came often, tod, to Finderne, nearby, where there were always to he found good horses, and those of you who knew the doctor well can recall what delight he took in having well bred stock. I remember a team of well matched sorrels, each nearly 16 hands high, which he used to drive here and to Princeton, Kingston, Somerville, Cranberry, and other places, and what immense pride and satisfaction he ex- perienced in driving this handsome pair, and what admiration they aroused as they went champing proudly by. We have advanced rapidly since those days in methods of locomo- tion. Distances formerly thought great are now considered slight, and we are able to accom- plish a great deal more since the advent of the automobile, but those who were really fond of horses must often regret their passing. I had the good fortune, too, to meet while on the Bellevue Hospital Staff, Miss Alice Schenck, who was on the nursing staff, daughter of one of your much respected and venerable physi- cians of a generation ago, and enjoyed visiting this lovely representative of the old fashioned doctor. He was then well advanced in years, small and frail looking, with snow white hair, and was very kindly and affable. 1 did not have the good fortune to know well Dr. Sproul, whom you are honoring today, but recall seeing him at the state society meet- ings, where his dignified and courtly manner made a great impression on me, as it must have on all the younger men. It is a splendid thing that you are doing — reminding future genera- tions of the fine, noble characters who repre- sented the medical profession in former days and whose lives of industry and sacrifice and self-denial endeared them to the people, who respected and revered them because of their goodness and helpfulness. These were the men to whom the present generation of medi- cal men are indebted for the high and proud position they occupy in the public esteem, and which they secured not so much by scientific at- tainments as by their mdefatigible labors and the character of their lives. They accomplished much because of the high regard they had for their sacred calling and love for their fellow- man. It was of such men that Holy Scripture speaks when it says : “Honor the Physician for the need thou hast of him; for the Most High hath created him. For all healing is from God and he shall receive gifts from the King. The skill of the Physician shall lift up his head JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 111 Feb., 1931 and in the sight of great men he shall be praised.” Times have changed and the types of physi- cian have also, of necessity, changed. The methods of doing things today are very dif- ferent, and this is reflected in the manners and customs of the present day doctor. But, while less personal and more business-like, there are still, on the part of the majority of physicians, the same ideals of service, as shown by the longer time spent in preparation, greater intensiveness in study and the wonderful re- sults being obtained. Just as in manufacturing and business, older methods have become ob- solete and newer ways, looking to rapid and larger results have come into vogue, so, in medicine, we are endeavoring to secure better results by sanitation, hygiene and prevention, as well as by more direct and intelligent ways of combating disease. In this respect, no one at all familiar with the efforts of our Boards of Health, both local and state, can fail to be impressed by the active and intelligent cam- paigns against disease and to make living more healthful and comfortable. The commendable altruism of the physicians of a former day may not be so much in evidence, but while this may be a matter of regret tbe altered financial con- dition of the laborer and the tradesman has be- come responsible for such change and no in- justice will result. At the same time, constant, scientific efforts, highly altruistic because of the consequences, are being waged against the causes of disease, resulting in the prolongation of human life and under more favorable and happier circumstances than ever before. One of the most interesting features of the recent annual meeting of our state society was a re- cital of the work of the many agencies of our state looking to the prevention of human suf- fering and the conservation of life. . Unless one has given thought to the subject, he will have little conception of the debt of gratitude due to scientific medicine; to the ac- complishments of those giants of the profession who have succeeded in wresting from nature the secrets of disease and made of scourges and pestilences that formerly ravaged and de- vastated the earth, only unpleasant memories. And, most surprising thing of all. is the fact that these wonderful achievements were ac- complished so recently by men whose life work was not ended when many of us here today had commenced the study of medicine. Time will not permit detailed reference to these epoch-making discoveries, but we may quote Dr. Osier, in his comment upon the blessings of anesthesia, antisepsis, and bacteriology: “Search the scriptures of human achievement”, he said, “and you cannot find anything to equal in beneficence the introduction of these agencies, a short half century’s contribution toward the solution of problems of human suffering hitherto regarded as eternal and insoluble.” We have ceased to wonder because of the daily application of the principles we have learned and the marvelous results being accomplished in medicine and surgery, yet I may remind you that Dr. Keen, of Philadelphia, who, happily, is still alive, records that he heard the first obstetrician of bis day say that “any man who opened the abdomen to remove an ovarian tumor should be indicted for murder”, and but a few years ago the same distinguished author said that the abdomen, which was formerly forbidden ground, might almost be called a play-ground in which surgeons dis- port themselves to their hearts’ content ; al- ways, however, in the perfection of some new technic or the performance of some needed operation. He tells us, too, that when he be- gan the study of medicine, about the same time as Dr. Sproul, whom you honored this morning, there were no laboratories of physi- ology, of histology, nor pathology, nor any instruction given in diseases of the eye, ear, nose or throat, orthopedics, diseases of chil- dren or gynecology. Very remarkable, indeed, are the advances that have been made in the last generation or so, and it would be hearten- ing and profitable had we the time to dwell upon these accomplishments, but it will al- ways be the glory of the nineteenth century that medicine was then placed on a rational, scientific basis, affording scientific methods of study which will ultimately lead to the unravel- ling of the mysteries of all infectious diseases and their conquest, and which will redound to the credit of medicine as a blessed and altruistic calling. I had the great pleasure of attending the last session of the American Medical Associa- 112 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1921 tion as a Delegate from our State Society. It is a great privilege and honor to participate in the transactions of that splendid body of physi- cians representing all parts of our great country and see how earnest and zealous they are in their efforts to elevate the standards of medicine and medical men, and thus help the people whom they worthily represent. It is very in- spiring to witness the business-like way these sincerely interested men deal with the many perplexing problems that arise and always with the thought in mind of justice to the rank and tile of the profession. Many important ques- tions of public policy, affecting the profession, hospitals and the laity were considered and judiciously disposed of. The Veterans’ Hos- pital Bill and the Veterans’ Pension Act, both of which were regarded by the majority as unwise and iniquitous legislation, were unani- mously disapproved, such action being tele- graphed to President Hoover, who referred in his veto message to having been influenced by the House of Delegates. But perhaps the most forward looking suggestion of some time, and which will have a profound influence upon the relations of physicians to the sick poor and the conduct of hospitals, came from the pen of William Gary Morgan in his inaugural ad- dress. In brief, this was to the effect that the expense of caring for the sick poor in every community should be borne by all the people of that community, and should be met by di- rect taxation ; that the physician was no more responsible for, nor bound to relieve, the illness or misfortune that might come upon his neigh- bor than any other citizen ; that in all semi- public hospitals the laboratories and operating rooms were to be kept up to the highest point of efficiency but that all use of such labora- tories by the well-to-do, or all services rendered to such people by members of the staff, was to be paid for, and paid to the physicians ren- dering such service; and. further, that in all purely public hospitals no charges for services should be made, and physicians or surgeons would have no right to serve if charges for service were made and retained by the city. While such propositions might seem revolution- ary and contrary to the long established tra- ditions of the medical profession, a little con- sideration and reflection upon the many in- justices perpetrated upon medical men will con- vince one of their fairness and justice. A hopelessly ill person, or an acutely ill person, without means is a charge upon his or her community and not solely upon Dr. Smith or Dr. Jones. If medical men choose to give their time and services, as they always have and will, to the purely public hospital, the city must j see that proper provision is made for rendering such care as is necessary, but that only those I who are totally unable to pay shall be admitted, I and that no attempt be made to help pay the ex- 1 pense for conducting such hospitals by charg- 1 ing for services of the members of the staff. I In short this address proposes to distribute the 1 burden of medical care and surgical skill of a the sick poor upon the whole community in- I stead of upon the physicians and surgeons, I and to prevent the abuses, prevalent in all I cities, of the fairly well-to-do profiting by the I appointments and laboratories of the semi-B public and public hospitals and of the time I and services of the attending staff. Consideration of this subject brings us nat- I urally to another, very much in the public eye I — the high cost of medical care — concerning I which I may repeat what has often been said, I that increased fees of physicians and surgeons ] are not alone responsible for the present agi-B tation. My own impression is that extravagant habits of thought and living on the part of nearly everybody have contributed most to the I present cost of illness. The era of prosperity I immediately following the World War, with j the unprecedented rise in wages of the laborer I and the ability to purchase, too often on the 1 installment plan, comforts and conveniences I formerly possessed only by the well-to-do, has I engendered in everybody habits of living up 1 to and well beyond their justifiable needs. And, i just as everybody today possesses automobiles. 1 radios, frigidaires, and the like, so everybody I when ill must go to the hospital, and only the 1 very poor will not insist upon having a private I room with special care day and night. Natur- 1 ally enough, hospitals have increased in num- ber, in elaborateness of construction and ap- pointments, until many of them are little less I palatial than the finest hotels. Every possible ] improvement in laboratory equipment and therapeutic appliances must be installed and. Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 113 rightly so, the executive, clerical, nursing, in- tern and culinary forces have to be enlarged, with resulting rise in overhead expenses, and so the cost has mounted until it has become a matter of investigation and, even, reproach. Perhaps no one concerned is entirely free from some responsibility in the matter, but I still feel that hospitals, for the successful ful- fillment of their work, need only be well con- structed, fire-proof, providing light and air, and clean rooms with capable nursing force, and the very best possible provision for good surgical work and medical investigations. This does not include rooms en suite nor suites for relatives and friends, nor even rooms with baths, which bath rooms arc very rarely used by the patient and are too often receptacles for soiled clothing. Nor is it necessary for every- body when ill to go to hospitals. Many such people can be properly cared for at home, and minor surgical operations properly performed there. Greater judgment should be exercised in ad- vising x-ray and other laboratory examinations and the routine, repeated blood and other ex- aminations are expensive and very often un- necessary. Not every abdominal pain calls for a G. I. series, nor every slight injury to head or limbs for x-ray pictures to determine the presence of fractures. Greater caution, too. should be taken in advising surgical procedures. Not every joint pain calls for removal of teeth or tonsils, and not every abdominal pain spells chronic appendicitis or diseased tubes. The truth is that the art of history taking, physical examination and diagnosis is being neglected and too frequent resort is made to laboratory and other aids which add materially to the cost of illness. Too many procedures are advo- cated, which often are of no avail. Trans- fusions, for instance, will replace blood that has been lost and supply needed elements to prevent further bleeding, and are wonderfully helpful and life saving procedures, but they will not cure septicemia nor pernicious anemia, nor septic peritonitis, and failure of any one method often brings other methods into disre- pute. X-rays and radium are, at times, valu- able aids in treatment but will not cure large uterine fibroids, nor cystic or colloid goiter ; much less will violet ray or other lights, which are rarely helpful. Indeed, while there may be a modicum of good in light therapy and physio- therapy, their indiscriminate use is not only needlessly expensive but often results in the loss of good chance of recovery by other methods. The nursing problem has become an acute one. We are well aware that the hours of duty are being shortened while the wages have in- creased, and often the presence of a large number of private nurses has, in my experience, lessened the inclination to work by the ward nurses, and many patients are compelled to employ special nurses in order to receive proper care. The matter of fees is one upon which it is quite impossible to draw any hard and fast lines. In general, charges should be based upon the character of the illness or surgical operation and the position, civic or otherwise, of the pa- tient ; in other words, in proportion to the re- sponsibility and the skill involved. It is my im- pression that excessive fees are charged by some specialists for operations where there is no great risk or skill required. But, after all, in discussing the high cost of medical care, let us not forget that many people boast of the number of operations they have had and of the fees they have paid. Many people seem to prefer the services of high priced specialists, partly, at least, for the pleas- ure of boasting about it; others, having only minor operations insist upon having nice rooms, which are kept filled with choice flowers, and which they gladly pay for because of the im- pression made upon visiting relatives and friends, and not infrequently at the expense of the physican when the question of payment is raised. All of which bears out my contention that extravagance has much to do with the cost of medical care. Please do not think that I am indicting the specialist or reflecting upon the general prac- titioner or surgeon, but there are practices which have crept into our methods which have a material influence upon the question at issue and which are often overlooked by those con- sidering the subject. 1 1 4 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 THE COUNTY SOCIETY* S. Emlen Stokes, M.D., Moorestown, N. J. When informed that I was supposed to give the annual address to this group, our secre- tary told me that the last 3 Presidents had writ- ten on the history of medicine in Burlington County and he thought it advisable for me to change the subject to something like “Golf as a Hobby for Doctors”. I must say that this was a good suggestion for I should have felt much more at ease in talking on that sub- ject, but once in a while my mind does strike upon more serious topics and, in thinking over what might be appropriate to say today, my thoughts have continually come back to one idea and that is : What does our County Medical So- ciety mean to its members? Is it an organiza- tion which lends its weight to the advancement of our profession? Are our meetings a place where we obtain helpful advice, not only from the papers read but from social contact with our fellow physicians? Are we working in har- mony, as a society, for improvement of the medical care of the citizens of Burlington County? Many other such questions have been passing through my mind. Please do not censure me too much if what I have to say does not agree with some of your thoughts or if some of my conclusions are wrong, but I do have a concern that our society shall keep in step with medical progress and that Burlington County may be recognized as a place where young medical men may come for general practice, and even for the special- ties, knowing they will find in our group men of the highest caliber and who will not let petty jealousies and criticisms obstruct good work. It has always been said that medical men are poor business men. In one sense of the word, I believe that is a compliment. The business world is a world of competition, of cutting prices, of under-selling and under-bidding, of patenting new discoveries, of criticizing com- petitors’ products, and so on. Fortunately, all ‘(Presidential Address to the Burlington County Medical Society, Nov. 12, 1930.) of these practices are frowned upon by the medical profession. They are discouraged and stamped out to a large extent but I see many signs which tell me there are still some who do not abide by the Code of Ethics of our so- ciety. There are men in our county who severely criticize, to their patients, the work of a fellow physician. Will it not leave a much better impression with the patient if the physi- cian in charge says nothing about the previous care a patient has had, but rather lays par- 1 ticular stress on careful history, physical ex- amination and treatment? I cannot help feel- ing that this type of friction has driven many of our citizens to cultists and to quack cures. ] I hey get tired of hearing one thing from one physician and something different from an- I other. The public is rapidly becoming medi- cally wise, and in order that we hold its re- spect we must keep abreast of the times and cease petty insinuations and criticisms. I should like to digress here just a moment and mention a subject which has made me feel that possibly the members of our society are not assuming proper leadership in the matter of preventive medicine. For the past 2 ' years our state society, through its county so- cieties, has been putting on a Campaign of Diphtheria Immunization. It seems to me that this can best be accomplished by every physi- cian in our county inquiring about and making a record of every child that comes to his office, as to whether this immunization has been car- ried out and, if it has not been done, to strongly j advise it. The same is true of vaccination. There j are entirely too many children of school age in our county who have never been vaccinated, and each one should be considered a menace. It was the custom, 30 years ago, for each pliysi- ] cian to automatically vaccinate every child un- der his care when 4 to 6 months of age, and the vaccination was almost included in the obstetric fee. I am convinced that the present laxness is largely due to us, as physicians; we have not brought it to the attention of the parents, and they naturally have overlooked it. It would not be necessary to put on campaigns if we individually assumed the responsibility which is ours and ours alone. T have already mentioned that some business ' practices are frowned upon bv the medical pro- Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JI RSEY 115 fession and justly so, I believe, but there are factors in a doctors life which should be strictly on a business basis. These factors have to do with the commercial aspect of our profes- sion, namely, fees, collection of bills, etc. Much has been written lately on the increasing cost of medical care. The American Medical As- sociation is now engaged in collecting figures on the cost of such care and by so compiling statistics to be able to draw some definite con- clusions. There is an excellent article in the Journal A. M. A. of March 29, 1930, dealing with the cost of medical care from the point of view of the general practitioner. The fac- tors discussed are: (1) The traditional opposi- tion to discussion of the so-called commercial aspects of medical practice. Dr. Holdbrook here points out that as a rule our patients seek medical and surgical advice without any definite understanding of the obligation incurred. Tra- dition has taught the patient that he is not expected to approach the physician as to cost of his services. He feels that the only ra- tional solution of this difficulty is to break away from illogical traditions and establish franker business relations with our patients. (2) The traditional custom of charging fixed fees. Here Dr. Holdbrook makes a plea for individualizing charges with particular con- sideration of 3 factors — the physician’s quali- fications, the patient’s ability to pay, and the service rendered. (3) Inconsiderate hospital- ization. (4) Unnecessary consultation of specialists. In my mind, there is no doubt but that the general practitioner is still the essential force in the profession. With him should rest the decision as to whether patients shou’d be hospitalized or should consult specialists. These decisions mean much more to the patient than we realize and we should not be too hasty in our advice. In speaking of hospitalization I want to mention a force that has entered our medical life during the past 2 years, which I feel is as big an influence in establishing harmony of thought and purpose in our society as any- thing we could hope for, and that is our County Hospital. Those men who are giving their time to this institution, which was so heartily en- dorsed by our society, are reaping untold bene- fits and pleasure from their work; they are on a much more friendly basis with their asso ciates, they are able to see the type of work that is being done in the county, and, above all, are exhibiting a type of work which we should all be proud of. The laymen of our county are also appreciative of the advantages of this hospital and are more than pleased with the treatment received. I wish I could prevail upon those of our county society who either are not on the staff or who have not sent pa- tients To the hospital that they make an effort to learn more about the work that is going on in this institution, for it is a real privilege to have this hospital so close at hand. Our membership is 54 and our average at- tendance at the county meetings for the past 2 years has been 18 to 20. This is not a good record and indicates either that our programs are not sufficiently attractive to call out our members or else that our members have lost interest in organizing and working together. Organizatioh and professional contacts are im- portant ; therefore, let us show more activity as a group. This has been somewhat of a rambling paper but has been stimulated by an honest desire to see our society grow. In conclusion, I would sum up by saying : Let us attend our county meetings with more regularity. Let us bring to our meetings topics for helpful and interesting discussion. Let us work in harmony and forget petty disagree- ments. Finally, let us give to our patients more time and thoughtful advice. MEDICAL SERVICE OF THE FUTURE G. W. Haigh, M.D., Worcester, Mass. In spite of the marvelous growth of the medical sciences and the abundance of well trained doctors, preventable and curable dis- eases cause an appalling proportion of the pre- vailing mortality. According to Dr. H. L. Willett, Jr., Assistant Director of the Gorgas Institute, they account for 61% of the total deaths. The corresponding amount of un- necessary sickness must be tremendous. The conditions surely present a momentous prob- lem challenging all classes entrusted with the 1 1 G JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 welfare of mankind. They testify to the gross deficiency of the prevailing competitive form of medical practice, a heritage from primitive ages. This astounding inability of man to derive commensurate benefits from modern medicine lies in the need of the proper organization of the separate health agencies. As no less an authority than Dr. Ray L. Wilbur, Secretary of the Interior, has repeatedly declared-, it is a matter of universally distributing the facili- ties for the best possible medical care. For this, the only practical method has been found to be a free service. In its incomplete form it has been developed in the out-patient depart- ments and the wards of hospitals, and in indus- trial and health clinics. In its complete form it has functioned notably in our navy and army. To our president and our representa- tives in Washington is furnished this very medical service. That free, universal medicine is no new or fanciful idea is shown by an editorial upon “Free Health” in the “Survey” of May 13, 1911, nearly a score of years ago. It is quoted in part, here: “Free education was once considered radi- cal, but it was followed by compulsory educa- tion, and with compulsory education illiteracy became extinct among the native born. This free, compulsory education was neither char- ity nor justice, though free schools began as charity. It was protection, for revenue only, for society saw that ignorance was costly and dangerous. Free health is now radical, but it will come and compulsory health will follow. No child is now allowed to be ignorant, whether its par- ents are willing or unwilling; but disease is both more contagious and more dangerous than ignorance. Conversely, health is more precious than knowledge, both to the individual and to the community. The tenement father who sees his boy go through grammar school and die of tuberculosis would rather have a live son than a wise one. The wages of unskilled labor in the tenements do not allow health but educa- tion is given free. Which would any father choose for his child? Which should humanity, or policy, first give? Public health is quite as important to the community as public educa- tion, and we shall some time have free doc tors as well as free teachers, leaving the private doctors, like the private schools, for the few who can afiford and prefer them. There are signs of this in the increasing number of doctors already in official service in our health departments and elsewhere. Twenty years ago we had city hospitals and city poor physicians. Now the public roster shows tuberculosis inspectors, tenement inspectors, food, milk, and drug inspectors, school medical inspectors, school nurses, bacteriologists, and even school dentists ; and we might add as health officials the smoke inspectors, public bath house keepers, and the playground direc- tors. Many cities pay for public lectures on sanitation, hygiene, feeding, and flies. The social value of public health is incalculable, and the public is realizing this.” These thoughts penned almost 20 years ago are not only true but singularly timely. In most countries of Western Europe var- ious systems of gratuitous medical service have been in operation for some time. Not one of them, however, as was observed by Dr. Wins- low, Professor of Public Health at Yale, in his tour of investigation as member of a com- mission of the League of Nations, is com- patible with our institutions and traditions, be- cause they savor too much of class legislation. 1 hey represent diverse insurance schemes, de- signed primarily for the poor. They resemble somewhat the cheap contract service rendered fraternal societies in many of our larger com- munities. Because of being incompletely or- ganized, they retain the evils of individualistic, competitive practice and lack the advantages of cooperative medicine. In an article published in the American Mag- azine of April 1916, entitled, “Better Doctor- ing for Less Money”, Dr. Richard Cabot, in- ternationally renowned in the realms of both medicine and sociology, showed the impossi- bility of the majority of the people obtaining the full blessings of scientific medicine so long as they depended upon the single practitioner. He explained that there were 2 reasons for this: first, the need of close cooperation and team work ; and second, the prohibitive cost of competition of unorganized individual special- Feb.. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 117 ists whose skill has become more and more in- dispensable. In 1916, also, there was held at Washington a conference on social insurance called by the international association of Industrial Accident Boards and Commissions. So important were its proceedings that they were published in full by the Bureau of Labor Statistics of the United States Department of Labor, in Bul- letin 212. About one-third of the sessions were devoted to the subject of sickness benefits and insurance. The speakers included represen- tatives of employees as well as employers of insurance companies and societies, government and private health and welfare agencies, *besides private and public health doctors of medicine. They were almost unanimously agreed that health insurance was needed. They favored an organization corresponding to the British Panel System in which the privilege of selecting one’s physician from among competitive individuals is permitted and in which are introduced in- termediary agents or referees of the insurance companies or the friendly societies to super- vise the work of the physicians, because the doctors, though paid by the insurers for services rendered to the insured, are tempted to be too partial to their patients, whose good will they naturally strive to keep. This particular system, which had not then been thoroughly tested, has since proved to be incompatible with scientific medicine. It will probably be super- seded by a free public service. During the World War fully organized medicine maintained the health and fitness of the naval and military personnel at such a level that for the first time more combatants were killed by projectiles than by diseases. Surely the sudden and vast recruiting of the regular medical corps of both the navy and the army subjected such a health system to a most severe and thorough test. Since their members, most of whom were enrolled tem- porarily for the duration of the war and had been unaccustomed to discipline and coopera- tion, did cope so successfully with the prob- lems of mobile forces exposed to the greatest hazards to health and vigor, certainly such an organization would insure the adequacy and efficiency of a permanent body with its in- herent esprit de corps, ministering to the rela- tively immobile civilian population. Since the war the necessity for such a free health service has become imperative. The medical sciences have been growing so fast as to increase the demand for genuine specializa- tion. But many specialists, self-appointed, have not complied with any recognized stand- ard. They have pursued their profession in- dependently and unrestrainedly. They have un- duly encroached upon the province of the gen- eral practitioner, disrupting his practice and increasing the expensiveness of medical diag- nosis and treatment more than ever. For, in general, the division of labor without organiza- tipn is bound to add to the cost of its product and, besides, because of waste and friction, competition in a public necessity cannot fail to do likewise. So these unbridled members of the profession require control and regula- tion by incorporating them with physicians, in general, into a service like that of the navy. Since the war, furthermore, private and pub- lic health agencies have so multiplied and ex- panded as to decrease materially the available profitable work for private physicians. More- over, with the decline of the prestige of reg- ular doctors struggling for a: livelihood, multi- farious healers have invaded the field of medi- cine. For these reasons specialists, particu- larly upon whom falls the burden of most charity seiwice in hospitals, have been com- pelled to demand of theii paying patients ex- cessive fees. Some have adopted the business principle of charging all that the traffic will bear. They were abetted by the recent period of unprecedented prosperity. Its collapse, however, and the return of a normal or sub- normal economic State will accentuate the urg- ency of cooperative public medicine. So, it is but natural that the present chaotic status of medicine should give rise to much dis- satisfaction. The poor, who are dependent upon hospital service, suffer from want of home treatment. The rich complain about the extortionate fees of the experts, whose time and energy are partly consumed by charity pa- tients. Middle class patients, blindly groping for succor, are embarrassed most of all by the prevailing disorder and confusion because they are paying dearly for the poorest treatment. 118 JOURNAL OK THE MEDICAL SOCIETY OK NEW JERSEY Feb., 1931 Among doctors, too, the conditions of prac- tice today are unsatisfactory. The medical man begrudges the surgeon his large fees, especially since many are derived from operations such as he himself performed while serving as an intern. He is vexed by the anomalous state of a profession in which hand work pays much better than brain work. The honest scientific doctor is disgusted or worried by a widening divergence between the intelligent pursuit and the actual practice of his profession. He re- sents the success of the dishonest practitioner who lures gregarious mankind by his sheer artfulness and his ostentatious appurtenances; not from envy of him but from sorrow for the beguiled and the benighted, denied the advan- tages of scientific medicine. In this day of quick transportation and instantaneous com- munication the conscientious physician depre- cates the fact that the practice of medicine con- tinues to lag so far behind the theory of medi- cine. Why should it have taken at least 15 years to educate the practicing physicians in the correct use of diphtheria antitoxin, one of the few specific internal remedies? Also, why should the mortality from appendicitis have actually increased during the last 5 years? The flagrant inadequacy of medicine has been fearlessly decried by a few leading medical men. They have piqued many of their fellows, smug and complacent, who like rabid members of trade unions have forgotten that every part of society exists for the good of the whole, not the whole for any one part. Dr. William Mayo, one of the founders of the far-famed Mayo/ Clinic, publicly declared that there were in cer- tain aspects of medicine too much salesmanship and too little humanity. He stated what Dr. Cabot implied in his article, to which refer- ence has already been made, that the ward pa- tient under the care of the regular hospital staff usually received better treatment than the private room patient attended by his in- dividually selected doctor. In the issue of Harper’s Magazine for Sep- tember 1929, Dr. Joseph Collins in his contribu- tion, “The Patient’s Dilemma”, showed that nowadays patients had to do considerable shop- ping among doctors before they could obtain personal satisfaction. He asserted that the root of the evils of medicine today lay in money. It is true that the vital perplexing questions he raised can be answered only by the deliberate institution of a free, ready medical service. Since, after all, the subject of proper medical care is sociologic, laymen have quite naturally undertaken to solve this baffling problem, than which there is not one more important. Soci- ologists have rightfully denounced medical prac- tices. Their studies and opinions, however, have not been widely diffused. The first busi- ness man openly to find fault with medicine’s unreasonable status was Edwin A. Filene, the Boston merchant. To. the January 1930 Gra- phic Survey he contributed an essay in which he condemned the inefficiency and waste of un- organized medicine, into which he has gained a clean insight through his personal relations with numerous employees about whose happi- ness he has been much concerned. .He advo- cated the injection into medicine of business methods such as have made possible so many beneficent industrial and philanthropic organ- izations of this progressive era. Without business profits, however, nothing can intro- duce into medical practice such efficiency and humanity as a free system patterned upon that of the United States Navy. Is it not evident, therefore, that at this stage in our civilization a system of free public medi- cine is urgently needed? In civilian life prog- ress in medical economics has obviously lagged far behind the advancement of medical science. In the navy, however, it is not so. As soon as the people are aware of this fact, like represen- tatives in Washington, they will adopt such a service as the Bureau of Medicine and Sur- gery of the Navy, whose function is to pre- serve the fitness of each of the personnel for his duties and to restore any of them to duty as promptly and as fully as possible. This means the practice of preventive medicine primarily and of curative medicine secondarily : without question a sensible purpose. With this, contrast civilian practice, in which, on the one hand, the patient procrastinates in seeking re- lief from his affliction and, on the other, the physician seems too busy prescribing for ail- ments to take much interest in keeping people well. As a matter of fact he is rarely hired to do so. So long as the civilian doctor is paid F'eb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 1 1 9 by the visits he makes instead of by the time that he spends, he will be tempted to neglect the most important phases of medicine, namely personal hygiene and public health. How does the medical corps serve the naval personnel? Every applicant for the navy is, of course, thoroughly examined by one or more medical officers. Every member is re- examined on frequent occasions, whenever he is promoted or transferred, as well as when ill or injured. All officers undergo at least one regular physical examination every year. So, every one must be found physically fit for his specific duties, whatever they may be or whenever they may change. Every member must be protected against infection with any communicable disease in which appropriate vaccination is effective. Whenever anybody appears to be unable to perform all his duties on account of illness or injury, he is immediately referred to the medical officer on duty. The medical officer must ascertain, if possible, the cause of the complaint and decide what should be done for the patient. If the patient be dis- abled, he is kept under the care of the medical department and his name is posted upon the sick list until he has been pronounced fit to return to duty. Possibly he requires admis- sion to the hospital, where he receives intensive study and appropriate treatment. The naval surgeon, moreover, takes a nat- ural interest in everything in the environment of the personnel that may affect health. He is responsible for sanitation of the ship or the shore station to which he is officially at- tached ; in particular, the clothing, food, quar- ters, working conditions, and athletics; in gen- eral, everything which may impair health, jeopardize life, or endanger limbs. He instructs members of the crew in first aid and in hygiene. He is a true teacher quite worthy of his title of doctor. The assignments of naval surgeons depend much upon their rank, which is determined chiefly by their knowledge, skill and exper- ience. The younger men are attached to smaller vessels or stations in charge of all medical matters or to hospitals or larger stations as assistants to their superiors. The older sur- geons fill administrative positions as command- ing or executive officers in hospitals, in the offices of the central bureau at Washington, or in the Naval Medical College. Those in the in- termediate ranks are usually engaged in active medical and surgical practice. They are en- couraged to become expert in at least one specialty of medicine. In contrast to the civilian doctor who renders whatever menial personal service his patients demand, the naval surgeon as he rises in rank is en- trusted with greater responsibilities and ac- cordingly relieved of the simpler routine duties which are carried out with more zest by his juniors. He aids those below him, he is aided by those above him, ever ready to co- operate. He is able to practice his profession intelligently, because he has no occasion to bluff or to guess. He does not need to hurry ; he must do his work with diligence and pre- cision, since he is supervised and checked both directly by those associated with him, and in- directly by those at the headquarters of the Bureau of Medicine and Surgery. If his effi- ciency be impaired by sickness or fatigue, he is temporarily relieved of duty. Since, as he attains the higher ranks, the scope for his energies increases he is happy to pursue his profession for its intrinsic gratifications, where- as the civilian physician aspires to attain a competence so as to escape from the servitude of his patients or to relinquish the private prac- tice of medicine entirely for something more congenial and less arduous, like business or banking or politics. To medicine alone the naval doctor dedicates his whole career and gives to his fellow men the full benefit of his mature judgment. The naval doctors are stimulated to main- tain a high standard by means of constant affiliation with their colleagues in 2 ways : through rivalry with those of equal rank and through supervision and control by those of superior rank. That they do maintain a qual- ity of practice above that of civilian physicians is attested to by many civilians serving with them during the World War. That fact is tacitly acknowledged, furthermore, by the American Medical Association, which admits all naval medical officers to fellowship uncon- ditionally, automatically by virtue of their commissions, whereas fewer than half the civilian physicians can meet the necessary pro- 120 HH RNAL 01 THE MEDICAL SOCIETY OF NEW JERSEY fessional qualifications for admission to fellow- ship. Finally, Congress has thought well enough of the medical corps of the Navy and Army to vote its members the right to free service. Surely at a time when congressional fact-finding and fault-finding committees or commissions are investigating almost every- thing there is no need of additional evidence of the superiority of such a medical service over competitive practice. Such an organization as the Bureau of Medi- cine and Surgery of the Navy can be applied to civilian practice either by expanding the present public health department of any com- monwealth or by creating a bureau of public medicine incorporating that department, the welfare department, industrial accident board, municipal and county hospitals, and what- evei private hospitals may be required to furnish a state-wide service. It would con- stitute a complete public system of medicine with free professional service for all estab- lished residents of the state. It would be composed of full time medical officers of dif- ferent ranks, according to their respective abil- ity and experience, working together in and about hospital bases with the necessary aux- iliary personnel, so well organized as to in- sure suitable discipline, supervision, and con- trol of each member, and to stimulate interest and effort by rewards of promotion and prizes. 1 he hospital units would be coordinated by a central state bureau with the requisite admin- istrative divisions. One of the most valuable functions of such a medical corps would be the keeping of permanent health records of each patient, in fact of every citizen, to facilitate and expedite the successful management especially of urgent cases. Whereas in the present cha- otic state of private competitive practice many people often do not know where to obtain proper medical attention or cannot afford it; government medicine, furthermore, would not only furnish the best possible service, but would also readily guide the patient, though suffering and bewildered, to the source of optimum treat- ment. Under this proposed complete system of co- operative medicine, since the individual physi- cian would necessarily be subservient to the whole, a patient’s choice of doctor would be absolutely precluded. And so it has been for dt cades for those ward patients who have avail- ed themselves of the superior service offered by tht larger well organized hospitals where the best scientific medicine has been practiced. And so it must be from the very nature of modern medicine, founded upon the rapidly growing and expanding sciences for which team work is die sine qua non. Today this freedom to select one’s physician actually redounds to the dis- advantage of the patient, who does not know where to procure the best advice, because of the obsolescence of the genuine family doctor, ever ready to serve the child or the grown-up' day or night, and the absence of any successor to aid or to guide. On account of the gre- gai iousness of mankind, this selective privi- lege has been responsible, according to esti- mates of drug salesmen calling upon physi- cians, lot about 20% of the doctors doing about 80% of the medical and surgical work. I his has certainly encouraged, on the part of the busy popular practitioners on the one hand, haste, carelessness, and fatigue with conse- quent inefficiency ; on the other, rank commer- cialization of medicine and heartless exploita- tion of patients. It has fostered the practice ol the art, or easier phase of medicine, and stifled the scientific or harder. It has nurtured much bunk, humbug, and license; it has sup- pressed much honesty and truth. Since, finally, the welfare of the people is a primary function of a democracy, only the government can supply a universal need which, h is generally admitted, private agencies have signally failed to meet. This utility is undeni- ably of prime importance to every one, young and old, unborn as well as born. For health has now become more essential to success and happiness than education. Public education has long ceased to be socialistic. So, surely, public or state medicine cannot be rejected as undemocratic. Moreover, no longer to be re- garded as untenable is the application to their own purposes of such an excellent medical or- ganization as that of the Medical Corps of the United States Navy. Jn conclusion are quoted 4 pertinent sen- tences from the inaugural address of President Hoover. Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 121 “In public health the advances of science have opened a new era.” “Many sections of our country and many groups of our citizens are suffering from dis- eases the eradication of which are mere mat- ters of administration and moderate expendi- ture.” “Public health service should be as fully or- ganized and as universally incorporated into our government system as is public education.” “The returns are a thousand fold in eco- nomic benefits, ■ and infinitely more in the re- duction of suffering and the promotion of human happiness.” SOME SOURCES OF INFORMATION AND MISINFORMATION IN CARDIAC DIAGNOSIS' Jacob Polevski, M.D., Newark, N. J. The clinician of today depends a great deal for his diagnosis on the so-called modern methods of precision that the laboratory offers, one of the most important of which is roent- genology in the study of cardiac conditions. A greater accuracy in diagnosis, is the concern of the present contribution. The amount of information the clinician de- rives from a roentgenologic plate or series of plates in the study of a gastro-enterologic or pulmonary condition is invaluable. The find- ings are fairly positive and sources of error are rather negligible. Not so with roent- genologic plates of the heart. The possibility of distortion of shape and configuration of the heart shadow on the film by improper position of the patient in relation to the tube is obvious. The attempt to obtain the actual size of the Fig'. 1. Short stocky patient with a high diaphragm. Heart shadow is of a distinctly aortic type; cardiac angle very pronounced, aortic knob prominent. cardiac roentgenogram taken at a distance of 6 feet is supposed to offer the clinician a tre- mendous amount of information regarding the actual size and the normalcy or abnormality of configuration of the heart as a whole or of its various parts. How much this laboratory aid, as generally carried out, helps to inform or misinform the clinician in his search for *(From the Department of Cardiology of the Newark Beth Israel Hospital.) heart by the plate at 6 feet distance, or by ortho- diagraphic tracing under the fluoroscope, is not always rewarded with an accurate result, as we shall point out subsequently. There are var- ious factors that influence and frequently vitiate the result. It is not within the scope of this contribu- tion to go into minute descriptions of all the possible errors, shortcomings, and methods of their correction, in the roentgenologic study of 122 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., I9:u the heart; we shall limit ourselves to a few phases of the subject, its difficulties, sources of error and methods of overcoming them. When one attempts to familiarize himself with an object whose surfaces are rather of a complicated nature, he will look at it from every side and angle. 'A picture of one sur- face will by no means suffice to give a com- prehensive idea to the shape and configuration of the object, and yet, this is precisely the situ- ation with roentgenology of the heart or of its various parts when we attempt to draw a con- clusion from study of one film only. The fal- lacy of this method is obvious. The heart occu- thus varies with the respiratory phase of the diaphragm and lung movements. It is also in- fluenced by many other extrinsic factors, as we shall point out presently. When the diaphragm descends during inspiration the heart not only assumes a more vertical direction but also changes from a somewhat levo to a more mesial position. While doing this, the heart also per- forms a rotary motion, thus bringing various parts of the heart that are usually seen en face, into a more profile position. Furthermore, on inspiration, the expanded lungs exert a great deal of pressure upon the surrounded heart and bring about an appreciable diminution in its Fig:. 2. Same case as in Fig-. 1 in deep inspiration, dia- phragm on descending carries heart with it; cardiac angle markedly diminished; aortic knob less prominent. pies the greater part of the mediastinum. It is fixed chiefly at its upper part to the tissues covering the spinal column by the large ves- sels. The major or lower part of the heart is suspended from above and is practically freely movable. Below, it rests on the more central part of the diaphragm, which structure under- goes upward and downward excursions during the 2 respiratory phases. On either side, it is surrounded by the lungs. The position and condition of the surrounding structures neces- sarily greatly influence the shape and apparent size of the heart. The position of the heart in the mediastinum, as well as its configuration. transverse diameter. This is particularly true in the case of a thin-walled heart of dilatation. 1 he aortic shadow, its size and width, as well as its intensity, play a great role in car- diac diagnosis. Here, too, there is much to be desired in greater accuracy of interpretation of the shadow produced on the film or on the screen. The usual report of the roentgen- ologist reads as follows : The aortic arch is widened, or the aortic knob is prominent or accentuated. Now, as in the case of the heart proper, the size and shape of the aorta, too, will vary not only with intrinsic changes with- in the aorta, but with numerous alterations in Feb.. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 123 position of the surrounding structures, parti- cularly by the condition of the spinal column. While studying a cardiac plate, the question whether the heart is that of a mitral or aortic type stands out foremost. The mitral heart, because of the enlarged left auricle and some- what more prominent pulmonary artery, causes a diminution in the cardiac angle — the angle between the upper vascular part and the lower cardiac part of the left border, which brings about a straightening-out or even a convexity to the left, instead of the concavity usually found. In the aortic heart, on the other hand, because of hypertrophy or dilation or both of tation, brings about a straightening of the left border, thereby causing a marked diminution and occasionally a complete obliteration of the cardiac angle, thus producing a typical picture of a mitral type heart where no mitral lesion exists. The same prevails in the case of the tall ptotic individual whose chest is long and diaphragm low, thus permitting a very vertical position of the heart even without the inspira- tory phase. (Fig. 3.) And it is particularly in these cases where an erroneous diagnosis of a mitral lesion is frequently made. On the other hand, one may err by being reluctant to make Fig. 3. Definite ptotic heart. Long and mesially placed. the left ventricle, the above mentioned angle becomes exaggerated and the concavity mark- edly increased. It is on the basis of these changes in the contour of the left border that the roentgenologist bases his opinion as to the type of heart he is confronted with. Changes in configuration of the left border can be and are frequently brought about by ex- traneous factors that are not given sufficient consideration, and the interpretation is there- fore frequently misleading. As stated above, on inspiration, due to the descent of the diaphragm, the heart assumes a more vertical position. This, coupled writh the incident ro- a diagnosis of mitral heart when bearing in mind the fact that this status ptoticus is con- ducive to a pseudo-mitral shape, and thus may miss the diagnosis ; particularly apt to occur in the case of a silent mitral stenosis. In case of die short, stocky individual with a short chest and with the usually high dia- phragm, the reverse is true. The body of the heart proper is forced by the high diaphragm upward, while the upper shadow, made by the large vessels, is fixed ; in this way the cardiac angle becomes exaggerated, and an impression of an aortic configuration is produced. Methods of overcoming, diagnostic difficulty. 124 JOURNAI. OK THE .MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 Fig'. 4. Heart in a ptotic patient. Very suggestive of a mitral configuration. There was a systolic murmur over apex. No other signs of cardiac difficulty. Fig. 5. Same case as in Fig. 4 in lateral position. Esophagus shadow not indented, showing no enlargement of either left auricle or right ventricle. Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 125 Fig. 6. A definite case of mitral stenosis with its typical configuration. Fig. 7. Same case as in Fig. 6 in lateral position on ingestion of barium paste. Upper half of retro- cardiac part of esophagus is definitely in- dented and displaced toward spinal col- umn by the enlarged left auricle. 126 JOURNAL OK THE MEDICAL SOCIETY OK NEW JERSEY Feb., 1931 In the questionable aortic type, the method is simple. Have the patient take a deep inspira- tion. In the true aortic heart where the in- creased cardiac angle is due to hypertrophy of the left ventricle the particular configuration will persist ; while in the pseudo-aortic con- figuration produced by high diaphragm, the heart will straighten itself out, and the cardiac angle will diminish as soon as the diaphragm descends. (Figs. 1 & 2.) In the questionable mitral heart the solution .is not so simple. Here, inspiration will not help us. On the contrary, it exaggerates the tion and asked to swallow a tablespoonful of barium paste ; when a marked indentation of the retrocardiac esophagus by the bulging left auricle can be clearly made out. This procedure establishes the diagnosis of a mitral lesion be- yond any doubt, and is an invaluable aid in cases of questionable mitral lesion where the only positive sign is that of a systolic murmur at the apex. These murmurs, as we all know, I frequently puzzle clinicians as to their sig-B nificance, and absolute diagnosis of an organic ; functional nature is frequently impossible.! (Fig- 7.) Fig. 8. Case of a young boy with mitral stenosis. The left auricle is definitely seen on the right side of the heart shadow v/hich is more intense at this point because of the super-imposi- tion of the 2 chambers. condition. So we must resort to another method. l'he esophagus is located immediately behind the heart in the lower part of the mediastinum. It courses downward in an almost straight line. (Pig. 4.) Now, in the case of a mitral lesion, some degree of enlargement of the left auricle takes place to the left but chiefly posteriorly, thus encroaching upon the posterior mediasti- num and particularly upon the retrocardiac part of the esophagus. The patient is placed in the right oblique, or even in the right lateral, posi- We might add here that occasionally the en- larged left auricle may assume such enormous proportions as to reach over to the right border of the heart and produce a paradoxic situa- tion where the left auricle makes part of the right border of the heart. The Roentgen shadow will show 3 curves, instead of the normal 2, making up the right border of the heart ; the lower curve being due to the right auricle, the middle curve due to the left auricle and the upper curve to the ascending Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 127 aorta. Such a third curve is often mistaken for an aneurysmal dilatation of the root of the aorta, or for a sacculated pericardial effusion. This mistaken diagnosis can also be obviated by the barium ingestion in the right oblique position where the auricular hypertrophy can be definitely made out. Occasionally such an enormously enlarged left auricle will produce physical signs of a sacculated pleural effusion in the right interscapular space. On doing a paracentesis one will naturally aspirate blood oblique position. The former will appear wider as compared with the latter. All conditions that change the anteroposterior relation between the ascending and descending parts of the arch will influence its apparent width. One of those conditions is kyphosis or scoliosis of the spinal column. In kyphosis the greater convexity of the spine carries the descending part of the arch to a position al- most immediately behind the ascending part. Such an arch, looked at en face will, naturally, Fig. 9. Severe case of mitral stenosis. Left auricle projects beyond the right border of the heart. Case proved by autopsy. and make the diagnosis of an hemorrhagic pleural effusion. (Figs. 8, 9, 10, 11.) As to roentgenology of the aorta, anatomi- cally the arch runs first upward, then back- ward and then downward, so that the ascend- ing part of the arch is anterior to the descend- ing part. It is easily conceivable that anything that will bring the descending part of the arch more anteriorly will cause a widening of the shadow of the arch as a whole on the screen. '1 his is made more clear when we think of the perspective view of a flat surface, in one in- stance looked at en face, in the next, in a more look extremely narrow. In scoliosis the de- scending part of the arch assumes a more lat- eral position in relation to the ascending part, and thus the shadow of the arch as a whole projected on the screen or film will appear much wider than it really is. There are many other factors that will influence the apparent width of the shadow of the arch. Anything that will flatten out the rotundity of the arch will cause its widening without bringing about a real change in the size of the aorta. A large substernal thyroid pressing down on the arch will do it. Likewise a very high diaphragm, 128 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 crowding the heart up against the arch, will do the same. Thus, we see that taking the width of the arch shadow as seen on the film, as an index of the real intrinsic condition of the aorta, may be frequently quite misleading. However, the question arises, is it the measurement of the width of the arch that is of diagnostic importance, or that of the cross section, or the diameter of the lumen of the aorta that is of greatest consequence. On care- ful consideration one realizes that it is the latter that is paramount. outermost tangential point of indentation caus- ed by the aorta, again by the aid of the ortho- diagraph. The measurement between the 2 tangential points minus 2 mm. that represent the thickness of the wail of the compressed in- terposed trachea, indicates the true width of the aortic tube, which m the normal male adult measures 3 to 3.5 cm. This procedure is known as the Kreuzfuchs’ method. (Fig. 12.) After a little application and practice, it is accomplished very easily and without appre- ciable loss of time. The additional few min- Fig. 10. A most severe case of mitral stenosis. The left auricle bulges out beyond the right border of ■ the heart. ' Case was diagnosed as a sacculated pericardial effusion, also as a possible tu- mor. Clinically it gave all the symp- toms of a pleural effusion. We must then endeavor to obtain, either on the screen or on the film, the shadow of the lumen of the aorta looked at en face, and then obtain its accurate measurement. This is ac- complished in the following way : Place the patient in the right oblique position. Under orthodiagraphic guidance, mark the left outer- most tangential point of the aorta. Then have the patient swallow a tablespoonful of the bar- ium paste. The aortic indentation of the eso- phagus is readily visualized. Mark the right utes thus spent are more than repaid by the greater exactness of information thereby de- rived. We pointed out above the influence of the respiratory phases of the lungs and diaphragm on the contour of the heart. At this point we want to emphasize the fallacy of taking heart roentgenograms in deep inspiration — a practice followed by practically all roentgenologists. We ostensibly attempt to be very exact in the measurements of the diameters of the heart. Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 129 yet we overlook the fact, as pointed out above, that deep inspiration will compress the heart, particularly so when the heart is dilated, and thus diminish the transverse diameter by 1 cm. or more. As a matter of fact the extent of in- spiratory compression and consequent reduc- tion of the transverse diameter of the heart can be utilized as a means to determine whether widening of the transverse diameter of the heart is due to prepondering hypertrophy or dilation. The hypertrophied heart will suffer little compression while the dilated organ will be materially compressed and thus will under- Best results and most accurate information are obtained by resorting to fluoroscopy, when the extent of the various changes in the shape and size of the heart viewed from different angles in either of the respiratory phases can be ascertained. The fluoroscope also offers us the opportunity to scrutinize the variation in the contractile power of the heart. The vigor or tardiness of the ventricular contraction con- veys a very definite impression as to the quality of the myocardium. If a roentgenographic film is taken, it is best done while the patient holds his breath midway between expiration Fig. 11. Same case as in Fig. 10. In lateral position on ingestion of barium paste. Upper half of re- trocardiac part of esophagus is definitely in- dented and displaced toward spinal col- umn by the enlarged left auricle. go marked diminution in its transverse dia- meter. It is obvious that cardiac roentgenograms must not be taken in either extreme inspiration, for reasons mentioned above, or in extreme expiration, as in this phase the higher position of the diaphragm tends to produce an apparent aortic configuration and a false impression of widening. In the case of severe myocardial degeneration, deep inspiration will allow length- ening of the heart and thus frequently obliter- ate the typical mushroom or bottle-shape of the heart that is of great diagnostic importance. and inspiration or, to be more explicit, with the patient holding his breath after a slight in- spiration. Of course, a film in deep inspiration looks prettier, but then, all know that beauty and accuracy do not always go together. As a matter of fact the film is to be used merely as a means of permanent record. Fluoroscopy of the heart is really the job of the cardiologist. He should attempt to view' the heart under the fluoroscope as one looks at an object under a glass jar. Being most conversant with all shades and phases of various pathologic conditions and congenital 130 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 anomalies, he is most qualified to interpret the findings and evaluate the various deviations from normal. Among all the methods at his •command, the fluoroscope should occupy the very most important place. Summary (1) The respiratory phases, by changing the pulmonic volume and diaphragmatic position, (5) Care must be exercised not to mistake such an enlarged left auricle for an aneurysmal dilatation of the root of the aorta, for a sac- culated pericardial effusion, for a mediastinal tumor or, clinically, for a pleural effusion. (6) The measurement of the width of the aortic arch is no criterion of the condition of the aorta. (7) The width of the aorta can and should Fig. 12. Kreuzfuchs’ method of measuring the width of the lumen of the aorta. The barium in the eso- phagus is definitely indented by the posterior wall of the arch. The distance between the 2 tangential points minus 2 mm. represents the width of the aortic tube. materially influence the cardiac size and con- figuration. (2) A low diaphragm is conducive to mitral configuration; conversely, a high diaphragm is conducive to aortic configuration. (3) Indentation of the retrocardiac part of the esophagus rendered visible by ingestion of barium paste is an important aid in the diag- nosis of questionable mitral conditions. (4) The left auricle may and often does as- sume such enormous proportions as to reach over posteriorly to the right border of the heart and even project beyond it. be determined by the measurement of the di- ameter of the aortic tube which is made pos- sible by the Kreuzfuchs’ method. (8) To properly and adequately visualize the heart and aorta one must not limit himself to the study of a film in the anteroposterior position, but must fluoroscope the heart from various angles in different respiratory phases ; also, one must observe carefully the vigor or tardiness of the cardiac contractions. (9) The fluoroscope is an invaluable aid in cardiac diagnosis in the hands of the exper- ienced cardiologist. Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 111 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J. Entered at the post office at Orange, N. J.f as second-class matter PUBLICATION COMMITTEE HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J. EDITOR: HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J. Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to receive the paper will conier a favor by notifying the Chairman ot the Publication Committee ol the tact. NOTE. — The transaction of business will be expedited, and prompt attention secured it: All papers, news items, reports for publication and any matters ot medical or scientific interest, are sent direct to The Editor, Atlantic City, N. J. All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements, or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication Committee, f address above), Newark, N. J. COUNTY SOCIETY ADVERTISING During the past year several articles have been published, one or two in professional journals, the others in secular magazines, urg- ing physicians to advertise or denouncing the medical profession because it does not adver- tise in the daily press. Quite recently one of the country’s prominent evening newspapers scolded us severely for not having aided in wider dissemination of the Coffey-Humber cancer cure, alleging that thousands of lives would have been saved if the profession had joined in the advertising of that marvelous discovery; but, by the irony of fate, that scold- ing was published in almost exact coincidence with publication of refutation of the Coffey- Humber claims. What a fine spectacle the pro- fession would have made of itself, had it, on the basis of such slight claims, advertised abil- ity to cure cancer. In so far as our observation has gone, the pressure brought to bear upon the pro- fession by advertising agencies, and the at- tempts to ridicule physicians for holding fast to a code of ethics that has well served them and their patients for hundreds of years, have been instigated by the “business” proclivities of those who would unscrupulously use an honor- able profession for the base purpose of bring- ing a few more dollars into the paper’s adver- tising office. We have yet to see a medical ad- vertising plan emanating from newspapers or magazines that bears any real evidence of in- terest in the welfare of the physician or the public. Some medical societies have engaged in ad- vertising to the extent of paying for newspaper publication space in which to provide the public with information concerning health promotion or sickness prevention ; educational campaigns for the public welfare but not for personal gain, benefit or aggrandizement. Even that sort of advertising has not been unanimously approved, and it remains to be demonstrated that it is wise policy for our county societies, or for any other units of organized medicine. Our attention has been forcibly drawn to this question during the past few weeks by a proposition submitted to one of our own com- ponent county societies. You may observe in the reported proceedings of the Camden County Society, in this issue, that the society “referred to the State Society Welfare Committee a sug- gestion from one of the local newspapers con- cerning paid educational advertisements which were to be run in series”. To be exact, the proposition was referred to the Chairman of the Welfare Committee, and by him was re- ferred to the Executive Secretary for consider- ation. We are publishing now our opinion be- cause we fear the same proposition may appear in some other county society, and deem it wise to endeavor to prevent any group from inno- cently falling for the scheme. The following letter to the Secretary of the Camden County Medical Society will explain the proposition and our views thereon : "January 18, 1931. Dear Dr. Buzby: On Friday evening-, January 9, I received as visitors, by appointment, 2 gentlemen who sought my approval of a plan to sell advertising space in a Camden newspaper to the Camden County Medi- cal Society or to individual members of that so- ciety. They exhibited the advertising material pre- 132 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 pared by a publicity expert in Indiana, together with a list of papers in which such ads have been published, and letters purporting to endorse the ads and the scheme in general. In the course of conversation I was informed that they had asked the county society $4000 for publishing 26 articles at weekly intervals for 6 months, and that offer having been declined they were seeking 80 sub- scriptions from members at $50 each to pay for such publication of said advertisements. They further informed me that you and Dr. Lippincott had refused to support the plan unless and until the State Society gave endorsement thereto, and that you had both advised consulting the Execu- tive Secretary of the State Society. I discussed the question with them in a friendly manner and stated my personal objections, but promised to think the matter over carefully and without prejudice if they would leave the material with me a few days. I have given the promised careful consideration to this subject, in so far as possible to all of its effects and ramifications in addition to its primary results, and I have to record the opinion that it would be unwise for any county society or individual physician to partici- pate in this scheme. To the newspaper this is purely a scheme for selling ad space— without even a pretense of in- terest in physicians or public; a money-making proposition — nothing else. To the medical profession it is a cleverly worded, alluring proposition to secure publicity without violating the Code of Ethics. I have said that the wording is a clever arrangement but I must add that the choice of subject matter is anything but clever. To harp upon the theme that physicians are not promptly or adequately paid for profes- sional services, weekly for 6 months, would be mighty poor psychology — especially at a time when there is so much discussion concerning ‘the high cost of medical care’. Furthermore, the only ‘in- direct advertising’ that organized medicine may justifiably (?) engage in is paid-for publication of the benefits which scientific medicine holds out for the public welfare. This proposed advertising does not fall within that classification. I am returning the documents to the paper’s representative, and most respectfully recommend to you and Dr. Lippincott that your county society members be advised to . have nothing to do with the scheme. Thank you most heartily for directing this mat- ter to my attention, and thus affording me the opportunity to become informed about another scheme for separating the hard pressed physician from his hard earned dollars. Sincerely yours, (signed) Henry O. Reik, M.D., Editor & Executive Secretary.” MEDICAL SERVICE OF THE FUTURE 1 hose of you who read the proceedings of the Annual Conference of County Medical So- ciety Secretaries and Reporters, in the Decem- ber Journal, will recall the amount of discus- sion devoted to so-called state medicine, and you may remember that the Secretary of the State Society gave a brief sketch of the steady advance of governmental control of medical practice, and the Executive Secretary alluded to the suprisingly large number of articles upon that subject that had been published in state society journals in the short period of time be- tween May and October 1930. We are still hoping to find time to abstract those articles, in order that a comprehensive survey of the situation may be laid before you. Recounting our vacation experiences, in the January Journal, we announced the intention to write later about the National Health Insur- ance Act of Great Britain and the present status of such legislation in England and in France. We shall reach that point in our travel talk next month, and will in successive monthly instal- ments cjuote sections of the English and French laws, together with authentic interpretations of important features, so that you may have an accurate picture of existing conditions. Meanwhile we must keep an eye on the progress of events nearer home. Legislatures are at present meeting in most of the New England and Middle Atlantic States and we shall not be surprised if some radical proposi- tions appear in several of the larger states. Acts embracing centralized control of practice, in one form or another, were under considera- tion in more than one state legislative assembly during the sessions of 1929 and 1930. In our own state we had in each of those years to combat an “Act to Control the Practice of Sur- gery and the Surgical Specialties”. Most of the Bills so far presented, whether applying to surgery or to general medicine, have been so extreme in their provisions as to kill them- selves. But, it behooves us to continue watch- ful and to study carefully every proposition that is submitted, in order that we may act intelligently, be prepared to support any move- ment that gives reasonable assurance of bene- fiting humanity, and to oppose any legislation that experience leads us to believe would be impractical, unworkable, or detrimental to pub- lic welfare. Our first duty is to become well-informed — as thoroughly so as possible — regarding the suc- cess or failure of such experiments elsewhere, and concerning measures that have been con- sidered or are being introduced in this part of the world. It is that conviction, i.e., that it is our duty to study this economic question Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 133 is scientifically as we would a newly proposed remedy for some bodily disease, that induces us to report upon the progress of events in uther countries and to direct attention speci- fically to projects that may suddenly present themselves for decision. There is an old adage that “where there is so much smoke, there must be some fire”. Generally, there is some good reason, some degree of truth, back of or under- lying any public clamor that persists for an appreciable length of time. Many of the books and articles criticizing the medical profession and threatening dire consequences if practice is not immediately revised, have been ridiculous, and not a few of them evidently inspired by prejudice, even at times hatred, based upon ignorance or falsehood. Not infrequently a sound basic complaint has been exaggerated and distorted and expanded into an unreason- able protest supported by an illogical argu- ment. But, we must admit that there have been some reasonable complaints, some justifiable protests against harmful procedures that have grown up in and become fastened upon the modern practice of medicine. These abuses must be corrected, and we are confident that none will excel the great mass of honest physi- cians— 90%, at least, of all members of the urofession — in applying the corrective, once it has been judicially determined what is wrong and what is the remedy. Admitting for the sake of argument, that the present state of unrest and of dissatisfac- tion with medical practice is in some measure justified, let us inquire whether state medicine is the proper, the best, or the only remedy. When its proponents have presented their case, we shall be in a position to answer, to argue, and, if necessary, to contend for an honest and just decision. Flat denunciation of any pro- posed change, especially if the proposition be vague and poorly understood, is futile. If there is anything radically wrong with the custom- ary procedures of professional practice we want to know it. If there is a better method of prac- tice we want to adopt it. If the great benefits of medical science can be more effectively sup- plied to a larger percentage of suffering hu- manity; if by a change of procedure we can more quickly wipe disease from the face of the earth; if there is a more rapid, more efficient, and more generally satisfactory means of bring- ing about the millennium — for Heaven’s sake, let’s have it ! Whether it be called state medicine or by some other euphonious term matters not ; to us, “a rose by any other name would smell as sweet”. Asking for information — what is state medicine — it would seem wise to direct the query to one of its most prominent advocates. In so far as we have seen, the most logical presentation as yet made of a concrete plan originated with the author of the Bill that, was last year before the Legislature of Massa- chusetts, and with a view to securing for your consideration the best possible statement of the fundamental facts to be embraced in a pro- posed American system of state medicine, and the soundest reasons in advocacy of such a system, we invited Dr. Gilbert W. Haigh, of Worcester, to prepare for us the paper which you will find under the title at the head of this editorial. Dr. Haigh is a worthy member of our profession, who, in addition to exper- ience as a general practitioner in private prac- tice, has served in the Medical Corps of the United States Navy and he knows whereof he speaks. Here is no “sensationalism”, no carping criticism, no threat of punishment for mis- deeds or short-comings ; here is a plain, straight-forward discussion of conditions un- satisfactory to the profession as well as to the public, and a tempered argument in favor of one method of socializing medical practice. It is constructed by “one of our own”, who has given much thought to this very serious prob- lem and who offers what he believes to be the best possible solution. ADDING INSULT TO INJURY BRAZEN EFFRONTERY OF THE AMERICAN TOBACCO COMPANY Has your quiet evening enjoyment of the radio ever been disturbed by the raucous voice of the Lucky Strike announcer, informing the world that “Luckies are kind to the throat”? Has your blood boiled because of the heat en- gendered by his slanderous pronouncement that “20,679 physicians have stated Luckies to be less irritating” to the throat and less likely than other brands of cigarettes to induce coughing? 134 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 Have your respect for science and love of truth suffered under his deceitful, tricky, distorting use of the language of science to bolster up an alleged scientific treatment of tobacco to im- prove its quality? Until recently you might have supposed the manufacturers of “Luckies” had sunk about as far as one could go in tbe slime of dishonest advertising, but there remained at least one lower level and the company has descended to that stage; and for brazen effrontery it takes the blue ribbon. We do not know exactly what has happened but apparently something trans- pired to make the company’s publicity agent realize that the usual radio talk constituted an insult to the medical profession. In conse- quence, it would seem, the speaker now occa- sionally throws out what he probably considers “a sop to Cerberus”; i.e., a gratuitious an- nouncement (in a tobacco advertisement) that periodic health examinations are or should be beneficial, and advising individuals to visit their family physicians at regular periods. Can you beat it? Insult added to injury! Evidently the sponsors of that program believe they can in- sult and slander physicians ad libitum, and then palliate the offense by publicly endorsing a welfare movement that was inaugurated by physicians as part of a disease prevention pro- gram. What next? Quite aside from its offensive character, as viewed by physicians, the Lucky Strike adver- tising matter is about the worst that the Ameri- can business craze for blatant, impudent, false, not-quite-provable-lying adveftisements has yet produced. Let us analyze the speech that is repeatedly broadcast and the wording of ads now appearing in daily papers like the New York Times and magazines like the Forum; publications that ought to be but are not above engaging in the spread of such deceptive and misleading material. I he statement that 20,000 physicians signed cigarette testimonials may be true, though we doubt it. But, if it be true that so large a num- ber of educated men could be induced to “sign a blank check”, the fact must not be over-looked that in this instance the signatures were secured by methods which smack of fraud. While we feel ashamed of the fact that so many of our brothers proved themselves “easy suckers”, the advertiser who procures testimonials through deceptive procedures has little to be proud of or boast about. The statement — “It’s toasted ! Everyone knows that heat purifies and so toasting re- moves harmful irritants that cause throat irri- tation and coughing” — is made to appear as evidence of a scientific fact, but is, in reality, nothing but a jumble of words covering 3 alleged facts which have no true relationship to one another. For instance: “Everyone knows that heat purifies.” We might retort that every- one knows also that heat destroys. What rea- son is there to suppose that heating will purify tobacco? We may assume the answer would be that heat is destructive only when applied in an intense form, and that purification attends upon the use of heat in n oderate degree. Very good, but if by “purifies” it is meant to imply that microorganisms — disease producing germs — are destroyed, we respectfully submit that a considerable degree of heat is required for that purpose, repeatedly applied in the case of spore- bearing germs, and that the heat of toasting is not sufficient to accomplish the purpose. A very simple experiment can be tried in the kitchen. Would any bacteriologist testify that toasting a slice of bread will destroy pathogenic germs on or in that bread, and thus purify it? We think not. Which disposes of that al- leged fact. Perhaps germs were not meant ; we admit they were not mentioned, but we are unable to think of any other form of purification that could have been alluded to in that statement. 1 he second alleged fact (or is it a deduction from the previously alleged fact) is that “toast- ing removes harmful irritants”. What irri- tants.'' Bacterial, as referred to above, or chemi- cal : 1 f the claim refers to chemical substances, pray tell us what chemical irritant can be re- moved from tobacco by the simple process of toasting . We have some knowledge of chemistry but need help to solve that problem. 1 hirdly, it is stated that toasting removes irritants that cause throat irritation and coughing . Again, may we ask what is the name Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 135 and nature of these irritants (characterization of a single one will satisfy our personal curi- osity) that irritate the throat and induce coughing? If the claim can be sustained, that smoking tobacco or cigarettes of any kind produces of itself a specific irritation of the throat and a characteristic cough, there are several thousand specialists in affections of the throat who will welcome proof thereof, and who will be particularly glad to be en- lightened as to the specific nature of the irri- tant. But that is not all — we had almost forgotten the greatest claim of all : “Everyone knows that sunshine mellows— that’s why toasting includes the use of the Ultra-violet Ray.” Ah ! What a lucky strike ! Ultra-violet rays (why not vi- tamins)—Uads of the day — must be worked in to aid the old-fashioned toasting. “Sunshine mellows” — perhaps, but who has proved that it is the ultra-violet end of the spectrum that produces the mellowing efifect, on fruit for instance, and what constitutes the mellowing of tobacco? Like Hashimura Toga, “we ask to know”. What, then, does our analysis show? In plain English, it shows that the bombastic radio an- nouncement and the printed advertisements re- ferred to are a tissue of falsehoods strung to- gether in such an impressive manner as to deceive the simple-minded listener and reader, and the advertiser doubtless hopes that repeti- tion of deceptive statements will give them the effect of truthfulness. And the medical pro- fession is made to appear as endorsing all this tommy-rot. What can we do about it? Shall we, 100,- 000 or more physicians, supinely submit to these nightly radio and daily newspaper in- sults of the Lucky Strike manufacturers, or shall we make some effort to suppress such ad- vertising and to protect the public and our- selves against misleading, deceptive and slan- derous broadcasting, whether by radio or print- ing? You may recall that the old slogan of this same Company — Reach for a Lucky Instead of a Sweet — was quickly withdrawn when the sugar trust aided the candy-makers in a de- mand for suppression. Special Article MEDICAL TRAVEL TALK A Physician’s Vacation in Ireland, England and France Henry O. Reik, M.D. (Continued from January Journal) Leaving Ireland by the route from Kings- town to Llolyhead, we spent a week touring in Wales, en route to England; passing from the Castles of the Donohoes and the Mahoneys to the Castles of the Conways (somewhere along the line an extra letter “a” seems to have been inserted by the American branch of the last mentioned family). Rain pursued our foot- steps but whereas it had been mist in Ireland it became a soaking and a cold rain in Wales. The country, too, changed from rolling hills and valleys covered with lush verdure, to bar- ren, rocky, wild scenery with rushing streams and waterfalls, and even in August it was necessary to have a fire in our room after din- ner or go to bed to keep warm. Wales does have the advantage of being a compact little country with much of natural beauty to in- terest the tourist and its most charming places made easily accessible. Travel by automobile buses has “caught hold” in Great Britain, and one can travel readily and cheaply from point to point by that means of locomotion. So, with Conway as headquarters, we made day trips to Llandudno, Colwyn Bay, Bettws-y- Coed, and other prominent resorts. It was amusing to compare the famed Welsh seaside resorts with those of our country — particularly because the most famous, Llan- dudno, is advertised as the “Atlantic City of Wales”. How the comparison first arose is incomprehensible, for there isn’t the slightest resemblance of one to the other. It was pitiful to see the children hunting for a patch of sand in which to dig, when the tide was out (the beach being covered with rocks and pebbles) and to watch those courageous enough to take a bath running into the water for a momen- tary dip and coming out shivering, to snatch robes and run to the bath house. ' These re- sorts. are famous only because they are all the country has to offer its people, and it is easy to understand that the inland city dweller and the invalids are glad to visit the coast occa- sionally to breathe a cleaner and more sooth- ing air even though sea bathing facilities and comforts are not to be had. Even the casual tourist cannot help feeling Puritanism in the Welsh atmosphere, especially if he is familiar with the general European 136 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 conditions; a puritanical frame of mind that extends even to the naming of places and things. An amusing example was observed in certain retreats which were labeled “Public Conveniences”, and the 2 sections were mark- ed lavatories for men and cloak rooms for ladies ; which we admit is a bit more esthetic than the customary signs elsewhere. To us Wales was essentially a country of castles and feudal estates. We were impressed by those impregnable, medieval fortresses, high, crenelated towers with slits like sword gashes in their sides, and with stone walls and strong iron gates that looked down as if dazed by the modern automobile buses scurrying along the highway. The castles seemed to play hide and seek with passers-by as glimpsed over the wall and through the surrounding charming remnant of medieval history. Let no one visiting England overlook Chester, for it is a very delightful place in itself and it is an excellent center from which to visit other noteworthy Welsh and English historic spots. For instance, it was from Chester that we em- barked on a tour of the English Lake Region, going by train to Windermere and thence by automobile in a circular trip about the lakes, with stoppings at various sites to pay our re- spects to Wordsworth, Southey and Coleridge - — for, as Moore sang of Killarney, and Burns and Scott of the banks and braes of Bonnie Scotland, these English poets found their hap- piness and inspiration on the lovely shores of Windermere, Rydal and Thirlmere. Liking one place better than another is purely a mat- ter of personal taste, or of some fortunate ad- Fig. 1. Carnarvon Castle. Heraldic Home of the Prince of Wales forests ; ivy-covered walls and marvelous old trees that have withstood the storms of innu- merable years, and a profusion of brilliantly colored flowers, especially rambler roses, against the slate gray houses. What a sense of security the barons must have had behind those walls, when the gates were closed and the drawbridge suspended in the air. Conway Castle at the head of Conway Bay, in a town that is further protected by a harp- shaped wall, is one of the best preserved in Wales; sharing that distinction with Carnar- von, birthplace of the first Prince of Wales, later King Edward the First, and scene of in- vestature of the present Prince Edward, heir to the throne, who is so deservedly popular. Entering England by the gateway of Ches- ter, we were immediately fascinated by that venture, and it is rarely safe to recommend a given place by using the most superlative ad- jectives in comparing it with others; for us, the Irish, English and Scotch lakes each has its special charms and any of them would be satisfying as our “little bit of heaven” in which to spend the remaining years of life. Wordsworth’s Seat, a massive rock situated in a grove of evergreens overlooking beauti- ful Rydal Water, gave us an hour’s delightful repose amidst scenery that might well inspire anyone to poetic discourse on the loveliness of nature. Dove Cottage, at Grasmere, his home from 1799 to 1808, was less inspiring but afforded some thrills from intimacy with his earthly possessions, at the same time that the visit aroused pity that so noble a man, such JOURNAL Or THE MEDICAL SOCIETY OF NEW JERSEY 137 Feb., 1931 a benefactor to mankind, had been compelled to live in such evident poverty and discomfort. Visiting the old church, St. Mary’s, at Ry- dal — an accidental visit occasioned by our seek- ing refuge from a shower of rain — we dis- covered a gloriously colored, stained glass win- dow (St. Luke and St. John) in memory of Wilson Fox, M.D., Physician-in-Ordinary to Queen Victoria, and who died in 1887 ; and. a bronze tablet to the youngest daughter of Dr. Matthew Arnold of Rugby, who had “served her community faithfully and well for 75 years”. Returning to Chester, and its own particular charms, let us recall that it is one of the very few cities that can today boast of an entirely surrounding old Roman wall (almost perfect- ly preserved by some bits of restoration), upon handsomest and best preserved bearing the date 1503) are quite remarkable, the style of architecture being peculiar to the place, and the carving upon posts and lintels, and the mural decorations, being entertaining and in- structive. Thus, Bishop Lloyd’s house pre- sents some rare wood carving illustrative of religious history, and God’s Providence House a dedication which proves the original owner to have been an egotist of supreme degree. Ac- cording to popular belief, the inscription — - “God’s Providence is mine inheritance” — was added after the plague which ravaged the city during the seventeenth century ; this was the only dwelling in Watergate Street which the plague passed over; and in gratitude for that remarkable deliverance, the owner had the in- scription carved on the main beam. Fig. 2. Rydal Water. View from Wordsworth’s Seat. the top of which one can promenade entirely around the city, a distance of about 2 miles. Then, in the very heart of the city, and more curious even than the wall, are the old “rows” — a double-deck sidewalk that affords passage for pedestrians in front of shops occupying both the first and second stories of the build- ings. It is worth noting that this plan of build- ing (probably of Roman origin) was estab- lished in Chester something like 400 years ago, and that only recently our exceptionally mod- ern city of New York has been considering the advisability of construction upon such a plan to relieve sidewalk traffic congestion; an excellent example of the manner in which civ- ilization, so-called, progresses in circles. Some of the older buildings in Chester (one of the Blossom’s Hotel, on Foregate Street close to the main gateway through the wall, is cen- trally located and furnished the most com- fortable and satisfactory accommodations we had thus far encountered on the trip. All points of interest were close at hand, and Ches- ter Cathedral, particularly, proved worthy of several visitations. It is one of the few cathe- drals which, at least so far as we are aware, seems not to have been awarded its due meed of advertising. Its friendly atmosphere — signs everywhere bidding you to enjoy this or that special feature — as well as the old Nor- man architecture produced a pleasing effect; and the cloisters of the old Abbey were among the finest we have ever seen. There, too. we stumbled upon a tomb inscribed : “William 138 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 Makepeace Thackery, M.D., Educated at Trinity College, Cambridge.” We chanced to be in Chester on August 21, when the Duchess of York gave birth to a daughter — “the first Scotch Princess for 300 years”. At breakfast in the hotel next morn- ing we found all the British guests devouring the newspapers and excitedly discussing the great event. Our waitress was as happy as if she, herself, had contributed this gift to the Empire, and was delighted by our willingness to listen and our expressed participation in the joy of herself and her nation. With the best of good will toward the Duke and Duchess, and appreciation of English feelings and cus- toms, we could not, however, help but enjoy the following sentences from the morning pa- per (Daily Herald. London, Aug. 22, 1930), We abandoned Chester with considerable regret and proceeded to London. Of that great city we shall have nothing to say here except regarding the practice of medicine. Our interest this time was principally to learn something about the working of the National Health Insurance Act, for we happened to have been in England when that law was en- acted in 1911, and to have been confused ever since by the conflicting reports of its success or failure. Before taking up that matter, how- ever, and comparing the progress of medical socialism in England and France, permit us to say a few words about medical study abroad. It has always been surprising to us that so few American medical students take advan- tage of the opportunities for post-graduate study in England, where knowledge of the Fig. 3. The “rows'’ on Chester’s main street. descriptive of the royal happenings at Glamis, Scotland : “The reception of the baby Princess into this world was Wagnerian in its tumult. Thunder pealed, lightning flashed around the castle, and the wind whistled through the trees. The anxious crowd of motorists waiting in the driving rain and pitch darkness outside the walls of the castle, watching the lighted window of the room on the second floor of the castle where the baby was born, saw the towers and pinnacles of the castle silhouetted vividly in the lightning flashes, and at the moment when the baby was born there was a terrible peal of thunder.” (Italics ours. ) In such manner does nature aid obstetrics in the advent of a royal daughter ; we are staggered by contemplation of what cataclysm might have attended upon the advent of a son. language enables them to understand what they see and hear ; and that so many proceed in- stead to lectures and clinics in other coun- tries, of whose language they have little knowl- edge, and where it is only with the greatest difficulty that they can understand fragments of lectures and not infrequently make an in- correct translation of those portions. The abundance of clinical material, in general medicine and each of the specialties, in Lon- don. Liverpool, Glasgow and Edinburgh, is evident, and in most of the specialties teach- ers of the highest standing are available. It is true that clinical material is not as well organized for teaching purposes in those cities as one finds it in Germany but, on the other hand, the teaching seems to us bet- ter. It depends, of course, to a large ex- Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 139 tent, upon what one desires. If one wishes to gulp his medicine in concentrated form, pack- ed in a capsule and administered in specific doses, then Berlin and Vienna are the places for study. By way of comparison we think of the teaching in German institutions as some- thing akin to the American business idea of efficiency and standardization, with lectures given in the most dogmatic manner, with lit- tle or no opportunity to consider other opin- ions, and the end-product to be a machine- made doctor housing a number of fixed be- liefs; while the English teaching, by contrast, is more comprehensive, considers all aspects of a problem, and is designed to turn out a doc- tor capable of thinking for himself. To our own way of thinking, the English system is during the summer months, these famous uni- versities are happy hunting grounds for the scholastic. To prowl at will among those charming old buildings, to feast one’s eyes upon their artistic construction, to muse upon the hundreds of great men who have through the ages studied and taught science within those sacred precincts, to walk with their ghosts from gateways to chapels, should' fill even a simple-minded medical tourist with re- spect for knowledge and enjoyment .of the happy brotherhood of students. Temptation is strong to write now of the 20 or more colleges that make up each of these great universities but we shall confine our references to a few that most impressed us. At Cambridge, for instance, we felt a peculiar attachment to Fig. 4. British Medical Association Building, Tavistock Square, London. preferable. As regards other countries, France and Italy, particularly, we may say that abund- ant material exists for study, and in some cities — Paris, Bordeaux, Marseilles, Rome, Florence and Naples — there are exceptional facilities for investigation provided one under- stands the language and is sufficiently inter- ested to explore upon his own account. In Paris and Bordeaux a few special courses are well organized ; in the Italian cities there is a wealth of clinical material in general medicine but there is little organized teaching. From London we made 2 pilgrimages of in- terest ; one constituting our third visit to Ox- ford, and the other providing our first view of Cambridge University. Fairly deserted Caius College, the main entrance to which is called the Gate of Humility. “Through this portal arrived the eager schoolboy and he walked along a shaded path till he reached a second, and more resplendent archway — the Gate of Virtue. Through this inner entrance he passed to his residence chamber, and lead- ing the virtuous life upon which he had em- barked he came ultimately to pass out by the Gate of Honour to take his degree at the Sen- ate House.” Founded by a doctor, Caius Col- lege has always been a home of medical learn- ing, and among those who once passed through the Porta Honoris, was the great William Harvey, discoverer of the blood circulation. At Oxford, probably because we had so of- 140 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 ten heard Sir William Osier speak affection- ately of them, we admired most Magdaleine and Christ Colleges— in the latter, reading the name of Osier’s only son inscribed upon the marble scroll of honor among those who gave their lives in the World War — and the Bod- leian Library which was very close to Sir William’s heart. Now, returning to observations made dur- ing this summer’s visit to London, let us say that we avoided hospitals and paid attention only to medical economics. We did take a look at the magnificent old homes of the Royal Col- lege of Physicians and the Royal College of Surgeons, and then visited the handsome new buildings of the British Medical Association on Tavistock Square. At B. M. A. Headquarters we made the acquaintance of the Deputy Medical Secre- tary, Dr. G. C. Anderson, in charge during the absence of Secretary Cox, who was then in Canada attending the British Medical Asso- ciation Convention, and in addition to show- ing us through the new building Dr. Ander- son was extremely kind in supplying informa- tion relating to the practice of medicine in Great Britain. From him we secured also lit- erature bearing upon the association’s work. What we shall have to say concerning Brit- ish medical affairs is the outcome .of person- al observation and of conversations with a num- ber of physicians, including Drs. Russell and Hennessy, in Dublin, and Dr. Anderson, in London, but we are solely responsible for in- ferences and conclusions and trust our read- ers will not hold any of the above mentioned persons responsible for our views; such views being a composite of impressions from many sources. Our attention was attracted first to adver- tisements indicating that insurance in the na- ture of defense and protection against mal- practice suits is just as necessary in England as in the United States, but some of the pub- lished matter left us in doubt as to whether such insurance was offered by the national medical society. That was straightened out for us and we learned that there are 2 policies available to physicians and surgeons ; one with the London and Counties Medical Protective Association ; the other offered by the Medical Defense Union ; each being essentially the reg- ular type of insurance company. The Brit- ish Medical Association has more than once considered the plan of self-insurance of its members but has so far resisted that proposi- tion, and at present the officials look upon the Defense Union as the more satisfactory of the 2 companies named above. The initial charge is 10 shillings ($2.50) and annual premium £1 ($5), for which subscribing members are entitled to unlimited defense and indemnity. The plan in vogue, then, is similar to our own group insurance but seems to be less expensive. We were most anxious to learn something positive and exact about the status of the National Health Insurance Act and its effect upon the medical profession. As stated be- fore, we happened to be in England when the law was enacted, in 1911, and again in 1912 and 1913 when opposition of the organized profession was very pronounced. Even in la- ter years some British medical journals, and letters from British correspondents published in the Journal of the American Medical As- sociation, have continued to criticize the scheme and to point out flaws in its construction and objections to its application. We were, however, at the same time aware of the fact that many practitioners in England and Scotland looked upon it as a beneficent law ; a law which, like many others, had some objectionable features, or that was susceptible to abuse, but which benefited much more than it harmed medical practitioners. Recalling some of the praise we had heard, especially from country practition- ers, we have been surprised at times to read articles declaring the whole plan a failure and the very special bete noire of British physi- cians. After a time we arrived at the con- clusion that objections came mainly from the highly business-successful practitioners, and that the average family doctor was willing to admit that he had gained, in a financial sense at least, from application of this law. Fur- thermore, it became evident that much of the criticism dealt with minor defects in the law and major defects in human nature, and con- sisted not infrequently in exaggerated state- ments, verging sometimes upon falsification. For instance, within the past year we have, in some of our best American journals, read denunciations of the law based largely upon the allegation that “the patient is deprived of his right to choose his own physician” ; a mis-state- ment of conditions that has been repeated hun- dreds of times and which could readily have been avoided by looking at the written law. For these reasons we wanted to get at the facts and, consequently sought interviews, asked questions and secured copies of authoritative documents. So, next month we shall present comments upon the existing law and upon the recently proposed extension Act. (To be continued.) Feb., 1931 141 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Esthetics RECOGNITION OF HOME TALENT Ic has been our custom to employ bits of poetry now and then to fill an unexpected space in the Journal, to enrich a tribute to some departed brother, or to enliven and en- tertain our readers. On several occasions we have enjoyed the privilege of presenting orig- inal poems contributed by members of our own state society. Never before have we devoted all of this departmental space to poetry but as we have at hand some material that has al- ready awaited publication far too long a time because we could not find an appropiiate Journal opening, we have concluded to offer you in this issue 2 contributions from the pen of Dr. Cone, and 1 from Dr. Corson — both of whom, as you well know, are prone to give vent to their feelings in rhymthic verse. THE WAR NURSE’S STORY Ralph S. Cone, M.D., Westwood, N. J. (Written January 1918.) Some folks think we nurses are heartless, How little they know, to be sure, When they say that our hearts become hard- ened Because of the sights we endure. Though we can’t let our feelings be master And must have control of our heads, Please don’t believe we are all alabaster, With hearts like our hospital beds. I could tell you, sir, many a story, Nightmares from the lines of the French; We have cases I hardly dare think of Brought in from the field and the trench. I’ve nursed all sorts and conditions, The coward as well as the brave, The good and the bad, the indifferent, And know how each can behave. I have loved and been loved by the grateful, Been insulted and cursed by the bad All kinds are brought in to us here, sir, And some cases are terribly sad. There was one, not so long ago, either, Of a poor little bairn we had here, I say bairn, but he was a soldier, In age about twenty-one year. Well, he was brought in, I was saying. It had been a hard day and ’twas late, He came with a number of others All scorched to the color of slate. Just breathing they were when they reached us And gently we cut off their clothes, Or what there was left of their garments, For not much remained but their shoes. Their heads were as bare as their faces, There escaped hot a vestige of hair, Their features were like nothing human And their eyes had a horrified stare. There were ashes and dirt clinging to them And the smell made me dizzy and queer, Though the doctors said they didn’t suffer And they’d all quickly die, it was clear. Well, it fell to my lot to nurse this one, I whispered a prayer and began To take charge of my terrible bundle That bore the rough shape of a man. Ah, we do grow fond of our patients, What injustice to say ’tis not so! I think, sir, that those who say such things Have never been where they could know. How can a nurse fathom the feeling She has for the helpless and ill? As a fond mother loves most her weakest, She loves those who most need her skill. Well, my boy passed this night and the next one, My duty was his case alone, All the others had died except him, sir, And I took him all for my own. ’Twas a labor of love as you might say. How I watched every breath that he drew, And at times he would seem to be conscious, But what he thought nobody knew. The doctors all marvelled he rallied And they said if his temperature rose ’T would mean rally from shock at the most sir, But my brave fight they feared I must lose. I rebelled at their verdict and nursed him I knew that he lay at death’s door, But I prayed to the good God to help me As never I’d prayed, sir, before. There he lay, like a ghost on his pillow, His face all enswathed in a mask His arms resting still alongside him No complaint and no questions to ask. Then came what the doctors predicted, He rallied and I watched and prayed So far God had seemed to be with me And the cruel hand of Death to be stayed. My ward here was crowded with soldiers. Each bed held a victim of war, And the dull heavy booming beyond us Made it plain we’d soon have many more. Every hour they’d come in on stretchers, Poor bodies all shattered and torn, While our doctors worked on like grim de- mons ; Brave Heroes ! Thank God such are borni 142 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 My helpers at this time were many, Extra nurses to us had been sent, That’s how I was spared to my soldier, My own now by common consent. In the ward we’ve a box of tin soldiers The recovering men use as toys, They amuse themselves, sir, by the hour Just like great big over-grown boys. J think there’s some fifty or sixty All painted in dirt colored hues To represent men in the trenches, No scarlets nor grays, sir, nor blues. Our men have them labelled by nations And arranged in the proper array They form them in different positions And battle it over each day. Though he seemed to grow weaker and thinner And his poor senses going a bit, My bairn followed the games of the soldiers, I could see by his eyes through the slit. Well, he lay in this state a whole fortnight, Being fed through a tube in his nose, For he’d breathed in the flames and to swallow Brought on the most terrible throes. One night between midnight and morning I thought that I noticed a change, • ’Twas like a mysterious warning, An uncanny thing, and so strange; The ward light had sunk in its holder So low it had almost gone out, When I looked at my boy on his pillows And saw his hands groping about. Quick I made a new light and came to him, Took his pale, waxy fingers in mine And said “Laddie”, but he was past knowing And I felt there the Presence Divine. I watched him perhaps half an hour, Lying there like a fluttering bird, When all at once up from that bed, sir, Came the sweetest voice ever I’d heard : “Dear Nurse, won’t you bring out the soldiers And set them up where I can see, It’s dark, but I know you can find them You’ll put them up, won’t you. for me?” Sir, these were the first words he’d spoken And they came from the pillows so clear; But I knew that they couldn’t be natural With Death’s Angel waiting so near. When I’d set up the soldiers I watched him, He just seemed to rise in his bed And reach his arms out toward the candle And that’s all I know — he was dead. The nurse bowed her head on the table, No more could the good woman say. There I left her alone with her reveries And. silently passed on my way. REQUIEM TO THE UNKNOWN SOLDIER Ralph S. Cone, M.D., Westwood, N. J. (Written December 10, 1929.) A silent mass before this brass, Stranger, it is his due ! For o’er this grass ye shall not pass, But pause this shaft to view. Perchance ye came to read some name Emblazoned bright as day ; Not to his shame, unknown to fame llis name rests with his clay. Or, knowing all, ye felt the call To mourn the Unknown Dead, To here let fall in Memory’s hall A tear above his head. The foe to block and kings unfrock, With steady eye and hand While earth did rock he braved the shock And shell of No Man’s Land. These wind-swept mounds are hallowed grounds, This shaft his resting gun, Ynd peace surrounds, no more the sounds Of war his senses stun. Ve placed this stone o’er the Unknown, It giveth him no pain. But hark his moan, “Lest ye atone Our sacrifice is vain”. No cenotaph nor epitaph Can make him live again Till holier deeds than his must needs Arouse the awe of men. No mortal praise his form can raise Nor should ye cry, “come forth” But meet his gaze through battle’s haze And show ye know his worth. Why weep ye so as on ye go With many a pensive sigh ! 1 tell ye though ye laid him low His God hath raised him high. PHLEBITIS E. S. Corson, M.D., Bridgeton. N. J. A gray little nerve cried an alarum For a little blue vein suffering harm. “Its walls are swollen turgid and thick, I am sure its owner must feel very sick”, And its owner feeling something awry, Feb.. 1931 JOFRNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 143 For pain and anguish raised up a cry The doctor came in with a wise look and said : “I advise this patient at once put to bed, Keep two little bulbs steady and bright Burning away, all out of sight ; Doing their duty in regular form, Under the covers cosy and warm. Patience, pluck, perseverance and prayer. Are needed indeed to make a repair, With pillows and crib and leg elevated Four weeks in bed surely you’re slated.” The little corpuscles got in their work, Nor did the blood plasma any bit shirk. They hurried by night as well as by day, For the two little bulbs lighted their way. Nor once did the cold their mission delay, The heat made their vigor more strongly dis- Pla>\ With petting, nursing, flowers and fussing, Time went apace and pain went a buzzing. Medical Ethics MORE HEALTH ETHICS John Hammond Bradshaw, M.D., F.A.C.S., Orange, N. J. When Walter Camp published on August 5, 1920, in Collier's Weekly, his article on “The Daily Dozen”, lie really started something. Born in 1859, Camp was then just 61 years of age, and like the beer that (once) made Milwaukee famous, it was Walter Camp that made Yale College famous as a center for all the best there is in college athletics and foot- ball activities. And now, his “dozen" has made Walter famous. Before this, notwithstanding the fact that the country was full of “deflated men and in- flated women”, calisthenics per se had never been popular. A well-advertised magazine on Physical Culture had long told us that exer- cise was the only straight and beautiful road to health. But, sad to relate, if one accepted the statements in this gem of literature, doctors were themselves the chief obstructionists to at- tainment of this blessing. The “big idea” seen in the pages of that magazine was that it was idle to throw down a medical pill when you could obtain your objective in throwing up a medicine ball ! To make calisthenics popular, beautiful girls, with all their curves, gave each page a pictured charm. Male ditto almost made one think that by following suit he, too. could make his life sublime; and if he had any doubt of this it was only necessary to read the any pages of advertisements. It seems a pity that this magazine still takes delight in knocking the doctors, for they might easily be won over to the cause. Doctors are just as much interested in health as they are in sickness ! They also cultivate their own muscles — vide any afternoon on any golf course. We live now in a standardized world. I doubt if Walter Camp, away back in 1920, when he advocated his daily dozen under the classified titles of ( 1 ) heads (2) hands (3) hips (4) grind ( 5 ) g rate (6) grasp The Daily Dozen ( 7 ) crawl (8) curl (9) crouch (10) wave (11) weave (12) wing ever intended them to be strictly standarized for the whole family from the baby to grand- ma. Nowadays, we eat to the accompaniment of jazz and naturally it follows that our morning set-up should have the same incentive. It is debatable whether this very much aids our di- gestion ; but possibly the timing and rhythm keep us bravely on our morning chore. It does appeal to the youngsters, I admit. Some say a few properly selected personal exercises would be better adapted in isolated cases. The human race (not using the word in the sense of speed) is peculiar. We really do hurry from one thing to another and often discard the good for something that is new. We are informed that Chauncey Depew lived into his 94th year and never walked a block (if he could help it). Our own Thomas A. Edison is going strong at 83, yet I have my doubts (being his personal physician) if he ever wants to exercise any part of his anat- omy except those parts above his collar. Here by contrast, you have Walter Camp dying of heart disease in his bed at night in his 66th year. Exercise is. however a good thing for the physical well-being of any animal, human or otherwise. There is no doubt that most mus- cles crave work. Did you ever see a team of huskies at their job? How do you explain the joy in mountain climbing which often dis- regards all danger? Watch sports on track and field. Any exercise can be taken in the wrong way, with resulting harm and resulting damage. It 144 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 has often been remarked that all this can be avoided. Doubtless there are many who should not even attempt the morning set-up. Now, this is important — “the real value of set- ting up exercises comes through the circula- tory system, the breathing and the general car- riage” , and all this can be effected in a short space of time with little effort, but the effort must be daily — it must be routine. Remem- ber if you are set down instead of set-up, you must leave it alone. Did you ever regard your side view in a long mirror with all your clothing removed? You will probably receive a shock ! What dis- pleases you can be corrected by suitable set- ting-up exercises. If you are a business man, it is foolish, intending to catch the 7.57 a. m. train to arise at 7.23, rush through your daily dozen, wash, shave, stop at the closet, eat your breakfast, kiss your wife and your five chil- dren, catch your train on a rush, and expect to be much benefited by these maneuvers. You must be willing to sacrifice a little of your sleep. The funeral is always your own. As one goes along in life, and gets older, one should be more and more careful about the proper exercise to be taken. To a certain les- ser extent this is true even in youth. Do we as doctors not believe that competitive athletics have their danger? Can we believe that the violent exertion of winning a crew race is of very much benefit to the health? It is not so very unusual to see some members of a com- peting crew, at the finish, fall back in their boats insensible, and sometimes even spit blood ! Did you ever watch the facial expres- sion of the flat or hurdle racer as he nears the tape? “One must put in it all that one has got and then some” to win the prize. And what prizes do they often win in later life? Possibly a dilated heart that certainly cripples their declining years. Do you think that Wal- ter Camp’s death from heart disease was in- fluenced by the intense football activity of his youth ? Go with me into the locker-room of any golf club and see the old men come in after their day’s sport. Some are hollow-eyed and show absolute fatigue ; some show cold hands and a leaking skin. How many of them will you find who at once call for a high-ball or a cocktail? This is not a diatribe against golf, to which the writer is absolutely sold. It only shows that when one engages in athletic ac- tivity after a certain (uncertain) age, one should have expert advice. With our excellent cardiac specialists easily on call, one should not neglect periodically to have an electro- cardiogram taken ; blood-pressure is not enough. We must remember that this is an age when deaths from heart disease have out- • stripped deaths from tuberculosis. There must be some reason for this. Why not find out what that reason is? But this paper remains what it at first in- tended to be — a plea for exercise. The thera- peutics of exercise have been told us so won- derfully by Goldthwait, Camp, Garthwaite, and many others. We do not need to answer the advertisements of what Fishbein humorously calls (yes, I said humorously !) “the big mus- cle boys”. Their appeal is more for money than health, just as so many Physical Culture magazines are money getters chiefly through their sex appeal lure. Walter Camp’s daily dozen have been so much disguised and distorted that not one in a hundred readers can off-hand give them their original names. Camp, however, did a great work. It will live ! He stressed the avoid- ance of strain, over-exertion, exhaustion. He proclaimed a system that could be adapted to the need and use of every one : little Willie and Dad, young and old, even the sick or the well. He also stressed the great benefit of the “rub down”. He, time and again, stressed the val- uable exhortation that it was not the spasmodic use of his system, but its daily, long-continued practice, a routine, — and that this only would surely afford the promised good. Collateral Reading SANTA CLAUS AND NEW BOOKS It has been our custom for some years past to scan the book publishers’ lists in the late autumn, to select those which seemed most promising in the way of affording knowledge and entertainment, and then to purchase such as we most desired for personal reading and for passing along in December as Christmas gifts to friends. By that process we gained a double joy from some books — the joy of read- ing and the joy of giving — and made sure of having some Christmas gifts, as it were, through retention of such of the books as we were too selfish to relinquish. Furthermore, kind friends, knowing our weakness — we might say double weakness, since our craving for books is probably quite as much due to a demand created by mental deficiency as it is to love of reading and possession of books — have usually on festive occasions presented us with books. The reading matter left here by Santa Claus on his most recent visit is so varied in char- Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 145 acter and the books so numerous that we are tempted to tell you just what is stacked upon the table awaiting a chance to regale and in- struct us during these long winter evenings. The list of titles and authors includes : Humanism as a Way of Life (J. George Frederick) Individualism, Old and New (John Dewey) Pre-War America (Mark Sullivan) Conquest of Happiness (Bertrand Russell) The Lives of a Bengal Lancer (F. Yeats Brown) The American Leviathan (Beard and Beard) Mrs. Grundy (Leo Markun) Pauline; Favorite Sister of Napoleon (W. N. C. Carlton) Cakes and Ale (Somerset Maugham) The Human Mind (Karl Meninger) Fads, Frauds and Physicians (T. S. Harding) Women and Monks (Kallinikov) Soviet Russia (W. H. Chamberlin) Enchanted Brittany (Amy Oakley) Between River and Hills (Sisley Huddleston) Roads to Roam (Hoffman Birney) Our New Progress (James Bayard Clark) Doctor and Patient (Francis W. Peabody) f What a feast in prospect! Philosophy, his- tory, ethics, morals, romance, science, an at- tack upon science, love and war, bolshevism, American prosperity ( ?), travel, and the poetry of a physician’s life. What more could one ask? Where shall we begin with our reading? In all probability we will express to you our opinions concerning some of these books but it is a duty first to dispose of one that has been on our desk for some months, and we there- fore offer the following review. The Biologic Basis of Human Nature H. S. Jennings Professor of Zoology in the Johns Hopkins University (Reviewed by the Editor) In his introduction to this book, Prof. Jen- nings says : “Human individuals are diverse — in their appearance, and in their behavior, and each has a separate consciousness, a separate identity ; so that the inward experience of any one of them is a distinct thing from that of all others. In some or all of these respects they are typical of the material of biology. How does it happen that individuals are thus diverse, both outwardly and inwardly? Why has my neighbor tastes and opinions so dif- ferent from my own? Why does he conduct himself in a manner that may seem to me un- desirable ; a manner so diverse from that which I would practice under the same conditions? Why is one man fitted for one sort of work, another for another sort ; and some for none at all? Why do precise experiments in the laboratory of psychology give with different individuals diverse and incpnstant results? Why are my own children so diverse from me and from each other? What is it that makes the behavior of human beings so incalculable, inconsistent, astonishing? These are the most practical , questions of life; and the most in- teresting in theomy.” Beginning with a detailed explanation, in simple, easily understood language, of the fundamental factors in the genesis of animal life, he carries us through the biologic growth of man, and discusses the effect and the limita- tions of genetics practiced scientifically. To indicate Dr. Jennings’ literary style and to give you an indication of his method of dealing with these important questions, we can do no better than quote several pertinent paragraphs ; at the same time advising you to read the en- tire book. “Characteristics do not fall into 2 mutually exclusive classes, one hereditary, the other en- vironmental. A given characteristic may be altered by changing the genes ; and this is the ground on which it is called hereditary. But the same characteristic may be altered by changing the environment ; and this is the ground on which it is called environmental. The genes supply one set of conditions for de- velopment, the environment another set, and there is no necessary difference in kind be- tween them. The characteristic produced may be changed by adequate alteration of either set. From the nature of a distinctive charac- teristic, it is not possible to decide whether it is due to diversity of genes or to diversity of environment, since the same peculiarity may be due in different cases to either set of causes. Which is more important for the charac- teristics of organisms, heredity or environ- ment? What is more important for the char- acteristics of man? Which is. more important for the manufacture of automobiles, tbe ma- terials of which they are made or the method of manufacture? This question is like the other. No single general answer can be given to either. For good results, both fit materials and appropriate treatment of these materials are required ; good genes and fit conditions for their development. From materials of a par- ticular sort, a good machine of one kind can be made, not of another kind. A method of manufacture that will fit one type of material fails with another. Materials that are excel- lent for one sort of machine are poor for an- other; and the fittest of materials require proper handling if their possibilities are to be realized. Either poor materials or poor hand- 146 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 ling can ruin a machine or an organism. If the materials are worthless, if the individual starts with thoroughly poor genes, the method of treatment, the environment, can do little. And it the material is spoiled in the process of development, it makes little difference what it was at the beginning. Most diseases are greatly influenced by the conditions of life; yet most or all of them are likewise influenced by the nature of the indi- vidual's genetic constitution. For the occur- rence of tuberculosis, infection with the tuber- cle bacillus is required; and this is not a mat- ter of genes, of heredity. But some combina- tions of genes yield a much better culture me- dium for the tubercle bacillus than do others. A pei son that has such a gene combination is much more likely to develop tuberculosis than another whose genes do not yield a good cul- ture medium for the bacillus. An “hereditary” element is therefore involved. Yet the indi- vidual whose genes produce a body that is prone to tuberculosis need not develop the dis- ease if he takes measures to prevent the bacil- lus from getting a foothold in his body. Doubtless there are many different types and giades of individuals with respect to this mat- ter. Some offer a particularly favorable ground for the growth of the tubercle bacillus ; others a less favorable ground, and so on through a series of grades, till we reach indi- viduals who are almost or quite immune to at- tacks of the disease. The genetic constitution is therefore of much importance in connec- tion with tuberculosis. \ et the environment is probably even more important. It is entirely conceivable that by the discovery of measures effective in preventing the transmission and development of the bacillus, tuberculosis could be brought to disappear ; so that genetic differ- ences m susceptibility to it would be of no further consequence. . Similarly some combinations of genes yield bodies that are much more prone than others to break out into that unregulated growth that is called cancer. In rats and mice, under the usual conditions of existence, individuals hav- ing certain sets of genes almost invariably de- velop cancer, while those with other genes do not. In other strains, with another set of genes, about half the individuals develop can- cer; in still other strains, none. These differ- ences are inherited in Mendelian fashion, showing that they are due to differences in 1 or 2 genes. There are in these animals strains in which a bit of grafted cancer tissue regularly devel- ops into a cancer; others in which this almost never occurs. There are strains that are par- ticularly susceptible to one kind of cancer, not to another. Many grades and qualities of sus- ceptibility exist, up to that of individuals derived from such combinations of genes that they almost never develop cancer. It is probable that in man there are similar diversities in susceptibility to cancer, resulting from the different genes of different individ- uals. There is. however, no indication that there exists in man strains having the extreme susceptibility to cancer, shown by certain races of mice. These extremely susceptible races of mice are isolated and multiplied by careful sel- ection and by breeding in such a way as to bring together and preserve the gene combina- tions that are most susceptible to cancer. This does not occur in man, so that there is no rea- son to suppose that there are any human be- ings who are predestined to develop cancer, whatever the conditions. The environmental conditions that play a part in cancer are little known; though it is known for rats and mice that under certain conditions cancer is pro- duced in individuals that under other condi- tions would not suffer from it. It is conceiv- able that knowledge and control of the envi- ronmental factors for cancer (as for tuber- culosis) should progress to such an extent that the genetic factors would, in the case of man, become of little importance. A situation that is similar in principle to that sketched for tuberculosis and cancer ex- ists for most, if not all, diseases, infectious or otherwise. Certain environmental conditions are required for the occurrence of the disease; or at least greatly influence it. But under con- ditions favoring the disease, some combina- tions ol genes yield to it, others do not. It is probablg that there is no disease whatever, acute or chronic, infectious or lion-infectious, whose occurrence is not influenced by the na- ture of the individual’s genetic constitution. I here can be little doubt that, other things be- ing equal, some genetic constitutions are more readily attacked by plague, by small-pox, by typhoid, by pneumonia, than others; just as some combinations of genes yield more readily to extremes of temperature, to exposure to the elements or to unfit food; just as some gene combinations are more likely than others to come off victorious in v struggle with a wild- cat, or to survive a bite from a rattlesnake.” Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 147 Lighthouse Observations REHABILITATION of the disabled Several original articles and discussion there- of published in the December and January Jour- nals, concerning industrial surgery and its rela- tion to the Workmen's Compensation Act, re- minded us of the recent work of the American Medical Association’s Council on Physical Ther- apy and the published recommendations hearing upon physical therapy in the handling of injured persons. Dr. Harry E. Mock, in a paper bear- ing the above title — ^Rehabilitation of the Dis- abled (Jour. A. M. A., 95: 31, July 5, 1930) — said: During the last 2 or 3 decades a new era in the practice of medicine has gradually developed. Healing the burns and then leaving the patient to his own devices to overcome scar contrac- tures is not adequate treatment. The best pos- sible reduction of a fractured leg and treatment until solid union has occurred is poor surgery if meanwhile the surgeon has paid no attention to the protection of adjacent joints, has given no consideration to maintaining muscle tone, and fails to utilize those adjuncts of treatment which will assure a rapid return to normal function of the injured leg. Only by continued interest of the physician in his patieftt during the long per- iod of chronicity of the disease or injury, during the long days of convalescence, even following the patient back on the job to ascertain that proper work is secured and making sure that both his mental and physical restoration is as- sured, can the ideals of physic logic medicine be achieved. The field and scope of rehabilitation of the disabled lead the physician to consider many lay adjuncts that heretofore have never been con- sidered a part of medicine. To accomplish suc- cessfully the rehabilitation of patients the pro- fession must make contacts with these lay agen- cies. Rehabilitation includes: Prevention. (1) By analytic study of the disease or accident to prevent a similar occurrence to other individuals. (2) By treating the case in such a manner that function will be preserved in adjacent parts; that traumatic neuroses will be combated from the start; that habits of idle- ness and loafing will be prevented. Every physician or surgeon engaged in private or hospital practice secures information from certain patients that shows a work hazard as responsible for a given condition. A short let- ter stating the facts to the responsible industry will in most instances result in a correction of the condition and therefore prevention of a sim- ilar disease or accident. This type of preventive work is just as essential as the reporting of con- tagious diseases or of lead poisoning, yet how few physicians think of this as a duty. Treatment. (1) The best possible treatment di- rected toward the earliest possible recovery with the greatest possible functional restoration. (2) Use of physical therapy as an aid in functional preservation and restoration. (3) Use of occupa- tional therapy to combat habits of idleness and often for the purpose of training for new work. To the surgeon interested in rehabilitation will be referred many patients in dire need of recon- structive surgery. Deformities and handicaps must be corrected and function restored so far as is humanly possible before the subsequent steps of rehabilitation can be completed. This is becoming so well recognized that state depart- ments of vocational, reeducation for the disabled, state compensation boards, schools interested in the training and education of crippled children, industries, and railroads and even private organ- izations interested in the disabled are frequently sending patients to such surgeons to ascertain whether anything can be done to improve their physical handicaps. Too often it is apparent that if proper measures had been instituted during the initial treatment this subsequent physical re- habilitation would not have been necessary. De- formities of the hands following tendon and nerve injuries contribute largely to reconstructive sur- gery. In many of these cases the original opera- tions by the surgeon treating the initial injury would have been successful if that surgeon had been familiar with and had possessed the facil- ities for administering proper physiotherapy. Breaking up stiff joints by manipulation under^ anesthesia results in many permanent, bony an- kyloses. The slower methods of physiotherapy are far better. In a certain number of skull fractures, the syndrome of persistent cerebral contusion develops. Too often these sufferers from indefinite symptoms are called malingerers and are mishandled for months or even years; making- up a pitiful class of the handicapped for whom rehabilitation is very difficult. No surgeon today is adequately equipped to treat trauma cases who is not familiar with those physiotherapy measures which will assist in the restoration of function. It is not necessary for him actually to administer the physical therapy but he must know when massage and active ex- ercise should start in every type of fracture; when heat, massage and muscle training exer- cises are indicated in nerve and tendon injuries; when heat in the nature of diathermy is indi- cated. Manufacturers of certain forms of ma- chine therapy, for example, lights and electric apparatus, have been active in advertising and selling these agents to the profession until many surgeons think that physiotherapy refers only to such modalities. They have their uses in the hands of physiotherapy specialists but are not necessary for the simple physiotherapy proced- ures that are required in 95% of trauma cases. Convalescent care. (1) Early removal of the pa- tient from hospitalizing influences. (2) Seeking convalescent provisions for those whose home conditions furnish unsuitable environment. Provision for proper convalescence is the miss- ing link in the chain for treating disabilities and injuries. Think of the saving to industry and to the hospitals if 25% of ward patients, after a month or 6 weeks’ treatment-, could be trans- ferred to a convalescent center where occupa- tional therapy, physical therapy, outdoor exer- cise and even vocational training could replace the idleness, the reading of cheap novels, the card games and the complaining about food and nurses which make up the life of the average ward patient in the average hospital. Placement at suitable employment. (1) Light occupations in the industry until such time as the patient can return to his regular position. (2) Choosing "a suitable job when disability pre- vents return to his old position. (3) Develop- ment of placement bureaus for the handicapped. There are thousands of handicapped individ- uals for whom employment is one of the gravest problems of our times. This is not medical work, yet if, as surgeons, we are aiming for an eco- nomic end-result for our patients, it is one of the most important steps in the rehabilitation pro- 148 lOl'RNAL OF THE MEDICAL SOCIETY CF NEW JERSEY Feb., 1931 giarn and it is a movement which every medical man should abet in every possible way. Medical follow-up. We must develop our fol- low-up clinics or office hours devoted to seeing patients with permanent disability periodically until assured that full functional restoration, so far as is humanly possible, has been secured; that the work they are doing is compatible with their handicaps, and above all that the microbe of de- pendence has not entered and undone all our ef- forts to rehabilitate. Message in Rehabilitation Work In connection with the article above abstracted, we would like to mention a special article by Drs. Mock, Pemberton and Coulter (Jour. A. M. A., 94:1989, June 21, 1930) covering in a de- tailed and very thorough manner the use of mas- sage and exercise in the treatment of injuries of all sorts and in the follow-up rehabilitation work. The article is too lengthy for satisfactory ab- straction and -deserves to be read in its entirety. Current Events TRISTATE MEDK AI, CONFERENCE The sixteenth session of the Tristate Medical Conference was held at the Chelsea Hotel, Atlan- tic City, Saturday, December 6, 1930, being called to order at 10 a. m. by Dr. George N. J. Sommer, of Trenton. Those in attendance were: New 1 ork : Drs. William FI. Ross, Brentwood, Long Island; James N. Vander Veer, Albany; and Joseph S. Lawrence, Albany. Pennsylvania: Drs. William T. Sharpless, West- chester; Ross V. Patterson, Philadelphia; Walter F. Donaldson, Pittsburgh; Frank C. Hammond, Philadelphia; and A. C. Morgan, Philadelphia. New Jersey: Drs. George N. J. Sommer, Tren- ton; and FI. O. Reik, Atlantic City. •Telegrams and letters of regret were read from Drs. Sadlier, Trick, Mayer, Overton, Dougherty, Donolioe and Conaway, who were unable to be present. Dr. Sommer : It is needless for me to welcome you here to Atlantic City. The session will be opened by Dr. Henry O. Reik, Executive Secretary of the Medical Society of New Jersey, who will read a paper, as scheduled upon the program. Automobiles More Deadly Than War Can We Control Their Death Rate? Henry O. Reik, M.D., Atlantic City, N. J. The subject which I am bringing to your atten- tion may, I fear, have seemed to you upon receipt of the preliminary program a queer one to pre- sent for consideration by this conference. It might better have been addressed to the general public, but, if discussion of it and action upon it meet with your approval it can be carried to the public later much more forcibly. If you disap- prove, and if mine be but “a voice crying in the wilderness”, I shall at least have had the comfort of crying aloud and of letting the world know about my woes. In my opinion we are too calmly watching a situation that disgraces civilization, and for the past 5 years I have not only been greatly agitated over existing conditions, but amazed that there has not been an outcry con- cerning the calamitous destruction of life that is daily recorded. In a country that claims to be the most en- lightened and the most humane, we sacrifice hu- man life to unrestricted pleasure on a scale that was never before known and is even now scarcely recognized by the majority of our people. And the contrast between certain rules of our conduct is almost unbelievable. We scathingly condemn bull- lighting', and refuse to permit, in New Jersey at least, even an exhibition performance (which ac- tion I, of course, approve) lest 1 or 2 animals may be tortured or killed. A considerable percentage of our people, as may be witnessed in this very city today, sets up a howl of protest against the vaccination of dogs, designed to protect those ani- mals and prevent the spread of rabies among hu- man beings, on the score that a hypodermic in- jection might discommode somebody's pet poodle. And yet, almost without protest of any sort, we read daily of the slaughter of innocents on our city streets and country roads by that modern jugger- naut— the automobile; an engine of destruction that is excelled only by major implements of war- fare. Human life seems to have become of so- little value that we can read unperturbed about murders and accidents that properly belong in the category of murder. On April 6, 1917, the United States of America entered the World Wart On November 11, 1918, the Armistice was signed. In that period of al- most exactly 19 months this nation lost in action 3(1,931 soldiers, and the number of deaths occurring later from the effects of wounds and diseases brought our total loss up nearly to 50,000. The average number of killed in war per month was 2100; the average number per day, 70. During the year 1929, the number of deaths in the United States caused by automobiles reached the total of 31,000, as against 28,000 recorded for 1928, and the prediction on the first day of this month, De- cember, was that the number of deaths due to au- tomobile accidents will reach in 1930 the astound- ing figure of 33.250. These last figures constitute an average of 91 persons per day, as compared with 70 per day killed in war. A community hav- ing a population of 33,000 constitutes a city of the first class, according to the census classification; and we nonchalantly wipe out of existence such a city each year. Worse than that shocking real- ization, is the fact that an additional 1,000,000 persons are during the same year injured and more or less permanently crippled by accidents in which automobiles play the main part. Every 15 min- utes throughout the day and night. 11 citizens are injured by those deadly machines. Incidentally, the property loss in damage from automobile accidents amounts to approximately $700,- 000,000 annually. All of these figures have been increasing at the rate of 10% per an- num since 1920, and the end is not in sight. It has been estimated that during the past 10 years more than 150,000 American citizens have been slain, and more than 5,000,000 injured by automo- biles, embracing pleasure vehicles and trucks; a death toll heavier that that of the worst was in which we have ever engaged. For 10 years we have been participating in peace conferences, war prevention plans, naval reduction and disarma- ment meetings — national and international — but nobody pays anything more than momentary at- tention to the horrors of automobile killings. We erect monuments to the killed in war — though the soldier had a ‘‘fighting chance”; but where is there a monument to the automobile victims? Where is the Kellogg pact that will conserve for us 33,000 Feb.. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 149 lives yearly, and the Dawes plan that will save the country $700,000,000 automobile wreckage annually? Studying the above figures, is it any wonder that the City Club of New York headed one of its periodic Bulletins with the statement, in heavy black type — “All Murder Records Broken; Motor Vehicles in New YTork Streets Make Their Heaviest Killing This Year!” It happened that the Bulle- tin was devoted to a plea for additional play- grounds and parks to keep children off the street, and safely out of reach of the automobile, but the automobile death toll is by no means limited to children, nor even to careless pedestrians — the so- called jay-walkers. The very article just referred to stated that the proportion of children to adults killed, out of the 950 deaths then under considera- tion, was 386 children and 564 adults (practically 3 children to 5 adults); which is contrary to the impression one gathers from general reading. The only statistics I have seen, analyzing groups of persons killed, stated ' that 60% of automobile fatalities in the United States are caused by auto- mobiles striking pedestrians, and only 20% are due to the collision of machines; that the auto death rate for females is only 35% of that of males; that the age period between 5 and 9 years carries the heaviest toll; and that between the ages of 4 and 65 the automobile is the most important cause of accidental death. It is, of course, always a pathetic occurrence when children are killed while engaged in some outdoor game, but it is a matter of no less importance that even a larger number of men and women are killed during the rush hours of traffic when they are returning home from their day’s work; for it has been shown that the highest percentage of accidents in the city occurs between the hours of 5 and 6 p. m. As regards the expo- sure of children to automobile accidents, Mr. D. S. Beyer, Director of the National Safety Council, made the following statement in an article on ac- cident prevention; “As children, we may have shuddered over the stories of persons maimed or killed by wild animals, but on looking up the com- parative figures, it is rather startling to learn that while there were 2600 people killed in India in 1 year by wild animals, poisonous snakes, etc., there were over 20,000 killed in this country by automo- biles alone. Apparently, it would be safer for my child to walk through the dangerous jungles of Africa or of India than to cross the street in front of her home.” When we come to consider the character and the causes of automobile accidents, we find a con- fused state of affairs, largely because there has been very little done in the way of thorough in- vestigation of accidents. Very naturally, a death- dealing accident is accompanied by a condition of excitement and there is generally no one at hand competent to investigate and study conditions thor- oughly and without prejudice. Attention is apt to be fixed upon ascertaining the person at fault, and but scant attention is given then or later to con- sideration of how and why the guilty party acted as he did in producing the accident. We cannot expect ever to have investigators on the ground at the time of accident, but there might well be some better provision for a later investigation of conditions precedent to the event. Some thought has been given to the sites most prolific of acci- dents, to the character of the highway at the time, to the existence of traffic signals, to the working capacity of the cars, to the speed of the vehicle, and to the sobriety of the driver; and the resulting conclusions are more than surprising. For in- stance: twice as many accidents are reported oc- curing at the intersection of cross streets, as oc- cur between those intersections — which would seem to indicate that the jay-walker is justified in crossing at the middle of the block. Most drivers have their accidents in their own home towns, where they are certainly more familiar with con- ditions than they would be in strange territory, which would seem to indicate gross carelessness; 80% of drivers accountable for accidents have had their trouble in the town in which they lived. Of all accidents reported, 58% have occurred in broad day light ; 75% occurred on dry — -not wet — road- ways; and the same percentage, 76, happened un- der clear weather conditions. Less than 5% of all accidents are the result of faulty mechanism of the vehicles; the human machine is responsible for 95% of automobile accidents and few people seem to have considered the importance of examining the human part of the automobile driving ma- chinery. Drunkenness or intoxication of the driver has come in generally for a large share of blame; a share which I am convinced has been grossly exaggerated. I would not be understood as excusing anyone for driving while under the in- fluence of liquor, but I would suggest a more care- ful investigation before denouncing a driver on that score; because it is so easy for the by-stander to mistake for a state of inebriety the mental con- fusion and bewilderment of the shocked author of an accident. As to active causes of accident, exceeding the speed limit, being on the wrong side of the road, failing to signal the other car, passing street cars or passing on the wrong side of other cars, all have received a due share of recognition and con- demnation. The one outstanding feature in the re- sults of investigation may be summed up in the very striking statement that in 75% of all acci- dent cases the driver was “going straight through”. I wish to emphasize that statement because I be- lieve that in those figures we. shall find the most important factor in the causation of automobile deaths. Who are they among drivers that “go straight through”, often, very often, regardless of traffic signals and road signs? The speed maniac is doubtless to be considered, but most observers have arrived at the conclusion that speed of itself is not the great source of peril it is presumed to be; that it is speed in connection with other fac- tors, such as negligence, recklessness and unfitness to drive, that is dangerous. The Royal Commis- sion on Transport, in Great Britain, has quite re- cently recommended abolition of all limitations upon speed, and that in the event of accident it be considered only whether the driver was ex- ceeding a speed reasonably adapted to conditions then and there existing. The road hog certainly must come in for a share of blame, but he con- stitutes only a small percentage of all the drivers associated with accidents. I believe we shall find that the “straight through”, dangerous driving, group is composed very largely of persons who should never have been given a license to drive; persons with bad eyes, bad ears, bad feet, bad hearts, bad nerves and a poor qual- ity of brain. In other words, I am personally con- vinced that the great destruction of human life annually produced by automobile accidents is due in the main to the issuance of drivers’ licenses to persons unfit to be entrusted with such responsi- bilities. Let us inquire under what conditions a license to drive an automobile may be obtained. Only 20 out of our 48 states have any laws whatever gov- erning the issuance of licenses to drive automo- biles, and in those 20 states the laws vary greatly. In all of those 20 states, and in the District of 150 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 Columbia, prospective drivers are required to show a sufficient degree of literacy to justify the belief that they can read road-signs. The only other test of a preliminary character, in which those states are in general agreement, consists of a demonstration that the individual can start, guide, turn and stop his car; for, though the tests leg- ally required in those states would seem to call for an adequate test of driving ability, the actual tests are frequently so hastily and so carelessly conducted that the examiner cannot possibly de- termine the prospective driver s ability even to handle the machine under the best of conditions. A.s to any examination of physical fitness, there seems to be no general agreement upon anything more than a visual form test, and no suitable provision for proper visual tests in any of those states. The 3 states with which we are concerned in this conference stand among the most advanced in legal requirements for licensing but even they leave much to be desired. New York, Pennsylvania and New Jersey motor vehicle licensing bodies require applicants to pass examinations — oral in New York and Pennsylvania, written in New Jersey — on the rules of the road and knowledge of mechanism of the car sufficient to enable the' applicant to oper- ate it, and practical tests on the street “to start and stop successfully, especially on a hill, and to back up and turn around properly". The total time devoted to such examinations averages 10 minutes for each applicant, divided into 5 minutes for the oral or written examination and 5 minutes for the practical demonstration. While an aver- age of 25% of applicants fail on first examination, the number of applicants ultimately refused li- censes is well below 5%. Practically speaking, exe- cution of the law has resolved itself into selling- drivers’ licenses at fixed fees, varying in the dif- ferent states from ,$l-$5, and annual renewal of licenses amounts to exaction of one form of state taxation. The so-called “Uniform Driver’s License Act”, which is operative in all 3 of these states, says that: "The Department shall examine every applicant for an operator’s or chauffeur’s license, before issuing any such license, as to his physical and mental qualifications to operate a motor vehicle in such manner as not to jeopardize the safety of persons or property and as to whether any facts exist which would bar the issue of a license.” The law does not state of what these examinations shall consist and, as already pointed out, the examinations as ordinarily conducted are in the nature of a farce. The law as it stands is sufficiently broad to cover all that is required; what is needed is better application and execution of the existing laws. In each state the motor vehicle commissioner has power to institute proper and adequate forms of examination; what each commissioner needs is a proper standard of ex- amination to be established and put into opera- tion, and, perhaps, some strong body of public opinion to support him in the exactions of such examinations. Herein, it seems to me, lies our op- portunity for public service. On this subject, the New York Times of Sunday. January 5, 1930, in a very able article written by Mr. Harry Tucker, Professor of Highway En- gineering, North Carolina State College of Agri- culture and Engineering, said: "Power and speed are the features in the design of new automobiles and trucks which some manufacturers emphasize most in their advertisements; and power and speed seem to be the most popular selling points with automobile salesmen. Yet these powerful machines are put into the hands of anyone who has strength enough to hold a steering wheel and to push on an accelerator. They are sent hurriedly along crowded streets and highways at a greater veloc- ity than closely supervised and carefully operated railroad express trains. * * * * A number of states now have laws requiring the licensing of drivers of motor vehicles. If the requirements were car- ried out strictly and only persons who are physi- cally capable and mentally alert received licenses, such laws would undoubtedly tend to reduce the number of accidents. Unfortunately, in many cases rigid examination is not given and a driver’s li- cense is issued to anyone who has the required fee. * * * * Practical laws, strictly enforced, would certainly make automobile travel safer for all con- cerned. And it would seem that traffic laws ought to be uniform, since the automobile and good roads have made us a nation of tourists. But, the mere enactment of laws will not prevent motor vehicle accidents.” Is it our duty, as physicians, to take action upon this question? I think it is. Who is in better posi- tion than the physician to recognize the needs of the situation and to offer the proper remedy? I recall an editorial in the Rhode Island Medical Journal of October 1924, which said in part: “Is it not time for the medical profession to take an ac- tive stand in a matter which so deeply concerns the safety and welfare of the state — namely, in the in- sistence upon more careful examination of appli- cants for license to drive motor vehicles? This im- portant matter is one in which physicians are con- cerned not merely in the role of protectors of public safety, but because a medical principle is involved, that is, some medical examination of applicants for license. Is it fair to have men and women li- censed to drive automobiles who are color-blind, who have serious defects of vision, who are feeble- minded or suffering from mental disease?” The Indiana Medical Journal carried a similar editorial in November 1928, concluding with the statements: “At present we permit the feeble- minded, the poor-sighted, the crippled and the underaged to drive over our city streets and coun- try roads automobiles, everyone of which may be considered high-powered and capable of making high speed. However, it is not speed alone which causes these misfits to have accidents. Instead of establishing speed limits we ought to establish ill iving tests and insist upon the examination of every person who would drive an automobile.” The New England Medical Journal of March 7, 1929, urging action by physicians, said: “Intelli- gence, caution, courtesy and equilibrium, added to good physical condition, are requisite to enable one to operate an automobile with safety to him- self and others. * * * * Has not the time come when every applicant for a driver's license should pass a physical examination, and be obliged to be again examined after a period of years (for no one can say that he will indefinitely remain physically fit) ? Who can suggest these requirements better than the physicians.” The Literary Digest of July 23, 1927, carried an article entitled “When the Auto Knows More Than The Driver”, from which I have culled the follow- ing: “Cars are now built for an intelligence that their drivers do not possess; 50 mile an hour cars are run by 20 mile an hour people; the public, 50% of which is incompetent to drive a car at all — these are the things that are making automobiles jug- gernauts and our highways places of slaughter. * * » ♦ when we look carefully at the world on wheels we can find one great underlying cause which seems to have been overlooked. The cause is not in bad driving. No attention to signals, lack JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 of control, speeding — none of these so-called causes are enough to explain it. Much deeper is the root from which all these accidents spring — the unde- veloped quality of consciousness at the wheel. The drivers of automobiles are unfit, both in mentality and application. The mass of people have had automobiles thrust upon them before they are qualified to use them.” About one year ago, November, 26, 1929, to be exact, the Newark Evening News published the report of an inquiry conducted in 11 states by the Traveler’s Insurance Company as to causes of revocation of licenses. The greatest number of cancelations and suspensions was made because of intoxication, but the inquiry showed as a coinci- dent discovery that the proportion of unfit drivers is variously estimated by the State Motor Vehicle Commissioners as between 10 and 15% of those who are licensed; that physical defects are an important feature in the rising growth of traffic 'disasters; and that 1 out of every 50 motorists suffers from some bodily ailment which interferes with his ability properly to operate a car.” A similar study of the Personnel Research Fed- • eration, reported in the Pittsburgh Press, March 23, 1930, shows that serious accidents are limited to about 20% of all drivers and that many of these are repeaters; that is, this 20% of operators is responsible for 45% of all accidents. The question is raised whether such repeaters can be cured, and some experiments indicate that psychologic tests of such persons and proper treatment of their de- fects may convert a reasonable proportion of them into safe drivers. This review leads us to ask— what are the prin- cipal physical defects that incapacitate one for safe driving? Apparently, the majority of such de- fects might be grouped under the general heading: defects of vision, including color-blindness; deaf- ness; crippled arms or legs; impaired hearts; un- stable nerves; defective mentality. Some reasons in support of this classification, taken from the reports of accidents and gathered from observa- tion, might readily be given. A few years ago one of my patients, so near-sighted that even with correcting glasses he could not possibly have seen an object the size of a man at a distance of 500 yards, secured a driver’s license; and I think we all know of drivers who have high degrees of myopia or hypermetropia uncorrected. Consider such a person as the patient I referred to and tell me whether he should have been permitted to drive. A car traveling 60 miles an hour (and that rate of speed is not at all uncommon on our high- ways) will cover 500 yards — 1500 feet — in less than 15 seconds. When that myopic friend realizes that there is a man walking on the road in front of his car, he and that man, both, must recognize the fact, make up their respective minds what each is going to do, and then do it, all in less than 15 seconds. If their minds happen to synchronize, well and good, but, if they are out of harmony, what chance has the pedestrian of escaping in- jury? Or, suppose another car, traveling at the same rate of speed and under guidance of a simi- larly defective chauffeur, coming from the opposite direction — is an accident avoidable? Another pa- tient of mine, stone deaf from otosclerosis, holds a license to drive. He cannot hear the traffic-cop’s whistle nor the horn signal of a passing car. I know it is customary to say that one depends less upon his ears than his eyes when driving, but ex- perience shows very clearly that a driver needs all of his special senses to be functioning properly. Some would, of course, put forth the argument that an individual deprived of one sense, like hearing, acquires increased sensitiveness of the other senses, let us say of vision and touch, but I need scarcely waste time with this audience in demolishing that bit of hokum. As a third instance of physical de- fect, I might cite the case of a licensed driver who has one artificial arm, one artificial leg, and according to her neighbors, a wooden head. She can drive her car, but she has proved that she cannot do so safely for she has had more than one road accident; yet she continues a menace on the highway. Regarding latent heart disease, epilepsy, unstable nervous systems and defective minds, I am sure you will agree with me that it is unwise to turn such people loose with such dangerous, high-powered instruments of destruction. Such persons are endangering their own lives and the lives of everybody they meet or pass upon the road. How frequently do we read of deaths at the wheel or immediately after leaving- the driver’s seat of a car? Each report of that kind suggests the idea that at least some accidents occur through the driver’s having run amuck because he was suffering at the moment an acute exacerbation of his heart lesion. Nervous and mental elements are perhaps less readily recognized but no physician will doubt that accidents result from a driver’s not having been able to coordinate his muscles properly at a critical moment because his nervous system was not functioning properly; his car may have been “hitting on all 6” but his nerve apparatus or his brain was 'missing fire”. It has been shown in 1 investigation that men over 50 years of age with abnormal blood pressure had on the average more than twice as many accidents as men of the same ages whose blood pressure was normal. Even when not so high as to indicate danger of sudden col- lapse, high pressure may be a symptom of systemic disease that affects the general health and tem- perament to an extent that may seriously interfere with safe driving. In all probability it is the true cause of accident much more frequently than any of us suspect. “Asleep at the wheel” is not at all an uncommon explanation of accidents. Not very long ago a prominent English surgeon, driving home from a night operation that followed upon a full day of professional labor, crashed his car against a tree and was killed. He lived long enough to pencil a note on his prescription pad: “It was my fault — I was asleep at the wheel.” Some of my friends tell me that often when driv- ing long distances alone they become sleepy and have to draw up beside the road for a short nap. The intelligent driver will do that, but not all drivers are intelligent, and many intelligent ones will take a chance in trying to fight off the sleepy feeling. I have even heard some reckless drivers boast of having driven a car 'while asleep, which makes me appreciate a witticism in the local paper of 3 days ago, saying: “There was a time when half-wits looked through bars instead of windshields.” The New York Evening Post, in an editorial April 30, 1930, said: “A railroad management which allowed an inexperienced man to drive a locomo- tive would be regarded as criminal, and yet a locomotive runs on rails and is regulated by a system of signals, whereas on the highway the driver of an automobile does his own regulating. To allow a person to operate a car without having proved his fitness and qualifications is simply to invite accidents.” This reference to railroads recalls to mind the fact that 35 years ago we had this same fight for conservation of human life, with regard to railroad engineers. Some of you will possibly remember how difficult it was to get rid of the color-blind J 52 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 engineer. Accidents were frequent, people were killed thereby, because the engineer could not properly interpret the signals, could not always definitely distinguish red, green, blue and amber lights. Today no color-blind man can reach the driver’s seat of an engine cab; he is disbarred be- cause of his defective vision, and railroad accidents have become rare. But on our highways and public streets, If out of every 100 male automobile drivers are color-blind, and 4 out of every 1000 female drivers may be similarly classified. Realize what that means in view of the fact that red and green light signals are now being installed at street and road crossings all over the country and that safe driving depends very largely upon recognition and proper interpretation of those lights. The traffic-cops may not be aware of the fact but color- blindness is the real reason why so many drivers mistake the signal lights and cause him and them- selves trouble even if no one else be injured by the mistake. What is to be done? I hope I have made out a case showing the necessity for reasonably strict physical examina- tion of those who seek license to drive an automo- bile. If I have succeeded, the next question con- cerns determination of a standard for such ex- aminations. In 1927, I requested the Welfare Com- mittee of the Medical Society of New Jersey to consider this question, and a special committee ap- pointed to do so spent some months at the task and on January 15, 1928, brought in a report which embodied recommendations as to appropriate physi- cal examination to be required as a preliminary to receiving a driver’s license, as follows: Questions to be Answered by Applicant for Driver’s License Note: The answers to these questions are partly for the information of the examining physician. Unfavorable answers will not necessarily result in withholding a license. 1. Age? 2. Are you subject to: dizzy spells? fainting attacks? fits or convulsions? pain around the heart? 3. Have you any serious disease of the heart or the kidneys? 4. Have you every had epilepsy? 5. Have you ever had a stroke? or any form of paralysis? 6. Have you any impairment of vision? Is it corrected by glasses? 7. Have you any impairment of hearing? 8. Have you entirely free use of both arms? hands? legs? 9. Have you been examined by a physician during the past year? If so, give name and ad- dress of the physician. 10. Are you physically and mentally capable of operating a motor vehicle on the public highways? I have read and understand these questions, and the answers are true to the best of my knowledge and belief. (To be signed and sworn to after the physical examination.) Signature of applicant Acknowledged under oath before me this day of , 19 Notary Public. Physical Examination (Answers to be filled in by a physician) 1. Is there evidence of heart disease? If so. what ? 2. Systolic blood pressure? (If applicant is over 50 years of age.) 3. Vision: right eye left eye (Vision must be at feast 20 /50 in the better eye and 20/200 in the poorer eye, with or without glasses. If less than 20/200 in one eye, the better eye must have at least 20/30 vision.) 4. Is the hearing good? 5. Has the applicant full use of both arms and legs? I certify that I have today examined an applicant for a driver’s license, and consider that he or she is physically and mentally fit to operate a motor vehicle on the public highways. M. D. Date of license to practice medicine in New Jersey. It will be noticed that the committee report omitted any reference to color-blindness. That was done because the committee feared that the color- blind test would arouse so much opposition as to endanger adoption of any physical examination. 1 thoroughly appreciate that point of view, but 1 do not agree that it carries sufficient weight to justify the decision to put color-blindness aside. I am personally inclined to add to the examination form submitted a requirement for passage of the color-blind test. Last winter I spent a Sunday with a very distinguished attorney who lives in New York City. Late in the afternoon, I requested that a taxi be called to take me to the railroad station, but my host courteously insisted upon driv- ing me there himself in his own car. Rain was not actually falling but the air was full of mist, a light degree of fog. As we approached the first corner on Fifth Avenue, my host interrupted our conversation to say — “Will you please watch the lights for me?” I was surprised at the request but soon recovered my wits sufficiently well to recog- nize the import of this question. Then he confessed that he was color-blind, that on clear days he managed fairly well to understand the light signals but with fog or rain he was rendered more or less helpless, and on such days was compelled to rely upon watching the movement of other cars in his neighborhood. Needless to say, I was con- siderably relieved when he unloaded me at the Pennsylvania Station. As a former practitioner of ophthalmology, and as an interested observer of automobile drivers, I am personally convinced that color-blindness plays an important part in the causation of road accidents. As Dr. Bulson pointed out. in an editorial in the Indiana State Society Journal: “It may be true that the color-blind in- dividual with otherwise normal vision may dif- ferentiate between “stop” and “go” lights by their position rather than by their color, but such an in- dividual is hopelessly lost if he drives in a strange city or even in his own city where the relative position of red and green lights may be varied from time to time.” I presume you are all familiar with the action taken by the House of Delegates of the American Medical Association at the recent meeting in De- troit, calling upon our state societies to aid in bringing about some form of physical examination as precedent to licensing automobile drivers, and submitting recommendations covering such an ex- amination. I am perfectly willing to accept the form of examination presented by the American Medical Association, with the exception that, as I stated with reference to the New Jersey Medical Society recommendation, I would advocate insertion of the color-blind test. It matters not what physical examination re- quirements we recommend, there will be objections Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 153 made against their adoption and application. The color-blind, the near-sighte 1, the deaf, the epi- leptics, the unfortunates with artificial limbs, will each and all demand exemption. It may interest you to know that one of our states now has a special law that specifically forbids the motor vehicle commissioner to refuse a driver’s license to a deaf-mute. We all know, of course, how such special legislation gets on the statute books, but it is our duty to prevent such laws when we can and, particularly, to recommend proper legislation designed to safeguard public welfare and to effect the greatest good to the greatest number. The ob- jectors must be dealt with in the interest of the larger number of citizens. On the whole, there would be less objection than we may fear, and such objection as will be made can be overcome by presenting the public with the real facts. My request of you today is, provided you accept in principle my conclusions, that this Tristate Conference shall recommend to our 3 state medical societies such action as you may deem proper to- ward securing uniform regulations governing phy- sical examination of automobile drivers, preliminary to the issuance of a driver’s license, and strict en- forcement of such regulations. To that end, I am offering a resolution for your consideration and I trust that it may be adopted. In conclusion, I would like to bring your minds back to a picture of the results of an automobile killing and ask you to remember that this picture, in only slightly varied forms, has -been multiplied 33,000 times in the United States during the past 12 months. The picture was painted by the Philadelphia Citizen’s Safety Committee and reads as follows: “Think, Driver, Think/ A wave of the hand, a kiss blown on the breeze — from the sweetest little pal in all the world. I stood for some moments watching her, a chubby little figure in blue and white, an extremely important little person on her way to school. And then she turned the corner. It must have been about 4 o’clock — my mind has been sort of deadened since — that the boss sent for me. ‘Bob’, said he, laying his hand on my shoulder, ‘there’s been an accident and you’d bet- ter hurry up to the house’. Well, there isn’t much more to tell. That little pal of mine — she — she wasn’t at the window watch- ing for me as usual. For an instant I faltered; it just seemed as though something within me went dead, and I had to fight for breath. In a little time I went out to the gate, just as I had that very morning. And I looked down the street as best I could. Right over there, a short block away, was where she turned the corner — : passed forever out of my life. Today, it was my little girl. Tomorrow, or next day, it will be some other little pal quite as dear. And so on, and on, until the conscience of men shall cry a halt to this passion for fast driving in localities where danger, obvious danger, stares drivers plumb in the eye.’’ Gentlemen, lest yoh think this closing a bit melo- dramatic, let me remind you that during the 45 minutes I have been occupied in reading this paper to you, 3 American citizens have been killed, and 29,700 American citizens have been injured in auto- mobile accidents. Discussion Dr. William H. Ross: One of the striking thoughts that came to my mind after Dr. Reik finished this rather impressive presentation was that his remarks were followed by silence. Usually, after any presentation so true and so striking as this, applause follows. But today the profoundness of the impression produced was so great that it caused silence, and that is a very interesting fact. Analyzing my own reaction, I was not at all in the mood to applaud because the whole subject seem- ed so serious. We have perhaps gotten into that frame of mind because he brought home to us the effect of things with which we are so familiar; we know all these things and yet we just com- placently go on. Frankly, I wondered just what was going to be said, when this subject was an- nounced, until a second thought brought home the importance of it, but in no sense have I ever grasped the great importance of the subject as I do at this minute. Perhaps the situation is just the same as it is in other things of life. The av- erage person is subject to so many dangers that he pays no attention to until he is hit on the head. I should appreciate this situation as much as any other human being because I have had to bear the application of it to 2 members of my own family who stand dearest and nearest to me, and under the surface I carry a sorrow that I will have all of my life. There are some rather interesting things in this connection. I have a niece, a deaf-mute, who has a splendid mind. She graduated at the head of her class in college and was signaled out and given a diploma alone because they wanted to say that she was the best loved individual in the college. She is a librarian in a city, ■ and has a license to drive a car and drives anywhere across the state. She has never had an accident nor come anywhere near one. It is an interesting reflection, whether her intelligent mind keeps her from hav- ing accidents or whether she is stimulated to more closely observe the signals, but I would rather ride with her than with some of my friends who have no conception of their physical limitations. However, there have been a sufficient number of accidents and deaths to urge us, as the guardians of health, to present effective arguments to the authorities for correction. It is true, as the speaker said, that the medical profession has an oppor- tunity here for service and as the situation stands at the present time we could present whatever we have because we have facts to prove our conten- tions. Dr. Ross V. Patterson : I was very much inter- ested in the subject and in the admirable presen- tation of it by Dr. Reik. It is not a subject to which I have given much thought but as he read his paper a number of reflections came to me. The paper is, of course, an argument for medical ex- amination and I km in thorough accord with his view that there should be such an examination. It seems, to me, however, that we must recognize that this would correct only a certain number of the causes of accidents. The paper stresses medi- cal defects as the cause of accidents. As medical men I think we should be more restrained in urg- ing medical examinations as being the solution of the whole question; we should recognize the fact that this is only a part solution. Dr. Reik speaks of the large number of accidents in this country. I wonder whether he can give us any figures as to accidents in other countries and the relative number of cars; whether there is a disproportion of accidents to cars in use. The reason we have such a large number of accidents is because of our 120,000,000 population and 20,000,- 000 cars in the United States of America; more than all the other countries in the world put to- gether. JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 154 So far as Pennsylvania is concerned, we have a motor vehicle law which states that there shall not be more than 3 riders on the front seat, and very frequently you will see 4, and the other day on a street in Philadelphia I saw a little runabout with 8 people in it. That was contrary to all rea- son, of course, but for 6 or 7 blocks I trailed back of the car and we passed 5 traffic officers who said nothing about it. You will frequently see that sort of thing at night. I have always been impressed by instances of automobiles driving into the city around 6 p. m. to get the “head of the house”, having a small boy, apparently under the legal age, driving the car with a chauffeur sitting beside him. I have mentioned that to the traffic officers and they have said that sometimes the man has a greater political pull than they have and they cannot lose the time to go to the magistrate’s hearing and have therefore passed it up. That is a potential source of danger, of course. The question of insurance is a very great feature in automobile accidents. The insurance rates are increasing each year. There are a num- ber of automobile drivers who take the atti- tude that the insurance companies will adjust the accident no matter what happens, so they ig- nore all the laws of common decency of traffic. That seems to be a very large source of automobile accidents today. As to the question of being asleep at the wheel. I think that occurs more frequently than we are cognizant of. I remember, 2 years ago, going to sleep at the wheel while driving up the Roosevelt Boulevard. I found myself in the gutter twice and finally pulled up along side the road, locked my- self in the car and went to sleep. I had been asleep about an hour when a park officer rattled the door and asked why I had locked it. I told him that I found myself going to sleep and I pulled up to protect the public and locked the door to protect myself. He saw the green cross on the front of the car and said I would have to explain this. I called up a friend of mine, explained thf whole situation, and he said he would take care of it for me. It was just a humilation, under the circumstances, but I was trying to protect the public by getting out of potential danger. The question of “going through the red lights" raised by Dr. Reik : we find that is a frequent oc- currence in Philadelphia. At 33rd Street, especially. 1 have seen cars time and time again going through the red signals. It is not particularly because the drivers are color-blind but they are simply blind to the lights. We had a very disastrous situation in Pennsylvania recently. One of our surgeons was on his way to Philadelphia to see a young girl who had been operated upon and who was not doing well. They telephoned the father to come to Philadelphia to see his daughter. The father was driving the car and beside him in the front seat was the physician, Dr. Holden, who was Chief Surgeon of the Locust Mountain Hospital. On the rear seat was the girl’s mother and grand- mother. Driving down the Highway, about 8.30 p. m., there was a truck stalled along the side of the road. Whether there was a rear light on the truck we do not know but there was a sudden crash and the automobile drove head-on into the rear of the truck. The doctor was instantly killed: also, the father and the mother and grandmother died shortly after reaching the hospital. Our feeling is that the gentleman driving the car was talking to the people in the back seat and his eyes were not in front of him, and they were no doubt travel- ing at a rapid rate of speed. Regarding defects of hearing, I may speak per- sonally. I find that while riding in an automobile I can hear better than I can in a room and that condition, of course, is well known to the medical profession. However, I cannot hear very well at times and must depend upon the officer’s whistle. I was recently crossing one intersecting street in Philadelphia and saw the officer put his hand up to his mouth and then take it down, and I thought he had blown his whistle, so started across. He stopped me and “bawled me out”. He had intended to blow his whistle but did not because he decided to let a truck go through. I did not argue that I had an impairment of hearing. I understand there is a law in France regarding pedestrians crossing the street, that frequently they are arrested for walking into automobiles and are fined when they are at fault. Very often acci- dents are due to the carelessness of the pedestrians. Week-end drivers also present a serious question. So many factors have to be taken into considera- tion. Those of us accustomed to driving on the streets every day realize these factors. Many of the dangerous drivers do not drive a. car at any other time than on Sunday and have little ex- perience. There seems to be a marked tendency every- where you drive for automobile drivers to demand the right of way whether they are entitled to it or not, which in many instances is responsible for accidents, so that the careful driver is being penal- ized to give the right of way on all occasions, in order to play safe. The right of way seems to be demanded in Pennsylvania to a greater extent than ever, notwithstanding the fact that a few months ago the Supreme Court of Pennsylvania issued an opinion on the automobile law of the state to the effect that the driver of an automobile has right of way over another car coming to his left, and that the car coming to his left cannot claim the right of way by blowing his horn, or by the fact that he arrived at the intersection first. It would seem that many of the automobile drivers in Pennsylvania do not know this ruling of our Su- preme Court, because they persistently ignore the question of right of way, or they are demanding the right of way regardless. I think Dr. Reik’s paper is excellent and T sincerely trust that the resolution he has pre- sented will be adopted. I think we should go on record as to the feeling on the part of the medi- cal profession in this regard. Dr. A. C. Morgan : The reader of the paper stated that 95% of the fault and responsibility for accidents has been shown to lie in the human element in driving, therefore this is an entirely proper paper for presentation before this body for our serious discussion. There are many laws on the statute books now that are not being enforced. It is proper that additional remedial legislation shall be presented for consideration by our Legislatures if these points are not already covered. The im- portant point for us to consider is to find modes of approach to impress upon these examiners of motor vehicles of the 3 states the importance of recognizing the fact that medical cooperation and medical advice are paramount in value to the im- position of rules and regulations upon those who apply for registration. This would concern itself in preparing questionnaires to be answered by the applicants in writing, and perhaps requiring the photograph of the applicant to be attached to necessary papers. We should demand a statement from the applicant in respect to fainting, epilepsy Feb., 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 155 Another thing which Dr. Reik’s paper does not stress, but a fact of which we are all aware, is the carelessness of pedestrians; and I wonder if it would be wise to urge that all pedestrians be given a medical examination to determine their fitness to be on the streets? Abroad this summer I travel- ed 3000 miles in an automobile, in 4 different coun- tries, and one of the things that very forcibly struck me, particularly in England, was the amount of road-courtesy as compared with our own country, and I think that must be a very con- siderable factor in lessening accidents in England where the roads are narrow, tortuous, and where there is no speed limit. There is the greatest amount of road courtesy. The driver ahead, when signaled, will instantly pull over. He will hold out a hand to notify the individual behind him that the road is not clear and he, being in front, can see farther ahead, and will motion him to go ahead when the road is clear and he can get by safely. There is the greatest difference in our own coun- try. In Switzerland, as you doubtless know, they enforce a different speed law on Sunday from that of other days. During the week there seems t.o be little regard to the speed which an automobile may attain but on Sundays, when the road is crowded with pedestrians, bicycles, and motorcycles, the speed is rigidly cut down to 20 miles an hour. Better enforcement of our laws, better education of the pedestrian, are all parts of the problem and as medical men we may contribute something, but I should feel that we ought to be careful not to claim that a physical examination, valuable though it is, would be more than a partial solution of the problem and in that view I am sure the author of the paper will concur. Dr. Vander Veer: This comes into my personal knowledge with one experience. I have a relative who drives a car but who has vision in only one eye. She obtained her license after 2 examinations but it was only the mechanical manipulation of the car that troubled her. There is a very excel- lent Examiner in Albany County who is in a meas- ure economically free from pressure of politics. He is a rather hard-boiled individual. He remarked about her having no vision in one eye, as she- had made that statement on her card of application. However, she had sufficient corrected vision in the other eye to pass the 20 foot card test given in the street along the curbstone. A man whom I attended as a patient in the Al- bany Hospital somp 20 years ago, amputating his leg, has a wooden leg and a contrivance on his car so that he may work it. When he got out of the car to take the examination he was told that he had illegally driven his car down there and was also told he could not pass the test because he had a wooden leg. The examiner was invited to get into the car and see the mechanical changes that had been made to accommodate the wooden leg, and the man was given a license. I have an- other patient who is absolutely deaf, and who passed the examination by reading the lips of the examiner. I do not believe the examiner knows that man is deaf. I know one gentleman in Albany who is ap- parently intelligent enough to fill a position in the state service, who has had 3 accidents with his car, once a very grave accident that had vis- ible results by reason of his face being cut up. He took 3 or 4 examinations before passing the test, because he could not grasp the mechanics of the car although he occupies a position requiring edu- cational ability. His secretary, a very intelligent woman, woke up one night in the ditch, having fallen asleep while driving. Fortunately, she was not going very fast and the car was upright. She had a nonshatterable glass windshield, but the wheel was broken in 3 places. Those are personal experiences that have come within the range of my knowledge. There is no gainsaying the fact that we should try to do something to better these conditions. The National Association of Engineers saw the light because it was put up to them in the proper way. I am Vice-President of our Albany County Automo- bile Club. The question of the modification of our laws in the state of New York came up some years ago and I was in a very marked minority in our Executive Committee when I advocated a rather harsh type of physical/ examination before the person appeared for the mechanical examination. The vote of the 15 members of the Board was 13 to 2 and as a result the State Automobile Associa- tion turned the proposition down and it did not get to the State Automobile Bureau. I know our State Commissioner of the Automobile Bureau very well and I also know his assistant commissioners. They are rather in favor of this and yet the pressure that is brought to bear on them by the thousands of automobilists in the state and by the County Automobile Association is great; so that pressure- brought to bear upon them by the other group does not get very far. A large number of applicants are turned down at the first examina- tion; most of these, however, because of the me- chanical features; very few because of physical defects. Quite recently there has been a scandal going on in New York State in that a number of people were taking examinations for others, so that now for a chauffeur’s examination one must present a pic- ture of himself which is fastened to the card. We have not been able to have it made obligatory that each operator should have his picture on the ap- plication blank and on his card in New York State because political pressure has been brought to bear and consequently we find scandals creeping out here and there and as a result a number of people who fail in one county go to another and take the examination, and also other individuals take the examination for them. There is no gainsaying the fact that now seems to be a proper time when we should determine some complaints as to the automobile deaths and as physicians try to obviate them even if in only this one little point. Dr. Frank C. Hammond: 1 think this is a very timely subject that Dr. Reik has brought up for discussion at this Conference and I do not know any group more fitted than the medical men to bring this matter before the Legislatures and I hope the suggestion presented by Dr. Reik will be adopted. It seems to me that this question brings up so many angles for discussion: first and pri- marily, the question of the traffic officers enforcing the law. We have so many laws that are not en- forced and if they were enforced to a greater ex- tent a great many conditions might be overcome. Those who drive automobiles on the street every day are conscious of the fact that traffic officers do not enforce the law. I have taken this matter up with some traffic officers and they say that when they report any one to the City Hall in Philadelphia they are compelled to appear before the magis- trate at 7 o’clock in the morning, the magistrate not arriving until 8 or 9 o’clock, and they have to lose that time to be present at the hearing and for that reason frequently do not report infringe- ments of the law. 156 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 and previous accidents sustained, occupation and perhaps other facts. Dr. Reik emphasized the fact that most accidents occur between 5 and 6 p. m. That bears out the study being carried on in this country particularly, and in other countries, in regard to the accidents in mines, in mills, on the streets and the occurrence of falls. For a few years past I have been inter- ested in the subject of falls and their causes and their application to the medical profession. That, of course, is from a medical internist’s standpoint, and yet I feel that it has a very valuable bearing on this subject before the house today. There are some people who tire very easily, mentally and physically, making them relatively unsafe to drive their cars or to have any responsibility that in- curs the possibility of danger to other people. This is a strictly medical and properly a medical phase of the subject that can be discussed with the State Commissioners of Vehicles. Dr. Hoffman, the eminent statistician, is carrying on some very valu- able work along this line. There is a very important point for us to con- sider as medical men, and that is to have unanimity as to what constitutes intoxication. We will find definitions quite variable, and likewise the testi- mony of the man who examines an individual and pronounces him drunk today may be changed after he sleeps over it and has a telephone call or a visit from a politician, as I have had reason to experience as one who made charges and then had the medical man reverse himself the next day in what I considered to be a wanton case of drunken- ness. Epilepsy is another feature that should be stressed. I know of a very eminent physician who while driving along the River Valley in New York suddenly wakened in a little ravine; his wife was dead, his boy escaped injury, and the father was so crippled that he could not get out of the car. The little boy had presence of mind to run back to a small place and summon help. This sad accident was not explained satisfactorily for 2 years, when the doctor eventually died of a brain tumor. He had a sudden faintness and loss of con- sciousness because of the beginning pressure of that brain tumor. Autopsy revealed the presence of this brain tumor and then in retrospect the cause of that accident w'as made clear. The matter of blood pressure should be em- phasized again by us in discussion of all periodic health examinations, particularly the marked im- portance of hypotension. A man with hypotension is, theoretically at least, potentially more likely to develop fainting than a man with hypertension. The man with hypertension is more likely to have fits of anger and disturbance of equilibrium and mental poise, and both phases of this blood pressure ques- tion are questions to discuss in respect to the abil- ity of a man to drive a car. Another important thing: It is proper to require an examination for fitness at the time that one makes an application, but there should be as a medical requirement a demand that every 3 to 5 years when the applicant applies for re-license he shall likewise be subject to a reexamination, be- cause physical alterations do occur and might greatly influence a man’s fitness as a driver. Those of you who have reached the age of 60 will recall that in your insurance policies at the age of 60 your rate of premium is greatly increased. It is rather astounding and rather jarring to have that fact made known, that the insurance carriers real- ize this and raise the premium of those who are carrying accident insurance after the age of 60. This is a proper thing for discussion in putting this phase of the problem before the Commission- ers of Vehicles for their legislation. A year ago an engine driver was taken from one of the speed trains leading into Atlantic City. His brother before him was a cardiac case and had dropped dead on the street. This man was ex- actly the same age as his brother had been when lie died. He went up for a physical examination before the railroad medical officials and was taken off the speed line and put on a shifting engine in one of the railroad yards. This man had a slight accident and was taken off that job and simply used as a guide or flagman. The patient was referred to me and my opinion was expressed that he was not a safe man to drive an engine. A couple of months ago I learned that with political pull in a certain part of New Jersey that man is back on a shifting engine in the yard. I shall be interested in the further progress "of that case. It is proper for us to study as medical men the occurrence of previous accidents so that the answer to Dr. Reik’s question as to why the person was at fault, why that accident occurred, should be settled not from the line of mechanics alone, which has to do with brakes, with laws, etc., but also with respect to the physical and mental condition of the individual at the wheel. There are many points that occur to me but I feel that they can be better discussed in round table conference, but I am strongly convinced that our easiest, shortest and best way to approach this subject for the present is to get in touch with the Examiners of Vehicles; if you please, give them transcripts of our meeting here today, have them put in reprint form so that the Commission- ers, the heads of departments, members of Boards in the respective states shall be given the printed suggestions, and later ask for a conference. Or, put them in the hands of the family physicians and reach these men as men rather than officials, and I think we will accomplish more good for the people of our commonwealths in a shorter time than by resorting to legislation which, as you know, it re- quires many years to accomplish. Dr. Joseph S. Lawrence: I want to add my ex- pression of appreciation of this splendid paper that Dr. Reik has given us on a very timely subject. We are the proper persons to give consideration to this subject, I believe, and the proper group to initiate some further consideration of it on the part of the public because we are the ones who are al- ways called in to salvage the wreckage of the human side of it. Dr. Reik gave such evidence of admirable study of the subject that I hesitate to make any suggestions with regard to the points that he did not mention for fear that he considered them of minor importance, but from my own per- sonal experience in a near-accident I cannot help but mention that a certain proportion of these accidents are due, as has been stated by each of the speakers, to a weakness on the part of the pedestrian. About a year ago I came within close proximity to running down, or killing, a child about 4 years old. About 6 o’clock in the evening I was driving at not more than 25 miles an hour when I saw a child on the curb who apparently saw me. When within 2 cars’ length, suddenly the child ran out in front of my car. I was fortunately able to turn the car across the street without upsetting it, and escaped the child. I also think of another factor, which was men- tioned once, and that is the condition of some cars that are out on the roads. We have, of course, our efforts at checking up on the brakes, etc., but even if right one day they may not be right the next day. Many people do take liberties on Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 157 account of the confidence they have after having had their brakes checked and they keep the slips on their windshield often for 6 months to show that their brakes were examined. With regard to the correction of some of these difficulties, it is a question whether we could get legislation for 5 years and maybe 10 years. At any rate, it is a question whether we could do it without the full hearted cooperation of the auto- mobile associations of our several states and of the national one. 1 have found in my experience with the Legislature in New York that when mat- ters relating to automobiles, and even certain con- ditions of the highway, are under consideration the opinion of the Automobile Association is very in- fluential. They attend hearings in large masses and usually have as their representatives influen- tial persons, and I believe that whatever we do we must seek the cooperation of the Automobile Associations. Now, I wonder if we would not make more rapid progress if, instead of an extensive examination such as suggested, we simply asked for inclusion in the examination that is now given of one or two more particulars. For instance, I am very much impressed by what Dr. Reik has said about color-blindness. If a certain percentage of the men are color-blind and they are in a hurry to make time, a red light would mean nothing to them and they would be the ones whc would pass the red lights, especially in strange communities. However, it was pointed out that the majority of accidents occur in one’s home community, and that is true in all accident experiences. I sold acci- dent insurance at one time and the most frequent place of accidents was one’s own home; the most intelligent person, the minister or doctor, was sure to fall over his own doorstep. I think if we could secure inclusion in the examination of the test for color-blindness, or the eyesight test, and also the exceedingly evident condition of epilepsy, it would be a good thing to accomplish. Those 2 conditions can always be proved as existing. If we could add these 2 conditions, which could not be changed, and in time add 2 or 3 more, this could be done with comparative ease I believe. Dr. William T. Sharpless: I think this discussion is very timely and Dr. Reik's paper has made a very deep impression upon us. My feeling is that while there are a great many matters that might be corrected by a physical examination, from my own observation a great many accidents have occurred from wilful disregard of the signals. That is not because of color-blindness or inability to use either hands or legs, nor because of any sort of physical defect, but simply because they wilfully disregard signals. It is just a part of the sheer disregard of law that is so common in all classes of society at present. Dr. Morgan spoke of the shock that he got when he learned t Hat at the age of GO his rate for acci- dent insurance would be increased. Wait until h on lie Hospital Clinical Conference Maurice Shapiro, M.D., Secretary The regular meeting of the Clinical Conference of Bayonne Hospital Staff was held Monday even- ing, January ;>, tinder the presidency of Dr. Donohoe. Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 181 Dr. Sklar reported cases from Medical Service of Dr. Deary. Case 1. J. G., aged 46, male, was admitted De- cember 5 with the chief complaints of cough, loss of weight, hoarseness and night sweats. Patient, a sand blaster, gave the history of a cough, pro- ductive of a thin, watery hemorrhagic sputum for the past 8 months, associated with loss of 20 lb. weight, extreme weakness and night sweats. Lung percussion resonance was slightly di- minished throughout both lungs. Breath sounds were also proportionately diminished in intensity, especially at the bases; sibilant rales were heard at both bases, but no moist post-tussive rdles could be elicited. On percussion, the heart sounds were regular, rhythmic and of good quality. The rate was normal. Pressure 124/70. Blood picture normal except for very slight secondary anemia. Sputum negative for tubercule bacillus. Radiography showed generalized, parenchymatous infiltration of both lungs. In the hilus a fairly large sized area of calcification, probably due to an old calcified gland. Tracheal shadow deviated to the right. Between the upper and middle lobes, right side, evidence of an old interlobar pleurisy. This was diagnosed as a case of pneumoconiosis, silicosis variety, due to steel and iron dust. With rest in bed and the usual expectorants improved slightly and was allowed to go home. Case 2. E. S., male, aged 20 years, white, was ad- mitted November 24 with chief complaint of swell- ing of right ankle. History of a gradual painful swelling over a period of 4 weeks, becoming so bad that he was forced to bed. No other joints in- volved. No history of trauma or rheumatic fever. Denied gonorrheal infection. - Examination revealed no positive finding besides several carious teeth and a swollen, reddened right ankle joint that was very painful on motion and tender to touch. Urine negative except for faint traces of albumin. Blood count, slight secondary anemia; W. B. C. 12,000; 80% polys. Wassermann negative. Pros- tatic smear showed many intracellular liplococci. X-ray examination of foot indicated the presence of an osteo-arthritis of the fourth metatarso- phalangeal articulation. Upon a diagnosis of gonorrheal arthritis, the foot ■ was immobilized and vaccine injections were in- stituted. In 24 hours after first injection he de- veloped an acute congestive conjunctivitis, from which we found some Gram-positive diplococci and a few Gram -negative bacilli. This conjunctivitis was at first thought to be a specific reaction to vaccine, but on later observation patient was found to have an infective origin. The foot responded slowly but surely to treat- ment so that presently he was up and about the ward. The conjunctivitis also responded well to cold compresses, argyrol and atropin. Case 3. J. C., male, white, aged 43, fireman in chemical works, was admitted complaining of weakness and increasing pallor. For 2 months he had noticed a progressive paling of his skin as- sociated with weakness, pain in chest, some cough and dark expectoration. No hemoptysis, numb- ness or tingling in hands or feet. He also noticed that he was dyspneic upon mild exertion and that his ankles had become swollen 2 weeks before ad- mission. Lungs negative except for occasional rales at both bases. Slightly enlarged heart ; regu- lar sound of good quality; hemic murmur, systolic in time at apex. Blood picture was that of a severe secondary anemia. Wassermann and Kahn tests negative. Consultation with genito-urinary department re- vealed the following; Left kidney diminished func- tion; right kidney no function. Pyelogram showed congenital kidney anomaly, probably a horse-shoe kidney and a right hydropyonephrosis. The pelves were drained several times, with some sympto- matic and subjective relief, but his anemia im- proved very slightly. Impression, severe secondary anemia on basis of urologic lesion mentioned. Dr. Madras reported from the Surgical Service of Dr. Donohoe. Case 1. S. J., aged 44, admitted with a history of acute abdominal pain of 20 hr. duration, following ingestion of heavy meals during the Christmas holidays. For about 3 years complained of occa- sional epigastric distress, with belching of gas and sour eructations, and chronic constipation. There was no nausea or vomiting. Had never consulted a doctor for this condition. On admission, in shock; pulse 140; temp. 104°; nausea and vomiting. Gen- eralized tenderness, most marked in epigastrium with marked distention. Perforated gastric or duodenal ulcer was diag- nosed and immediate laparotomy advised. Abdomen was filled with a tremendous quantity of fluid, together with a mass of undigested food. This was sucked out as rapidly as possible, the fluid being deeper in color near the pyloric region, where the structures were bound down, and be- cause of mordant condition further exploration was inadvisable. Drains were inserted and abdomen closed rapidly with through and through silk worm sutures. Patient was given stimulants, hypoder- moclysis of 1000 c.c. warm glucose and saline, but he expired 10 hours after operation. Case 2. J. M., aged 13 years, male, admitted be- cause of pain in lower abdomen ; onset 1 day pre- viously, pain being centered around umbilicus and accompanied by nausea and vomiting. Vomiting continued and pain finally became localized in right lower quadrant. Diagnosis of appendicitis was made and immediate operation advised. The appendix was markedly swollen in distal third; vessels congested; serosa covered with fibrin; and the tip, adherent to the mesentery, was packed with fecal material. Postoperative course was turbulent, and on sixth day wound was inspected and probed in lower angle, and about 100 c.c. of pus evacuated. On seventh day occa- sional vomiting, wound broken down, draining, but no relief from ileus. An opening was made into abdomen with a Kelly clamp and 5 oz. of an opa- que, yellow fluid was removed; culture from which showed Gram-positive cocci and Staphylococcus aureus. On ninth day patient vomited fecal mat- ter and distention showed no signs of decreasing; temperature 103°, pulse 140. The old incision was lengthened and the rectus retracted medially. The cecum was found distended and there was a partial volvulus caused by adhesion of a loop of small in- testine to the lower portion of the cecum. The child’s condition became desperate — almost pulse- less— so the adhesions were separated and a rapid cecostomy performed. Stimulants were given and saline intravenously. Following day there was a re- markable change for the better, and the wound was draining large amount of fecal matter. Abund- 182 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 ance of fluids was forced by mouth. Six days fol- lowing: the lube was removed but cecum was drain- ing- profusely. Seventeen days following operation patient had a bowel movement but the fistula drained profusely. Wound began to heal, fistula becoming smaller and gradually closed. Child was extremely emaciated — appetite became voracious. Discharged 2 months after admission, and his con- dition has remained excellent. Dr. Antopol reported upon a patient, male, aged 45 years, admitted to the hospital with a chronic cough of 2 years’ duration, and loss of considerable weight. Two weeks before admission had coughed up a copious amount of foul smelling sputum and complained of pain in the right chest. On admis- sion a right thoracentesis was performed and the chest found to contain a considerable amount of purulent material, which on smear and culture showed Gram-positive diplococci and streptococci. The material coughed up by the patient contained the same organisms and was similar in nature to that of the chest fluid. The patient died 4 days after admission, and autopsy disclosed a massive purulent effusion, 1000 c.c., in the right chest; pleura markedly thickened; in the right lower lobe main bronchus a marked infiltration of the entire wall causing a bronchostenosis at this point; di- lation of all the bronchi of the right lower lobe, with purulent material similar to that found in the pleura. On microscopic examination the diagnosis of metaplastic bronchus carcinoma of the right lower lobe, with extention into the peribronchial areas and metastases to the tracheobronchial lymph-nodes was confirmed. The cells appeared to be of the squamous variety, in places showing a tendency to pearl formation. The origin was thought to be from metaplastic columnar epi- thelium of the bronchus lining. Clinical Society of North Hudson Hospital J. Africano, M.D., Reporter The regular monthly meeting of the Clinical So- ciety was held Tuesday, January 13, with Dr. Louis C. Lange acting as chairman; 44 members and guests were present. Dr. Tanncrt read the hopsital report for De- cember: 250 admissions and 284 discharges; 21 deaths, of which 12 were medical, 3 surgical, 2 pediatric, 2 gynecologic, 1 urologic and 1 new- born: 7 autopsies were performed, or 33% of all deaths; clinic cases 415, emergency cases 419, am- bulance calls 93; there was a tremendous amount of work done by the laboratory — 1989 miscel- laneous examinations. Dr. IT. Braunstein discussed 6 of the autopsies, the report of the seventh being withheld pending a court trial. One death resulted from peritonitis and septicemia following self-induced abortion: a patient who had successfully induced 9 abortions but following the tenth developed trouble. Dr. M. Green : Unusual Case of Bronchopneu- monia. It. S., male, aged 31, colored, admitted De- cember 1 complaining of cough, frontal headache and hemoptysis. Past history : frequent sore throats during childhood; diphtheria at 13; chancre (?) at 17; pneumonia 1 yr. ago and confined in the Jersey City Hospital for 3 weeks, since when he has noticed a steady loss in weight amounting to about 30 lb. Three days before admission he had a severe chill , became very weak, with marked vertigo, and had to go to bed; developed severe cough and frontal headache, and coughed up some bright red blood. Bronchovesicular breath sounds and increased vocal fremitus heard anteriorly over both sides of chest; dulness and amphoric type of breath- ing found over the left lower lobe; friction rub heard below angle of the left scapula; fine, moist rales audible over both apices, while coarse rales could be heard at both bases. Heart sounds of poor quality. Abdomen slightly distended. Blood pressure 118/68; temp., 106°; pulse, 112; resp., 40. The outstanding features during his 4 days in the hospital were the profound toxemia and de- lirium, with aggravation of symptoms; temperature ran as high as 106°; icteric tint of the sclera; pneu- monia signs spread over wider area in both lungs; because of the mental state, no oral medication or nourishment cOidd be given. The clinical diagnosis was pulmonary tuber- culosis with a terminal bronchopneumonia. Au- topsy disclosed moderate amount of clear peri- cardial fluid; no free fluid in the pleural cavities; left lung adherent to the parietal wall and dia- phragm, and showed beginning gangrene at the base; right lower lobe consolidated. The chronic cough, loss in weight, hemoptysis, anorexia and color of the patient certainly war- ranted diagnosis of pulmonary tuberculosis, but no evidence of such lesion could be found at autopsy, The other interesting feature in this case was the over- whelming toxemia which persisted for 4 days. Dr. Terk : Recurrent Lobar Pneumonia. S. lb, male, aged 24, pipe fitter, admitted with history of an occasional non-productive cough and 3 previous attacks of right -sided pneumonia. From the anterior axillary line going posteriorly, including axillary area to about midway in the right interscapular region, there was a definite dul- ness, bronchovesicular breathing, increased vocal and tactile fremitus, with scattered crepitant rales. Roentgenogram showed: “Obliteration of the en- tire right chest. No fluid level. Left chest and heart normal.” Examination indicated effusion in the lower right chest. An attempt to aspirate was made, but we obtained only a few drops of frothy blood, and the needle was immediately withdrawn; patient then began coughing up considerable blood. Blood pressure 410/60;. temperature rose to 102°, and pulse to 100. Condition remained about the same for 1 week and then showed improvement. At end of 3 weeks radiograph showed islands of infiltration reported as sequels of pneumonia. Ex- amination at this time showed the lungs clear ex- cept for slight impairment of breath sounds and a few crepitant rales in the lower right base. Dis- charged 4 days later as cured. Dr. Justin said that although aspiration was negative, fluid was undoubtedly present as shown by the physical signs and x-ray plates; the needle punctured the lung and the patient promptly coughed up some blood; the fluid was absorbed rapidly and completely: reappearance of fluid made it suspicious of a tuberculous origin, though sputum examinations were consistently negative. Dr. Pearlstein emphasized that pneumonia pro- duces no immunity, but on the contrary, increas- ing susceptibility; some patients are peculiarly susceptible to the pneumococcus. Eeb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 183 Dr Arthur Justin Bronchopneumonia a, Post- operative Complication. J. R., male, aged 56, mar- ried, laborer; admitted with past history negative except for excessive alcohol consumption, and present history of cough tor 2 years, productive of yellow phlegm, recently lessened since be re- duced his smoking. Illness began with dull pain 1 in. below the umbilicus and shifted to the right abdomen. This distress continued, with pain worse in hr. after eating, and on deep breathing. Tem- perature, 102°; pulse 90; resp., 20. B. P. 170/84. Systolic murmur at apex. Coarse moist rales over entire anterior chest and posteriorly over the apices and interscapular regions. Abdomen showed, moderate rigidity over the right side from costal margin to iliac crest. Tenderness 2 in. below right costal margin. Blood count: YY. B. C., 8200: polys., 80%; Hb., 80% ; R.B.C., 5,000,000. Tentative diagnosis: Acute appendicitis; acute cholecystitis; pulmonary tuber- culosis. On the day following admission, he was operated upon under ether anesthesia, with find- ings of a thickened gall-bladder, many adhesions, no stones, appendix twisted and fibrotic with many adhesions. His first week was a stormy one; developed severe delirium tremens and reefuired restraint. Surgical progress was reported as satisfactory, but we noted an acutely ill man, moderately delirious', dyspneic, cyanotic and presenting signs of bron- chopneumonia with areas of consolidation in the left upper, left lower, and right lower lobes. Sputum showed pneumococcus Type IV: negative for tubercle bacillus. After 4 days, improvement began and radio- graph indicated generalized tuberculosis of both lungs. A left pleural to-and-fro rub was felt and heard; 1 oz. blood tinged, turbid, yellowish fluid was removed from the base of the left chest, and smear showed round cells with very few polys. During this period of 1 month there wife a di- minished expansion of the left chest, dulness in the left axilla, both bases showed harsh breath sounds, rales above and below both clavicles an- teriorly and posteriorly and over both lower lobes. Repeated radiographs showed the same original findings although the bronchopneumonia areas were greatly diminished in size. The patient was seen by Dr. Spalding, who reported bronchopneu- monia and chronic fibroid phthisis. The case is presented to emphasize the im- portance of a. careful examination of the chest of all patients who are to •have an ether anesthesia; and the prolonged duration of findings which must lie regarded as chronic bronchopneumonia, in the absence of finding tubercle bacilli, although clini- cally the history would indicate an activation of tuberculosis of the lungs. Dr. Lange. Empyema a Postoperative Complica- tion. N. »M., male, aged 38, admitted with history of having been shot in the abdomen 1 hour pre- viously. Immediately brought, to the. operating room where 8 perforations of the jejunum and 4 of the mesentery were closed. He reacted fairly well from operation and was doing well until the fourth day postoperative, when he had a chill and tem- perature rose to 102.2°. Tissue about the wound of exit, about % in., was gangrenous and emphy- sematous on palpation. Diagnosis of gas-bacillus infection was made and he was given gas-gangrene polyvalent antitoxin on 3 days following. On the fourth day postoperative, examination of the chest showed tubular to bronchial breathing in the lateral aspect of right lower lobe, as well as pos- teriorly. Slight impaired resonance on percussion over same area. Radiograph on seventh day post- operative revealed a pneumonic, process in the right lower lobe. Physical signs remained the same until tenth day, when flatness on percussion was elicited in the right lower chest, with distant to absent breath sounds. A diagnosis of fluid in the right chest was made. Thoracentesis was done at this time and 8 oz. blood-tinged serous fluid was withdrawn — there was no evidence of any purulent material. The physical signs in the right chest have re- mained the same up to the present time — no change after repeated thoracenteses. Dr. Sell wfflnzwalil : Empyema a Postoperative Complication. G. YY., female, aged 17, admitted with chief complaint of pain in light lower quad- rant of abdomen. Two years ago, patient suddenly had a severe pain in, the right lower quadrant, which was intermittent, dull and cramplike in character. .Pain lasted 1 day and then disappeared. In May 1930 she had a severe attack, and was told she had appendicitis. Examination negative except for some tenderness in right lower quad- rant, about 1 in. medial and 1 in. above the an- terior superior spine; also some tenderness to right of the umbilicus. No rebound tenderness, no rigidity, no masses palpable. A few rales, heard anteriorly, disappeared on coughing. Appendectomy was performed December 5. The findings were a mobile dilated cecum, about 1 oz. serous fluid in the abdomen and a subacutely in- flamed appendix. The first day postoperative, tem- perature rose to 102", pulse 110, respirations 26 and patient was coughing and expectorating mucus streaked with bright red blood. The second day she complained of slight pain in the chest, and examination showed bronchial breathing at the left base. Diagnosis: Postoperative pneumonia. She developed an extensive pleural exudate, and it was decided to tap the chest to determine na- ture of the fluid. Thoracentesis was done and about 16 oz. of a pea-green purulent fluid was re- moved from the left chest. X-ray picture taken the next day showed heart pushed to right; obliteration of lower left lobe with pneumothorax upper left; collapsed lung with fluid level; hydropneumothorax. Because this was a streptococcus empyema, it was decided to wait several days before operating. Rib resection was performed, releasing about 2 % quarts of a bright, yellowush-green, purulent ma- terial. containing thick, coagulated, fibrinous clots. The pleura and the pericardium were covered by a thick, coagulated fibrinous material. Closed method of drainage was employed by suturing the opera- tive wound tight about the tube, and tubes attached for irrigation with Dakin’s solution. Postopera- tive course uneventful. Discharge rapidly cleared. Radiograph now shows the left chest to be clear except for a slight amount of fluid at the costo- phrenic angle. The left lung is expanding. Dr. Roberts: Case of Postoperative Pulmonary Embolism. A well-developed and well-nourished woman of 36 suffering from fibroid tumor of the uterus. Uneventful convalescense after hysterect- omy except that she had a, slight rise in tempera- ture on the eighth day, which, apparently was due to a dry pleurisy. There was no suspicion of a lung infarct. Heat, strapping and the administra- tion of 10 gr. acetysalicylic acid relieved the dis- 184 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 comfort. Suddenly, on the night of the tenth day postoperative, the patient was seized with severe pain in the chest, was markedly dyspneic and cyanotic, and died in about 2 minutes despite all remedial measures. I thought it might be of interest to scan the records of the hospital for similar cases in the past 2 years. In that time we have had 6 deaths from postoperative pulmonary embolism, ranging in time from 2 to 42 days. Two followed hyster- ectomies, while the remaining 4 followed extensive abdominal work, such as colostomy, release of post- operative adhesions, jejunostomy, and drainage of an extensive peritonitis. The age incidence was 38 to 63. In all cases there was no warning whatso- ever; 3 patients had been up and about for several days, while the other 3 were still confined to bed. HUNTERDON COUNTY Barclay S. Fuhrmann, M.D.. Reporter The regular quarterly meeting of the Hunterdon County Medical Society was held at Frenchtown, January 20, at 11 a. m. Present: Drs. Gramsch, Slavin, Decker, Closson, M. H. Harmon, B. M. Harmon, Salmon, McCorkle, Tompkins, Sommer and Fuhrmann. The meeting was called to order by Dr. W. E. McCorkle, Second Vice-President. After reading the minutes, which were approved as corrected, and correspondence which was ordered filed, the censors having approved the application of Dr. F. O. Slavin he was unanimously elected to member- ship. The subject of Councillor District Meetings was presented by the secretary, quoting from the re- port of The Conference of Secretaries and Report- ers as found in the December Journal, and after some discussion it was decided that the subject be held in abeyance for further consideration at a future meeting. The program for the April meeting in Fleming- ton is to be devoted to the subject of "Potter’s Version”, and Dr. E. F. Purcell is to be invited to be present and show his pictures on that sub- ject. Dr. McCorkle extended greetings to our new member, Dr. Slavin, after which the meeting ad- journed, dinner was served, and then our usual round-table discussion ensued. MERCER COUNTY A. Dunbar Hutchinson. M.D., Secretary The Mercer County Medical Society met in the Carteret Club, January 14, Vice-President William L. Wilbur presiding in the absence of President Swern who was ill. The minutes of the preceding meeting were read and approved. Dr. John A. Kolmer delivered a very interesting address on "The Nature of Bacteriophage and Its Practical Application in Treatment". Dr. Kolmer reviewed the early study of agar plate cultures in 1918, with a synopsis of results obtained by Dr. Durrell and others. The culture, development, re- actions and manner of application, with resulting effects upon involved tissues, were most entertain- ingly and instructively defined. Dr. Kolmer very kindly answered many ques- tions propounded during the interesting discussion which followed. Dr. L. Samuel Sica presented a copy of recom- mendations drawn by the Committee on the Bureau of Compensation, as follows: ' “It is suggested by the Mercer County Com- ponent Medical Society that in formal hearings held by the Compensation Bureau a physician should be designated by the Commissioner of Labor, who shall receive a salary from the De- partment of Labor, and shall recommend to the referee holding such informal hearings (upon re- quest of such referee) the extent of temporary and permanent disability of persons applying to the bureau for compensation; to be made after proper examination. This physician shall not, in any compensation case, whether heard informally or formally, before a referee or deputy commis- sioner, give testimony on behalf of either the pe- titioner or respondent, but such physician may, under regulation of the Commissioner of Labor, give testimony at formal hearings in cases where he has previously examined the petitioner on be- half of the state, with the restriction that he shall not be employed by either the petitioner or the respondent to give expert testimony in their behalf, but such testimony shall be given only to assist the referee or deputy commissioner in ar- riving at a decision. Such physician shall not, while he is employed by the Department of Labor in such capacity, be in the employ of any insurance carrier or self-insurer handling compensation cases.” Dr. Peter J. Warter was elected an active mem- ber. Drs. Harry R. Aronis, Herman Cohen, Mor- ton Reese-Cohen, and Thomas V. Murto were elect- ed associate members. MIDDLESEX COUNTY S. G. Berkow, M.D., Reporter Regular meeting of the Middlesex County Medi- cal Society was held January 21 at the Perth Am- boy City Hospital, Dr. Wm. J. McCormick pre- siding. Attendance, 27. The regular order of business was dispensed with to enable Prof. Bryans, of Rutgers University, to address the members on post-graduate courses offered this year by the State Medical Society in co- operation with the University. Suggestions by sev- eral of the members were noted by the speaker for consideration by his committee. The scheduled address was given by Dr. H. H. Ritter, Associate Professor of Traumatic Surgery, Post-Graduate Hospital, New Yrork, on “Some In- teresting Phases of Traumatic Surgery". The speaker gave a practical outline of the treatment of burns and other wounds and showed pictures of the blanket treatment of separation of the symphy- sis pubis. He then exhibited lantern slides of 2 rare cases, one an anterior dislocation at the knee joint, and the other a midtarsal dislocation. Active discussion attested the interest of the members. At the suggestion of the Chair, a short discussion was held on the advisability of changing the meet- ing time from afternoon to evening. Without form- al motion and vote, the members declared in favor of holding the next meeting at 9 p. m. Feb., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 185 Medical Section Rutgers Club J. H. Rowland, M.D., Secretary The regular monthly meeting of the Medical Section of the Rutgers Club was held at the Elks’ Club. New Brunswick, on Friday evening, January 16, Dr. William Klein presiding. There were 35 members, friends and guests present. There being no business to transact, the speaker of the evening was immediately introduced. Dr. Myron Sulzberger, Associate Professor of the Post- Graduate Hospital, New York, gave a very in- structive talk on “The Association of Industry and Skin Diseases”. His talk was very complete, and considered principally the frequency and the eco- nomic aspect of industrial skin diseases. He stressed the importance of differential diagnosis, especially where it concerned compensation ; emphasized the importance of diagnosis, establishment of cause by means of the patch testing method, and treat- ment. which concerned principally removal of cause, if possible, desensitization, and symptomatic treatment. Lecture was illustrated by lantern slides. Following the lecture, members adjourned to the dining room where entertainment was provided by the hosts of the evening, Drs. Hoffman, Howley, Johnson and Karshmer. MORRIS COUNTY Marcus A. Curry, M.D., Reporter A special meeting of the Morris County Medical Society was held the evening of January 22 at the New Jersey State Hospital at Greystone Park. Vice-President Krauss, in the absence of Presi- dent Sutphen, who is convalescing from a severe cold, presided over an attendance of approximately 60 members and guests. Routine business included the reading by Secre- tary Ward of minutes of the special meeting of December 18. 1930, and the proceedings of a meet- ing of the Executive Committee; the latter em- bracing plans under wav for a Post-Graduate Course of Lectures. Dr. Frost, of the committee that is working out the plan with Rutgers Uni- versity, reported the tentative arrangements for the courses; indicating that they will be given at Morristown Memorial and All Souls’, in Morris- town, and the Dover General : and stating that within a few days each member will receive a let- ter outlining the plan. Vice-President Krauss announced that Dr. Ross, of New York, will speak on “State Medicine” at the Academv of Medicine in Newark at 8:45 the evening of February 12; this being a meeting of the First Councillor District of the state. Two new members were unanimously elected: Drs. George Mitchell, of Hackettstown, and J. H. Harrington, of Rockaway. The scientific chapter of the evening was given over to very interesting moving pictures, the films for which were obtained from the Eastman Kodak Company: the subjects covered being “Infections of the Hand”, “Normal Brech Presentation” and “Tests of Vestibular Function”. The pictures were well and clearly projected, attentively witnessed and proved to be very interesting. The evening was rounded out with a social ses- sion during which, at the invitation of Medical Superintendent Doctor Curry, refreshments were enjoyed. PASSAIC COUNTY W. W. Hall, M.D., Reporter The regular meeting of the Passaic County Medi- cal Society was held at the Valley View Sana- torium, Paterson, on January 8, at 9 p. m., with 78 members present. 'Dr. Wm. P. Healy, attending Gynecologist to the Memorial Hospital, New York, presented a most interesting paper on “Pelvic Neoplasms, with Special Reference to Carcinoma”. Two applications for membership were presented to the Board of Censors: Drs. Fritz Plinke, 99 Gregory Avenue, Passaic; and Nicholas Palma, 281 Broadway, Paterson. A collation was served by the institution. UNION COUNTY Russell A. Shirrefs, M.D., Reporter The regular quarterly meeting was held at the Elizabeth General Hospital on the evening of January 14, with Vice-President H. V. Hubbard presiding. The essayist was Dr. Arthur R. Cassili. of Elizabeth, who spoke on “The Third Circula- tion (Cerebro-Spinal Fluid) and its Reflection of the Central Nervous System Pathology”, illustrat- ing his lecture with lantern slides. The discussion was opened by Dr. Norton L. Wilson, who was followed by Dr. Jack Blumberg and others. New members elected were Drs. Herman H. Goldstein, Walter H. Cole, Jr., Joseph E. Frank- lin, George H. Friedburg, Joseph J. Butenas, Joseph Sadoff, Albert G. Gorczyca, Russell G. Bir- rell, all of Elizabeth; and Fred T. Hutton, of Plain- field. Four proposals were also received for action at the next meeting. While the society was in session, its Woman’s Auxiliary held a meeting at the Nurses' Home. Mrs. H. V. Hubbard presided and Mrs. Charles A. Hoffman, of Plainfield, was elected recording secre- tary. Following the meeting both groups joined and refreshments were served. Summit Medical Society W. J. Lamson, M.D., Reporter The regular monthly meeting of the Summit Medical Society was held at Wallace Pines on Tuesday, January 27, with Dr. Prout entertaining, and the President, Dr. Smalley, in the chair. Present: 26 members and 8 guests. The paper was read by Dr. Aaron S. Price, of the Polyclinic Hospital, New York, on “The Clini- cal Interpretation of Differential Blood Count”. In appendicitis we look for an average leukocy- tosis of 15,000 to 20,000. In general the more acute the attack the higher the count will be. In tuberculosis the polys are slightly diminished, with a relative mononucleosis. An increase in the polys shows a secondary infection. In acute rheumatism the leukocyte count will run to 16,000, and in order to avoid cardiac compli- 18G JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Feb., 1931 cations it is necessary to keep the patient flat on his back in bed until the count reaches normal, generally about G weeks. In post-hemorrhagic anemia, and after splenec- tomy, there is a transitory leukocytosis. Eqsinophilia, as high as 20%, occurs in trichin- iasis. It is an allergic reaction, and occurs also in chronic bronchial asthma and in some skin dis- eases. Mononucleosis, 8 to 10%, in tuberculosis denotes activity of the disease, but this is a favorable sign. In typhoid there is a leukopenia with relative mononucleosis. The toxin is destructive to leu- kocytes. In children with acute infections there is a tendency to revert to the primitive kinds of leukaeytes; thus, in pertussis, we find a large per- centage of lymphocytes. The paper was discussed by Drs. Thomson, Dis- brow, Krauss, Prout and Johnston. WARREN (OI'NTV F. A. Shinier, M.D., Reporter A regular quarterly meeting of the Warren County Medical Society was held January 20 at Farrell Arms Plaza, Washington, at 10.30 a. m., Dr. H. B. Bossard, the President, officiating. Mem- bers present: Drs. H. B. Bossard, A. Zuck, F. Cur- tis, G. H. Bloom, L. C. Osmun, C. B. Smith, G. W. Cummins, G. O. Tunison, G. G. Mills and L. H. Bloom. Drs. H. O. Reik and .1. B. Morrison, of the State Medical Society, and Dr. Paul Correll, of Easton, Pa., were in attendance as guests. Dr. Correll read a very interesting paper on ' State Medicine”. Dr. Morrison also read a paper on the present medical conditions, and Dr. Reik discussed both papers. Dr. Osmun spoke of the advantages of a Post-Graduate Course offered by the State So- ciety and urged the support of members. There followed a general discussion in which everbody took part. The meeting adjourned, and dinner was served in the dining room of the Plaza. Obituaries SAVOYE, Richard G., of Westfield. Resolutions adopted by the Union County Medical Society in special session : Whereas, Almighty God in His all-wise provi- dence has chosen to remove from our midst our fellow member, Richard G. Savoye, of Westfield, New Jersey: Therefore, be it resolved that in his death this society, the community for which he lived, and the profession at large have sustained a great loss. Resolved, we express our appreciation of his in- terest in Public Health work as President, for many years, of the Board of Health of Westfield, as a member of the Mosquito Commission of Union County, and as a public spirited citizen. Further, be it resolved that our sympathy be extended to his bereaved family; that these reso- lutions be spread in full on the minutes of this society: and that a copy be sent to his. family. .1. B. Harrison. F. A. Kinch. G. S. Laird. MOORE, John H., of Bridgeton,, passed away Jan. 2, 1931, at the age of 75 years. Born in 1S55, son of a physician, Dr. Joseph Moore, he graduated with honors at Princeton and then acquired his medical degree at the University of Pennsylvania in 1880. Throughout his long and successful career as a physician and an active civic worker, Dr. Moore found time to pursue steadily his study of the classics. One could not know him an hour without discovering that he was a ‘‘learned” man; and yet withal he was modesty personified. Outside the field of medical practice his greatest service was rendered to the school affairs of Bridgeton, and he served for 1!) years upon the local Board of Education — continuing in that office until he had attained his dream of a satisfactory High School for that community. The Meeting By Anna Hamilton Wood When Death and I come face to face at last, 1 do not think the burden of the past Shall lean between us, but that I shall find A gentle, valued friend, consoling, kind, With depth of understanding so profound That rituals and creeds shall be unwound And, like frayed edges of a garment worn Past usefulness or beauty, shall be torn And thrown to discard. My nude soul shall stand. Humble but shameless, and await command For further service; years that went before Locked out of sight forever by the door Of silent Time, their only impress shown By the degrees my spirit-life has grown. How I shall smile to think that once I feared This kindly comrade whose dread shape appeared Cruelly distorted in his earthly guise — For Death is God’s dear shadow to the wise! The Cumberland County Medical Society, at a special meeting called for the purpose, adopted the following resolutions: “The passing of Dr. John H. Moore has left, in medical and social circles, a gap we cannot hope to fill. A scholar and a gentleman of the old school, Dr. Moore has exemplified for us the high standards and excellencies of his generation. Per- sonal dignity was his, unswerving loyalty to his obligations and a fine sense of values, which led him always to set the spiritual things of life, above the gross and mercenary. Primarily he was a man of intellect. Those of us who were associated with him in hospital and general medical work, as well as those who shared his leisure hours, were alike im- pressed by the brilliant mentality that enlivened all he did. Fullness of years brought him a pro- found philosophy of life, so that he met ill-health and misadventure without bitterness, and con- templated the inevitable with a calm fortitude. In the feverish rush of crowded days, it behooves us, his colleagues, to pause a moment for his memory’s sake, and take heart and inspiration from the honorableness of his wise and quiet ways.” 187 Journal of The Medical Society of New Jersey Published on die First Day of Every Month Vol. XXVIII., No. 3 ORANGE, N. J., MARCH, 1930 Subscription, $3.00 per Year Single Copies. 30 Cents DEVELOPMENT OF PUBLIC WELFARE WORK* Commissioner William J. Ellis State Department of Institutions and Agencies Trenton, N. J. The law creating the State Board of Con- trol of the Department of Institutions and Agencies expressly enjoins that the state wel- fare activities “shall be humanely, scientifi- cally, efficiently and economically maintained and operated’’. As a major policy, in pursu- ance of this requirement of law, the State Board of Control has recognized the funda- mental importance of emphasizing the ad- vantages of a program of intensive treatment, training and rehabilitation instead of mere custody of the wards of the state. To the medical profession of the state and to the al- lied professional workers in the laboratories, in the nursing and educational profession, the welfare institutions of New Jersey have turned with confidence for the purpose of carrying out these general policies. Great progress has been made in the past 12-15 years in transforming public institu- tions from places for custody only into treat- ment hospitals and community centers for physical, mental and social rehabilitation. The legislature and successive governors have sup- ported this program of treatment and rehabili- tation because they, were convinced that the advantages, both in terms of happiness and *(Read at the 164th Annual Meeting of the Medical Society of New Jersey, Atlantic City, June 13, 1930.) human welfare, as well as in terms of dollars and cents, are outstanding. In hospital and other treatment institu- tions of the state and counties under this pro- gram of treatment and rehabilitation, keepers and guards have largely been replaced by nurses, teachers, and occupational and physi- cal therapy workers. The medical staffs have been enlarged. They have also been supple- mented by the addition of resident dentists, pathologists, laboratory and x-ray technicians. It is an out-worn view of public institutions that they are places in which unfortunate in- dividuals with mental or physical illnesses should be locked up, simply to protect the rest of society from infection or annoyance. Modern institutions, such as the state and county institutions in New Jersey, are most important factors in the care, training and rehabilitation of mentally and physically dis- ordered persons. They play an important role in the prevention and control of the dis- eases afflicting these persons. In addition, they are or can become very important hu- man laboratories. New Jersey has taken a leading place in the work of modernizing and equipping state and county institutions to pro- vide scientific care and assisting these insti- tutions in serving as centers for disease pre- vention activities. Work in the Field of Tuberculosis Great progress has been made during the last 25 years in reduction of the tuberculosis mortality rate in New Jersey, as elsewhere, due to the joint efforts of many cooperating forces. The remarkable decline in the num- ber of cases throughout the state has been an 188 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 important contributing factor in prevention of the spread of tuberculosis. This decline is indicated by a drop in the mortality rate from 179.5 per 100,000 of the population, in 1904, to 74.9 per 100,000 of the population in 1929; a decline of 58%. Many patients are now seeking hospitalization in the early, cur- able stages of that disease, when they will re- spond to treatment. Thus the chances are in- creased, that they may be discharged from a sanatorium without danger to the community. Improved state and county hospital facilities and the application of modern medical meth- ods have been instrumental in reducing the number of cases of tuberculosis in the state. I hrough the Extension Department of the New Jersey State Sanatorium at Glen Gardner more than 50 regular clinics are held ever)' month in various parts of the state for ex- amination and consultation, and approxi- mately 7500 patients annually are thus ad- vised by competent tuberculosis specialists. The work of the County Sanatorium clinics in Hudson, Bergen, Passaic, Union, Camden Counties and elsewhere is outstanding in this connection. The specialists serving these clinics report that the majority of patients are referred to them by practicing physicians, and the clinics are working in thorough accord and cooperation with the medical profession. These clinics serve a most important function in making competent, specialized diagnostic facilities available to the people of the state, even in remote rural communities. The re- search activities of the Department and of the Glen Gardner Sanatorium play an import- ant part in pointing out the nature and extent of the tuberculosis problem. A survey re- cently completed by the Research Division in- dicates that despite progress made in this field there is still great need for intensive, curative, as well as preventive work. The re- cently published study revealed that 42% of the 2500 patients entering New Jersey sana- toriums for the first time in 1929 were be- tween the ages of 15 and 29. This study further showed that there is special need for increased activity on the part of clinics and the sanatoriums for the negroes; as 20% of the cases of tuberculosis in New Jersey occur among negroes, who make up only 4% of the state’s population. This recent study also re- vealed that patients are not remaining in sana- toriums as long as is desirable; 15% of those discharged remained less than 1 month; 27% less than 2 months ; and 38% less than 3 months. Due to economic and social reasons, many patients leave the sanatorium while they are still a source of contagion to the com- munity. Further success in solving the problem of tuberculosis in New Jersey can best be secured by emphasizing to the public the necessity for recognition of the early symptoms of tuber- culosis and the prompt seeking of competent medical care and direction. Campaign Against Mental Disease New Jersey, in common with other states, has been waging an active campaign against the apparent increase in mental disease. The disturbing fact is that the rate of increase of populations of hospitals for mental disease here, as elsewhere throughout the country, is exceeding the rate of increase of the general population. Between 1910 and 1920 the gen- eral population in New Jersey increased 24.4%, while the population of the mental hospitals increased 36.4%. The Medical So- ciety of New Jersey recognized the outstand- ing importance of this problem when at its meeting in 1929 it appointed a special com- mittee, headed by Dr. Elmer Chase Jackson, to cooperate with other agencies in dealing with this problem. The State Board of Con- trol, through its Committee on Mental Hy- giene, of which Drs. Ambrose F. Dowd, Augustus S. Knight, Joseph E. Raycroft and George O’Hanlon, Mrs. H. Otto Wittpenn and the writer are members, has cooperated with Dr. Jackson and others in outlining a program that is adapted to the needs of this state. The Mental Hygiene Committee has conferred with leading specialists in this and other states and has outlined the following major objectives as a means to check the growth of mental disease and to discover ef- fective preventive measures: (1) We should continue our efforts to trans- form existing mental hospitals into modern treat- ment and curative institutions; this means the March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 189 provision of adequate treatment facilities' and a trained medical staff with consultants to carry on intensive treatment work, using the approved methods of treatment applicable to these patients. (2) There should be an increase in the psychia- tric social service or follow-up field work, so as to enable mental hospitals to parole early, under proper conditions and safeguards, a greater num- ber of patients who can be satisfactorily adjusted in the community. (3) There should be a continued extension of the mental clinics based on the mental hospitals to serve the communities in the diagnosis of men- tal and nervous disorders, and to reach potential sufferers from nervous or mental disorders. (4) The local communities should be encouraged to develop psychopathic departments for mental and nervous patients as part of the local general hospitals. Such a psychopathic department con- nected with a general hospital would be valuable as a “first aid station’’. It is suitable for the nervous patient who feels the need of special care but is unwilling to go to a public hospital for the insane. Under these conditions the physicians and psychiatrists can make their observations and diagnoses and can outline treatment. This, in many cases, will make it unnecessary for these patients to seek admission to the state and county mental hospitals. Medical specialists in mental diseases, psychiatrists in the local communities or from the state or county hos- pitals, can be secured as consultants to these psychopathic departments of the general hos- pitals. Mental patients should not be committed to jails or lockups, as is now often done. These persons are sick mentally and should be sent to psychopathic departments of gener- al hospitals, properly equipped to care for such persons. The Department has issued a publication outlining some practical suggestions for the development of psychiatric wards in connec- tion with the wards of general hospitals. Copies of this pamphlet were mailed to all members of the State Medical Society and the recommendations of this report have met with the cordial approval of such outstanding lead- ers in this field as Dr. Adolf Meyer, of Johns Hopkins University ; Dr. Samuel Hamilton, of the New York State Commission on Men- tal Disease, and many others. Those persons whose mental condition re- quires hospitalization, and yet are not willing to enter public institutions for the care of mental diseases, can frequently be persuaded to enter general hospitals equipped with psychiatric wards. The success of psychiatric wards in connection with the general hospitals in Detroit, Albany, Jersey City and elsewhere argues for the practicability and effectiveness of this plan. General hospitals in most com- munities already possess most of the facili- ties necessary for treatment of nervous and mental diseases, with relatively minor changes in physical equipment and with the services of practicing physicians and specialists in the community, supplemented by consultation service from state and county hospitals and clinics. Great progress can be made in bringing about earlier recovery and in making com- mitments to the county and state hospitals unnecessary. The establishment of such psychiatric departments in general hospitals throughout the state is being urged by the Department, and cooperation of the medical profession and hospital boards is asked to assure success of this plan. Mental Hygiejme Clinics Probably no phase of the state mental hy- giene program is more important than that dealing with mental hygiene clinics. The major work of these clinics is to provide op- portunities for early diagnosis of tendencies and weaknesses that may, under strain, de- velop into some form of mental weakness or insanity, and to suggest treatment that will counteract such tendencies. Twenty-five men- tal hygiene clinics have been established in co- operation with local medical authorities and general hospitals. Cooperation of the medical profession is particularly essential to their success. If incipient nervous and mental dis- orders can be detected in the early stages, many social and economic disasters can be avoided. That practicing physicians recognize the value of these clinics for early diagnosis of mental affections is indicated by the fact that during the past year more than half of the patients attending such clinics were referred by their own physicians. The state does not aim to duplicate any existing diagnostic services, but rather to supplement the work of the general hospitals and the local medical profession. In no case have the clinics been established ex- cept upon request of local authorities. 190 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 Mental Hospitals Great progress has been made in the treat- ment of mental diseases in state hospitals. 1 liese hospitals, which only a few years ago were looked upon as asylums for the insane, have been provided with modern equipment for complete diagnostic services and for in- tensive treatment of complicated physical and mental conditions. The half-mill tax has f made possible, for example, provision of a modern treatment and reception unit at Grey- stone Park State Hospital, where well-equip- ped departments are provided for the resi- dent and visiting staffs of the institution to carry forward their complete diagnostic and treatment services. Similarly at the Trenton State Hospital, with provision of modern equipment such as is found in general hospitals, the physical plant for correction of all types of physical and mental defects has been pro- vided. In addition to medical services render- ed to patients, occupational therapy, physical education and recreational activities of these hospitals are under close supervision of the Medical Department and are regulated in accordance with the mental and physical needs of the individual. The modern conception of mental disease as something capable of im- provement and cure in a large proportion of cases under proper care and attention, has resulted in preventing many patients from be- coming custodial patients requiring a long term of hospital residence. Many valuable research studies into the causes, treatment and preven- tion of mental disorders have been made at the state institutions and the Department is beginning to put into effect the results of their findings. The place of New Jersey, as a leader in the field of mental disease treatment, has already been established through work accomplished by the Medical Director of the Trenton State Hospital, Dr. Henry A. Cotton, and Dr. Mar- cus A. Curry, Superintendent of Greystone Park, and the well trained and experienced resident staffs of these institutions. Work for the Epileptics The work of the State Institution for Epi- leptics, at Skillman, which is recognized throughout the country as one of the leading institutions of its kind, is especially worthy of mention. The gap left by the death of Dr. David F. Weeks, for more than 20 years Medical Director of the Skillman Village, has been ably filled by his associate for more than 15 years, Dr. Daniel S. Renner, who has built up during the past year a splendid staff of competent medical men who are pursuing careful investigations into the causes of epi- lepsy and the most promising methods of treatment. The Training of Mental Defectives In the field of mental deficiency New Jer- sey has developed a plan of segregation and intensive treatment looking toward self-sup- port for those who are capable of being re- turned to the community. The work of the Vineland institutions is well known to all. Through cooperation of the Research Depart- ment of the Training School at Vineland the State Board has outlined a program which counts upon the full cooperation of medical and educational authorities, social agencies, and public health officials. Fundamental to such a program is the provision for early identification of all persons of degenerate stock, with institutional care for those whose degree of intelligence is so low that they can- not care for themselves or provide decent sur- roundings for their children. Industrial col- onies and agricultural colonies for high grade defectives are being developed so that men- tally defective persons may find protection and an opportunity to contribute largely to their own support while under institutional control and supervision. Further extension of the training of backward and defective chil- dren in the public schools is an essential and important phase of this program of control of the mentally deficient. It was through the work of Goddard and Doll, at the Training School at Vineland, that adaptation of the Binet tests for the measurement of intelligence of English speaking children was made pos- sible. This laboratory is continuing to make im- portant advances in the field of research. It is our belief that the state could well afford to concentrate upon additional efforts in this March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 191 direction. We have passed the period when the public generally is satisfied! with mere segregation as an adequate solution on the part of the community to the growing prob- lem in the field of mental deficiency, as in the field of mental disease. New Jersey has been a leader in developing methods of diagnosis, institutional training and reeducation. It must also develop, and, in every possible way, in- crease the fund of knowledge as to causes of mental disease and mental deficiency. In this connection our chief reliance is upon the well trained professional workers — psychiatrists, psychologists and laboratory aides — -who can point the way to better control of, these prob- lems. Crime and Delinquency The field of crime and delinquency, which has attracted special attention in the past year, looks to the medical profession and to sociol- ogists for basic data, so that promising efforts can be made to prevent and control the appall- ing increase in delinquency and crime. For the past 12 years New Jersey has been apply- ing in its correctional institutions methods of diagnosis and treatment made available from the fields of psychiatry and general medicine. Thorough-going physical and mental examin- ations have been made of all individuals com- mitted to the penal and correctional institu- tions. Recently, at the request of the National Committee on Prisons and Prison Labor, a complete survey of the findings of the indi- vidual classification and study of the popula- tion of the State Prison has been completed. In this work the Department has had the assist- ance of Hon. Joseph D. Sears, a member of the Board of Managers of the State Prison, and Dr. Edgar A. Doll, of the Research Depart- ment of the Vineland Training School, a mem- ber of the managing Board of the Rahway Re- formatory, and the personnel of the Mental Hygiene Clinic which senses the correctional institutions. The study, based on the classifica- tion of 2500 male prisoners, includes 2000 prisoners committed to the New Jersey State Prison during the past 3 years, and 500 addi- tional prisoners who were committed prior to 1927. ft will be of interest, I am sure, to those of you who have been watching closely the public discussion of crime and delinquency to know that New Jersey, through a modern plan of classification, has grouped its prisoners into 4 general classes, as follows : (1) Difficult Class. This class is composed of prisoners who are recidivists, who have antisocial tendencies or who are diagnosed as psychopathies and constitutional defectives, etc. This class makes up a large percentage of the prison population and requires, by and large, close custody and close supervision. (2) Better Class. This class is composed of normal prisoners who are mentally and physically able to be adjusted to society. For the purpose of custody and training this class has been divided into 3 groups: (a) Normal prisoners who because of the type of crime committed, or the length of sentence, require close custody but are suitable for shop work and will probably form the backbone of the prison shop organization. (b) Normal prisoners who are believed to be stable and trustworthy and may be employed at prison farms, road camps, etc., where only limit- ed security and supervision are necessary. (3) Feeble-Minded. Composed of border-line, feeble-minded and simple feeble-minded, which in- clude high and low grade morons and high im- beciles. (4) Infirm or Indigent. Composed of aged or senile, chronically ill and the seriously crippled. This group mq,y be segregated on farms of limited security where they may be required to do no more difficult work than their infirmities will allow. Of the 2000 commitments to the State Prison during the past 3 years, 35.5% have been placed in Class 1, the so-called “Difficult Class”. The classification grouping of prisoners designated as the more reformable, better type of prisoners includes those normal prisoners who are mentally and physically able and likely to respond to processes of rehabilitation. This group has been subdivided into those normal prisoners who, because of crime com- mitted or length of sentence, require close cus- tody but who are suitable for assignment in the Industrial Department and are capable of industrial trades training with favorable out- look for parole; 13.4% have been grouped in this class. A subdivision of this same classi- fication of normal prisoners who are believed to be stable and trustworthy and who may be usefully employed at prison farms, road camps and land clearing enterprises, where only limited supervision is necessary, included 37.5% of the 2000 prisoners studied. Group 3, the definitely feeble-minded, makes up 10.5% of the whole number of 2000 prison- 192 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 ers. Nearly 2 % (1.7) were classified as aged or senile, chronically ill and seriously crippled, requiring segregation on farms with limited security. Of the total number of 2000 com- mitments only 1.5% were diagnosed as defin- itely psychotic and epileptic. Institution for Defective Delinquents an Urgent Need In developing a state program for meeting the penal and correctional problems, special attention must necessarily be directed toward the mentally deficient group, including also the psychopathic and constitutional defectives, who are not good risks for parole from the penal and correctional institutions to the com- munity. The classification studies of these prisoners indicate the necessity for a special type of institution for defective delinquents, as developed at Napanoch, New York, and Bridgewater, Massachusetts. It is unwise pub- lic policy, and in every respect poor business, to release this type of offender under parole conditions without a long period of penal or correctional institution care. One of the outstanding needs in New Jer- sey is the development of a specialized insti- tution for defective delinquents, thus remov- ing from the penal and correctional group the type of prisoners with whom these institutions are ill prepared to cope. They should be placed under medical and custodial supervision, as they are not likely to respond to processes of social rehabilitation and at the end of a fixed term in a penal institution must under exist- ing laws be released only to repeat their offenses. No more urgent problem faces those responsible for penal and correctional affairs. No adequate solution can be projected for the problem of crime and delinquency without stressing the need for specialized facilities for segregation and long continued care of this type of prisoner under conditions where he may be usefully employed and where society can be secured from repetition of his criminal propensities. Throughout the institution system the work of the medical profession and other specialists has been of the greatest helpfulness and sig- nificance. Summary and Conclusion I would sum up the development of the out- standing policies for the institutions of the state as follows. (1) We have emphasized the importance of treatment, training, and wherever possible social rehabilitation, instead of mere custody of the wards of the state. (2) The cooperative features of institu- tions have been stressed particularly by em- phasizing the unity of the institutions of the state, providing for interchange of products of institutional labor, for example, and appli- cation of methods of treatment developed in the hospital group, to the same types of indi- viduals when found in the correctional group. (3) Through its welfare divisions, we have stressed the importance of prevention and of using the institutions as social laboratories where the lessons learned through treatment of the abnormal may be brought to the public. (4) There has been developed a plan for informing the public along constructive lines of the work of the local institutions -and agencies. In addition to the responsibilities for gen- eral policy-making for the development of the state institutions and agencies, the State Board has responsibility for visitation and inspection of all county and city jails, places of detention, county and municipal work-houses, county penitentiaries, county insane and tuberculosis hospitals, poor farms, alms-houses, county and municipal schools of detention, and of privately maintained institutions and agencies for the care and treatment of insane, blind, deaf, dumb, epileptic, feeble-minded, or other physically and mentally defective, and for the care of dependent and convalescent children. In its relations to local institutions, whether public or semi-public, the Department has sought to assist in building up local initiative and promoting a sense of local responsibility. It has aimed to promote a wider knowledge of the methods of care, treatment and training of the mentally and physically handicapped, and has advised as to standards of manage- ment, building, construction and medical care for the wards of the state, counties and mu- nicipalities. Through the Department there is March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 193 afforded an opportunity for leadership in specialized service, utilizing not only the full time employees of the Central Department, but also making available the expert heads of the several institutions of the state or the members of the staffs of these institutions, for the benefit of other institutions of the state and its subdivisions. In line with its general policies, the De- partment and the institutions have developed specialized clinics, based upon the large state hospitals and staffed by experts from these hospitals. These clinics, serving in the field of mental hygiene and tuberculosis, have ex- tended their services from the state institu- tions without duplicating or interfering with the services of the local hospitals. Underlying policies in the development of clinic service have been cooperation with local general hos- pitals or special hospitals for mental diseases or tuberculosis; limitation of service to diag- nostic work or follow-up work of patients who have been released from the state insti- tutions ; and development of the full use of local physicians and local hospital facilities. These policies have won support and coopera- tion in all centers where clinics have been es- tablished, and have brought about a splendid spirit of cooperation between state institutions and local clinics and hospitals. INFLUENCE OF PUBLIC HEALTH ACTIVITIES ON MEDICAL PRACTICE* Julius Levy, M.D., Newark, N. J. For the past 2 or 3 days we have been hearing a great deal about the relation of the profession to public health activities, and I think you have had it dealt with in several ways. One of the speakers was disposed to give us a sense of security by ridiculing some of the modern trends and tendencies. Another was disposed to instil in us a considerable *(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Atlantic City, June 13, 1930.) sense of fear in dealing with the subject. I am prompted to try rather to help us under- stand some of the motivations behind both the public health activities and the medical profes- sion. I think we can take a leaf from the modern tendency in psycho-analysis and real- ize that if once we succeed in understanding why we do things, it is much easier to correct our method of doing them, and so I ask you to follow me in an attempt to explain in a rather cursory way the trend of public health and also the trend of medical practice. It is perfectly obvious to all of us in this discussion that public health activities have removed from medical practice a considerable amount of disease and sickness. It is also obvious, I think, that public health has created a great amount of practice, if we are dis- posed to take advantage of the opportunity. Public health can be divided practically into 3 phases: The first may be described as that which deals with prevention of disease through the control of environment. Public health de- partments, learning through the research work of epidemiologists that certain diseases could be controlled and prevented by controlling milk and water supplies, established elaborate systems for inspection and control of those essentials in living, which have practically eliminated milk-and-water-borne diseases ; for instance, typhoid fever. Now it is import- ant to point out that individual physicians recognized that this type of control could not be accomplished by the individual doctor but had to be accomplished by governmental bodies; and so physicians, themselves, were the first to encourage and help to develop this governmental activity in the prevention of dis- ease. You know that today, as a result, there is practically no typhoid fever for us even to demonstrate to younger medical men, while a generation or so ago it carried off a goodly percentage of our population. Then came, a little later, recognition of the relationship of carriers of infection by insects; and again the medical profession heartily helped to develop control of disease through the elimination of breeding places of mos- quitoes and flies and by the screening of homes to protect individuals from infected in- 194 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 sects ; and m that way we have practically eliminated yellow fever, malaria, and similar insect-borne diseases. This type of public health activity received full support of the medical profession, although it very obviously eliminated disease and reduced medical prac- tice. It is worthwhile to stop a moment and ask why this type of public health activity ob- tains so fully and readily the support of the medical piofession? I believe the reason is that it dealt largely with environment ; and I think in the development of our thesis if we will keep this in mind we will see the gradual shift, and possibly an explanation for the change of attitude on the part of doctors. The second phase of public health activity concerned itself more with prevention of dis- ease by protecting the individual. Into this category we would place activities for the pre- vention and control of small-pox, diphtheria, seal let fever, and measles. Diphtheria, you know, can be prevented by the immunization of individual patients, not by control of the environment. Of course, the classical ex- ample of this type of activity is the control of small-pox. Here we are dealing with a con- siderably different type of public health ac- tivity. The purpose again is to prevent dis- ease and to postpone death, but it is accom- plished not by the control of environment, as was pointed out in the first phase, but by dealing with the doctor’s patient or prospective patient directly. Vaccination has been carried on largely by the individual physicians. How- ever, with the recent development of hospital clinics, and, more particularly, medical depart- ments in boards of education, the tendency has been to vaccinate children, without charge, at public expense, irrespective of the financial status of the child s family. More recently, there has been introduced the prevention of diphtheria through immunization by toxin- antitoxin. Again physicians and the organ- ized medical profession lent themselves en- thusiastically to propaganda for the preven- tion of disease through treatment of the indi- vidual. It was obvious that the effect of this kind of public health activity would be markedly to reduce medical practice which came from the treatment of this rather fre- quent and serious disease of childhood. In the zeal to protect children against disease, it was recommended in many cities and states that this immunization be carried out at public ex- pense in clinics established by the health de- partments or boards of education. This plan meant free treatment, irrespective of the finan- cial status of the family. In some places the community itself employed a single physician to administer the treatment ; but this last men- tioned activity is a type of public health ac- tivity which, to my mind, should become part of the newer medical practice and should not be carried on through free clinics, even though the administering physician is paid. The function of a public health department should be to stimulate an interest in the medi- cal profession to carry on this newer kind of medical practice, and to arouse an interest in the public to have the children promptly and properly immunized. I know that this is a much more difficult and slower way of getting children immunized, but I somehow feel that public health departments are breaking faith with the medical profession and, in the long run, will injure the cause of public health if they do not insist that this phase of the pre- vention of disease through treatment of the individual shall be carried on by the individual doctor rather than by public departments. It must be said, however, that the attitude of many physicians has been the very reason or excuse, if you will, for public departments carrying on this work. Many physicians have not taken an interest in the newer methods of prevention and actually have been indifferent to or antagonistic toward such methods. The third phase of public health activity may be described as dealing with personal hy- giene. It has to do with education of the in- dividual in the art of living, and in the in- dividual s control of his own environment. The purpose of this type of public health activity is much more than the prevention of disease or the postponement of death. It has for its object an increase of the individual’s health- fulness and vigor. In a larger sense, its pur- pose is the individual’s happiness through physical well-being. It includes prenatal care, infant hygiene, preschool hygiene, mental hy- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 195 giene, the more modern development in school hygiene, annual examination of adults, and so on. In this group of public health activities we have again developed a type of work for the physician which the doctor, steeped in tra- ditional medicine, has hardly considered medi- cal practice. It has no morbid anatomy, it has no pathology, it does not consist in the dis- covery of diseased organs, it cannot be carried on by the writing of a prescription. It con- sists very largely of advice, of teaching a per- son what the normal individual should be like and is capable of, how he should eat, sleep and live. The development of public health activities, then, has run from the control of environment to the education of the individual in the art of living, together with protection of the in- dividual from disease by immunization. If we will consider for a moment the history of medicine, I think we shall be able to see why it is that certain physicians are unable or un- willing to adjust themselves to what must be- come part of the newer medicine, if the doc- tor, as we know him today, is to survive or if he is to render the fullest service to humanity. We need only look at medicine less than a century back to note the great change which has come over medical practice. Then, the doctor felt that his whole purpose was to dis- cover the disease from which the patient suf- fered. The etiology of disease was too in- definite to permit any rational therapeutics, and so the scientific doctor felt that it was quite beneath him to concern himself with anything more than an accurate diagnosis. As Jacobi expressed it, in describing medicine as he was familiar with it in Germany around 1850 : “The best a patient could expect was to be auscultated by Schoda and autopsied by Rokitansky.” Toward the end of the last century, as a result of work by Pasteur, Ehrlich, and Koch, the etiology of disease be- came clearer and therapeutics developed its more rational basis. In addition to our interest in morbid anatomy and physical diagnosis, therapeutics became a well-established and ac- cepted part of scientific medicine. Physicians eagerly used antitoxins for diphtheria, tuber- culin, vaccines, and the many different meth- ods for specific treatment which developed as the result of the scientific work of that period. But during the past 25 years, medical educa- tion and training have quite naturally been given over entirely to study of the pathology of disease and its treatment. A few men have recognized that much disease can be prevented, » but it has been practically impossible to famil- iarize all physicians with this newer knowl- edge, or to arouse a general interest in its ap- plication. I think the attitude of certain physicians toward the more modern practice of medicine, which should include every possible method for furthering human welfare, wheth- er it be by education or by the prescrib- ing of a drug or by the administration of an antioxin, can be understood, if we think of the medical profession as being made up of individuals some of whom have been ar- rested in their development at one or another period in the development of the art and science of medicine. Lombroso, in his study of criminology, has explained the antisocial conduct of individuals by pointing out that their conduct is only antisocial because they are apparently living in a former stage of civilization. Those people who are considered criminals in this generation or century would be considered normal with similar conduct several generations back. So it is with physi- cians. It is very natural that physicians should think of the practice of medicine as dealing only with the recognition and healing of dis- ease, but it becomes necessary to point out that unless they recognize also that, we have reach- ed the point where the public demands it be educated in the prevention of disease, in per- sonal hygiene, in development of the fullest vigor and health, the public will obtain this instruction from other sources. We must re- alize that society in America is organized on quite a different basis from that of a genera- tion ago. There are enormous foundations eagerly awaiting the opportunity to subsidize large community efforts, first for the preven- tion of disease, but not far off for the treat- - ment of disease also. Public departments na- turally will respond to pubic demand. There are today in public health departments men 196 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 who feel it is their duty to protect the public against disease. If they find the individual physician indifferent or antagonistic to assum- ing the role which is offered, it, of course, will be assumed by public departments. Public health activities, then, have had a » two- fold effect. They have eliminated dis- ease, itself, but they have replaced it by a new type of medical practice. The future develop- ment of medical practice and public health ac- tivities will depend upon the attitude of physi- cians and the organized medical profession. If it becomes sufficiently aware of the trend of public health activities and satisfies the community that it can be protected through the private physician, there will be less ten- dency to place the new public health activities, which deal with individual protection, in the hands of public departments. Welch, in his second Sedgewick Lecture in Boston, summed up this question as follows : “I should like to refer very briefly to a matter which seems to me of serious concern to modern public health. This is the lack of sufficient active participa- tion of the general medical profession in public health activities, especially as developed in this country. The fault is on both sides. There has been encroachment upon the field of the private practitioner and there has been a lack of sympathy and cooperation with public health officials and with health programs on the part of practitioners. There can be no real lasting success of efforts to promote the health of the people and to prevent disease without the active sympathy, support and participation of the medical profession. How this is to be more largely secured merits the most serious consideration.” HEALTH DEPARTMENT GROWTH IN NEW JERSEY* D. C. Bowen, Director of State Department of Health, Trenton, N. J. Public health work in New Jersey, as a function of state and local governments, is 53 years old. The first State Board of Health •(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Atlantic City, June 13, 1930.) was created in 1877, and 10 years later the law requiring local hoards of health was en- acted. In this one small state there are now 561 local health boards. They consist of more than 2800 members and employ about 580 persons on full time and 760 on a part time basis. Appropriations from public funds for the work of these 561 boards in 1929 amount- ed to over $2,000,000. It should be borne in mind, for the purpose of this paper, however, that many of the 1340 employees are clerks and secretaries and that only 119, or 21%, of the 561 municipalities and townships employ licensed health officers, and that three-fourths of the money is spent in the 50 cities and towns having over 10,000 population. This vast number of separate bodies is the result of a law that requires each municipality and each township, no matter how small in size or population, to have its own public health organization. Four decades ago, such boards may have been able to carry out the best sanitary practices of that day. Today, many of them are not. In the field of medicine, the advances of the last half century have been monumental. As a result of some of these advances and those in other professions, health departments have grown in the amount and complexity of work delegated to them, as well as in numbers. Their activities now include control of com- municable diseases, supervision of milk, food and water supplies, recording of vital statis- tics, regulation of plumbing, inspection and abatement of nuisances, health promotion, and a multitude of related matters. They may adopt ordinances and enforce rules and regu- lations relating to a wide variety of subjects. Public health laws of New Jersey fill a volume of nearly 400 pages and the State Sanitary Code adds 30 more. Wise, indeed, is he who can find his way through such a maze of words and not get lost. A number of these laws impose exacting duties on physi- cians. In the busy round of practice, it is easy to understand how some of these duties are occasionally forgotten by doctors. It has occurred to me that a small booklet setting forth these requirements of law in compact form might be helpful to you. Such a book- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 197 let is now being prepared by the State Depart- ment of Health. One important change since 1S77 is in our point of view toward communicable diseases. Emphasis used to be placed on human sur- roundings and on filth, in the belief that dirt bred disease. This idea probably helped to make us a cleaner race but it fixed attention on visible and often harmless dirt instead of on the unseen kind which we know now is often deadly. With the knowledge that each communicable disease has a specific, living causative agent and that sources of most of these diseases are persons, not things, our whole attitude to- ward disease prevention and control has changed. The spectacular retreat of typhoid fever, tuberculosis, diphtheria, malaria, plague, and yellow fever are some of the results of this newer information and viewpoint. Knowledge as to how disease producing or- ganisms enter the body, battle with the cells and secretions of the body, leave the body and are carried to other persons has put the struggle against this group of diseases and their partial control, at least, on a scientific basis. For this reason, if for no other, common sense and good judgment alone no longer fit a man for board of health work, as they might have done 40 years ago. The efficient sanitary officer today must know something of bacteri- ology, chemistry, epidemiology, engineering and statistical methods, and also appreciate the practical problems of the dairyman, butcher and restaurant proprietor. He should also possess the diplomacy that will enable him to use this knowledge. Health officers and in- spectors were formerly sanitary policemen, in- tent on arbitrarily enforcing sanitary regula- tions. The modern official, if he is really modern, is a teacher and leader in sanitation and hygiene. He has found that with most people, force is likely to fail in the long run and education is apt to succeed. The effect of the changes just pointed out has been unmistakable in the growth of both state and local health departments in New Jer- sey. I have been connected with public health work in this state for 39 years, and with the State Department of Health since 1903. In that time, I have seen the Department grow from a little group of 15 employees to an or- ganization which is exceedingly crowded in 19 office rooms and 3 laboratories. Its office and field staff now numbers 155 and this number is not sufficient to carry out in a satisfactory way even the mandatory duties imposed by law. On many occasions, small groups, to whom the department’s organization and duties were being explained informally, have expressed surprise and unexpected interest in these mat- ters. Since the physicians of the state are probably the largest group of persons with which the department deals directly and in- directly, I believe the members of this society will be interested in a bird’s-eye view of the organization of the State Department of Health, which may have seemed an imper- sonal sort of thing but which is really com- posed of men and women whose interest and problems often run parallel to your own. The work of the department is carried on by 10 divisions or bureaus. They are the Bureaus of : General Administration ; Local Health Administration; Food and Drugs; Vital Statistics; Engineering; Venereal Dis- ease Control ; Child Hygiene ; Bacteriology ; Chemistry ; Public Health Education. The Bureau of Administration is defined by its name ; it is the business branch of the Department. The Bureau of Local Health Administration is one with which many of you have direct con- tact. Epidemiologists connected with this bu- reau investigate and help control epidemics and smaller outbreaks of communicable diseases, and assist local health and school boards to inaugurate and conduct toxin-antitoxin and Schick test clinics, make sanitary surveys and deal with most of the problems which annoy local health boards until they ask for help. This bureau also receives, tabulates and studies reports of cases of communicable diseases filed by doctors with local reporting officers and by them transmitted to the department. Certain contagious diseases that occur on dairy farms are dealt with by men from this bureau. Other duties too numerous to mention, together with those just enumerated, make greater demands 198 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 on the small staff of this bureau than it can possibly meet. The Public Health News, which I hope you all read and enjoy, is also prepared in this bureau. The 2 district health officers, stationed at Freehold and Pitman, re- port through the chief of this bureau. Contrary to popular belief, much of public health work is not medical. One of the ear- liest and still very important parts is sanitary engineering, which has contributed very greatly to progress in disease control and sanitation. The engineering bureau of the State Depart- ment of Health carries out duties placed upon the department by 16 different laws. Approval of sewerage systems, disposal plants and water supplies are among these. The word “ap- proval” may suggest a simple procedure but actually it demands a great deal of investiga- tion and study. The examination and ap- proval of plans for nearly $10,000,000 worth of construction a year is in itself a time con- suming and extremely exacting duty. Investi- gations of stream pollution are conducted by this bureau and also a check on the operation of the 704 water treatment and sewage treat- ment plants in New Jersey. Three laboratories are maintained by the department ; 1 for bacteriologic examination of specimens from communicable disease cases. .1 for chemical testing of food and drugs, and 1 for testing water and sewage. With the facili- ties and services of the first, you are doubtless more or less familiar. Specimens from known or suspected cases of communicable diseases, which many of you submit in special contain- ers deposited by the department throughout the state, are grown and examined in this laboratory. Its work has increased each year and reached the impressive' total in 1929 of 60,000 specimens. Our chemists examine a wide variety of products for detection of adulteration and misbranding. These products range from Hamburg steak, artificially colored cakes, can- ned products and milk, to soft drinks, drug preparations and extracts. Testimony in court takes an appreciable amount of time of the men who make the analyses. An important branch of this laboratory is conducted aboard ship; on the department’s floating laboratory boat, “The Inspector”. Sanitation of the shell- fish grounds of New Jersey is secured partly as a result of tests of the water and of oysters and clams themselves at Delaware Bay, Maurice River, Wildwood, Tuckerton, Rari- tan Bay and other producing areas. The third portion of the laboratory, which is really a part of the engineering division, tests water and sewage. The thousands of samples examined each year come from public water supplies, state institutions, parks, schools, sum- mer camps for boys and girls, bottled waters sold in New Jersey, private wells and springs believed by local boards of health to be pollut- ed, and from sewerage systems and sewage disposal plants. Both chemical and bacterio- logic tests are carried out. The laboratory co- operates with the Fish and Game Commission, State Department of Conservation and De- velopment, State Department of Public In- struction, and Interstate Commerce Commis- sion, in testing water used for public or semi- public purposes. Inspection of foods, and establishments where foods are stored, handled, manu- factured and sold, is made by representatives of the Bureau of Food and Drugs. Dairies, pasteurizing plants, creameries, ice-cream plants, slaughter houses, cold storage ware- houses, bottling plants, egg breaking establish- ments, hotels and restaurants are among these. Samples of foods and drugs are collected regularly for laboratory examination. Alert- ness of this bureau uncovers dangerous prac- tices and products from time to time, stories of which occasionally appear in the public press. When you sign a birth or death certificate, perhaps you have wondered what happens to the document before it reaches its final resting place. Perfection is hardly too strong a word to apply to the system by which these im- portant records, gathered by over 560 local reg- istrars, move with precision on the tenth day of each month to the Bureau of Vital Sta- tistics of the State Department of Health for final study, classification, tabulation and filing. The originals are bound in books, about 6 in. thick, and filed in fireproof vaults in the State House. Searching old records and pre- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 199 paring certified copies of these filed certificates for employment, pension, passport and other legal purposes, keep 3 persons constantly busy. About 150,000 certificates are received yearly and approximately 7,000,000 are now preserved in the vaults. A transcript is made of each marriage, birth and death certificate filed in the State Bureau of Vital Statistics, and forwarded to the Bureau of Census, Washington, D. C., for use in compiling re- ports on vital statistics issued by the United States Government. Qiild welfare appeals to all normal people and the growth of the child hygiene movement in the last decade has been phenomenal. New Jersey’s progress in this field has attracted wide attention. The Bureau of Child Hy- giene now supervises the work of 132 nurses carrying on a unified program in 400 com- munities (not municipalities) in the state. Its activities, however, have reduced the number of midwives in the state and greatly elevated their standards of practice. Boarding homes for children, and maternity homes are under its supervision, and courses of lectures on normal children, for nurses and teachers in training, help to keep before them the ideal of healthy, happy childhood. After receiving silent treatment for cen- turies, venereal diseases have been attacked since the beginning of the World War in much the same way as other communicable diseases. The Bureau of Venereal Disease Control carries on a two-edged program. On the one hand, it attempts to get cases reported and treated and to learn the name of the per- son who transmitted infection in each case so that she (or he) may also be treated. Many of you doubtless are active in the medical part of this effort. Demonstrations of newer meth- ods of treatment are given occasionally to medical groups in different parts of the state. On the other hand, the Bureau seeks to in- form parents and older boys and girls as to the facts regarding sex and venereal diseases, so that ignorance may play a lessening part in the social problem as time goes on. Three phases have marked the evolution of public health since its birth 50 years ago. The first was sanitation ; the second, disease pre- vention ; and the third, health conservation. In this last phase, education is of signal value and the most recently created division of the Department is the Bureau of Public Health Education. Newspaper stories emanating from this bureau have been used throughout the state during the last year and a half. You have noted that the State Department of Health has been able to expand its work to conform in some measure to progressive ideas of public health service. What of local health departments ? In cities and wealthy towns where appro- priations for public health work are sufficient to employ trained personnel, the services of the health department have kept pace, in gen- eral, with our knowledge of sanitation and hy- giene. Approved activities for the protection and promotion of health are carried on with rather limited budgets, to be sure, but in ways which throw about residents and visitors to these communities creditable safeguards against preventable ill health. In most bor- oughs and townships, however, little progress has been made, because of lack of funds. Per- sonnel competent to carry out the activities just ' mentioned is more costly than a small community can afford. Conversely, most boroughs and townships do not have suffi- cient board of health work to require the full time of even 1 individual. Organized public health work might be car- ried on in a state the size of New Jersey in either of 2 ways. One method would be to cen- tralize all responsibility in a State Department of Health and perform the necessary services through a network of employees spread over the state. Such a system is contrary to the principle of local self government, and, so far as I know, is not recommended nor desired by anyone. Another method places responsi- bility on local bodies and makes the State De- partment of Health a supervisor, with power to act in case a local board fails. The State Department of Health could also act in inter- municipal matters and could assist local de- partments through its specialists and labora- tory facilities. The latter is the system adopt- ed by the legislature 43 years ago. It should be a good system but it breaks down if local 200 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 boards cannot carry their share of the burden, and that is just what has happened in hun- dreds of places since public health work be- came such a complex, technical procedure. What can be done about it? The only prac- tical correction that I can suggest is to en- large the local sanitary district until it can support, at reasonable per capita cost, a health department that is able to function. The same problem has been met by several other states in this way. In the south and west, usually the county has been the unit because the county, rather than the town, is actually the local political unit in those areas. I doubt if the county would be satisfactory in all cases in New Jersey. Our counties vary so widely in size, population and in the number of cities and large boroughs which already have excel- lent health departments, that difficulties would surely arise in reshaping a state-wide reorgan- ization on county lines. Several rural counties in New Jersey might each comprise a unit for health administration. In other sections, a combination of adjacent small boroughs to make a district of 20,000 to 30,000 population might be better. Cities and large towns should maintain their own health departments. Legis- lative action will be necessary to make the change suggested or any other change which will set up workable health departments in suburban and rural districts. To draw a bill which will meet the needs of the state as a whole and insure a smoothv operating public health organization throughout New Jersey is no small task. To secure legislative approval of the needed changes may be difficult. But the effort should be made, for in the midst of a world moving rapidly toward public health achievements of a high order, many of our small communities are practically standing still, in so far as official health departments are concerned. No group knows better than the physicians of the state the difference between the care- fully planned and executed programs of our better health departments and the haphazard, bungling efforts of the poorer ones when con- fronted by emergencies. When a plan of re- organizing local health work has been drawn up and meets with your approval, will you, the medical men of New Jersey, lend your strength toward placing the public health ser- vices of this state on the high plane which pre- ventive medicine, sanitary engineering, chem- istry and bacteriology make possible? STATE DEPARTMENT OF LABOR IN RELATION TO THE PUBLIC AND THE MEDICAL PROFESSION* Henry H. Kessler, M.D., Newark, N. J. The Department of Labor was organized and established by law in 1904. Most of you are familiar with the department, particularly in its workmen’s compensation and its rehabili- tation aspects. The department, however, did not begin as a workmen’s compensation bureau nor as a rehabilitation division ; it started os- tensibly to overcome the exploitation of child labor, which had become rampant in the years just before 1904, when the department was established with a Commissioner of Labor at its head and 2 Factory Inspectors, who were to seek out and investigate any violations of the Child Labor Law. Since that time the de- partment has been enlarged so that at the present time there are 9 bureaus and about 175 employees to carry on its different func- tions. The first Commissioner of Labor was Col. Louis T. Bryant, who functioned from 1904 to 1923. From 1923 to 1929, Dr. McBride was Commissioner of Labor. The present incumbent is Col. Charles Blunt. The Department of Labor is now composed of the following Bureaus: (a) General and Structural Inspection Bureau and Explosives ; (b) Sanitation and Hygiene; (c) Women and Children; (d) Statistics and Records; (e) En- gineer’s License, Steam-Boiler and Registra- tion Inspection; (f) Employment and Wage Collection; (g) Workmen’s Compensation; (h) Rehabilitation. Each bureau is in charge of a head, who is responsible for the activities of his particular department. *(Read at the 164th Annual Meeting of the Medical Society of New Jersey, Atlantic City, June 13, 1930.) March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 201 In order to carry out the functions of the Bureau of General and Structural Inspection the state has been divided into 22 districts, in each of which a factory inspector is charged with the responsibility of investigating viola- tions of the State Labor Laws ; fire apparatus must be investigated, elevators must be prop- erly guarded, as well as machinery, approaches to stairs and fire-escapes must be kept clear at all times, healthful working conditions must prevail, ventilation and exhaust systems, must be installed where necessary, buildings hous- ing more than 25 people must be provided with a standard system of fire signals and fire drills must be held. Accidents are investi- gated as to their occurrence, so that others may be prevented in the future. Where mines and quarries are located, these must be prop- erly safe-guarded. Assembly halls are inspect- ed if no building supervision is at hand. Wherever explosives are stored these must be maintained in accordance with departmental rules. In addition, illegal employment of women or children is investigated by the fac- tory inspector. The department also conducts a safety museum, in Jersey City, where is maintained an exhibit of safety appliances and safety methods, which is open to the general public at all times. Safety talks are given from time to time, at different plants, by members of the department. The function of the Bureau of Hygiene and Sanitation is very closely allied with that of the Department of General and Structural Inspec- tion. The same factory inspectors, in addition to their previous duties outlined, must pay special attention to health hazards, such as dust, fumes, excessive heat, poor lighting or ventilation, washing and toilet facilities, and any special health hazards that may exist. These are all regulated by law, and this is of particular importance in this state because of the wide and extensive existence of industrial hazards, particularly in the northern part of the state. No less a person than Sir Thomas Oliver, of England, several years ago, when here, stated that within a 25 mile radius of Newark existed the largest geographic area in the world from, the standpoint of specific industrial health hazards. A little over a year ago there was estab- lished in Newark an Occupational Disease Clinic. In view of the unusual publicity and unusual number of cases in the field of occu- pational disease that we had to deal with in previous years, it was thought wise to establish a clinic where such cases might be studied, men might be examined, and a certain amount of information might be disseminated to lay- men and to the medical profession. In the past year and a half over 800 persons have been examined in this clinic. Cooperation of the medical profession has been urged, in the reporting of occupational diseases, for the specific reason that as soon as a case is re- ported to the State Department of Labor a Factory Inspector or the Deputy Commis- sioner will immediately investigate that case. If poisoning or a special health hazard does exist, he will take measures to remove it, cor- rect it, or eliminate the plant. In the northern part of the state, history has been made in the field of occupational dis- ease. Radio-active poisoning was put on a definite, pathologic basis by Dr. Martland, and recently a new form of occupational disease, that of silicosis, has been giving us a great deal of thought and trouble. In addition to these bureaus, there was re- cently established, under the leadership of Mrs. Summers, a Bureau of Women and Children, to investgate violations of the law pertaining to women and children in factory, mercantile, field and home work. Especial in- terest in the migratory child labor problem exists at the present time. As you know, New Jersey has been progressive in the regulation of labor by women and children. We have a Child Labor Law which provides that no child under the age of 14 may be employed, and no child under the age of 16 may be employed in specially hazardous work ; we have no night work for women ; a 10 hour day law for women; and an 8 hour law for children of 16 years and under. The Engineer’s License Bureau supervises licenses for steam boiler engineers, and steam 202 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 boilers are also investigated by the Depart- ment of Labor. The Bureau of Statistics and Records is very important. Records are important in any field of public endeavor, but they are es- pecially so in the Department of Labor, par- ticularly in the Workmen’s Compensation Bureau, because rates of compensation and premiums are passed upon and are based upon the accurate statistics kept by this bureau. The Employment Division conducts free employment bureaus, licenses and regulates private employment agencies, investigates the extent and causes of unemployment, and also cares for the claims of those who have been refused payment of wages earned. Of especial interest to the medical profession is the agita- tion recently developed for the preemploy- ment examination of domestic servants, similar to that of food handlers for contagious and venereal diseases. The Employment Di- vision has been asked by several Boards of Health to cooperate in refusing employment to those who are found harboring disease. Only c small number of municipalities, however, are as yet cooperating. Of additional interest in this Division is the regulation of commissary camps, which are nothing more in many cases than boarding houses that receive the privilege of housing workers in rural sections. For about 3 years these camps have been licensed and gradually efforts have become successful in securing higher standards of physical con- dition. It was found that the State Health Code set up regulations affecting these camps only as to polluted water supply, the fire- proofing of privies and cesspools and disposi- tion of excremental matter. It was found also that the state of Pennsylvania, through its Labor Department, had developed a very ex- tensive set of regulations concerning every de- tail of these commissary camps ; so a similar set of regulations has now been developed in this state. To the medical profession, the 2 divisions of the Department of Labor that are of par- ticular interest are the Workmen’s Compensa- tion Bureau and the Rehabilitation Division. Enough reference has been given to indus- trial medicine and traumatic surgery yester- day and today to give you a little insight into the difficulties that exist and arise between em- ployers and industry at large and the medical profession. The Workmen’s Compensation Law, which is a munificent piece of social legislation, was passed in 1911; New Jersey being one of the first states to pass such a law. Unfortunately, the Department of Labor, or perhaps for- tunately, had nothing to do with the passage of that law, and unfortunately the medical profession was given very little voice in making that law, so that we find today a very anomalous situation : We find that a contract exists between 2 parties, an em- ployer and an employee, in which nothing is said about a necessary third party — -the medical profession, The Department is charged with the responsibility of passing on claims for industrial accident, determining the awards for disability, passing on bills, etc. In Newark, a Medical Bill Committee was es- tablished in order to adjust these matters of disputed medical service bills. This method of handling disputed fees has been found to be a happy solution. There are 3 men ap- pointed to this Committee: Dr. Kraker repre- senting the Essex County Medical Society, Dr. Jackson representing the employers, and myself representing the state. We meet once a month. Bills are referred to the committee for arbitration. The physician involved is asked to appear at this informal meeting, and we invite also a representative of the insur- ance carrier or the employer. At this meeting differences are ironed out, and in approxi- mately 95% of cases the carrier is willing to and usually does pay the bill or pay whatever this Committee recommends, despite the fact that we have no power in law. In 1919, New Jersey passed the first Re- habilitation Law. New Jersey felt that her citizens were entitled to the same consideration that war veterans received. When the Federal Government passed a law for rehabilitation of the disabled veteran, it felt that the tin cup and the lead pencil were not the answer to disablement. New Jersey felt the same, and 6 clinics were established in large centers of population throughout the state where any in- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 203 dividual who was physically handicapped by virtue of disability, caused by accident or dis- ease, could come for those services to which the law entitled him. Those services meant treatment, vocational training and placement in remunerative employment if he could work. In the past 10 or 11 years, since New Jersey led the way in the field of rehabilitation, other states have fallen in line, so that almost 40 states now have laws providing for rehabilita- tion of physically handicapped persons. The Federal Government assists some of these states by subsidy of monies in order to speed the work on. I have some slides here which will demonstrate some of the rehabilitation work and some of the rehabilitation cases, which I would like to show you. (Lantern exhibition.) THE DOCTOR AND THE LAW* Robert Peacock, Mount Holly, N. J. On the subject of the Doctor and the Law, I want to speak of law enforcement, not the law enforcement that has caused such an up- heavel in the minds of the people of this coun- try but the enforcement of laws concerning your profession and the public health of the state; enforcement of the laws of this state not for restriction of the rights of its people, but the protection of public health. The law that keeps your profession on a higher plane ; that rids the community of quackery. Quack- ery is more detrimental to your profession and the public health, than the radical red attempt- ing to supress the functions of government ; because if we do not have a healthy people we cannot have a healthy government. The gullible public is falling more each day to these so-called “new ideas” of cures, and gradually drawing from the care of doctors, who are trained to cure and keep the public healthy. Is it because your profession deems its standards so high, that you are not educat- *(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Atlantic City, June 13, 1930.) ing the public against these tenets of mal- practice. while your opponents are spreading propaganda throughout the. state advertising their wares and condemning medicine? It is your duty to start a campaign of education among the people of this state to stamp out these fakers in medicine; to have committees of your state and county medical societies co- operate with the State Medical Examining Board which has this subject at heart, and educate the public on this subject. Medicine is- of all arts the most noble, and the profession should be on a plane of nobility and free from imperfections, and my duty as attorney for the State Medical Board has been to uphold the Medical Practice Law of this state and try in my feeble way to keep your profession on a holy plane, free from violators who would practice this noble art without license. Hippocrates said in his oath : “As a physi- cian I will keep this oath and this stipulation, by an oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients and abstain from what is mis- chievous.” That same oath still remains the duty of physicians to this day, and it is the foundation of our law that life and health are protected by the law of this state for the benefit of its people, and to protect those who- practice the noble art of medicine. Instruction in medicine is like the culture of the productions of the earth. Our natural disposition is, as it were, the soil ; the tenets of your teachers are, as it were, the seed; in- struction in youth is like the planting of seed in the ground at the proper season; the place where the instruction is communicated is like the food imparted to vegetation by the atmos- phere; diligent study is like cultivation of the fields; and it is time which imparts strength to all things that bring them to maturity. Hav- ing brought all these requisites to medicine, and having acquired a true knowledge of it, it is your duty to uphold the traditions of your profession and be physicians in reality, and to cooperate with those in authority to keep from the profession those who do not hold this to 204 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 be the law, and without partiality prosecute to the fullest extent those who violate the con- fidence of the people and violate the laws upon which your profession is founded. For that purpose, the Legislature of this state has said that to be a physician to practice in this state certain qualifications are to be had before a person can take the examination, others who do not possess those qualifications are not en- titled to take the examination and practice medicine in this state. Our law says that any person who shall use the word “doctor” in connection with his name and hold himself out as being able to diagnose, treat, operate or prescribe for any human disease, pain, etc., who does not have a license to practice medicine from the State Medical Board is violating the law of this state. Our courts have passed upon this act and have said that it is constitutional. A chiropractor or osteopath cannot use the title doctor. A chiropractor or osteopath cannot •give electric treatments. A chiropractor can- not use a concusser or a light to shine in the eye. An osteopath cannot examine eyes. An osteopath can only use his hands for certain replacements. An osteopath or chiropractor v cannot give medicines or prescriptions. A chiropractor can only manipulate the spine, by Land. The Act sets forth $200 for the first viola- tion, and $500 for the second violation, or in the alternative a jail sentence. The Board can revoke the license of a physician for the fol- lowing causes : chronic and persistent in- ebriety; criminal abortion; conviction of crime involving moral turpitude; for publicly ad- vertising special ability to treat or cure chronic or incurable disease, or where a license has been obtained through fraud of any kind. From the year 460 B. C. physicians were or- ganized into a corporation or guild, with regu- lations for the training of physicians, and with an esprit de corps and a professional ideal which with slight exceptions can hardly yet be regarded as out of date. The physician must not only be prepared to do what is right himself, but also must be willing to uphold the law and prosecute others who do not up- hold the same. He must report violators of the law and generally cooperate with those in authority to enforce it. Law enforcement is a duty that is incumbent on all of you; whe- ther you believe in it or not the duty rests with you to protect the public from the tenets of those who have no license to practice medi- cine and impose on a public that is always willing to grab some new novelty in the way of healing or some other faker who advertises his wares without any foundation for the good of the public. Law enforcement is an ideal not a fallacy, and it cannot be enforced with- out cooperation. The State Board has its corps of investigators and spends time and money to protect the profession, but it can- not find all the violators through its own searching. Complaints are made to the Board by people who are not doctors, more so than bv the doctors themselves, so you see the gen- eral public is exercised over these violators; and if the public is exercised, you as physi- cians should be more so, not only to protect your profession but to protect the public. Our fore-fathers said the Constitution was to pro- tect life and property. Property’s greatest as- set is health. Howr can it be better protected than by prosecuting those who have no right to encroach on the title of property? 1 he State Medical Board is working for your benefit and devotes its time for the bene- fit of the profession, and it must of necessity know where to locate those w'ho traverse the law. in order to prosecute, so I call on you, as citizens who believe in upholding the law, for your full cooperation in law enforcement in this matter in this state, and in doing this, gentlemen, you will not suffer the most hon- orable of all professions to be debased into a sordid lucre traffic by the fakers outside of this profession who have neither license nor knowledge to practice. Especially is it your most sacred duty to yourselves and your pro- fession to help prosecute these violators ; it constitutes an important part of justice, and if cooperation is not forthcoming from you doctors then this and other abuses of your profession will continue and the people will suffer from a lack of enforcement. For a moment I will call your attention to some classes of fakers we are called upon to March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 205 prosecute. I will not mention names but the files are in my office and will corroborate what I cite: “Dr. L.” — in Ocean County — claimed to free the body from toxic poisonings and said it was necessary to create “new pores” in the body. He proceeded with a woman to insert new pores in her body. He had a machine with 26 needles in it and from the woman’s shoulders to her heels he placed this machine drilling holes in her body. She had 1000 in- fections in her body, and subsequently died ; and her husband died within 3 hours as the result of the shock. A man, “Mr. C.”, of Bergen County, claimed to have a cure for tuberculosis and he obtain- ed $10 per bottle for this so-called cure, which a subsequent analysis showed contained only lard, molasses and vinegar ; and he accum- ulated a fortune from sales of this sure cure for tuberculosis. Another “Mr. G.”, of Hudson County, had a sure cure for cancer and diagnosed and treat- ed conditions as cancer, and he even claimed that our investigators had cancer. Analysis showed his medicine was nothing more than plain chocolate in wafers. “Mrs. W.”, of Gloucester, was a practicing midwife without license ; no care was taken of the children’s eyes after birth ; 3 children went blind and 1 mother died as a result of her ignorance. “Mr. W.”, son of a minister of Union County, was an “expert on foot diseases” ; he studied in a correspondence school, and ruined quite a few people’s feet in his ignorance. Druggists are treating gonorrhea and dis- eases of that character, and in Hudson County one druggist had blank prescriptions signed by 2 doctors, and he treated patients and gave medicine with doctor’s names on the bottles, and these doctors admitted they never saw the patients. “Mr. J.”, of Essex County, practicing chiro- practic, was convicted and then started prac- ticing dentistry and was convicted of both violations. “Mr. W.”, of Newark, claimed to be an “expert in stomach diseases” and had quite a practice, and the only thing he gave was an ordinary cereal in cans, which he said he ob- tained from Germany. Certain chiropractors are now trying electric treatments in connection with manipulations by hand, which is a violation of the law as our courts say chiropractors can only manipulate the spine with the hand ; there have been several convictions of these men. Osteopaths are doing the same thing, claiming they are also “naturopaths” ; and many convictions of these people have been obtained by your state board. Fake advertising is another evil which is being corrected ; both within and without the profession. Fake certificates from other states are also presented to the Board, which call lor constant supervision and investigation. It will be a grave indictment of you men, as physicians, if you fail to cooperate in this, the most serious of crises. I crave for your earnest consideration of these facts, for an in- fluence in quickening of your profession in this matter ; in deepening your seriousness and in assisting the State Board to carry out the law of this state. A very few words more and I will be through. Those words are words of hope. Indeed, if I have said anything that seemed to you to be bitter, it has been in a spirit of friendliness, to help me in a cause I have at heart. I know this cause will conquer in the end for it is an article of faith with me to protect the health of our people of this state from quacks. I know well it is not for me to prescribe the road to success of this under- taking, but faith in my work impels me to- speak according to my knowledge, feeble as it may be and rash as the words may sound, for every man who has a cause at heart is bound to act as if it depended on him alone. I am practicing the things I have asked you to do; it is a pleasure to work for you and try in my feeble way to bring results and uphold the dignity of your profession, and to prosecute those who violate the law, and with this all in mind you have asked me to speak to you as a friend. I could do no less than to be open and fearless before you, my friends. So, in closing, I plead with you to start a system of education among the people of this 206 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 state and nation to combat this insidious propaganda of these so-called modern cures and faith healing and other fakes and quack- ery, to combat the propaganda of those who piactice such methods. To strengthen the law of this state so that for a second or third violation of the Medical Act the sentence will not be a fine but imprisonment in jail of not less than a year; as fines will not stop the illegal practice of medicine in New Jersey. Discussion Chair vi(i7i McBride. I wish to express our ap- preciation to all the gentlemen who have render- ed these very excellent papers. They are now open for discussion. Dr. Frank. W. Pinneo (Essex): We are to be congratulated, I believe, on the progress which the government is making in New Jersey, and in ha\ ing the Assistant Attorney-General enforce, with such an ardent spirit of cooperation, the law, Which is so often flagrantly violated. From the way the law is now worded, in spite of the ardor of the enforcing authorities, they often cannot prosecute from lack of the required evidence of specific deeds done besides the misuse of the title “Doctor”. However, we can help to get this evi- dence, and with the combined forces always on rthe alert to the evils, which are well known, the advancement ought to be great. We, in Essex County, where the evil is perhaps more rampant than anywhere else in the state, are willing to co- operate, and we want to say we appreciate the very great help that the Board of Medical Ex- aminers is giving and the marked improvement that has been made in our county. Dr. J. Bennett Morrison (Newark): The address of the Assistant Attorney-General is going to go a long way toward remedying illegal practices in this state. He may not know it, but for a great many years we have been discouraged and handi- capped, in prosecution of these cases, by the negligence, if not refusal, of the county legal au- thorities to help; but if the medical profession can know that from now on, if these cases are reported, they will be brought to justice through the office of the Attorney-General, it will go a long way to- ward ridding us of illegal practitioners in the state of New Jersey. Dr. Charles B. Kelley ( Tersey City) : The amount of material that was covered here this afternoon caused me to take enough notes to really produce a paper of my own; however, inasmuch as I am most familiar with the work as outlined in Mr. Peacock’s paper, I shall confine my remarks to that paper with the one exception of Commissioner Ellis’ statement in regard to Dr. Renner’s work at Skillman Village. There is one thing that he has done, and that is to insist upon his medical staff being licensed men. It has been and still is in parts of this state the custom for institutions, state, county and municipal, to have as full-time,' paid physicians, for an indefinite number of years, men who never had a license, some of them unable to obtain a license, and your state, county and municipal wards are being treated by physicians who cannot go out and treat the general public. Now, Dr. Renner has been particularly careful in that respect so that at Skillman there is now, I believe, nobody who is not a licensed physician. Unfortunately, in other institutions there still are; and the way by which these institutions keep these physicians is simply the clause that was put in the law to cover interns; it was never meant to allow physicians to stay in institutions indefinitely. Only recently we issued a license to a doctor, the head of one of our big institutions, who has been the head of that institution for 12 years. He was well entitled to a license, we found out, but he had novel secured it, and yet he had been in the mean- time, President of his County Medical Society. In regard to Mr. Peacock’s paper, the Medical 1 lactice Act of the State of New Jersey is un- doubtedly one of the strongest in the union, and it has become that by the activity of the various Attorneys-General, since enforcement has been placed in the hands of the Attorney-General, a matter of some 10 or 12 years. Prior to that time the County Prosecutor was the one who was sup- posed to enforce this law. There was no en- forcement. When it was placed in the hands of the Attorney-General there was activity, and from my own personal knowledge, the Medical Practice Act has been very largely built up by the activity of Mr. Peacock’s predecessor, Mr. Grover C. Rich- mond, of Camden, who obtained many excellent court decisions, and it has been further strength- ened since the work has been in the hands of Mr. Peacock. The other person in this state who is doing more to enforce the Medical Practice Act than any one other individual is the Inspector of the State Board of Medical Examiners, and I certainly feel that she is well entitled to tribute, not only from me but from the entire profession in the state. Mrs. Frances Wilkinson is a woman who seems par- ticularly adapted to that kind of work, and as In- spector of the Board she is just as vigilant as Mr. Peacock, the prosecuting attorney. The functioning of the Board of Medical Examin- ers could be improved. The Board meets only once a month. The secretary is only a part-time man; consequently a large part of the work drifts into the hands of lay people, and the profession of the state is being protected by virtue of the fact that the lay woman who is the chief employee of the Board is extraordinarily capable. The pi ofession thinks that a report of the vio- lations is all that is necessary, and that it is an easy matter to obtain convictions; and now after hearing from Mr. Peacock I know how much re- porting there is going to be done, and if you don’t get action I want to let you know why. The prim- ary reason is that a man is always innocent until he is proved guilty, and to prove a violator guilty is a hard job. There are all sorts of investigators and investigations necessary. The Courts have ruled that a given number of treatments must be given. The treatment must be corroborated, the testimony must be corroborated, and it is only right that the judge will give the defendant the benefit of any doubt. In certain types of cases it is utterly impossible to prove the charge. In the cases of alleged abortion it cannot be done as the pei son upon whom the abortion has been perform- ed will not appear, and certainly you cannot send investigators in for that work. Injections of vari- cose veins — I wonder how many of the profession ho have varicose veins would go and have them treated by quack hypodermic injections of all sorts. Still it is necessary for investigators to be so treat- ed if the case is to be proved. There are innumer- able obstacles to the enforcement of the law, and the greatest obstacle of all is the limitation of March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 207 funds. We have a very small corps of investi- gators. Outside of Mrs. Wilkinson, our inspector, we have to depend entirely upon 3 or 4 investi- gators who only work part time and who receive a very nominal amount of money for services ren- dered. For every case that is prosecuted the cost is something like $75 or $80. At the utmost the Attorney-General will get $200 back. The average is cut down by virtue of the fact that a certain number go to jail for a day, and by other factors. The general cost of enforcement always shows a deficit at the end of the year, and it was largely in order to obtain funds for maintaining a more strenuous enforcement, such as Mr. Peacock has outlined, that the Board advocated an annual reg- istration fee. Of course, the history of annual registration we all know. We may have annual registration some day, but that is another ques- tion that need not be discussed now. However, if you are going to send in a lot more complaints, we will do our best to investigate them. In the mean- time, as far as the actual legal end of it is con- cerned, the state takes care of that wonderfully well by giving us such competent men as Mr. Peacock. Dr. Henry O. Reilc (Atlantic City) : I appreciate Mr. Peacock’s coming here and making a clear statement to us as to what his Department is willing to do. I am very appreciative because I have heard of how ably he is supporting the Medi- cal Practice Act, and is prosecuting offenses against that act. I do want to take exception, however, to one or two things that he said, and ask him to look a little further for some information on this subject. From certain necessary implicatioiis from some of his remarks, I gathered that he laid the obligation upon the medical profession to do this prosecuting and informing. I doubt whether that is an obligation that properly belongs to the medical profession, but it is an obligation which the medical profession has accepted almost from the beginning of time. He implied that the medical profession should always give information con- cerning quacks and charlatans in the state, re- ferred to the lay information received, and im- plied that we had been negligent in that sort of thing. I doubt if 10% of the information that has come to his Department has been from lay or- ganizations. I am under the impression that 90% of this information does come from the profession. I doubt very much if any layman has presented any complaint and information except in the few instances where that layman has been individually “stung” or some intimate friend or relative of his has been seriously defrauded. He also puts upon us the obligation of educating the public regarding quacks and charlatans'. I am sorry he did not hear Dr. Fishbein’s lecture last night. What other body than the Medical Society is doing anything toward education of the public with regard to quackery and charlatanism? This educational work the medical profession has teen carrying on for a long time, is carrying on con- stantly; in contrast to the great public institutions of the country that are constantly aiding the quacks and charlatans. I hope, Mr. Peacock, you will deliver your story to some of those organiza- tions. While we are fighting quackery and charla- tanism, and trying to educate the public to under- stand the falsity of quackery, 90% of the maga- zines and newspapers in the country are spread- ing broadcast the advertisements of these very quacks and charlatans that you talk about; and, worse than that, we heard last night the extent to which the radio stations are supporting them. You have only to tune in tonight on any station you please, and you will probably pick up one or more of those patent medicine talks; certainly you can pick up one any time during daylight hours. Those are the 2 great “educational institutions” of the country- — the newspapers and magazines, and the radio — and they are backing the quacks and charlatans all the time; and so far as I know, the medical profession is the only institution that is carrying on an educational campaign to instruct the public about such dangers. Mr. Peacock meant well and honestly in what he said, and we all know he has proved himself to be our friend, but I want to set him straight on those points. Dr. E. P. Darlington (Burlington) : It seems to me that this State Medical Society should go on record in opposition to the Act that permits our State, County and other Municipal institutions to employ unlicensed practitioners. The inhabitants of those institutions would not be allowed to em- ploy those physicians were they not in the insti- tutions, and a man in an institution should have as good care, or have the same care, as he could employ on the outside. Those physicians cannot have general practice so they ought not to prac- tice on the patient after he goes into an insti- tution. Dr. Fred J. Quigley (Hudson) : I thoroughly en- joyed hearing Mr. Peacock’s talk, and certainly it is pleasant to know that the State Board has en- joyed and does enjoy such splendid cooperation from the Legal Department of the state. There is one question that I have in mind, that I would like to have Mr. Peacock’s opinion on, and possibly Dr. Kelley’s, and that is the matter of offenses against the Medical Practice Act so far at it affects second and third offenders. I don’t know whether Mr. Peacock will agree, but it seems to me that one of the weaknesses is that the penalties for second and third offenders are not sufficient. Dr. Kelley tells us of the tremen- dous expense entailed in obtaining evidence against these quacks, that for each case it means 5 or 6 treatments before they can obtain a conviction; and after they have obtained convictions there have been quite a number of cases where within a month they are practicing again, and then the state has to go through the same procedure, the offenders receive a slightly higher fine, and then go out again and continue practicing; and the same proposition has to be met again. I have sometimes wondered, whether there was any method by which these quacks, after con- viction could be enjoined from practicing again, and if they continue to practice, instead of again being fined, whether appropriate action could not be taken under contempt of court proceedings. Mr. Robert Peacock: No injunction would lie. Dr. George N. J. Sonvm&r (Trenton): I am sure that most of the membership know of the action taken by the Mercer County Medical Society this year in relation to state employees on a full-time and part-time basis with maintenance, to declare that private practice by them after a certain date shall be unethical. I have arisen to speak on this occasion merely to pay a compliment to the Department of Insti- tutions and Agencies and . to its representative, Mr. Ellis, who spoke here today, and to offer thanks for the cordial treatment accorded a Committee from our County Society. This action 208 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 caused a great deal of excitement in the county at first, but the Committee, with the aid of the De- partment of Institutions and Agencies, has been able to adjust the matter. The Department treated us very well, and agreed that our points were well taken, and I presume so far as the state of New Jersey is concerned, this practice will prob- ably be abolished within the time limit set by our county society. Dr. John F. Hagerty (Newark): I would just like to give expression to a thought that occurred to me while listening to all these papers. It is very instructive to learn of the manifold agencies there are in this state concerned with the protection of our lives, the preservation of our health and of our comfort. It would seem as if every detail of our lives was being watched over and guarded by agencies in this state, for which we are all thoroughly appreciative. Yet, in spite of all that, we learn through Mr. Peacock that there are still many people who barter away their lives, their health and their comfort by entrusting their lives, when ill, to irresponsible practitioners. It is hard to understand this, and I felt that possibly if what we have learned this afternoon could be brought home to our people, could be emphasized over and over again to our people, just what the various agencies throughout the state are doing, how much concerned they are with the lives and health of the people of this state, and what they are doing to protect them, it might help a bit in discouraging ether people from resorting to the help, such as it is, of these irresponsible practitioners. I think it is a very splendid thing, Mr. President, to realize what is being done by the various agencies throughout the state for the people of this state. MALNUTRITION IN CHILDREN; AN ATTEMPT AT STANDARDIZATION OF A DIETARY* L. Charles Rosenberg, M.D., Newark, N. J. Statistics regarding the incidence of mal- nutrition made by various authorities indicate that about one-third of the children of this nation are nutritionally below par. Wood esti- mates 15-25% of the school children as being undernourished. Perlman states that in a re- cent survey conducted throughout the United States there were found 5,000,000 cases of malnutrition in children — almost one-fifth of the entire number of school children in the nation. T hat as a nation we have been neglect- ful of our greatest asset — the child — has been more and more recognized in recent years. ♦(Abstract of paper read before the Pediatric Section of the Medical Society of New Jersey, at the Annual Meeting, in Atlantic City, June 12, 1930.) Roberts expresses her opinion very well when she says : “We must admit that we have little reason as a nation to be conceited over the stock we are producing.” She adds: “It is true, moreover, that our standard of nutrition is higher than that of some other countries though poorer than many.” Statements such as these make the problem appear worthy of our serious consideration and effort. So im- portant does the problem of child welfare and protection seem to the government that some months ago President Hoover, at a White House Conference, initiated an investigation of the present situation. One of the larger committees was charged and is active with the study of child nutrition. Much investigation has been done, especially during the last decade, in an attempt to estab- lish a standard dietary for children suffering from malnutrition. We also have confined ourselves to this phase of the problem, but have devised a dietary which is a decided de- parture from the usual one employed in this condition. This paper is a discussion of an experiment conducted on a group of mal- nourished children who were put on this special dietary to test its nutritional value. Relation of Disease to Malnutrition In dealing with malnutrition one must not over-emphasize the importance of diet to the neglect of other factors. Nevertheless, in a considerable proportion of undernourished children, a cause for the nutritional state can- not be detected. It is especially in this type of case that the outstanding method of cor- recting the condition is the dietary treatment. While it is not the primary object of this paper to enter into a discussion of the rela- tion between disease and malnutrition, stress, however, must be placed upon the fact that, if a thorough enough study (including painstak- ing physical examination, laboratory tests of the blood, urine and stools, metabolic rate, oph- thalmoscopic examination and radiographs) of the children suffering from malnutrition were made, the great majority would show disease or defect somewhere in the body responsible for the condition. This view of the relation- ship between disease and malnutrition is borne March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY .i09 out by the difficulty we had in selecting a group of disease-free children suitable for the experiment conducted. We were offered ap- proximately 200 underweight children from which to select a group for our experiment. Some were excluded because x-ray examina- tion of the chest showed active tuberculosis, 4 had a 4 -)- Wassermann test, some had rheu- matic carditis, some were suffering from in- testinal parasites, others from obvious en- docrine dysfunction, many from badly dis- eased tonsils, from carious teeth, from ne- phritis, pyuria, vulvovaginitis, chronic otitis media, tracheobronchial adenopathy and para- nasal sinus disease, so that by the time we had examined the entire group there were only 56 children left who we felt reasonably sure were not suffering from any disease or defect and on whom the experiment could be con- ducted. Development of a New Dietary in Malnutrition During the course of clinical observation an attempt was made to trace back the type diets that yielded the healthiest looking children, and contrariwise, the diets that yielded chil- dren in a state of undernutrition. It appeared convincing that those children that were ex- cellent examples of well-nourished individuals were the ones who consume ample quantities of milk, whole grain cereal products, an abun- dance of fresh vegetables and much fresh fruits, meat not being a prominent article of the diet ; whereas those that composed the group of malnourished, consume large quan- tities of flesh foods and comparatively little milk, little or no whole grain cereal products, fresh fruits and fresh vegetables sparingly. Further thought and observation seemed to verify this impression. The average dietary of the infant under 2 years of age is one in which flesh foods are en- tirely omitted, or, if present, are in so small a quantity that little credit can be given to them, and yet malnutrition today is compara- tively rare in infants. It is chiefly a condition of older children. This would indicate that the dietary changes made during the transition into childhood are not entirely successful. Many parents to whom I have spoken empha- sized the fact that until 2 years of age their children were pictures of blooming health, but after this period gradually developed into a state of malnutrition. It was elicited that radi- cal changes had taken place in the dietary, flesh foods and other foods were being intro- duced to the partial or complete exclusion of milk, whole grain cereals, fresh fruits and fresh vegetables. While many children of the older age groups coming under observation were .splendid look- ing specimens who have been given meat since infancy, in nearly all these cases careful ques- tioning revealed the fact that it was used so sparingly and so infrequently that it could not be responsible for the excellent physical development. Many pediatrists, I am sure, have seen fine examples of physical develop- ment in children who have persistently refused to eat meat because of a natural dislike for flesh foods. The vegetarians bring up their children on meatless diets. It has been my privilege to have been able to examine a large group of these children. While hitherto I had considered the vegetarians an erratic group of individuals, repeated observations showed these children to have such splendid posture, firm musculature, high color, excellent teeth, glossy hair, a good layer of subcutaneous fat, bright eyes and a high degree of energy, that I was forced to give the matter of a meatless diet serious consideration and to experiment along this line. Discussion of Experimental Dietary The dietary consisted of about 1 quart of certified milk and of many milk products. Whole grain cereal products were served 3 times a day, fresh vegetables twice a day, both raw and cooked being served, fresh fruits twice a day, freshly ground nuts and large quantities of legumes to keep the protein in- take high. Moreover, the legumes are com- plete proteins, and are a good source of the amino-acids essential for growth. No meat, poultry or fish was used in any form. No animal broths were given. Neither gelatin nor eggs were included. The purpose of omitting eggs was to confine the animal protein of the dietary to milk alone. 210 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 There are certain factors which we desire to stress. The diet meets the caloric need, cov- ers the requirements of fat, protein, and car- bohydrate, for the age group. It is high in essential mineral content, contains the essen- tial amino-acids, is rich in all the known vitamins, is decidedly prominent in alkaline- ash foods, and embraces all the “protective group” of foods. By the use of certified milk and the avoid- ance of meat the diet is obviously low in bac- terial content. The reason for using so much whole wheat is because of (1) its ability to build up hemoglobin; (2) its richness in min- eral content, and (3) its richness in vitamins. (4) It is well known that a diet of milk and whole wheat cereal with no other addition but a small amount of sodium chloride will sup- port growth of experimental animals through as many as 21 generations, and that the last members of the family will be more vigorous, larger and stronger than the first generations. Experiments performed on animals by Rose, Yahlteich and Bloomfield have proved the value of whole wheat in producing an increase in hemoglobin. Morgan and Barry point out the importance of whole cereal, particularly wheat and rice, as a possible source of the vitamin complex B (B + G). It is noteworthy in this connection that in an experiment they conducted on a group of underweight chil- dren they were able to show decided increases in weight and height through the addition of wheat germ to the diet. At the beginning of the experiment an at- tempt was made to equalize the caloric intake of both groups and weigh the foods, much as is done in diabetic or ketogenic diets. This, however, was found to be highly impracticable. The appetite of the different children varied, and the same child’s inclination varied on dif- ferent days according to its disposition. Fur- thermore, it was felt that children should be given as much as they wanted, and then after several weeks of observation the average in- takes could be weighed and measured. This plan was carried out. The procedure of or- dering weighed and measured portions of foods for children is not practical nor possible in daily practice. All foods used were very fresh, no canned articles of food being employed. No white bread at all was served. The spaghetti used was prepared from whole wheat flour; the rice was unpolished ; to the gravies, sauces and soups an autolysed extract of yeast was added, imparting a flavor resembling meat ; cakes and puddings were made of whole grain cereal products ; the mayonnaise was eggless ; no ice- cream was given because of its high bacterial content. Brown sugar and maple sugar were used for the additional mineral and vitamins they provided; only certified milk was served. Extra care and precautions were taken in selecting and preparing the vegetables. Only very fresh vegetables were used, for their flavor is decidedly better. The vegetables were placed in parchment paper and steamed, be- cause by this method of cooking they retain their entire mineral content and also their flavor. The raw vegetables were always con- sidered a treat by the children. They were made attractive by shredding them extremely fine by machine and this was always done immediately before serving, so that they would not become dried out. The various colors, particularly when the food was served on colored plates, appealed to them. Because the children had always had meat previously, it became necessary to devise sub- stitutes that resembled meat, both in taste and appearance. This was easily accomplish- ed by serving the foodstuffs as “roasts”, “steaks", “croquettes”, and “meat balls”, cov- ered with tasty sauces, the chief constituent of these substitutes being legumes. In addition, varied and unusual dishes were devised, as vegetable broths, vegetable stews, cold creamed soups, vegetable potpourri,, squash pancakes, buckwheat vegetable mixture, braised vegetables, vegetable turnovers, glaced vegetables, cakes and cookies made of whole wheat flour, pudding of whole cereal grains combined with nuts, fruit and cream, vege- table gelatin desserts, chocolate pudding made of whole wheat flour instead of corn starch and crullers made of whole wheat flour. The possi- bilities of substitutes and combinations are both interesting and unlimited. A large variety of breadstuffs was used — March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 211 whole wheat, whole wheat with nuts or raisins, whole wheat muffins, bran muffins, whole wheat rolls of all sorts, rye bread, corn bread, corn muffins and Graham bread. Summary Two groups of underweight children, each consisting of 25 subjects, were selected and matched according to age, height, weight, and sex. One was put on a special dietary (ex- perimental) and the other on a good average American dietary (control), and the progress of the 2 groups was compared at the end of a period of 6 months. The essentials of the experimental dietary were a quart of certified milk daily, a variety of nuts, whole grain cereal products 3 times a day, fresh fruits and fresh vegetables twice a day, with the exclusion of meat and eggs. The weight increase showed that the experi- mental diet proved superior from the stand- point of rapidity as well as of the permanence of its results. The weight increase in the ex- perimental group at the end of the 6 months’ period was 32% greater than in the control group. The height increase was 24% greater in the experimental group than in the control group. The more extensive anthropometric data es- tablished the validity of the weight-gain study, while further technical treatment of these data in relation to the arm and calf girth and sub- cutaneous tissue over biceps, corroborated the superiority of the experimental dietary. The results show that the experimental dietary proved to be superior for girls to a greater extent than for boys. It is very likely that psychic factors played an important role in the production of this sex difference. The blood studies showed no difference in progress for the 2 groups. The urinary analyses indicated a much lower acidity for the ex- perimental group than for the control group. The psychometric studies and x-ray studies of the bones were not conclusive. The stools ■of the 2 groups showed a decided contrast in physical appearance, with a diminution in the total number of bacteria in the stools of the experimental group. The ni- trogen balance studies indicated a slightly better retention for the experimental group. The experimental dietary was proved to be rich in vitamin B complex, as indicated by our studies on rats. The importance of the vitamin B complex content in a child’s dietary is stressed. Both diets, as tested on rats, were shown to contain sufficient vitamin B to effect a complete cure of deficiency symptoms with the same rapidity. Discussion Dr. Arthur Heyman (Newark) : Dr. Rosenberg has given a tremendous amount of thought and energy to the preparation of this excellent paper. Any physician who treats children cannot help but be impressed with the importance of his sub- ject. He needs no statistics to emphasize in his mind the prevalence of malnutrition in children apparently free from physical and mental defects. The diet used by Dr. Rosenberg is not original in itself but is ingeniously conceived in the selection of individual dishes and in their preparation. After carefully analyzing the dietary, one can easily un- derstand exceptional weight-gains in the experi- mental group. There are so many elements which we know to be highly conducive to good nutrition. Certified milk, which forms a large part of the menu, has long borne an excellent reputation, es- pecially in the city of its birth. We have all had personal experience with its growth producing qualities and appreciate the reasons for its supe- riority over pasteurized milk. Dr. Rosenberg mentioned the glossy hair of the experimental children. Dr. Wherry has shown this effect by feeding certified milk to his house-dog, producing a glossy hairy coat, and then undoing his work by changing to pasteurized milk. The value of whole-grain products is clearly shown by the references in this paper. I should like to ask Dr. Rosenberg how he explains their failure to stimulate hemoglobin production? Fresh fruits and vegetables so generously sup- plied, with their rich content of easily available foodstuffs, vitamins and ash, undoubtedly con- tributed much to the improvement of these chil- dren. Samuel Kugelmass, in the April 1930 number of the. American Journal of Diseases of Children, feed" ing rats a diet rich in base-forming foods, as is Dr. Rosenberg’s, demonstrated that it accelerates the rate of growth, development, metabolism and activity. I am glad to see that Dr. Rosenberg points out in his summary that exclusion of flesh foods plays only a small part in the success of his dietary since, exclusive of meat and its products, the con- trol and experimental diets differ so markedly. In conclusion, let me congratulate Dr. Rosenberg on his courage in tackling such a difficult study on actual children instead of adopting the easier method of animal experimentation, and on the thoroughness and painstaking exactitudes of this work. Dr. F. 1. Krauss (Chatham): I would like to ask Dr. Rosenberg how much milk the children in the control group were given? I am very partial to giving a small portion of meat. I feel that meat once a day is a boost to their vitality, and I like to give them a minimum of a pint of milk a day. Under these control diets, if these children had no 212 JOURNAL 0/ THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 milk or very little milk, by increasing the milk the same results might be gotten. I would like to ask whether Dr. Rosenberg feels that the re- sults are due to an increase of calories by giving more milk, or to an increased vitamin diet? Dr. Charles Rosenberg (Closing) : Roth groups of children had an equal intake of milk in their dietary and they had about the same amount of calories. I think the thing that did the trick was not merely the exclusion of meat but the fact that we freely used whole-grain products, combined with a quart of milk a day. I do feel, however, that eliminating meat was one of the great factors. Dr. Heyman asks why it is if all experimenta- tions show that these products, particularly whole- wheat, build up the hemoglobin, that we do not have any contrasts between the groups. We had some difficulty with the hemoglobinometer during the course of the work and I think that is where the trouble lay. The children on the experimental diet, despite the lack of contrast, had better color than those of the control diet, and their general ap- pearance was better. ESSENTIALS IN INFANT FEEDING* Percival Nicholson, M.D., Philadelphia, Pa. Gradually there has evolved out of the tremendous amount written on the subject of infant feeding, some fairly definite facts and underlying principles, so that it has become much more of a science and less of an art. The physician confronted with a feeding problem has so many methods of treatment that he is often confused as to which method or food to employ in a given case. This paper is written to aid in determining a definite course in a normal feeding case, with no aim to handle the special or unusual cases which require different forms of treatment. Even in the normal case there are many individuali- ties, as to frequency of feeding, strength of food and quantity of food to be given, and it is not always possible to at once start with the best type of feeding, but at the outset any food must of necessity be an experimental or trial formula, often requiring considerable al- teration to suit the individual infant’s needs. The type of infant feeding used, often mars or makes the child’s future health. It is not only of importance to have a healthy looking, well-nourished infant, desirable as that may *(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Pediatric Section, Atlan- tic City, June 12, 1930.) be, but what is more important is to have an infant supplied with the proper food ingre- dients in a balanced relation, one to anothr. so as to produce the best cells and tissues pos- sible, so that not only will he gain and grow well, but, in addition, have the ideal physical and mental developments with the greatest possible resistance to disease. It is a great responsibility when one stops to consider that even the brain power of the future adult, as well as his general physical health and endur- ance, largely depends on the character of his previous infant feeding and care through childhood. It is a fact, definitely proved on many occasions, that for the normal baby, good breast milk from a healthy mother, supplies the type of food, both as to quantity and qual- ity, best suited to develop the ideal infant. In the beginning of modern infant feeding, an at- tempt was made to imitate in cow’s milk form- ulas the exact percentage of fat, carbohydrate and protein found in normal breast milk. These earlier attempts at scientific feeding, while a decided advance over previous methods, were found to be deficient in many respects and have been abandoned. Recently, food for the infant has been regulated more to fulfill the physiologic needs of the child’s digestion. As a result of numerous researches in the physi- ology and chemistry of digestion, new facts have come to light. Without burdening you with all the details of the various and long pieces of research which have led up to the present knowledge of infant feeding, I shall try to state rather briefly the more salient points on which infant feeding depends. In the normal breast fed child the ingre- dients are in proper amount and relation one to another for ideal growth ; the problem being mainly one of seeing that the infant receives his food in the right quantity, at the right speed and the correct feeding interval, to satisfy all his growth needs. As breast milk reaches the stomach it is coagulated into a fine, soft floc- culent mass and the whey or liquid portion quickly separates, and as soon as the stomach contents reach a certain degree of acidity the pyloric sphincter opens and allows the acidulat- ed whey to pass rapidly on into the intestines,, March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 213 while the soft curd is more slowly digested, the stomach being emptied in 2 to 2 y2 hours. The most important part of gastric digestion is in relation to the protein of breast milk, which being largely lact-albumin contains practically no buffer substance. By a buffer substance we mean a substance which is capable of producing a combination with the gastric hydrochloric acid, thus lessening the available free hydro- chloric acid in the stomach. The emptying time of the stomach depends on the rapidity with which the gastric contents reach a cer- tain degree of concentration of free hydro- chloric acid. As the proteins in breast milk contain practically no buffer substance and during the gastric digestion produce a fine flocculent curd, allowing free access of the gastric juices to all portions of the food, there is very efficient gastric digestion with rapid emptying of the stomach. The thoroughly acidified gastric contents, on reaching the duo- denum, further stimulate the intestinal mu- cosa which, in turn, produces secretin, an acti- vator of biliary and pancreatic secretion, to insure good intestinal digestion. Of all the constituents in breast milk, the most important is protein, for it is only through protein that new cells are produced ; neither fat nor carbohydrate being able to cause growth. Another very important fact in considering the digestion of breast milk protein is that it is made up of a number of component amino-acids which are essential to normal growth. Thus 2 facts stand out prom- inently: first, breast milk protein, by its lack of buffer and formation of flocculent soft curd, favors both rapid and efficient gastric and intestinal digestion ; and, secondly, that the protein, or growth element, of breast milk •contains the kind and amount of amino-acids best suited to the infant’s growth. In good breast milk mineral salts are found in normal amounts. Antirachitic vitamin D and antiscor- butic vitamin C, however, are deficient and should be supplemented. B vitamin is in small quantities, and it is therefore necessary to give additional B vitamin in some cases. As a substitute for breast milk, when arti- ficial feeding is necessary, good cow’s milk is almost universally chosen. So, let us con- sider for a moment in what way the protein of cow’s milk differs from that of breast milk. Holt and Fales conclusively showed that as the amino-acids in cow’s milk protein varied in number and amount from those of breast milk, to obtain the necessary amount of the essential amino-acids of breast milk it was necessary to supply twice the amount of cow’s milk protein. In the digestion of raw cow’s milk protein, we find 2 very important differences from that of breast milk, namely, a high buffer sub- stance, and the formation of a firm tough curd in the stomach. When raw cow’s milk reaches the stomach a certain amount of free hydrochloric acid combines with the buffer substance, and, as a result, the gastric acidity is lowered and the emptying time of the stom- ach delayed. The formation of a large, tough, firm curd further slows digestion and delays gastric evacuation. As the protein is the essential growth ele- ment we must determine the protein need of the infant and build our formulas around it. The various food elements, fat, carbohydrates and protein, have their own particular func- tions to perform, for which they are best suited and are so interrelated that to produce the ideal results they must be in proper bal- anced relation one to another. The relative amount of fat and protein found in cow’s milk is a good one but the carbohydrate should be increased. In ideal digestion, Holt and Fales have shown that about 35% of the calories should come from the fat, 50% from the car- bohydrate, and 15% from protein. As, for example, a formula of 3% fat, 7.5% carbo- hydrate, and 2.8% protein has such a relation- ship, and gives 21 calories to the ounce, the same as good breast milk. To fulfill the pro- tein needs of an infant, 1.5 gm. cow’s milk protein per pound of body weight are required or, the equivalent, the protein contained in 1^2 to 1^4 oz. of whole milk per pound of body weight in the entire day’s food. After determining the basic protein re- quirement it is important to supply the infant with the necessary amount of fluid, namely, 3 oz. per pound of body weight for the first 3 months, 2J4 oz. per pound during the next 214 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 6 months, and 2 oz. per pound in the last 3 months of the first year. The amount of fluid necessary in 24 hours includes the milk in the formula. It is an easy matter to divide the total quantity in amounts suitable to the in- fant’s gastric capacity relative to its age. The infant’s physiologic capacity per feeding can be counted as 2 oz. more than the age esti- mated in months up to the sixth month, after which no further increase is made, but the formula is supplemented with other more con- centrated types of food. The feeding inter- val is made as long as possible, to give the correct amount at each feeding and use the total 24 hr. fluid. In normal infants, never feed less than 3 hours, and when possible 4 hour intervals. Having made up our formula with whole milk to satisfy the infant’s protein needs, and as in whole milk fat is in a proper balanced relation to the protein, both fat and protein requirements are fulfilled. Then, we add enough carbohydrate to make up 50% of the total calories. The fluid, fat, carbohydrate and protein needs are met, and such an amount of whole milk contains enough mineral salts for all requirements. Such a formula contains sufficient fat vi- tamin A, but the C, or antiscorbutic, vitamin is deficient to a varying degree, so this has to be added either as orange juice, lemon juice or strained canned tomato juice. B vitamin may or may not be sufficient, so that recently it has become customary to add such a vi- tamin either as malted cereal germ, or brew- er’s yeast extract. Vitamin D is deficient in all milk, so must be added by giving cod-liver oil, newer preparations of rayed egosterol, or ultraviolet light treatment. Finally, the 24 hours’ food for the normal infant should contain from 45 to 55 calories per pound of body weight. In addition to satisfying all the above food needs the formula should be made as digest- ible as normal breast milk, or as nearly so as possible. The digestion and assimilation of the food itself require a considerable number of calories at best, so that the more easily digestible we can make our formula, without replacing normal gastric and intestinal func- tion, the better. Additional calories are thus made available for growth. Fortunately, there is a means of reducing the buffer substance in cow’s milk and alter- ing the character of the curd formation, so that the degree of free hydrochloric acid at the height of digestion and curd digestion ap- proximates very closely that when breast milk is given. Boiled cow’s milk acidulated with proper amount of either acetic, lactic, citric or hydro- chloric acid reduces the buffer substance and gives a fine flocculent curd, so that it is di- gested with about the same ease as breast milk. In varying degrees the same lessening of the buffer and the production of a fine, flocculent curd is also produced by the heating and processing of the protein by boiling, evaporat- ing, or drying of milk, with or without acidu- lation. This was amply proved by the work of Marriott, Hess, Brennemann and others, and we now have available a method of mak- ing the protein element of cow’s milk nearly as digestible as the protein of breast milk. One is often asked as to the advisability of routine feeding of acidulated food for normal infants, who in many cases could handle a raw milk formula with comparative ease. As acid- ulation of the formula aids greatly in diges- tion it would seem the logical thing, especially during the first 5 months, when the demands on digestion are great and the organs of di- gestion immature, to acidulate the formula for the following reasons: ( 1 ) Acidulation causes a fine precipitation of protein, rapidly and easily digested, when prepared from either cold boiled milk or evap- orated unsweetened milk ; whereas the curd of raw milk is large, tough and slowly di- gested. (2) The buffer substance in the protein of acidulated cow’s milk is so reduced that the gastric acidity and the emptying time of the stomach approximate very closely that when breast milk is fed. On raw mixtures the buffer causes a very decided slowing of gastric evac- uation. (3) In acidulated food the acid is suffi- ciently high to inhibit bacterial action prevent- ing fermentation and diarrhea. The formula March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 215 keeps well even when refrigeration is poor or the food is carelessly handled. (4) The gastric contents of acidulated milks are more acid on leaving the stomach than when raw milk is given. This increased acid- ity accomplishes 3 things: (a) Gives a greater stimulation to the flow of secretin, which in turn causes better biliary and pancreatic secre- tion and, as a result, better intestinal diges- tion. (b) The increased acidity helps in the solution and better absorption of calcium and phosphorus, (c) It inhibits bacterial growth in the intestines, of a fermentive type, and permits a higher amount of carbohydrate being fed without gastro-intestinal disturb- ance. Tf one uses organic acids, lactic, citric or acetic, which are quickly broken down to car- bon dioxide and water, the acid base equilib- rium is not disturbed and an alkaline type of stool is produced, putrefactive in odor and of a slightly constipating type. An acidulated milk supplies a food which physiologically is digested with almost as much ease as breast milk, but does not replace gastric or intestinal function as peptonized food does. As the aim is to produce a food as digestible as breast milk and at the same time supplying all the necessary food ingredients, in a proper bal- anced relation, acidulated formulas should be advocated for routine feeding. Kerlev, in 1923, used evaporated, unsweet- ened milk, acidulated by bacterial inoculation, for the treatment of diarrhea. Shortly after- ward, Marriott brought out his epoch making article on acidulated milk treated with lactic acid. When Hess and Matzner, in 1924, ad- vocated the use of lemon juice to acidulate milk, I used both cold boiled milk, and un- sweetened, evaporated milk acidulated by this means, in preference to either the culture method of Kerley or lactic acid as used by Marriott. The work of Brennemann seems to show that plain, unsweetened, evaporated milk produces a fine flocculent curd, almost as digestible as breast milk, comparing favorably with the unsweetened, evaporated milk acidu- lated by lactic acid as advocated by Marriott. I prefer, however, unsweetened, evaporated milk, acidulated by lemon juice, to either plain unsweetened milk or that acidulated by lactic acid, because: (1) It affords an easy way of giving an antiscorbutic, which neither of the other meth- ods supplies. (2) The acidulation produces a better emptying time of the stomach than plain, un- sweetened, evaporated milk. (3) The citric acid in lemon juice inhibits bacterial growth and makes the mixture safe even in hot weather, lessening the liability to diarrhea. Kerley mentions that he w^as unable to treat diarrhea cases satisfactorily with un- sweetened, evaporated milk, no matter how modified, until it was cultured with lactic acid bacilli, after which it was as valuable as pro- tein milk. (4) The gastric contents being more acid when they reach the intestine, give a better absorption of calcium and phosphorus than when evaporated, unsweetened milk is used without acidulation. (5) The lemon juice mixture has a less acid taste than the cultured mixtures advocated by Kerley, and is much less troublesome to pre- pare. It is also less acid to taste than w’hen the lactic acid mixtures of Marriott are used; hence it is taken better and is less liable to cause vomiting. (6) Lemon juice produces a finer curd, and hence more digestible protein, than either plain, unsweetened, evaporated milk, or evap- orated milk acidulated with lactic acid. In addition to the above facts, unsweetened evaporated milk has certain other advantages over raw milk clearly brought out by Mar- riott : (1) It is relatively very cheap. (2) Percentages are very uniform, being approximately twice the strength of good raw cow’s milk (fat 8%, sugar 10%, protein 7%), and is safeguarded by federal inspection. (3) In certain cases it affords a means of giving very concentrated, easily digested food. (4) Processing of the protein, due to homo- genization and heating, aids in cases of eczema and allergy to cow's milk protein. (5) It is a nonproprietary food, available anywhere. (6) Although there is a slight precipitation 216 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 of calcium and phosphorus into insoluble salts, this deficiency is off-set by the fact that these elements are present in 3 times the amount found in breast milk and are dissolved by the digestive juices. It requires less acidu- lation to maintain a good gastric acidity, with evaporated unsweetened milk, than when boiled milk is used. (7) Fat being homogenized is thereby made into a fine emulsion, more easily digested. As a routine in normal infants, I am accus- tomed to place the baby on a formula a little below his caloric needs, as it is important to give a food within the infant’s digestive abil- ity, but to maintain his full fluid requirements. The strength of food is increased as rapidly as the digestion will tolerate, up to the infant’s protein requirements, and enough carbohydrate added to balance the food so that it gives 21 calories to the ounce, as in good breast milk. Enough of the food is given to supply 45 to 55 calories per pound. In normal babies I prefer food giving 21 calories to the ounce, as there is less danger of protein intolerance than when whole undiluted milk and sugar is used, with a caloric value of 30 calories to the ounce. Once having obtained such a strength formula, simply give the child an in- creased quantity of the same strength through- out the first year. To supply food almost as di- gestible as breast milk, and of the same cal- oric value, is as near as one can approach breast feeding with a formula. In normal cases all the calories necessary can be sup- plied from such a formula, as in the case with breast milk, up to the sixth month, when other more concentrated foods, such as vege- tables, cereals and egg-yolk, should be added to the diet. Starting infants with their fluid needs and enough milk to give 1.75% to 2.3% protein, with additional carbohydrate, this is rapidly increased, depending on the gain and diges- tion of the infant, to a formula of 3% fat, 7.5% carbohydrate, and 2.8% protein, which will be found, if given in sufficient quantity, to fulfill the child’s protein needs, and all the in- gredients will be in a balanced relation. For every 2 34 oz. evaporated milk, 1 teaspoonful of strained lemon juice is added, and the food should not be heated above 100°F. when given to the baby, otherwise there will be undue curdling. Very satisfactory results were obtained in 400 children fed evaporated milk acidulated with lemon juice, and boiled whole milk acidu- lated with lemon juice. The records from the Dispensary of the Children’s Hospital of Philadelphia and from my private cases were used. On evaporated, unsweetened milk and lemon juice the average gain was 6.1 oz. per week or .87 oz. per day, and the average length of time on the food was 6j4 months. The average age at which the food was begun was 8 weeks. On boiled whole milk and lemon juice the average gain was 6 oz. per week or .86 oz. per day, for an average duration of 6j4 months. The average age when this formula was started was 11 weeks. The above figures show very satisfactory gains when one considers that the average start of these cases was not until the second or third month, and extended over an average period of 634 months, bringing the feeding well into the second half of the first year, when the normal rate of gain diminishes. Summary (1) Normal infants can be fed very satis- factorily on boiled whole milk or unsweetened, evaporated milk, acidulated with lemon juice. (2) Evaporated, unsweetened milk is some- what more satisfactory when acidulated with lemon juice than other formulas. (3) Regulate the formula to give the in- fant’s fluid needs, then the protein requirements and enough carbohydrate to balance the food, giving 21 calories to the ounce. (4) Mixture of 3% fat, 7.5% carbohy- drate, and 2.8% protein, acidulated with lemon juice and made up with unsweetened, evapor- ated milk gives such a formula. (5) This feeding, giving 21 calories to the ounce, as breast milk, shows in a review of 400 cases very satisfactory results, and is pre- ferred to a stronger formula of higher calories. Discussion Dr. F. I. Krauss (Chatham): I am very much interested in Dr. Nicholson’s paper. When Dr. Mar- riott first published his results on lactic acid milk I was very partial to the use of it; and I have been March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 217 using practically the same type of lemon juice milk as Dr. Nicholson has for the past year. My routine in most cases is to use the certified raw milk and karo sugar. In the more difficult feeding cases I use an evaporated milk in the same way and my results have certainly been as good as with the lactic acid milk; the mothers have less difficulty in making it up and I think the children take it more readily. Children who have a ten- dency to regurgitate retain the lemon milk better than the lactic acid milk. I have been disappointed with the use of lactic acid milk in vomiting babies. Unless thickened with some flour, they vomit it quite easily. I should like to ask Dr. Nicholson why he uses boiled milk and not certified raw milk in making the lemon juice formula? Dr. Charles Rosenberg (Newark) : Dr. Nicholson did not say anything about the bacterial content of the milk. To my mind that has always been an important phase of the question. A large propor- tion of evaporated milk has a high bacterial con- tent and it has always seemed to me that the bac- teria of milk after being destroyed are still able to produce gastro-intestinal disturbances. It is for this reason that I am opposed to both evaporated milk and pasteurized milk. I would ask Dr. Nidholson what he does about selecting milk of low bacterial content for use in infant feeding? Dr. Percival Nicholson (Closing) : It makes very little difference whether you use raw or evaporat- ed, unsweetened milk, if there is thorough boiling of the raw milk. If milk is boiled 10-12 minutes it will be much better than when just brought to a boil. After boiling, the milk should be thor- oughly cooled before acidulation. If large curds form beat with a Dover egg beater in order to break the curd up. In Eweiss milk the Germans advocated boiling after making the mixture and then beating until smooth. When first used in the Children’s Hospital the nurse, instead of beating it at the end of the process, filtered out the curd of the milk and gave the whey to the children, with disastrous results. It is very important to see that these mixtures are not heated too hot, when being fed to the infant. If you boil the milk and cool it before acidulation, you get very much better results than when raw milk is acidulated without boiling. I have had no pustular rashes in any of the infants fed evaporated, unsweetened milk. In regard to the bacterial content of evaporated, unsweetened milk, the milk in sealed cans is steril- ized at a temperature of 240°, so that there are not even any spore-bearing organisms left. There is no danger of any kind of contamination. While it is true that some of this milk may not have been 100% pure, companies usually get their milk where they are close to the source of supply and have very satisfactory means of producing it. I have not had any trouble with gastro-intestinal dis- turbances, but in diarrheal cases most of these children will do well on acidulated evaporated milk. So far as the bacterial toxins are concerned, I think there may be some present even when the milk is sterile, but from a practical standpoint I have had no bad results whatsoever from them. DIET IN ECZEMA OF INFANTS* F. I. Krauss, M.D., Chatham, N. J. My reasons for presenting this paper on the relationship between diet and the eczema of infancy are, first, that eczema is one of the most common and unsatisfactory conditions we have to treat, causing much embarrassment both to the doctor and parent, and secondly,, the relative value of dietetic and local treat- ment offers opportunities for interesting dis- cussion. I wish to present the results whicbL may be obtained by diet. To estimate the value of any treatment in a condition which often has abrupt cyclic variations, and which tends to spontaneous cure, is difficult and may be erroneous. We are faced with a problem on which the physician's reputation is often at stake; how frequent is the history of patient being taken from one physician to another, the final result being accredited to some patented medicine. Our present knowledge would indicate that most cases of eczema in infancy are either of an allergic or anaphylactic nature. Cutan- eous protein tests prove this in. many cases. There are a considerable number in which tests are either temporarily or permanently negative, but which are proved by clinical treatment to come under this class. Other cases are associated with some difficulty in the met- abolism of fat or carbohydrate, or possibly mineral salts. A combination of any of these causes increases the difficulty. Associated with metabolic disorders is some individual hyper- sensitiveness of the skin. Eczema cannot, from' an etiologic view, be considered alone but is grouped with all the other types of metabolic imbalance. In this discussion we will assume this as our background, and consider the re- sults of our clinical experience from a dietetic standpoint alone. Those cases of eczema which are of external origin are excluded ; this applies especially to seborrhea with which *(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Pediatric Section, June 12, 1930.) 218 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 eczema is frequently confused. A few cases will indicate the scope of this paper. Case 1. In January 1921, S. T. aged 2 months, weight 9 lb. 5 oz., developed an acute eczema of the face while on a diet of dryco and dextrimaltose. He improved on skimmed milk and dextrimaltose, became worse on the least addition of cream, became even more irri- tated on skimmed milk and wheat flour, and again on malted milk. In April 1921, skin tests showed a marked sensitiveness to cow’s milk and egg. Mother was advised to con- tinue skimmed milk. Goat’s milk was tried without success. When 7 months old, he weighed 13 lb. 2 oz., and was covered with a diffuse erythematous, squamous rash. Milk was discontinued, and a soup mixture made of dextrimaltose, farina, granum and dried peas, which contain 25% by weight of pro- tein, in conjunction with cod-liver oil and or- ange juice, was fed according to caloric re- quirements Fresh vegetables were also given. In 4 days the body was practically clear, and in 2 weeks the entire eczema had almost dis- appeared, except for a little dryness of the face and scalp. This disappeared after 1 month. One month later 1 oz. of milk was given and the eczema broke out again, but dis- appeared when milk was withdrawal. Until over 2 years of age eczema would appear whenever milk was given. Case 2. Poppere, Doris A., born August 13, 1929, weight 6 lb. 10 oz., was nursed 1 month and then put on a milk and dextrimaltose mix- ture. Began to have colic, and entire body be- came covered with a fine papular rash. Father had eczema until 2 years old ; 1 older child had eczema of face until 1 year of age, and vomits any egg preparation. Oct. 9, 1929. Aged 2 months. Wt. 9 lb. 9 oz. Acute generalized eczema of entire body. Diet : DTyco and barley. Nov. 8, 1929. Aged 3 months. Eczema worse. Given soy bean flour, olive oil, and barley. Feb. 28, 1930. Not improved. Wt. 14 lb. 5 oz. Skimmed milk and barley cooked 6 hr. March 14, 1930. Aged 7 months. Very much worse. Soy bean flour, butter, vege- tables, cod-liver oil. March 22, 1930. Eczema gone except on face and shoulders. April 9, 1930. Slight return of eczema. May 10, 1930. Aged 9 months. Wt. 15 lb. 6 oz. ; 2 teeth; few areas of induration on arms and legs; no itching. Skin Tests: Egg Yolk + + + + O at meal — 0 Casein -j- Barley -f- -J- Milk + Wheat + + + + Diet : Soy bean flour, dextrimaltose, rice, dried-pea mush, vegetables, orange juice and cod-liver oil. Allergic eczema cured by omitting causative proteins. Case 3. Audrey Grampp, born Sept. 12, 1929, weight 7J4 lb. Nursing. Oct. 19, 1929. Aged 5 weeks. Wt. 9 lb. 7 oz. Rash on head, face, hands since 3 weeks of age. Father has had eczema since child- hood. Mother told to omit eggs, milk, wheat, potato from diet. Locally, bran baths, cold cream, and 2% resorcin on scalp. Dec. 28, 1929. Wt. 12 lb. 10 oz. Eczema extensive over whole body and face. Feb. 14, 1930. Wt. 14 lb. 2 oz. No improve- ment. Nursing discontinued. Mead Johnson’s soy bean, barley, and olive oil (Sobee) started, together with orange juice, vegetable pulp and oatmeal. March 4, 1930. Wt. 15 lb. 2 oz. Moist eczema of face and body worse. Began skim- med milk and barley cooked 6 hr. March 7. 1930. Eczema worst. Omitted barley and began rice. March 21, 1930. Improved. Wt. 15 lb. 3 oz. Vegetables, cod-liver oil, olive oil and tomato juice started again. Skin tests on abdomen: Milk -f- -f- ; Oat- meal -J- ; Wheat -f- ; Lamb -j- ; Barley — | — |- ; Egg + -J- ; Egg Yolk 0. April 2. 1930. Wt. 16 lb. 1 oz. ; body clear; slight scaling and itching of face April 25, 1930. Egg yolk added to formula. May 20, 1930. Aged 8 months. Wt. 17 lb. 2 oz. ; skin clear; slight itching. Diet: Whole milk cooked 6 hr. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 219 Allergic eczema cured by prolonged boiling of skimmed milk. None of these cases developed rickets, scurvy or any deficiency disease ; they were underweight but full of energy; they teethed normally. It is most important to obtain the parent’s cooperation. They must be made to under- stand that eczema is both a state of abnormal sensitivity of the skin, and of abnormal reac- tions to food, with which the infant was prob- ably born ; that it may be most obstinate to cure or to relieve ; that it may persist through- out the first or even the second year of life; that it is not permanently disfiguring; it may not be detrimental to the health ; tends to spontaneous cure after 2 years ; and that, most important of all, we must consider primarily the general development of the infant, and whatever we do in the modification of diet must have this as a basis. Unless we explain these factors we will soon lose our patient to another physician. Among nurslings a large percentage of eczemas are due to allergy to foreign proteins to which the mother herself is not sensitive. Dr. O’Keefe states that when the offending protein is removed from the mother’s diet, cure or improvement in more than half the cases follows. I recently saw a child, 5 weeks old, where omitting wheat from the mother’s diet cleared up the condition immediately, with a recurrence when wheat was added again. If the nursling is sensitive to cow’s milk or egg, removing these from the mother’s diet will often help. The supply of the mother’s milk can be kept up by other foods. It is wise to omit from the mother’s diet any food to which the infant gives a positive reaction. However, as we do not always get a positive reaction to the offending protein we must con- sider our clinical judgment as of equal value with skin tests. Eczema may be a general protein sensitization or a hypersensitivity to fat or carbohydrate metabolism. Case 4. Typical of eczema in a nursling. Born Nov. 4, 1929, weighing 9 lb. 10 oz. Seen first on Jan. 21, 1930, aged 11 weeks, wt. 14 lb. 11 oz. Nursing 8 times in 24 hours; bow- els constipated ; regurgitates ; past 6 weeks itching rash on face, head, and back. The mother is stout ; had an acute eczema before the baby was born. The baby has an acute erythematous eczema of the face and body with crusts in the scalp and on the cheeks. Tests: Mother, cow’s milk -j- + ; oatmeal -j- -j-. Baby, human milk 0; cow’s milk 0. Treament: Mother’s diet to consist of fruits, vegetables, soups and nuts and to take soda bicarbonate 51, b. i. d. Local treatment for the infant — calomine lotion with cold cream. The eczema cleared up in 1 month. This infant was probably sensitive to over- feeding with too rich milk. Many nurslings with eczema are overfed; they are usually overweight. In such cases lengthening of in- tervals between feedings, reducing length of nursing period, and supplying water, plain or alkaline, is of benefit. Many nursing mothers drink too much milk or eat too much carbohy- drate ; a more liberal use of fruits and vege- tables, with less milk and no food between meals, should be tried. Skin tests on the mother are of no practical value. If these various measures fail, then one can consider artificial feeding. Nursing infants sometimes do better when nursing is discontinued. Whether or not to continue nursing is a very difficult question. If the infant is near the age when bottle feed- ing would have to be started soon, it is ra- tional to begin cautiously. If the eczema is aggravated, one can still fall back on breast feeding a little longer. I think the very young infant should be breast-fed, with the mother’s diet adjusted, and with the use of local sooth- ing applications. The limitations in the diet of a very young infant are too great to permit of much experimentation without danger to the vitality. In the bottle fed baby a detailed history is very important. We usually find that the eczema started a short time after cow’s milk was begun. Then arises the question whether the fat, carbohydrate or protein is at fault, or whether all these may play some part; usually it is the protein. Case No. 1 illustrated this. The eczema appeared on a diet of dryco and dextrimaltose ; it improved on skimmed milk and maltose, showing an idiosyncrasy to- 220 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 ward fat. The skin tests showed a marked re- action to cow’s milk protein. Thus, in this case, these 2 factors had to be considered. The mother was most anxious to get rid of the eczema; her entire attention was focused on it. One of our best pediatricians advised her to continue skimmed milk with the dictum that the protein of cow’s milk was absolutely essential to the baby’s growth. With consider- able hesitation I took the child off milk and made up an artificial milk, obtaining protein from dried peas. The results were immediate. This was my first experience in feeding a young infant permanently without milk. For these cases of milk protein sensitiza- tion, an artificial milk using soy bean flour as source of the amino-acid protein, has been re- ported recently. Soy bean is rich in amino- acid. Drs. Hill and Stuart, of Boston, have reported gratifying results in a series of cases. Soy bean contains 40% protein and 20% fat, and according to Osborne and Mendel con- tains an adequate supply of both fat soluble A and water soluble B vitamins. Dr. Schloss reported the use of soy bean protein in 1920; 6 cases of milk protein eczema put on a diet of lactose, mineral salts, washed butter and soy bean protein, and eczema practically disap- peared in 3 days ; the mixture caused vomiting and diarrhea in 4 cases. Since soy bean flour has been put up in combination with olive oil and barley flour for commercial distribution, I have used it in 6 cases ; 3 were cured, 2 were improved, and 1 unimproved. A few cases in which I wished to use it either refused the food in sufficient amount to maintain nutrition or developed diarrhea. Three cases which made partial im- provement gave a reaction to barley, and did not clear up until the pure soy bean flour was used. I am indebted to the Mead Johnson Company for a supply of pure soy bean flour for these cases. The preparation now put up by them should be adequate in most cases of milk allergy, as it is only the very exceptional case which will be sensitive to both milk and barley. If further clinical experience shows that infants will thrive on this soy bean diet, it will furnish a valuable addition in our treat- ment of milk allergy. The importance of keeping up nutrition must be strongly emphasized. If these in- fants lose weight they lose vitality very quickly. They are particularly sensitive to skin infections, especially of the face with secondary cervical adenitis, and to catarrhal in- fections of the nasopharynx and bronchial tract. They lapse very quickly into a danger- ous state of infection or malnutrition. As omitting milk from the infant’s diet is an uncertain and possibly dangerous proced- ure, methods of modifying milk protein must be considered. First, a reduction of protein to the minimum needs, according to age and weight, should be undertaken. Schloss states that lactalbumen is the most active protein; in which case, feeding a high casein milk may be of some value. Dr. Kerley told me that he uses it in cases where he is not getting the results which he desires with the prolonged boiling of skimmed milk. Several of my pa- tients are taking casein satisfactorily. Protein can be modified by either drying the milk or by prolonged boiling, especially with a cereal flour. Complete or partial drying, as in pow- dered milk and evaporated milk, helps many cases. Kerley believes in boiling the milk in some cases 6 hours. He uses skimmed milk boiled with rice for from 3 to 6 hours. The prolonged heat changes the protein. Rice is used in preference to barley because fewer in- fants are sensitive to rice than to any other grain. Kerley stresses the importance of pro- longed heating. We frequently hear the his- tory that the milk was boiled a few minutes, sometimes for an hour, without results. There are a number of mild cases that are cured this way, just as many are cured by the heat changes produced by drying milk ; severe cases, however, need prolonged boiling of the milk. There are certainly many cases of milk allergy which do well when the protein is modified by one of these methods. I have not found acidified milk of any particular value in eczema unless there is an associated entero- colitis ; when improvement occurs in these cases it is doubtful if the eczema is a true al- lergy. Protein eczemas seem to be cyclic. It is re- markable how an acute condition will subside March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 221 and hardly be noticeable in 24 hours, then re- appear suddenly without any change in the diet whatever. The skin tests also show this tendency, so that a negative test does not necessarily rule out a food. A test negative at one time may be positive at another. On account cf this, many cases should be diag- nosed by the history, and treated accordingly if tests cannot be made. I, personally, rely more on the history than I do on the skin re- actions, for we know that these are only posi- tive in 60-80% of cases. Other cases of al- lergy such as those due to egg, wheat, potato, orange juice, beef, lamb, are easily amenable to the omission of these foods from the diet. Next to milk protein, egg albumen and wheat are the most common proteins causing eczema. Eczema in infants in the second year and in young children respond very satisfactorily to the omissions of the causative proteins. The eczemas are usually small areas of a chronic type, which are not subject to the severe itching and infection which complicate with babies under one year of age. The opportunities to vary the diet are much greater without danger of under-nutrition or vitamin deficiency. Overfeeding with fats or carbohydrates: Some infants cannot tolerate any milk fat what- ever, and must be given a centrifuged skimmed milk, and their fats supplied either by olive oil or cod-liver oil. White found in the stools an excess of fats in the moist type of eczema, and an excess of starches in the dry type. I find it difficult to form any opinion from the appearance of the eczema whether the carbo- hydrate or the fat is at fault ; clinically, I have found the fat usually the important fac- tor, and next in importance to milk proteins. If the skin tests are negative or cannot be done, and an analysis of the history and diet give the impression that the infant is not metabolizing fat, it is a simple matter to try skimmed milk for a few weeks. Boiling the milk, as mentioned before, will also help. Naturally, reduction in either fat or carbo- hydrate means an increase in the other, if suf- ficient calories are to be given. These chil- dren have what Czerny calls the exudative diathesis. The balance in diet is very sensi- tive. When feeding carbohydrates, it is usually wise to use the cereal flours cooked a long time rather than any of the pure sugars. Rice is probably the safest of all as there are fewer infants sensitive to rice than to wheat, oatmeal, or barley. As soon as possible, cereals, vegetables and fruits should be added to help supply caloric requirements. The more varied the diet from day to day, the less likely is the eczema to become severe. Here, also, prolonged cooking is of assistance. So many of these eczema babies have colic that careful preparation of the food is essential, the colic being another evidence of sensitivity. Malnutrition is a common cause of eczema; mostly of the seborrheic type. The mild cases are simple seborrheas of the scalp, and the more severe are dry, indurated, scaly, or fis- sured areas, especially on the outer aspects of the arms and legs. These cases respond quickly to general improvement in the infant’s nutri- tion ; the easiest cases to cure by diet. They must be differentiated from myxedema, with which they are sometimes confused, as thy- roid medication is not indicated. I have not found constipation an etiologic factor in my cases ; the condition of the skin does not seem to depend upon it. Constipa- tion is often present, but not more frequently than in the large number of bottle-fed infants. One does notice an improvement sometimes after an attack of diarrhea, which might indi- cate some relation between eczema and consti- pation ; but I have not seen that giving laxa- tives or laxative foods has helped. This idea is at variance with the opinions of others who lay stress on the necessity of 2 or more free move- ments daily. The local treatment of eczemas of dietetic origin is directed to : first, protection from trauma ; second, cure of infection ; and third, relief of the burning and itching. Those which respond most rapidly to diet are the dry type with very little itching. If the infant is al- lowed to scratch an infected area, this alone will keep up the dermatitis indefinitely. The burning sensation is the last symptom to dis- appear and the skin must be protected during this length of time. A few minutes rubbing will undo the work of days. Most of our local 222 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 treatment fails because it is not persisted in thoroughly. When once clear, the skin will remain well or improved so long as the diet is carefully adjusted and the hypersensitive skin protected. In the majority of cases the local treatment is not as important as the dietetic treatment ; the difference between al- lergic eczema and dermatitis of other origins being that an allergic eczema cannot be cured or kept cured unless the allergic factor is modified or removed. Conclusion In considering diet in infantile eczema, the causes to be considered are milk or other protein allergy, overfeeding both in the nurs- ling and bottle-fed, fat or carbohydrate im- balance in the diet of the individual, and mal- nutrition. The most difficult cases are those due to milk protein allerg)'. There is no universal substitute for milk. Some infants can be made to thrive without milk, but the danger of un- der-nutrition is too imminent to permit this therapy except in carefully supervised cases. The protein of the soy bean is rich in amino- acid, and apparently can replace the protein of milk in early infancy. Some infants who can assimilate this protein, gain in weight and energy; others suffer in vitality. Mild cases of milk protein allergy are helped by prolonged boiling or drying the milk. The milk must be boiled from 3 to 6 hours; suc- cess or failure often depends on this point. This is the most conservative and safest way to treat milk protein cases. It is wise to be satisfied with the improvement obtained when an absolute cure does not occur. Eczemas due to fat or carbohydrate imbal- ance respond satisfactorily to diet modifica- tion. Eczemas due to malnutrition respond quickly to the general improvement in tissue turgor. Diet alone will clear up many cases if trauma is prevented and infection removed. Allergic cases will relapse if the diet is neg- lected Most allergic eczemas disappear spontan- eously by the end of the second year. The welfare of the infant must not be sacrificed for the local condition; and any modified diet must be balanced sufficiently to- maintain health and promote growth. Discussion Dr. Arthur Stern (Elizabeth): Dr. Krauss was kind enough to let me have an advance copy of his paper on a subject which has been of extreme interest to all of us and as it deals mostly with the treatment, I must confess that his part has been to me in my practice full of pleasure and disappointment. Pleasure, when by removal of the child from the breast to artificial food, the eczema disappeared, never to return; disappointment, if after all cutaneous tests and changes of the food according to reactions obtained, the results are negative. Dr. Krauss states that our present knowledge would indicate that most cases of eczema are either of an allergic or anaphylactic nature. I thought once that I was convinced of this but there are other factors which play an important part in the appearance and disappearance of the eczematous eruptions. .Just let me mention one case to show how hard it is to understand the underlying con- dition. Baby W., 3 years old, had slight eczema when breast-fed. The child was then tested and reacted positive on peas, white potatoes, wheat, tomatoes; and negative on cow’s milk. It was then put on many different milk formulas, with the result that the eczema became much worse. While potatoes, wheat and tomatoes did not increase its severity, peas caused an enormous, edematous swelling of the lips but did not affect the eczematous areas. At random let me recite from Finkelstein the following observations in his text-book on Dis- eases of the Nursling, page 797: “I removed a large number of eczema children into a room where all the windows were covered' with red paper, so that the spectral colors on the other side of green could not penetrate, and left them there for sev- eral weeks. Mild cases were cured within a few days. After they had been put back into the ward, the eczema reappeared. Severe cases were not in- fluenced whatsoever.” Furthermore, if the eczema would be due ex- clusively to allergic or anaphylactic conditions, there would be no reason why we see (and most all authors differentiate between these fioints), the 2 types, namely, the facial form, mostly in older nurslings, and the universal form, the eczema' simplex et intertriginosum, in older children. Another observation made by Samberger is in- teresting. He found in the eczematous crusts a ferment similar to trypsin and as the reaction of the crusts and their serum was alkaline, he tried an acid salve consisting of acetic acid and lano- lin, which is said to have acted remarkably well in his cases. KJingmueller then introduced the acid tar baths into the treatment of general eczema and in one of the large hospitals of Europe they have been in use for several years. The patients are bathed for 10 minutes and then dried and powdered. The results are reported to be very good. If we assume that eczema, asthma, urticaria and hay-fever belong to the allergic group of diseases, we still cannot understand why in some persons their occupation produces localized eczematous conditions as we see them in plasterers, bakers, gasoline workers, furriers, and also eczema in dia- betics, gouty people, and so on. I have seen a boy March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 223 who had a lip eczema which had been treated by the foremost dermatologists and it was very ob- stinate. The other part of his body was free. Changes in diet had no influence whatsoever. 1 have also seen a diabetic child after a few years of insulin treatment develop a dry eczema. The rash disappearance of an eczema during an acute in- fection or even during the weeks of the healing of a fractured leg, gives us food for thought. So, after all, there must be a peculiar condition of the skin itself which, as the dermatologist Ber- ing, in a recent paper on “Poor Results in the Treatment of Eczema” emphasizes, is the cause of eczema. In order to develop an eczema, he says, 2 things are necessary, the eczematous irri- tation and the peculiar condition of the skin. He mentions the following experiment: Small pieces of gauze soaked in different test solutions are put on healthy skin, then covered with oilskin and ad- hesive plaster; after 1 or 2 days the degree of irritation is controlled. Several persons who had eczema showed a very sensitive skin, but in several others, who never had a skin eruption, the same degree of irritation was found. These latter may be potentially eczematous and will get eczema ■when the special irritation will attack the per- fectly healthy skin. But with all these newer ideas I have very little to offer in connection with Dr. Krauss’ paper, which is excellent and timely, nor with his deal- ings with eczema which in my private practice are similar to the treatment described in the paper. The few thoughts mentioned in this discussion have come to me during the treatment of some of the obstinate cases but as the etiologic factor is hard to define in many other diseases, this also holds good for the treatment of eczema at the present time. Bering says: “The physician who follows the principle to remove the cause of the disease, if such is known, and then treats carefully and systematic- ally wTill have the best results, surely, in the fu- ture treatment of eczemas in childhood.” Dr. F. C. Johnson (New Brunswick) : I would like to ask whether any one has had experience with cases which have been determined to be sensitive to arsenic? ECZEMA IN INFANCY, FROM THE DERMATOLOGIST’S STANDPOINT* F. J. McCauley, M.D., Newark, N. J. Eczema, as it occurs in infancy, does not differ from its manifestations in adult life; i.e. a dermatitis, of varying intensity of inflam- mation, appearing as erythematous, vesicular, papular, or pustular lesions ; or as any com- bination of these. The most recent conception of eczema is that it is a hypersensitivity of the skin to some irritant. Instead of consider- *(Read at the 164th Annual Meeting of the Medi- cal Society of New Jersey, Pediatric Section, June 12, 1930.) ing eczema as a clinical entity it is best to re- gard it as an inflammatory reaction in which 3 clinical types can be observed. First, are cases considered under acute der- matitis, in which the skin is sensitized mainly to known local causes, and which quickly re- spond when irritants are removed. Another group can be regarded as allergic in character. In these cases we will generally find some form of protein, to which the patient is sensitized, giving rise to repeated attacks throughout the lifetime of the individual ; this type is com- monly associated with asthma and hay-fever. The third group, and by far the most common in early life, is seborrheic dermatitis. Here we have a classic progression of clinical signs, by which we can place it definitely as an entity, varying in intensity according to the peculiar predisposition of the individual. We have therefore in eczema a dermatitis where many causative factors will have to be considered but by grouping, as above outlined, we can greatly simplify our efforts. In group 1, local causes can easily be established in most cases ; group 2 may offer considerable difficulty, but we are getting into a better position, in our methods of isolating causative allergic factors ; group 3 cases have a well established clinical entity, and in looking at the subject from the standpoint of early infancy, we find this type so frequently that from a therapeutic view- point it occupies the most important position, constituting by far the majority of our cases. In the etiology of eczema today, we are mostly concerned with conditions that lead to skin sensitivity. Under local or exciting causes, we have to consider all forms of irritation applied to the skin of a susceptible individual. This in- cludes mechanical factors, such as friction of clothing, scratching, simple pruritus and para- sites ; thermal agencies, such as cold, heat, therapeutic lamps, acting rays of the sun and therapeutic lights ; chemical irritants like soap, saliva, nasal discharge, urine and feces. While there is a diversity of opinion regarding mi- croorganisms, we feel they play an important part in the causation of this disease and are entirely responsible for the group 3 cases. In this type, experiments have proved the dis- 224 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEi’ March, 1931 ease has been reproduced by inoculation of pure culture of the spore of Malassez, and Elliott and Merrill produced the disease with a diplococcus and a bacillus, and recovered and cultivated the microorganisms. Further, Bock- hart has advanced the theory that the Staphy- lococcus albus may become active in the fol- licles, producing toxins, and by diffusion of these products in the epidermis cause eczema. Under internal or predisposing causes, nu- tritional and digestive disturbances are mainly responsible. A majority of patients in this group have been overfed, while others will show excessive fats or starch in the stools. In prolonged cases, a sensitivity peculiar to the individual constitutes the important factor, and this may be hereditary or acquired, transitory or permanent. In the hereditary type we usually find a 'congenital functional defect. The skin of these individuals is abnormally dry and represents a mild type of ichthyosis, to which the term xerodermia has been ap- plied. Cases are presented, however, in which this feature is hardly evident, and only care- ful inspection will reveal the abnormal dry- ness of the skin. These people are prone to develop eczema during the winter months, when the skin function of stabilizing tempera- ture is at its maximum. In the acquired type the skin may become sensitized by a single ap- plication, or by repeated exposure to an irri- tant, and continue to develop eczema from very mild and dissimilar irritants. Other in- ternal causative factors are various conditions responsible for an elevation of temperature, such as intestinal disturbances, the various toxemias and dentition. In treatment, our first endeavor is proper feeding of the patient, and this is referred to the pediatrician or family physician with gen- eral instructions : if overfed, to modify the amount of intake, and if a nursing baby, the suggestion is made to reduce the amount of intake by giving a small quantity of cereal water before each nursing. In cases that are normal in weight, an examination of the feces is advised and, if unsuccessful in determining an abnormal digestion, further tests for pro- tein reactions should be tried. If milk is found responsible, an attempt at desensitization is advised by giving milk in small amounts and gradually increasing the quantity as the pa- tient’s tolerance is increased. This procedure has been found successful in many cases. After the nursing period we are usually in a better therapeutic position, and in cases that are very resistant we can substitute a diet free from allergic articles, or a diet in which they can be brought down to a point of tolerance. Among the foods most frequently at fault in producing a dermatitis we would place or- anges, eggs, butter-fat, milk and cane sugar. Next, the character of the skin must be taken into consideration: if abnormally dry, infractions as to a diet rich in fats, or cod- liver oil is advised during the winter months; and the patient protected against exposure to severe winds or drafts. Cases of this type are very frequently misjudged, being treated with all kinds of stimulating ointments which in- crease the irritation and add to discomforture of the patient, while the use of mild soothing remedies will succeed in affording relief. We now come to the most common causa- tive factor, namely, seborrheic dermatitis, which is a parasitic infection. While errors of diet and skin hypersensitivity play an import- ant part in seborrheic dermatitis, in most cases we succeed by local treatment exclusively. The clinical symptoms of this condition are present in the majority of cases of so-called infantile eczema, and as it may continue throughout the life of the individual, its recognition in in- fancy becomes an important feature, as proper treatment at such time frequently results in its termination. In the local treatment of infantile eczema we are dealing with an acute dermatitis, and although remissions in intensity are the rule, the end-results of infiltration and keratotic de- velopment seen in adults seldom show in early life. Stimulating remedies such as tar, sulphur, mercury and resorcin, unless used with extreme caution, will tend to defeat our purpose by increasing the inflammation rather than reducing it. Only in cases that have pro- gressed to a low grade inflammation, the lesions being of a continuous character and consisting of a few circumscribed patches, should these remedies ever be considered. Local treatment March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 225 can be summed up under 2 headings., namely, antisepsis and soothing protective applications. In the management of a case we pi'oceed about as follows: the child is to be guarded against undue exposure; cotton or silk is sub- stituted for woolens, which increase pruritus ; linens should be soaked in an alkaline solution before washing. The important question of cleanliness now presents itself. Soap is an irritant to an inflamed skin, but washing with- out soap is our basic therapeutic forte. A solution of borax is used and, regardless of the extent of the eruption, a borax bath (one tablespoonful to a gallon of water) is given. In very acute cases intervals between baths are extended to 3 or 4 days, depending upon the amount of reaction induced ; gradually the in- tervals are shortened as the inflammation sub- sides, until a daily bath can be given. For in- flamed areas, including the scalp, washing morning and night with borax solution is ad- vised, using absorbent cotton for sponging; or, in very acute cases an oatmeal or bran sponge may be found helpful — gauze bags of cooked oatmeal or bran. These sponges can also be used in tub bathing and will be useful as a soothing agent. Recently, witch-hazel has been used and will be found a valuable addi- tion, particularly in washing the scalp, or on other areas preceding each application of medication. It is especially indicated if the borax solution be found irritating. Any oint- ment of a non-stimulating character is then applied. A base of lanolin or petrolatum, add- ing oxide of zinc as a mild astringent, and salicylic acid to prevent decomposition, will make a good combination and fulfill all re- quirements. This is to be applied sparingly, using only an amount sufficient to cover the skin as lightly as possible, and then dusting over the surface a drying powder of either starch or talc. It is important that only a small amount of ointment be used at each dressing, as the object to be obtained is to cover the affected areas with a soft, pliable protective covering, and an excess of grease will tend to cake and form lumpy masses which add to the discomfort. Applications morning and night are usually sufficient, keeping the parts covered in areas of moderate inflamma- tion, but in locations in which exudation is present, especially on the cheeks, more fre- quent applications will be required. On the abdomen and back, the eruption is usually less aiute and the patient can be made comfortable with a less oily preparation. An alkaline wash followed by application of ung. aqua rosae, with gentle rubbing until the skin feels only slightly oily, and then covered with a dusting powder, will make an easy and comfortable dressing, and in most cases require only morn- ing and night applications. The scalp will require special attention ; in cases with heavy, oily, adherent crusting, washing with any of the solutions mentioned and covering with gauze spread thickly with petrolatum, 2 or 3 times a day, will be found effective. In a few days the crusting will cease to develop, and a lotion can then be added as it is less objectionable than a greasy ointment. A solution of salicylic acid, beta- naphthol, or resorcin may be used, adding a small amount of castor oil. In cases that have progressed beyond the stage of acute inflammation, a half-dram of beta-naphthol may be substituted for the re- sorcin as it is slightly stimulating in character and a good bactericidal remedy. In using beta-naphthol care should be taken to limit ap- plication to the scalp, as it causes an uncom- fortable smarting or burning sensation on other locations. These applications should be con- tinued over an indefinite period, either daily or at intervals sufficient to keep the scalp clean and clear of scales. This step is important and will prevent recurrences in cases of the seborrheic type. The plan as outlined above, while not al- ways effective in controlling the intense pruri- tus accompanying acute exacerbations of the disease, tends to greatly modify the discom- fort, and in the quiescent period supplies a protective covering for the epidermis, thus aiding in the process of repair, in the repro- duction of the horn cell or protective layer of the skin, which is all one can aim to do from indications in local treatment. The subject of infantile eczema is a most troublesome one both from the standpoint of the patient and the family, but with persistence 226 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 and cooperation in carrying out the plan of treatment outlined, we can always look for a good result. Cases due to simple errors of metabolism usually respond quite readily. The most difficult to control will be the patient in whom we find a protein sensitivity, but by careful and painstaking efforts at desensitiza- tion to the specific proteins we can often suc- ceed in bringing even these cases to a favor- able issue. Discussion Dr. H. J. F. Wallhauser (Newark) : I have en- joyed listening to the various papers presented and wish to extend my thanks and voice my ap- preciation of the progress that has been made in infant feeding and the resulting improvement that has been developed in the treatment of mal- nutrition in infants. Drs. Nicholson, Krauss and Rosenberg have cov- ered the subject from the standpoint of diet very well, and Dr. McCauley has brought out the main features from a dermatologic viewpoint. In a brief way I would like to stress a few points re- garding the various phases described. Eczema of infancy constitutes one of the most trying maladies with which we have to contend; the intense pruritus which accompanies this in- flammation, causing the patient to scratch until raw bleeding surfaces result, is evidence of the ex- tremely annoying character of the condition, and the effect on the family is likewise a serious fea- ture, since the discomfort of the patient is ever before them. We are, therefore, many times placed in a difficult position in finding remedies for relief or palliation. In my early days, eczema was regarded as an entity and we were taught to treat the acute stage with soothing remedies and the chronic stage with stimulating remedies and, so far as adult cases are concerned, this plan still holds good thera- peutically in regard to local measures, but in in- fants we are dealing only with the acute type of inflammation, and even though cases occur that show a low grade inflammation, with infiltration and thickening in patches, they seldom if ever re- quire stimulating remedies. Eczema, as Dr. Mc- Cauley has suggested, is being considered today as an inflammatory reaction which may be due to some local irritant or internal constitutional cause leading to the development of skin sensi- tivity. This does not differ greatly from Bate- man’s description of nearly 200 years ago, in which he described eczema as an inflammation of the skin due to external and internal causes in an individual who was susceptible. The term skin sensitivity, however, more briefly defines the con- dition. We have succeeded in isolating many of the conditions that are responsible, both of internal and external origin, and have a better understand- ing of the principles involved, yet we are a long way from the final analysis of this protein disease in which the skin manifestations can only be con- sidered as a symptom in the complex forces con- cerned in its production. Considered as a skin sensitivity, which may be permanent or transitory, we are in a position to group our cases under defiinite conditions leading to therapeutic measures in management and treatment; i.e., under perm- anent sensitivity we find congenital skin de- fects; in the transitory class, digestive disturb- ances; while under local causes all factors of an irritating nature are included. In the local causes, Dr. McCauley laid great stress on parasitic infection and described the definite clinical manifestations of dermatitis seborrheicum as the most common, in which var- ious parasites, although not definite, are held re- sponsible. Isolating the various clinical manifes- tations of this disease under a specific cause has added greatly to our success therapeutically in adopting aseptic measures. In the application of treatment all the conditions that may be respon- sible, both internal and external, are taken into consideration, including particularly the nature or degree of the inflammation. A slowly progressive, mild, scaly, erythematous eruption, without in- tense reaction, can be treated by local measures alone, while cases that show intensive inflamma- tory exacerbations will require careful study re- garding internal contributory causes. In the pro- longed persistent type, protein sensitivity is most generally found responsible and offers the great- est difficulty in control. These cases will have to be tested for specific allergic articles and treated by methods of desensitization. Of all the predis- posing factors, however, overfeeding is probably the most common, and is generally apparent by the robust fat, healthy appearance of the majority of cases of infantile eczema that come under ob- servation. Dr. McCauley mentioned orange juice as a pos- sible allergic article. I would like to add that this is the most common cause leading to skin sensi- tivity, and should receive more careful considera- tion in advising parents as they are very apt to encourage immoderate quantities of orange juice to the exclusion of other fruits of equal value. In local treatment, we regard the condition as an acute or subacute inflammation and treat it ac- cordingly with soothing and protective measures, including cleanliness. Regarding the latter, we were taught, and followed for many years, the teaching that water was harmful and should never be used in eczema, and it took many years to wear out this erroneous impression, for we had to over- come the fact that washing actually aggravated the condition. Persuasive measures finally succeeded in proving the temporary aspect of this excitant and that cleanliness was an important aid in treat- ment. Experimenting with various liquids that might be used for this purpose, in the removal of scales and crusts, the various fixed oils were employed, including olive oil, sweet almond oil, cocoanut oil, oil of sessame and milk, all of which seemed to be beneficial for a time, but in the end would be found irritating and in many cases responsible for re- lapses. This was especially so regarding milk, which was responsible for recurrence in cases in which protein sensitivity was present. All the above applications were found unsuited and grad- ually gave way to alkaline lotions, which were found less irritating and often tended to relieve the intense pruritus. The method of bathing has been well defined by Dr. McCauley and I have mentioned it only to show its importance and the obstacles in its establishment as a routine measure. Particular attention was called to the treatment of the scalp in the prevention of relapses, and I would like to add that all cases showing a predis- position to development of decided scaling in the scalp should continue the use of antiseptic lotions and cleanliness as a toilet measure indefinitely. Eczema or skin sensitivity leading to dermatitis, as it is now being regarded, constitutes a problem that appeals to all of us, in working out the var- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 227 ious responsible causative factors, and in childhood we are in a better position than later in life in determining- many of the predisposing causes, more especially those relating to congenital ab- normalities and digestive disturbances, and our success in treatment will depend upon giving each case careful study, especially regarding the con- stitutional contributory causes, in the development of skin sensitivity. Dr. Elmer G. Wherry (Newark) : I would like to congratulate Drs. Krauss and McCauley on then- courage in coming here and talking about a subject that is so hard to deal with. I can add nothing whatever to what Dr. Wallhauser has said except a few practical suggestions which have possibly already been brought out but perhaps have not been sufficiently stressed. Dr. Wallhauser told me 25-30 years ago that it was very easy to cure such cases provided you did not have to save the child, and I think that is still true. Where we get a case of eczema that has not an intolerance to milk, the patient can be made very much better by changing to skimmed milk. As the baby loses weight the eczema will disappear. That may be very gratifying for a short time but if it develops a bronchial pneu- monia and dies the treatment is of no avail, and that may easily happen. Regarding the subject of tolerance, I believe that a child can be kept for a few days on skimmed milk and then the milk can gradually be made stronger, for I believe that the child has the abil- ity to establish a tolerance to almost any kind of food even though that food may be toxic to him at the start. If you consider that when we were small boys we sneaked behind our father’s barn and got sick on a cigar, and yet all those of us who had the courage to persist are now able to smoke several cigars a day; when you consider that nicotin' is a poison and that we were able to establish a tolerance for it; it is not so strange that we can establish a tolerance for orange juice, milk and eggs, if we go at it patiently and per- sistently. One most important thing that has been left out entirely in this discussion, as a therapeutic meas- ure, is insisting on the child drinking plenty of water. I think that is of great importance. Dr. Krauss did speak about giving fruits and vege- tables to the mother in order to reduce the fat, but that simply reduces the fat in the milk, as meat is the substance of the mother’s diet that will produce fat in the milk. That is simply an- other way of giving the child a starvation diet. Dr. McCauley, speaking of dermatitis, really gave us the hint of how to be successful in most of our cases, and that is simply a matter of curing the scalp and you cure the disease. Some of these cases can be cured only when we ’ have the active cooperation of some intelligent caretaker in place of the mother. The mother will not always do what a trained nurse will do. We have frequently taken cases to the Babies' Hospital in Newark, and we cure them by what the nurses call crucifying them. We do not dare do that in the home. By crucifixion we simply mean pinning the child’s sleeve to the mattress so that it cannot scratch, and that is done con- stantly except when the children are being held by the nurse. I had a case a short time ago, a 21 months’ old child, well nourished but unable to sit alone; had no teeth; had many of the signs of rickets, and with a severe dermatitis which was vastly worse than any of the pictures shown by Dr. McCauley. The child had been treated by a dermatologist in Buffalo for several months, with no results. The family then moved to Arlington and the baby was treated by other doctors, with no results. I was consulted and I spent an hour telling the mother, who was a very intelligent woman, what to do. I decided that she would fol- low my instructions and expected some improve- ment. There was no improvement for Sy2 months. I then took the child to the hospital and within 3 days, on skimmed milk, the child lost approxi- mately 3 lb. and became so weak that it could hardly cry aloud. His condition was so bad that I feared I would lose him. However, his eczema im- proved on the same treatment he had been having in his own home. I then put him on a most lib- eral diet, excluding orange juice. The child im- proved wonderfully and within a few weeks was practically cured. That child’s scalp was shaved. The improvement of his general dermatitis follow- ed immediately the curing of his scalp. A short time after that a similar case was brought to my office and I absolutely refused to treat it unless I could have the child in the hos- pital. The mother was about as stubborn as I was and asked me to give her a chance to see what she could do at home. I gave her the same general advice which had been used so success- fully in the first case and 6 weeks later the child was entirely cured. These cases can be handled much more easily in a hospital than at home and are ordinarily cured more rapidly. Dr. Percival Nicholson (Philadelphia) : There is a method of treatment that has not been mention- ed. A great many of these children can be fed on ordinary types of food if they are given in ad- dition ultraviolet treatment. If the chronic type of case is given rather massive doses locally and then general tonic treatment of ultraviolet lights you can usually maintain fairly liberal diet with- out detriment to the child. In 1909, Dr. Ruhrah, of Baltimore, used soy bean flour in the treatment of diarrheas. That was used very extensively in giving high protein long before “sobee” was brought out. My experience with goat’s milk has been rather unsatisfactory. It has very little effect in most of these cases. There are lots of children that give no active skin reactions to certain food ingredients but seem to have a distinct eczema that is im- proved by changes in food. On skin tests, they may not have a very distinct wheal but these children are greatly improved when they are put on acid- ophilous milk. This changes the- whole intestinal flora. Acidophilus bacillus is the only organism you can recover from the bowel movement. It is true that in most of these cases diet has been unbalanced. There is an improper relation between the carbohydrate, fat and protein. These cases are rather difficult and I make a plea to stop giving over a long period of time an excessive high protein, as in dryco. The danger about protein intolerance is that it is very insidious and not realized until an intolerance has been established and improper feeding has been going on for some time. One of the most recent treatments in eczema, which was rather startling but which was men- tioned to me by a very eminent dermatologist, is the administration of boiled milk hypodermically to give protein shock. The reported results have been very satisfactory in many cases so that in the future I intend to employ a certain amount of protein shock as a means of clearing up some of these difficult cases. 228 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 Dr. F. /. Krauss (Closing) : These papers have brought out just what I was after, a discussion of various ideas in regard to the treatment of eczema in infancy. It is particularly interesting to hear it from the 2 standpoints, that of the dermatolo- gist and that of the pediatrician. I wish to discuss 1 or 2 points that were brought up. First of all, the skin test alone should not be relied on; 60 to 80% are positive in cases of pro- tein sensitization. We know that a child may be sensitive to a skin test at one time and not at an- other, and that complicates the feeding problem; because we may put the child on a diet and it will suddenly show reaction to some of the foods to which it was previously negative. In these cases it is a question of recurring eczema and re- testing whenever there is a flare-up. The metabolic imbalance should be considered, of course, as well as the hypersensitiveness of the skin; things over which we have no control. Men who are dealing with allergy group these cases with asthma and we know how many cases later in life suffer with asthma, migraine headaches, vomiting, etc. I do not know how to treat a child who is sensitive to arsenic — I presume the doctor referred to the small amount found in foods. I do not agree with Dr. McCauley in that the majority of the cases are of seborrheic type. When I started to write this paper last spring I went through my files and took every case in infancy that had a skin test. I took 112 babies under 18 months of age. In treating them from a dietetic standpoint there were only 7 which I could not in- fluence by diet. Those were of the seborrheic type. That is a small proportion in contradistinction to what Dr. McCauley reports. I am very much in- terested in his viewpoint and in that of Dr. Wall- hauser. I found in this group of 112 cases that 14 were nursing babies — 7 cured, 7 unimproved; 11 were cases of malnutrition and 10 were cured, 1 im- proved; 33 were due to milk protein, 20 of whom were cured by drying or boiling the milk, 9 were improved and 4 unimproved; 7 more were milk protein, of which 5 were cured, 1 improved and 1 unimproved by omitting milk; 29 showed fat me- tabolism, 18 of which were cured, 11 improved; 3 had a sugar metabolism, 2 of which were cured and 1 unimproved; there were 2 with egg protein, 1 cured and 1 unimproved; 6 milk protein cases put on “sobee” diet, 3 cured, 2 improved and 1 un- improved; cause undetermined in 7 cases, 1 of which was cured and 6 unimproved. In desensitizing with hypodermics of boiled milk I have had no results. I have tried it in 3 or 4 cases. One family thought I was a very cruel doctor, and it did no good in the cases that I have seen. Dr. G. W. Jones, of Clovis, New Mexico, is trying the injection of mother’s blood to desensitize these patients and he has reported in his paper and also in a letter to me some very interesting re- sults. I am rather anxious to try it. I also do not find that oranges are a frequent cause of eczema according to my skin tests. I would like to ask Dr. McCauley how frequently the der- matologist makes skin tests? It is my principle to do it in every case where there is an area free enough to be tested. One point that Dr. Kerley taught me was that you may very often get a re- action on the abdomen but not on the fore-arm, because there is an increased sensitivity of the skin of the abdomen. Also, up over the bend of the elbow we can get positive reactions, whereas near the wrist the skin is not so sensitive. I do not find that overfeeding is as common as protein sensitization, except possibly overfeeding by fat. My knowledge of goat’s milk is practically nil. I have only used it in 1 case and with no results, although I understand in reading about the chem- istry of goat’s milk that the chemistry is so near that of cow's milk we cannot expect any wonder- ful results from its use. I am glad to hear Dr. McCauley mention the use of baths. I think the plastering of children from head to foot with ointments is very messy and a horrible way of taking care of the condition. The parts should be cleaned with borax and water. Speaking of the reaction of milk on the skin in these hypersensitive cases, a few months ago a man brought me a cold cream in which he had incorporated a certain quantity of fresh cream and wanted me to try it out. I found that every child who had a milk sensitivity was made worse by rubbing this cold cream into the skin. I had the mothers report to me within a week, and or- dinarily if there was an irritation it was increased by this cold cream containing the cream of cow's milk. If seborrhea is a factor in producing this condition of baldness, why do we not see more eczema in females? I presume when Dr. McCauley speaks of drink- ing of plenty of water he refers to the nursing mother, because giving plenty o'f water to the babies seemed to make the condition worse. Dr. Francis J. McCauley (Closing) : Regarding the case Dr. Wherry spoke of clearing up in the hospital and the condition recurring again when the baby was taken home, I think that might be explained from the sensitivity standpoint. That baby was either susceptible to an infection or to some other condition in the home, possibly a very slight difference in the diet. In the hospital it was taken away from the allergic factor and the con- dition disappeared. Dr. Nicholson mentioned the ultraviolet light. Our limited experience corresponds with that of most dermatologists as being unsuccessful in this type of inflammation in which the neurocutaneous apparatus is easily affected, resulting in increasing the inflammation. Regarding Dr. Krauss’ figures on the percentage of cases in which a seborrheic element is present in only a limited number of cases, they do not agree with the experience of the dermatologist in which this condition is present so constantly as to be considered for local treatment in every case of so-called eczema that comes under observation, and if the simple plan of borax washings and soothing protective applications is followed, most cases will recover quite readily. I do not wish to give the impression that there is not also a constitutional factor present in many of these cases. Allergic response may be due to internal and external causes. Hypersensitiveness from internal causes my be due to undigested foods, or to a protein in some food that is prop- erly digested ; or the patient may become sensitive to local bowel organisms and these cases require additional management. iBoth internal and ex- ternal factors may be present. The dermatitis may start as a sensitization to food or bowel or- ganismal protein and, as a result of scratching, end as a sensitization to the skin organisms. The majority of cases, I believe, due to the skin or sebaceous glands become sensitized to the protein of the seborrheic virus from the outside. The use of skin tests, in our experience, has not been valuable in directing the management of diet, as we frequently found that cases showing a sensitivity to certain proteins could continue the use of such substances without creating reactions. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 229 This was especially so with regard to milk in which a positive reaction resulted and which could he continued in the diet without causing any ex- acerbations. For this reason, we have practically discontinued the use of this procedure, relying rather on clinical observations following the inges- tion of certain articles of diet. In answer to Dr. Nicholson’s question regard- ing the use of an ointment containing cream of cow’s milk, this is easily explained by the sensi- tization of the infant to a protein of cow’s milk contained in this preparation. THE MODERN TREATMENT OF VARICOSE VEINS V. Earl Johnson, M.D., F.A.C.S., Atlantic City, N. J. Varicose veins are frequently encountered and the writer has been impressed with the amount of disability which they occasion. When they become complicated the suffer- ing is much increased and, if neglected, the patient may become an invalid for life. It is in the interest of the many suffer- ers from varicose veins that this communi- cation is written. In the past these cases have been treated conservatively or radically. In the conserva- tive treatment the patient was given an elastic stocking or bandage to wear. This was fol- lowed rather indifferently, both by the physi- cian and patient. The patient, usually a woman, objected to the presence of the band- age as being unsightly. The radical treatment consisted of operations which removed the varices, or the entire saphenous vein was re- moved from groin to ankle. Neither of these methods (conservative or radical) gave re- sults satisfactory to the parties concerned. The conservative always failed, except in cases where the veins were very small, but it did accomplish one thing when the treatment was sufficiently persistent ; it did keep the veins from getting worse. In fact, that was all that was even hoped for. The radical method was applied when the veins were extremely di- lated, usually the entire saphenous trunk, or when ulceration had supervened. Very radi- cal procedures were then necessary and the surgical treatment was successful only in so far as the efficiency of the operation allowed. The most successful was the Mayo method in which the great saphenous vein was ligated at the sapheno femoral junction, and the saphenous vein removed as far down as the ankle. This was, at times, supplemented by additional incisions, with excision of outlying varicose bunches. This method, however, car- ried a direct mortality of 1 in 200 and a sub- sequent mortality of 1 in 200 ; that is, a total mortality rate of 1% resulted from the radi- cal surgical treatment. This, in itself, caused many physicians to advise against operation and some conservative surgeons refused to operate. One of the real drawbacks to the operative treatment, from the patient’s stand- point, was the economic factor. The period of disability following operation was usually about 6 weeks and sometimes much longer. The treatment of varicose ulcers was fre- quently unsuccessful, regardless of how radi- cally the operation was done. The above status of the former treatment of varicose veins is not exaggerated and it is not sur- prising that other and better methods have been sought and that the injection method of treating these cases has been developed, and, fortunately, this method marks a great ad- vance in handling these cases. It is very surprising, however, that the method has not enjoyed the full sanction of the rank and file of the profession. It is also unfortunate that more physicians do not know more than they do about this method, its ap- plication and end-results. It is a fact, that comparatively few varicose vein cases are re- ferred for treatment. Sometimes this is due to the fact that the examining physician does not know about such treatment at all, or if knowing, he does not know anyone doing that work. Most often it is due to the fact that examination does not disclose the presence of the veins, and again, when they are found they are passed over as an insignificant find- ing. If I can succeed in bringing this method to the attention of a few more men, and can impress upon them the necessity of treating varicose veins, when found, I will feel that the time expended hereon has been well worth while. The term “varicose veins” may be applied 230 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 to veins in any part of the body, but, due to common usage, it has come to be associated with varicose or dilated veins of the lower ex- tremities. That is the application in this paper. If one examines the accompanying plates, showing the normal anatomy of the leg, it is apparent that there are 2 principal sets of veins. Those beginning over the top of the The posterior veins are known as the short or lesser saphenous veins. The long internal chain of veins becomes known as the long or great saphenous vein. Both of these sets of veins run in the subcutaneous tissue through- out their course and both sets have communi- cating veins which join them with the deep veins. These deep veins are entirely beneath the muscle fascia layer. Plate 1 Legend: Illustrating the 2 main venous channels of the leg below the knee. Those beginning about the internal malleolus ascend as the great saphenous vein on the anteromedial aspect of the leg, while those begin- ning about the external malleolus pass up the posterior surface of the leg as the lesser saphenous. The course of the great saphenous above the knee and relations about the fossa ovalis are shown. The connecting veins between the super- ficial and deep veins are well illustrated, as well as is the relationship between the superficial veins and the muscle fascia. foot and around the internal malleous unite and extend upward to the inner and antero- medial aspect of the thigh to the groin, where it joins the femoral vein about 2 inches below Poupart’s ligament. Those beginning about the external malleolus extend up the posterior surface of the leg, over the calf, and end in the popliteal space where they join the popliteal vein. The popliteal vein then passes to Hun- ter’s canal where it becomes the femoral vein. Thus, there are 3 sets of veins in the leg that one has to consider in the diagnosis and application of treatment— the superficial, the deep, and the communicating. Each of these systems has valves placed at irregular inter- vals and usually just distal to where a branch joins. The presence of normal valves throughout prevents varicose vein formation, but when some of them give way and become incompetent, then varicose veins are sure to March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 231 develop, and the extent and type of varicose veins that will develop is dependent upon the number of valves involved. Etiology of Varicose Veins Much has been written on the etiology of varicose veins and a vast amount of experi- mental work has been done in an effort to locate the cause of the condition. A review of this work would not be in the scope of this manuscript. Among the theories advanced are: (1) Congenital weakness of the vein walls or valves, or both; (2) that there de- velops a loss of nerve and muscular tone of the vein wall; (3) that the cause is an in- fectious one — a low grade periphlebitis or phlebitis secondary to emboli, or through or- ganisms being brought to the vein by the blood stream or by extension from adjacent infec- tion; (4) that the endocrine system is respon- sible; (5) that occupation is the principal cause. It is difficult to account for the cases seen in young people unless congenital weakness is the etiologic factor. The youngest patient was 9 years of age. We know that varicose veins develop following infections such as scarlet fever, pneumonia, rheumatism, typhoid fever and influenza. We also know that vari- cose veins may follow trauma, and we have seen them follow a superficial phlebitis. By far the most frequently associated factor is occupation. We find them in people whose occupation requires a great deal of standing — barbels, policemen, waiters. It is probable that in the great majority of cases we have to deal with both a congenital weakness and the associated factors such as infections, occupa- tion and influence of conditions producing an increased intraabdominal pressure, like con- stipation, asthma, chronic cough. Besides the above types of cases we see varicose veins secondary to obstructive pathology — fibroid uterus, intraligamentous pelvic cysts, tumors of the inguinal glands, cirrhosis of the liver. We also see them in the presence of marked cardiac decompensation and during and fol- lowing pregnancy. Diagnosis The diagnosis of varicose veins is perfectly obvious. It is necessary, however, in the av- erage case, to have the patient stand flat on his feet. The mere diagnosis of varicose veins, however, is not sufficient. One must de- termine, as far as possible, the etiologic fac- tor. It should be easy to rule out those cases due to obstructive lesions outside of the vein ; cirrhosis of liver, cardiac decompensation, fibroid uterus, pelvic cysts, inguinal adenitis, advanced pregnancy. It then matters little, so far as relief to the patient is concerned, what is the etiologic factor, but it is still im- portant to determine how extensive the veins are. Is there only a short segment involved? Is the entire great saphenous vein involved or the entire lesser saphenous? Is the superficial, deep or communicating system at fault? Is there a combination of any of the systems? It is obvious whether the varix is a short one or whether the entire length of either the greater or lesser saphenous is involved, but in order to determine whether the superficial system is alone involved, or whether the sys- tem and communicating systems are simul- taneously involved, or whether the superficial, communicating, and deep systems are all in- volved, requires the application of 2 tests. Trendelenburg Test (1) Have patient lie flat on the table. (2) Elevate the leg so that the veins be- come empty. (3) Place the radial edge of the thumb across the upper thigh and make pressure about 3 in. below Poupart’s ligament and medial to the pulsating femoral artery. (4) Have patient stand up, meanwhile keep the hand applied as directed, as this obstructs the great saphenous vein. Now, the test de- vised by Trendelenburg advised that the hand obliterating the saphenous vein be removed and immediately following this the column of blood would fill the great saphenous trunk with a thud. In other words, the entire trunk would become filled instantly. This would occur when all the valves of the great saphe- nous were incompetent. Instead of doing the 232 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 above as soon as the patient stands, continue to apply the pressure to the saphenous origin and if the veins fill slowly from below up- ward one knows that the valves of the com- municating veins are intact. Then, release the pressure on the saphenous and if the entire saphenous trunk fills immediately one knows that the valves are incompetent in that system. This is the Trendelenburg positive test. If, Plate 2 Legend: The negative, positive and double posi- tion Trendelenburg test. The patient’s leg is ele- vated and pressure is made on the great saphenous vein and the patient is asked to stand up. (a). If the veins remain empty or fill up slowly, from below, and do not change in size after the pressure is released, the test is negative. There is no re- versed flow in the saphenous system, (b). If the veins remain empty so long as pressure is main- tained, but fill up from above with a sudden gush when the pressure is released, the test is positive. The flow of blood in the saphenous vein is re- versed. (c). If, however, the veins fill up suddenly on standing, in spite of saphenous compression, there is a reflux from the deep veins. Releasing the compression may produce a further filling of the veins, thus making the test doubly positive. This latter condition, indicating a valvular insuffi- ciency of the communicating veins, is not favor- able to the injection treatment and is a frequent cause of recurrence. — (Diagram from Homan). on the other hand, the veins below fill very rapidly, one knows that the valves of the com- municating veins are incompetent. If now the pressure on the saphenous is released and the entire saphenous fills with a splurge, this is known as the “double positive’’ Trendelenburg test. If the veins below fill rapidly and when the pressure on the saphenous is released there is not a rapid filling of the trunk from above downward, then we have the Trendelenburg negative, denoting that the valves of the saphenous trunk above the varices are com- petent but that some of the communicating valves are incompetent. There now remains another very important point to determine. Having determined the condition of the superficial system, it is neces- sary to determine whether these are dilated and varicose as the result of obliteration of the deep veins obstructed from a previous phlebitis or otherwise. In other words, are the superficial varices compensatory in their nature? If the superficial veins are obliterated by treatment, are the deep veins competent to care for the venous circulation? This is determined by Perthe’s test, as follows : Place a tourniquet about the upper- third of the thigh while the patient is in the standing position, only sufficiently tight to obstruct the super- ficial veins; the patient is asked to walk to and fro for about 2 minutes ; the leg muscles squeeze the blood out of the deep veins and aspirate the blood from the varicosites; and the superficial veins become diminished in size. If these veins do not diminish in size the deep veins are not competent. So far we have diagnosed the presence of and the type of varices. Now we have come to the clinical side of the case. Many of these patients present themselves for treatment be- cause of pain in the calf or joints. A differ- ential diagnosis must exclude Buerger’s dis- ease, neuritis (this includes pressure pain of pelvic tumors), tabetic pains, arthritis, and weak feet. Actually, the only important ones of those to rule out are: (1) Buerger’s dis- ease, as the veins are not the cause of the pain in this disease, and (2) pain produced by pres- sure of pelvic or inguinal masses. Buerger’s disease is easily ruled out by determining the presence or absence of pulsations of the dor- salis pedis and posterior tibial arteries. Pelvic tumors and inguinal tumors are ruled out by adequate examination. The other conditions are actually benefited by treatment of the varices, thus improving the circulation. This improvement is especially marked in cases of arthritis of the knee joint associated with vari- cose veins and pain due to weak feet. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 233 Treatment The treatment should be approached by 3 different methods : (1) The injection method: This can be de- pended upon to give excellent results when used on properly selected cases. The proper cases are tabulated : (a) Those cases where there are scattered or segregated varices. This includes those on the thigh, as well as the lower leg. (b) All cases where the posterior veins (the lesser saphenous trunk) are alone involved or when combined with the great saphenous trunk, provided the latter is not involved higher than 4 or 5 in. above the knee. If the varices are particularly large, amounting to venous sinuses, this method may fail to give a permanent result when used alone. (2) Operative ligaturing of the great saphe- nous followed by injection treatments. (a) This is indicated in all cases giving a positive Trendelenburg test. That is, when the entire great saphenous chain is involved. Much more rapid results are obtained by this combination. While it is possible to inject the entire trunk, in segments, and even at the saphenofemoral junction, the method is far from being as safe as ligation. (b) Those cases that have progressed so far that the veins have, literally, become pools of blood, instead of having the outline of a vein. One reason why these cases fail to give results with the injection method is because the intima has been so stretched as to be mostly scar tissue and therefore cannot react to the injection solution to form a good thrombus. (3) Operative treatment. This is indicated for those cases giving a Trendelenburg double test. In these cases the valves of the great saphenous trunk are incompetent and, in ad- dition, the valves of the communicating and deep veins are also incompetent. Ligation would not control the reflux from the deep system. The procedure of choice in these cases is to ligate the great saphenous vein at the saphenofemoral junction and then strip the saphenous vein as far as the knee and ex- pose the trunk below the knee so as to be able to ligate the communicating veins and remove the varices. In some of these cases it has been possible to obliterate the veins be- low the knee instead of excising them. This latter may first be tried, but the great saphen- ous must be ligated first. Technic of Ligating Saphenous Veins This operation is done under local infiltra- tion anesthesia. The line of incision is made 2 fingers’ breadth below Poupart’s ligament to the inner side of the anterior surface of the thigh. The line of incision is infiltrated with 1 % novocain-adrenalin solution and the in- cision made about 1)4 in. long through the skin, in a transverse direction ; then the sub- cutaneous tissue is infiltrated with the same solution. The vein is then exposed and 2 cat-gut ligatures are placed and tied and the vein divided between the ligatures. Do not use artery clamps ; in order that the intima may be traumatized as little as possible. The incision is then closed with black silk or Michel clips. I use the latter because I feel that a source of infection is thereby eliminated. These clips are removed on the third or fourth day. The procedure may be done in the office and the patient allowed to go home and follow usual routine or it may be done in the hospital and the patient kept in bed for 5 days. Either method is safe. Technic of Injection Treatment There have been many solutions advised and used with varying results. My exper- ience with invert ose (aqueous invert sugar solution) 60% or 70% has been entirely satis- factory. In the beginning, I used 20% sodium chloride, but gave it up because of the severe pain occasioned by each injection. Some patients complain of a heavy feeling of the entire leg, others of a mild pain in the in- jected areas and a few have felt a mild sen- sation of electric shocks, but this immediate pain always disappears very shortly after they have walked out of the office and the subse- quent course is entirely painless. In a few cases there has been a moderate soreness last- ing 2 days. 234 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 Technic for Invertose Injections (1) The syringe, a 10 c.c. Luer-lok type is filled with the invertose solution, and a 23 gauge, short, bevel needle attached. (2) The patient has been standing during the period of filling the syringe and the veins are now distended. The vein is selected and the skin over this vein painted with tr. iodin. Now the patient is asked to lie down on a low table and the needle inserted into the vein without delay. Do not lose any time after the patient lies down or the vein will collapse. After the needle is in the vein have an assist- ant strip the blood out of the segment to be injected and hold the skin taught during the entire procedure of injecting. Then inject the solution fairly rapidly. Be sure your needle is in the vein. As soon as the injection is completed, note the time but don’t remove the needle. Now allow 5 minutes to pass before the assistant releases his pressure and before removing the needle. Then apply a small sterile pad, with a strip of adhesive, over the puncture wound. Apply an “Ace” bandage from ankle to above the injected area. If one has difficulty in keeping the vein dis- tended long enough to insert the needle, a tourniquet may be applied above the selected vein while the patient is standing. If still the vein collapses as soon as the patient re- clines, then the injection may be given with the patient standing. In the latter cases, as soon as the injection is completed it is wise to have the patient lie down for the 5 minute pressure period. The patient is then allowed to leave the office and go about his usual duties. Injections are given in the same leg at weekly intervals, but one may inject 2 or 3 veins in the same leg at one time. The “Ace” bandage should be worn continuously during the entire course of treatment in order to obtain the best re- sults. The average cases will require from 3 to 5 injections for each leg. The worst case of uncomplicated varicose veins in my practice required 6 injections after the great saphenous had been previously ligated at the saphenous opening. However, I used 10. 15 and 20 c.c. injections for this particular case. So far I have not had a failure with this preparation (invertose), but should I run into such a case, I would follow the suggestion made by de Takats and use 70% invertose and 30% salt solution mixed in equal quantities. Mechanism of Obliteration of Veins with Solutions Much space has been used to present the exact changes occurring after the injections have been given, and experimental work has been produced to prove the exactness of state- ments and accepted theories. To be concise, the solution acts as a chemical irritant on the intima, causing it to become swollen, fibrin is deposited and red cells become entangled in the fibrin network, and within a few hours the vessel is filled with a blood clot. After a few days (4 to 6) organization of this clot is evident by penetration of the clot by fibro- blasts and the presence of new capillaries. These new capillaries spring from the intima out to the clot, thus anchoring the thrombus. Contraction of the clot, with narrowing of the vessel, proceeds until at the end of about 3 or 4 weeks the original varicose vein can be felt as a small cord beneath the skin. There are 2 principal reasons why the incidence of embolism in this type of treatment is so small. The first reason has been given above, in which it was shown that the clot is fixed to the intima with newly formed blood vessels. The second reason is that the circulation in varicose veins is reversed. This has been positively proved by injecting lipiodol into a varicosed great saphenous and then watching the behavior of it, inside the vein, under a fluoroscope. The lipiodol particles are seen to go downward, instead of upward toward the femoral artery. Provided cases are properly selected for the 3 forms of treatment, one can feel confident of promising a cure of the veins present, but other veins might become varicose at some time in the future. The most promising group of cases consists of those selected for the injection treatment March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 235 alone; all of which can be cured. This is naturally so because the disease has not progressed to the extent that requires op- erative treatment, either combined with in- jections or alone. As compared with the old forms of treat- ment, in which operation was the only radical treatment, a very decided advance has been made, not only from the standpoint of cures and improvements, but most especially from the standpoint of mortality of the treatment. The treatment of varicose ulcers has not been attempted in this communication because it is a condition warranting a separate presen- tation. Conclusions In the foregoing paragraphs it has been my desire to discuss the treatment of varicose veins from a purely practical and clinical standpoint. I particularly wish to make 2 points clear. (1) That the injection treatment of vari- cose veins is now a legitimate procedure. Be- cause of this established fact, it should be recognized more widely by the rank and file of the profession, and furthermore, patients should be advised of this form of treatment, and they should be encouraged to have their varicose veins treated before they become so extensive as to require more than injection treatments. The next generation, if the above advice is followed, will be treated so early in the stage of the varicose vein development that the injection treatment alone will suffice. (2) That the injection treatment of vari- cose veins is not a panacea. All veins can not be so treated. It is not now sufficient to say : “Varicose veins; injection treatment indi- cated.” It is necessary to segregate the dif- ferent types of veins and apply the appro- priate type of treatment. Some cases require surgery alone, while others require a combina- tion of the two, and still others should not be treated radically at all, because they are com- pensatory in nature. INTRADURAL CAUDAL ANESTHESIA AS AN OFFICE PROCEDURE G. T. Spencer, A.B., M.D., Hornell, N. Y. The advantages of intradural anesthesia are its low toxicity, its totality, and the complete relaxation of such voluntary muscles as are under its influence. No other anesthesia gives with equal safety either so deep insensibility to pain or such entire muscular flaccidity. Its great disadvantage is the vascular depression caused when the splanchnic nerves are blocked. The use of an anesthetic solution of high viscosity and specific gravity, however, enables the operator successfully to limit the anesthetized region by mere control of posi- tion of the patient. Such a solution is now marketed under the trade name of gravocciin, and produces perfect caudal anesthesia via the intradural route. It has been described by its originators, Pitkin and .McCormack, and by its proper utilization blocking of the splanchnic nerves and dilatation of the splanch- nic blood vessels are avoided and complete anesthesia is secured, for more than 2 hours, of the lower 4 in. of the rectum, the anus, cervix and vagina, perineum, scrotal integu- ment and part of the scrotal contents, the penis, urethra, prostate, and floor of the blad- der. The successful attainment of so deep and lasting caudal anesthesia opens new fields for office procedures, otherwise necessarily performed in a hospital, in urology, gynecology and proctology. These operations are limited only by the convenience of the operator and the severity of aftermath, for the patient can be at home, in bed if necessary, before the anesthesia has worn off. Gravocain is usually injected while the pa- tient is in a sitting posture, with elbows rest- ing on knees, the back bowed outward and the head inclined forward. Since experience has shown that 0.2 c.c. of this solution yields complete caudal anesthesia lasting 2 hours, it is my custom to introduce it with a tuber- culin syringe to permit more accurate dosage. No admixture with spinal fluid is necessary, 236 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 and anesthesia is almost invariably attained within 5 minutes. I have had no failures. Im- mediately after introduction of the solution and withdrawal of the needle the patient is instructed to sit as erectly as possible in order to minimize leakage of spinal fluid. He is kept in this position until anesthesia sets in, and then placed — or places himself — in the semi- recumbent posture for the operative work to be done. The third or fourth lumbar inter- space has proved most satisfactory as the point of injection, for if injected higher the solution anesthetizes, to variable extents, the higher nerve roots as it sinks to the bottom of the dural sac. When locomotion is interfered with, the ab- ductors of the thigh are first and most affect- ed, since their nerve supply is from the sacral plexus. If the subject attempts walking too soon, in such case, he stumbles over his own feet and his knees interfere. He cannot sep- arate his lower extremities successfully until the abductors’ nerve control is reestablished. There occurs little or no paralysis of the thigh abductors, because their nerve stimuli proceed through the third and fourth lumbar roots via the obturator nerve. Intradural caudal anesthesia was given in the office to 24 ambulant patients, with an av- erage dose of 0.22 c.c. gravocain. at either the third or fourth lumbar interspace. The av- erage time elapsing between administration and unaided departure from the office was 1 hr. and 24 minutes. The only advice given these patients concerning the anesthesia was to keep their heads and shoulders higher than their hips until at least 3 hours had passed. Some of them walked home, some took cabs, and some drove their own cars. The series comprised the following: fulguration of verumontanum, 3 ; injection of vas, 1 ; fulgur- ation of median bar, 3; intraprostatic injection, 4 ; fulguration of caruncle, 1 ; relief of acute retention from urethral stricture, 1 ; internal urethrotomy, 1 ; circumcision, 1 ; diagnostic cystoscopy, 2 ; injection of hemorrhoids, 5 ; fulguration of cyst of bladder neck, 1 ; open- ing of ureterocele with scissors through cysto- scope, 3. The ages of the patients ranged from 26 to 74 years. No preliminary narcotics or sedatives were given. The con- dition of the heart, blood pressure, and lungs was given no consideration. Pallor and faint- ness occurred twice, in each case before the anesthetic wras given, and were recovered from by the time anesthesia was complete. There was 1 post-puncture headache. (The patient, a male of 26, left the office at 10.30 p. m. with instructions to go home to bed. He did so, but arose again at 1.30 a. m. and drove a milk wagon for several hours.) There was no such dread of repetition as general anesthesia causes. One patient received intradural caudal anesthesia 3 times, and 4 others took it twice apiece. Conclusions (1) Intradural caudal anesthesia with gravocain seems to be a safe and conservative office procedure. (2) . Vascular depression, the most constant deterrent to spinal anesthesia in general, is avoided because the splanchnic nerves are not blocked. (3) Certain contraindications usually re- cognized as pertaining to intradural anesthesia, such as hypotension, cardiac weakness or in- competency, limited pulmonary capacity, and extreme hypertension, do not apply to intra- dural caudal anesthesia. (4) The technic is simple and the dosage small and accurate. (5) Anesthesia is rapid in onset and en- dures from 2 to 3 hours. (6) Patients undergo it gratefully and re- peatedly since it causes no such dread of repetition as does general anesthesia. A SKIN TEST FOR WHOOPING-COUGH; PRELIMINARY REPORT Charles V. Craster, M.D., D.P.H., Health Officer of Newark, and Ellis Smith, M.D., Superintendent Essex County Isolation Hospital, Belleville, N. J. With the exception, perhaps, of measles, there is no more difficult disease to control than whooping-cough when it becomes epi- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 237 demic in character. The reason is the pres- ence at such times of great numbers of un- recognized and undiagnosed cases, in which children with spasmodic coughs, not quite severe enough to show or entirely lacking in the tell-tale whoop, are unsuspected of being true cases of pertussis, and are enabled to broad- cast infection among susceptible persons of all ages. The diagnosis of whooping-cough, even by the physicians, has depended upon history of the child’s cough, of his having been exposed to a known case, or to acciden- tal occurrence of a cough paroxysm in the presence of the physician. The laboratory diagnosis of pertussis by sputum examina- tion, or by the plate method, is seldom at- tempted as a routine procedure by practicing physicians or the local health department. The inciting cause of whooping-cough, the now generally accepted Bordet-Gengou bacillus, has been characterized by a signal absence of toxin formation in culture, and a remarkably low virulence toward laboratory animals. Cul- tures of the bacillus, in strength of billions of bacteria per cubic centimeter, have been in- jected into small guinea-pigs without produc- ing untoward results. Similarly, in use of the vaccine for prophylaxis and curative action in cases of whooping-cough, children have shown a remarkable tolerance for quite enormous doses of the bacillus. The toxin of this bacil- lus, although of only limited toxic power, is capable of producing a very definite amount of immune bodies in the blood stream of the infected individual, as is shown bv the high degree of immunity following an attack of whooping-cough. Second attacks are so rare as to be curiosities of medicine, and this im- munity is presumably of life-long duration. In 1928, M. V. Pechere, of Brussels, re- ported the results of intradermal tests upon 104 children, 70 of whom gave positive re- actions and in 60, or 84% of these, whooping- cough was actually present. Of 23 children with a negative reaction, 16% had whooping- cough and 84% had typical paroxysmal coughs. Among 10 children in whom whoop- ing-cough had been definitely diagnosed, there were 10 positive reactions. In 24 cases of pertussis in process of evolution 20 gave posi- tive skin reactions, while in 7 children who did not have whooping-cough, 6 gave negative re- actions. Pechere was of the opinion that the test would be useful for early diagnosis of the disease. For the purpose of determining the^ charac- ter of reaction described by Pechere and use- fulness of the test in hospital work, the writers decided to test out this action in patients suf- fering from acute attacks of whooping-cough and in a number of children free from that disease. In this intradermal test the antigen used was a vaccine made from stock culture of the Bordet-Gengou bacillus containing on the average 1,000,000,000 bacteria per cubic centimeter. The amount used for each in- tradermal test was 0.05 to 0.1 c.c., the point of injection being the forearm. In this preliminary work the group of chil- dren was composed of those in the hospital wards at that time, suffering from whoop- ing-cough in various stages of severity, from the recently arrived case with frequent par- oxysms to the case nearing the end of a 6 weeks’ quarantine period. There were 11 children injected intradermally ; 6 with 0.1 c.c. and 5 with 0.05 c.c. of the stock vaccine. In all these cases the results were the same. There appeared at the site of injection, with- in 12 to 24 hours, a distinct area of redness varying from J/2 to 1 inch in diameter. The reaction, however, was transient in character and within 48 hours faded, leaving nothing visible but the point of injection. There was no pain or discomfort and no subsequent scal- ing or pigmentation. For the purpose of finding how far the skin reaction could be used to show the ab- sence or presence of immune substances in the blood of average individuals, a group of 24 children were tested, 10 of whom had his- tories of a previous attack of whooping-cough and 14 who had no such history. Among the 10 with histories of whooping-cough, there were 8 positive and 2 negative reactions. These results would indicate the very definite pres- ence of immune bodies in 80% of recovered cases. In the 2 negatives, the possibility of errors in the original diagnosis cannot alto- gether be excluded. With regard to the other 238 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 group, the results were not quite so clear-cut. Among the 14 children having no histories of a previous attack of whooping-cough, 7 were positive and 7 negative. Of the 7 positives, 2 were very slight reactions and 1 was negative at the end of 24 hours. The results in this group could not be said to be conclusive and did not parallel the experiences of Pechere who had a much higher percentage of nega- tive tests. His group was, however, small ; only 7 children. These results substantiated the claims of Pechere, that there is present in the individual suffering from whooping-cough very definite antibodies which are specific against the Bordet-Gengou bacillus. This was particularly clear in our group of children suffering from active symptoms of whooping-cough, all of whom showed positive skin reactions. The conclusions derived from this study, al- though covering only a small group of super- vised cases, are significant enough to suggest use of the intradermal test for whooping- cough as a means of quick diagnosis, especially where there is immediate need of segregation. This test can also be used to determine suscep- tibility to whooping-cough, and enables us to separate susceptible children from suspected cases and to determine whether prophylactic doses of whooping-cough vaccine should be administered. Summary The group of children upon whom intra- dermal tests for whooping-cough were made, although small, indicates without doubt the constant presence of an allergic skin reaction in active cases of the disease. The intradermal dose of the antigen, whe- ther 0.1 or 0.05 c.c., provoked the same re- action in all the children. The transient character of the area of red- ness, appearing quickly between 12 and 24 hours after injection and disappearing more or less completely within 48 hours, is in keeping with the known low toxicity of the Bordet- Gengou bacillus. In the group of 24 children tested for sus- ceptibility, 80% of those having a history of a previous attack of whooping-cough showed positive skin reactions. In the group having no record of previous whooping-cough, 50% were positive and 50% negative. Further work along these lines with a slightly stronger antigen is in contemplation. SOME THOUGHTS ON MEDICAL ECO- NOMICS AND MEDICAL PRACTICE S. Rubinow, M.D., Newark, N. J. The symposium on medical economics which appeared in the November issue of our State Society Journal is so excellent, so rich in ideas and originality, that the editor de- serves the gratitude of the members for giv- ing it a proper place and for calling the pro- fession’s attention to it editorially. Not that the subject is new; indeed, we are fed up with it of late in the medical and lay press, but it is presented so clearly and eloquently by all the speakers that any member, if he devotes a little time to reading these addresses carefully, will be fully aware of. the magnitude of a problem which now worries the best minds of our profession. He will see that here is a topic of the utmost importance to the profes- sion and to himself, whatever his age, his standing, his line of work, or his economic status may be. He will also realize that he must make up his mind as to his own views, as to his own attitude toward a new trend in practice of medicine, so as to be ready to act accordingly when the time comes that some practical plan shall be offered him for con- sideration and for vote. It is gratifying to notice that all 3 speakers are fully in accord ; there is no disagreement among them on any vital point. They not only agree among themselves but all support the views of Dr. Harris, recently President of the American Medical Association, and of Drs. Pusey, Bevan and West. It appears that they all agree as follows : ( 1 ) They are opposed to state medicine. (2) They agree in the desire and efforts to preserve our individualistic medicine. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 239 (3) They agree that the medical profession, as it stands today, is not doing all it should to bring the fruits of scientific achievement to all classes of the people. (4) They agree that the cost of illness is not within the means of the majority of the people. (5) They warn the profession that if it does not remedy existing conditions, by its own efforts, outside forces will attempt to do so, and will lower the dignity and usefulness of the profession and make the doctor a hire- ling of big capital ; in short, will introduce some kind of public control over medicine. Such is the issue. What is to be done about it? In their answers to this vital question, the speakers likewise agree fully. The profession must take into its own hands the remedy, must change conditions so as to render adequate scientific aid to the people, must reduce the cost so that it shall be within reach of every one, and must by adequate service gain the confidence of the people. But how are these pia desiderata to be brought about? Here, after all, lays the crux of the whole matter. Dr. Harris made the following definite pro- posal : Every county society shall organize all its members and establish a medical center, owned, controlled, and managed by the so- ciety itself. This center should function as a pay clinic with every reputable physician a member on the Hospital and Clinic Staff. Services rendered should be complete, and charges made according to nature of services rendered and the means or economic status of the patient. After necessary over-head ex- penses are deducted, the balance would be paid to the physicians on the basis of services rendered. Later, arrangements should like- wise be made for the care of patients at their homes, as well as for hospitalization when necessary. Obviously, this institution is not meant for the rich class, who can afford to have the best services privately, but for the large middle-class of our people. Drs. Hall, McBrayer and Reik endorse the Harris plan but, ideal as it may seem, the writer of these lines feels convinced that it is utterly unworkable and is destined to remain a scheme on paper only. To begin with, the medical profession traditionally has always been poor material for any concentrated ef- fort. A county medical society has no uni- form membership, such as a labor union has ; there is no resemblance of equality among members as to education, achievements, per- sonality, ethics, etc. One cannot see how, in a large community with several hundred physicians, all or even a majority of them could be attached to the proposed center on an equal basis. The difficulties met by the managing board would be no less than unsurpassable. A physi- cian friend, discussing this plan, expressed himself thus : “I would rather see some kind of state medicine.” It might be workable in a small community, with a dozen or so medi- cal men, but originally the issue arose, not in small communities, but in large centers. In spite of great interest in the problem, the writer is not aware of any other definite plans to improve upon the present method of practice of medicine. It is true that the na- tional “Committee on the Cost of Medical Care” has not yet completed its elaborate sur- vey of all the contributing factors and one must patiently wait for a complete report and some definite recommendations. But, acknowl- edging the very high standing of the mem- bers of that committee, one wonders whether its membership includes an ordinary prac- titioner of medicine, one who in his daily and hourly work is confronted with all those countless details which arise in any sphere of purely human relations and which slowly, gradually, but persistently, have brought the big issues to the front. Such a practitioner, small as his voice may be, is entitled to a hearing. Let one stop and consider what are the fac- tors which in the last decade or so haA^e changed the character of medical practice and contributed to the high cost of medical care to such a degree that it has become a national issue? Realizing, as every one must, that a certain rise was inevitable on account of the diminished value of the dollar, the higher cost of all other commodities and the higher stand- 240 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 ard of living, the following 3 factors are, in the writer’s opinion, at the base of the whole issue. (1) Gradual disappearance of the general practitioner, the family doctor, and the rise of specialists. The practitioner always was, and is today, reasonable in his fees and hardly any complaints are made against him. He is in closer contact with his patients, better acquainted with their family standing, and in most cases money matters between them are being arranged without dispute or hard feel- ing on either side. He will always try to place his patient in the most favorable condition without undue strain on the victim or his family. There is no reason whatsoever why he cannot take care of the great majority of cases of illness. A somewhat more adequate preparation of himself is desirable, and could be achieved by adding 1 year more to his medical course, taking this year from the pre- medical college requirements. Not so with the specialist. After having trained himself in a certain branch of medicine (this training often of quite a short duration), he believes himself on a much higher plane and entitled to higher remuneration for his services. There is no sound reason why the young man who shortly after concluding his internship starts as a pediatrician, or nose-and-throat man, or dermatologist, or any other kind of specialist, should be entitled to fees higher than those of a general practitioner. It may be a simple conjunctivitis, an every-day nasal condition, a healthy infant requiring a routine formula which may take 2 minutes to determine, for which the specialist charges double the amount of what an experienced practitioner charges for half an hour’s general examination of his patient. This by no means applies to the ex- pert, but the average specialist is not an ex- pert ; he is only a practitioner in a limited field. Experts are rare, and should handle only cases referred to them by the practitioner, general or special. In a city of 500.000 popu- lation, one will find hundreds of specialists and hardly a dozen experts. One must admit that the present specialist’s fee, which is charged often not for the nature of his services but for his alleged higher standing, is not justified. (2) The most serious factor contributing to the high cost of medical care is found in use of the latest developments of medical science, requiring often costly procedures in rendering a diagnosis. Various laboratory examinations, including use of x-rays, are often necessary and are at present quite costly. It is true, that more than 20% of patients visiting the physi- cian are suffering from minor ailments and do not need more laboratory tests than the well-equipped practitioner is easily capable of making, but the other 30% constitutes quite a problem to be reckoned with. Complete and repeated blood examinations, blood chemistry tests, gastric radiography series, pyelographs, electrocardiograms, metabolism tests, etc., are at times necessary and often not within the financial possibilities of the patient. It greatly handicaps the medical man who has for his clientele the workingman, the white collar man, and the small tradesman. One can easily understand that the private laboratory, with considerable overhead expense, having but 2 or 3 Wassermanns to do. must charge $5 each, while it would not require much more time and labor to make 20 or 30 similar tests at the rate of $1. The roentgenologist’s charges of $50 to $100 for gastric series are, again, due to big overhead, to time utilized only in part, to the comparatively small number of such cases. The active laboratory working full time could reduce these fees to $10-$20. Here iij a field where the organized County Medical Society might render invaluable ser- vices to the community and its practitioners by establishing a completely equipped labora- tory, to be run on business principles, on a pay basis, with charges commensurate with the pa- tient’s financial standing, compensating ade- quately all professional workers, and paying interest on the invested capital but without further profits. By engaging an adequate number of technicians and a competent staff of scientific physicians, such a laboratory could serve the needs of the whole county and to a great extent reduce the cost of all laboratory examinations. The writer feels that such a scheme, rather March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 241 than antagonizing the group of laboratory men, might meet with their approval and co- operation. It is not at all unlikely that they would be glad to close their individual costly laboratories ; glad to be relieved of high rents, large investment in equipment, technicians and so forth. All of them, if competent, could easily become connected with such a central professional laboratory. The number of var- ious examinations would increase consider- ably and, in spite of reduced fees for each ex- amination, their aggregate income would not be likely to suffer. Capital for such an under- taking could be raised either among members of the profession, or through some rich men whose interest in such a useful undertaking could be aroused. It is to be expected that by such a scheme, conceived and brought to life by county medical societies, the profession would advance in public esteem. (3) High cost of hospitalization. It is a fact that the demand for hospitalization has in the past decade considerably increased, partly due to better equipment of the hospitals and more complicated methods of diagnosis, partly to the change in living conditions of the popula- tion. But it is also a fact that the cost of hos- pital care has risen beyond the general rise in other commodities. There are large new hos- pitals where the patient, paying $5, $6 and even $7 per day, is classified as semi-private; meaning that the total expenses of his main- tenance therein are not fully borne by him. And, at that, he is charged separately for laboratory examinations, use of operating room, anesthesia, and so forth. If one con- siders that on one hand all the patient gets for his money is a bed. limited food and or- dinary nursing, often far from adequate; and that, on the other hand, the hospital has no rent to pay, no interest on investment (as all this is supplied by public funds), and no taxes, the high cost of maintenance appears puzzling. It might be because of a tendency of over- expansion, recently in vogue, or due to the fact that general hospitals are being built on the style of luxurious first class hotels, with large amount of space wasted, too many richly outfitted private rooms that are often vacant, and too large an office force. One has a feeling that the same hospital which runs up a yearly deficit, might, in private hands pay dividends while rendering the same kind of service. This high cost can hardly be ex- plained by the number of free patients, be- cause this number in our private hospitals is not so large, and besides, the hospitals are being paid for the care of indigent patients by municipalities, counties and, in our city, by considerable allotments from the Welfare Fed- eration. There is a growing tendency among hos- pital executives to advocate “big business" methods in hospital management. The writer is opposed to these tendencies. He cannot see how hospitals can be compared with industrial productive plants or distributing agencies. Methods in hospital management must be dif- ferent, must be individualistic and humani- tarian. It may be perfectly proper for a hotel to refuse accommodations to a patron unable to pay the fixed rates, but it is not so when a hospital refuses admission to a patient in need of hospital care, who cannot afford to pay more than $3 per day, on the ground that all the $3 beds are occupied, while there are a number of higher-priced beds vacant. This is an every-day occurrence and is likely to be the source of discontent and bad feeling toward the hospital and the profession. One is aware of the complexity of this hos- pital problem, [t is this complexity which is likely to have brought about the organization of the “Committee on Cost of Medical Care”. It is up to the county and state societies to de- termine whether they are willing to wait for a report of this committee or to take the matter in their own hands and appoint their own local investigating committees. And yet, with all the adjustments which are within the power of the organized profession, and which to a great extent are likely to allay the existing unrest among people and various agencies, and will increase the good-will and respect toward the profession, one realizes that the whole problem of sickness cannot be easily solved. There are other aspects, requir- ing broader public measures. Sickness will still remain a frequent emergency with which the average wage worker, small salaried man, 242 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 small business man, will be unable to cope if left entirely to his own resources. Sickness al- ways was, even with the lowest cost of medi- cal care or with no cost at all, the greatest factor in causing destitution and pauperism. The principle of Health Insurance in the same degree as it is accepted in fire insurance must be recognized, with the important difference that it should not be left in the hands of profit- making agencies. The state seems to be the logical carrier for a health insurance scheme, and it is likewise logical to expect that the state shall carry part of the financial burden. Various schemes of health insurance exist abroad, and- it is up to our Commonwealth to work out its own plan in accord with our economic status. It is evident that a proper health insurance scheme will greatly change medical practice. There would not be any more the great prevailing demand on the medi- cal profession to render free services. It would cease to pauperize the people who crowd the innumerable dispensaries. It would decrease the demand for free beds in the hospitals, and the profession, which will be paid for its services by a greater number of people, will be in a position to charge lesser fees to the rich and middle class. Wasn’t this aspect admir- ably brought out by Dr. Linn Emerson in the August number of our Journal? The writer is not an economist, and he has no intention to go any further than to express his faith in the principle. Does state health in- surance necessarily imply state medicine? We believe not. There does not seem to be suffi- cient reason why state health insurance may not be compatible with individualistic medi- cine, regulated by better organized county so- cieties. The state insurance fund might ex- ercise its legitimate control over expenditures through aid of these county societies. To conclude this possibly too lengthy dis- course, I wish to say that it was stimulated by the aforementioned essayists. Like our edi- tor, Dr. Reik, I am tempted to quote the statement by Dr. McBrayer “that every unit of our organization and every member there- of should familiarize himself with the trend of things that affect in any way, either for good or for evil, the practice of medicine”. And let us not talk generalities, which are not get- ting us anywhere, but discuss real, every-day conditions, even if they do affect one or other groups of the profession. Let us be candid in appraising values, as well as in finding faults. The writer hopes to be forgiven for dissenting from the others with regard to the much dis- cussed plan of our Dr. Harris. No one will be more happy than he if this plan will stand a real test in any large community. And, I wish to call the attention of our county so- cieties to the suggested Laboratory Scheme, which to its author, at least, looks practical and worth the efforts necessary to its realization. DE PROFUNDIS By Rollo de Caen Out of the depths have I cried unto Thee: “Lord, hear my cry!” The answer comes in the smile of a friend Passing nigh. Out of the depths have I cried unto Thee: “Lord, still my wo!” The answer comes in the voice of a friend, Comforting, low. Out of the depths have I cried unto Thee: “Lord, heal my pain!” The answer comes in the tears of a friend, Sympathy’s rain. Out of the depths have I cried unto Thee: “Lord, make me strong!” The hand of a friend is laid on mine, Clasping it long. Out of the depths have I cried unto Thee: “Clear Thou my doubt!” The answer comes in the faith of friends, Encamping about. — The Homiletic Review, New York. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 243 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J. Entered at the post office at Orange, N. J., as second-class matter PUBLICATION COMMITTEE HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J. EDITOR: HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J. Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to receive the paper will confer a favor by notifying the Chairman of tie Publication Committee of the fact. NOTE. — The transaction of business will be expedited, and prompt attention secured if: All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to The Editor, Atlantic City, N. J. All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements, or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication Committee, (address above), Newark, N. J. CONTROL OF SPECIALISM Repeated appearance in legislative halls of the Act to Control Practice of Surgery and the Surgical Specialties suggests the advisa- bility of giving that question more serious con- sideration than it has yet received within our professional ranks. We were fortunate this year, in so far as legislative course of the Act was concerned, in having it blocked at the very entrance to the Legislature but we cannot count upon always having such an interested and capable friend on guard in the Senate, and we should not throw the whole burden of defense upon our friends in Tren- ton. If there exists any material abuse of practice in the surgical field it is our duty to ascertain the character and extent of such abuse and to correct any discovered faults, so that the people will have no need for recourse to legislation. This is by no means a local problem. It is being considered not only in New Jersey and neighboring states but even in foreign coun- tries. The French Academy of Medicine adopted last year a series of regulations quite similar to the requirements for a surgeon’s license set forth in the legislation then pro- posed here. At this very moment the Royal College of Surgeons of England is preparing a fellowship examination to which surgeons in Australia will shortly be submitted as part of the plan for establishing another branch of the College, and those candidates for fellow- ship are expected to subscribe to a set of rules which include the following : “ ( 1 ) The patient, or the person legally re- sponsible for him, must consent in the choice made of a surgeon to perform the operation. It is to be noted that such a consent would be an essential factor in the successful suit by a surgeon for the recovery of his fee. (2) Having been selected by the patient, the surgeon is personally responsible to him for the operation. He is also responsible for, and shall conduct, the postoperative treatment, ex- cept by special arrangement with the patient. (3) The surgeon must render his account direct to the patient. (4) The surgeon must not accept his fee for an operation from the practitioner in charge of the patient, unless the surgeon forwards a re- ceipt for the fee received direct to the patient. (5) If circumstances compel the surgeon to delegate the postoperative treatment of a pa- tient to another practitioner, the latter must collect the fee for so doing direct from the pa- tient. The surgeon must not pay the prac- titioner in charge of the patient a fee for con- ducting the postoperative treatment. (6) Separate accounts for the assistant, anesthetist or other necessary services must be sent to the patient, or the surgeon must state on his account form the exact amounts due for these services. (7) The assistant’s standard fee shall be not more than one-eighth of the operation fee. 244 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 or, alternatively, nor more than 5 guineas ($25). When, owing to special circumstances, the assitant’s fee is larger than this amount, the assistant must render his own account on his own account form. (8) The anesthetist’s standard fee shall not be more than one-eighth of the operation fee, or alternatively, not more than 5 guineas. When, owing to special circumstances, the an- esthetist’s fee is larger than this amount, the anesthetist must render his own account on his own account form. (9) It is desirable that the practitioner in charge of the patient should be present at an operation on his patient. Should he have to travel any considerable distance for this pur- pose, the patient must be informed before- hand of the extra fee involved.” It will be observed that the above rules deal mainly with the prevention of fee-splitting , while the French action and the proposed New Jersey law dealt chiefly with the qualifications of surgeons and specialises. As reported in the February Journal, the New York Aca- demy of Medicine has under consideration a plan submitted by its president, Dr. Flartwell, for some degree of control of this matter by special class recognition within the Academy ; the title of “Fellowship” being reserved for such members as can show special qualifica- tion. Another plan, or rather, what appears to be a step on the way toward solving quali- fication by applying the stamp of professional approval, appeared in the January issue of the Journal of the Indiana State Medical Associa- tion ; consisting in publication monthly of the names of all state society members who are Fellows of the American College of Surgeons, or of the American College of Physicians, or who hold certificates from one of the na- tional boards of examination — those now recognized covering ophthalmology, oto- laryngology. and gynecology and obstetrics. None of the plans thus far disclosed com- pletely or even satisfactorily meets the situa- tion. So, for the double purpose of correct- ing any discoverable evils and of preventing or avoiding undesirable legislation, we urge the society to make a deeper study of com- plaints and to formulate a definite plan of action. NEGOTIATING LOANS FOR MEDICAL EXPENSES The persistence of credit agencies in be- seeching our endorsement of schemes for loaning money to patients with which to con- tract for contemplated surgical operations or to pay for medical services previously render- ed, in other words the application of “instal- ment buying” to the practice of medicine, has caused us to keep an eye open for informa- tion bearing upon this question. None of the schemes so far presented has seemed to us worthy of approval ; even the best of them have held for the practitioner no advantages over means of collection already at his com- mand, and seemed to hold for the patient only another means of borrowing money to pay for things he could not afford. The national committee engaged in study- ing the cost of medical care has recently issued a pamphlet covering an investigation of “the use of small loans for medical expenses”, which gives us some new light on this kind of borrowing. Among the facts deduced by the investigation are: (1) That 28 persons out of every 100 who borrow from small loan companies do so because of expenditures as- sociated with or growing out of sickness. (2) Interest rates on such loans vary from 12% to 42% per annum. The high cost of such loans is certainly not conducive to a lessening of the high cost of medical care, and physicians should not, for other good and sufficient rea- sons, encourage the financial victimizing of their patients by usurious interest charges. Information was obtained from 271 loan agencies located in 135 different cities in 21 different states; incidentally, from 29 agencies in 23 cities in New Jersey. It is interesting to learn that in New Jersey those who gave “medical expenses” as the chief reason for borrowing formed only 11% of the whole number of borrowers, as contrasted with an average of 28% in all the states studied ; and, that our 11% was the lowest, and most favor- able, score of any state examined. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 245 LEGISLATION IN THE MAKING As we go to press this month the General Assembly of New Jersey, session of 1931, is just entering upon the stage of enacting a series of new laws. Under a new plan of pro- cedure, tried out in some measure last year, a date was set for terminating the “open sea- son" for introduction of new Bills — a date later than which no Bills could be introduced save by unanimous consent — and legislators took a recess of 2 weeks’ duration for study of newly proposed measures, and to afford citizens an opportunity to do the same. At the session of February 9-10, a great mass of documents was dumped into the hopper ; a total of 672 Bills having been presented to the Senate and House as this year’s contribu- tion of new offerings. In this welter of proposed laws we find the “steady-regulars’’ designed to confer special privileges upon osteopaths' and to create a new group of licensed practitioners to be known as naturopaths ; also the usual number of provisions that would make it mandatory upon the Board to grant special licenses to “pets" of certain statesmen— pets who have found it difficult to comply with the require- ments of existing law. The legislature has more than once rejected each of these pro- posals, and we believe the same fate awaits the present group. That one of the Abell Commission Bills which occasioned the profession some con- cern toward the close of last year’s session — - the proposition to amalgamate into a single bureau 12 of the special Boards of Examina- tion and Licensure — seems to have been dropped ; at least, it has not yet made a re- appearance. IN THIS ISSUE At the last Annual Meeting one of the most valuable program contributions was the sym- posium presented by representatives from the several state departments having to do with medical problems. Taken as a whole they supply a comprehensive picture of medi- cal practice as at present conducted by or under guidance of the state ; and possibly the alliance between the state and the profession is closer and its effects more extensive than many of you supposed. Commissioner Ellis’ paper is particularly illuminating; and the ex- planations given by Director of Health Bowen and one of his chief aides, Dr. Levy, help materially to elucidate the development and progress of public health work. In our travel talk this month we have tried to explain the British National Health Insur- ance Law — the so-called state medicine of Great Britain. As explained there, we are not posing as an advocate of state medicine, not offering even the recently proposed law of the British Medical Association as appli- cable to these United States, but have at- tempted to secure and describe an honest, un- biased report of conditions in England with respect to this question. We do think the time has arrived when medical societies should carefully study the development of state medi- cine in other countries and consider what ac- tion the profession of this state and country should take to prevent, or be prepared to take to counteract, imposition of state medicine in an aggravating form. Next month we shall write of conditions in France. CORRECTIONS In the reported proceedings of the Tristate Medical Conference, February Journal, an er- ror was made by the printer which may have caused some of our readers confusion; what should have been pages 154 and 155 are pub- lished in reverse order. Please make that cor- rection in your copies of the Journal ; i. e., renumber the pages and in some manner di- rect attention to the fact that what was printed on page 155 shall precede what is on page 154. Furthermore, on page 148, near top of first column, the center headline reading “Message in Rehabilitation Work" should read “Mas- sage”— etc. A mistake in spelling the word “rehabilitation” was corrected in proof-read- ing but in the process of resetting the type the printer corrected the first mistake and then made a new one. 246 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 Special Article MEDICAL TRAVEL TALK A Physician’s Vacation in Ireland, England and France Henry O. Reik, M.D., Atlantic City (Continued from February Journal) In preceding letters we promised to submit this month some of the information picked up during the summer regarding the National Health Insurance Act of Great Britain. To re- print in its entirety the original law enacted in 1911 and amendments adopted at various times since, notably in 19 13- ’20- 22 and ’28, together with commentaries upon the working of the law, explanation of the necessity for changes and the effect of such modifications, and then to add even an abstract of the recently pro- posed substitute, would require a great deal of space and might result in confusing rather than clarifying your concept of the situation. \\ e will, therefore, endeavor to digest both the old and the new plan and to present you with the essential facts correlated in such man- ner as to give a comprehensive picture of ex- isting and prospective conditions. In order that our statements shall be as accurate as may be, we shall quote only from official docu- ments : ( 1 ) The Statutes, Regulations and orders relating to National Health Insurance, published for the Ministry of Health, by His Majesty’s Stationery Office, Adastral House, Kingsway, London, 1929. (2) Medical Insur- ance Practice, prepared by R. W. Harris and Leonard S. Sack, and issued by the British Medical Association for the guidance of health insurance practitioners. We need scarcelv ex- plain that the first mentioned book comprises the original law and its amendments, in 133 paragraphs each of which bears marginal an- notations of explanatory nature, and such official regulations as have been found neces- sary in application of the law. The second book is of greater value for our present pur- pose, because it constitutes an interpretation of the law in the light of all that has happened since its inception 19 years ago. In September 1922, Mr. Harris, an Assist- ant Secretary in the Ministry of Health, and Mr. Sack, Barrister-at-Law, both of whom had been associated with the Government’s efforts to apply the Insurance Act and make it workable, joined in writing this “book of ref- erence” so that the insurance physician could have at hand authentic answers to all ques- tions arising in his work. A second edition, made necessary by amendments incorporated into the law, was published by the authors in 1924. Publication of the third edition, in January 1929, was taken over by the British Medical Association, for the benefit of its many interested members, and bears the stamp of that organization’s approval. The preface to this most recent edition was written by the Chairman of the Insurance Acts Committee of the British Medical Association, Dr. H. G. Dain, and the first paragraph reads as fol- lows : “It must to many have seemed amazing that so everyday a matter as the doctoring of a person could have produced or required such a mass of regulations and terms of service, but the present conditions are the outcome of experience and neces- sity. Consideration will show that the need for so complicated a system is brought about in the main when the service rendered by the doctor to the patient is provided and paid for by a third party who is never present when the service is rendered, and by the insistence of the medical profession on the right of every registered medical practitioner to go on the panel, if he wish, and on the right of free choice by both doctor and patient. For these fundamental principles we pay in complicated regu- lation." Half-submerged in that paragraph is a phrase worthy of special attention by those of us who have been fearing the advent of state medicine in this country. Recall the facts that the Association strenuously fought against acceptance of this law and a large proportion of its members refused at first to enroll for service, and then note the present “insistence of the medical profession on the right of every registered medical practitioner to go on the panel, if he wish”; and ponder on the changed attitude. At present the law is limited in application to about 15,000,000 persons — embracing only persons, of either sex, above 16 vr. of age em- ployed in manual labor or in other labor for which the remuneration is not more than £250 ($12501 a year; and a small group of per- sons who because of previous alliance with other health insurance schemes are permitted to hold over as “voluntary contributors” to this plan. The insurance benefit fund is provided through contributions by the insured em- ployees, their employers and the state. In the original scheme the fund was to come — “as to seven-ninths from contributions of the em- ployed person and the employer, and two- ninths from the Exchequer”, but numerous changes have been made as necessity required an increase of the total fund, and consequent increase in the per capita assessment, until at present “a sum of 13 shillings ($3.25) per an- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 247 num is ear-marked by statute for medical benefit (average per person), **** and “the contribution of the Exchequer (toward this 13 shillings) is one-seventh in the case of men and one-fifth in the case of women”. If we study the figures for a fiscal year, which take into consideration interest earnings, etc., it will be seen that each 13 shillings’ item is secured by assessing the employer for one- third, and the insured laborer a trifle less than one-third ; or, in simpler language, the em- ployee secures health insurance at a cost of approximately 4 shillings ($1). Enforcement of the Act is under direction of the Minister of Health, but practically all normal negotiations with the insured are car- ried on through “approved societies” — insur- ance companies, as it were — with whom the Government has contracted to look after such details. The benefits provided for insured persons comprise : (1) Medical treatment and attendance (called “medical benefit”), including proper and sufficient medicines and chemicals as may be prescribed, and surgical dressings and ap- pliances ; but does not include obstetric at- tendance or treatment. (2) Periodic payments while incapable of work because of some disease or bodily or mental disablement, for a period not exceed- ing 26 weeks (called “sickness benefit”). (3) In the event of disease or disablement lasting longer than 26 weeks, payment of a “disablement benefit” during continuance of incapacity for work. As will readily be seen, the above provisions make it necessary that the attending physician shall furnish : ( 1 ) Medical attendance and treatment such as is expected of a general practitioner. (2) The prescribing of proper and suffi- cient remedies. (3) Prescribing or supplying suitable sur- gical dressings and appliances. (4) Keeping of accurate records and fur- nishing if and as required certificates of dis- ablement or incapacity. We may be forgiven for saying at this point that the last mentioned requirement has been the cause of more trouble than all the others combined. Physicians, everywhere, just love what in the army they called paper work. No group of people understands better the neces- sity for and the value of accuracy in small things ; and no group has a greater dislike for the task of making and preserving accurate records. Who mav practice? In theory, at least, this service might have been rendered by full-time salaried medical officers, or it could have been entrusted to specially selected part-time gen- eral practitioners, but, in fact, “Parliament decided to throw this service open to the whole medical profession and accepted the basic principle that every qualified medical practitioner is entitled to treat insured per- sons”, provided that he has not been disquali- fied by misconduct. Any qualified medical practitioner (in ef- fect, that means any member of the British Medical Association in good standing) can share in the insurance practice by merely ex- pressing the wish and signing the roll of The Panel, more formally called “The Medical List”. Here let us again pause for comment. In confiding this work to properly qualified, li- censed, registered physicians, and in other- wise placing all professional matters under control of the regular profession, Parliament and the Health Ministry knocked the props almost completely from under the cults, bur- thermo re, you may have noted that the panel doctor is only required to serve as a general practitioner ; he is not expected or required to act as a specialist in any branch of medicine or surgery. In practice, that pro- vision has helped materially to solve the prob- lems involved in fixing a dividing line between general and special practitioners. The insur- ance Act provides for consultations and for referring patients to surgeons or other special- ists, but as it does not provide payment of panel doctors for work out of their proper sphere they are not tempted to perform any operation except those required by emergency — and small emergency operations are recog- nized and compensated for when properly attested. Selection of Physician. “Every insured person is entitled to medical treatment, within the range of service provided, whenever and wherever required (in Great Britain). The insurance doctors in any area have a collective responsibility for the medical treatment of every insured person in the area who applies for it.’’ As previously indicated, the worker regis- ters with and pays dues to an insurance com- pany.— “approved society” — and receives a card of identity, which card he takes to the physi- cian of his own choice, and, if acceptable to the latter, registers upon that physician’s panel. The chosen physician is, however, entitled to refuse to accept the applicant, and in that event the Insurance Committee will aid the insured person in selection of or assignment to another physician. The only obligatory 1 ac- ceptance of a patient deals with the rendition 248 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 of service in an emergency. There are elabor- ate provisions covering every possible exigency that may arise to disturb the relations of physicians to patients, and in dealing with such problems, as with all other problems as- sociated with application of this law, the medi- cal profession is adequately represented on the committe of adjustment. Limited Size of Lists. “As a limit to the number of insured persons, well and ill, for whose treatment an insurance doctor can undertake responsibility, a maximum of 2500 insured persons is fixed and no single-handed insurance doctor may ordinarily have more than this number on his list. * * * Where 2 or more doctors carry on a practice in partner- ship, any one of the partners may have up to 3000 names on his list, but the average of the lists of all the partners must not exceed 2500.” Keep in mind that the above mentioned figures do not mean 2500 patients; they only mean 2500 persons any of whom may become patients at some time. Save during epidemics, there is rarely more than 1% of such listed persons ill at any given time. Payment for Services. Various methods of payment were considered — such as payment by salary, payment for number of cases treated, payment by a fee system according to char- acter of services rendered — but it was finally decided to pay on a per capita basis of the insured population, well and ill. So, at the beginning of each year the department sets aside a specific fund based upon an estimate by the Government Actuary of the number of insured persons multiplied by the agreed capi- tation fee. The gross fund available for medi- cal service is then apportioned among the counties or boroughs, according to respective proportions of insured persons, and allotted to physicians in accordance with the relative number of persons on the list of each. There is also an apportionment to pharmacists, to cover prescriptions filled and appliances fur- nished, and an additional fund to cover medi- cines and supplies furnished by physicians in areas where pharmacies are not available. The distance a physician may have to travel to care for a patient is also taken into consideration and he receives mileage for all calls beyond a certain distance from his office. It might be expected that incomes from this source would vary considerably, and we as- sume that they do, but we were told that the average income from this insurance work in manufacturing districts, where laborers are naturally congregated in largest numbers, is approximately £1000 ($5000) and that in- comes of £1500 are not uncommon. We can- not vouch for the accuracy of those figures ; they were proffered, in fact, as estimates, or guesses, but by individuals who were or had been in positions that enabled them to make a “reasonable” guess. We can, however, offer some figures from a reliable source and ap- plicable to the entire country. The Eleventh Annual Report of the Min- istry of Health, covering the year 1929, shows that there were 14,000 physicians on the panel, and that they received the sum of $31,250,- 000 in respect of their duties of attending and treating insured persons ; the insurance roll for that year numbering a little over 14,000,000. Those figures would indicate an average of $2232 for each panel physician in the entire country ; not a bad average income from one single line of practice. In addition, the treas- ury reports, for the same period of time: "About $1,000,000 was paid to country doctors on account of mileage, another $1,000,000 was paid to doctors for medicines and appliances supplied by them as part of emergency treatment or dispensed in country districts, and $50,000 was set aside to enable country doctors to attend courses of post- graduate study and to provide them with other de- sirable facilities (maintenance of telephones, motor cars, branch surgeries, or reasonable vacations).” Some details of service. When a physician signifies his willingness to register on the “Medical List”, for health insurance service, he receives along with notice that he has been enrolled a conv of the List of Insurance Phar- macies, a supplv of prescription blanks, record cards, certificates of illness or incapacity, and other regular forms. The general standard of treatment required is that which one would observe in his private practice as a general practitioner. Every formal complaint, or any other formal question arising between a physician and an insured person, is required to be in- vestigated by a body composed of an equal number of medical men and of insured per- sons’ representatives, with an independent chairman — the Medical Service Subcommittee of the Insurance Committee. There is a sub- sequent right of appeal to the Minister. In complaint cases an insured person’s Ap- proved Society may be permitted to assist him in the presentation of his case; the Society itself may be the complainant in certification cases ; but, apart from this, and excepting cer- tain details of certification procedure, you will find that your only relations with Ap- proved Societies are those of an informal na- ture in which the officials communicate with you on behalf of members. Such informal communications are all to the good— partic- ularly where an illiterate member is concerned — if on both sides it is recognized that the communications have no official footing. For purposes of local administration of Medical Benefit, each country is divided into areas, one for every county (in Scotland, March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 249 areas are amalgamated in 2 or 3 instances) and one for every county borough, and in each area there is set up an Insurance Committee, responsible to the Minister, for the adminis- tration of medical benefit within its area. There are also set up in each area: a Local Medical Committee, representative of doctors generally who are resident in the area ; and a Panel Committee, representative of the in- surance doctors who are under agreement with the Insurance Committee. In his relation to insurance doctors, the Minister is placed in a somewhat unusual position. While he is responsible for the spending of public money on the administra- tion of medical benefit, he has not the cus- tomary powers of selecting the persons by whom the work is to be carried out — every qualified doctor having, as already explained, the right to treat insured persons. The Minister, is, however, entrusted with the responsibility for the issue from time to time of the Regulations, etc., which define the insurance practitioner’s Terms of Service. He must also, in view of his responsibility to Par- liament, have some check on the way in which these doctors carry out their obligations. But the Regulations afford evidence that the Min- ister in the exercise of his powers under the Acts is relying more and more on cooperation of the medical profession, especially where professional questions or professional conduct are at issue. In this connection his main concern must be that the committee coming to discuss mat- ters with him must (1) have the necessary mandate, and (2) if undertakings are given, be in a position to secure that they are carried out. The body which is recognized by the Minister as the representative body is the In- surance Acts Committee of the British Medi-- cal Association, and all questions affecting re- muneration or other Terms of Service for in- surance doctors, have always been made the subject of consultation with this representa- tive body, and Ministerial undertakings have been given that this course will continue to be pursued. Panel Committees are required by the Na- tional Health Insurance Act to be set up, and Insurance Committees are directed to ascertain through these bodies the opinions and wishes of insurance doctors, wherever these are re- quired to be ascertained by the Act or the Regulations. The Panel Committee can require that the Medical Service Subcommittee shall investi- gate any question relating to the administration of Medical Benefit or to the discharge by an insurance doctor of his duties. It has also the duty of adjudicating in cases where there is prima facie evidence of extravagant pre- scribing by a doctor. The scheme of National Health Insurance does not, it will be seen, provide for “specialist services”, i.e., services which are ordinarily beyond the skill or experience of general prac- titioners. Questions of importance, and often of no little difficulty, may, therefore, arise as to whether a particular operation or service which an insured person admittedly required falls within the definition of general prac- titioner treatment quoted above. The Regulations provide that, where a question of this nature arises, it is to be re- ferred to the Local Medical Committee, and if that Committee and the Insurance Com- mittee— on considering the Local Medical Committee’s report — fail to agree, it is to be submitted for decision to 3 Referees, appoint- ed by the Minister, 2 of whom must be doc- tors, the third being a barrister or solicitor in actual practice. Emergency Treatment. In case of an emer- gency the doctor is required to render what- ever services are in the best interests of the patient, having regard to the circumstances. In other words, the test must be solely what treatment, within his capacity, the patient ur- gently requires. Thus, cases of great urgency mav arise, more frequently in country dis- tricts, “where the risk to the patient, through your undertaking an operation which, in other circumstances, would better be left to a specialist, is less than the risk entailed by de- lay”. The general capitation fee, paid for the treatment of insured persons in town and coun- try alike, covers professional services and practice expenses. It therefore includes pay- ment for a certain amount of traveling. Doc- tors who practice among insured persons in rural and semi-rural areas receive an extra payment in connection with work done (1) beyond 2 miles from the doctor’s residence or main surgery, and (2) in districts which pre- sent exceptional traveling difficulties. This extra payment is one which takes account both of the time occupied in traveling and the cost of traveling. Insurance premiums are paid to the doctors in the Insurance Service for every insured person in the country, well and ill, and the remuneration of every practitioner is provided for in the Distribution Scheme for the area in which he practices. “Accordingly, the Regula- tions provide that you must not demand or accept any other payment for giving treatment, within the range of service laid down by the Terms of Service, to any insured person who is on your list, or who represents to you that 250 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 lie is an insured person except by way of deposit, in cases of doubt.” Criticism of existing plan. As already stated, in the beginning, this law was strongly opposed by the medical profession. Nearly all physicians looked upon it as an unwarranted interference with their legally established pro- fessional and business rights, and many de- nounced the general plan as a socialistic ex- periment fore-doomed to failure. Prediction was made that if it should happen to succeed to a recognizable degree it would, nevertheless, prove detrimental to the public and degrading to participating physicians; these dire prophe- cies being based upon the fear, or expectation, that the service rendered could not or would not be up to standard, and that through such a lowering of professional service physicians would themselves deteriorate. There was even talk of a “strike” — of medical men refusing to have anything to do with this new form of “contract practice”. Well, like many other horrors, these were disposed of with less difficulty than had been anticipated. Sober second thought must have convinced many objectors that (1) the oft- repeated experiment of holding back the tides with a broom had never yet succeeded, and (2) that their fears of professional deteriora- tion— in practice and in reflex effect — were not flattering to themselves. At any rate, 14,- 000 physicians in England, Scotland and Wales are now “on the panel”, and our inquiry as to how the organized profession now feels about it brought the response that: “If sub- mitted to the British Medical Association for a vote, the question of supporting the present health insurance law or having it abolished would bring out a tremendous majority in favor of existing conditions, because it has benefited both public and the profession.” In recent years criticism has taken the form mainly of charges that some bad results have accrued, or may yet develop. For instance: excessive prescribing of extravagantly expen- sive drugs; malingering, encouraged by doc- tors who may be too easily induced to sign certificates of disability or incapacitation ; repetition of the fear that the profession will ultimately suffer a slump in scientific output as an indirect result of slothfulness that some consider a natural development among those engaged in contract practice or institutional work. We sought factual information upon those points. There have been many instances of malingering and some cases of certificate falsi- fication and of improper prescribing. There is some evidence that malingering exists among the insured ( especially among married women under 45 years of age) to a greater extent than among people of the same class in other comparable countries or in Great Britain prior to enactment of the insurance law. Advocates of the insurance scheme are, however, quick to point out that all the above mentioned com- plaints and objections are criticisms of human nature rather than of the law; that the bad re- sults, where proved, are due to moral defects and obliquities on the part of some patients or some physicians, and do not constitute any more serious criticism of this law than do evasions of other laws justify their condemna- tion. Inquiry through medical channels elicits, as might be anticipated, the prompt denial of pro- fessional abuses on any large scale ; admit- ting that a few panel physicians have been guilty of aiding and abetting malingerers, and of abusing prescription privileges, it is claim- ed that the total number of such transgressors constitutes but a small percentage of the whole number of panel doctors. Honest panel physi- cians also point out the fact that moral delin- quency is not an unknown occurrence among physicians engaged solely in private practice. In so far as the medical profession is con- cerned we may safely conclude that the per- centage of wicked physicians is not higher among those engaged in state medicine than among those occupied with private practice alone ; that the number and the percentage of wicked workers in either group is very small; and that such abuses of the law as have grown out of too great complacency on the part of physicians — •'whether to favor patients or pharmacists — are reflections upon human character rather than justifiable criticisms of the law. There is apparently mighty little complaint in England as to the quality of service render- ed by panel doctors; and that is not only what we would expect but speaks well for the honor of our profession. The people appear to be satisfied ; the Government seems to be satis- fied ; in fact, the opinion seems to be gen- eral that the class of people insured is now better cared for medically than ever before, and that physicians are now paid for services which formerly they were compelled to ren- der mostly on a charity basis. The intimation that physicians, as a group, will render a lower grade of service to panel than to private patients, and the fear that any considerable number of physicians will lose in- terest in medical science just because they happen to be engaged in what somebody has called wholesale, as compared to retail, prac- tice, are propositions that seem to us unworthy of discussion ; indeed, they can hardly be dis- cussed without first accepting fundamentally the implication that the medical profession is March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 251 composed largely, if not in the main, of greedy, grasping, reward-seeking individuals who base the quality of their service upon the amount of pay to be derived and who have no other interest than a selfish financial one in the progressive development of themselves and their science — and those are allegations that all history denies. Control of excessive or extravagant pre- scribing, and of improper certification of ill- ness or incapacity to work, is to a certain ex- tent in the hands of our profession’s represen- tatives upon the various committees executing the law and in the British Medical Associa- tion. The extent of malingering is in a manner indicated in the Health Ministry’s Annual Re- port previously referred to : “The number of references to regional medical officers for advice as to incapacity for work in 1929 was 410,903 (408,934 from approved societies, 1079 from insurance doctors, and 890 from insurance committees). Of these references 133,707 (or 33%) related to men and 277,196 (or 67%) to women. The number of persons actually examined on ‘in- capacity references was , 211, 634. The number who declared themselves off the funds before the date fixed for examination was 109,661, and 89,750 failed to attend for other reasons. Of the persons ex- amined 143,898 were reported as incapable and 67,- 736 as not incapable of work.” The above figures show that practically one- half (49%) of all malingerers who carried their claims to the point of demanding a certi- ficate of incapacity were eliminated by the ex- pedient of requiring submission of the ques- tion to a referee. Of the number submitting to reference examination, approximately two- thirds were found to be actually incapacitated and one-third to be malingerers ; which, in turn, indicates that only about 35% of the original claimants was sustained, and 65% was weeded out. Before leaving this portion of our letter — this summary of such facts as we were able to glean from a cursory study of the law oper- ating in Great Britain — let us say emphatically that we have not attempted nor meant to ad- vocate, or argue in favor of, establishment of so-called state medicine here. We have tried to ascertain the facts concerning national health insurance in Great Britain and to pre- sent those facts in logical sequence and in an unprejudiced manner; at the same time pre- senting such answers as were vouchsafed us with reference to criticisms. We confess to having been aggravated many times by state- ments published in various American medical journals — statements which we felt certain were misrepresentations, or unjust charges, or unfair deductions and inferences — and it is possible that we have exhibited the reaction effect of such an influence. It is difficult, for us at least, to present any debatable question with absolutely perfect impartiality. Herein, we have tried to present both the facts and the explanations without bias, even when em- phasis seemed necessary, but we have been conscious, too, of a feeling that the facts, in their strongest form, had best be faced. If there is either a threat or a natural prospect of state medicine coming soon for consideration here in New Jersey, or in any of these United States, we cannot afford to blink the facts; and in our humble opinion the wisest prepara- tion for dealing with the problem consists in first learning all we can about the experiences of other countries. Stand of ti-ie British Medical Associa- tion as Regards the Future Whatever opposition the British National Health Insurance Act encountered in the begin- ning, and whatever criticism may be directed at it now, it is a noteworthy fact that the Brit- ish Medical Association has recently submitted to the Government a proposal to extend that law — with slight modifications — to embrace the entire populace and to cover medical practice in all its varied aspects. The proposed plan in- cludes preventive as well as curative medical service ; treatment by specialists as well as by general practitioners ; hospitalization and con- valescent provisions as necessary ; auxiliary service in the line of radiography, electro- therapy, physiotherapy, hydrotherapy and massage ; mental disease institutions and ma- ternity homes; infant welfare and school in- spection ; coordination with public health de- partments ; and all to be available to the in- digent as well as to those who can pay in part or in full for health insurance. It is a thor- oughly comprehensive scheme. And this is the result of 19 years of observation, study and experience on the part of the physicians of Great Britain. If adopted, the plan would not entirely destroy private practice ; while all physicians would be eligible to state practice, none would be forced to take part, and persons desiring to employ private, nonparticipating, practitioners — general or special — would be at liberty to follow their own bent. The single modification of the existing law asked for, in so far as we have discovered, is that provision shall be made for direct contact between patient and physician instead of ne- gotiations through any third party — meaning the “approved society”. “That the interposition of any third party between the doctor and the patient, so far as actual medical attendance is concerned, shall be as limited as possible. In the first place, t1- 2 relations between doctor and patient are 252 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 so intimate that both doctor and patient right- lv resent any outside interference. Such in- terference is bad for the doctor and worse for the patient. It is bad for the doctor because his whole training and the traditions of his profession tend to foster the idea of personal responsibility, and this can be undermined only at the risk of rendering the doctor less efficient. It is worse for the patient, because, ex hypothesi, he or she is a sick person whose cure depends very largely on complete con- fidence in the doctor, and this confidence is built up to a great extent on psychologic fac- tors which are disturbed by the intrusion of outside agencies. The Association pleads on behalf of the poorer section of the community that they should have the same consideration in this matter as is demanded as a matter of course by the more wealthy sections of the community. There is no more reason why any third party should come between the pa- tient and his medical adviser than between the individual and his spiritual adviser. The experience gained from the National Health Insurance system has shown that the interests of the public are best served in any organized medical service by putting as much responsibilty as possible on the doctors giving the service — responsibility, that is, for the quality of the service and for its smooth work- ing. There are no severer critics of delinquent doctors than a body of their own colleagues invested with the control of purely profes- sional affairs. And there is no surer and easier way of securing an efficient service than to enlist the active interest of those whose reputation as a profession is involved in the way in which the-” exercise collective respon- sibility entrusted to them.” In sponsoring the proposition, the Associa- tion further says: “During the past 20 years the attention of the public has been directed more than ever before to the subject of ‘The Health of the People.’ Many factors have led to this increase of attention. The systematic medical inspection and treatment of school children; the National Health Insurance system and the varied experience gained from it, including the striking evidence as to the loss of millions of weeks of work in a year owing to ill health among the insured population; the establish- ment and the activities of the Ministry of Health; the devastating influenza epidemics; the experience gained from the operations of the maternity and child welfare schemes of the local authorities; pub- lic inquiries into different aspects of the question, such as the reports of the Consultative Medical Councils in 1920, the Report of the Royal Com- mission on National Health Insurance in 1926, and, more recently, the inquiries into the subject of maternal mortality; the increasing interest in the subject taken by the press — all these have combined to make the problem of how best to promote the health of the people one of che most interesting and pressing public questions of the day. The British Medical Association, as a body repre- senting the great majority of doctors in this coun- try and in the British Empire, has not been inac- tive all this time. It has indeed, been busily en- gaged in studying in detail various arpects of the question, with the object, first, of eliciting the views of the main body of the profession and then of focusing those views into practical schemes. Many of these sectional schemes have been placed before the Government; some, such as the recent plan for dealing with maternal mortality, have been given wide publicity. The Association now feels itself to be in a position to piece these plans together and to submit to the public a coherent and inclusive scheme of medical service based on a few simple basic principles. This scheme would, it is believed, provide the community with a service available for every class of the population, comprehensive enough to cover the whole field of preventive and curative medicine, and sufficiently elastic to permit of fur- ther developments as these may be found neces- sary. As the Association said in a pamphlet pub- lished in 1918, stating its views as to the way the new Ministry of Health should work: ‘The system of medical provision which the Ministry of Health should seek to establish is one which would give to all who need it every kind of treatment necessary for the cure or alleviation of disease, and would utilize for this purpose every class of medical prac- titioner.’ A comparison of the National Health Insurance system of this country with those of other coun- tries shows that the quality of the service given here is in many ways superior to that of many other countries, and certainly there is a more con- tented service, mainly because the management and control of the purely professional side of the work and the disciplining of the doctors connected with it have been increasingly entrusted to the profession itself.” (To be continued.) Medical Ethics THE PHYSICIAN IN HOLY WRIT John Hammond Bradshaw, M.D., F.A.C.S., Orange, N. J. Every book dealer will tell you that the Bible for many years has been the “best seller ’. To be mentioned over a score of times, in different places, in such a work, and in a generally complimentary way, is an ac- complishment no profession other than medi- cine has achieved. Without entering into the subject of inspiration of the Scriptures, we know that they are classified by scholars as be- longing to the world’s best and oldest litera- ture. The authorship and the first allusion in the Bible to a physician dates back, we may safely say, 10 centuries before Christ. This is found in Genesis 50:11, “* * * and the physi- cians embalmed Israel.” This is not mentioned March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 253 alone because of its antiquity, as 20 centuries before this physicians were known in Egypt. The Bible was an unwritten book at the time of Esculapius. It is gratifying to our pride to be told that Esculapius was the son of Apollo and that Homer mentions the fact that 2 of hi. 3 sons were physicians in the Greek Army at the Siege of Troy, for we like to think of Esculapius as the head of our clan. Of course Hippocrates was a “modern” by comparison. Aside from these reflections, it is inter- esting now to go back to the Bible. II Chronicles 16 \12 : “And Asa in this thirty and ninth year of his reign was diseased in his feet, until his disease was exceeding great: yet in his disease he sought not to the Lord but to the physicians.”- We are naturally elated at the above passage until we are knocked flat by: Job 13:4: “But ye are forgers of lies, ye are all physicians of no value.” Job, you know, was not himself when he said this ; he not only had a most prolific crop of boils, but had been through a stock-market crash. When his friends sweetly told him this was all because the Lord loved him so much, it was more than he could stand, and his doctor’s head was the nearest within reach. Now when we come to leremiah 8:22: “Is there no balm in Gil- ead : is there no physician there ? Why then is not the health of the daughter of my peo- ple recovered?” We know that Jeremiah was growing old. Many a modern, and not very old at that, has raised his voice and reached out his hand for some “balm in Gilead”. It is the cry of the world, and antedates even Jeremiah. There may be other references to physi- cians in the Old Testament, but the writer has overlooked them. Our Lord mentions physicians many times. Our calling him “The Great Physician” con- fers honor upon ourselves. Matthew 9:12: “But when Jesus heard that, he said unto them, They that be whole need not a physician, but they that are sick.” The philosophic truth of this statement being so apparent, we aie quite likely to miss its ab- solute profundity. Here is a passage especially built for the gynecologists : Mark 5 : 25-26 : “And a certain woman, which had an issue of blood 12 years, “And had suffered many things of many physicians, and had spent all that she had, and was nothing bettered, but rather grew worse. . .” But this does not refer to modern times or modern physicians, although we must admit that a certain part of this passage is a little pointed. Here is an interesting verse: Luke 4:23: “And he said unto them, Ye will surely say unto me this proverb, Physi- cian, heal thyself : whatsoever we have heard done in Capernaum, do also here in thy coun- try.” It would be a good thing if we all could take this verse to heart. The trouble is, how- . ever, that we do not think zve need to be healed! Here is a passage so often quoted, it is good to know its source: Colossians 4:14: “Luke, the beloved physi- cian, and Demas, greet you.” It is well to close this short article with a few verses from Ecclesiasticus 38, the poetic beauty of which is acknowledged by all. Ecclesiasticus 38: 1. Honour the physician for the need thou hast of him : for the most High hath created him. 2. For all healing is from God, and he shall receive gifts of the king. 3. The skill of the physician shall lift up his head, and in the sight of great men he shall be praised. 4. The most High hath created medicines out of the earth, and a wise man will not abhor them. 5. Was not bitter water made sweet with wood ? 6. The virtue of these things is come to the knowledge of men, and the most High hath given knowledge to men, that he may be honored in his wonders. 7. By these he shall cure and shall allay their pains, and of these the apothecary shall make sweet confections, and shall make up ointments of health, and of his works there shall be no end. 8. For the peace of God is over all the face of the earth. 9. My son, in thy sickness neglect not thy- self * * *. 11. * * * then give place to the physician. 12. For the Lord created him: and let him not depart from thee, for his works are neces- sary. 13. For there is a time when thou must fall into their hands: 14. And they shall beseech the Lord, that he would prosper what they give for ease and remedy * * *. 254 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 Esthetics APPRECIATION OF GOOD MUSIC America’s Orchestra Abroad (Editorial in N. Y. Herald-Tribune, June 5, 1930) It was Nietzsche, that mystic realist, who declaied, with an audacity which the wise will not too hastily rebuke, that “we have our highest dignity as works of art, since it is only as esthetic phenomena that existence and the "oi Id ai e eternally justified . Not many Europeans have been willing to credit mod- ern American civilization with the distinction of illustrating that profound truth. Ameri- cans, indeed, have somewhat uneasily sus- pected that their civilization is misprized by Europeans chiefly because of its supposed em- phasis upon other things than the dignity and beauty of life. I his estimate of the measure of American enlightenment may have been subjected to a process of revision in the minds of thought- ful foreigners by consideration of the remark- able European tour which the Philharmonic Symphony Oichestra, of New York, under the direction of Arturo Toscanini, has just concluded. That tour, which carried the old- est of American orchestras and its illustrious conductor over the length and breadth of the Continent to a resounding finale in London, has been made to an accompaniment of ponu- lar and critical acclaim unprecedented in the history of musical tournees accomplished with- out benefit of jazz bands, prima donnas, 01- tenors excitingly equipped with high Cs. For the Philharmonic Symphony’s tour, let it be remembered, placed no dependence upon sen- sational appeal. Ihere was nothing sen- sational about it save musical excellence. The attraction , as professional showmen would call it, was merely an orchestra of consum- mate quality, playing standard concert works, under a conductor who is the personification of esthetic simplicity, sincerity and high-mind- edness. And what hoped-for recompense can have been in the minds of those reckless American Maecenases who sponsored the formidable un- dertaking? Surely nothing more alluring than the certainty of being out of pocket some hundreds of thousands of dollars; nothing more tangibly rewarding than the possibility of suggesting to an Old World racked and discordant that in place of those “dark say- ings in a thousand tongues” which have long confused it, the New World was prepared to speak to it in the tongue of an ideal confra- ternity— in that transcendent form of human utterance which is essentially, as one of the greatest of music-makers knew and said, only a means by which one may talk with one’s fellows”. Collateral Reading ON AN ANTHOLOGY OF CHESTNUTS By the Shop Philosopher (The Kalends of The Williams & Wilkins Co.) Insufficient attention has been given by the literati to the lowly chestnut. It is too hastily dismissed as a trivial and unworthy form of literary expression, the mere plaything of raconteurs, particularly those of small skill who nevertheless view what skill they have with complacence, or of desperate editors of the scissor variety, the exigencies of whose office compels them to leave no glaring hiatus in their columns. The chestnut is good only for a passing smile, a quick guffaw — that is the casual view ; a view I venture to believe, which offers opportunity for revision upward. For observe you this : the chestnut is a true exemplar of folk-lore ; folk-lore in the mak- ing. It is impossible to trace authorship. Chestnuts spring full panoplied from some mysterious splitting of the rocks. They emerge 1 rom the hodge-podge of hurrying human atoms, particles thrown off from the boiling pot of social interactions, products not of one im- agination but of many, having phvlogenesis rather than ontogenesis. And while by far the greater portion of this spontaneous ex- ciement must of necessity be wholly dross, a modicum of precious metal is also found. Now being distilled of human life itself, it follows that the chestnut (when it rises above mere wise-cracking, when it is genuine and not an imitation strained after by one under the compulsion of filling a minute of time or an inch of space) at the very least must cap- ture some tidbit of human nature; and at the most may come close to a sublime summation of the whole of it. For so-called nonsense is tar more likely to be profound than are the gaunt vaporings of those with the presumption to match wits with the infinite. So, I hope that some scholar, with the requisite balance of scientific thoroughness and poetic intuition, will give the world an anthology of chestnuts. It is a far more reasonable undertaking and far more likely to be fruitful than Dr. Wil- stach’s compilation of metaphors. It is unnecessary to say that the anthology must represent something other than one in- dividual s idea of what is funny. Imprimis March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 255 the stories must be chestnuts. The good story, new last week, may not have staying qualities. Each must demonstrate its validity by its vi- tality. For that vitality demonstrates that at least the anecdote has found a responsive chord in many bosoms ; the presumption is raised that it belongs to the warp and woof of the human fabric. That presumption must be tested against the compiler’s intuitions and ex- perience ; for the carefully selected chestnut must have the human quality. Then it must have subtlety and the flavor of the epigram. And finally, of course, it must have true ele- r.: jnts of humor — indirection, incongruity, surprise or any like factor which titillates the risibilities. As a beginning, hardly more than a hint, a few candidates for admission are appended. The teacher picked on Johnny to demand, “What is the shape of the earth?” “Round”, said Johnny promptly. “How do you know?” — explosively, “Oh, all right, it’s square then.” Hay the tribe of Johnny increase! And may the tribe of those wretches who forever are challenging our faiths, opinions and prefer- ences, who forever are scheming to “sell us the idea”, who forever are laying traps for us, causing us to commit ourselves that they may smackingly show us how mistaken we are, burn forever in a specially constructed hell where they will be slowly argued, debated and talked to a crisp ! Zeke was a country boy, and ambitious. He decided to study law. Preliminaries arranged, he left home on a Monday. He returned the following Friday. “ ’Lo, Zeke”, an acquaintance hailed, “How do you like the law?” “Don’t like it” said Zeke positively. “I’m sorry now I learnt it.” This is a study in intonation. The night be- fore an engagement the Irish sergeant en- deavored to inspire his men. He explained what was to take place. Then ensued this colloquy : “Bhoys, will yez fight or will yez run?” “We will !” “Will what?” “Will not?” “That’s the spirit, bhoys ; I knew yez would.” The eccentricity of the inebriated is a fruit- ful source of chestnuts. Few indeed however have the superb balance of this one: Two are seated in the smoking compart- ment of a Pullman car. Says one, “What time is it?” The other gropes shakily into a waistcoat pocket, discovers his watch, consults it pains- takingly, and announces at length, “ ’S Thurs- day.” “Y’ don’t say!” returns the First Inebriate agitato. “I’ll have to leave you. ’S where I get off.” Speaking of potations, this is the choicest example of morning-after story that has come to my knowledge : The hero wakens in a state of utter physical and mental disrepair, but at least in familiar surroundings. It is his own room and his pet kitten is meandering across the floor. “Great Scott, cat”, moans the sufferer, “don’t stamp your feet so!” That, my friends, is some headache. And I love the absent-minded professor who scratched his pancake and poured syrup down his neck. In the days when the genus taxicab was not so conspicuously marked as at present, a man emerged from a building on lower Broad- way, and finding a car at the curb with a driver, he got into it and directed : “Grand Central Station.” Now it chanced that the car was not for hire ; but the driver, having nothing better to do, fell into the role so unexpectedly assign- ed him and drove his fare in accord with the directions. Arrived at the station the fare said, “What’s the damage?” “Twenty-five cents.” “What? Making a mistake, aren't you?” “No, sir. That’s all we ever get for this trip.” “And that dirty bum yesterday soaked me 2 bucks !” It would take a lengthy essay to elucidate the human nature in that. The proud owner of an ancestral “place” near London was showing a visitor about. In due course they came to the family portraits. “My great uncle” said the host standing before a canvas. And added in that tone of voice which demands that the auditor be awe- struck and break into wordless exclaimings — “Lost a leg at Waterloo.” The Visitor: “Beastly place, Waterloo. Lost me golf-clubs there last week.” It is said that President Lincoln in the first days of his term of office when he was tor- tured with a pertinacious horde of office- seekers, was especially annoyed by 3 par- ticularly importunate ones, who always came to him in a group. Standing one day before a window which commanded a view of the street below, he turned to a vis-a-vis and told this story : “When I was a boy in school the reading lesson was carried forward by using the Bible 256 March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY us a \ chicle. I he practice was for each mem- ber of the class to read a verse in turn. One day we read the story of the burning fiery furnace from the Book of Daniel. To little Ebenezer fell the verse in which first occurred the names of Shadrach, Meshech and Abednego. Eb stumbled on Shadrach, was staggered by Meshech and fell entirely to pieces on Abednego. He was reprimanded by the teacher and promised a spat with a ruler unless he improved. The reading proceeded, almost all the way around the class again. Suddenly Ebenezer broke into noisy tears. The reading was in- terrupted while the teacher endeavored to as- certain the cause of Eb’s lament. Eb pointed to the verse which would, by rotation, fall to him. It contained the fateful names again.” The President paused and called his com- panion to the window indicating the approach of the particularly unwelcome visitors. “What Eb said then is what I say now”, Mr. Lincoln continued, “Here come them same damn 3 fellers.” One of the compensations of the Great War was the number of excellent tales it produced. There was the better ’ole story, as a classic instance, which Bruce Bairnsfather has made immortal. It is certainly no better, however, and I think not so deliciously subtle as the following: ' A company of Tommies was detailed to guard a certain road and ambush a German patrol which was confidently expected. The in- structions were to capture the patrol if pos- sible, to scatter it and disintegrate it as a second choice, but if necessary to annihilate it. The Tommies in general regarded the last alterna- tive as the most certain to accomplish the re- quired end, and set themselves in array ac- cordingly. Midnight came and past. One o’clock. Two. I he patrol was long hours overdue. Three o'clock came; then 4 and still they waited. Finally, a voice, filled with concern, was waft- ed through the inky darkness: “I ’ope as ow nothin’ ’as ’appened to the beggars !” And that reminds me. The surviving con- tingent of the G. A. R. in a western town planned and carried out a successful celebra- tion. It was a large and noteworthy affair and the editor of the local paper produced a special edition in honor of it. On publication he was horrified to discover that in a fervid and sentimental editorial on which he had expended his most flowery rhet- oric an egregious typographic mischance had caused him to allude to “the battle-scored veterans”. Mortified beyond measure he took firm ac- tion to recover every copy of the luckless edition. He sent out boys to canvass the en- tire community, extending their activities into the neighboring country for miles around. He recovered other copies by mail. They became precious and for some he paid as much as a dollar apiece. He ceased not until careful check gave him assurance, as nearly positive as possible, that every copy had been restored and destroyed. Meanwhile, though type had been remelted, ; he set up a corrected edition in its entirety. Extraordinary care was taken. Proof was j carefully read at every stage of production. In particular the editor in person certified ] with each reading that the omitted r which caused all the trouble was in its place. At length the presses were allowed to turn and they turned to some purpose. Once again the special was distributed far and wide. And with a sigh of satisfaction, with the sense of high duty nobly performed, the editor opened his own copy for a loving look. Especially did he look for that unfortunate r. Had anything, at the last moment happened? No, thank God! It was in place ! The line now read, “bottle-scarred” . The Absent Minded Professor This is a true story. Moreover it has a moral. If you smile, don’t do it with self-as- surance. Any one of us may be next. An eminent scientist wrote us that he was constantly discovering, by mere chance, that we had published certain books ; he mention- ed specifically a book — call it A — which he said should have been announced from the housetops. Yet he had to find out who pub- lished it by writing to a colleague. He ordered 2 copies of A as well as 2 copies of B, another book he was much interested in and had discovered only casually. B was not our publication. It was, of course, a polite letter but the inference that we didn’t let folks know about our books was pretty plain. Records indicated that the correspondent received The Kalends, and The Kalends had rather conspicuously referred to A at least 3 times. Records also indicated that an- nouncement of A had been sent to a list on which the correspondent’s name appeared. But that is far from the point. The point is that 3 weeks prior to the writing of his letter, the correspondent had purchased by letter personally signed, 2 copies of A, and a week after that had paid for the 2 copies by personal check. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 257 Lighthouse Observations THE PATIENT WITH HEART DISEASE; CONSIDERED AS A SURGICAL RISK Physicians are often asked whether a particu- lar person can safely undergo an operation, gen- erally with reference to physical ability to with- stand the shock of an anesthetic and the manipu- lation of a major surgical procedure. Butler, Feeney and Levine (Jour. A. M. A., 95; 85, July 12, 1930) have presented us with a review of the case histories of 414 patients who were under ob- servation at the Peter Bent Brigham Hospital, in Boston, or were seen in private practice. None but definite cases of organic heart disease were in- cluded in the study; 120 cases of valvular heart disease; 138 of so-called chronic myocarditis; 86 of permanent auricular fibrillation; 35 of angina pectoris; 20 of coronary thrombosis; and a few scattered cases of less common cardiac affections. The analysis considers the type of operation per- formed; character of heart lesion and age period of the individuals in each of these groups; the rela- tion of nephritis to the mortality recorded; and the relation of blood pressure to the seriousness of the varying conditions. The study is summar- ized as follows: (1) The 414 patients suffering from heart dis- ease, who underwent 494 operations, were studied in order to determine the risk of operation and the role played by the heart in the outcome. Deaths were divided into unexpected and inevitable. There were 28 unexpected deaths; a mortality of 6.3%. (2) Patients with valvular heart disease; 147 operations were performed on 120 patients; with 3 unexpected deaths — a mortality of 2.1%. (3) Among 138 patients having chronic myocar- ditis, there were 8 unexpected deaths in 167 opera- tions— a mortality of 4.9%; these patients were mostly older persons and tolerated operation well. (4) There were 108 operations performed on 87 patients with auricular fibrillation, with 3 unex- pected deaths — a mortality of 3%. Contrary to the general opinion, the risk of operating on such pa- tients is not great. (5) There were 41 operations performed on 35 patients having angina pectoris, with 3 unexpected deaths — a mortality of 7.7%. There seems to be a slight risk of coronary thrombosis following in the wake of surgical intervention upon patients with angina pectoris. (6) There were 20 operations performed on the same number of patients with coronary throm- bosis; 8 unexpected deaths — a mortality rate of 44.5%. (7) Of patients with syphilitic aortitis, 11 were submitted to 13 operations; with 1 unexpected death. (8) There were 6 patients with paroxysmal tachycardia, 3 of whom had attacks during opera- tion and 3 after operation ; all recovered. (9) There were 50 operations performed on as many patients with congestive heart failure; 7 unexpected deaths- — mortality rate 17.1%. (10) There were 433 operations upon 359 pa- tients having heart disease without nephritis; 20 unexpected deaths — a mortality of 4.9%. Among 61 operations performed on 55 patients having heart disease with nephritis, there were recorded 8 un- expected deaths — a mortality of 14.8%; which well illustrates the increase in risk resulting from the presence of nephritis. (11) Survival of the patient with heart disease is not the only consideration. Conditions for which there are nonoperative palliative methods of treat- ment should not be subjected to surgery when the heart disease is so great that the ultimate life ex- pectancy, at best, is short. (12) In most types of heart disease, the surgical risk is not appreciably greater than in the normal person. In some where the risk would - be great, it may be materially diminished by proper pre- operative diagnosis and therapy. VOCAL CORDS OF METAL Metal vocal cords are restoring the power of speech to persons who have become mute. An artificial larynx which, when attached to the throat, functions in all respects like that of na- ture, is one of the latest products of scientific research, according to a report issued by the En- gineering Foundation. The new artificial larynx, prepared by Dr. R. R. Riesz of the Bell Telephone Laboratories, New York, is a thin metal reed, clamped at one end and free at the other, and can be attached to the windpipe by a rubber tube and coupling pad. When air is expelled from the lungs and direct- ed through this larynx, it sets the metal reed to vibrating, and the speaker, by the ordinary mo- tions of tongue, lips, and throat muscles, trans- forms the vibrations into speech. So complete is the mechanism that by a simple adjustment one can change the pitch of the vi- brations, producing the tones of either a man or a woman. The instrument is thus adapted to use by both sexes. Dr. Riesz (Literary Digest, Nov. 22, 1930.) explains: “Speech sounds in general may be divided into 2 groups. In the first group are placed all the ‘voiced’ sounds, in the production of which the vocal cords play an important part. Vowels, semi- vowels, diphthongs, transitionals, and voiced con- sonants are members of this group. The second group comprises the ‘unvoiced’ sounds, in the pro- duction of which no sound is generated by the vocal cords. The unvoiced sounds in general are produced in the mouth. For the voiced sounds, the source is the larynx; where there is a pair of exceedingly adjustable lips — the vocal cords which during ordinary breathing are drawn out of the way, allowing air to pass freely to and from the lungs. When a person desires to pro- duce a sound, the vocal cords are drawn close to- gether, leaving but a narrow slit between them. As the lungs force a current of air through this slit, the cords vibrate, changing the current of air into a pulsating sound-wave which is modified by the cavities of the throat, mouth, and nose, and emerges as recognizable speech. Instead of a pair of vocal cords, the vibrating element in the artificial larynx is a thin metal reed, clamped at one end and free at the other. One of the metal tubes leading from the artificial larynx is connected by means of a rubber tube and coup- ling pad to the termination of the windpipe on the front of the neck. The user blows air from his lungs through the larynx, setting the metal reed in vibration. This vibration generates a train of sound-waves similar to that generated by the vocal cords of a normal person. The fundamental frequency of sound must be about 125 vibrations per second for a man’s voice and 250 vibrations per second for a woman’s voice. 258 JOURNAL OF THF. MEDICAL SOCIETY OF NEW JERSEY March, 1931 An adjustment is provided for changing the pitch of the larynx so that it can be used by either men or women. The sounds of the unvoiced group are produced by blowing air through the larynx in such man- ner that the metal reed is not thrown into vi- bration. A breathing hole in the side of the instrument enables the user to inhale air into his lungs. This hole he covers by pressure with his thumb when he wishes to speak. By practice, persons can become very proficient at speaking with an artificial larynx, and so be re- stored to the useful normal activities which at- tend the power of speech.” Current Events THE PHYSICIANS’ ECONOMIC CONTRIBU- TION TO THE COMMUNITY (An abstract of the Presidential Address of Charles Gordon Heyd, M.D., to the Medical Society of the County of New York) The Medical Society of the County of New York is dedicated to the proposition that: (1) The fundamental object of medical practice is to provide and make available adequate, effec- tive and efficient medical service at all times for every member of the community, regardless of race, color or creed. (2) Medical service as provided today is in a large measure effective and efficient although not always adequate or available. (3) The payment to physicians for medical ser- vice is not a large item in the so-called cost of medical care, as only about 50% of patients hos- pitalized in general hospitals pay a doctor’s fee. (4) There is no logical reason for believing that the professional item for adequate and effective medical service in the cost of medical care can be materially lessened or reduced; on the contrary, there are many reasons for believing that it will be increased, as it must eventually have added to it a charge for professional services. (5) The doctor is a citizen and must discharge all of his obligations of citizenship the same as any other member of the community. (6) The doctor is entitled to a monetary return (or his labor that is fair and commensurate with his service, training and experience; the fact that the practice of medicine is a profession does not mean that the doctor shall continue to work under a system that is ethically wrong and economically unsound; he must be paid for his services in order to function as a useful and contributing member of society. These postulates present the background for my remarks and serve as an introduction as to what is the economic contribution of physicians to the community. It is claimed by competent statisticians that physicians treat % of the population of the United States free of charge. Since at all times there are 2% of the population incapacitated and about 4% physically impaired, it follows that from 375,000 to 500,000 persons are daily treated with- out charge. If only $2 per person were charged tor treatment, the sum total monetary equivalent lor contributions annually made by physicians in the form of free medical treatment would be $365,- 000,000. If all the medical and quasi-medical foun- dations were consolidated into one organization their entire contribution to society in dollars dur- ing the last 20 years would not equal the annual donation of the physicians of the country. The medical profession may, therefore, justly claim that under the present medicosocial system it stands without a rival in the entire field of medi- cal charity and health philanthropy. In this connection it is interesting to note that only 4,000,000 Americans submit any income tax reports at all and, in 1927, 1,600,000 of these paid no taxes because exemptions exceeded net income. As returns are expected when income reaches $2500 for a married person, or $1500 for a single person, these figures throw a powerful search- light upon the phenomenon of our ability to pay for things. Assuming 27,000,000 heads of families, less than 10% of them had income sufficient to warrant the preparation of a tax return with the expectation of making payment. It follows that with only 43% of the community gainfully em- ployed and 87% of the community receiving less than $2000 a year, no matter how much the cost of medical service can be reduced, it cannot be reduced sufficiently low to allow this large group of persons to pay for medical services out of in- come. One of the fundamental difficulties in consider- ation of the high cost of illness is that the pub- lic has not been educated to realize that a certain sum of money must be expended to keep the human machine in a state of efficiency. There are approximately 450,000 persons passing through the wards of the New York hospitals in a year; practically 1,500,000 other citizens avail themselves of the dispensaries. It is evident that this entire group of people, nearly 2,000,000, makes no provision for paying a physician or for pei iodic visits to the doctor. A very important aspect of the problem is that when sickness ap- pears the cost and expenditure under the present system of payment is an immediate one, forced and made under stress. Out of every 100 who borrow from small loan companies, an average of 28 persons do so because of expenditures aris- ing from illness or death. Interest rates on these loans vary from 12 to 42% per annum, which ma- terially increases the burden of the average wage earner with a family. There is hardly a member of the community who is gainfully employed that would not be able to handle a reasonable professional charge, in keep- ing with his economic position, if the load or charge were spread over a sufficient period of time. It seems inevitable that we must come to some scheme whereby the cost of professional attention, oi even the hospital, might be spread over a sufficient number of months to enable the patient to liquidate his indebtedness and be a self-respect- ing, responsible member of the community. It is not for the best interests of society that such a large body of the population should be remiss in its rightful obligation and obtain medical services free of charge. It is not good public policy to disburse money given or donated, or ex- tracted from the public by taxation, for such wide- spread hospital and medical services. It would be a splendid move in social medical ad- justment (1) to curtain the unrestricted system of gratuitous relief, by excluding those not entitled to gratuitous medical advice; (2) to insist on pay- ment of the medical staff, even those engaged in out-patient work, and the payment of fees by patients in the pay ward and in the consultation departments of voluntary hospitals. March. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 25& If the doctor could be assured of, let us say, a minimal revenue from all the patients that he takes care of he could well afford to permit a re- duction on some percentage of his work. But what is attempted, if one may judge from recent news- paper publications, is to oblige the doctor to con- tinue his free medical service and at the same time accept a reduction in his charges to the pa- tients that he takes care of and who are occupy- ing certain types of rooms which are essentially private hospital accommodations. It .would appear that the time is not far distant when the County Medical Society must decide whether as an organization it shall enter into what may be termed the business of medicine. It is apparent that with our nearly 4000 members we have a sufficient clientele to seriously consider the establishment of an insurance bureau, or even an insurance company. It might also suggest itself that there could be formed and managed under the auspices of the County Medical Society a credit and funding society, a collecting bureau, and we might even go so far as to organize the personnel for the management of clinics. It might be considered the proper function of the Bureau on Publicity of the Medical Society of the County of New Y'ork to devise and draw up a list of zones within the city so that persons in- quiring for competent medical service could be given a list of properly qualified physicians, mem- bers of the County Medical Society residing or practicing within the zone, and to make available to the inquiring public the names of certified specialists residing or practicing in certain desig- nated zones. PRESENT STATUS STATE SOCIETA-RUTGERS’ POST-GRAD- UATE COURSE The committee is offering this year 6 distinct courses from which the county societies may select according to local choice. In each county local committees are working with the State Society Committee and representatives of Rutgers, en- deavoring to meet the desires of each group and to enlist as many students as possible. To us the plans seem very attractive, and we hope our readers will carefully inspect the following syn- opses of lectures and list of exceptionally talented teachers engaged, and then communicate with their own county society committee about sub- scribing. Synopsis of Lectures on Cardiac, Vascular and Renal Diseases Lecture I. Diagnosis from the etiologic, anatomic and physiologic viewpoints. Elementary electro- cardiography. Discussions of cardiac arhythmias. — - Dr. Arthur De Graff. Lecture II. Rheumatic heart disease — Bacterial endocarditis. — Dr. Irving Graef. Lecture III. Thyroid heart disease — Essential hypertension. — Dr. William Goldring. Lecture IV. Syphilitic heart disease — Degenera- tive (arteriosclerotic) type of heart disease. — Dr. De La Chapelle. Lecture V. Heart failure. Types; Clinical Pic- tures; Course; Treatment. — Dr. John C. Wyckoff. Lecture VI. Classification of Bright’s disease — - Urine Sediment count — Kidney in pregnancy (Eclampsia.) — Dr. William Goldring. Lecture VII. Function of normal kidney — Renal insufficiency — Uremia; Kidney function tests. — Dr. Norman Jolliffe. Lecture VIII. Prognosis; clinical course; treat- ment of hypertension and various types' of Bright’s disease. Treatment of uremia. — Dr. Will- iam Goldring. Outline of Newer Therapy Course / Lecture I. Introductory Lecture: (a) Pharma- cology of drugs; (b) scientific methods of study of therapeutic agents; (c) principles of dosage; (d) the place of mixtures in modern drug therapy; (e) rational versus empiric drug therapy; (f) the proprietary drug problem; (g) the Council on Pharmacy and Chemistry; (h) “Useful Drugs” and “New and Nonofficial Remedies”. Lecture II. Diuretics; (a) Newer conceptions of the diuretic action; (b) organic mercurials — novasurol and salyrgan; (c) urea; (d) acid-form- ing diuretics — ammonium chloride; (e) theocin. Lecture III. Circulatory Drugs: (a) Purines — coronary vasodilators; (b) camphor and its deriva- tions— cardiazol; (c) barium chloride; (d) quinidin; (e) drugs for the reduction of blood pressure — • sodium sulphecyanate, cucurbocitrin, bismuth sub- carbonate. Lecture IV. Digitalis. Lecture V. Digitalis, continued. Lecture VI. Hypnotics — analgesics — anesthetics: (a) The barbituric acid group; (b) fixed anesthe- tics; (c) mixed analgesics in labor. Lecture VII. Recent studies in the treatment of anemia: (a) Liver extract; (b) stomach extract; (c) copper. Lecture VIII. Hormones and glandular products: (a) Pituitary; (b) insulin; (c) miscellaneous. Outline of Obstetrics Course Lecture I. Antenatal care: General care; im- portance of cardiovascular -renal systems; pelvi- metry; types of pelvic deformity; border-line con- tractures; forming an estimate of labor. Lecture II. Abortion; miscarriage; placenta pre- via; abrupto placentae; other sources of ante- partum and intrapartum hemorrhage. Lecture III. Obstetric forceps: Indications; contraindications; varieties and special indications for each; manikin demonstration and practice. Lecture IV. Version; breech extraction; mani- kin demonstration and practice. Lecture V. Management of third stage; manage- ment of puerperium; complications of pregnancy; of the puerperium ; labor anesthesia. Lecture VI. Puerperal sepsis. Lecture VII. Toxemias of pregnancy. Lecture VIII. Postpartum gynecology of obstet- rics: Postpartum follow-up; epdocervicitis; cer- vical erosions; uterine displacements; prophylactic and nonoperative treatment. Outline of Pediatrics Course Lecture I. Feeding problems in infancy. A sim- ple practical method, with illustrative cases. — Dr. Charles Hendee Smith or Dr. Gaylord W. Graves. Lecture II. Periodic health examinations and preventive pediatrics. Methods, records and in- structions to parents. Defects foupd. Cases dem- onstrated.— Dr. Gaylord W. Graves or Dr. Jose- phine H. Kenyon. Lecture III. Malnutrition in childhood: Among school and pre-school children. Diagnosis and treatment. Clinical demonstrations. Lantern. — Dr. Hugh Chaplin or Dr. Edward S. Rimer. Lecture IV. Tuberculosis in Childhood. Acute (in infancy) and “infectious” (latent) in older children. Lantern cases. — Dr. Charles Hendee Smith or Dr. Edith M. Lincoln. Lecture V. Heart disease in childhood and oral 260 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 infections. Prevalence, importance, diagnosis, treat- ment, clinical cases. — Dr. Lucy Porter Sutton or Dr. Alfred Langmann. Lecture VI. Differential diagnosis of pulmonary diseases. Pneumonias* empyema, abscess, bron- chiectasis, nilus nodes. With cases. — Dr. Howard H. Mason or Dr. Charles Hendee Smith. Lecture VII. Endocrine disorders and develop- mental defects. Goiter, cretinism, dyspituitarism, thymus, mongolism, dwarfs, mental defects. — Dr. Herbert B. Wilcox or Dr. John B. Caffey. Lecture VIII. Subject and lecturer to be chosen. Four electives of which one may be chosen: (a) Acute disease in childhood; (b) laboratory aids to diagnosis: (c) acute infectious diseases; (d) sensi- tization in childhood. Outline of Course in Gynecology Lecture I. Etiologic significance of prominent gynecologic symptoms. Disorders of development and function; malformations, amenorrhea, dys- menorrhea, intermenstrual pain. Methods of exam- ination. Lecture II. Infections of female pelvic organs; (a) Septic genital infections (non-specific); (b) septic urinary infections; (c) specific infections. Lecture III. Diseases of vulva and urethra. Dis- eases of vagina. Lecture IV. Diseases of uterus: Endometritis; lacerations and displacements. Lecture V. Diseases of uterus continued; tumors. Lecture VI. Diseases of fallopian tubes: Inflam- SCHEDULE OF CLASSES AS ARRANGED TO DATE— FEBRUARY 20 First Lecture Time of Meeting Course Given at Starts Meeting Place' Day Hour Drug Therapy Atlantic City April 1 Atlantic City Hospital Wed. 8:30 p. m. Drug Therapy Trenton April 2 Mercer Hospital Thurs. 8:00 p. m. Gynecology Trenton April 7 St. Francis Hospital Tues. 4:00 p. m. Pediatrics Trenton April 3 Mercer Hospital Fri. 8:00 p. m. Pediatrics Newark Mar. 20 Presbyterian Hospital Fri. 8:45 p. m. Cardiac Newark Mar. 18 Academy of Medicine Wed. 8:45 p. m. Gastro-enterology Newark Mar. 20 Academy of Medicine Fri. 8:45 p. m. Combination course: 4 lectures on Gastro- enterology 4 lectures on cardiac diseases Camden April 1 Camden Dispensary Wed. 4:00 p. m. Combination course : 4 lectures on obstet- rics 4 lectures on gyne- cology Bridgeton April 2 Bridgeton Hospital Thurs. 4:00 p. m. Gastro-enterology Somerville Mar. 16 Somerset Hospital Mon. 8:30 p. m. ♦Gynecology — Combina- tion course Newton Mar. 26 Thurs. 8:30 p. m. General course Mt. Holly Mt. Holly Hospital New Brunswick Combination course 4 lectures on gyne- cology 4 lectures on obstet- rics Hackensack May 1 Hackensack Hospital Fri. 3:30 p. m. Combination course Gastro-enterology — 4 medical and 4 sur- gical Paterson April 3 Health Center Fri. 8:30 p. m. Obstetrics Jersey City April 6 Jersey City Medical Center Mon. 4:00 p. m. Gastro-enterology Jersey City April 4 Jersey City Medical Center Sat. 4:00 p. m. Pediatrics Elizabeth Mar. 18 Elks Club Wed. 8:30 p. m. Gastro-enterology Elizabeth Mar. 19 Elks Club Thurs. 8:30 p. m. REMARKS : ♦There will be a combination course in Newton. Three of the lectures will be on gynecology. The local committee has not decided definitely the subject for the other lectures. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 261 mation, ectopic pregnancy, tumors. Diseases of the ovaries; inflammation and tumors. Lecture VII. Office gynecology. Lecture VIII. Indications for surgical treatment; after treatment of gynecologic operations. Outline of Gastro-Enterology Course Under the direction of Mills Sturtevant, M.D., Clinical Professor of Medicine, New York Univer- sity. Lecture I. Gastro-intestinal symptoms as an ap- proach to diagnosis. Gastric neuroses. Gastric functional diseases. Gastroptosis. Gastric symp- toms in diseases of other organs.— Dr. Mills Stur- tevant. Lecture II. Gall-bladder disease. Liver function tests and their value to the general practitioner. — Dr. Norman Jolliffe. Lecture III. Diseases of the esophagus. — Dr. Robert P. Wallace. Lecture IV. Peptic ulcer: Etiology — pathology — symptomatology — types — diagnosis — roentgen- ology.— Dr. Louis L. Shapiro. Lecture V. Peptic ulcer; medical treatment. — Dr. Mills Sturtevant. Lecture VI. Peptic ulcer; surgical treatment in- cluding perforation and the relation of ulcer to carcinoma.- — Dr. Arthur Wright. Lecture VII. Tumors of the stomach and intes- tines: Diagnosis; pathology; and treatment. — Dr. Irving Graef. Lecture VIII. Diarrhea; constipation; colitis; diagnosis of rectal disease. — Dr. M. P. Cowett. Faculty The lecturers have not been selected for all cen- ters but we can now name some prominent doctors from New York and Philadelphia who will give lectures. In Jersey City, they are using a com- bination of local men with New York personnel. The following doctors have already accepted invi- tations to lecture: Mills Sturtevant, New York Norman Jolliffe, New York Robert P. Wallace, New York Louis L. Shapiro, New York George Stewart, New York Irving Graef, New York M. P. Cowett, New York Wm. Goldring, New York De La Chapelle, New York John C. Wyckoff, New York Arthur Wright, New York Arthur DeGraff ,New York Hai’ry Gold, New York Cary Eggleston, New York Alfred C. Beck, Brooklyn W. E. Caldwell, New York John Osborn Polak, Brooklyn John C. Gittings, Philadelphia W. Wayne Babcock, Philadelphia Charles H. Smith, New York Gaylord W. Graves, New York Josephine H. Kenyon, New York Hugh Chaplin, New York Edward S. Rimer, New York Edith M. Lincoln, New York Lucy Porter Sutton, New York Alfred Langmann, New York Howard H. Mason, New York Herbert B. Wilcox, New York John B. Caffey, New York FIFTH COUNCILLOR DISTRICT MEETING We are informed that an interesting program is in process of development for a joint meeting of all the county medical societies of this district — embracing Atlantic, Cape May, Cumberland, Glou- cester and Salem Counties, to be held in Atlantic City on Friday, April 10. An afternoon session will be devoted to discus- sion of economic problems introduced by distin- guished members of the profession invited because of their knowledge of such matters, and that ses- sion will be followed by a dinner at the Hotel Chal- fonte. An evening session will then convene at the At- lantic City Hospital where an address upon some scientific subject, by Dr. Joseph C. Doane, of Phila- dephia, will be associated with clinical demonstra- tions by members of the hospital staff. It is expected that this district meeting will be well attended. It should be, with such an attrac- tive program. Public Relations DISCLOSURE OF DISEASES UNDER PROHIBITION ACT ABOLISHED (Editorial Jour. A. M. A., Feb. 7, 1931.) Physicians who prescribe liquor need not state on the stubs of their prescriptions the ailments for which it is prescribed. The item on the stubs of outstanding prescription blanks calling for this information may be ignored. When new prescrip- tion blanks are printed, the item calling for such information will be omitted. The Wickersham Commission, in its report released January 20, recommended that physicians prescribing under the National Prohibition Act be no longer required to state on blanks going into the public files the ailments for which prescriptions are given. Two days, later, the Commissioner of Industrial Alcohol issued a circular letter instructing all supervisors of permits under the act that , ailments need no longer be stated on the stubs of prescriptions and directed them to advise the physicians in their several districts to that effect-. Physicians are still required, by the National Prohibition Act itself, to keep in their offices book records of prescrip- tions for liquor, including records of the ailments for which it is prescribed, subject to inspection by prohibition officers. WARNING TO PHYSICIANS (Editorial New England Jour. Med., Dec. 25, 1930.) Most of the physicians of the state, registered under the Harrison Narcotic Law, have no doubt by this time received their warning notice rela- tive to re-registration and payment of special tax on or before July 1 of each year. We trust that all have given due consideration to the second paragraph and have correctly in- terpreted its significance. “Section 9 of the Har- rison Narcotic Law provides that anyone who vio- lates or fails to comply until any of the above re- quirements shall, on conviction, be fined not more than $2000 or be imprisoned not more than 5 years, or both, in the discretion of the court.” The medical profession, it will be seen, under a law of the land of the free and the home of the brave, constitutes a privileged class. It is privi- 262 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 leged to prescribe narcotics on the payment of a special tax which allows it to assume the privilege of bearing the financial burden of narcotic con- trol; its members are given the privilege of languishing in jail, fortunately for a period of not more than 5 years, if by a simple error of omis- sion they should fail to fulfill an imposed obliga- tion on a certain date. Perhaps the court, in its infinite mercy, might not impose the extreme penalty; perhaps incon- venience, indignity and humiliation might be the only penalty involved in a given instance; never- theless the specific penalty is provided by law and to no one is it guaranteed that he will not suffer it if he innocently fails to fulfill the requirements. Here, if ever there was one, is a wrong which needs to be righted. Here is an instance of legis- lation gone awry. A learned profession, a pro- fession which ministers to the needs of others, a profession which has little interest in or aptitude for practical politics must suffer from discrimina- tory legislation of the less intelligent sort. How long must this continue? THE NEW ENGLAND MEDICAL CENTER The New England Medical Journal of February 5, 1931, contains a report of the proceedings at- tendant upon laying the corner-stone of the first of the buildings for this new project. In the same Journal is a letter from Dr. Otis, for many years an eminent teacher and practitioner of medicine in Boston, upon the passing of the country doc- tor and the development of medical centers. These literary contributions bear so directly upon the question we discussed in our issue of last Novem- ber— when we suggested utilization of centrally placed county hospitals, under control of the county medical society, as medical centers — that we take pleasure in presenting abstracts of each for your consideration. “The honor of laying the corner-stone was given to Dr. Merritt H. Eddy, of Middlebury, Vermont, the oldest family doctor in New England. Dr. Eddy came to Boston on his ninety-eighth birthday to take part in these exercises. He is a graduate of the University of- Vermont College of Medicine (class of 1865) and for 65 years has been practicing his profession. As it is the purpose of the New England Medical Center to assist in the training of general practitioners for New England, it was eminently fitting that the laying of the corner- stone be done by the oldest living physician in the New England States. After the laying of the corner-stone Dir. Rotch introduced Dr. Alfred Worcester, Professor of Hy- giene at Harvard College, who delivered a short address : 'We old-fashioned country doctors are delighted with the building of this Health Center. For we believe that in it not only will there be larger provision for the sick but also far better facilities for training young doctors to be general prac- titioners. Medical science can be learned from lectures and books and in the laboratories. But the art of medical practice, like every other art, can be learn- ed only by imitation, that is, only by apprentice- ship under masters of the art. The Boston Dis- pensary has always afforded such opportunities to medical students. Indeed in its earliest years, be- fore there were any hospitals in this part of the country, this was the only place where group teaching of medical students was possible. Nearly a half century ago I myself learned more here than in any other clinic. We old general practitioners have for many years been fearing that in the marvelous advance of medical science the art of practice is being lost. But this need not happen. Specialists we must have for no one can now, as formerly, be equally pro- ficient in all branches of medical practice. And although in some of the specialties master of the art of practice is not so indispensable as it is to the general practitioner, yet in every one of the specialties medical students can be taught and ought to be taught how to treat the patient him- self while learning how to treat his disease. However great the need may be for specialists the greater need just now is for general practition- ers, who. answering every call by either night or day, will do all they possibly can for the relief of the sick and suffering. Such doctors must know at least enough of the specialties to summon the aid of specialists when such service is needed. They must also know enough for emergency service when there is no time to lose, and when so far away as to make the summons of a specialist prac- tically impossible. For, as ought to be more gen- erally known, in many emergencies the patient has better chances from early, even if somewhat crude, service than later he would have from the service of the most expert. In this new Health Center, as we confidently believe, it will be possible to give future medical students just the kind of training needed for gen- eral practice.’’ The following message is from the letter of Ed- ward O. Otis, M.D., Emeritus Professor Tufts Col- lege Medical School: “In a recent memorial to a very worthy coun- try doctor in Vermont occurs this significant state- ment: ‘There is no question that “the country doc- tor” is passing.’ If this, as it appears to be, is the case, is there not good reason why this should not happen in the general advance and progress of medical science? I believe that something bet- ter is to take the place of the old-time family practitioner, but I do not believe that it will be accomifiished by trying to replace what we have known as the ‘country doctor’. After a student of medicine has spent 7 to 8 years in preparing him- self for practice, at a large expense of time and money, he will rarely be willing to take up an or- dinary country practice and establish his home in a small community. Furthermore, having been trained at a first-class medical school, he has learned the necessity of near-by facilities of a well-equipped hospital. He knows that he can- not in many cases make an accurate diagnosis without the aid of laboratory and x-ray facilities, and therefore, besides the other reasons, he is un- willing to go into the country where these facili- ties are not readily available. In my service as teacher at the Tufts College Medical School for the last 25 years, I have met many of my old pupils in different parts of the country, but I have found few who have settled as country doc- tors. Therefore, in the march of time and progress, it will not avail much to look ‘mournfully upon the past’ of the country doctor, but to see how his place can be better filled through better knowl- edge of medical science and treatment. Many sug- gestions have been offered; the first requisite is to supply everyone, rich and poor alike, with mod- ern medical service. This, it seems to me, might be done through smaller medical centers through- out New England, at which centers there should be a well-equipped hospital with a lying-in depart- ment and with a high-grade personnel. Such a center could easily, it seems to me, serve an area within a radius of 10 or 15 miles through the pres- ent system of good roads, the automobile and tele- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 263 phone. Doubtless other plans of affording ade- quate medical service to everyone can be sug- gested— but one thing seems evident to the observ- ant modern physician, and that is that the country doctor as he existed previously is fast passing and times and conditions have changed. It is well that it is so — although we take off our hats to him as he passes with bowed shoulders but head erect.” ANNOUNCEMENT OF THE FIRST AWARD UNDER THE THOMAS W. SALMON MEMORIAL Dr. Adolf Meyer, Professor of Psychiatry, Johns Hopkins LTniversity-, has been chosen to receive the first award under the recently established Thomas W. Salmon Memorial. Announcement to this effect was made Saturday, January 10, at a meeting held at the New York Academy of Medi- cine at which an endowment fund of $100,000 contributed by friends and associates of the late Dr. Salmon was officially presented to the Academy and active work under the Memorial was begun. The award was made by a committee appointed by the Academy to survey the field and select the outstanding contributor to scientific advance in mental medicine, and Dr. Meyer was selected in recognition of his distinguished services to psychi- atry and mental hygiene over a period of years. The award carries with it an honorarium of $2500 and the recipient will give The Thomas W. Sal- mon Lectures during 1931. The dates of the lec- tures and the places at which they are to be de- livered will be announced later. Dr. Meyer is an outstanding man among the psychiatrists of the world and has been for many years a leader in the development of his specialty. A teacher from his earliest days in the United States, his influence on psychiatry expressed through his pupils is well known abroad. Conserva- tive and sound, but with broad vision, and at all times in contact with his anatomic, neurologic, physiologic and psychobiologic laboratories, he has given a powerful stimulus to the building up of a dynamic and progressive conception of psychi- atry. Not generally known is the fact that Dr. Meyer is the man who suggested and first used the term “mental hygiene” and gave the mental hygiene movement its name. By that very naming of this great movement, with which he has been identified from the very beginning, he gave it the initial im- petus and forward-looking, comprehensive pro- gram. He was one of the original organizers of the National Committee for Mental Hygiene, the agency largely responsible for development of the mental hygiene movement in this country and the world over. School Health Department SPECIAL MEETING OF SCHOOL PHYSICIANS Allen G. Ireland, M.D., Director of Physical and Health Education, State Department of Public Instruction, Trenton, N. J. The meeting of school physicians inaugurated last June at the Annual Convention of the State Medical Society will be repeated this year. The day is Wednesday, June 3, in the afternoon. The place is the Berkeley-Carteret Hotel, Asbury Park. Watch this column for further announcements. American Association of School Physicians This infant society, now about 3 years old, is enjoying phenomenal growth. This month it cele- brates the appearance of “The School Physician’s Bulletin”, a neat appearing, promising journal which, hereafter, -will be published monthly. The secretary of the Association is Dr. William A. Howe, of the State Department of Education, Albany, New York. A New Jersey physician, Dr. Brinkerhoff, chief of the medical inspection department of Jersey City schools, is one of the vice-presidents. Notes of Interest Unique Recording and Filing System. The indi- vidual examination record cards of the pupils are filed by classrooms. The guide card has the grade, the teacher’s name, and the summary of the physi- cal defects of the class. Thus, at a glance, one can tell the needs of the group. As a defect is cor- rected, the child’s name is crossed off in red ink. The nurse who devised this system reports it as more satisfactory than the method of having de- fects reported on separate forms. Each time she consults this new file, the existing needs are re- peatedly brought to mind. Weight and Height. The American Child Health Association announces abandonment of its height- weight charts. This is the outcome of an exten- sive research throughout the country with school children. The report is contained in a booklet en- titled “Present Practices in the Light of Research”. The address of the Association is 370 Seventh Avenue, New York City. Crippled Children. “The Crippled Child” is the name of a monthly journal published by “The In- ternational Society for Crippled Children, Inc.”, located at Elyria, Ohio. It is said to be the only magazine published in English on the problems of the crippled child. Mental Hygiene. Dr. Uel W. Larkin, President of the National Education Association, said at its last convention: “Never before has there been so much general interest in safeguarding the men- tal health of school children. It is significant that approximately 20 courses have been introduced into our colleges and universities to train visiting teachers, workers who are equipped with an under- standing of psychology, mental hygiene and social adjustment. The visiting teacher will in time re- place the attendance officer. Instead of maintain- ing a police force to keep children in school, we shall draw them there by the intelligent and friendly guidance of teachers who understand the problems of childhood.” Joint Committee. The Joint Committee on Health Problems of the American Medical Associa- tion and the National Education Association an- nounces the revised edition of its famous report “Health Education”. It is certainly worth having, even better than the 1924 edition which sold to the extent of 75,000 copies. Address the National Education Association at 1201 Sixteenth Street, Washington, D. C. Reports from the Field. This office is receiving glowing accounts of your field secretary’s (Mrs. 264 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 Taneyhill) success in putting over her new talk on mental hygiene. More requests for her ser- vices are coming in than we can meet. It is one more indication of the great interest in mental hygiene. In Lighter Vein Hand Him a Fan Sam, who had just fulfilled a lifetime ambition and bought a fur coat, went strutting down the street. He met a poor friend, shivering with cold, who said : “Say, Sam, it’s pretty cold today, ain’t it?” “Is it?” said Sam, peering out from the depths of his fur collar. “Now, you know, I really haven’t looked at the paper today.”— Wall Street Journal. No Sale Sporting goods salesman (who has talked golf for an hour) : By the way, I don’t know if you are interested in golf. I hope I haven’t been boring you. Girl customer: Not in the least — but tell me, what is golf? — Gocd Hardware. The Planet’s Complaint “What’s wrong with the world, anyway?” asked the first pessimist. “Too much rope is being used for making cigars and not enough to hang gangsters,” growled the other one. — Cincinnati Inquirer. On a Strafing Cruise Mother — “Why ever are you sitting there when you ought to be in bed?” Peter — “There’s a mosquito in my room.” Mother — “It hasn't bitten you, has it, darling?’’ Peter — “No, but it came close enough for me to hear its propeller.” — Humorist (London). Speaking of teamwork we’ve noticed that it’s usually the case when a family is fighting to keep the wolf from the door that the stork takes the opportunity to slip down the chimney. — Ohio State Journal. One doesn’t hear anything about the dangers of kissing any more, so we suppose the educational campaign must have broken up that deadly habit. — Ohio State Journal. “My advice to those who want to live to a good old age,” says a doctor, “is — walk slowly.” Those who follow this advice should take the precaution of keeping to the sidewalk.— The Humorist. Master-Mind The bridegroom was in a poetic frenzy as he strolled along the seashore. “Roll on, thou deep and dark blue ocean, roll”, he recited to his bride. “Oh, Gerald”, she exclaimed, “how wonderful you are. It’s doing it.” — Exchange. Funny Finny Stuff Did you ever stop to think that a fish may go home and lie about the size of the bait he hooked? — Judge. May I Cut In? Friend: Isn’t your youngest son a surgeon? Actor (proudly): Yes; he opens in Bellevue Hos- pital tonight! Woman’s Auxiliary WOMAN’S PART IN MEDICAL HISTORY Some months ago we read, in the New England Medical Journal probably, a suggestion that in paying tribute to those physicians who pioneered in the use of chloroform and ether as anesthetics it might not be amiss to consider the heroism of the first patients who submitted to such anesthesia. Now there comes to our attention the report of a ceremonial in Kentucky, where, at the unveiling of a statute to Dr. Ephraim McDowell, an ap- propriate tribute was paid to his patient on the historic occasion when he performed the first ovariotomy. The Woman’s Auxiliary to the Kentucky Medi- cal Association played an important role on that occasion, and it occurs to us that many similar events might be arranged in our several states by the local auxiliaries — events that would serve at least as acknowledgement of debts long unpaid to men and women patients who served humanity quite as effectively as and perhaps more heroically than the surgeons who devised and performed new operations. We reproduce from the Kentucky Medical Journal of January 1931 an account of the incident to which we have referred. Jane Todd Crawford — The Model Patient* By Mrs. P. E. Blackerby, Past-President Woman’s Auxiliary to the Kentucky State Medi- cal Association, Louisville, Ky. It is peculiarly gratifying to the Woman's Aux- iliaries to the Kentucky State and the Southern Medical Associations that we should have been invited to be represented on this historic occasion when the medical profession is paying its tribute to the memory of Ephraim McDowell, of whom Dr. David W. Yandell, when contrasting the fame of the statesmen, the orators and the military men of Kentucky with that of McDowell, said: “Chief among all of these is he who bears the mark of our guild, Ephraim McDowell ; for the labors of the statesmen will give way to the pitiless logic of events, the voice of the orator grows fainter in the coming ages, and the deeds of the soldier eventually find place only in the library of the students of military campaigns, while the achievements of the village surgeon, like the widening waves of the inviolate sea, shall reach the uttermost shores of time hailed by all civilization as having lessened the suffering and lengthened the span of human life.” In the history of no other state or nation has its medical profession contributed more glorious pages as the record of its service to humanity than have the physicians of Kentucky. Towering among these stands this pioneer surgeon, whose lineaments stand revealed before us by the art of the sculptor, to live forever as a memorial to one of the greatest servants of mankind. It is fitting that this monument should be presented to the Commonwealth so glorified by its organized medi- cal profession. It is fitting that it should proudly stand in the Rotunda of our beautiful Capitol, that all who behold it in these Halls of State may be stimulated by his illustrious example. Physicians, yes, statesmen and citizens, too, may better serve their kind by familiarizing themselves with the "(Delivered at the Unveiling of the Niehaus Statue of Mc- Dowell in the Capitol, Frankfort, Ky., November 15, 1930.) .larch, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 265 itory of this man and by dwelling upon the ma- ured product of his labor, as the great orator of his occasion has so well done. It is fitting, too, that a woman should have been ;elected to pay the tribute of womankind to the nan whose courage and scientific study opened v-hat seems to us as the magic doors which restore lealth and peace and comfort and usefulness. TV e ire appalled as wTe contemplate the untold suffer - ngs of our sex through the ages before McDowell naugurated the era of modern surgery. One shud- lers as one thinks of the hopeless horror of the niserable sufferer condemned helplessly to her leathbed. Picture for yourself the scene on those winter lays of 1809, when Jane Todd Crawford lay suffer- ng in her farm home, in Green County. Already he mother of 5 children she had experienced the xtremity of pain and the happiest reward within he hope of her sex — motherhood. Now, however, tretched upon her bed of pain, the kindly minis- rations of her family -were only able to make her ?onscious of their love and sympathy. She was fiessed, as all are blessed who have that happy ex- perience, with the service of her family physi- cian. Women know best what this means. Too ’requently they, themselves, are the sufferers from illness. When they are not, the strain upon them is the greater, for the child they have borne or the husband and helpmate is in danger. Then, oesides her faith in the Great Physician, her human helper is her family physician. It is he who alleviates the pain, assuages the fever, exor- cises the infection, inculcates confidence, restores hope. Mrs. Crawford was fortunate in having such intimate guidance, and yet there arrived the time when the family physician became hopeless, too. And, as family physicians, realizing their responsibility for a human life, have always done, and will always do, her family physician sought the aid of the foremost specialist of his time, the first surgeon of the scattered community that had so recently been transformed from an Tndian hunt- ing ground to a proud, though still feeble, Com- monwealth. Responding to this urgent call Dr. McDowell rode over the but recently marked trail through the woods from Danville to her home. He found her trouble really to be an ovarian tumor, imme- diately threatening a fatal end. To quote the graphic description of Dr. Samuel Gross: “After a most thorough and critical examination, Dr. McDowell informed his patient, a woman of unusual courage and strength of mind, that the only chance for relief was excision of the diseased mass (an ovarian tumor). He explained to her, with great clearness and fidelity, the nature and hazard of the operation, he told her that he had never performed it, but that he was ready if she were willing, to undertake it, and risk his repu- tation upon the issue; adding that it was an ex- periment, but an experiment well worthy of trial. Mrs. Crawford listened to the surgeon with great patience and coolness, and at the close of the in- terview, promptly assured him that she was not only willing but ready to submit to his decision; asserting that any mode of death, suicide excepted, was preferable to the ceaseless agony which she was enduring, and that she would hazard any- thing that held out even the most remote pros- pect of relief. The result has been long before the profession. Mrs. Crawford submitted to the op- eration, and thus became the first subject of ovariotomy.” This courageous woman was 47 at the time of the operation, and, as a result of it her life was extended 31 more years and she died in 1841 at the age of 78. In his description of the operation, Dr. Mc- Dowell stated that Mrs. Crawford had been affect- ed with continuous pains for which she could find no relief. After having determined that it was a tumor of the ovary, he states: ‘‘Having never seen so large a substance extracted, nor heard of any attempt or success attending any operation such as this required, I gave to the unhappy woman in- formation of her dangerous situation. She appear- ed willing to undergo an experiment, which I promised to perform if she would come to Dan- ville, the town where I live, a distance of 60 miles from her place of residence. This appeared almost impracticable though she performed the journey in a few days on horseback.” Mrs. A. T. McCormack has graphically drawn a picture of the scene: “For a moment, let us go back to that primitive operating room improvised in the home of Dr. McDowell, in Danville, which is still standing, and visualize the scene. The room is rather bare and quite cold, too, for it is a wintry day, this December 13, 1809. In the center of the room, near the window, is a long wooden table covered with a folded blanket. On this lies a woman patient — not in surgical gown and stockings, but apparently, fully dressed, her head resting on a pillow covered with a white slip. Her abdomen, deformed by the massive growth, forms a veritable hill under the light blanket that covers her. She is a courageous woman, a quiet, practical woman, unafraid of plunging into the unknown, a pioneer all her life, used to the hardships and the hazards of the frontier, yet a woman of fine feel- ing and tender sensibilities. But, here she is pioneering in a new field. Pioneering for you and for me even though she did not realize it. Actually, she is about to submit to an experi- ment on her own body, one that had never bef oi e been accomplished. Her abdomen is to be de- liberately cut open with a knife by this equally brave and equally heroic man, several years younger than herself, all for the purpose of de- termining whether or not he can relieve her agony by removing this painful growth from her interior. It is a new experiment, and, although the outcome is questionable, she is determined to carry through her share in it. But — how does this woman feel under these cir- cumstances? What does she say and do during that 25 minutes’ ordeal? From her grandson, James Crawford Brown, it was learned that during the operation she occu- pied herself repeating the Psalms. The strength, the beauty, the sustaining power of the Psalms to a brave woman, who was also an idealist, could scarcely be better demonstrated, for Jane Craw- ford had no other comfort, not even a relative standing near, no anesthetic whatsoever, either local or general, not even a hypodermic of mor- phin, for neither anesthetics nor morphia had been discovered. She had only a supreme faith in her Heavenly Father, a hopeful dependence in her surgeon and the indomitable courage of a wonder woman to carry her through this crucial ordeal that has blazed the trail of abdominal surgery, 266 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 bringing its inestimable relief to countless thou- sands of women since. And — let us remember that although today the blessed relief of anes- thesia brings total oblivion for the patient, Jane Crawford went through the experiment perfectly conscious of every movement, every word and every glance of the surgeon and his assistants. To restrain her involuntary muscles, men held down her arms and legs with force in order to permit the surgeon to work.” Dr. McDowell concluded his description of the operation and its results as follows: “In 5 days I visited her, and, much to my astonishment, found her engaged in making her bed. I gave her par- ticular caution for the future and she returned home, as she came, in good health, which she con- tinues to enjoy.” Upon the occasion of the dedication of the monu- ment to McDowell at Danville in 1879, Dr. Lewis Sayre, of New York, then President of the Ameri- can Medical Association, said: “Another fact strikes me very forcibly, Mr. President, and that is the heroic character of the woman who permitted this experimental opera- tion to be performed upon her. The women of Kentucky in that period of her early history were heroic and courageous, accustomed to brave the dangers of the tomahawk and scalping knife, and had more self-reliance and true heroism than is generally found in the more refined society of city life; and hence the courage of Mrs. Crawford, who, conscious that death was inevitable from the dis- ease with which she suffered, so soon as the village doctor explained to her his plan of affording her relief, and convinced her judgment that it was feasible, immediately replied, ‘Doctor, I am ready for the operation; please proceed at once and per- form it.’ All honor to Mrs. Crawford! Let her name and that of Ephraim McDowell pass down in history together as the founders of ovariotomy.” Dr. Samuel D. Gross, one of the famous sur- geons of the world, said: “All honor to the man who had the courage and skill to do that which no man had ever dared to do before! All honor, too, to the heroic woman who, with death literally staring her in the face, was the first to submit calmly and resignedly to what certainly was at the time a surgical experiment. To her, too, let a monument be erected, not by the Kentucky State Medical Society nor by the citizens of Kentucky, but by suffering women, who, with her example before them, have been the recipients of the inestimable boon of ovariotomy, with a new lease on their lives and with immunity from subsequent discomfort and distress. I know of no greater example in all history of heroism than that displayed by this noble woman in sub- mitting to an untried operation.” To these tributes from these great authorities I am honored today to add my humbler note, my meed of praise to this heroic, pioneer woman and to urge those who contemplate this noble monu- ment to consider, along with the fame of the sur- geon, the essential part played by this model pa- tient. It is in the program of the Woman's Auxiliary to the Kentucky State Medical Association to some day fittingly honor the memory of Jane Crawford with a service similiar to this which brings us here today. Thoughtful physicians and grateful woman- hood will encourage our efforts in this direction. Atlantic County Reported by Mrs. W. Blair Stewart Friday, February 13, was not in any way a hoo- doo day, for the Atlantic County Medical Auxiliary gave a very successful and delightful musical-tea in the Solarium on the twentieth floor of Hotel Claridge, a skyscraper for the seashore! This was given to honor the President of the Woman’s Aux- iliary to the Medical Society of New Jersey, Mrs. John Nevin, of Jersey City. Mrs. James Hunter, Jr., of Westville, Gloucester County, a Past-Presi- dent, was also a guest. At 1.30 p. m. the regular business of the aux- iliary was transacted, after which the hotel or- chestra gave a choice program of music with Mr. William Stoking as leader. An hour’s program of vocal and instrumental numbers was given by Atlantic City talent. Addresses were given by both the State Aux- iliary President and by the Past-President, upon the work of the auxiliaries, the fine work accom- plished, and what may be accomplished. The Claridge Hotel should be called the house of hospitality, for the management did everything possible to make our musical-tea a success. Essex County Reported by Mrs. F. J. McCauley The regular meeting of the Essex County Aux- iliary was held on January 26 at the Nurses’ Home of the Newark City Hospital. Mrs. John Nevin, our State President, addressed the meeting with her usual good cheer and a message advising us to read the Journal. Following this, Dr. Henry Barkhorn, of Newark, President of the Essex County Medical Society, gave us a very enlightening talk on medical wel- fare work and current medical legislative meas- ures. Later, we had a well attended tea. The report of our Scholarship Fund Chairman, that we had swelled our treasury fund by the last card party to the extent of $150, was very reas- suring. Plans have been completed for a theater benefit performance to be given on Monday and Tuesday, March 9 and 10, at the Lyceum Theater in East Orange. The play is the popular comedy “Pigs”. The parent teaching classes held monthly at the Y. W. C. A. are well patronized; the average at- tendance is about 125. Twenty thousand pamphlets explaining the ma- ternity work being carried on through the Y. W. C. A. have been sent to the physicians in Essex County Society for distribution among their pa- tients. Copies of Dr. E. .T. Ill's speech at the convention in Atlantic City last June, on the Widows and Orphans Society, are being sent to every member in the State Society and all the men who are not members will be asked to join. Gloucester County Reported by Mrs. Henry B. Diverty A meeting of the above auxiliary was held at the home of Mrs. Elwood I. Downs, January 28, at 8 p. m. All of the officers and many members were present. The business meeting was unusually interesting- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 267 is not only our county business was discussed but )Ur part in the coming American Medical Associa- ion Convention to be held in Philadelphia, June 5-12, 1931. A social hour followed. February Meeting The Woman’s Auxiliary of the Gloucester County Medical Society held a meeting at the same time md place as the physicians, 9 p. m., Hotel Pitman, Pitman, N. J. All officers and a goodly number of ?ther members present. All committees reported progress. Ways and Means were discussed and ar- rangements made for Gloucester Auxiliary s part n the A. M. A. convention to be held in Philadel- jhia, June 8 to 12. After adjournment we joined the physicians in the dining room where a fine rollation was served, adding much to the social lour. Hudson County Reported by Miss Anne Hetherington The regular meeting of the Woman’s Auxiliary to the Hudson County Medical- Society was omitted in January in order that the members might de- vote themselves solely to the mid-winter card party held on February 4, in the Jersey City y. W. C. A. A steadily increasing interest in this annual event was shown by a larger attendance than ever; the spacious auditorium being filled with players and their friends who came in later for tea. Mrs. George Culver was chairman of the day. The President, Mrs. John Nevin, had as her guests Mrs. H. Roy Van Ness, of Newark, Presi- dent-Elect of the State Medical Society Auxiliary; Mrs. Theodore Teimer, of Newark; Mrs. Joseph Morrow, of Ridgewood; and Mrs. Winfield Kilts, of Teaneck, President of the Bergen County Auxil- iary. Mrs. Nevin made a strong plea for a large atten- dance at the State Medical Society Convention to be held in June at Asbury Park, outlining the fine program planned for entertainment of the Woman’s Auxiliaries. Mercer County Reported by Mrs. George N. J. Sommer While the county medical society members at- tended the meeting at the Carteret Club in Tren- ton, their wives were left at “Fannie Gerson’s Shop”, West State Street, for the auxiliary meet- ing, after which bridge and a buffet supper were enjoyed. Mrs. George N. J. Sommer, as Director, and Mrs. D. Leo Haggerty, President of the Branch, were in charge of arrangements. Reports were given by the chairmen of speak- ers’ bureau; of the hospitality committee; of the membership committee, and by the Treasurer. “Medical Legislation” was the topic of the ad- dress given by Dr. D. Leo Haggerty, member of the Welfare Committee of the State Medical So- ciety. Ocean County Reported by Mrs. E. G. Herbener A meeting of the Woman’s Auxiliary to the Ocean County Medical Society was held at the residence of Mrs. Frank Denniston, 420 River Ave- nue, Point Pleasant, Friday, February 6, at 3 p. m., with the following members present: Madames V. M. Disbrow, Frank Denniston, F. N. Bunnell, F. N. Bunnell, Jr., Alfred Woodhouse, B. Sawyer, H. B. Disbrow and E. G. Herbener. Mrs. Nevin, President of the State Society Aux- iliary, was also present and gave a very interest- ing talk about visits to the different county meet- ings and how they were conducted; and she also made several valuable suggestions on how to in- crease our membership. It was agreed that a card party be given, at the American Legion Home at Toms River, April 3, at 2 p. m. At the same time a business meeting of the members can be arranged for. A vote of thanks was given to Mrs. Denniston for the delightful afternoon and the nice refreshments served. Union County Reported by Mrs. H. V. Hubbard The first of a series of afternoon meetings was held by the Woman’s Auxiliary to the Union County Medical Society in the Winfield-Scott Hotel, Elizabeth, and 40 guests and members sat down to the luncheon; physicians’ wives from all over the county were present and Plainfield had a very large representation. The President and President-Elect of the Auxil- iary to the New Jersey State Medical Society, Mrs. John Nevin, of Jersey City, and Mrs. H. Roy Van Ness, of Newark, were the guest speakers. Mrs. Nevin brought a very encouraging report of her visits to other county auxiliaries and told of their activities and work accomplished, as well as of their difficulties. Mrs. Van Ness gave an inspiring talk on the 2 projects the Essex County Auxiliary has started. The first is a series of lectures on prenatal care and parenthood for women who are neither very rich or poor and who lack the opportunity to get such authentic information; the other is a scholarship fund for worthy sons or daughters of physicians. Mrs. F. A. Kinch, of Westfield, a Past-President from Union County, outlined the spring program for the Auxiliary. Mrs. George L. Orton, another Past-President, reported plans for the entertain- ment of Auxiliary members at the meetings of the New Jersey State Medical Society, in Asbury Park, June 3-4-5, and those of the American Medical Association, in Philadelphia, June 8 to 12. Mr. Charles Audsley, of Rahway, accompanied by Mrs. Orton, rendered 2 groups of songs during the afternoon. Mrs. Taney hill, Field Secretary of the New Jersey State Medical Society, conducting its pro- gram of- health talks and preventive medicine, re- ported some of the benefits derived from atten- dance at the national meetings in Detroit last year and briefly outlined her work this year on Mental Hygiene, which she will present in every county in the state during the year. Mrs. H. V. Hubbard, of Plainfield, President of Union County Auxiliary, presided. At the close of the meeting the following officers were pre- sented to those present: President-Elect, Mrs. Har- old Corbusier, of Plainfield; Vice-Presidents, Mrs. Norman Currie, of Plainfield, and Mrs. George L. Orton, of Rahway; Secretary, Mrs. Charles Hoff- man, of Plainfield; and the Treasurer, Mrs. Den- nis McElhinney, of Elizabeth. The next meeting of the Union County Auxiliary will be a luncheon-bridge held at Plainfield, in March. 26S JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 County Society Reports ATLANTIC COUNTY John S. Irvin, M.D., Reporter The regular monthly meeting of the Atlantic County Medical Society was held at the Chalfonte Hotel, February 13, at 8:30 p. m. The meeting was called to order by the President, Dr. Norman J. Quinn. The minutes of the previous meeting were read by Dr. Joseph H. Marcus, secretary, and approved as read. There were 43 members present. A communication was received from the Glou- cester County Medical Society inviting the local society to attend a meeting to be held February 19 at the Hotel Pitman, Gloucester. There were 2 applications for membership, one from Dr. Herman Kline, graduate of the Hahne- mann Hospital of Philadelphia, and one from Dr. Jesse D. Rork, graduate of Jefferson, June, 1924. Dr. Joseph Poland asked whether a veterinar- ian could be admitted to the society as an asso- ciate member, and was informed that there was nothing in the by-laws contrary to this. The Treasurer’s report of January, 1931, showed a balance of $665.71. A committee of 2, consisting of Drs. Silvers and Carrington, was ap- pointed to audit the account. Report of Committees: Dr. W. Blair Stewart spoke about a meeting of the Atlantic City Res- taurant Association, in which the matter of the “fly-by-night” eating houses who operate here in the summer was discussed. In many cases these restaurants and cafes are unsanitary. Ordinance No. 44 governs restaurants and their sanitary ar- rangements. The Restaurant Association is de- sirous of having the Medical Society impress the Mayor and the Bureau of Health that this Ordin- ance is to be enforced. This ordinance says that anyone with a communicable disease is barred from working in restaurants and hotels; but it does not go any further into the question of the health of the employees. The question of having employees examined physically before being al- lowed to work was discussed. It would be an easy matter to pick out major difficulties, such as advanced cases of tuberculosis and venereal diseases. The society should be will- ing to cooperate with the restaurants and hotels to check up on the health of employees and to give them at least a reasonable bill of health, and they should be willing to pay the doctors a reasonable amount for the examinations. The following motion was adopted: “The County So- ciety endorses Ordinance No. 44 and requests that the authorities make every effort to enforce it during the coming year/’ Concerning the Daley Collection Agency, Dr. Scanlan reported that Mr. M. R. Daley proposed the establishment of a collection agency within the society with himself as business manager, but as this proposition was no different from any other, collection agency, it is recommended -that the matter be dropped. A motion to this effect was passed. Committee on Post-Graduate Study: Lectures will be given by Rutgers University if there are twenty members interested, and the cost for the course will be $30.00. The lectures are to last an hour and a half, as last year the 2-hour lec- ture was considered too long. There will be one man in charge, and the topic will be “Newer Drug Therapy”. Literature in these courses will be sent to the members shortly. Dr. W. B. Stewart congratulated the members upon having so well attended the Philadelphia County Medical Society to hear the talk on the heart; 18 members of the local society were in attendance. It was moved and seconded and unanimously voted that Dr. Henry O. Reik should be made an honorary member of the society in recogni- tion of his excellent work. The President introduced the speaker of the evening, Dr. Clay Ray Murray, Associate Pro- fessor of Surgery at the College of Physicians and Surgeons, Columbia University, who spoke on the “Treatment of Fractures.” (Paper to be pub- lished later.) Following his paper he showed a moving pic- ture of himself treating a Pott’s fracture; a talking moving picture, but unfortunately the talking unit could not be used as it was for alter- nating current while the current available was direct. Dr. Murray covered this defect by talk- ' ing during the showing of the film. Atlantic City Hospital Staff Joseph H. Marcus, M.D., Secretary The stated monthly meeting of the General Staff, Atlantic City Hospital, was held in the auditorium on the evening of January 23, under President David B. Allman. Dr. Allman: The report of a Surgical Service 6 months after its beginning might blur some of the details of each individual case but the per- spective of ideas and ideals of the service cer- tainly has not been impaired. For the purpose of record, a brief summary of the statistics is necessary: Admissions on our service were 397; of which 354 recovered, 25 signed releases and 18 died. There was a total of 147 free operations; the largest number of cases ever treated in this hospital on one service. Naturally, the period of August, September, and October always has the largest service because of the increased popula- tion of this city during that time. The service that I have just finished as chief was my tenth, and I can well remember my first. There was formerly ample work for one man, who could very nicely use an assistant and, of course, an intern, but with such help there was no great stress or strain. Today things have changed. Even with 1 competent assistant, 2 residents who devote their time solely to the ser- vice, and the help of a capable Chief Resident, the work has increased so in volume that it often occupies more of one’s time than it is convenient to give. This is in some measure due to the fact that we have more patients, but more largely to the fact that each patient receives more treat- ment because there are more things to do and newer methods — and in the traumatic cases be- cause of the multiplicity of injuries. I can vis- ualize the time, not far distant, when the Surgical Service will be relieved of its fracture work and still have ample to do. As a matter of fact, we have already been relieved of most of the rectal work and practically all our genito-urinary work — and I, for one, can truthfully say “good rid- dance”. And, although we surgeons will proba- bly fight tooth and nail against loss of our frac- ture cases, I do not doubt that 10 years hence some Surgical Chief will report how “rushed to- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY .269 death” he was in spite of the fact that he treated no fractures. While on the subject of fractures, I wish to emphasize what has been said by several others, and what I stated in my last annual report — they are constantly becoming more complicated, more unusual and more trying and difficult to treat. Fractures of the skull are not operated upon now with nearly the frequency of 10 years ago. The Orr method has been a boon in the treat- ment of osteomyelitis. It is the only condition in which our work has been lessened rather than increased — and where the number of hospital days has been markedly diminished. It is radi- cally different from our old method of daily re- dressings. The operation consists, briefly, of a gentle cleansing of the wound through a large incision; removal of loose sequestra; painting the interior with iodin and alcohol; packing the wound with vaselin gauze; and applying a cast which is not to be removed for 4 to 6 weeks in most cases. Just how it performs its seeming miracles is not quite clear, whether the meddle- some interference of former days delayed heal- ing of those caess, or whether action of the bac- teriophage now hastens healing, but from a fairly large experience I am fully prepared to say that they do heal much quicker, with infinitely less attention, and when the wound is finally healed the patient is strong and robust and not a pale nervous wreck. Spinal anesthesia was used on my past service in certain selected cases, much to my gratifica- tion. It is not an a'nesthetic of ch.oice for routine use, but it certainly has a definite field, and when properly used at the right time is a most valuable adjunct. To handle as many thousands of cases as I have seen in the wards without a case of tetanus, and then to have 2 develop in rapid succession during this service, makes one pause and consider. Both patients were brought to our Dispensary imme- diately following their accidents; both received 1500 units of antitoxin; both were promptly ad- mitted to the ward; both developed tetanus; both were actively treated; and both died. They were not in the same accident — and one was only slightly injured and was discharged as recovered the day following his accident. The lesson to be gathered from these 2 cases is, as reported at our last clinic night, that in every suspected case the prophylactic dose of antitoxin should be 3000 units, and 1500 units should be given every fifth day thereafter until all danger has passed. I have figured out that each ward patient ad- mitted to this house receives the attention of 25-30 different highly trained individuals, all acting as cogs in the wheels which bring about his recovery — and the fact that these wheels run so smoothly and so efficiently speaks well for the organization of the hospital; and I take this op- portunity to thank all who so kindly helped dur- ing August, September and October, and whose cooperation is essential for the continuance of the excellent work that has been done and that we are continuing to do. A review of the 18 deaths which occurred on our service follows: Of fractured skull cases, 4 were in a total of 14 hours; all of these patients were severely shocked, all had complicating frac- tures in other parts of the body, and none reacted even to the slightest degree. There were 2 cases of fractured pelvis and each died within 3 hr. after admission. One of these patients had a fracture of both arms and both legs, in addition, and the other was the ‘‘parachute jumper” from the Steel Pier — our first case after taking over the service — who had a complete tear through the perineum and through the abdominal wall with evulsion of his intestines, rupture of the bladder and other complicating internal injuries. One case of ruptured lung died 6 hours after admission. Pour patients died of ruptured gangrenous ap- pendicitis, all from toxemia — 3 were rather elderly people and 1 a child 3 yr. old; 3 of the 4 cases were sent in by local physicians not members of our Staff, and the fourth was a woman, 6 0 yr. old, sent in by a Staff member 3 days after he had made the diagnosis and 3 days after he had insisted upon operation. One death was due to gunshot wounds of the head and neck; a colored adult who had an alter- cation with her sweetheart. The bullet wounds in her skull were numerous and at no time was the condition such as to warrant operation. A patient with very severe, compound, badly comminuted fracture of the femur died 3 days after admission, never having reacted from shock. Another with multiple compound fractures of the left tibia and fibula, with severing of all muscles and tendons, and profuse hemorrhage, died 2 hr. after admisssion. One man, aged 68 died of toxemia from a viru- lent spreading cellulitis of the thigh. A gall-bladder case terminated 1 day after op- eration for reasons which we were not able to ascertain, as an autopsy was not obtainable. The woman was in good general physical condition prior to operation; temperature 100°, pulse 96, and respirations 22; mild nephritis; leukocyte count of 21,500, of which 90% were polymorpho- nuclears. Immediately following operation, her temperature jumped to 104° and pulse to 110; pulse later reached 120, where it remained until death, and temperature varied between 102° and 104° axillary. A death from nephritis occurred, in a young man, 21 yr. of age, 1 month after admission be- cause of an automobile accident in which he re- ceived a very bad compound, comminuted frac- ture of the right humerus with extensive lacera- tions of the skin and muscles. In spite of blood transfusion , and all other recognized forms of treatment, this boy gradually became more toxic and finally died. While he was moribund it was ascertained that he had been refused life insur- ance 3 yr. prior to this accident because of a nephritis, and that explained the fact that his nephritis, which we assumed to be toxic in origin and due to the accident, did not respond to treat- ment. The eighteenth death was a case of suicide in a colored woman 6 0 yr. old, which occurred in our ward. She was admitted with a huge, strangu- lated hernia and intestinal obstruction. An opera- tion „was advised and refused and the patient died 48 hr. after admission from toxemia. As we look back upon the large number, of cases — 39 7 — which we handled on our service, and when we deduct from the total number of deaths the 8 patients who died within 24 hr. after admission and 1 patient who refused to take our advice, we do not feel that 9 deaths on an active traumatic service is more than should reasonably be expected. Dr. Walter B. Stewart. Report of Pediatric Ser- vice: In a review of the second and fourth quar- ters of the pediatric service of 19 30 it is gratify- 270 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 j ing to observe a rapid increase in the number of admissions to the ward. The majority were of great diagnostic interest. Nutritional and res- piratory cases occurred, as usual, in about equal number. More cases of lobar pneumonia than of any other one condition occurred, 12 out of 96, or 4 times as many as of bronchopneumonia. However, contrary to the usual supposition, the mortality from lobar pneumonia in children is low, only 1 death among these 12 cases; but 2 deaths of the 3 cases of bronchopneumonia. Death occurred in 16 of the 9 6 cases summarized. In 6 of the 16, necropsy was done; an average of 38%, a figure considerably below that of the pre- ceding year. Tuberculosis took the greatest toll; 5 of the 16. Acute gastro-enteritis and pneumonia took 3 each; congenital defects took 2 (1 an in- fected myelocele, and 1 cardiac anomaly); star- vation, acute encephalitis, and streptococcus men- ingitis each took 1. It is worth noting that no case of meningococcus meningitis was admitted during this period. There was 1 case of typhoid fever. Many of these cases have shown such interest- ing features that the histories should not be filed without recording a few points. Since the chief complaint in 3 of them was almost identical — painful, swollen, immobile legs — let us consider the differential diagnosis. All 3 developed symp- toms during' their first year. Each was brought to the hospital because of pain on passive motion of the lower extremities, which were swollen, par- tially flexed, and apparently paralyzed, because of the absence of active motion. The painful joints of rheumatic fever can be eliminated at once because of the age. Poliomyelitis can be ex- cluded because of the acute tenderness present. None of them was rachitic; enabling us to rule out the multiple fractures of rickets. In the first child, aged 3 mo., the cause was congenital syphi- lis, and the symptoms appeared at 2 mo. There was no active motion in either the upper or the lower extremities, except the fingers. Passive mo- tion was very painful. The underlying lesion is an epiphysitis. Restoration of function was rapid and complete within 3 days of the onset of treat- ment with mercurial inunctions. This syndrome develops typically from syphilis during the first few months of life. Symptoms in the second case, a child of 12 mo., were caused by an acute osteomyelitis. The swell- ing and immobility were unilateral, involving the right lower extremity. The swelling was greatest just below the knee. There was very little super- ficial redness. However, the high fever and the prostration indicated a deep-seated, acute infec- tion. The osteomyelitis involved the shaft of the right tibia, which was curetted by Dr. Allman, packed with vaselin gauze, and put into a plaster cast. A rapid and beautiful recovery resulted. Scurvy was the diagnosis in the third case, a child aged 9 mo. This is the first condition to suspect in an infant during his second 6 months of life whose mother gives the following story: “The baby has been increasingly fretful and irri- table, particularly when I go to change his dia- pers, or move his legs. He won’t kick any more, but just lies there with his legs partially flexed, and yells when I touch him. I've fed him on condensed milk and have given no orange juice.” This story makes the diagnosis. The gums around the upper incisors may or may not be red and swollen. The pain in these cases is caused by subperiosteal hemorrhages. Orange juice cured within 2 days. Suspect an error in diagnosis if such a case, the child being under 12 mo. of age, has been called rheumatism. It is not always easy to be sure of the presence of a non-opaque foreign body in the bronchus of a child. This boy, aged 14 mo., was admitted with signs typical of a foreign body in the left main bronchus; almost complete suppression of breath sounds front and back on the left side, and marked emphysema on the left side. How- ever, no foreign body was rendered visible by x-rays. The onset had been sudden, 6 days be- fore, when the child had a severe coughing spell while playing on the floor. He had coughed fre- quently and paroxysmally since that time. Res- pirations were normal, except that at times in- spiration grew labored and at times there was an audible wheeze, with typically asthmatic rales. No cyanosis or chest retraction. Temperature not above 100°. At times the breath sounds were nor- mal posteriorly but were always suppressed an- teriorly. He appeared to be getting better rather than worse. This variability in signs seemed to indicate that the position of the foreign body in the bronchus shifted from time to time. Bron- choscopic examination revealed a small piece of tinfoil in the left main bronchus, which was re- moved successfully. The next case is one of generalized enlarge- ment of the lymph-nodes presenting unusual fea- tures. The diagnosis lies between tuberculosis and Hodgkin’s disease, the weight of evidence favoring the former. The patient was a 6 yr. old colored girl who during the preceding 2 yr. had a firm, easily visible enlargement of the left inguinal gland- and of the cervical lymph-nodes; the former was the size of an English walnut, while other nodes were palpable but small. There had been no recent increase in size, and none had softened or broken down during this period of 2 years. Radiograph showed the mediastinal nodes as large masses on both sides, extending well out into the parenchyma of the lung. General nutri- tion good. At no time during 5 weeks of obser- vation did the temperature go above 100°. Intra- dermal tuberculin was negative to 0.1 mgm, but positive to 1 mgm. Two blood Wassermanns were negative. Erythrocytes and hemoglobin were almost normal. Leukocytes numbered 9 000 to 12,000; polys 70%; lymphos. 28%; eosins 2%. The histologic picture of a lymph-node obtained at biopsy was inconclusive, showing only inflam- matory reaction. In favor of tuberculosis were the greater frequency of occurrence, especially in a colored child, typical appearance of the medias- tinal nodes, and positive tuberculin. Against tuberculosis were involvement of the inguinal nodes, good nutritional condition, failure to soften or break down, and normal temperature. Two cases of acute encephalitis occurred, 1 with recovery, 1 with death. Tuberculosis men- ingitis had been the first diagnosis in both. The first, a colored boy of 20 mo., had been ill for 2 weeks with restlessness, irritability, piercing cries, occasional vomiting, loss of weight, and at- tacks of muscular twitchings. Low grade fever, not over 101°. Marked malnutrition with begin- ning dehydration. Marked rigidity of neck and body. Extreme irritability. Spinal fluid under high pressure, with increase of globulin and pel- licle formation, but a cell count of only 4. Dur- ing a month in the ward the symptoms subsided, and the weight increased from 15% to 19 lb. Tuberculin tests and Wassermann reactions were negative. It will be interesting to follow this child for the possible development of postence- phalitic syndrones. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 271 The other instance of acute encephalitis, in a colored boy of 6 yr., had a duration of 5 days from the onset with severe pains in the head up to the death in coma. Fever of 102° to 107° and numerous convulsions followed. Pupils small and fixed. No rigidity. Spinal fluid under moderate pressure, with increase of globulin and formation of pellicle, and cell count of 2 6, all small lympho- cytes. Necropsy revealed no evidence of tuber- culosis, but only focal congestion in the brain. Two cases of dysentery caused by the dysentery bacillus (Hiss-Russell) will be mentioned because of the late development of the condition, the onset of the one on Oct. 7 and of the other on Oct. 10. Dysentery is usually met here in August or early September, rarely as late as October. Eoth were severe and typical cases, with blood- streaked watery stools containing mucus and pus. They were handled successfully by an initial star- vation period with intraperitoneal injections of normal salt solution, followed by increasing amounts of reinforced protein milk with dextri- maltose, i. e. skimmed buttermilk with junket curd. The last case is one of lung abscess in a girl of 8 years. Five days after removal of her ton- sils and adenoids severe pain developed in the lower left chest. Several days later 11 oz. bloody serous fluid were aspirated from this side. She was admitted 3 weeks after the operation because of recurrence of pain in the chest and a persis- tently elevated temperature of 101° to 104°. In spite of all the physical and roentgenographic signs of fluid in the left side, 3 attempts to ob- tain fluid failed to yield a drop. Evidently the main lesion was one of unresolved pneumonia. Three weeks after admission temperature was still 101° to 103°, but the signs indicated resolu- tion of the general process. However, radio- graph showed a localized area of thickening and of retracted pleura, suggesting an abscess. Dr. Johnson inserted a needle in the mid-axillary re- gion and obtained a small amount of thick green- ish pus from a small cavity which could not have held over 60 c.c. Convalescence has been rapid since drainage of the abscess. BERGEN COUNTY Charles Littwin, M.D., Reporter The regular meeting of the Bergen County Medical Society was held at Holy Name Hospital, Tuesday evening, February 10. The minutes of the Annual Meeting and also of the Executive Committee were read and ap- proved. Approval of the appointments to the Executive Commitee was voted. The recommedation of the committee, that delinquents be notified by registered mail that unless their dues be paid in full by the March meeting they would be suspended, was moved and passed. Applications for membership of Drs. J. Willis Demarest, Franz Kastler, and Trevalyn W. Omstead were read. Drs. King and Hallett brought up the subject of “courtesy to the physician in court”. Both have recently waited all morning without pur- pose. It was regularly moved and passed that the Executive Committee take up this subject with the Bar Association. The program for the evening was presented by Dr. Louis Rene Kaufman, M.D., F. A. C. S., Professor Urology and Head of Urologic Section Flower Plospital; his subject being “Recent Ad- vances in Diagnosis and Treatment of Urologic Lesions; Uroselectan; Prostatectomy”. The talk was illustrated by original motion picture film. BURLINGTON COUNTY Roscius I. Downs, M.D., Reporter A regular meeting of the Burlington County Medical Society was held Wednesday afternoon, January 14, in the Burlington County Plospital, at Mount Holly, under the President, Dr. Joseph M. Ruder, with 14 members present. Because the State Medical Society decided to continue the Post-Graduate course of instruction, Dr. Kuder had appointed the following com- mittee: Drs. Richard D. Anderson, Chairman; Howard C. Curtiss and Marcus W. Newcomb, to determine upon the course desired, time and place of meeting, and to give assistance in organ- izing our membership into groups subscribing to these courses. Dr. Anderson’s report stated: that questionnaires were sent to 49 doctors, that 13 replies were received and 7 would take the course, but it is necessary to have an enrollment of 20 to have the course given at Mt. Holly. There were 3 applicants elected to membership: Drs. P. H. Corpening, of Marlton; Eugene A. Meyer, of Moorestown; Francis H. Borzell, of Philadelphia. Dr. Richard Anderson was elected Historian of the Society, as Dr. Joseph Stokes felt that he had not the time necessary for the work. A letter of resignation from Dr. I. W. IPollings- head was read, and received with regret. Dr. Harry L. Rogers, Chairman of the Section on Practice of Medicine, took charge of the meet- ing and announced the following program: “Agranulocytosis”, by David S. Farley, M.D., of Philadelphia. “Consideration of the Causes of Diarrhea”, by E. W. Rodman, M.D., of Beverlyj N. J. Dr. Farley commenced by saying that the term agranulocytosis means an increase of granular cells, while the disease really shows a decrease of the granular cells, therefore, agranulocytopenia is a better term. In 1922, agranulocytic angina, a rare and fatal condition, was described. The causes of this disease are divided into 3 groups: first is from chemicals, mainly following the use of arsphehamin; the second,' is from radiation, as following the use of radium and x-rays; the third is from unknown causes and is by far the largest group. The characteristics are leukopenia with pro- nounced reduction of polymorphonuclear neu- trophiles, decrease of blood-platelets, alteration in bone marrow. There is no change in the erythrocytes or hemoglobin; no purpura or bleed- ing. Three cases were described. The first followed administration of neo-arsphenamin. A man, 3 3 yr. of age, complained of soreness of the mouth and eruption of the skin. He had been given 5 doses of neo-arsphenamin at weekly intervals. After the fifth dose he had sore throat and con- junctivitis. He was given the sixth dose and de- veloped sore throat, jaundice, a toxic condition, enlarged spleen, a typhoid type of fever and died in 11 days. Another case was of a child 3 yr. of age, following an influenzal attack, Marked pallor. 272 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 yellow skin, marked anemia, enlarged liver and spleen developed. The treatment is symptomatic. Use sodium theosulphate in arsenic cases as soon as possible. Use many blood transfusions, radiation of the long bones, ultraviolet light, liver extract. Shock treatment consists of intravenous injection of typhoid vaccine, and also the use of fixation ab- scess by injection of turpentine. This last is quite painful. The abscess must be opened. Dr. Rodman’s paper was so definite and com- plete that the society requested its publication in full in the Journal. C AM DUX COUNTY R. S. Gamon., M.D., Reporter The monthly meeting of the Camden County Medical Society was held Tuesday, February 3, at 9 p. m. Dr. E. G. Hummell, Vice-President, presided in the absence of Dr. W. J. Barrett, President, who is on vacation in Florida. This meeting was the annual Case Report Night and the program consisted of the following: (1) “Loss of Sugar Tolerance in a Diabetic’’, by Dr. A. J. Casselman. (2) “Two Cases of Stone in the Urethra’'', (with lantern slides), by Dr. D. F. Bentley, Jr. (3) “Epidemic Cerebral Spinal Meningitis with Recovery and Secondary Total Nerve Deafness”, by Dr. Jos. E. Lovett. (4) “Streptococcus Faucitis with Erythema No- dosum and Erythema Multiforme Exudativum”, by Dr. Hyman I. Goldstein. (5) “Sub-total Gastrectomy for Carcinoma of the Pylorus” (with lantern slides), by Dr. P. M. Mecray. (6) “A Case of Appendicitis with an Unusual Complication”, by Dr. E. Shull. (7) “Bilateral Congenital Dislocation of Hips” (with lantern slides), by Dr. O. Carlander. The Committee on Rutgers Post-Graduate Ex- tension Work reported that applications will be in the hands of members in the near future. Drs. E. A. Y. Schellenger, 414 Cooper st., Cam- den, and Max Ruttenberg, 210 State st., Camden, were elected to membership. Appropriate action was taken upon the death of Dr. E. E. DeGrofft, Woodstown, who passed away January 6, 1931. The meeting was well attended. ESSEX COUNTY E. LeRoy Wood, M.D., Reporter The Essex County Medical Society was host to the Medical Societies of Union, Morris and War- ren Counties which together constitute the First Judicial Council District of the State Medical So- ciety, Thursday evening, February 12, 1931. The Essex County Medical Society elected 9 new members: William M. Brams, George M. Cohn, Geza M. Frank, Harry Klein, Sol Parent, Christopher J. Reilly, Henry M. Woolman, and A. Russell Sherman, all of Newark; C. Franklin Turner, Montclair. Dr. Henry C. Barkhorn, President of Essex County Medical Society, called attention to a series of meetings being held each Wednesday evening at 8.15 at the Academy of Medicine in Newark to consider the subject of “Industrial Poisonings”. The meetings have been organized by the Safety Council and endorsed by the Medi- cal Society. There will be 4 meetings, February 18, February 25, March 4, and March 11, ad- dressed by prominent members of the profession, authorities on their subjects. Dr. E. G. Wherry, Chairman of the Medical Milk Commission, offered a resolution, which was passed by the society, supporting the use of clean raw milk in certain cases in preference to pasteurized milk. The resolution backed the stand taken recently by Dr. J. G. Lipman, Di- rector of the State Agricultural Experiment Sta- tion at New Brunswick, in opposing “an organized effort by milk dealers to eliminate raw milk as a market commodity even though such raw milk may be entirely safe to use and of greater food value than pasteurized milk”. The medical milk commission called attention to the fact that certified milk, produced and dis- tributed raw under medical supervision, “affords utmost security in this most important article of human food”. Dr. Lipman’s opinion was ex- pressed in a letter to the International Associa- tion of Milk Dealers which had asked his opinion on the advantages of pasteurized milk. He re- ferred to pasteurization as “the lesser of 2 evils” and declared health officers are “right in insisting on pasteurization of all but the finest grades of raw milk”. The medical society resolution read: “The question of the place of raw milk and its super- vision by the government suggests the reminder that certified milk is the standard by which all grades are judged. Being raw and certified by a medical milk commission under very rigid re- quirements of law, it affords the utmost security in this most important article of human food and is indispensable for infants. The Essex County Medical Society reiterates its frequent action re- commending certified milk, not only because it is raw but because its purity is unaltered by any process in any respect.” After the local business was completed, the meeting was turned over to Dr. A. J. Ward, Secretary of the Morris County Medical Society, who presided and introduced the speaker, Dr. William H. Ross, President of the New York State Medical Society. After the reading of Dr. Ross' paper, Dr. J. B. Morrison read one on the “Possible Advent of State Medicine”, and discus- sion was carried on from the floor to a late hour. The combined meeting was considered a great success and Essex felt honored by the privilege of entertaining her neighboring societies. Academy of Medicine of Northern New Jersey Eye, Ear, Nose and Throat Section E. LeRoy Wood, M.D., Secretary Several patients with interesting conditions, and reports of many instructive cases, were presented at the meeting of the Eye, Ear, Nose and Throat Section of the Academy of Medicine of Northern New Jersey, 91 Lincoln Park, Newark, Monday evening, February 9. The Chairman, Dr. J. Wal- lace Hurff presided. In the business portion of the meeting, the chairman appointed as a nominating committee Drs. Elbert S. Sherman, Henry C. Barkhorn, and Dennis F. O’Connor. The subject of the high price of eye glasses was discussed and general disapproval of the increas- March, 1931 JOURNAL OF THE MEDICAL mg' costs was expressed. One instance was cited where the ophthalmologist’s prescription for a person of very moderate means, with a small re- fractive error, was filled by glasses costing $5 0. This must work to the disadvantage of patients, because they* cannot then afford the ophthalmolo- gist’s supervision sufficiently frequent. The routine urging by the optician of the more expensive lenses, such as Punktal, Orthogon, and Tillyer, for patients with small refractive errors, is likewise condemned because unless the prescription calls for a lens of 5 diopters or more, there is a negligible difference between the expensive lens and the ordinary lens. It was also mentioned that very serviceable frames can be supplied, of gold filled material, making the added expense of the solid gold and the highly decorated frames unnecessary. Drs. O’Connor and Sherman sug- gested that a committee be appointed to study and discuss the optical question. A motion ,vas passed to that effect. Dr. A. Russell Sherman, of Newark, who re- cently returned from an extended visit abroad, described in a very practical and interesting man- ner the Eye Clinics in Vienna, Austria; his com- plete paper Will be published in the Journal at some future date. In the clinical portion of the meeting, Dr. Lee W. Hughes showed 2 patients. The first, a man from whom he had removed a retrobulbar tumor, giving the following description: This patient came to my office on October 3, 1930, complain- ing that there had been a protrusion of the left eyeball for past 7 years and shortly after the condition was noted he consulted a physician. Radiographs were taken and a tumor mass local- ized behin’d the left eyeball and to the outside. An operation was advised but refused. The con- dition had grown progressively worse and tumor had increased to almost twice its size. Patient stated that whenever he lifted heavy objects or leaned forward there was a further protrusion of the eyeball, sufficient to cause him great annoy- ance, and he feels that he is unable to pursue his occupation, which is that of a mason. He re- quested that an operation be performed. No his- tory of injury; had always enjoyed good health. Married, and father of 7 children all well and healthy. No history of eye trouble in family. Vision O.D. 20/20; O.S. 20/200. There was a marked proptosis of the left eye which was prac- tically 1/3 out of its socket; eyeball appeared to be fixed and stationary. The anterior struc- tures were healthy; cornea clear; pupil round, regular, reacted to light and accommodation. General fundus was negative. Field of vision normal. Upon light palpation a tumor growth could be distinctly felt and this appeared to be in the upper and outer part of the orbit and ap- parently fairly adherent tio the superior and lateral walls of the orbit. Retrobulbar tumors are usually slow in growth and are to be differentiated from orbital cellu- litis or acute inflammatory ^processes by the absence of swelling or edema of the structures surrounding the eyeball. Even though the move- ments are greatly limited or even immobile, there is a gradual stretching of all the muscles and tissues attached to the eyeball so that sometimes useful vision is maintained. In slow growing tumors there is stretching of the optic nerve so insidious that no changes are noted upon exam- ination of the fundus. There is usually marked proptosis, depending, however, upon the size and location of the tumor. In deeply situated tumors SOCIETY OF NEW JERSEY 273 the external orbital wall must be removed to gain free access to the orbit, and the operation of choice is the so-called Kronlcin operation. This patient was operated upon October 7, 1930, at the Newark Eye and Ear Infirmary, under local anesthesia (novocain adrenalin solution). The Kronlein-Kocher incision was used — a curved incision extending from the junction of the middle and inner third of the brow downward to the fold of skin approximately 10 mm. from the outer canthus, and then continued toward the temple for a distance of 3 to 4 cm. The tissues were separated down to the bone and the upper arm of the zygomatic bone was removed. The peri- osteum of the orbital cavity was incised above and below to allow free separation of the tissues of the outer wall of the orbit, being careful not to cut any of the muscular attachments of the eye- ball. The tumor was readily outlined and by Anger dissection was removed from its attach- ment. Following removal of the tumor the eye receded into the orbit in the normal manner. The muscles were approximated by 00 catgut and skin edges sutured with fine silk. The wound was closed tightly. There was considerable swelling of orbital tis- sue following operation and on the fourth day patient was discharged and told to report to the office for further treatment. On the tenth day a hematoma was opened in the brow and a large amount of blood evacuated, and 10 days later the wound had firmly healed. Four weeks from the operation patient was able to read 2 0/20 in left eye. The last examination made on January 27, 1931, vision was 20/20 in each eye without correction. No diplopia with or without red glass when fusion is broken; 12° esophoria distance; 1° right hyperphoria distance. The tumor was sent to the laboratory and the following measurements given: Length 39 mm., breadth 2 6 mm,, depth 22 mm. Sections made and decription given: tumor is composed of many di- lated blood vessels filled with blood and lined by inactive endothelium. There is a considerable amount of fibrous tissue stroma which appears to take part in the tumor formation. No evidence of malignancy. Diagnosis: cavernous fibro-hemangioma. Dr. Hughes presented his second patient hav- ing the interesting condition, keratoconus, as fol- lows: This patient came to my office on December 3, 1930, with a request fj-om the United States Veterans’ Bureau for an examination of eyes, ears, nose and throat. The patient stated that he was discharged from the Army in 1919 and was then told that he had a cataract in the right eye. Realized that the vision was poor at that time but since the vision in the left eye was prac- tically normal, and the right eye did not cause him any annoyance, he did not seek further medi- cal advice, taking as final the statement of the army doctor that nothing could be done to improve the vision in the right eye. He has been working as a night watchman and ha^ experienced little difficulty in attending to duties. However, during the past 3 or 4 years he has been complaining of headaches (especially in the region of the tem- ples), some difficulty in nasal breathing. General health has always been good; has never had any operations; family history negative so far as eye diseases are concerned. Vision: O.D. counts fingers at 4 ft. O.S. 20/50. The conjunctiva of the right eye showed a mild catarrhal inflammation. Cornea was conical in shape and the apex of the 274 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 cone was situated just below and to the outer part of the center of the cornea with a small opacity at the apex of this cone which appeared like a bleb formation. The left eye showed a mild catarrhal inflammation of the conjunctiva with a beginning conical cornea. I was unable to obtain a view of the fundus of the right eye, but examination revealed approximately 2.75 diopters of myopic astigmatism, which corrected did not improve the vision. Examination of the left eye revealed 3 diopters of myopic astigmatism which corrected the vision to 20/3 0. It is my impres- sion that there is a higher degree of astigmatism in the cornea of the right eye than that noted by the keratoscope. Keratoconus. The central part of the cornea very gradually and without inflammatory symp- toms begins to bulge forward in the form of a cone. At first the cornea is perfectly transparent and its peripheral portions keep their normal curvature, but with a continual bulging of the cornea the apex of the cone becomes opaque with an uneven surface. Keratoconus first makes itself apparent to the patient by disturbance of vision. The eye be- comes myopic but there is usually astigmatism. It is a rare disease which as a rule affects both eyes, beginning usually between the twelfth and the twentieth year and very gradually in the course of years coming to a standstill. There is no increase of tension; neither is there ulceration or rupture of the cornea. A keratoconus of slight degree may be easily overlooked, since the cornea is transparent, and where there is even the slight- est suspicion of this condition the cornea should be carefully examined by Placidios keratoscope. The corneal reflex is irregular in outline and the apex of the cone is not usually in the center of the cornea but somewhere below it. Treatment is very unsatisfactory. Where the patient has been under observation for some time and we are satisfied that the condition is station- ary, it is best to content ourselves with a cor- i ection of the refractive error, which is usually a moderately high degree of myopic astigmatism, bj concave spherical glasses alone or in combina- tion with a cylinder. In certain selected cases improvement of vision is secured by the use of discs with stenopeic holes or slits, the size and shape of these to be determined by examination. Certain men have operated for conical cornea but the results have only been imaginary and not convincing either to their patients or their fellow practitioners. Dr. Dennis F. O'Connor described in detail per- sistent pupillary membrane and showed patients with the condition. Dr. Andrew Rados showed a patient who had i ecovered, with good vision, from sympathetic ophthalmia following enucleation of the other eye. The opportunity to examine this patient was most valuable, Di. E. A. Curtis read the following description of Infantile Tay-Sachs Disease, an example of which he had recently seen in one of his patients m the Newark City Hospital. In 1881 a case was reported by Dr. Tay with the title, ‘ Symmetric Changes in' the Region of Macula in Each Eye of an Infant”. In 1887, Dr. Sachs reported a case of blindness 'associated with idiocy, entitled ‘‘Arrested Cerebral Development”. Mne years later he also recognized the familial elements in the disease in another case, and gave it the name of ‘‘Amaurotic Family Idiocy”. These diseases occur between the age of infancy and 35 5 ears. The different varieties are infantile, juve- nile, and adolescent. Case Report Hebrew boy, 13 months old, normal delivery, full term, weighed 8 lb. at birth; parents not blood relations. The child was admitted to the Newark City Hospital on October 25, 1930, weighing 23 lb. Since birth the child has been back- ward, took no notice of its surroundings, and did not appear to see or hear. He began to have convulsions 2 weeks before admission. During these attack? he became cyanosed, with toxic spasm of both hands lasting 3 to 4 minutes. He had 10 or 12 of these in all. During these last 2 weeks, the child had changed perceptibly. While in the hospital, he would lie quietly with no re- action to any of his surroundings. He was a well-developed, normal looking child. When placed upright, he would fall over in any di- rection. The anterior fontanelles would admit 1 finger, and the posterior fontanelles were closed. There was a paralysis which was flaccid. The reflexes were deficient. A fast pulse but the heart was normal, and his chest was normal. No gland- ular involvement, and no bone tenderness. The urine was negative. No nystagmus and no stra- bismus. Temperature ranged from 98° to 105°. Died October 30, 1930. Memorial Tribute to Dr. Charles J. Kipp E. LeRoy Wood, M.D., Reporter Leaders of the medical profession in North Jersey met at the Newark Eye and Ear Infirmary Sunday afternoon, January 18, to pay tribute to the memory of Dr. Charles J. Kipp, Founder of that institution, who died 20 years ago — January 13, 1911. Mr. Edgar Heller, President of the In- fiimaiy, presided at the simple exercises in which representative speakers recalled Dr. Kipp's ser- vices to the community. On the program were Drs. Edward J. Ill, of Newark; Norton Wilson, of Elizabeth; John F. Hagerty, Medical Director of St. Michael’s Hos- pital; Frank W. Pinneo, Secretary of the Essex County Medical Society; and Wells P. Eagleton, Medical Director of the Infirmary. Each of the speakers had been a friend and colleague of Dr Kipp. With Dr. Wiliam R. Rankin, Dr. Kipp GO years ago founded the first eye and ear clinic in New- ark, at St. Michael's Hospital. He was credited with being the first to describe manifestations of abscess of the brain in the eye, and the influ- ence of malaria on the eyes. In addition to found- ing the infirmary, Dr. Kipp was closely associated with the late Dr. Henry L». Colt in the establish- ment and development of Babies Hospital, Colt Memorial, and with others in planning the New Jersey State Sanatorium at Glen Gardner. Mt. Kipp, near Glen Gardner, was named in his mem- ory. Dr. Kipp was active also in the origin of the Society for Widows and Orphans of Medical Men, the Journal of the Medical Society of New Jersey, and the Medical Library Association of Newark, now the Medical Library of the Academy of Medicine of Northern New Jersey. The build- ing ot the Newark Eye and Ear Infirmary, a monument to Dr. Kipp’s vision, was built from contributions of Robert T. Ballentyne, Frederick Frelinghuysen and J. William Clark. When the March, 1C 31 joyrnal of the medical society of new jersey 275 clinic from which it grew was started in 18 80 by Dr. Kipp, there was a budget of $750. Dr. Edward J. Ill related from memory many personal incidents, being acquainted with Dr. Kipp from the time he came to Newark in 1868. Dr. Norton L. Wilson paid the following tribute to Dr. Kipp: “We are gathered here today to do honor to the memory of one who established this Institution and did much for the City of Newark. Dr. Charles J. Kipp came to this coun- try from Germany. He graduated from the Col- lege of Physicians and Surgeons in New lrork in 1861. About that time the War of the Rebellion broke out and he enlisted as a surgeon with the Northern Army, serving faithfully and well. Those of you who attended his funeral service will re- member the tender words of Dr. John Wyeth, who served in the Southern Army as a surgeon, paying high compliment to Dr. Kipp, praising Dr. Charles J. Kipp his skill and devotion to the sick and wounded not only of the Northern Army but also those of the enemy. He related the story of Dr. Kipp saving his life by his skill and devotion and they remained staunch friends ever after. I well remember when I first became associated with him, at the old Infirmary on Sterling Street, in 1885. He was then at the pinnacle of fame, and was one of the foremost oculists in America. He was a student and a dextrous operator. He was exceedingly modest, and a man of few words, which caused many to think him gruff, and yet I have seen him as tender as a woman in hand- ling a child. His contributions to medical lit'era- ture were of the highest character. He never married, but devoted his entire life to his pro- fession. This institution was his child and he gave of his means and very life that it might live. He was the ‘old type gentleman’, never indulging in excesses of any kind. He acquired a stoop in his shoulders from his devotion to study; and was somewhat deaf in one ear, which made him sensitive in conversation. It was my good for- tune to have served under him for a period of 8 years and during that time he was not only my instructor but also my friend. May his memory ever be cherished in our hearts.’’’ Dr. John F. Hagerty spoke as follows: “I deem it a great privilege to represent St. Michael’s Hos- pital at this splendid gathering of distinguished men and women, assembled to do honor to the memory of Dr. Charles Kipp, who was a mem- ber of our Medical Board during the early years of its organization- and who established there, 60 years ago, an Eye and Ear Infirmary, the first of its kind in the state of New Jersey, and continued its active and guiding force for many years. The success and, indeed, the permanency of many in- stitutions is largely dependent upon the start which they receive, and St. Michael’s Hospital was exceedingly fortunate in having for its spon- sors and guides during its formative period a re- markable group of men whose names are held in grateful and reverent memory in many homes of our city, not the least worthy among them being the subject of this gathering. They were whole- heartedly and devotedly interested in the welfare of this young hospital, the second to have been started in the state, St. Barnabas having preceded it a very short time, and are, in large measure, responsible for its successful continuance during all the succeeding years. Dr. Kipp was so con- vinced of the necessity for such an institution and of the benefits to be derived from such a clinic that he fitted it out with all necessary instruments and apparatus at his own expense, some of which are still in use at the present day. It is not easy to put into understandable terms the value of such interested and devoted lives as these, but their successors are always aware of some in- tangible force and stimulus which enable them to carry on in sustaining their ideals. Dr. How- ard Kelly said: ‘Even a cursory glance at the deeds of the illustrious dead should encourage those who are left to pass along the torch to greater zeal in their daily tasks.’ I trust I may be permitted to refer to my own acquaintance with Dr. Kipp. Soon after com- ing to Newark I learned that he was one of the outstanding figures among the medical men of that day and, indeed, the most prominent of them all. And I had not been long connected with St. Michael’s before learning of his wonderful work there and the indelible impress his talents and skill had left upon that institution. I had the good fortune later to become a member of the. Medical and Surgical Society with which he was actively identified, and can testify to the remark- able influence he had upon every member of the society. Upon hearing him talk one felt that he was in the presence of a Master, of one pos- sessed of abundant knowledge acquired by study and travel and experience. He had a very direct, lucid and convincing way of telling a thing, and we listened when he spoke and were educated and stimulated to aspire to higher and better things. I wish to thank Dr. Eagleton for his kindness in permitting us to be here, and to compliment him upon his thoughtfulness, not only in keep- ing alive the memory of one whom I know he reveres as his mentor and guide, but in helping to perpetuate the beneficent influence of a good name and an active and useful life. Pasteur, the great French scientist, whose marvellous ac- complishments w^re wrought during the life period of Dr. Kipp, looked upon the cult of great men as a principle of national education. ‘From the lives of men w.hose passage is marked by a trace of durable light’, he said, ’let us piously gather up for the education of posterity, every 276 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 detail down to the slightest words, likely to make known the incentives of their great souls.’ We are grateful for the opportunity of attest- ing our high regard for the memory of Dr. Kipp and appreciate the good that will result from re- flection upon his life and work." Dr. Frank W. Pinneo said: "Dr. Kipp was the first President, and, only Life Member, of the Medical Library Association of Newark. During October 19 05 subscriptions ‘to establish a medi- cal library and organize a Medical Library Asso- ciation' had been secured by some personal soli- citations and when these reached 130 names it was suggested that an organization meeting be called. The plan included the cooperation of Mr. John Cotton Dana and the Trustees of the Pub- lic Library in providing the place in the ser- vices of trained librarians, while the Medical Asso- ciation would hold possession of its books. Dr. Kipp took such interest in the success of the movement that he wanted the plan of this co- operation assured before organizing, and when informed this had been secured a meeting' was held on November 18, 1905, and the Association was formed. Dr. Kipp was, with universal ap- proval, elected the first President and, the next day, sent a check for the Life Membership fee, thus becoming the first life member. After organization of the Academy of Medi- cine of Northern New Jersey and its possession of a home, an agreement was negotiated, May 18, 1921, merging the 2 associations whereby the property of the Library Association, accumulated through the 16 years, with its cash balance as a Library Endowment Fund, was transferred to the Academy which agreed to ‘maintain, operate and develop’ the medical library.” Dr. Wells P. Eagleton, who has been Medical Director of the Eye and Ear Infirmary since Dr. Kipp’s death, read the tribute paid on that occa- sion by the staff of the institution: “This insti- tution was founded through his instrumentality and he brought with him a body of personal friends who undertook the work because they were assured, by being associated in a beneficent work with a man preeminently qualified by mag- nificent ability and great nobleness of character.” In the minds of those who knew Dr. Kipp the memory needs no sustenance but the attention of those who follow is directed to his character, the ideals which he so nobly exemplified and his life of generous service. Following the service Dr. Eagleton entertained the staff of the Infirmary at dinner at the Essex County Country Club, West Orange. Honor to Dr. Max Danzis E. Leroy Wood, M.D., Reporter More than 200 medical associates and friends gathered at the Newark Athletic Club to pay honor to Dr. Max Danzis, for many years chief of staff of Newark Beth Israel Hospital. Speakers dwelt on his long services to the com- Tnunity and the aspects of his work that have gone beyond the usual sphere of the physician in social and scientific accomplishment. A framed scroll containing resolutions was presented to Dr. Danzis by the hospital’s medical staff, which gave the dinner. The speakers included'David I. Kelly, secretary of the Essex County Park Commission; Frank I. Liveright, president of Beth Israel; Dr. Nathaniel C. Price, and Dr. Henry C. Barkhorn, who was toastmaster. Dr. Danzis responded. Features of the program were several piano solos by Rev. J. Pierre Connor of Our Lady of Lourdes Church, West Orange, and vocal solos by Paul Largay. The arrangements were directed by Dr. Paul Keller, executive director of Beth Israel. At the speaker’s table also were Dr. Edward J. Ill, Dr. and Mrs. John F. Hagerty, Dr. and Mrs. H. J. F. Wallhauser, Mrs. Keller, Mrs. Barkhorn and Mrs. Price. The resolutions presented to the guest of honor follow: “Whereas, Dr. Max Danzis has served in the capacity of founder, member and chief of the medical staff of Newark Beth Israel Hospital and has exercised his duties unselfishly and with great efficiency as director of the medical staff of New- ark Beth Israel Hospital, and ‘Whereas, Under guidance of Dr. Max Danzis, Newark Beth Israel Hospital from a humble be- ginning has reached a plane whereon it is one of the leading medical institutions of the country. Therefore be it Resolved, That the medical staff of Newark Beth Israel Hospital does hereby express its ap- preciation of the unselfish services rendered to this institution and to the community at large by Dr. Max Danzis during his long years of ser- vice; that the staff does further express its grati- tude for the understanding and utmost patience and unflinching fortitude with which Dr. Danzis has ever performed such service; and be it further Resolved, That the staff hereby records its appreciation of the quality and extent of the work done under Dr. Danzis’ direction, and trusts that it may continue to enjoy his just management for many years to come.” First Councillor District Albert J. Ward, M.D., Reporter Through the courtesy of the Essex County Medi- cal Society, the First Annual Meeting of the First Councillor District, comprising the County So- cieties of Morris, Essex, Union and Warren, was held in the Academy of Medicine, Newark, Thurs- day evening, February 12. The purpose of these joint meetings of the county societies comprising each Councillor Dis- trict in the State is to promote better acquain- tance and understanding between neighboring county societies, to strengthen and solidify the profession, and so the State Medical Society, and to advance medical practice. About 150 members of the various societies attended and the new undertaking was considered a success. The speakers of the evening were Dr. W. H. Ross, President of the New York State Society, and Dr. J. B. Morrison, Secretary of the New Jer- sey State Society. Dr. Ross’ topic was, “A Way to Avoid State Medicine”’. Dr. Morrison followed this paper with one on “Some Phases of State Medicine”. Both papers were enthusiastically re- ceived, and lively discussion by Drs. Sommer, Reik, Quigley, Hagerty, Lathrope, Beling, Polevski, and other members followed. The First District Councillor Committee wishes to extend thanks to President Barkhorn and members of the Essex County Society. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 277 GLOUCESTER COUNTY Henry B. Diverty, M.D., Reporter The February meeting of the Gloucester County Medical Society was held February 19, with a large number of members present at the Hotel Pitman. The meeting took place in the form of a “round table” discussion concerning the affairs of tl\e society and an interesting discourse on the milk question. Mr. TV. H. MacDonald, the acting chief of the Bureau of Local Health, took the place of Mr. D. C. Bowen, the State Health Director, who was called to Washington, and proved a very able speaker and held the attention of his lis- teners throughout his talk. The members present were Drs. S. F. Ashcraft, I. W. Knight, W. J. Burkett, R. K. Hollinshed, F. G. Wandell, E. E. Downs, C. F. Fisler, A. B. Black, H. B. Diverty, Duncan Campbell, C. I. Ulmer, B. A. Livingood, Wm. Brewer, H. M. Fooder, C. A. Bowersox, Paul M. Pegau, Edwin Ristine. Delegates included Drs. Miller and Ben- nett, o7 Cumberland County; Dr. Oram R. Kline, of Camden County, and Dr. Franklin Church, of Salem County. HUDSON COUNTY E. G. Waters, M.D,. Reporter The regular meeting of the Hudson County Medical Society was held at the Carteret Club, February 3, with Dr. J. M. Cassidy presiding. The minutes of the previous meeting were ac- cepted as published in the Bulletin. The president reported for the Executive Com- mittee, speaking of a letter received from the Kings County Medical Society in reference to un- ethical practices of the Hudson Clinic of Jersey City, which has been referred to the State Board of Medical Examiners for action. Communications had been received from the Gilbert Acceptance Corporation and were con- sidered by the Executive Committee, with the de- cision that this was purely an individual proposi- tion and there was no reason to make it official by the society. The matter of re-zoning the city was discussed, and its effect upon the location of physicians’ offices. The question is whether a physician is to be considered in the same category as a business man. The Executive Committee had recommend- ed the plan of engaging a counsel to represent the society whenever necessary. The President spoke of the notice in the Bul- letin requesting members interested in having their names presented for an office, or as a mem- ber of a committee, to sign the form and return to the secretary. This was an opportunity for every member of the society to come forward if interested in doing any work. Up to the present, the response has been practically negligible. The resignation of Dr. Maurice Shapiro as Chairman of the Publicity Committee was re- ceived and accepted, and a new appointee is to be named shortly by the President. Dr. Edward G. Waters, as a member of the State Committee on Post-Graduate Instruction, asked concerning the plans of the local com- mittee, as the State Committee was waiting to hear of the plans of the local committee, and thus avoid complication. The revision of the Constitution was presented, read article by article, and adopted. A communication from the Hudson County Tuberculosis League, inviting the membership to attend a series of lectures on “Occupational Dis- eases” to be held in Newark, was read. Classified Advertising: Dr. H. C. Benjamin stated that the Telephone Company had been soliciting the profession to place an advertisement in the classified section showing office hours and specialties. Dr. F. Quigley moved that the members of the society should not participate in this until after it had been considered by the Executive Com- mittee. Dr. M. Swiney moved to amend that the county society !s against such a practice. Dr. C. B. Kelley wanted a definition of “medi- cal advertising”. He stated that practitioners not in the society would advertise. He advocated the publication of a list of members of the Hud- son County Medical Society under such a head- ing. Dr. I. L. Gordon stated that from the infor- mation he had received only the office hours were to be published, but suggested that we get a definite statement from the Telephone Company. It was incidentally mentioned that the classi- fied list contained the names of other than reg- ular qualified practitioners. Dr. Kelley stated that the Board of Medical Examiners had taken this matter up with the Telephone Company and that it was cooperating to eliminate the names of any but regular practitioners. Further dis- cussion by Drs. Nelson and Perlberg. The amend- ment of Dr. Swiney was lost; the motion of Dr. Quigley was carried. It was regularly moved and seconded that the Secretary be authorized to notify the Telephone Company to hold this matter up until it had been sanctioned by the society. Dr. S. Yachnin stated that some companies are distributing lists of business and professional men to apartment houses. Dr. IT. C. Benjamin moved that the Executive Committee consider this mat- ter. The' motion was carried. The members were asked to send in any information concerning such procedures to the Secretary. Dr. F. McLoughlin spoke on the rule of the American Medical Association that all hospitals to be approved must have 20% of postmortems. He stated that the undertaker stood in th s way ■ and suggested that this society take the matter up with the Undertakers’ Association. It was regularly moved and seconded that a committee be appointed by the president to confer with the Undertakers’ Association relative to this matter and secure its cooperation in dealing with the relatives of the deceased in an endeavor to limit this conflict. Dr. Cassidy stated that this is a very vital question to those interested in hospitals and therefore merits serious consideration. Dr. W. Barbarito felt that it should be the duty of the hospitals themselves to get together and work out this problem. Dr. Nelson suggested that the Secretary get in touch with the State Society Secretary and have it taken up with the State Undertakers’ Association. Dr. Larkin believed that this is a local prob- lem and that the County Board of Health and the County Physicians should be asked to cooperate. The following applications were received and referred to the Board of Censors: 278 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 Drs. John L. Varriano, Jacob A. Riese, Samuel A. Cohen, Henry C. Fattel, and Arthur Trewhella. The following applicants having' been approved by the Board of Censors were unanimously de- clared elected as members: Drs. William F. Schuchner, Benjamin Leavitt, Perry O. Hall, all of Jersey. City, and Morris Green, of Weehawken. Dr. Thomas White, reporting for the County Committee on Post-Graduate Instruction, stated that the program had been completed and was to be given in conjunction with the State Com- mittee. The 2 subjects were obstetrics and gastro- intestinal diseases. They were to include lectures, ward rounds, case illustrations, and obstetric demonstrations, to take between 1 Ms and 2 hours. The course was to be partially clinical, and was to commence after Easter. The members to be given further information through the mail. It was regularly moved and seconded that this re- port be accepted. Scientific Program Dr. Charles B. Kelley: “Gynecologic Thoughts”. This symposium has been arranged at the re- quest of our president, in furtherance of his ideas that local talent can produce programs sufficiently interesting to attract the membership of this society. It has given me a great deal of pleasure to help arrange this presentation, and I have reserved for myself the introductory position in order to outline to you just what our group has attempted to do in carrying out the experiment; whether noble or otherwise we will leave to your judgment. At first glance, our program may ap- pear extremely ambitious; perhaps it is. We have arranged 6 papers which will be covered in very little over an hour's time. Necessarily, only the high spots can be touched by each essayist, but I feel sure this will result in concentrated papers, full of facts. Gynecology is the mother of all abdominal sur- gery. In 1809, Ephraim McDowell removed, for the first time, a large ovarian cyst, and abdominal surgery had its inception in a gynecologic opera- tion. There can be no doubt, historically, that by this operation McDowell earned for himself the title of ‘‘Founder of Abdominal Surgery”. Not only did he revolutionize the treatment of ovarian cyst, which up to that time had simply been ab- dominal paracentesis, but he demonstrated for the first time the possibility of invading the peritoneal cavity. The awe in which the peritoneum had previously been held was dispelled and it was not long before general abdominal explorations had over-shadowed in importance the primary gynecologic event. As this is a symposium in gynecology it would perhaps be well to define gynecology. Dorland de- fines it as being that branch of medicine which treats of woman’s constitution and diseases, es- pecially of the genital, urinary and rectal tracts. The definition is perhaps a little broader than usually accepted although the ability to properly diagnose rectal and urinary diseases is certainly quite properly required of the gynecologist. As my contribution to this symposium, I would like to offer some general thoughts about gyne- cologic diagnosis and in so doing I would em- phasize the fact that gynecologic conditions, with the exception of hemorrhage and ectopic preg- nancy, are seldom urgent. Even ruptured ectopic pregnancy is often best treated expectantly. The term “acute surgical abdomen”, in the sense of meaning immediate operation, seldom applies to the female pelvis. Consequently, in the great ma- jority of cases, the opportunity for careful study is present. The gynecologic history is of a fair amount of importance, but the examination is of far greater importance. A general, physical examination should precede the strictly gynecologic one. This does not have to be slow nor too detailed, but should include listening to the heart and lungs to rule out gross lesions and, of course, should include an abdominal examination. It is well to remember that heart disease often shows itself as uterine hemorrhage. A digital examination of the rectum and also a proctoscopy are often very important, as lesions of the rectum are often the etiologic factors in gynecologic complaints. Many a dysmenorrhea is due to an anal fissure and more than one retro- verted uterus has been due to a redundant and impacted sigmoid. I have seen many cases of retroversion cured by properly given colonic irri- gations. Cystoscopic examination is often a big help, and everyone doing gynecology should be able to distinguish the ordinary bladder lesion. Empty- ing the bladder before a vaginal examination is important. A full bladder may easily be mis- taken for a fibroid uterus. Lumbar pain is due in many instances to causes other than gynecologic, and it is always well to exclude orthopedic conditions as etiologic factors of a backache. Finding a retroverted uterus does not necessarily mean that it is the cause of a backache. More than one abdomen has been opened for pain when the pathology was a tuber- culous spine or a dislocated sacro-iliac joint. Bi- manual vaginal examinations will be helpful in finding pathology in many instances. It seems unnecessary to say that every gynecologic ex- amination should include the use of a speculum; it is surprising that a different impression of a cervix is gained through a speculum than is obtained by digital examination. In recent years, introduction of the insufflation test of the fallopian tubes has been of great value in cases of sterility. But even better- than the gas test is the injection of iodized oil into the tubes; a very reliable and permanent x-ray record may be thus obtained. A very important diagnostic aid is the curet, as this instrument is of far more importance in diagnosis than it is in treatment; and there is a world of truth in that statement. The laboratory is becoming more useful in gynecologic diagnosis. Routine urinalyses and blood counts have their spheres. The sedimen- tation test is often a valuable diagnostic aid. The Ascheim-Zondek test seems to be proving its value in early diagnosis of pregnancy, which of course makes it valuable in cases of suspected ectopics. Basic metabolism readings become of value in interrelated ovary and thyroid disturb- ances. Biopsies and laboratory sectioning are most important diagnostic aids. I once heard John B. Deaver say that “when all other diagnostic aids fail, there still remains the aseptic scalpel”. Fortunately, in gynecology we are getting further away from this philosophy. Exploratory laparotomies are much less frequent than they were. While the opened abdomen still reveals some surprises, we have much more larch, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 279 efinite pre-operative ideas of the pathology than ormerly. Due to improved diagnosis, conditions hat were once quite problematic have been re- uced to a more definite basis. This subject of gynecologic diagnosis might asily use up the time allotted to the entire ymposium, but the attempt of our group has een to give you a real snappy program and con- equently I am pleased to move along, well within he time assigned me and to give way to those rho are to follow. “Noil-Malignant Lesion of the Cervix” Dr. F. J. Quigley: Any consideration of diseased conditions of the uterine cervix should be pre- aced by that of the histologic structure of this mportant portion of the female generative tract, n thinking of the diseases to which it is subject ve must ever bear in mind the fact that its lining nueous membrane is abundantly furnished with ’lands the behavior of which, if infected or :raumatized, is definitely characteristic. The endo- :-ervix, especially, is equipped with a deep epi- :helial layer in which are many compound race- mose glands, normally secreting a considerable amount of mucus. Under pathologic stimulation ;he output from these glands is enormously in- creased. Should drainage also be defective — tvhich is most likely to be the case — the condi- :ions will favor the setting up of a chronic eon- lition which will not be associated with a gland- ular origin. Treatment will be directed toward :he lesions presented by a condition of such long- standing that its actual source may be ent’rely iverlooked. The commonly occuring inflammations of the cervix of the uterus are customarily divided into :hose which affect only the intracervieal mucous membrane — endocervicitis — and those which take place in the squamous epithelium of the cervix’s raginal aspect, in its glands, its muscular struc- :ure, or the entire lining mucosa of the cervical canal, which we term cervicitis. These infiamma- :ions are due in nearly all cases either to gonor- rheal infection, or the entrance of some other or- ganisms during parturition, or other manipulation and trauma to the genital canal. It is probable that trauma alone would seldom bring about extensive inflammatory changes in :he cervical mucosa. It is the practically inevitable entrance of bacteria and their retention and propagation in the glands, which lead to chronic inflammation with eventual invasion of the deeper structures, with the establishment of the wide variety of pathologic conditions making up the bulk of the gynecologist’s daily practice. The necessity for prompt recognition of such a situa- tion and its adequate treatment, should need no emphasis. Cervicitis begins most often in simple erosion. Viewed through the speculum, such an erosion appears as an area of congestion upon the vaginal aspect of the cervix, most often on the anterior lip. Its salmon-pink color differentiates it sharply from the normal tone of the surround- ing mucosa. A section of the involved tissue will sometimes present a rough surface with a partial covering of columnar epithelium. If healing is already well advanced, the surface will be rela- tively smooth and a covering of squamous epi- thelium be visible. In the follicular type of cer- vical erosion, the involved glands in the deeper tissues will have undergone a certain amount of cystic degeneration, with infiltration by round cells, polynuclear leukocytes and the prevailing type of invading organism. When cervicitis is due to gonorrheal infection — less often if some other organism is responsible — the immediate result of invasion is hypersecre- tion from the racemose glands. When the infec- tion has become chronic we have hyperplasia of these glands, and this may later bring about stricture or even complete occlusion of the cervi- cal canal. With this interference with drainage, the conditions for continuance of the infection become even more favorable. The retained secre- tions macerate the tissues, stimulating them to greater activity, resulting in still further hyper- plasia and the discharge of an even more exces- sive secretion. The difficulties which are ex- perienced in breaking the vicious circle thus in- itiated are many, and vexatious to patient and physician alike. The use of local applications — ioain, nitrate of silver, sulphate of zinc — has long been the regu- lar gynecologic routine, followed by douching and the insertion of tampons. In a certain percentage of cases these measures relieved, or even cured the patients. More often the effect was briefly palliative, or wholly ineffectual. High amputa- tion, which removed all the affected tissue, often found favor, but in many instances the cure has proved far worse than the original disease. Par better is the Stur-mdorf procedure, which excises the diseased glands but leaves most of the muscu- lar structure. If we are faced with a condition of long-standing, old tears with extensive scar tissue, nothing but radical measures will be of any avail. Operation thus becomes our only alternative. Milder treatment, as by cauterization or dia- thermy, has no place in such conditions. The erosions following recent delivery, and the cervicitis seen at this time, can often be well handled by diathermy, provided they have not been too long neglected. Heat treatment should not be used if pelvic dellulitis is present, or in the early acute stages of inflammation, particularly that of gonococcal origin. In chronic gonorrheal cervicitis diathermy is particularly successful. This organism succumbs at a temperature of 113°. Within the cervical canal it is possible to maintain a temperature of 116° to 118° P. with- out the slightest discomfort to the patient nor damage to the tissues, for a period of 40 minutes or more. The indications for use of this agent are, however, too limited to permit its very gen- eral employment in the routine treatment of cervical infections. For the majority of cervical, conditions some form of cauterization will prove most helpful, but one must select with considerable care the type of lesion to be dealt with in this way. It must be kept in mind that external treatment is sel- dom enough. Frequently the endometrium is diseased all the way from the internal to the ex- ternal os. Under such circumstances only deep cauterization, after careful dilatation, will be of any lasting benefit. For that large group of women presenting conditions too well established to be wiped out by local applications, but not sufficiently .serious to call for the Sturmdorf or other operative intervention, the Dickinson cauterizing method of- fers the most efficient aid. Some gynecologists of wide experience do not favor the idea of re- peated slight cauterization, feeling that a single deep application is more logical and generally effective. I am of the opinion that the operator’s professional judgment must be the guide. Each case must be individualized. The only general- 280 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 ization possible is that, the longer the condition has been present the deeper will the infiltration of the tissues be, and, consequently, so much more drastic will be the measures required for their eradication. Graves, of Boston, not long ago told me that he seldom applies the cautery more than once, depending upon the thoroughness of this single treatment to bring about abatement of the glandular infection. Dickinson's technic aims to produce an in-roll- ing of the inflamed lips as scar formation takes place, stricture of the os being thus avoided. This is important in women who can be expected to bear more children. Using a cautery outfit simi- lar to that employed in nose and throat work, a fine platnium tip burns “tiny gutters’’ about V4, in. apart. If only small areas are eroded it will be sufficient merely to puncture the affected tissue at frequent intervals. This treatment is repeated at intervals of about 2 weeks. If cystic degenera- tion of the glands has taken place, the fine cau- tery will open up the cyst, a tenaculum holding open the canal so that it can penetrate to the very lowest depth reached by the disease. This method has many advantages, and if prop- erly used will save the great majority of women suffering from cervical inflammation the strain and expense of surgical interference. General anesthesia may at times be neces- sary, but in the average office patient it can usually be dispensed with. It is important to have the canal thoroughly dry before the cautery is applied. Too great heating of the tip is likely to cause bleeding, which interferes with operator and operation alike. Though a description of the method sounds simple enough, as many other things outside the practice of medicine as well as in it, practice is necessary in or- or to obtain the best results, and it is only by experience that one can learn exactly when and where to apply it. Because cervical infection is such a common finding, and the presence of a discharge is taken as so much a matter of course by* the majority of gynecologic patients, we are often prone to over- look its importance. Anything that interferes with free drainage from the genital canal is of gave consequence, and a disregarded benign les- ion may eventually lead to something quite beyond hope of any aid from us. There is impressive evidence that the pathologic cer- vix may serve as a focus of infection quite as virulent as tonsil, appendix or gall-bladder when similarly invaded by bacteria. The re- lation of birth trauma and other injuries of the cervix to malignant disease, has been too widely discussed to make it necessary for me to dwell upon it. The routine care of such lesions is tire- some and, apparently, often unprofitable both spiritually and financially. But as a measure of preventive medicine and a step toward the con- trol and eradication of one of the greatest afflic- tions of womanhood, it immediately assumes dignity and consequence — something quite worthy of our best efforts and highest professional skill. Dr. Margaret Sullivan Herbermann : “Acute Pel- vic Lesions.’’ In early and accurate diagnosis of acute pelvic lesions, one must have in mind 2 out- standing thoughts: (a) The conservation of life, (b) The importance of conserving, as much as possible, the function of the pelvic organs. Be- cause of the future comfort and welfare of the patient, avoid unnecessary removal of the pelvic organs, the early artificial menopause, with sub- sequent suffering and neurosis and the arresting of the child-bearing functions. These factors have great influence on the patient's future. In cases where surgery is indicated, it is important that an early diagnosis should be made without loss of time because: (a) Hemorrhage may take un- due toll, (b) Sepsis may have made such progress as to seriously damage the patient’s chance of either life or complete restoration to health. Acute pelvic conditions should, therefore, be classified into surgical and nonsurgical. Surgical: (1) Septic abortions. (2) Ectopic pregnancy. (3) Tumors having twisted pedicles — either fibromas or ovarian cysts. (4) Accidental perforation of the uterus. Nonsurgical: (1) Septic abortions; no curretage where there is fever or sign of per- itonitis. (2) Acute puerperal sepsis. (3) Acute salpingitis. Development of sepsis requires time between the implantation of septic contamination and the picture of septicemia — the interval depending upon: (1) The invading organism. (2) Resistance of the patient. (3) Site of the septic implanta- tion. Such interval is longer in the pelvis than in the upper abdomen. Gonorrhea is the exciti-g factor in most cases. Most seriously infected cases have followed pre- liminary instrumentation, and infection rarely follows a single invasion of the uterus, but usually follows repeated instrumentation. Dissemination of infections occurs chiefly through the walls of the uterus and frequently begins at the site of the placental implantation. Pelvic cellulitis resulting from such infection should, if treated by surgical means, delay oper- ations from 6 months to 2 years. Indications for surgery: (1) Persistent pelvic pain with disten- sion1, some rigidity. (2) Functional bleeding. (3) Chronic ovarian abscess. (4) Inflammatory masses which arrest function or menace health. (5) Chronic intestinal obstruction due to pressure of inflammatory processes on intestinal tract. Pelvic peritonitis associated with acute salp- ingitis is treated upon expectant lines. Except when a definite abscess forms, which should be drained through the cul-de-sac, salpingitis should be treated conservatively. It usually localizes and the child-bearing function may ,be preserved. Even if there is doubt about the diagnosis, it is far safer to make an incision and retire without further interference. Mayo says he has seen many cases die when no exploratory has been made, but he has not seen any one die as result of an ex- ploratory operation. Dr. James L. Cobham: “Early Diagnosis of Pel- vic Infections.’’ The fact that pelvic malig- nancies are usually unattended by pain in their early stages places upon the physician a grave responsibilty. When symptoms have arisen which justify the classification of cancer, as such, a favorable prognosis may be considered ex- tremely doubtful. On the other hand, the stage of the disease in which treatment is instituted is a prime factor influencing prognosis, as it is well recognized that the average period of ex- tension of malignancy beyond its localized limi- tations is only from a few weeks to a few months. The task of the physician is further compli- cated by the fact that cancer is often superim- posed upon a noncancerous condition at some site of chronic irritation or a benign tumor; in fact it may safely be said that the earliest symp- toms of cancer are really those of the precan- cerous condition itself. March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 281 In considering malignant disease of the female generative organs, carcinoma of the cervix is, by far, the most frequent type with which we have to deal; this has been ably shown by Ewing in his studies of 8 55 8 cases of malignant tumors in Women at Memorial Hospital covering a period of 12 years. He found cervical cancer ;n 2134 in- stances, or 24.9% of the entire group, while car- cinoma of the body occurred in only 233, or 2.61%, of the entire group. Malignancies at these 2 sites differ widely in etiology and behavior; nor does the age incidence correspond; carcinoma of the cervix is most frequently seen in women who have borne children and are between 40 and 50 years of age, while that of the fundus occurs at the average age of 55 and in those who are single or have had a sterile marriage. For practical purposes, an accurate diagnosis of the extent of cervical cancer is of prognostic importance and Greenough has set a standard. (1) Where the disease is limited to the cervix — - prognosis good; (2) extension to the uterine body or vaginal wall; (3) to the broad ligament; (4) widespread, producing extensive pelvic fixation and involving bladder, rectum, lymph-glands and even remote organs. The early symptoms of cervical malignancy are so general that the physician, as well as the pa- tient, may be entirely unsuspecting. A suspicious symptom is leukorrhea with intermenstrual bleed- ing. Do not wait for pain because, as a rule, when this appears the disease is too advanced for cure. The initial vaginal discharge may not dif- fer from ordinary leukorrhea, except in quality. It soon, however, assumes a watery consistency, characteristic of cancer, and should lead to a thorough examination of the patient. At a later stage, the discharge gives evidence of infectious decomposition and is of a foul odor. Small, bluish white, glazed nodules are often seen on the in- durated cervix. Another important diagnostic sign is intermenstrual bleeding due to trauma of the eroded cervix in ordinary muscular move- ment, or during coitus or digital examination. In the advanced stage, the diagnosis is most obvious and needs no mention. Leukorrhea, menorrhagia, metrorrhagia, and the eroded hypertrophied cer- vix demand a microscopic examination by biopsy. Some men oppose this but the concensus of opin- ion agrees with Greenough that biopsy is safer than delay. There are several conditions that simulate cancer of the cervix and, among them, are deep-seated Nabothian cysts, chronic cervi- citis, tuberculosis, syphilis and sarcoma. Here, again, the importance of biopsy cannot be too strongly emphasized. Prophylaxis against cervical cancer deserves a word. Since one of the impulses that start cel- lular activity upon its wild ungoverned growth is conceded to be some sort of chronic irritation, it is obvious that removal of abnormal friction and repair of conditions, causing mechanical or chemical irritation, cannot be overlooked. In this connection, I mention infected leukorrheal dis- charge, malposition of the cervix, ncomplete drainage from the genital canal and repair of traumatisms after child-birth. In the majority of cases, the symptom pointing to cancer of the body of the uterus is spotting of a pinkish, or crimson hue after the menopause. In addition, a profuse watery discharge is usually present. Before menopause, a symptom may be menorrhagia or metrorrhagia. As in cervical cancer, pain is not evident until the disease is ad- vanced. As in cervical cancer, too, the final diag- nosis can only be made with the microscope. Since the uterus may be completely invested with cancer but retain its normal size, the sense of touch is of little diagnostic value. A warning note may be sounded here that, since corpus cancer ex- hibits a strong tendency to seed implantation, manipulation, in curettement of the uterus for a biopsy specimen, should be exceedingly gentle so as not to force cancerous material, if present, into the fallopian tubes. (Sarcomas, originating in the cervix or body of the uterus, are fortunately rare, and, when they do occur, the early symptoms are very similar to those of cancer; especially so, the diffuse variety, and the diagnosis can only be made with the mi- croscope and curette; even this may fail if the endometrium is not involved. By the time the dis- ease exhibits its grapelike, polypoid mass from the cervix, or the finger detects the soft, smooth growth on the endometrium of the uniformly en- larged softened uterus, or bimanual examination reveals the hard nodules of fibrosarcoma, the dis- ease is beyond control. Carcinoma and sarcoma of the ovary, in their early stages, have no distinguishing features, from benign growths except earlier onset of pain. Ewing found carcinoma to have occurred in 1.88% of his entire group and the age period varied from 5 years to 6 5. Unfortunately, when most of these cases are seen, it is too late, due to the early and extensive metastasis. Any woman pre- senting herself, complaining of pain, with any alteration in the menstrual cycle, and enlarged, tender adnexa, should be regarded as a possible malignancy. Dr. John B. Faison: “Therapeutics of Pelvic Malignancy”. The purpose of this paper is to summarize, as briefly and concisely as possible, the present status of the treatment of pelvic malignancy with particular reference to cancer of the cervix and body of the uterus. Roughly speaking, 25% of all carcinomas that afflict the female occur in the uterus and, unfor- tunately, cancer incidence is steadily increasing. Almost all of us are called upon, at some time or other, to face the problem of what to do for a patient with uterine cancer, and at such times our first thought is naturally what wlil give this woman her best chance for survival. And this is often no easy question to decide for it involves many factors: the nature of the growth; extent of the disease; condition of the patient; and most vexing of all, the, procedures to'be followed — sur- gery or radiation, or both. Obviously, all carcino- mas of the uterus are not alike in their cellular make-up, nor are they encountered at the same degree of advancement, and since the results to be expected from any form of treatment depend almost entirely upon these variations we must consider them closely before a prognosis can be made. It is now the practice to try to place these neoplasms clinically under 1 of 3 heads, namely, early, border-line, and advance. In carcinoma of the cervix the early group is composed of cases in which the malignancy is localized to the cervix. The border-line cases are those showing slight extension into the tissue about the cervix, with moderate fixation of the cervix but a freely mov- able uterus. The advanced group comprises those cases in which there is wide extension in all planes with complete or almost complete loss of mobility. In carcinoma of the body the gradation is an- 282 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 alogous except for the added factor of uterine enlargement. Our next consideration is the histology of the growth. It is a well known fact that cancerous growths of the uterus, even though discovered in an early stage, may show widely different de- grees of response to treatment in different in- dividuals. Allowing for the so-called personal factor, why should this be? The answer lies in the cellular make-up, or histology, of the tumor. The lining epithelium of the corpus uteri is columnar celled and malignant growths of the body are almost invariably adenocarcinomas. I am purposely omitting reference to sarcoma and chorio-epithelioma which are exceedingly rare forms and are almost never seen by most of us. These cancers are relatively slow growing and are fairly uniform as to rate of growth. The lin- ing epithelium of the cervix, on the other hand, is almost entirely squamous celled and unlike the body there are- widely marked degrees of cell pro- liferation and malignancy. This fact has been recognized by pathologists for years but it is only recently that its significance with relation to treatment and prognosis has been realized. It is on these histologic variations that Broders, of the Mayo Clinic, and Ewing, of the Memorial Hospi- tal, have based their gradations of squamous cell carcinoma. Dr. Ewing’s classification, which is most commonly used in and about New York, recognizes 3 grades based upon the degree of anaplasia of the tumor and by anaplasia is meant, in brief, collularity, variations in shape and size of nuclei, tendency to infiltrate, number and qual- ity of mitotic figures, and absence of adult cell characteristics. At one extreme there is a small group (about 17% of total) showing tumor cells closely ap- proximating the adult normal cells and with marked squamous tendencies, which he calls Grade 1 or Adult type. At the other extreme is another slightly larger group (21% of total) where the cells have lost all differential character- istics and show marked powers of proliferation and infiltration; the anaplastic and highly malig- nant form. In between, is a larger group (ap- proximately 62%) which shows characteristics in- termediate between the extremes and which is called the “plexiform type”. The great impor- tance of this histologic classification, upon the prognosis and mode of treatment, will, I hope, become apparent as we go on. Now as to treatment. First, let us consider carcinoma of the corpus uteri. As has been said, it is much less frequent than carcinoma of the cervix; about 1 out of 10 cases of uterine malig- nancy occur in the body. It grows relatively slowly, spreads first by direct extension to the parametrium and involves the lymphatics later. For these reasons it is usually considered to be, in favorable cases, primarily a subject for sur- gical attack. My own feeling is that, except in very early cases, it should be treated by com- bined radium and surgery. Cancer being what it is, it behooves us to give our patients every pos- sible chance for recovery and thorough irradia- tion of the uterus before operation, with maxi- mal possible tumor destruction and lymphatic blockage, certainly seems to be a safer and more reasonable procedure than surgery alone. The morbidity from treatment is slight and if 2 to 3 weeks are allowed to elapse before operation, the technical difficulties for the surgeon are enhanced very little, if any. Late cases, which are in- operable, leave us no choice. Here, radium and deep x-ray therapy, as palliative agents, are generally regarded as the only therapeutic means at our disposal. The treatment of carcinoma of the cervix presents quite another problem. Here we have marked variations in tumor histology to consider as well as the degree of extension of the disease. And this is where the pathologist's gradation is of vital importance. Recent work at the Memorial, in New York, has shown a distinct relationship between the cel- lular structure of a tumor and its response to radium or surgery. In other words, the more anaplastic or malignant the growth the greater its sensitivity to radium and the more prompt its recurrence following surgery. Conversely, the less anaplastic and the more adult the cell type the greater its resistance to radium and better the results from operation. In other words, the point I am trying to make is this, we must know accurately not only the extent of disease but also the histologic nature of any cancer of the cervix before we can know how to serve the best interests of our patient. And what is best for the patient with this disease? To my mind the answer is definite — complete and thorough irradiation — and the easiest way to prove this contention is by comparing the end-results of surgery and rad-ium. Dr. Wm. P. Healy, Attending Gynecologist to the Memorial Hospital, has kindly allowed me to use the following statistics taken from his ser- vice for comparison with analogous groups re- ported by the Johns Hopkins Hospital and the Mayo Clinic. These figures represent 200 cases of proved carcinoma of the cervix treated in 1922-23 by radiation as compared with the same number treated surgically. Radiation Surgery State Per Cent Cured J. H. H. Per Cent Cured 5 yrs. Mayo Clinic Per Cent Cured Grade I Operable 50 47 53 Advanced 4 Grade II Operable 43 Advanced 14 24 21 Grade III Operable 66 Advanced 42 9% 9 V2 Analysis of these figures shows that only one group (Grade I) 17% of total cases, is surgery comparable to radium as far as end-results go. In group II, the advantage of radium is marked; in Group III (the highly malignant type), it is overwhelming. In other words, sur- gery at best has little to offer except in a rela- tively small percentage of early and border-line cases of the adult type. And even there, it offers no advantages over radium in end-results and im- poses a major surgical procedure and relatively long hospitalization upon the patient besides. In the highly cellular, malignant group radium at times works almost miracles, with a record of G6% 5-year cures in so-called operable cases and 42% cures in advanced cases as compared with 9 Vi % cures, obtained in early cases only, by the most expert operators. Therefore, since the histologic gradation of epi- dermoid tumors has not yet been widely adopted by pathologists over the country, and since sur- gery even in properly selected cases imposes a greater physical and financial strain upon the patient, than radium, it is my belief that car- March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 283 cinoma of the cervix should be a problem for radiation and radiation alone. As for malignant diseases of other pelvic or- gans, such as ovary and fallopian tube, suffice it to say now that results with radiation alone are not very satisfactory- Radium and the x-rays have some value as palliative agents but our main hope in these diseases is still early and competent surgery. By way of summary, we may say that: (1) Cancer of the corpus uteri in early or border-line cases is best treated by surgery, al- though pre-operative radiation would seem to be advisable if there is any question as to extent of the disease. In late cases radium is useful for palliation. (2) Carcinoma of the cervix is preeminently a condition for radiation and the results we may expect from this method of treatment depend in large measure uion (a) the clinical degree of the d.sease — early border-line or advanced; and (b) adult type and radio resistant, anaplastic type and radiosensitive or intermediate type. These factors, if kept in mind, may make a trifle easier the approach to an unfortunately obscured and complicated question. Dr. Frank J. McLoughlin. “Importance of the Pelvic Fascia in the Repair of Cystocele and Rectocele.” Injuries to the birth canal resulting in hernias of the pelvic tract. Fascia is to be used in their repair as it is now being used in the repair of other forms of hernia. Rectocele is due to injury of the rectovesical fascia. There are three layers to be considered. (1) The layers of fascia on the 2 surfaces of the levator ani muscle. (2) The triangular ligament. (3) The rectovaginal fascia. Dr. McLoughlin gave a lantern slide demonstra- tion of the fascial layers and the development of cystocele and technic of repair. This was fol- lowed by a similar group of pictures depicting rectocele development and repair. In conclusion he stated, that since rectocele and cystocele are essentially hernias, the available fascia should foe used for their correction. Bayonne Hospital Clinical Conference Maurice Shapiro, M.D., Secretary The regular meeting of the Clinical Conference of Bayonne Hospital was held Monday evening, February 2, at 9 o’clock. In the absence of Dr. Donohoe, Dr. Sexsmith acted as Chairman. Dr. Morgensteiru reported for the service of Dr. Weiss. Case 1. Cardiovascular syphilis with multiple aneurysms. A. C., aged 68, male, admitted December 17 with swelling of right knee and in- ability to walk. Three weeks prior to admission knee began to swell tremendously and then could not move knee at all; is mentally dull, very inco- herent, and connected history could not be ob- tained. Denies venereal history. Pupils did not react to light, but did react to accommodation. Low systolic murmer at apex; low diastolic mur- mer at aortic area. Heart enlarged. In right axilla there was a marked pulsation. Radial and brachial arteries markedly tortuous and pul- sating. Corrigan pulse at wrists. Right popliteal artery greatly enlarged, and forming a pulsating mass. Left knee swollen and painful over an- terior aspect. Numerous varicosities in both legs. B. P. 156/62. Wassermann and Kahn tests posi- tive. While in hospital general condition became gradually worse; developed Cheyne-Stokes’ res- piration, and expired on January 14. Case 2. Chronic rheumatic endocarditis. Z. P., aged 26, admitted for last time on June 16, com- plaining of difficulty and shortness of breath, ab- dominal distention and edema of ankles. Present illness began about 3 yr. ago with swelling of legs, dyspnea on slight exertion, orthopnea, associated with an intermittant non-productive cough. Was sent to hospital at that time and condition im- proved in a few weeks so that he was discharged. A year later dyspnea and cough returned. Was re- admitted to hospital and after a few weeks im- proved and was again discharged. Some time later gave history of having been struck in ab- domen with a baseball and above symptoms again recurred, and after another stay in the hospital was again discharged as improved. Had several more readmissions with same symptoms until present time. Heart very much enlarged; loud systolic mur- mur at apex; fibrillation present. Lungs: moist, crackling rales present at bases posteriorly, with dullness. Progress very unfavorable; developed marked ascites, severe dyspnea,, became very despondent, refused medication and went into a coma for several days. Toward the end, became markedly cyanotic and finally expired on January 25. Case 3. Subacute endocarditis. E. M., aged 20, female, admitted January 10 complaining of sore- ness of right shoulder and swelling of right leg. Influenza 11 weeks before and had been confined to bed ever since. During this period she had cough, chill, fever and dyspnea. About 2 weeks prior to admission she got up from bed against doctor’s orders, and soon began complaining of pain in right ankle and knee joint. Loud systolic murmur at apex transmitted to axilla; also mur- mur over aortic area, systolic in time. Tempera- ture from subnormal to 105°. Blood culture showed Streptococcus viridin. Given total bed rest, salyeilates and supportive treatment. Still alive. Has periods when she feels better but condition is practically unchanged. Dr. Sklar, discussing the prognosis of bacterial endocarditis, stated that text-books all claimed a 100% mortality. However, at a recent confer- ence at the Academy of Medicine, Dr. Emanuel Libman presented several cases of cured subacute bacterial endocarditis. Dr. Antapol then told of the healing and of healed subacute bacterial endocarditis cases which developed glomerulonephritis. Dr. Sexsmith questioned why so many children should have rheumatic heart conditions at an early age, proceed to grow normally without any bad signs in spite of the fact that loud murmurs are heard in the heart, and that at the age of 17 or 18 he finds no evidence of damage to the heart; that in his opinion 90% of these cases get well and show no after symptoms. Dr. Antapol replied that in spite of rheumatic in- volvement the individual may be compensated and die of some condition other than rheumatic involvement of the heart. There is also patho- logic evidence of repeated acute attacks, one superimposed on another. Cases have also been observed in which at death no evidence of rheu- 284 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 matism was present, and yet Aschoft bodies were found in the myocardium even though the last clinical attack had been observed 17 years pre- viously. Dr. Fifer, service of Dr. Sexsmith, presented a case of fracture of the femur with over-riding. F. D. V, male, aged 19, was admitted November 12. Sustained an injury to left thigh in automo- bile accident. Admitted to hospital immediately after accident. X-ray examination then showed an oblique fracture at the middle of the femur, with a slight amount of over-riding, probably about iy2 in.; lower fragment displaced inward and backward. A Buck s extension splint was applied. On December 1 — 19 days after admis- sion— radiograph disclosed the fragments with the same alignment, but the over-riding more marked. On December 5, a spica cast was ap- plied. Three days later, x-ray examination showed the fragments to be in the same position as previously reported; a very slight amount of callus seen; an over-riding of at least 3 in. and the lower fragment displaced inward and back- ward. Buck’s extension apparatus was re-applied with 24 lb. weight. On December 22, a reexamination of the frac- tured femur showed the fragments in about the same alignment but the amount of over-riding markedly diminished. The extremity was kept in counter extension until January 20 — 9 weeks after admission — and as there was still no evi- dence of union an open reduction was decided upon. Under ether an incision was made at the outer side of the thigh through the skin and superficial fascia, along a line from the anterior superior iliac spine to the outer angle of the patella. The external circumflex vessels and nerve were retracted proximally upward, the vastus intermedius was divided in its upper part, and the shaft of the femur exposed. The ends of the fragments were found to be over-riding approximately ‘1% in., and covered with fibrous tissues. There was no union between the frag- ments. The line of fracture was at an extremely oblique angle, which made it impossible to bring the fragments together. An attempt was made to sever the irregularity on the distal fragment, by means of a Gigli saw, but without success. Ron- geur forceps were then resorted to and the pro- jections of bone on both fragments were pared off. It was then possible, with the aid of counter extension on the foot and leverage under the frag- ments, to approximate the bones so that the normal anatomic relationships, as in horizontal and right angled planes, were restored. Upon ro- tating the foot from side to side, the entire femur now rotated with it. The deep muscle fibers, to- gether with the retracted periosteum about the fracture site, were then approximated with in- terrupted sutures. No drains were inserted. The skin incision was closed with interrupted silk- worm gut. A plaster of paris spica was applied from the pelvis to below the knee, with a window at the site of incision. The patient’s immediate postoperative condition was good. On the follow- ing day he complained of considerable pain and discomfort in sacral region. A cotton pad was applied. Two days later, patient took it upon himself to cut away cast from pelvis. Radiograph showed fragments in much better alignment, as compared to previous examination, but lower fragment still showed a slight posterior displace- ment. The particular point of interest in this case Is the lack of cooperation of the patient and the amount of damage that can be done by a patient of that type. The Surgical Service also brought up a dis- cussion as to the proper time for amputation in traumatic injuries of the legs. The question is one which has been under discussion for a long time. Some authorities claim that the amputa- tion should be done before the patient comes out of his initial shock, while others say wait. Drs. Sexsmith, Pinkerton and Chayse were all of the opinion that the mortality in early amputation is far greater than in later amputation. Dr. Chayse brought out the interesting fact that in the war most amputations were done anywhere from 1 to 3 weeks after the injury and that the death rate was low. However, one must take into con- sideration the fact that these men were young and in good physical condition. In civilian life, we have to deal with people of all ages and physical disabilities and that there can be no set rule as to when to amputate. Dr. Eisner reported a case of subcutaneous emphysema of the chest in conjunction with a case of pneumonia on the service of Dr. William- son. Patient entered January 16. Chief com- plaints were cough, vomiting, chills and fever. Duration of present illness was 1 day. Began with slight “head cold”. The next morning, following a severe vomiting and coughing spell, tissues around the neck and upper thorax began to swell. There were 2 soft cushion-like swellings of the upper thorax and swelling involving the sub- cutaneous tissue of almost the entire neck, face and scalp, and downward the chest wall, ab- domen and even thighs. It was impossible to auscultate because of the crackling of air in the tissues. Dr. Pinkerton reported a case of papilloma of of the vagina in a woman 29 years of age. There was a cauliflower mass filling the vaginal en- trance which appeared to be on the right labia extending above the clitoris. This mass had the appearance, grossly, of a malignancy. Wasser- mann was negative. Biopsy was negative as to malignancy but suggestive of lues. The mass was removed and a broad fibrous base attached to the labia was found. The base and mass were cut away and the stump coagulated by surgical dia- thermy. MERCER COUNTY A. Dunbar Hutchinson, M.D., Reporter The Mercer County Medifcal Society met in the Carteret Club on February 11, President Swern in the chair. The usual order of business was suspended, and the program taken up at once. “Diagnosis and Treatment of Non-Tuberculous Diseases of the Lungs’’ was discussed by 4 emi- nent men from Philadelphia. Dr. Elmer H. Funk defined in a most entertaining manner the clini- cal symptoms. Dr. John T. Farrell, Jr., described in detail the value of roentgenologic study. Dr. Louis H. Clerf emphasized the importance of bronchoscopy with lipiodol instillations. Dr. George Willauer, speaking upon the surgical as- pect, outlined in a general way the several heroic measures employed. The speakers confined their discussions to 3 March, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 285 conditions most frequently diagnosed; abscess bronchiectasis, and new growth. The applications of Drs. Harry J. Majeski and Anthony J. Lettiere were read and referred to committee. Drs. Vartan Kachdorian and Joseph Ragany were elected to Associate Membership. Dr. Little reported that the Post-Graduate Course will consist of 3 subjects: Operative Gyne- cology; Newer Therapy; and Pediatrics. A report of the Committee on Public Relations, relative to printed forms, explaining the value of toxin-antitoxin to accompany birth certificates, was read and the recommendations endorsed and the committee authorized to confer with Plealth Officer Alton S. Fell. Dr. D. L. Haggerty gave a very interesting ac- count of recent legislative action, urging on every member the necessity of attendance upon hear- ings that may be called. Expressions of regret concerning the present illness of Dr. C. J. Craythorn were attended by a motion that a remembrance in the form of a basket of flowers be delivered to him. MONMOUTH COUNTY W. Von Oehsen, M.D., Reporter The monthly meeting of the Monmouth County Medical Society was held at the Red Bank Yacht Club, Wednesday evening, January 28, with Dr. William K. Campbell presiding. Minutes of the previous meeting were read and approved. Com- munications were read and ordered filed. A let- ter was read from the First Aid and Safety Squad of the Belmar Fire Department in which it was requested that the doctors cooperate with the squad by giving them a special memorandum, or order, to prevent delay at hospitals. On motion of O. R. Holters, seconded by H. B. Slocum, the matter was referred to the Committee on Public Relations. J. C. Clayton reported, as a member of the State Society Welfare Committee, the opposition to passing the so-called Jones-Cooper Bill. On motion of Dr. Clayton, seconded by W. G. Herr- man, it was carried that the Secretary write to Congressman H. G. Hoffmen and advise him of our opposition to this bill, which is a revival of the old Sheppard-Towner law. On motion of Dr. Clayton, seconded by Dr. Warner, the Minimum Fee Schedule of the County Society is to be enclosed to all new mem- bers at the time of notification of election to membership. It was also moved and carried that a Code of Ethics be incorporated in the new Con- stitution and By-Laws. On motion of Dr. Slocum, seconded by Dr. Clayton, it was carried that when the new Constitution and By-Laws are accepted all present members and all new members be re- quired to sign same. Drs. J. Nelson Douglas, of Manasquan, Emer- son S. Haines, Asbury Park, and Benjamin S. Levine, Asbury Park, were elected to membership. The applications of Drs. Morris Woronoff, Frank Niemtzow, George G. Reynolds and William Mat- thews were read and referred to the Board of Censors. Dr. George N. J. Sommer, President of the State Medical Society, spoke on the revival of the Woman’s Auxiliary. The paper of the evening was given by Dr. David Warren Kremer, on “Circulatory Disturb- ances of the Extremities in Diabetes”. A buffet lunch was served. PASSAIC COUNTY Wayne W. Hall, M.D., Reporter The regular meeting of the Passaic County Medical Society was held at the Health Center, Paterson, February 12. The minutes of the Jan- uary meeting were read and approved. The scientific program consisted of a paper on the “Treatment of Bright’s Disease”, by Dr. Rolfe Floyd, Attending Physician, Roosevelt Hospital, New York. This paper stimulated considerable discussion and the speaker was requested to send it to the Journal for publication. The following doctors were elected to member- ship: Fritz Plinke, 99 Gregory Avenue, Passaic; Nicholas Palma, Broadway, Paterson; George W. Surgent, Clifton, N. J., by transfer from the Al- bermarle County, Virginia, Medical Society. The following applications for membership were received: James Marshall Allen, 67 Main Avenue, Passaic; Albert S. Irving, Radburn; and M. Joel- son, 122 Paterson Street, Paterson. Dr. Carlisle announced the schedule of lectures to be given each Friday at 8:30 p. m., beginning in April. There will be 4 lectures devoted to gas- trointestinal surgery and 4 to medical gastro- enterology. The fee for this course is $30. SAT/EM COUNTY William H. James, M.D., Reporter The Salem County Medical Society met at the Memorial Hospital, Wednesday, February 11, at 2 p. m. The meeting was not very largely attend- ed owing to the epidemic of La Grippe and var- ious other winter diseases. President Frank Perry, of Woodstown, called the meeting to order and we had as our guest speaker Dr. Frederick J. Kalteyer, Associate Pro- fessor of Medicine at Jefferson Medical College. Dr. Kalteyer gave a most interesting lecture on Constitution and Colitis, illustrated by moving pictures from the Mayo Clinics. Among other things, Dr. Kalteyer said that frequent purgation that produces watery stools is very dangerous. The essential remedies were rest and diet. Chronic constipation in time will produce anemia, skin eruptions and dizziness. The paper was freely discussed and a great deal of practical knowledge was obtained. At the close of the meeting the usual dinner was enjoyed at the Johnson Hotel. SOMERSET COUNTY J. L. Young, M.D., Reporter The Somerset County Medical Society held its meeting in the Nurses’ Home of the Somerset Hospital on February 12, Dr. E. G. Brittain pre- siding. The following applications for membership in the Society were read: Drs. Louis D. Hind, S. H. Husted, Alfred Sferra, Berner Wallock, and George E. Barbour. These applicants were voted upon and made regular members. Letter read from Dr. Carrins asking to be al- lowed to withdraw his application since he was not going to locate in New Jersey; withdrawal was granted. Communication from Dr. Lathan asking that the society investigate telephone company’s list- ing names in telephone directory as doctors. Mo- 286 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY March, 1931 tion made and carried that secretary investigate this matter and answer as he saw fit. The president appointed Drs. Ely, Halstead, and Lawton as members of Good and Welfare Com- mittee. There was an open discussion as to the rights of insurance companies to regulate medical fees in compensation cases; following this there was appointed a committee of 3 to formulate a reso- lution condemning this practice of insurance com- panies. SUSSEX COUNTY P. H. Morrison, M.D., Reporter The bimonthly meeting of the Sussex County Medical Society was held January 29 at the home of Dr. F. p. Wilbur, in Franklin. There was a large attendance of county physicians and a most enjoyable evening was shared by all present. The guest speaker of the evening was Dr. Spencer T. Snedecor, of Hackensack, who spoke on “Medical Economics”. Dr. J. Bennett Morrison, Secretary of the New Jersey State Medical Society, and Dr. Henry O. Reik, Editor of the New Jersey State Medical Society Journal, were also present and made brief addresses. Following the official session, the doctors and their wives enjoyed a buffet supper which was served by Mrs. Wilbur and Mrs. Drake, acting as hostesses. Obituaries BLAKE, Duncan Williamson, of 212 Third st., Gloucester City, New Jersey, who was born of Amos R. and Elizabeth F. Blake, March 7, 1844, in Philadelphia, died at the age of 87. He was married and had five children. Dr. Blake attended Terall’s Academy, Chester County, Pennsylvania, and graduated from Jeffer- son Medical College. He reported for military duty during the civil war and was present at the sur- render of General Lee to General Grant at Appo- matox Court House. He was also Pension Exam- ining Surgeon, at Camden; member of Chosen Freeholders of Camden County; and member of Board of Education and School Physician, Glou- cester City. He was especially interested in edu- cation. Resolutions on the death of Dr. Duncan W. Blake, Sr., adopted at a special meeting of the Camden County Medical Society: Whereas it has pleased Almighty Providence to remove by death from our professional circle, Dr. Duncan W. Blake, Sr., an honorary member of this Society; Be it Resolved, That we hereby give expression of our sorrow at his departure; and to do honor to his memory. Dr. Blake was active in the professional and also the political affairs of this county; and he truly represented that fast disappearing type— “The Old Family Doctor.” As a general practitioner of medicine, he was recognized by his confreres as a very able mem- ber of the profession and he was beloved by a very large clientele, whom he served so faithfully for a long period of years. H. F. PALM, M.D. J. F. LEAVITT, M.D. W. H. PRATT, M.D. KITCHEN J. M. W., of East Orange, died February 3, at the age of 84. Born in Newark, Dr. Kitchen was educated at Newark Academy and Pennsylvania State College, where he received the degree of M. S. Choosing a medical career, he entered the College of Physi- cians and Surgeons of Columbia University, gradu- ating as an M.D. in 1882. He practiced in New York 18 years before removing to East Orange. Dr. Kitchen was widely known some years ago as a crusader for pure milk and inventor of de- vices for saving fuel and heat. The pride of Dr. Kitchen’s long list of inventions was a sanitary milk container devised after much experimenta- tion on a farm he had in New Hampshire. He also conducted experiments there on cattle breed- ing and crop production. Going to East Orange at the turn of the cen- tury after practicing medicine in New York, Dr. Kitchen took special interest in the pure milk problem and became a leader in raising the stan- dard of milk, especially that for infant feeding, lie was keenly interested in civic affairs and wrote extensively about them. He founded a dairy com- pany in East Orange that produced milk under what were called the Robinswood Farm methods. His container was designed to protect milk in bottles from infection. His other devices pertained to production of heat, light and power. Dr. Kitchen once was a familiar figure at the Patent Office in Washington. While there he made a study of the activities in the Deparment of Agriculture and assisted officials in investigating milk and butter infections. The physician had a large collection of his inventions on his estate, which was one of the largest in East Orange. He made a hobby of flower cultivation and had large greenhouses on his property, which ran from Prospect Street to the west side of the en- closure at Ashland Stadium. DcGROFFT, Eugene E., died January 5, 1931, at his home in Woodstown, aged 80 years. Dr. DeGrofft was born in Smyrna, Delaware, October 3, 1850. His parents moved to Auburn, N. J., in 1859, where he attended public school until 1863, when he enlisted as a drummer boy in one of the Maryland regiments. He was a school teacher from 1867 to 1869, and then studied pharm- acy in the drug store of Dr. Johnson, at Penns- grove. He was graduated from the Jefferson Medi- cal College in 1875. He practiced medicine at Mullica Hill from 1S75 until 1892, and then moved to Camden, where he practiced until 1900, and to Woodstown, where he practiced until recently. The death of Dr. DeGrofft removes from us a man of high professional standards — esteemed professionally and beloved socially. He was spared the disability which overtakes many men before they reach the age which he attained, for he was able to pursue his work until a few weeks before his death. Dr. DeGrofft was an actice member of the Salem County Medical Society and had contribut- ed several valuable papers to the society. He was a member of the Medical Society of New Jersey, the American Medical Association and the Philadelphia Club, and served as Physician to the County Home near Woodstown. He leaves a widow and 2 sons by a former mar- riage. Dr. Vernon C. DeGrofft, of Swedesboro, and William C. DeGrofft, cashier of the Woodstown National Bank and Trust Company. 287 Journal of The Medical Society of New Jersey Under the Direction of the Committee on Publication Vol. XXVIII., No. 4 ORANGE, N. J., APRIL, 1931 Subscription, $3.00 per Year Single Copies. 30 Cents A DOCTOR’S CONFESSION OF FAITH— I SPEAK OF THE CHILDREN OF HIPPOCRATES, OF THE CULT OF AESCULAPIUS* Wells P. Eagleton, M.D., Newark, N. J. One day in the middle of the last century, a sensitive young Englishman, a recent gradu- ate, after a few months in English mercantile life, depressed by its narrowness, suddenly de- termined to visit America. Landing on a beautiful Sunday morning he walked up Broadway. Suddenly he stopped and joy- ously exclaimed to himself : “This is the coun- try for me ; there are no poor.” Later, to his only child he often said: “Wells, don’t make the mistake that I did ; don’t enter business ; don’t be a white collar drudge. Have your craft in your hands or your profession in your head ; be a painter ; be a lawyer ; be a parson ; but best of all, be a doctor for you will acquire medical traditions — and if you are true to them, its practice will satisfy the crav- ings of your soul. For the thought of all trade — be he clerk, or financier — is profit for self ; while the ethic of the true physician is achievement that chiefly benefits another, even all humanity. The merchant at most can but make a fortune, which is ephemeral, but the physician can make a name which may en- dure.” And in time that Englishman and his wife *(An Address at the 33rd Annual Banquet of the Washington Medical and Surgical Society, May- flower Hotel, Washington, D. C., May 5, 1930.) were on-lookers as that boy with his class, stood, while the Oath of Hippocrates was read to them in Greek; not one word of which did that boy understand, although the English curriculum had compelled the father to be a “Grecian”. One day the god Apollo, son of Zeus, the mighty ruler of the world — Apollo, the per- fection of manly form — Apollo, who possess- ed the intelligence of Zeus, his father, and the agility of Mercury, his brother, had a son, Aesculapius, who turned his thought to the curing of the bodies of men. “For”, said Aesculapius : “Does not my grandsire Zeus care for the intelligence, and my father Apollo, look to their comeliness and strength, and so, I, Aesculapius, will cure their ills.” And the power of Aesculapius so increased that at last he raised the dead; which did not meet with the approval of Zeus, because Zeus being a conservative, thought “if this offspring of mine can make people live forever, some day some one may think he can rule the world as well as I” ; and Zeus killed Aesculapius with a thunder- bolt. And then, perhaps in contrition, he placed Aesculapius among the constellations; and if we will but fix our minds on the heavens, we can catch gleams from the constellation of Aesculapius, our forbear. For while Aesculapius lived, he established a fraternity, the Cult of Aesculapius, in which all were brothers who devoted their lives to healing. And not only were the Aesculapians healers, they were priests — for it was a divine calling that has been handed from sire to son, to grandson, to this day ; and with their mighty ancestor a constellation among the stars, the JOURNAL OF THE MEDICAL SOCIETY OF xVEW JERSEY April, 1»31 288 Cult of Aesculapius grew strong and power fill. The original practice of the cult was largely a temple worship, it had to do with dreams and incantations and suggestions, much after the present mode of psycho-an- alysis. Its insignia was the serpent, the sym- bol of wisdom. But the Greeks were a wise people ; they soon learned not to take the Aesculapians as seriously as we moderns have1. Incantations gradually gave place to the worship of nature; for the Greeks looked life fully in the face — and the beauty of na- ture, the beauty of the human form, became their religion2. Soon the priests, doubtless perceiving that they were being found out, employed physi- cians to assist them with their cures and to do their surgery. Apd one day down in the Pelopoponesins, amid the pine trees of Epi- dauras, surrounded by glorious mountains yet sea washed, Mrs. Eagleton and I scrambled over what was once reputed to be the most beautiful temple in all Greece, the serpentine Temple of Aesculapius; and over that temple was written : “Only pure souls can enter here.” And there we saw instruments, curettes and forceps, of which today’s are but imitations. These temple physicians understood many ihings that we think modern : they understood the necessity of diet, and that nature is the real curative agent in diseases ; they recog- nized the critical days in pneumonia ; they practiced cardiac ascultation3, I think, for a memorial tablet depicts the Aesculapian. seat- ed, with his head pressed against the left side of the sufferer’s chest, apparently listening to his heart, while an attendant stands, his left hand on the patient’s pulse with his right arm outstretched apparently keeping time with its beat. So true were these doctors to the ethos of a profession — a calling — that one day Xerxes coming as a conqueror (and like all conquer- ors, to murder and to steal), said of the Aesculapians: “What manner of men are these, that contend with one another, not for money, but for honor?” And one day Hippocrates4, of the Cult of Aesculapius, took the real religious ethic, the ideal, that was in the cult, and adapted it to the workings ot life; and thus for all time established a union between the transcendental and the earthly. This he formulated into an oath — The Hippocratic Oath : “I swear by Apollo the physician, and Aes- culapius, and Health, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath. To reckon him who taught me this Art, equally dear to me as my parents, to share my substance with him, and to relieve his necessities if required; to look upon his offspring in the same foot- ing as my own brothers, and to teach them this Art, without fee or stipulation. I will im- part a knowledge of the Art to my own sons and to those of my teachers, and to the dis- ciples bound by the oath according to the law of medicine, but to none others. With pur- ity and with holiness I will pass my life and practice my Art5.” And one day all the extant works of Hip- pocrates were collected6, but no one knows which of these were written by the Father of Medicine7 s. For medicine did not originate in Greece, but was brought from Egypt, the fount of civilization. Many days before Greece, the Egyptians employed special physi- cians for different parts of the body ; which makes our present day specialists look rather old-fashioned. Among them were many skilled ophthalmologists and dentists, although I had thought that the art of dentistry or- iginated in America5. But the medical profession even then had notoriety hunters — “up to daters” — among them; for a papyrus of 1600 B. C. entitled “How to change an old man into a young man of twenty”10, is manifestly the work of a specialist given to exaggeration. Its author can justly claim to be the father of medical publicity. I have no doubt that in his day he was a leader of the medical profession, had a large practice and died very rich ; but that, in reality, he was little different from the self-exploiting specialists and surgeons of today, that is, possessed of a good technical knowledge although lacking in real ethical sincerity, as is shown by the fact that the papyrus contains the statement that paralysis on one side of the body is caused by an affec- tion of the opposite cerebral hemisphere; a April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 289 physiologic truth that was lost for 3000 years ; its anatomic demonstration being fur- nished by Gall11 only a little over 100 years ago. And one day, as we gazed at the Step Pyra- mid, I was thrilled to learn that its architect, Imhotep12, was a physician 2900 years before Christ. When Imhotep died, so great was his reputation, they made him a god and placed him among the stars. So, in the whirli- gig of time, the title of Father of Medicine has passed from Hippocrates to Imhotep, but the Hippocratic Oath still lives. The Egyptians believed that after death man’s soul is weighed against a feather, the symbol of truth and justice — a quill — so light and ephemeral, and still so powerful and en- during. But the philosophy of Egyptian life taught what is to be, not what is, and this led to dogma; and formalism gradually froze the mind of man; and medicine passed from Egypt. For medicine is of life, and life lives and expands in myriads of forms ; and so long as the mind of man looks frankly at life, medicine grows. Medicine, like life, is catho- lic; it is not sectarian. All countries have made great contributions •to medicine, but only at such times as man’s thought was free; for all oppressions stop thought, and whenever a restraining hand is placed on the mind of man, be it the hand of King, Priest or rigid formula, creative medi- cine, the understanding of life, sickens and fades. For despotism, priestcraft, rigid form- ulas, creeds — all that would control the mind of man — all disguise life, stop an understand- ing of life. Creeds are but rules of life as it was; of forms that have been or that have become ; but life is not confined by rules ; life, as it grows, as it expands, as it evolves, such life creates the rules for life that Is Becoming. “What is important in life is life and not a result of life”, said Goethe. Greece, in the height of her thought, sent many out to colonize and some of the great- est pages of Grecian history were written in the colonies. Sicily, even today, furnishes a most fascinating picture of Grecian culture, because its great monuments are still standing ; they are not buried ; the conqueror, that wor- shipped marauder, has not passed over the land and swept all beauty away. In Sicily, is the volcanic mountain, Etna. Its smoking snow-capped summit, 10,000 feet above a tropical land, is one of the most entrancing sights in the world. At its foot, 450 years before Christ, lived Empedocles. He was a physician who did such wondrous things that at last he came to regard himself as a god, at least he made little effort to discredit the assertion. But when we think of what he accomplished it is small wonder. First, he drained marshes to stop the miasma which in- fested the city13. And when we consider that it is only in our day that our own land has thus been released from malaria, and that during 2300 years, his knowledge was neg- lected, it is not for us to question. In an age in which the gods controlled all the acts of man and of nature, in a land continuously stricken by fevers, to observe that an intermit- tent type of fever was endemic among those who lived near stagnant water ; to conceive that removal of the water would eliminate the disease ; to dream such a dream, and then to demonstrate that the dream was true, would try the mental equilibrium of a god. Empedocles was not only a physician, he was a statesman, an inventor, a philosopher and a poet14. All his works were in verse, and, like all the great, he was a dreamer : “For each age is a dream that is dying or one that is coming to birth”15. He dreamed and taught the natural selection of species and the sex of plants ; he recognized the weight of the air, understood the position of the sun in re- lation to the earth and the planets; and while he was working miracles of healing, formu- lating thoughts only fulfilled by Darwin and Newton, he wrote a Constitution for his city which established civil equality. No one knows how Empedocles died, but there is a legend that he threw himself into the crater of Etna to lead men to believe that he had been taken up by the gods ; but the mountain refused to be a partner to the sham and expelled one of his sandals. And when I think of Sicily, the island of Penelope, nymph of the flowers, my vision is of the white summit of Etna, and of the aspiring Empedocles, the creative physician, standing there, looking at the 290 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 stars, weary after a life of labor for his fel- low man, still questioning: “And you, ye stars. Are you, too, what I fear to become? Yrou too, once lived; But now, ye kindle Your lonely, cold-shining lights, Unwilling lingerers ****** Weary like us, though not Weary with our weariness”i6. Rome came and absorbed Greece with all her learning ; and Alexandria became the medical center of the world. And then Celsus tried to systematize medicine17 ; and Galen epitomized the medical art of the classical world18. Galen, being a man as well as a physician, was greatly interested in Cleopatra; and from him we learn that Cleopatra had written 2 books, one on “cosmetics” and the other on “diseases of women”19 (Whether there was any relation between them Galen does not state). Galen believed that Cleopatra had special recipes for curling and dyeing the hair29; so, perhaps the “permanent wave” is not such a modern affectation after all. In the Second Century something happened to the mind of man ; again, it became fixed, held as in a mold ; the mighty spirit of man, his god-like gift, passed under theocratic dom- ination. God, the spirit, the truth, life, could not be looked in the face ; the world groveled, and with it medicine. In the thousands of days from Galen to Vesa- lius, creative medicine slumbered, but to the credit of the heart of man the tradition of un- remunerated service was not lost ; for in By- zantine times a common vow was “By the Unmercenary Ones” — referring to St. Cos- mos and St. Dameon, physicians, who visited the sick without fee. . Thomas Aquinas, the most learned of all the theologians, but with a medical mind filled with faith in the power of the spirit over body, entered the presence of Innocence the Fourth while His Holiness was counting the church money. The Pope, to excuse the accumula- tion of which Aquinas disapproved, said : “Father, the Church can no longer say, ‘silver and gold have I none’,” to which Aquinas re- plied haughtily — “Neither can the church now say to the lame, ‘Rise up and walk’ ”. Then St. Francis came; came in a day full of hatred; full of dogma; and taught that love of humanity, love of all life, was the thing; that loving was living. And one day we stood on the parapet where St. Francis walke'd and worked, on the hilltop of Assisi overlooking the pastures and vineyards of Umbria canopied by Italian skies, supreme blend of 'beauty and peace ; and here we could understand how such surroundings, and on such a highly sensitive body, could cause the imprint of the Cross being placed upon him21 ; for environment and disease both play a role in man’s spiritual growth22. The best explanation for the East Indian’s pessimism is the universal prevalence of chronic malaria among them. I know that there are moments in the lives of all thought- ful and sincere men in which stimulating sur- roundings force them to see that the great spiritual power within man actually can talk with God, as Moses did on Sinai. For life and my experience persuade me that, no man can increase his height by an inch, his frame is given him by his forbears ; no man can en- large his intellect, he inherits his mind; but each man’s spiritual possibilities are limitless, and depend on himself alone; God lends him His hand, but he rises by his own exertions. Paracelsus23, the father of modern internal medicine, then came. Up to his day alchemists had chiefly tried to convert other metals into gold ; but it took Paracelsus, the physician, to show them that they were wasting their time ; that the object of chemistry was not to create gold that warps man’s soul but to make medi- cines to cure man’s body. Paracelsus .traveled all over the world con- sorting with barbers, artists, physicians, sooth- sayers and conjurors, listening to their ex- periences and traditions, observing life, and thus he became a great physician, one of the greatest physicians of all time ; and then, his greatness affected him and he became a bom- bast. But his great crime in the eyes of the medical profession was in burning the Canon of Avicenna, its medical Bible, and in pub- licly advertising and delivering his lectures in the vernacular24 ; the so-called education of the public (and the exploitation of themselves) by leaders of the medical profession through April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 291 “radio talks” had not yet come into vogue, and so he was denounced as a charlatan. But no matter what the middle ages thought of him, no matter how he has been defamed, he revo- lutionized internal medicine, for Paracelsus did for medicine what Luther did for theology ; he freed the mind of men from the shackles of tradition. From the day of Paracelsus, cre- ative medicine again lived and if we consider its course we will perceive that the traditions, the beliefs, the ideals of a people have dic- tated their contributions to medical progress. Italy, the fount of esthetic thought, brought forth Leonardo de Vinci25, and one day while looking at his St. Jerome we were pleased to recall that Leonardo was not only a great painter, but also a great physiologist, and, above all, he was a great dreamer, for like all students of life, be they painters, philoso- phers, physiologists, physicians — if they are truly great — they are poets, they are idealists, they are dreamers ; they all sing : “But we, with our dreaming and singing, Ceaseless and sorrowless we! The glory about us clinging To the glorious futures we see; Our souls witn high music ringing; O men! it must ever be, , That we dwell in our dreaming and singing A little apart from ye”26. Leonardo de Vinci lived a court life, but while working and dreaming he observed life; and so he discovered the inverted image of the retina ; he discovered the effect of light on the pupil ; most remarkable of all, he un- derstood and described the involuntary move- ments of animals — the function of the sympa- thetic nervous system27 — a fundamental truth neglected until Gaskell28 in our day elucidated it. In France, the fount of individualism, the home of pure thought, Vesalius29 came and re- created anatomy, and Ambrose Pare revo- lutionized surgery30. Pare followed common sense, and not tradition ; he put ligatures around vessels ; he taught that it was possible to turn the child in order to deliver it ; and in an early translation of his works is found his observations on the treatment of brain ab- scess— how he used tubing to drain the abscess and caused the remaining pus to be expelled by instructing the patient to close his nose and mouth and to blow into his cheeks, thus increasing the intracranial pressure. And this latter device described by Pare in 153631, was only rediscovered and adopted in 1925. Visiting French hospitals we met Vesalius and Pare, Dupuytren32 and Meniere33 and Charcot34 and hosts of other doctors whose names previously meant simply a disease. For the French have a very fine custom. When you “walk the wards of a hospital” you not only meet the usual financial Memorial Tab- lets, but you read the names of the men who have contributed something to medicine, in the hospital in which the work was done, al- though the walls of that hospital may have long since ceased to stand. The French use their hospitals to commemorate the advancers of medical thought, so that the doctor as he labors has an inspiration to say : “Some day perhaps I may do something worthy and then the French people will not forget to engrave my name among the Children of Hippocrates of the Cult of Aesculapius.” In time England awakens ; England who knows how to make a practical application of scientific truths ; who has the power to com- mand without oppression, that has made the Anglo-Saxon the ruling race of the world. Harvey35 came and physiology was born ; Mal- pighi36, and pathology, histology and embry- ology came into being; Sydenham37, the “Eng- lish Hippocrates”, who taught that the way to study disease was not by books but at the bedside of the patient; a great contribution. And if I read the signs of the time aright we must return to the methods of Sydenham, we must examine the patient ; we must look at him ; we must feel him ; we must listen to him; we must clinically, diagnose his disease; and then, and only then, should we read lab- oratory reports. From the day of Sydenham the medical profession waxed strong and Cuts (the father of Dutch poetry) said of the doc- tors ; “Hail, hail ingenious folk, success attend your ways ; May fortune send you gold, not merely empty praise.” Then came the American and the French Revolutions, fighting for the rights of man ; and in that day we find physicians, men of 292 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 culture, became men of public affairs because of the duty that they felt and the patriotism that was in them ; and we as doctors are proud that of the 59 signers of the Declaration of Independence, 6 were physicians38, who left their homes to make effective that immortal document and the work accomplished ; 2 quietly returned to their practices30, while 2 became governors40 of their native states and one its chief justice41. America, the mother of technical efficiency, added her quota, largely in the perfection of technical details, and McDowell42 and Marion Sims43 came and passed. Morton44 and Simpson45 annihilated pain. Pasteur46 and Lister47 conquered suppuration, and modern aseptic surgery was born. One day we found ourselves in the surgical amphitheater of Sir Victor Horsley43. He was a great big genial man who really felt honored that we had come to see his work. And today I think of his lonely grave in far off Mesopotamia, and how he, one of the most distinguished of surgeons, at 59 years of age insisted on going into unlivable Mesopotamia while his country was at war because he thought he was needed; and of his last words to his wife — -“Don't worry about me, I do not matter. I can’t live forever. It is the young that matter”49. And I feel proud that I belong to his profession. In America, Halsted50 came ; catne in a day when surgery was crude ; when “do it quick and get through with it, don’t mind the blood, you can’t operate without losing blood”, was the general surgical doctrine. But Halsted, in his quiet way, said: “Rough handling of tis- sue is not physiologic, it matters not whether the trauma be from an accident or an opera- tion. The patient suffers chiefly from loss of blood and from suppression of function. The surgeon should handle all tissues delicately, patiently, bloodlessly.” Out of these physio- logic principles has come the surgery of the central nervous system, the greatest contri- bution that American surgery has made in our day. Today, as one travels, one is impressed by the universality of high grade medical prac- tice throughout the world. We landed on an island in the southern Pacific Ocean and found 2 doctors with their wives and a few native nurses, in a hospital made of bamboo, super- vising medical care of the inhabitants of 14 islands, the furthermost 700 miles away, and doing as good surgery as is done anywhere in the world; doing everything from a cataract extraction to an appendectomy. We found ourselves in India, India the home of metaphysical thought, and in a labora- tory manned by Hindus we saw that sensitive plants must have a type of nervous mechanism because plants apparently have cycling “per- iods of sleep” during which their sensibility is diminished ; that certain plants apparently “feel” as they react to injury, and that these reactions are lessened by “putting them under an anesthetic”51. All this puts a new construc- tion on life. It suggests that there is no break of continuity in the evolution of the nervous system from the plant to the animal, although no nerve fibers have been anatomically demon- strated. While in India the Anglo-Indian Medical Service took us by the hand and joy- ously showed us their work, for it is in the by-ways of the world that the fraternal feel- ing of the Cult of Aesculapius is most mani- fest. We peeped in on Australia, a country that looks toward America as at a big brother who has “made good”. And here one day a young anatomist52 said “the stiffness, the spasticity, of the legs of the poor fellows who were shot in the head during the war — the spasticity that prevents them from walking — is due to an over-action of involuntary nerves” ; and an- other new page in surgery of the sympathetic nervous system was written. We reached sunny Spain. And we could understand how, under that incessant glow, the histopathology of the nervous tissue was elucidated. For the Spanish people live among bright pigments ; they think in colors ; they play with them ; as Goya did. It was through the appreciation of color by artist scientists that the anatomic complexities of nervous tis- sues were unraveled; and this in a laboratory on the second floor of a house in the poorest of neighborhoods.53 Creative medicine is a strange nymph. She comes to her devotees at odd moments and in unexpected places ; to Koch54 in the midst of a country practice; to April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 293 Pasteur in the fields ; to Lister in the operat- ing room ; to the Curies55 in a barn ; but sur- round her with marble walls and large awards and she eludes them all. Details are perfected in laboratories but principles are born in lofts. Next, Russia, whose philosophy of life is that there is no God ; that man is God ; that the living of this life to its full — and that for all — is the important thing. Russia, that says only those that work ; work with their hands or with their heads— for all — shall reap the harvest. For the Soviet Government says — you work or you starve. From the simple fact that the ringing of the dinner bell will cause the saliva to flow from a dog’s mouth, Russian thought has demonstrated that involuntary reflexes de- pend upon conditions ; that many of the ways of animals that we have regarded as instincts, are acquired; that man himself largely cre- ates his involuntary reflexes as he creates his spiritual nature56; a profound contribution to an appreciation of creative life. What does it all mean? That we as doctors are the inheritors of a great tradition. That by our training ; by our insight into life which that training should bring ; by the spirit that its traditions should develop ; it is possible for us to become (no matter in how small a way) members of a great band. In our own city, did not Coit57 say babies should have clean, un- altered milk? And from his years of unremun- erative toil, the young of all the world are healthier, and only the Milk Trust richer. He was true to the traditions of the Cult of Aesculapius. He gave something big — and it was commercially valuable — without thought of recompense. It is that band that today, as through all the ages, by infinite labor and joyous self- sacrifice, is revealing life to man and man to himself. If the doctor, when he starts life, but sees the Spirit of the Cult of Aesculapius, its precepts and traditions will mold him and he will become a true child of Hippocrates, for while inheritance is the greatest factor in man’s physical and intellectual being, it is his environment and himself that construct his character. I have never met a lawyer who is an idealist ; yet he may be an optimist. He deals with the laws made by man. I am sorry for the doctor who is not an idealist, for I think he is missing the greatest thing that his training and his experience should teach. Every day, all day, in his practice he may see the eternal if he but will. And does it pay? When I think of how dis- ease has been steadily exterminated, each epi- demic promptly controlled and life prolonged for the good and happiness of all — for this is the aim of the medical profession — when I see our judiciary so corrupted, and hampered, our laws so distorted and perverted that govern- ment almost seems helpless to protect itself — - then I feel that those who follow the ideal reap the rewards. How are we going to reach it and to hold it? There is a beautiful story about Clemenceau58 — and Clemenceau was a doctor. Somebody said : “How do you keep at it, overthrowing government after govern- ment, always do you fight for what you believe is for the Republic?” And Clemenceau replied: “When I falter, I think of my father. He, like myself, was a doctor. He believed in a Republic even when the second Empire came and was mighty. And one day, Napoleon the little, sent his soldiers and took him, chained between 2 criminals, simply because he could not see that ideal sacrificed for which his countrymen had fought and died. And when I would falter, I think of my father and I become he”59. A doctor, McCrae, who died in the line of duty in Flanders Fields60, wrote : “In Flanders fields the poppies blow Between the crosses, row on row * if * * * * sje To you from falling hands, we throw The torch. Be yours to hold it high! If ye break faith with us who die, We shall not sleep, though poppies grow in Flanders fields.’’ And this same doctor taught his class : “What I spent, I had; What I saved, I lost; What I gave, I have.” And at the end of the road, we think of Os- ier’s last saying : “Such good fellowship, all the way”61. For the longer I live the firmer is my faith in the idealism of the medical profession as a whole, the rank and file of the family physicians of all lands. The vast majority sing in their hearts “For no one shall work for money and no one shall work for fame, 294 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 but each for the joy of the working 6\ And doctors all have been true to their oath : “I will impart a knowledge of my art— to the disciples without fee or stipulation.” And the average doctor can honestly say: “I have prac- ticed my art in purity and holiness, and its practice has satisfied the cravings of my soul.” Bibliography 1. Bick, E. M.: Cult of Askelapios, Annals of Medical History, Vol. 9, No. 4, page 330, Decem- ber 1927. 2. Wile, Ira S: The Worship of Asklepios with special reference to the Tholos and the Theater, An- nals of Medical History, Vol. 8, No. 4, page 413, De- cember 192C. 3. Laennec, Rene Theophile Hyacinthe (1781- 1826), author of “De l’Ausculation Mediati, 1818. 4. Hippocrates of Cos, the seventeenth descendant of the God Aesculapius: born 460 B. C., died be- tween 365 and 351 B. C. 5. Adams, Francis: The Genuine Works of Hip- pocrates, published under the auspices of the Sydenham Society, London, 1849; and New York, 1886. 6. Hieronymus Mercurialis and Louis de Lenios; Censura Operum Hippocrates, Venet; 1583, 4th mo. 7. Lenios after examination of all works ascribed to Hippocrates (De Optima Praedicandi ratione item judicii operum magni Hippocrates liber urius, Salamanticae, 1585, 12 mo.), admits only 19 works as authentic. 8. Littre, Emile, Oeuvres Completes d'Hippo- crate, Paris, 1839-53. 9. Seelig, M. G.: Course of Medical History epitomized. Proceedings of the Staff Meetings of Mayo Clinic, Vol. 3, No. 6, page 41 (February 8, 1928.) 10. Breasted, Prof. James Henry: The Edwin Smith Surgical Papyrus of the New York His- torical Society 1600 B. C., reviewed in New York Times, March 24, J925. 11. Gall, Francis Joseph (1758-1828); “Anat. et Physiol, du Systeme Nerveux en General et du Cerveawen Particular”, Vol 4, Paris, 1808-1820. 12. Breasted, J. H. : Conquest of Civilization, “Imhotep the wise”, Pyramid Age, page 61, Harpers, N. Y„ 1926. 13. Hutton, Edward; Cities of Sicily, Girgenti, page 123, Little and Brown, Boston, 1926. 14. Symonds, J. A.: Studies of the Greek Poets, Empedocles, page 126, 3rd Edition, Black, London, 1920. 15. O’Shannessy. 16. Arnold, Matthew. 17. Celsus, Aulus Corneleus; date of birth and death in dispute, probably born in time of Augus- tus Tiberius and lived until reign of Trojan. He wrote an encyclopedia entitled: “De Artilus”, 8 volumes of which were a hand-book to medicine. It was rediscovered in Fifteenth Century and printed in Florence in 1478, before the works of either Galen or Hippocrates. (Taylor, H. O. : Greek Biology & Medicine, page 92, Harrap, London, 1922.) 18. Galinus, Claudius, born about 131 A. D., date of death unknown; physician to Marcus Au- relius; author of S2 authentic medical treatises and 18 of doubtful authenticity, as well as 30 to 40 manuscripts. (Anthon, Classical Dictionary, page 529, Harpers 1873.) 19. Neubruger, M., History of Medicine, trans- lated by Playfair, London, 1910. 20 Walsh, Jos., Galen’s Studies at the Alexan- drian School, Annals of Medical History, Vol. 9, No. 2, June 1927, page 143. 21. Rrumbraar, E. B., The Stigmata of St. Francis of Assisi — Annals of Medical History, Vol. 9, No. 2, June 1927, page 111. 22. Moorman, J. : Tuberculosis and Genius as Manifested in St. Francis of Assisi, Annals of Medical History, Vol. 2, page 556, September 1930. 23. Paracelsus, 1493-1541. 24. Todd, T. W., The Medieval Physician, An- nals of Medical History, November 1929, page 628. 25. Leonardo de Vinci, 1452-1519. 26. O’Shannessy: Ode. 27. Wilhelmj, C. M., A sketch of the life and work of Leonardo de Vinci : Proceedings of Mayo Clinic, Vol. 3, November 18, May 2, 1928. 28. Gaskell, W. H., Series of papers, 1888-1896. 29. Vesalius, Andreas (1514-1564), author of De Humane Corporis Fabrica. Printed at Basle by John Oporinus in 1543. It is believed that either Titian or Titian’s brother or son, Horatio, made the drawings of the dissections. The work was preceded by the publication of Tabulae Anatomicae, in 1538, drawn by John Stephen de Calcan who painted the famous portrait of Vesalius dissecting a woman’s body, now in the Royal College of Physicians in London (Riciiardson, B. W. — Dis- ciples of Aesculapius, Vol. 1, page 80, Hutchinson, London, 1900). 30. Pare, Ambrose, 1510-1590, Hugenot barber — surgeon to Henri II, Francis II, Charles IX and Henri III; author of 10 books on surgery and sur- gical anatomy, published in 1568; 5 books of Sur- gery, 1572 (now extinct); 2 books of Surgery, 1573 (Paget, S. Ambrose Par£ and his Times, page 246, Pulman, 1897.) 31. “When the Patient is in dressing, if there comes much matter out of the wound, you shall wish him, if he can, to lie upon the wound, and now and then by fits to strive to breathe, stopping his mouth and nose, that as the brain lifted and swollen upwards, the matter may be the more readily cast forth.” (“The Works of Ambrose Par£. Translated by Th. Johnson, London. Printed by Mary Clark, and are to be sold by John Clark at Mercer’s Chappel at the lower end of Cheapside, M1DCLXXVI1I.” “Page 250, Book X." “Of Green and Bloudy Wounds of each part.” Chapter XXI “of the discommodities which happen to the Graffa Meninx by fractures of the Skull.”) 32. Dupuytren, Guillaume (Baron), 1777-1835. 33. Meniere, Emile Antone, first described aural vertigo (Gaz. Med. de Paris, 1861.) 34. .Charcot, Jean Martin, 1825-1893. 35. Harvey, William, 1578-1657. Exercitatio de Motu Cordis et Sanguines, was published in 1628. There is an oil painting of Harvey, by William van Bemmel, in the Hunterian Museum, at Glas- gow, which probably was painted from life. 36. Morgagnus, Joannes Babtisia. 1682-1763. 37. Sydenham, Thomas, 1624-1689. 38. Bartlett, Josiah, M.D., 1727-1795; graduated from Yale; began practice in 1750 at Kingston and April, 1931 JOURNAL OF THE MEDICAL SOCIETY GF NEW JERSEY 295 acquired reputation during epidemic of Angina Mialigna, in 1754, by using Peruvian bark. Had several appointments from the Royal Governor, John Wentworth, but deprived of them in 1775 because of his political activities. Appointed to command regiment of militia 1774. He was the first who voted for and the first, after the president, who signed the Declaration of Independence. Ac- companied Stark to Bennington in 1777. President of New Hampshire 1790. First Governor 1793. (American Cyclopedia; Ripley and Dana, Vol. 11, page 350. Appleton, 1874.) Hall, Lyman, 1725-1790; graduated from Yale 1747. Studied medicine. Practiced in South Caro- lina and Georgia from 1752. Influential in inducing Georgia to join the Confederacy. All his property confiscated by the British during the revolution. Governor of Georgia 1783. (Amer. Cyclopedia, Vol. VIII, page 400, 1874.) Wolcott, Oliver, 1726-1797. Graduated at Yale in 1747 and studied medicine with his brother Alex- ander. In 1751 entered politics and from there on apparently did not practice medicine. Raised troops and helped defend New York in 1776. Commissioner of Indian affairs of the Northern Department 1775 and negotiated the treaty of Fort Stanik. In cam- paign against Burgoyne and in defense of Con- necticut. Rush, Benjamin, M.D., 1745-1813, studied at the College of New Jersey and took his preliminary degree in arts in 1760. Studied medicine for 6 years with Redman in Philadelphia. Took Doctor’s degree in medicine in Edinburgh University, 1768. Spent 2 years in medical studies in London and Paris. Twitted because of his studious habits, he wrote “Medicine is my wife; science is my mis- tress; books are my companions” (Richardson, Disciples of Aesculapius, Vol. 1, page 64). Physi- cian General Military Hospital 1777. Established Philadelphia Dispensary 1786. Helped found Dick- inson College, in Carlisle, President of the Amer. Society for the Abolition of Slavery. “The loss of no individual of this country, excepting that of Washington or of Franklin, has been lamented with more universal and pathetic demonstrations of sorrow.” (Biography of the Signers to the Declaration of Independence, by John Sanderson, Vol. IV, page 283, Philadelphia 1823-27.) Thornton, Matthew, 1714-1803. Educated at Worcester, Mjass. Studied medicine and com- menced practice in Londonderry, New Hampshire. Surgeon to New Hampshire Division of 500 men in expedition against Louisberg in 1745. Colonel of Militia at beginning of Revolution. President of Provincial Convention and Chairman of the Com- mittee of Public Safety. Elected to Continental Congress and permitted to sign the Declaration of Independence in September (?) 1776 (Amer. Cyclopedia, Vol. XV, page 723.) Taylor, George, 1716-1781. Received a good edu- cation in Ireland and came to America as a “re- demptioner.” (Goodrich’s Lives of the Signers, Phil- adelphia, 1827.) Was an iron worker and a manu- facturer of iron and later a practicing physician in Easton, ■ Pennsylvania. Elected to Continental Congress July 20, 1776. Signed the Declaration of Independence, August 2, 1776. (Amer. Cyclopedia Vol. XV, page 592.) Monument erected to his memory in Easton in 1847 but place of burial un- known (from old paper presented to Easton His- torical Society by W. P. Eagleton.) Letter from Taylor in Broderhead’s Book of the Signers per- taining to Fac Simile Letters of the Signers of the Declaration of Independence, Philadelphia, 1861, page 37-38, from Freeport, N. J., dated March 3, 1776, offering to enter service as commander of battalion to guard the sea coast. “In the printed public Journal of Congress for 1776, Vol. 2, it would appear that the Declaration of Independence was signed on the fourth of July by the members whose names are there inserted, but the fact is not so, for no person signed it on that day nor for many days after, and among the names subscribed one was against it and several were not in Congress on that day, namely, Messrs. Morris, Rush, Clymer, Smith, Taylor and Ross, of Pennslyvania, and Mr. Thornton, of New Hamp- shire, nor were the 6 gentlemen last named at that time members; the 4 for Pennsylvania were appointed delegates by the Convention of that state on the twentieth of July and Mr. Thornton en- tered Congress for the first time on the fourth of November following.” (From letter of Kean, Thomas W„ dated Philadelphia, August 22, 1813. Broderhead’s (William) Book of the Signers per- taining to Fac Simile Letters of the Signers of the Declaration of Independence, 1861, page 68.) 39. Rush and Taylor. 40. Bartlett, Hall. 41. Thornton. 42. McDowell, Dr. Ephraim: Born Nov. 11, 1771 —Died June 20, 1830. 43. Sims, James Marion, 1813-1883, organizer of the Women’s Hospital, New York and Anglo- American Ambulance in Franco-German War. 44. Morton, William Thomas Green, 1819-1863, first administered sulphuric ether in 1846. 45. Simpson, Sir James Young, 1811-1870, intro- duced chloroform. 46. Pasteur, Louis, 1822-1895, first described bacteria as cause of disease in discussion of child- hood fevers. 47. Lister, Lord Joseph, 1827, began antiseptic treatment of wounds in Glasgow, 1865. 48. Horsley, Victor, 1857-1916. 49. Horsley, Sir Victor, 1857-1916, A Study of His Life and Work by Stephen Paget, Constable, London, 1919. 50. Halsted, William S., Biography by McCallum, W. G., Johns Hopkins Press, Baltimore, 1930. 51. Bose, Sir J. C, Growth and Movements of Plants, Longmans, 1929. 52. Hunter, John L, 1898-1924. 53. Cajal, S. Ramony, 1852. 54. Koch, Robert, 1843. 55. Curie, Pierre, 1859-1906. Curie, Marie Sklo- dowska, 1867 (Curie, Marie: “Pierre Curie” trans. by C. & V. Kellogg, Macmillan Co., 1923). 56. Pavlov, I. P., Conditioned Reflexes; trans. by Anrep, Oxford Press, 1927. . 57. Coit, Henry, 1854-1917, Originator of Cer- tified Milk under Medical Commissions. 58. Clemenceau, Georges, 1841-1929. 59. Reilly, J. J. de S., The Drive Behind Clemen- ceau, The Living Age (September 1, 1929). 60. McCrae, John D., died January 28, 1918, written during the second battle of Ypres, April, 1915. 61. Osier, Sir William, 1849-1919, Biography by Cushing, Oxford Press. 62. Kipling. 296 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 TREATMENT OF ACUTE CORONARY THROMBOSIS Albert S. Hyman, M.D., F.A.C.P., New York City, and Aaron E. Parsonett, M.D., F.A.C.P., Newark, New Jersey The incidence of coronary thrombosis, while probably no greater today than it has been in previous generations, because of widespread publicity and more frequent recog- nition, appears to be on a decided increase. Modern methods of intensive propaganda, both in lay and medical publications, have done much to focus attention on cardiovascu- lar disease in general, and coronary disease in the guise of “acute indigestion” in particular. A staggering mortality percentage following even the so-called “mild attacks” of this malady places it high in the statistical tables of the principal causes of death. Its grue- some and deadly selectivity among that group of our citizenry most useful in the average in- telligent community is only too well known. Removed at the zenith of his productive abil- ity, the usual victim of this disease is to be found among that middle aged class composed of physicians, lawyers, clergymen, and busi- ness executives. Even though death may not supervene, the amazing transformation that renders a previously vigorous and energetic individual into a decrepit and enfeebled old man only serves to swell the roster of those struck down by this most serious cardiovas- cular accident. 1 he symptoms of coronary thrombosis in its protean syndrome have been developed to such degrees of diagnostic niceties, by the many contributions made to medical literature within the past few years, that the subject requires but little additional elucidation. In its frank form, the sufferer from coronary thrombosis is readily recognized by the clearly defined series of events which transpire in rapid succession. Probably the most conspicuous feature of the attack is the immediate prostration of the individual ; how much this initial collapse is due to the prolonged, excruciating, and un- abating pain and how much to the abrupt al- teration in the hemodynamic factors of the damaged heart muscle may be difficult of true evaluation. Both these factors unquestionably l’lay an important role in establishing the general clinical picture of shock. Dyspnea, cyanosis, pulmonary edema and other signs of peripheral circulatory failure add to the grav- ity of the patient’s condition. Pathologic changes observed clinically in the marked fall of systolic pressure, and local manifestations of the necrosing heart muscle suggested by temperature, leukocytosis and pericarditis, later to be followed in many instances by em- bolic phenomena, serve to complete this vari- gated symptom complex. Faced with the problem of treating a pa- tient in the agonizing throes of acute coronary occlusion it is essential to be equipped with a thorough and clear concept of the pathologic processes so rapidly taking place in the crip- pled heart. Probably in no other acute con- dition is such knowledge of greater impor- tance for the successful combating of an ap- parently hopeless condition ; in the face of newly acquired knowledge, proper and prompt therapeutic steps guided by recognition of the various phases presented by the disease are not altogether futile. From a purely clinical point of view, the acute coronary thrombosis syndrome may be divided into 3 readily distinguishable stages : first, the onset with its immediate alarming symptoms of pain, shock and prostration ; second, the intermediate stage extending from about the third day of the attack to about the tenth, during which time all signs and symp- toms of necrosing heart muscle become evi- dent ; and third, the stage of convalescence which is exceedingly slow and protracted, not infrequently lasting many weeks and months. It must be constantly borne in mind, however, that death hovers no closer in one stage than in another and with fatal impartiality selects its victims in any period. Mortality tables gleaned from many observers place the prob- ability of recovery slightly less than 50% ; in other words, any patient has almost an even chance of recovery. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 297 With this in mind, therapeutic measures will be successful only insofar as the proper stage of the disease is recognized, for the treatment in one stage may be decidedly con- traindicated and, perhaps, even hazardous in another. For this reason, therefore, any con- sideration of treatment in this disease must be based entirely upon the stage in which the patient is seen. Stage of Onset When an important blood carrier to the heart muscle is suddenly stopped, that segment of the myocardium nourished by this vessel and its branches is immediately set into a dis- turbed chemical balance. The initial stage of anoxemia rapidly gives way to a series of pro- foundly altered electrodynamic and hemody- namic response. If the electrodynamic changes are so intense that the normal cardiac cycle can no longer be maintained, death immediately supervenes. This is especially true when the impoverished segment lies in the walls of the ventricular chambers. During the period of anoxemia the myocardium becomes hyperir- ritable and in it are born many foci for ectopic beats; when several foci became simultan- eously operative, ventricular tachycardia will develop. Depending upon the number and distribution of such ectopic points is the prob- ability of ventricular fibrillation enhanced; the development of this latter condition is usually promptly fatal. When, however, the infarcted area lies in the auricular walls, the pathologic changes which follow are no wise different than those developing in the ventricular areas with the important exception that, whereas ventricular fibrillation is incompatible with life, auricular fibrillation is not an uncommon clinical discovery. When this latter condition occurs the life-saving phenomenon exhibited by the conducting tissues in filtering out most of the stimuli arising in the auricle becomes effective. An adequate circulation can thus be maintained without great difficulty. Sudden death, therefore, when it occurs during the very onset of the attack, is usually due to the above phenomena ; no remedies of any kind can be administered promptly enough, nor with any hope of success in com- bating its development. As high as 55% of such individuals are said to die during the in- itial stage from this cause; for them nothing can be done. In other cases, the infarcted area may not be so large nor lie in such im- portant portions of the myocardium ; electrody- namic disturbances, if they occur, may not be sufficiently disturbing to seriously hamper car- diac function. At the same time the involved segment may set the entire heart into a state of irritability still fraught with no little danger. Complex neurogenic arcs are appar- ently quickly established and help to augment the factors of shock produced by such serious cardiovascular impairment. A profound drop in blood pressure levels usually accompanies the local reaction to the infarcted area. This life-saving mechanism is dependent upon the peculiar balance established between the needs of minimum pressure for an adequate peri- pheral circulation and the resistant qualities of the damaged heart wall. Where the pressure is maintained at high level, rupture of the weakened musculature may result, while, on the other hand, a too great fall in systolic blood pressure may lead to urinary suppres- sion and peripheral vascular stasis. With these facts in mind, treatment of the initial stage of acute coronary occlusion should be focussed upon amelioration of those factors leading to the extreme shock and pros- tration. The element of pain is unquestion- ably of the greatest importance; the agonizing and crushing character of this pain tends to enhance the danger and likelihood of increased myocardial damage, since agitation of the pa- tient as he restlessly thrashes from side to side will quickly complete the picture of ex- haustion. For this there is only one remedy; narcosis, no matter how produced, is to be sought for as expeditiously as possible. While a wide variety of drugs may prove to be use- ful for this purpose, morphin is, in the last analysis, of the greatest help. Dosage of this drug to be effective, must be large; this is no place for the timid and halting administra- tion of the remedy. We have never given less than ^2 gr. for the initial dose subcutaneously ; morphin in this instance is practically useless when given orally. The question is often asked, how much morphin can be given in such cases with safety ? The answer seems to be 298 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 that morphin can be given in larger doses in acute coronary thrombosis than in any other known disease condition, and the full dosage is only achieved when the patient is rendered free from pain. If this result can be obtain- ed by minimum dosage, no further medication may be necessary in the satisfactory handling ot the case; more frequently, however, large and massive doses are required, running as high as several grains in the first 24 hours. We have never seen any untoward results from such large dosage, but we have seen pa- tients who have been insufficiently narcotized because of the timidity of the medical attend- ant. From time to time individual cases may be found where the pain factor is so overwhelm- ing that nothing short of general anesthesia is of the slightest value. It has been neces- sary in 2 of our cases to resort to administra- tion of ether in order to prevent the pa- tient from literally tearing himself apart in frantic attempts to secure respite from the terrific stenocardia. General anesthesia in acute coronary occlusion must, however, be used with the greatest caution, as its contra- indications far outweigh the rather dubious re- sults to be expected. Other drugs of the opium series like codein, pantopon, papaverin, and tincture of opium have also been suggested by many authors; all these drugs may prove to be more or less efficacious in individual cases but the results obtained never approach those secured by morphin itself. Of the hypnotics, luminal, allonal, dial, and the bromides in one form or another, have been suggested in those cases where the pain factor is not especially con- spicuous. We have found, however, that even in such cases a small dose of morphin may prove to be more reliable than any of these. Next in importance is control of the symp- toms of shock; little need be said concerning this as it differs in no way from shock and prostration met with in other conditions. Warm blankets and hot water bags should be used liberally to combat the vasomotor col- lapse associated with the cold, clammy sweat- ing found in this condition. One exception might be made in treatment of the shock occurring as a result of a coronary accident, and that is in regard to the relation of the head to the rest of the body ; when shock occurs as a result of accident or after a surgical opera- tion the patient’s head is usually lowered, the belief being that an adequate cerebral circula- tion must be maintained in this way ; in coron- ary occlusion, however, the head must be kept elevated and, indeed, if the dyspnea, accom- panying the attack be marked, the patient will himself insist on assuming a more or less up- right position Ordinarily, no other treatment is required during the initial stages of the attack ; the question of stimulation may arise if the peri- pheral circulation is markedly impaired. Hypo- dermic administration of adrenalin, strophan- thin, either alone or in such combinations as digibaine, digitalis, or caffein sodium ben- zoate, may be given. Here again, as in the use of morphin, dosage must be controlled by the signs of full physiologic effect. In desperate cases intravenous administration of these substances may be demanded ; only under the most unusual circumstances is the intra- cardiac administration of these substances to be recommended. If cardiac arrest occurs, this latter method of treatment may save an otherwise hopeless individual. It has been our experience that intravenous medication is pre- ferable so long as the heart is beating ; when cardiac standstill occurs, intracardiac medica- tion must be resorted to. A word in regard to the use of digitalis must be made here. Inasmuch as the heart in acute coronary thrombosis is usually regu- lar and the action slow, nothing can be hoped for from this drug, while, on the other hand, owing to increased irritability of the ventric- ular musculature, heart block and ventric- ular fibrillation may result. If circulatory failure is present at this time, digitalis may be used, but the indications for its use are rather infrequent. Intermediate Stage Forty-eight hours after onset of the initial attack finds the patient more or less relieved from the terrific pain and recovering from the symptoms of shock and prostration. He will then be .concerned with gastro-intestinal com- April, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 299 plaints, chief of which is a peculiar type of nausea unrelieved even if vomiting occurs. It is strange that although this symptom is one of the most conspicuous features of the entire attack and next to the pain factor is the one most often recalled by the patient, this type of nausea has received but scant attention in literature. Relief of this symptom may cause the medical attendant no little concern, as the ordinary measures for combating such com- plaints are useless. While there seems to be some question as to the actual origin of this nausea, whether it be local in the stomach, reflex from higher centers, or the result of vascular changes in the mesenteric division of the arterial tree, there can be no question but that it presents an almost insurmountable problem for therapy. Probably no remedy in our experience has been as efficacious as em- ployment of the alcohol-sugar combination or- iginally suggested by Libman ; these mixtures, the Volstead Act notwithstanding, may be and frequently are life-saving at this critical stage of the disease. Of these alcohol-sugar mixtures the essential liqueurs like creme de menthe, creme de cacao, benedictine, Coin- treau and others if available, may promptly control this most distressing symptom. Given in 1 oz. doses with cracked ice every hour or two, our results have been almost uniformly favorable. The difficulties encountered in se- curing these remedies have made it necessary for us to develop synthetic formulas for them. At the Beth David Hospital, for example, synthetic creme de menthe and creme de cacao, fortified with theobromin sodium salicy- late to prevent diversion into unorthodox chan- nels, have been used for the past several years. The official U. S. P. preparations of elixir aromaticum to which has been added an equal volume of grain alcohol is perhaps the most readily obtained synthetic liqueur avail- able to the general practicing physician. Gastric lavage cannot be too strongly con- demned and is mentioned here only to focus at- tention upon the need for correct diagnosis ; as indicated previously, the gastro-intestinal symptomatology of the coronary thrombosis syndrome may so predominate in the clinical picture that erroneous conclusions may be easily drawn and the case treated as an acute gastro-intestinal upset. Likewise, cathartics and strong purges must be carefully avoided and enemas if given should be only of the blandest type and in restricted volume. Associated with the nausea may be a pain- ful type of eructation; patients frequently plead for relief from gaseous discomfort and indeed the belching of gas may be followed by prompt amelioration of all symptoms. To the usual remedies for this complaint may be added the cautious administration of carbon- ated waters. About this time local manifestations of the cardiac injury will be making themselves evi- dent ; there will be a slight rise of tempera- ture, moderate leukocytosis, and perhaps the evidences of pericardial involvement. Ordin- arily the area of pericarditis is not sufficiently large to give the patient much discomfort but an ice bag placed over the precordium will do much to relieve heart consciousness. If the signs of circulatory failure with pulmonary edema, engorgement of the liver, ascites and pitting of the lower extremities supervene, digitalization should be proceeded with at once. We wish to take this opportunity of warning against the massive dosage method so popular in other cardiac conditions ; the hazards in- vited by rapid digitalization in coronary thrombosis greatly enhance the probabilities of embolism. Digitalis in combination with caroid or any other proteolytic ferment in doses up to 8 or 10 gr. a day seem to be the most satisfactory. Diuretics of the group like metaphyllin, theobromin calcium salicy- late, theominal and others are also useful. Dyspnea and cyanosis may be difficult to control even when there does not appear to be marked signs of circulatory failure. With a slow and regular pulse and with no discov- erable indications of edema the dyspnea and cyanosis may still be very great. If difficulties of breathing approach orthopnea, sedatives may be required. Within recent times oxygen therapy has been used with striking results ; administered either by an oxygen tent or by the intranasal catheter route, patients appar- ently obtained prompt relief, so much so, that they demanded its administration. In ex- tremely severe cases, pure oxygen has even been injected intravenously with a favorable 300 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 outcome. Oxygen is, however, a recent addi- tion to therapy and sufficient data are still not easily available for true estimation of its ef- ficacy. Irregularities of the pulse ordinarily require no specific medication inasmuch as they are merely manifestations of the myocardial re- action to injury sustained by the occluded cor- onary vessel. Most irregularities are extra- systolic in origin and may be disregarded ; when, however, they occur very frequently and tend to produce paroxysmal tachycardia they must receive special attention. Quinidin sulphate has been recommended by Levine for this latter condition ; we have also used stro- phanthin with favorable results. When the myocardial damage has been so extensive as to cause complete heart block the complications of this type of arhythmia may lead to the symptoms found in the Stokes- Adams syndrome ; periods of unconsciousness lasting from a few seconds up to several min- utes may be successfully combated by adren- alin injected hypodermically, and in extreme cases by the intracardiac method. Stage of Convalescence As the patient approaches the tenth day he may be considered as having escaped the im- mediate hazards so inherent in the acute phase of this disease. The temperature by this time has probably completely subsided ; the leuko- cyte count, on the other hand, may still re- main somewhat increased. Libman has pointed out that the white blood count offers a far more accurate index as to the reparative pro- cess in the myocardium than the temperature curve ; for this reason he would keep such patients at rest in bed until the count reaches a normal figure, regardless of any other nega- tive symptoms. While this may be a good general rule to be carried out if possible, many patients, more especially those of a hyper- active temperament, may become so restless under the enforced regime of prolonged bed- rest that more harm than good will result. Such individuals may actually develop a sec- ond attack of coronary occlusion because of the extreme irritability entailed ; it is a well established fact that an uneasy state of mind will often lead to or precipitate a secondary attack. For this reason, therefore, the medical attendant must invoke his clinical judgment and experience in determining just how long any individual patient should be kept in bed, remembering always that the best interests of the patient are those conducive to complete mental and physical repose. If this can be secured by bed rest the problem is consider- ably simplified ; where, on the other hand, the patient is the type previously described, it may be necessary to get him out of bed and into a comfortable chair as soon as this is compatible with safety. Medication at this time has probably been reduced to symptomatic needs in those pa- tients who have suffered no serious complica- tions during the first and second stages of the disease. The question may arise as to how long coronary dilatation therapy should be continued? Ordinarily, if the blood pressure levels are still low but the pain factor gone, the special indications for this group of reme- dies are less apparent than in those cases where the pressure has quickly risen to the former high levels. When the original signs of cir- culatory failure have subsided, digitalis should be discontinued at once, but to be resorted to from time to time as signs of decompensation make their appearance. Indeed, prolonged ob- servation of coronary patients extending over some years will show an entire gamut of myo- cardial degenerative changes during which many local signs of the decompensated heart will become evident ; pulmonary edema, in chronic or acute forms, circulatory stasis phenomena with engorged and tender liver, general and local edema, all will demand spe- cific and prompt digitalization. Irregularities of the pulse and conduction disturbances not infrequently go hand in hand with the other symptoms of myocardial failure ; the electro- cardiograph will be of great assistance in dis- tinguishing the types of such disturbances. All of them, in the last analysis, are merely differ- ent phases of the same degenerative etiologic background and therapy to be of any value must point toward the establishment of better nutrition of the heart muscle. Where this can be secured by improvement in muscle tone and general contractility of the myocardium, digitalis and its allies are to be utilized in full April, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 301 physiologic dosage; as the fear of emboli in this stage, in contradistinction to the others, is remote. More often, however, those remedies seeking to establish a better coronary circula- tion are to be preferred ; in our experience, metaphyllin has rendered the most consistently good results. Of the more recent remedies, acecolin, either alone or in combination with dextrose, administered intravenously may be of definite prophylactic value. A series of 6 injections given on alternate days has in a group of 56 cases rendered very laudable re- sults in that of the entire group only 16 had subsequent attacks during a period of 18 months of constant observation. A word in regard to dextrose alone ; in our experience this has been the one substance of undisputed value when given intravenously in the second and third stages of the coronary attack. In spite of the general widespread belief that dextrose should be given in very dilute form, we have found that 50% solutions are readily tolerated by the patient. Our usual dosage has been from 10 to 20 c.c. of this strength repeated every other day. In a series of nearly 1000 injections at the Beth David Hospital there has not been a single untoward result ; very rarely patients com- plain of a peculiar taste immediately following injection of the dextrose, and from time to time others speak of a flushing of the face. An interesting difficulty in the treatment of coronary thrombosis is encountered in diabetic individuals ; Levine has shown that as high as 24% of the patients studied in his series were known to have had diabetes. This figure would suggest that this disease is not an un- common complication in the coronary syn- drome and when discovered the question of insulin administration immediately arises. Friedman was the first to point out that dia- betic patients are rendered more susceptible to coronary pain when insulin is given in the attempt to reduce hyperglycemia; in fact, severe coronary attacks are often precipitated. Unless the blood sugar has reached danger- ously high levels and acidosis is likely, insulin should not be employed. Dietary measures including even the older, and now unpopular, starvation methods should be tried. This brings us to the question of diet in general and we wish to point out here that no hard and fast rules can be laid down in re- gard to special dietary measures. During the first stage of the disease the problem is ex- ceedingly simple, as the patient will himself refuse all food. Fluids like the citrous fruit juices, thin gruels and albumin waters and some of the fermented milks will comprise the total selection. If the nausea and vomiting factors are prominent, the dangers of dehy- dration must not be lost sight of ; a careful check of the water balance must be one of the essential nursing procedures. Where there is a negative balance and the output considerably diminished, immediate measures must be un- dertaken to correct this feature. During the second stage of the malady the choice of diet is considerably augmented and is comparable to the average soft diets as used in most hos- pitals ; the exception being the total exclusion of ordinary milk. We cannot too strongly in- terdict the use of milk diets like that of Car- rel so frequently employed during these stages of the disease. In our experience, milk taken by such patients leads to considerable gastric distress and, if anything, adds to the discom- forts already present. Unless there is some definite contraindication, a relatively high carbohydrate ratio should be maintained; such substances as honey, molasses, or sugar syrups can be given liberally. At approach of the third, or convalescent, stage a rather liberal selection may be per- mitted ; with the exception of heavy proteins, the diet need vary in no wise from that of a careful normal diet. We have no special ob- jection to tobacco, tea or coffee, so long as these are kept within moderation and, indeed, we feel that in certain instances they may be especially beneficial. Of great importance to the patient is the problem of physical activity, and such questions as “when can I go back to work”, “how far can I walk”, “can I play golf or do any gymnastic work”, “can I in- dulge sexually”, and many others of similar nature, greet the medical attendant sooner or later in every case of coronary disease. The answer to this very complicated phase of the disease is one which requires the ut- most caution ; realizing on the one hand that sudden death may overtake such patients at 302 JOURNAL OF THE MEDICAL SOCIETY OF 1STEW JERSEY April, 1931 any time, and, on the other, that a certain amount of exercise is therapeutically indicated, it may be a question of fine discernment to de- termine how much or how little the patient may be permitted to do. Here again, no gen- eral rule can be made elastic enough to cover all cases and it will be necessary to take into consideration not only the patient’s previous habits but also the extent of damage suffered during his first or subsequent attacks. Prob- ably in no other instance in clinical medicine will good judgment and experience stand the doctor in better stead in determining the fu- ture conduct of individuals. Gradually increas- ing the amount of physical exercise until the patient’s daily routine has been reestablished to a point to render his forced seclusion less irksome, but conducive to safety, is the ideal goal to be sought. THE CLINICAL SIGNIFICANCE OF HIGH AND LOW BLOOD PRESSURE* R. Burton-Opitz, M.D., New York City I have selected this particular topic because a study of the large array of papers on blood pressure published each year proves that their authors are frequently quite ignorant of the fundamental laws of pressure. An error re- peatedly made is to consider blood pressure as an entity, while in reality it is the result of the interaction of several factors. Thus, it is stated in “Classification and Diagnosis of Heart Disease”, by Bainton, Levy, Munty and Pardee, that: “Essential hypertension is a dis- order in which the arterial pressure is per- manently increased without cause. It is a dis- turbance in function rather than in structure. In the early stages of it there may be no signs other than the increased arterial pres- sure, while later on there may be an enlarge- ment of the heart. When other cardiac signs and symptoms appear, it is probable that ar- teriosclerosis of the aorta or coronary arteries has developed. For the purpose of this classi- *(Read before the Bergen County Medical So- ciety, September 9, 1930.) fication the term of hypertension as an etio- logic diagnosis should be restricted to cases without demonstrable arteriosclerosis. When the latter is present, the etiologic diagnosis should be entered as arteriosclerosis, the hypertension being then a physiologic diag- nosis.” Questionable statements of this and similar kind appearing in print from time to time do not render this subject more comprehensive but tend to dim the issue. The classification offered by these authors cannot be accepted, because it is not built upon a solid physiologic basis. Just as surely as blood pressure is a product derived from the interaction of a number of physiologic processes, so may every increase or decrease in pressure be traced to one or several of its causative fac- tors. Keeping this in mind, it will be seen that such terms as “essential hypertension” must be used with care. Essential means in- dispensable and necessary. In a medical sense it refers to something idiopathic and inde- pendent of others. Blood pressure is a normal physiologic function. It is not idiopathic. Consequently, any labnormal state, such as hypertension or hypotension, must be the re- sult of an abnormal interaction of its causa- tive factors. Hypertension is no more essen- tial or idiopathic than pneumonia or any other pathologic condition. The principal factors responsible for blood pressure are: (a) the energy of the heart; (b) quantity of the circulating blood; (c) elasticity of the vessels; (d) the peripheral resistance. Each ventricular systole forces about 60 c.c. blood into the aorta. Assuming that the other 3 factors remain constant, the pressure must rise whenever the energy of the heart is increased and fall whenever it is decreased. The ventricular output is pro- portional to the cardiac energy and is based upon the following secondary factors: the volume of each discharge, the frequency with which these discharges are repeated, and the force with which they are effected. The first is determined by the capacity of the cardiac chambers, or their power of filling; the sec- ond concerns the cardiac output per unit of time in that the aorta usually receives about April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY COS 4 liters of blood in the course of 1 minute ; the third pertains to the force of ejection. The total quantity of the blood is calculated at 1/20 to 1/13 — average 1/17 — of the body weight. It does not vary much. Marked vari- ations occur during hemorrhage or during in- fusion. Provided the other 3 factors remain constant, any addition to the , amount of the circulatory blood must lead to an increase in blood pressure, and vice versa. The elasticity of the vascular system pre- sents itself as an alternate distention and elas- tic recoil of the vessel wall, and is due very largely to the connective tissue framework. The aorta is not equipped with muscle cells and merely serves the purpose of an elastic reservoir, the recoil of which is largely re- sponsible for onward movement of the blood during the resting period of the heart. When the elastic property of the vessels is diminished by infiltrations, the pressure must rise ; con- trariwise, any unusual relaxation of these ves- sels must lower the pressure. The principal factor concerned in forming the peripheral resistance is the size of the arteriocapillary outlet. The arterioles are heavily beset with smooth muscle tissue which on account of its contractile power is able to diminish, sphincter-like, the outlet into the capillary system. This part of the vascular sys- tem serves the purpose of a gate which may be closed or widely opened. If it is closed, the arterial blood is hindered in its escape into the capillaries and the arterial pressure rises ; if it is opened, more copious escape of the arterial blood diminishes the arterial pressure. It is a simple matter to analyze changes in blood pressure when only 1 of the 4 factors mentioned is affected. As a rule, however, the changes produced by one are modified by those produced by a second or even a third factor. Thus, it frequently happens that an increase in energy of the heart, which ordi- narily would result in a rise in blood pressure, is compensated for by a lessening of the peri- pheral resistance. The reverse is also true. It is a well known fact that a vasoconstriction which would otherwise lead to a higher blood pressure, is often offset by a lessened fre- quency of the heart and ventricular discharge. A loss in the total quantity of the blood which should reduce the pressure, is often compen- sated for by vasoconstriction, i.e., by an in- creased peripheral resistance. Examples which could be mentioned to illustrate this interac- tion are in reality too numerous to include in this brief discussion. What is true of these normal interactions is also true of the abnormal ones. Let us look for a moment at an outline of the more common types of hypotension and hyperten- sion : Hypotensions. Functional : Chronic val- vular disea'ses of the heart ; irregularities in its beat ; hemorrhage ; vascular relaxation as in: neurasthenia ; and shock. Organic : Loss of constrictor substance, as after destruction of adrenal bodies. Hypertensions. Functional: Diet, excessive weight, obesity; habits of life and physical efforts ; menopause ; hyperthyroidism ; chronic valvular diseases of the heart. Organic : Ar- teriosclerosis, local and general ; diseases of the kidneys. It is now a simple matter to analyze any of these conditions in accordance with the out- line given above. Let us take, for example, the hypotension of neivous debility and ex- haustion. The chief factor is lessening of the peripheral resistance by vasorelaxation. The fall in blood pressure is reflexly compensated for by an increase in energy of the heart. The frequency of contraction is increased in order to. augment the ventricular output, thereby en- deavoring to retain an efficient pressure. Quite similarly, we may select samples of hypertension which may be arranged causa- tively in accordance with the preceding table. Mitral stenosis is usually associated with a hypertension. A young person, exhibiting a pressure of 140 to 150 mm. Hg., may be sus- pected immediately of being afflicted with an obstruction at this orifice. Nature endeavors to counteract this hindrance to the ventricular output by increasing the energy of the heart. This organ beats more frequently and in- creases its force of ejection. The early dilata- 304 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 tion of the left auricle is superseded by an hypertrophy of its wall. In its endeavor to propel the required amount of blood the heart slightly overdoes it, and the result is an ar- terial pressure somewhat above normal. Local and general sclerotic changes of the vessels invariably lead to a hypertension, which increase in pressure can make itself felt only after the compensation resident in a re- duction of the cardiac energy has failed. Thus, the high pressures (180 mm. Hg.) usually present in people of about 70 years of age have their cause, as a rule, in a general ar- teriosclerosis which has passed beyond the aid of cardiac energy. Never try to lower this pressure, because a perfectly serviceable hypertension may then be changed into a ter- minal hypotension either by a loss of the car- diac energy (heart failure) or an excessive reduction in the resistance. The hypertension of a hyperthyroidism finds its origin in an increase in the peri- pheral resistance. The latter is due to a spas- tic setting of the vessels in consequence of thyroid toxin. Later on, the initial hyperten- sion may give way to a hypotension provided the heart has been affected sufficiently to cause an irregularity in its beat and atonia of its muscle tissue. The hypertension of the meno- pause has a similar cause. The hypertension of obesity may be traced to an increased peripheral resistance and cardiac energy brought about by the fact that the extra capillary expanse has overloaded the circulatory system. Additional pressure is required to provide an efficient circulation. These few examples, I hope, will prove my contention that the abnormal blood pressures have as definite a cause as the normal ones. Thus, if we restrict ourselves to solid basic principles, such conflicting terms as essential need not be employed at all. They only serve to complicate matters. Analyzed in the above manner, any type of blood pressure, whether high or low, normal or abnormal, must as- sume a more plastic and simple aspect. PRACTICAL MANAGEMENT OF DIABETES* James Ralph Scott, M.D., New York City Management of the diabetic patient resolves itself into a consideration of 2 distinct mani- festations of the disease — acute and chronic diabetes. Acute Diabetes with Coma The classic signal of the acute diabetic is coma, resulting from one of the following causes: (1) dietetic irregularities; (2) sudden withdrawal of insulin; (3) infections; (4) acute surgical conditions, such as appendicitis, cholecystitis, or carbuncle. The symptoms associated with diabetic coma are: (1) nausea and vomiting; (2) abdominal pain; (3) rapid, shallow respiration, or air hunger; (4) subnormal temperature, unless complicated by infection; (5) soft eyeballs (almost pathognomonic) ; (6) acetone breath; (7) albumin and casts in the urine; (8) anuria, as contrasted with polyuria of the pre- comatose state; (9) sugar and acetone bodies in the urine; (10) high blood sugar, low plasma CO, nitrogen retention, urea nitro- gen 50 mg. per 100 c.c. ; (11) coma. Whether the condition be an uncomplicated coma due to overindulgence in food, or one brought on by infection, or one complicating an acute surgical condition, the treatment is the same. The condition should be regarded as an emergency and, if possible, the patient taken immediately to a hospital. A known diabetic who is the victim of an infection or who develops a fever from any cause should be regarded as in impending coma, and should be treated vigorously from the start to forestall the threatened onset of acidosis. The patient should of course be put to bed, with a nurse in constant attendance. If con- scious, hot tea, coffee, broth, orange juice, or water should be given every hour in 6 oz. •(Address delivered before the Passaic County Medical Society, September 11, 1930.) April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 305 amounts ; he should be kept warm ; a com- plete enema followed by a retention enema of 1 pint normal saline; if there is evidence of gastric distension, lavage should be done. If the patient is actually in coma, hot cof- fee or normal saline (6 oz.) should be given by rectum every 3 hr. and supplemented by hypodermoclyses of 1000 c.c. physiologic sal- ine every 6 hours. With suppression of urine, an infusion of 1000 c.c. saline twice daily is the best possible diuretic. Caffein sodium benzoate gr. 71/ 2, should be given subcutan- eously every 2 hours. If the pulse is rapid and of poor quality, digifolin should be given intravenously, gr. 1^4, every 4 hours till an effect is noted. All the above measures are directed toward correcting 3 conditions that invariably ac- company a coma of diabetic origin, namely: (1) extreme desiccation of the body tissues; (2) circulatory collapse; (3) urinary suppres- sion. To overcome the high blood sugar and elim- inate acetone bodies from the blood, insulin is the remedy par excellence. If the blood sugar, on admission, is over 500 mg. per 100 c.c. and the CCA is below 25 volumes per cent., give 40 units of insulin intravenously at once, to be followed by 20 units subcutaneously. Re- peat the 20 units subcutaneously every hr. until the urine sugar is reduced to a faint trace and the blood sugar is below 200 mg. At first the blood should be examined at hourly intervals for sugar, urea and CCA A catheter should be inserted and kept in place, and the urine tested every y2 hr. for sugar, acetone and diacetic acid. In from 2-6 hr., with this intensive treat- ment, the acidosis should be under control. During this time no glucose is required either by mouth, rectum or intravenously ; the pa- tient already has too much glucose in his blood and his tissues are saturated with it. At St. Luke’s we have abandoned giving glucose to patients in the early intensive treatment of acidosis. Formerly, when it was given, the second and third blood sugar determinations were frequently higher than the first, and re- covery was only delayed. What the patient needs at this stage is plenty of fluid to over- come desiccation of the tissues and promote elimination, and adequate amounts of insulin to neutralize the acidosis. The reason glucose was formerly given was, of course, the fear that not enough glucose existed in the body to oxidize" the excessive fatty acids circulating in the blood. When successive blood sugar determinations showed, however, that even with insulin additional glucose only increased the blood sugar, this practice was discontinued. With hourly or even two-hourly blood sugar determinations and half-hourly urinalyses there is no danger of insulin reactions. There is usually more than enough sugar already in the tissues to remove the excess fatty acids provided insulin is given in adequate amounts. We now accomplish in a shorter time, with smaller doses of insulin given more frequently, without glucose, what formerly we accom- plished over a longer period of time with larger doses of insulin and additional glucose. The patient needs in the first 24 hr. of treat- ment 50 to 100 gm. of glucose, but this is be- gun only after the body fluids have been re- stored and the blood sugar has fallen to at least below 200 mg. per 100 c.c. By that time the patient is probably conscious, and fluids can be taken by mouth. As soon as the urine becomes sugar-free, give 4 oz. orange juice by mouth at once. The patient can now be regarded as out of coma. Acute Diabetes Without Coma At St. Luke’s we have a definite routine for patients who have traveled thus far on the road to recovery. I have devised what is known among the members on the staff as the B and O diet : buttermilk and orange juice al- ternating in 6 oz. amounts every 2 hr. for 16 of the 24 hr., making a total of 4 glasses of each in 24 hr. ; it is not given during the night. This diet is supplemented by water, tea, coffee or broth, so that the patient re- ceives a glass of fluid every hour. This diet contains C 122, P 21, F 7 gm., and amounts to 641 calories. Being relatively high in C and low in F, it is an ideal diet for combating acidosis. If the patient dislikes buttermilk, skimmed milk is given instead. At this stage the blood is examined once daily for sugar, urea, and CCA If acetone disappears from the urine, but the blood CCA 306 April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY remains low , it is probably due to some un- identified organic acid. In this case the CO will return to normal if soda bicarbonate is given in small amounts; 30 gr. t. i. d. The urine is examined -with Benedict’s quali- tative solution every 3 hr., and insulin given according to what is called the color formula : If the test is orange, 15 units of insulin. If the test is yellow, 10 units of insulin. If the test is green, 5 units of insulin. If the test is blue, 4 oz. of orange juice. Ibis is absolutely a fool-proof formula, and can be followed literally without danger to the patient. I first saw it in use on Dr. Joslin’s service at the New England Deaconess Hos- pital, in Boston. It now has the status of a ward order at St. Luke’s Hospital, and works perfectly. If the patient is obese, he is kept on this reducing diet — with the necessary insulin — foi several days or even a week or more while he is in bed. The urine is then tested 4 times daily — before breakfast and 1 hr. after meals and insulin is given before meals in the usual way. A blood chemistry is done twice weekly while in the hospital. If the urine be- comes sugar-free, the noon insulin is reduced 2 units a dose until none is being taken at that time. Then the night dose is reduced ; and finally, if the urine remains sugar-free and the blood sugar becomes normal, the morning dose is reduced or eliminated. At least a week before the patient leaves the hospital, a maintenance diet is prescribed. An average diet on discharge is about as follows: C 120; P 75; F 110; 1770 calories. Approxi- mately 1/3 of the surgical diabetics leave the hospital without insulin. The Ambulatory or Chronic Diabetic After the patient is discharged from the hospital he joins the ranks of the chronic dia- betics, and requires management of an en- tirely different character. The criteria by which the success of the treatment may be judged are: (1) A sugar-free urine. (2) A normal blood sugar; fasting sugar below 125 mg. per 100 c.c. ; after meals sugar below 170 mg. per 100 c.c. (3) A weight 10% below average for age and height; tables for these weights are mere- ly approximate, but nevertheless serve as an extremely useful guide. If these conditions are met, the patient is being adequately treated. The chief instru- ment in accomplishing this is education of the patient. In the Diabetic Clinic at St. Luke’s each patient, or some member of the family, is taught to do 3 things: (1) Test the urine for sugar, using Benedict’s qualitative solu- tion. (2) Calculate his diet. (3) Give him- self insulin, this can be done anywhere, and the equipment required is simple: a test tube, a medicine dropper, a bottle of Benedict’s qualitative solution, a 500 gm. food scale, and an insulin syringe with insulin. With a very little patience, this training is not so formid- able a task as it might appear to be. By ac- tually performing a sugar test before the pa- tient he can learn to do it in 5 minutes. All except the mildest cases are placed on weighed diets fiom the first. I his often necessitates a struggle, but the effort expended will be re- paid many times in the increased interest of the patient once he has mastered the intrica- cies of this fascinating subject. I often tell my patients that one reason I enjoy treating diabetics is that the patient does all the work. 1 he routine of a clinic patient who is taking insulin would be as follows, and this applies to private patients as well as clinic patients. (1) He tests his urine before breakfast and 1 hr. after each meal. A daily record of this is kept and brought to the clinic on each visit. \\ e rarely do 24 hr. determinations now. The 4 daily tests are more reliable in- dices of how much insulin is required and at what time of day it is most needed. (2) He weighs all his food until he has become familiar with the prescribed amounts of each ; is then allowed occasionally to dine at a restaurant where he has to estimate the quantity of food, after which he does a urine test to see how close he came to his allowance. This can become a fascinating game. (3) He gives himself insulin. After fol- lowing the effects of insulin on his tests, he is allowed to increase or decrease the insulin 1 unit a dose as indicated by his tests. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 307 (4) He visits the clinic anywhere from once a week to once a month, depending on the severity of his case. A well trained pa- tient not on insulin need not come oftener than once in 2 or 3 months. Blood sugar de- terminations are done at least 4 times a year. At the clinic a specimen is examined for sugar and acetone ; the patient’s weight is taken and recorded on his chart to compare with his theoretic normal ; and instructions given as to diet and insulin. Insulin Of the patients in the clinic 30% are using insulin; amount varies from 5 to 120 units a day; number of doses varies from 1 to 4 a day. The insulin is usually given about 20 minutes before the meal ; in some instances as long as 2 hr. before. If 1 dose, it is given be- fore breakfast; if 2 doses, before breakfast and dinner ; 3 doses, before breakfast, lunch and dinner ; 4 doses, before the 3 meals, and a small dose, from 3 to 5 units, is given at bedtime. When cutting down on the number of injections per day this order is reversed. I am often asked how to determine the quantity of insulin required in each individual new case. There is no infallible rule. Any patient showing sugar in the urine can start with 5 units of insulin before breakfast. If sugar appears in the urine after the other meals, he can take 5 - 5 - 5 ; i. e., 5 units before each meal, running the dosage up or down until the necessary quantity is being given. By varying the dosage according to tests of the 4 daily single specimens, an equi- librium is soon reached. Keeping the urine sugar-free appears to improve the patient’s tolerance. After a week of sugar-free urine, therefore, the diet can gradually be increased or the insulin decreased. With a thin person the former procedure would be adopted, and with a fat person the latter. A certain quantity of insulin given 3 or 4 times a day is more effective than the same amount given only once or twice a day, with less risk of an insulin reaction. A patient was referred to me recently who was taking 80 units of insulin daily — 40 B — 40 D on a carbo- hydrate allowance of 170 gm. — a severe dia- betic. He frequently suffered from insulin reaction, and showed sugar in his urine on one or more of his 4 daily tests. By redis- tributing his insulin so that he was taking a dose before each meal and 3 units at bed- time (11 p. m.) he became sugar-free on all his tests and had no more insulin reactions — and this was accomplished on 60 units per day, as contrasted with the 80 units he was pre- viously taking, with no change in his diet. Insulin reactions are comparatively infre- quent in adults. In children they are com- mon. Every child taking insulin of 10 units or more a dose should carry 2 lumps of sugar or an orange to be used in such emergencies. If insulin is taken at all it must be used daily. Patients who test their urine 4 times daily, and vary their insulin accordingly, rarely suffer from insulin reactions. At the most, insulin reactions are disagreeable rather than danger- ous. Liver has recently been added to the dia- betic diet. It is an insulin saver ; lb. liver a day will take the place of from 5 to 10 units of insulin. I have a private patient who has been taking liver for 3 months with gratifying results. With no other change in diet he has been able to reduce his daily insulin from 10 units t. i. d. to 5 units once a day, without showing sugar in the urine and with no ele- vation of the blood sugar. Whether or not this marked improvement can be attributed entirely to liver, I do not know, but it certainly has helped. After 3 weeks of the liver diet the patient balked but since giving him before 2 of his daily meals a well seasoned broth prepared from fresh liver, he has taken it willingly and has thrived on it. The broth is prepared by macerating ^4 lb. liver (it can be put through a meat chopper), and steeping it for an hour in warm water. The pulp then squeezed into the water and the broth set aside in the icebox to be served as required. The preparation is not boiled, aS boiling de- stroys the insulin-saving principle. Another insulin saver is exercise. A good vigorous walk will use up a considerable quantity of sugar and allow the insulin to be decreased accordingly. Two walks of Yz hr. are better than 1 walk of an hour. Patients are encouraged to experiment with exercise as they do with food and insulin to determine 3 08 April, 1931 JOURNAL OF THE MEDICAL their tolerance. Unusually prolonged or vig- orous exercise in a diabetic using insulin will produce insulin reactions unless the insulin is reduced from the usual amount. In a diabetic, exercise is a drug second in potency only to insulin and food. After insulin, the next most confusing as- pect of treatment of this disease is the diet. Except in the mildest cases all foods at first should be weighed. This accomplishes 2 things : ( 1 ) Educates the patient in the funda- mental principles of treatment of his disease, and this is extremely important. (2) Increases cooperation of the patient. In all our cases in which the patient has made a serious attempt to calculate his diet, it has evidently aroused his interest and resulted in more complete co- operation with his physician. There are 3 types of patients to consider: obese, thin, and children. Obese patients can usually be rendered sugar- free on an un- der-nutrition diet alone. The buttermilk and orange juice diet already mentioned is an ex- cellent reducing diet provided the patient can be put at rest. Any reducing diet should be as low as possible in fat. Reduction can be accelerated by using insulin, although at first, due to water retention, there may be no ap- parent loss in weight. With malnourished individuals, however, and children, no attempt should be made to do without insulin. They need to build up strength and promote growth. Therefore, ade- quate diets should be prescribed at once and enough insulin given to handle them. Children require from 40 to 50 colories per kilo body weight, and 3 to 4 grams of protein per kilo. For dietetic instruction the patients fall into 2 categories: (1) Mild cases require only general directions about diet. (2) Those with moderately severe and severe conditions are taught to weigh their diets, or at least to measure them* i. e., to calculate them by the cupful and tablespoonful, instead of by the gram. Patients in mild condition are merely told to avoid sweets, starches, butter, oil or fat, and anything made with flour. They can usually stand a little reduction in weight, which this so-called “restricted diet” will accomplish. 1 hat leaves the patient on a diet consisting SOCIETY OF NEW JERSEY mostly of vegetables, meat, eggs, milk in mod- erate amount, cheese, and all but the particu- larly sweet fruits, but he is of course instruct- ed to eat moderately even of the foods allowed. If vegetables are restricted to the 5% variety and fruit limited to grapefruit and oranges, the patient would have difficulty in eating more than 100 gm. C. in a day. Of course broth and tea or coffee without cream or sugar are allowed in unlimited amounts. Water drinking should be encouraged. A few days to a week on this diet will render the urine sugar-free. Bread is then allowed in increas- ing amounts up to a reasonable number of slices a day, one at each meal. It is well to maintain a moderate restriction of fats and sweets at all times, and to guard constantly against overweight. I hose in severe or moderately severe cate- gory are first placed on one of Toslin’s main- tenance diets ; the food to be weighed directly on the food scale without calculating the C., P. and F. food content. Later, as the pa- tient acquires more confidence, he is trans- ferred to a formula, and can vary his diet at will; i.e. his C., P. and F. for the day are pre- scribed and by calculating these values for the foods he selects he can arrange his diet to suit himself. Nowadays every diabetic about his usual daily life should be taking at least 100 gm. C. per day. None of my patients are taking more than 190 gm., and the average is about 120 gm. The protein requirement is 0.67 gm. per kilo body weight, and fat enough to bring the diet up to caloric requirements — 30 cal- ories per kilo. 4 he fat rarely exceeds the carbohydrate, whereas in the beginning of the insulin era it was usually 2 or 3 times the carbohydrate. In those days patients who were treated most scientifically according to our knowledge at that time were most apt to de- velop acidosis, while now acidosis in a well treated case is rare. I he surgical diabetic is a special problem and requires careful pre-operative and post- operative treatment. If time permits, 7-10 days should be devoted to preparing the pa- tient for operation. The buttermilk and or- ange juice diet plus insulin will accomplish this in the allotted time. Fluids should be given April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 309 freely, over 100 oz. per day, and should be continued up to 1 hr. before the operation ; 6 oz. orange juice with 10 units of insulin are given 3 hr. before the operation; and after the operation 500 c.c. saline is given by clysis and fluids — broth, water, orange juice — are given by mouth as soon as they can be retained. About 100 gm. C. should be given during the first 24 hours. The buttermilk and orange juice diet is employed routinely for the first 2 or 3 days post-operative. It has been shown experimentally, however, that healing of a wound is retarded by a diet too low in protein ; hence, after the third day a diet is prescribed containing at least 1 gm. protein per kilogram body weight, and is continued until the pa- tient is discharged. The acute emergency surgical case on ad- mission to the hospital is practically always on the verge of coma, if not already in coma. These require the prompt and vigorous meas- ures already described under treatment of dia- betic coma. An immediate infusion of 500 to 1000 or even 2000 c.c. saline is given, and in- sulin in half-hourly or hourly intervals as in- dicated by the blood and urine analyses. In as short a time as 2-3 hr. the acidosis may be sufficiently under control to permit the opera- tion. The anesthetics of choice are either local, gas-oxygen, or spinal. Ether should be avoided as it tends to damage the liver and increase acidosis. Finally, as you all know, infection of any kind is bad for a diabetic. The first break- down in S. tolerance is often initiated by an infection. Infection causes a mild case to become severe, at least temporarily, and is frequently fatal to a severe case. Therefore, care should be taken to remove obvious foci of infection ; particularly the teeth should be x-rayed, and those teeth showing apical ab- scesses should be removed. Infected tonsils should be removed. Particular care also should be devoted to the feet. Arteriosclerosis is more marked in diabetics than in others, and it occurs earlier in life. I have .seen in a diabetic girl of 17 arteries so calcified that they cast a shadow on an x-ray film. Hence, abrasions and injuries to the feet are slower to heal, with the conse- quent onset of gangrene. This condition is easier to prevent than to cure. HEREDITARY EPISTAXIS; WITH AND WITHOUT HEREDITARY (FAMILIAL) MULTIPLE HEMORRHAGIC TELANGIECTASIA* * Hyman I. Goldstein, M.D., Camden, N. J. Since I published my paper on “Hereditary Hemorrhagic Telangiectasia with Familial Epistaxis” in the Archives of Internal Medi- cine, January 1921, a number of excellent re- ports on “Hereditary Nosebleed”, “Familial Hemoptysis”, “Familial Hematuria”, “Osier’s Disease”,** “Hemorrhagic Telangiectasia”, gastric, rectal, and renal bleeding of unex- plained etiology, have appeared in the medical literature of the world. Most of the papers were published in the medical Journals of Germany, France, England and only a few in America. In study of the subject of “Epi- staxis”, I reviewed the medical literature for the past 300 years, but especially reports pub- lished since 1830. Nosebleed, or epistaxis, has been an im- portant subject for discussion since Biblical times. It was one of the earliest complaints treated by medical men and healers. Hippoc- rates (450-357 B. C.) in Epidem. Lib. I. Aphor. 33, spoke of vicarious menstruation (rhinorrhagia) through nosebleed, remarking that those who have confirmed nosebleed into a habit are young persons apt to incur diseases of the chest, pleuritis, pneumonitis, hemoptysis and consumption, probably owing to a metas- tasis of the nasal irritation to the lungs, but such not taking place, it is held to have a con- *(Read at the Annual Meeting of the Medical Society of New Jersey, Atlantic City, June 13, 1930.) * * The following terms here used as eponyms and synonyms: Osier’s Disease; Rendu-Osler Weber Disease; Ullmann-Goldstein’s Hereditary Angiomatosis with Hemorrhages; Hereditary Hemorrhagic Telangiectasia with Familial Epi- staxis and other hemorrhages. 310 April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY trary, or preventive, effect of pulmonary af- fections. Nasal hemorrhages may be very profuse, Johannes Rhodius (1587-1659) of Padua, in his Observationum Anatomico-Medicarum Centuriae Tres (1657, I b, also Frankf. 1676), mentions a patient losing 18 lb. of blood with- in 36 hours. Bartholin’s patient lost 48 lb. and a writer in the Leipsic Acta Erudita men- tions a patient losing 75 lb. within 10 days. The Ephemera of Natural Curiosities contain a case report in which the patient bled from the nose without cessation for 6 weeks. In 1820, Professor Chapman treated an elderly gentleman who lost several quarts of blood and mentions 2 persons who bled to death. Claudius Galen (131-200 A. D.), Coschwitz (1616), Fabricius Hildanus (1560-1640), Friedericus Hoffman (1660-1742), Sebizius (1630), Kau (1710 Jena), Block (Jena, 16/9), J. Rhodius (1587-1659), Henricus Petraeus (1589-1620), Samuel Rumpler (1615), Taunton (1830), Sutton (1864), Babbington (1865), Albert Rosenberg (1900 Berlin- Vienna), and others too numerous to mention, have discussed nosebleed or epistaxis associated with various diseases and different constitutions, and often leading to fatal re- sults. Ihus, Albert Rosenberg, of Berlin, in Handbuch Der Laryngologie und Rhinologie, Vol. III., 2 Halfte, (by Professor Paul Hey- mann, pages 697-722, Vienna, 1900), writes on Das Nasenbluten giving 369 references from Hippocrates, 400 B. C., to Hastings, De- cember 1897. Friedericus Hoffmann (1740) long ago remarked that persons with frequent and profuse epistaxis when young, had a pe- culiar constitution like that observed in “bleeders”; also similarly discussed bv Lay- cock in Medical Times, page 501, May 17, 1862 (London). Hoffmann observes — “ob- servamus porro, omnes fere eos, quibus san- guis copiosus et frequentius in primis annis per nares erumpit, natura valde imbecilles, animo quoque sensibiliores, varisque mor- borum afflictionibus, spasmis et doloribus per omnen fere aetatem subjectos esse ; rarius etiam vitam diu protrahere; quippe in juven- tute in phthisin inclinent, in consistente aetate in malum flatulento-spasmodicum sive hypo- chondriacum facile incident, atque aetate pro- vectiori ad dolores nephriticos et podagricos mul turn proclives sunt”. (Hoffman-Medic, rational, systemat. Pars II. Sect. I, Cap. I u. Opuse, physioco-medica p. 196, 1740.) Thomas Laycock, of London (1862) in his lectures on The Haemorrhagic Diathesis and Haemoptysis says : “epistaxis is a symptom of considerable significance, although generally overlooked in persons of phthsical habits”. He had often noted it as being premonitory of fu- ture hemoptysis, and often, too, observed it as coinciding with intercurrent attacks. In many of his 227 cases of diathetic “bleeders” it was noted that bleeding was nasal (about ^ the cases) and he found that epistaxis, hemopty- sis, hematuria, and hematemesis succeeded or alternated with each other or were “meta- static”. He emphasized the fact that epis- taxis, repeated and profuse attacks about puberty, in certain constitutions indicates a tendency to hemoptysis and tuberculosis sub- sequently. Laycock, Chapman (1839), Sutton (1864), and others believe there was a class of cases in which the hemoptysis and the nose bleed did recur from time to time rather as an here- ditary or a rheumatic than a tuberculosis af- fection, the condition being a “constitutional epistaxis” or “hemoptysis”. Laycock (1862) further speaks of mitral constriction as a source of hemoptysis and epistaxis and their close relation to rheumatism. He empha- sized the hereditary relationship of nosebleed and blood-spitting. He concludes by saying that the hemorrhagic diathesis presents many of the peculiarities of the rheumatic or gouty, whether we regard the age, sex, hereditari- ness, tendency to, articular affections, or the exciting causes of the periodic or paroxysmal bleedings. Hoffman (1740), Taunton (1830), Chap- man (1839), Babbington (1865), Rosenberg (1900), Frohlich (1891) and many of the other older writers recognized the importance of heredity in relation to repeated and habit- ual nosebleed. It has also been emphasized that attacks of nosebleed frequently precede attacks of acute rheumatic fever. Chapman, who was Professor of Physic, University of Pennsylvania, prefers the term “hemorrhagia nasi” to “epistaxis” (Medical April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 311 Examiner, Phila., Feb. 23, 1839, II, No. 8, p. 117-118). Rosenberg (1900) prefers the term “hemorrhagia narium” or “rhinorrhagia”. Chapman says (Jan. 5, 1839) those with short neck and large head are prone to have epis- taxis or apoplexy, while those with a narrow, ill-shaped chest, are equally subject to hem- optysis. Nor is it uncommon for whole families to be thus distinguished, and who, in some in- stances, seem to derive the peculiarity by in- heritance. He refers to instances reported in Andral’s work on Pathologic Anatomy, and in an essay on the subject by Dr. Reynell Coates, in the North American Medical Journal. He mentions the writings of Morgagni, Bichat (Anatomie Generale), and Marendel. Mar- Fig. 1. — Telangiectases on the face. The family tree of this patient is given in Figure 3 (Family 28, Steiner 1, III, 22). Dr. Goldstein — Telangiectasia. Steiner: Archives of Internal Medicine, 1917. endel found no ruptured blood-vessels in these fatal cases of vital (spontaneous) hemor- rhages even with the microscope. Chapman says “the dermoid usually effuses in the shape of petechiae or vibices, or what is called hemorrhea purpurea”. Aristotle, Theophras- tus, Lucan, and Huxham speak of these hemorrhagic “spots”. I am of the opinion that these old writers saw cases of epistaxis with telangiectatic skin and mucous membrane lesions. C. Hanfield Jones (Medical Examiner, London, I, Nos. 46 and 47, p. 806 and 823, Nov. 16 and 23, 1876) in his Clinical Lectures on Epistaxis does not mention telangiectasia and familial epistaxis. He says, however, that “in these hemorrhages, the deterioration of the capillaries seems to be the essential morbid change”. Valsalva knew that nosebleed occurred more often from the anterior portion of the septum (des knorpeligen septums), and also that “san- guifera vasa intra nares valde turgida circa earn sadem, ubi alae nasi digito plus minus trans- verso ab imis naribus cum osse committuntur”. Dr. Marvin, of Geneva (Jour, de med. et de chirurg. practique, 1872) stated that as blood in epistaxis generally came from only one nos- tril, and most frequently from the anterior third of one of the nasal fossas, he was led to believe that by compressing the corresponding facial artery on the superior maxillary bone near the ala of the nose, the afflux of blood would be diminished and the hemorrhage at once arrested. Dr. Brunner (Huf eland’s Journal) stopped epistaxis by blowing powdered gum arabic through a quill into the nose. In the Phila. Monthly Jour. Med. and Surg., I, No. 2 p. 102, July 1827, a case is reported of a young man aged 19, who continued to bleed until stopped by this method. Fabricius (Guilhelmus) Hildanus (1682), in his op. observ. et curat, med chir., reported a young married man who had severe nose- bleed after each coitus. J. Rodius mentioned nosebleed following smelling a rose. T. A. Flail (Virginia Medical Monthly, 1896) says the powder of fungus myces (F.), commonly known as “devil’s snuff”, has in- variably stopped epistaxis when snuffed up the nostrils. In “Epidemics”, Liber I, in the Third Con- stitution, Paragraph VIII, Section 2, Hippoc- rates speaks of epistaxis as one of the 4 modes by which ardent fevers came to a crisis. When in these attacks of ardent fevers there was a proper and copious hemorrhage from the nose, they were generally saved by it, and “I do not know a single person who had a proper hemorrhage who died in this consti- tution”. The hemorrhages attacked most per- sons, but especially young persons and those in the prime of life, and the greater part of those who had not the hemorrhage died. In certain individuals, he says, both the hemor- rhage from the nose and the menses appeared at the same time. 312 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1S31 Winstead (1858) stopped severe nosebleed by cold, wet applications to the scrotum. Rosenberg (1900) says Hoffman recog- nized the importance of heredity in cases of nosebleed. He mentions a case of epistaxis m a child whose father and 4 brothers suffered from epistaxis. Among 27,000 patients of the University Polyclinic for Throat and Nose Diseases (Berlin), he found 367 instances of nosebleed, of which 247 were in males and 120 in women. The largest , number occurred in the period of puberty; 101 were between 15-20 years. He mentions a case of a young girl aged 15, who had not menstruated norm- ally but who bled irregularly from the nose, and a woman who missed her periods for 5 or o months without pregnancy and who had suf- fered from epistaxis for 6 weeks when she was seen by Rosenberg. He found nosebleed to vary with climate and seasons — the largest percent- age of cases occurred in May, June and July. Obermeier mentions an interesting case in a young man who had bled from the nose every month for 3 days since the age of 15 j'ears. Rosenberg mentions severe nosebleed at times after postoperative menopause. Hubbard reports a pregnant woman who died from profuse nosebleed. Urbantschitsch, Taubhert and Blondeau noted pregnant women wdio aborted after nosebleed. Blondeau (Gaz. des Hop. nr. 149/51 1874) recorded a case of a pregnant woman who aborted following blood transfusion for epistaxis. Under the term “nosebleed” or “epistaxis” (nasenblueten) as used in this paper, I in- clude bleeding from the nose, the source of which is to be found in the nose. Bleeding from the nose, as may occur in hematemesis, hemoptysis, postoperative (tonsillectomy and adenoidectomy) conditions, vegetative aden- oids, ulcerations and new growths of the naso- pharynx, middle ear bleeding, fracture of the base of the skull, etc., is not included. Nor am I considering the numerous other causes of nosebleed in general diseases. I limit myself in this paper to a discussion of a definite clinical entity, namely, cases of hereditary (familial) nosebleed occurring in rami lies and often associated with telangiec- tatic lesions of the skin and mucous mem- branes. Cases of nosebleed in several members of a family may occur, without a definite his- tory of the presence of telangiectasia. How- ever, in some instances, as well as shown by Fitz-Hugh (1923), other members may be thus affected (with skin lesions) in future generations. He believes an atavistic tendency m this condition has been demonstrated, hav- ing noticed atavistic skipping of a generation in 7 cases. Foggie’s family shows this atavis- tic tendency. Gossage believes that in some of these fam- ilies many of the children die young, before an opportunity has been afforded to know whether they would also have been similarly affected — which accounts for fever affected ones. He says “the condition of multiple hereditary telangiectasis seems also to be a dominant to the normal condition”. Henle believes the condition acts as a simple dominant with some variations. It is also true, I believe, that cases of familial hematuria (Apert 1907, Foggie 1928, Attlee 1901, Pearson 1904, Aitken 1909, Guth- rie 1902, Hurst 1923, and Grandidier), familial hemoptysis (Libman and Ottenberg, Dec. 1923. and Mantchik, 1922), familial hemorrhagic nephritis— (Hurst 1923) and hereditiary hemorrhagic telangiectasia, with or without familial epistaxis, are all properly classified under the same heading. H. Gawen Sutton, Assistant- Physician to the Metropolitan Free Hospital, in the De- cember 1864 issue of the Medical Mirror (pages 769-781) in a thorough manner dis- cusses “Epistaxis as an Indication of Impaired Nutrition, and of Degeneration of the Vas- cular System . He emphasizes the important part played by imperfect nutrition and de- generation of the vascular (capillary) system, and discusses the well-known fact that those who bleed habitually from the nose are more liable to certain diseases than others. Thus, he shows that it frequently occurs in indi- viduals subject to rheumatic fever, hemoptysis and phthisis in adult life. J. J. Kam (1745) in “De haemorrhagiae nariutn in junioribus nimiae noxis” (Argen- April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 313 torati) also observed that there is a connection between the epistaxis of youth and the hemophysis and phthisis of adult life. J. Haan 220 years ago, in ‘De hemorrhagia narium” (1711, Argentorati) reported similar experiences. Lavcock (1862) stated that he has often noted epistaxis as being premonitory of future hemoptysis. French, in his “De Curandis Hominum Morbis”, stated “that young people who had been subject to oft repeated nasal hemor- rhage have to fear hemoptysis, and that hemop- tysis is hereditary in some families, and those liable to it may succumb in the flower of their age to this hemorrhage or to consumption”. Fig. 2 — Telangiectases on the tongue. The family tree of this patient is given in Figure 3 (Family 26, Steiner 1, IV. 12). Dr. Goldstein — “Epistaxis and Telangiectasia.” Steiner: Archives of Internal Medicine, 1917 Chomel has stated in his essays on rheu- matic fever that Hippocrates said, in the end of the second volume of Prorrheticon, that those who had been subject to epistaxis in their childhood and youth were particularly predisposed to arthritic fevers. Chomel found that 1/3 of those who had rheumatic fever had previously suffered with nosebleed. Sutton (1864), too, has found that of 31 patients suffering from rheumatic fever, 21 previously had epistaxis. There are patients who have previously suffered from -rheumatic fever who later have repeated attacks of epi- staxis. He reports the case of a lady, age 74 years, who had severe attacks of hemoptysis and bled profusely from the nose when a young girl, and another woman aged 46 years who had bled from the nose when a child and now was suffering from hemoptysis ; her father suffered from a “ruptured blood-vessel of the lungs” and hemoptysis ; an only brother, who died of inflammation of the lungs, also had hemoptysis and for a number of years before his death often bled profusely from the nose; her 3 sons all bled from the nose; an only daughter, aged 28 years, had never had attacks of epistaxis. Sutton reports a second family in which there were 3 brothers who had nosebleed; one who died at 31 years of age, bled profusely from the nose for many years before he began to spit up blood (“pints”) ; another who had suffered from epistaxis was later laid up with rheumatic fever. Sutton says the belief that epistaxis is hereditary in some families has been asserted by so many physicians that it would be diffi- cult not to believe that it is so. It is import- ant to remember that there is a connection be- tween epistaxis of youth and rheumatic fever, valvular disease, hemoptysis and phthisis of adult life. Hoffmann, also, has stated that those who suffer with frequent and copious epistaxis in early years are often subject in youth and adult life to hemoptysis and phthisis, and mid- dle age to gravel and gout. Sutton tabulates 83 cases of phthisis of which number 55 had epistaxis at some periods of their lives. He also found that during phthisis epistaxis often occurred be- fore the hemoptysis. J. C. Taunton (Article III, June 1830, p. 489, IV, No. 24, London Med. and Surg. Jour.), Surgeon to the City of London Dis- pensary, reported his own case of recurrent epistaxis for 20 years. Llis parents were ap- parently healthy. Boenninghaus, of Breslau (1923), speaks of habitual nosebleeds in patients he has seen off and on during 20 years, bleeding from “vena liminis” and not from “locus kisselbach of the septum”. He mentions that Valsalva knew of this source of habitual nosebleed, and stopped the hemorrhage by means of finger pressure. Boenninghaus stopped the bleeding point with the electric cautery or the chromic acid bead. Frohlich, of Cassel (1891, Der Artzliche Praktiker), reported a young patient with re- current severe nosebleed; a brother died from 314 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 epistaxis; his only sister bled profusely since the first menstrual period ; no mention is made as to the parents bleeding from the nose. Korstakow ( 1886) mentions a case of menstruatio precox with severe periodic epi- staxis. Fricker (1844) reports fatal nosebleed of vicarious menstruation. Barford (1926) reports 2 cases of recur- rent gastric hemorrhage without organic lesion and associated with other hemorrhages. In 1 case there occurred recurrent severe hema- temesis with occasional epistaxis and hema- turia. Hurst (1923) reported 16 individuals in 3 generations suffering from hereditary familial congenital hemorrhagic nephritis. These cases were similar to Guthrie’s (1902) series of congenital hereditary and familial hematuria. Up to 1912, Hurst could only find records of 2 other families similarly affected. Since 1912, he says (1923) he learned of 2 additional families through Dr. W. W. D. Thompson, of Belfast. E. Libman and Reuben Ottenberg, of New York (Dec. 15, 1923), reported 7 members of a family suffering from rather profuse hemoptysis at intervals for years, beginning at puberty or in early adult life and not ser- iously impairing the general health. Tuber- culosis was excluded. No telangiectases were seen in the upper air passages broncho- scopically. No mention is made of telangiec- tases in any other part of the body. In the cases recorded the condition seems not to skip generations. The coagulation time was normal. Blood platelets were normal. They say that “if the condition is due to telangiectases, they must be localized in the finer bronchi or in the pulmonary tissue”. They were unable to find a report similar to theirs in the literature. “Idiopathic familial hematuria”, reported by Apert, is mentioned as perhaps being “com- parable” with their cases. It seems probable, according to F. Parkes Weber, of London (1924) who has studied this subject extensively, that “gastrostaxis” cases, as reported by Sir William Hale White, and I may add, those reported by Pons, Meine and Blenkle (Feb. 1929), before our New Jer- sey State Society, may have been of similar telangiectatic origin. Pons, Meine and Blenkle (Jour. Med. Soc., N. J., 26:143, Feb. 1929) did not mention telangiectasia as a possible cause for the hematemesis in their cases. Foggie (Edinburgh Med. Jour. May 1928, p. 280) of St. Andrew’s University and Dun- dee Royal Infirmary, reports the case of a woman, aged now 47 years, who suffered from hereditary hemorrhagic telangiectasia with re- curring hematuria. He was able to collect 41 reported families ; with his family making al- together 42. He includes the 31 family groups 1 was able to collect from the literature of the world up to 1920. inclusive, and reported in January 1921. I did not include the cases of familial nosebleed mentioned by Sutton (1864), and Rosenberg (1900), and the case reported by Professor Vincent Tanturri, of Naples (Morgagni, XXI, Aug. 1879) under the title of “Un caso di dermostasi venosa generale ed idiopatica”. In this case no men- tion is made of epistaxis or other recurrent hemorrhages. The girl was 14 years of age and had generalized telangiectasia. Babington (1865), Rosenberg (1900), Richardson (1917), Boston (1930), Goldstein (1922), Lane (1916). Verneuil (1894), Frdh- licli (1891), Griffin (1927), Blumenfeld (1926), Sutton (1864), reported cases of familial (hereditary) epistaxis. In 1922 I re- ported several cases of recurrent nosebleed in one family and recently I met with another family in which several members (father, sons and daughter) bled profusely from the nose. Foggie’s patient gave a history of nose- bleeding in 5 generations associated with telangiectases. She only occasionally bled from the nose but bled from the urinary tract for 20 years, due to these vascular dilatations. T. C. Fox ( 1908) reported a case of bilat- eral telangiectases of the trunk with a his- tory of marked epistaxis in childhood and re- cent rectal bleeding. Erasmus Wilson, of London (Jour. Cutan. Med. and Dis. Skin, London, III, p. 198-199, 1869), under “Clinical Memoranda” and the subtitle of “Eruptive Angiomata” reports a case of a publican, aged 30 years, who had copious bleeding from the gums, epistaxis and an eruption of red papules on the face, neck. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 315 hands and arms — “Angeiktasia” or multipli- cation and hypertrophy of the venous capil- laries of the skin. He says “the case is very rare” ; thought this was a sudden eruption of “angieoma associated with hemorrhage from the mucous membrane of the nose and mouth”, hut fails to mention other members of the family with this condition. Kalischer (1901) reports a case of telan- giectasia (angiom) of the face and “der Weichen Hirnhaut” (Archiv. f. Psychiat, Ber- lin, 1901, Bd. 34, pages 171-180). R. H. Kennan, of Sir Patrick Dun’s Hos- pital (April 30, 1902) reported a typical fam- ily with telangiectasia and epistaxis, mention- ing Osier’s report in the Johns Plopkins Hosp. Bull., November 1901. Osier, however, over- looked several previously reported cases of familial epistaxis and of hereditary telangiec- tasia. He includes several of these in his second paper in the quarterly Journal of Medi- cine (London), October 1907, with colored plates of A. Brown Kelly’s (1906) case. Rendu ( 1896) was the first to associate the tendency to epistaxis with multiple telan- giectases as manifestations of a distinct clini- cal entity, now, however, frequently called “Osier’s Disease”. Time will not permit to review the addi- tional cases reported from 1876 to 1930. Suf- fice it to say, that Coe (1906) reported, er- roneously, a case as hemophilia which was re- ported as a typical case of “hereditary telangi- ectasia” by Osier, and that since Legg (1876) and Chiari (1887) reported their cases there "have been reported a total of 65 families and about 350 individuals suffering from heredi- tary (familial) epistaxis with hemorrhagic telangiectasia including my cases reported in 1921 (Arch. Int. Med.) and in 1922 (Jour. Med. Soc. N. J., 1922 p. 50), and including Kofler’s (1908) cases. Since the publication of my first paper there have appeared a num- ber of excellent reports on the subject. It might be of interest to list all the typical and atypical cases reported to date, but I shall limit myself to the more easily accessible and available reports. Recently, Professor Rudolf Schoen, of the Morawitz Clinic, in the University of Leip- zig, reported 2 cases of “Familiare telangiek- tasie mit habituellen nasenbluten” (affecting 4 generations), in the Deutsches Archiv fur Klinische Medizin, Bd. 166, Heft )4, 1930. A. Arrak (1925), of Masing’s Clinic, in the University at Dorpat, Esthonia, reported 2 families with hereditary hemorrhagic tel- angiectasia (Deutsches Arch. f. Klin. Med., 147, June 1925, pp. 287-291). Dore’s (1927) case of multiple familial telangiectases was a woman, aged 56 years, who had multiple telangiectases for 14 years. She had them also on the tongue, lips, hands, under one nail, a few on the body. She suf- fered from frequent nosebleed. Her mother had multiple telangiectases. Patient does not know whether other members of the family were similiarly affected. Electrolysis was tried. Dore used carbon dioxide snow. This was the third case of the kind he had seen. One of the patients (a man) said that the condition had been known in his family for a hundred years. The third patient was a young woman, but no other members of her family appeared to be affected. F. Parkes Weber, of London, discussing this presentation, said that “though the tend- ency was inborn, the lesions of the skin and mucous membranes manifested themselves or were often first observed at relatively late periods. The nosebleeding, however, was often noted earlier”. R. A. J. Harper (Apr. 1929) reports the case of a man, aged 45 years, who had hemor- rhages from the nose, gums and tongue. He had red “spots” on the cheeks and ears, ton- gue, gums and palate. Epistaxis was fre- quent. Stools were black at times. No blood in urine. His father and a sister (47 years of age) and her 2 young sons suffer similar- ly. The patient himself has 7 children ; 3 sons are well, while 4 daughters are all af- fected. Willis C. Lane (Mar. 1916, University of Maine) reports cases of “hereditary nose- bleed”, but no mention of telangiectasia is made. Schwartz, of Minneapolis (1925), reported a case in a woman, aged 49 years. She suf- fered from severe nosebleed since the age of 14; also severe hemorrhages from the tip of the tongue and from the tip of her right lit- 316 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 tie finger. She had reddish “spots” on her face, tongue, soft and hard palate, nose, con- junctiva, auricles, cheeks and hands, for many years. Her mother died of frequent and almost uncontrollable nasal hemorrhages. The coagulation time was 5 minutes, bleeding time 2y2 minutes. Curschmann, (April 1930), of the Medical Clinic of Rostock, reports 2 families with familial epistaxis as an expression of “pseudo- hemophilia ’. He overlooked, entirely, the ex- tensive literature now available on the subject of familial epistaxis and hereditary telangiec- tasia— (“Rendu-Osler- Weber Disease”). Be- cause of the free nosebleed in all these cases, Curschmann calls it “monosymptomatic bleed- ing without thrombopenia and without hemo- philia”. He advises the use of Roentgen ray therapy over the spleen. Kozach, of Hamburg, discussing Cursch- mann s paper before the Northwestern Ger- man Association for Internal Medicine at Hamburg- Eppendorg, January 31, 1930, men- tioned a family suffering from epistaxis. Thomson and Mason Lamb, (1928) of Birmingham, England, reported a case of an unmarried woman of 30 years who had severe bleeding from the mouth during the night, lasting 9 hr. continuously; blood “ran in a stream out of her mouth”. Since the age of 12 years she had severe bleeding from the nose, and also bled from the ear, scalp and lip. Her father, paternal grandfather and 1 of the father’s cousins were similarly affected; 1 of the father’s brothers died at 14 months, following hemorrhage after operation (in 1876 or 1877). The patient’s coagulation time was 1 minute and 30 seconds. The blood-calcium and cell fragility were normal. Blood Wasser- mann was negative. They discuss Sir Thomas Lewis’ theories and explanations for the de- velopment of telangiectases. Williams (1926) reports instances of hered- itary hemorrhagic telangiectasia with nose- bleed in 4 families. He believes that the dis- ease is “exceedingly common”. While, perhaps, many cases go undiagnosed, I do not believe that the familial hereditary type of this con- dition is so very common. I agree with Will- iams that the hereditary character of this con- dition is necessary for a correct diagnosis and it is precisely this feature which is sometimes difficult to establish. Further, that the essen- tials of the disease entity described here are as follows: (1) The occurrence of nosebleed in childhood, often recurring throughout the life of the patient, and sometimes associated with bleeding from other mucous membranes — stomach, bowel, bronchi, gums, and even from the skin, lips, ears, fingers, conjunctiva, tongue, and meninges. The bleeding may de- crease, but very often becomes more serious and may even prove fatal as the patient grows older. The mother of 1 of my patients died as the result of a severe nasal hemorrhage. (2) The development of telangiectases, some- times as dilated capillaries , or as arborescent, distended venules, or as small pinkish or dark red spots, smooth and uniform with- out visible venules which disappear completely on pressure often only pin-point in size. They may appear suddenly and last for several years and then disappear. Small nodular forms raised, and of bright red or purplish color may be met with. lliese were formerly thought to be associated with malignancy of the stomach and liver. We also meet with spider forms (naevus araneus type), often seen on the cheeks and eyelids of children and young patients. The mat form being large lesions, sometimes seen associated with cirrhosis of the liver and leukemia, and lastly the generalized forms of telangiectases noted by Osier and so thoroughly discussed in one of the best papers on the subject by Becker, of Chicago (1926). In my paper I am dis- cussing only the multiple hereditary forms of telangiectases associated with recurring hemor- rhages, and present in several or many mem- bers of the family and in several generations. (3) The occurrence of these symptoms in several members of the family is essential for the diagnosis. We may have, however, in some members of the family, hemorrhages from the nose alone or from other parts of the body, with or without hemorrhagic hered- itary multiple telangiectasia. 1 ime will not permit the review of many interesting cases of this clinical entity. I will simply list the typical and atypical cases re- ported in the entire medical literature of the world since 1830. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NF.W JERSEY 317 Typical cases of hereditary hemorrhagic telangiectasia with recurring epistaxis and other hemorrhages: Wilson (1869), Legg (1876), Chiari (1887), Chauffard (1896), Rendu (Oct. 23 and Nov. 24, 1896), Osier (1901), Josserand (1902), R. H. Kennan (April 30, 1902), Kelly, A. B. (1906), Coe (1906), Hawthorne (Jan. 13, 1906), Osier (1907), Weber, F. P. (1907), Gottheil (1907), Kofler (1908), Ballantyne (1908), Semon (Jan. 10, 1908), Waggett (1908), Phillips (1908), Hanes (March 1909), Lang- mead (1909 and March 1910), Laffont (Oct. Dr. Goldstein — Telangiectasia. Osier’s Paper: Quarterly Journal of Medicine, 1907. 30, 1909), Audry (Jan. 1911, and 1920), Osier (1911, mentioned by Steiner 1917), . Van Wagenen (1912), Sequeira (1912-1913), Gjessing, E. (1916), Hutchison and Oliver (Jan. 1916), H. B. Richardson (1917), Steiner, W. R. (1917), Paul, S. N. (1918), Gundrum (March 1919), Goldstein, H. I. (1921), Freudenthal, W. (1921), Goldstein, H. I. (1922), Fitz-Hugh (Dec. 1923), Schwarz (1925), Gulland, G. L. (May 19, 1923), East (Oct. 12, 1923 and Feb. 13, 1926) , A. Arrak (June 1925), Emile- Weil (June 25, 1926), Williams (1926), Mekie (March 5, 1927), McKinstry (May 1927), Archer (Sept. 17, 1927), Balph (Dec. 22, 1927) , Mackay and McKenty (1927), Thom- son and Mason Lamb (1928), Van Gilse and Postma (1928 and 1929), Roles (1928), Flan- din and Soulie (Jan. 2, 1929), Erdheim (Feb. 1929), Harper (April 1929), Rudolph Schoen (1930), Boston (March 1930), and Cursch- mann (Apr. 12, 1930). Cases of familial epistaxis. Sutton (1864), Babington (Sept. 1865), Frohlich (1891), Verneuil (1894), Rosenberg (1900), Lane (1916), Blumenfeld (1926), Giffin (1927), Goldstein, H. I. (1930). Atypical cases of (familial) epistaxis or hereditary telangiectasia. Taunton (1830), Tweedie (1841), Sutton (1864), Babington (1865), Tanturri (Aug. 1879), Vidal (1880), Frohlich (1891), Gaston (Feb. 8, 1894), Ver- neuil (May 29, 1894), Ullmann (1896), Ivopp (1897), F. J. Smith (1898), Blaschko (1899), Du Castel and Baudouin (1899), Kalischer (1901), Joseph (1904), Armand (1905), Weber (1°07) mentions a case reported Dec. 12, 1900, before the Dermatologic Society of London, with familial multiple venous angio- mata; W. Bligh (Feb. 23, 1907), Adamson (1907), Passini (1907), Pollitzer, Mayou (1907-1908), Lack (1908-09), Fox (1908), Hyde (1908), Steiner and Voerner (1909), Galloway (1910), Frick (1912), Stokes (1915), Lane (1916), Miescher (1919), Mil- ler (May (1923), Blumenfeld (1926), S. W. Becker (1926), Giffin (1927); (Becker," Sept. 1927), Weber, F. P. (Sept. 24, 1927), Mem- mesheimer (1928), H. I. Goldstein (1930), Kozach (1930) ; Terrien and Prelat (“Telangiectasie gener- alised et cataracte congenitale”, Nov. 6, 1909) and M. Vulpian report patients dying from epistaxis and hemoptysis under the title “Hemophile — Pas d’ antecedents cl' heredite ou de famille” (Feb. 1886). Familial hemorrhages, hemoptysis, hema- turia, hematemesis, bowel and rectal bleeding, and other atypical cases — (non-hemophiliac and non-purpuric). Atlee (1901), Guthrie (1902), Pearson (1904), Bennecke (1906), MacCallum (1906), Thomson (Belfast), Ohkubo (1907), Grandidier, Kausch, Apert (1907), Aitken (1909), Adler (June 1909), Mantchik (1922), Libman and Ottenberg (1923), Hurst (1923), Barford (1926), Fog- gie (1928), Virgil Schwartz (1925), and others. Miescher (1919) reports a case of telan- 318 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 giectasia in a woman, aged 71 years, whose mother died at 80 years from epistaxis. Her 31 years old daughter is well. She had telan- giectases and tortuous capillaries on the nose, cheeks, forehead and legs. Blood Wasser- mann was positive. He reports a second simi- lar case. He was able to find 19 similar cases since Brocq’s compilation. He fails to men- tion epistaxis or other hemorrhages in his 2 cases. Steiner and Voerner (Deutsch. Arch. f. klin. Med. 1909, Bd. 94, 105) speak of “angi- omatosis miliaris” and report several cases. They report a young man aged 29 years, with general symmetric telangiectases — pin-point to pin-head in size, on the chest, abdomen, geni- talia, arms and lips. He had pollakuiria, quick pulse, neuralgias, and anidrosis. Francis C. Roles (November 1928, pp. 19 and 20, St. Bartholomew’s Hospital Tournal, V°l. XXXVI, 1928-1929, London), reports a case of multiple telangiectasis with spleno- megaly in a married woman aged 65 years, a machinist, suffering from “abdominal pain and indigestion”. She had red “spots” on the face and hands, nose, lips, tongue, cheeks, and legs, which appeared to “come out” singly or m crops. Three years ago she had a thrombo- sis in the right calf and cirrhosis of the liver. A large telangiectasis on one of her fingers bled profusely; there was no hematuria but increased frequency of micturition. She had severe epistaxis. No family history of epi- staxis or of “spots ’. She had lesions of 3 types: pin-point, spider form (most com- mon), and the nodular variety. Three of the nodular type on a finger, each side of nose, and on left cheek bled quite profusely. The spleen formed a firm, well-defined tumor the size of an orange and showed a well-marked notch. It was not tender. The coagulation time was 2 minutes, 27 seconds ; and the bleed- ing time, 2 minutes, 36 seconds. Gastou, P. (Feb. 8, 1894) speaks of “con- genital and hereditary vasomotor telangiec- tases” and reports the cases of a father and daughter. The father, daughter, and paternal ancestors, all had red hair and a very high fac- ial color. Both father and daughter had gen- eralized telangiectasia. When 23 years of age the father had a “stroke” with left sided hemi- plegia which almost entirely disappeared in 2 months. The daughter had vascular dilata- tions on the hands, and after a confinement the telangiectases showed a tendency to spread. He concludes that these cutaneous vascular dilatations may be the result of a vasomotor paralysis through congenital, he- reditary or acquired modifications of the vas- cular vasomotor centers, and he therefore des- ignates the condition as “generalized vasomo- tor telangiectases”. He fails to mention epi- staxis or other hemorrhages. Romme (Presse Med. Paris, Apr. 24, 1909) reviews the literature and discusses hemophilia and hereditary hemorrhagic telangiectasia but does not report any cases of his own. E. Gjessing (1916) reports 3 cases. One of his patients, a man aged 30 years (whose father and sister were similarly affected), bled profusely from the nose when a child. Nose- bleed became more severe as he grew older. He had bled from the mouth on one occasion. He suffered from heart disease, severe an- emia, and from retinitis hemorrhagica. Coschwitz (1616) mentions that frequent scratching with the finger-nail at the anterior part of the septum may be responsible for epi- staxis. Valsalva knew that the most frequent source of nosebleed was a site on the anterior por- tion of the cartilaginous septum. This site of predilection for nosebleed was later de- scribed by Michel, Little, Hartmann, Kiessel- bach, Zuckerkandl, Hajek and others. Rendu (Semaine Med. IV, June 12 and 26, 1884) emphasized the interesting fact that epistaxis in a young patient (with or without valvular disease) is often a premonitory symp- tom of an attack of rheumatism, particularly in girls, when not occurring as vicarious men- struation. Verneuil (May 29, 1894) speaks of “Juven- ile, Hereditary and Heredo-Hepatic Epi- staxis and reports illustrate familial cases. He speaks of familial and hereditary epistaxis as a reality. Forgues and Besnier say this form of hereditary epistaxis in children and ad- olescents occurs in families predisposed to spontaneous hemorrhage and which is often mistaken for hemophilia. Curtius (Nov. 1928) speaks of nasal septum April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 319 varicosities and Osier’s disease as a manifes- tation of general hereditary dysplasia of the venous wall or a “status varicosus”. Du Castel and Baudouin (1899) report a case of hereditary telangiectasia in a man aged 25 years. Other members of his family had the same condition. No mention is made, however, of familial nosebleed. Becker (Sept. 1927) in his paper on “Gen- eralized Telangiectasia” reports (Case 2.) the case of a girl aged 29 years, complaining of changes in the skin and nails. One sister and Dr. Goldstein — “Telangiectasia” case of Prof. Schoen, Leipzig. Prof. Schoen (Leipzig) Deutsch Archiv. f. Inn. Med., 1930 2 brothers were subject to frequent nosebleeds, and her father also had nosebleed occasionally. She had nosebleed when in a warm climate, generally at the time of the menses. She had bilateral coronary cataract ; apparently no telangiectatic lesions of the mucous mem- branes. Her finger nails were abnormal, and she had marked follicular hyperkeratosis. Marked erythema of her cheeks and chin and dilated vessels were noted. Flandin and Soulie (Jan. 2, 1929) reported a woman 54 years old affected with hereditary hemorrhagic angiomatosis. She suffered from profuse epistaxis and had carmin-red vascular spots on the cheeks, chin, tongue and fingers. She had an intense anemia. The bleeding and coagulation time was normal and the clots were retractile. Mekie’s (March 3, 1927) patient was a man aged 38 years who had numerous telangiectases on the lips, nose, cheeks, tongue, nasal septum, gums, soft palate and penis. He suffered from frequently recurring nosebleed and ad- vanced pulmonary tuberculosis. His father, grandfather, 2 uncles, sister and 3 cousins were similarly affected. His 7 children, under 15- years, were apparently not affected. One of the affected cousins died at the age of 28- years from a “ruptured vessel in the brain”. Kofler, (Karl, 1908) reported a man aged 50 years who had repeated hemorrhages from the nose and lips. He had “spots” (telangiec- tases) on the face, lips, nose, nasal septum, mouth, ears, scalp, extremities and trunk. His mother and brother were similarly affected. His children were apparently not affected. Kofler erroneously reports this case as “Naevus Pringle of the Skin” and while he knew of Osier’s and Parkes- Weber’s cases, he did not think they were the same. I consider this a typical example of hereditary telan- giectasia with epistaxis (familial). Van Gilse and Postma (1928) of the Uni- versity of Amsterdam, report 4 cases ("from 2 Dutch families) all suffering from severe persistent nasal hemorrhages as a symptom of congenital telangiectases of the skin and mucous membranes. Audry (Jan. 1911) reports the case of a man aged 70 years who for many years had almost daily nosebleed. He had telangiectases on his face, lips, palate, tongue, trunk and arms. His mother, great aunt, cousin, niece, maternal uncle, 5 brothers and sisters, 2 sons and several nephews were all similarly af- fected. He considers Chauffard’s (1896) a non-familial (atypical) case. Langmead’s (March 1910) patient was a man aged 68 years. He had 30 small tel- angiectases, and frequent nosebleed; occasion- ally the face or tongue would also bleed. 320 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 Secondary anemia was present in 1907. In 1909 the blood count was normal and he was considerably improved. Four brothers, 1 sister, his father, and 2 sons, and a daughter of 1 of his brothers, were similarly affected. The patient’s mother suffered from severe epistaxis. Erdheim (Feb. 1929) was able to collect from the literature 55 families with this dis- ease. He reports 6 persons (who are now alive) in 1 family, who have frequent attacks of epistaxis with no serious consequences. He also gives reports of 5 persons deceased, 2 of whom probably died as the result of the severe repeated hemorrhages. He is con- vinced from his studies of 49 cases that the telangiectatic lesions were first noticed in 31 cases under the age of 30, and in the other 18 past the age of 30. The lesions seem to be- come aggravated in many patients in later life. Fatal hemorrhages in some of these cases were reported by Kelly, Legg, Chiari, Phil- lips, Gottheil, and others. Paul ( 1918) reported the first Australian cases. He reported a woman aged 32 with hereditary angiomas and epistaxis. He traced the disease as far back as the great-grand- mother and both her daughters, and grand- mother of Paul’s patient; 21 members of this family were affected. Archer (Sept. 17, 1927) reported a case of multiple cavernous angiomas (“of the sweat ducts”) associated with hemiplegia in a man aged 30 years. One brother shows the same telangiectatic lesions. Parents are alive and well. Patient suffered from frequent at- tacks of bilateral frontal headache. In 1918 he developed a right hemiplegia (at 21 years of age). The attack came on suddenly during the day. Complete recovery took place in 2 years. In 1922, he had a similar attack in addition to involvement of the left side of the face with loss of speech. There was no loss of consciousness in either attack. He re- covered completely from the last attack, ex- cept for pain in the extremities and back. The patient seems mentally dull. Pie always feels “cold”. The optical discs show a varicose and degenerated condition of the retinal vessels, but not hemorrhages. The skin shows multi- ple small pinhead disseminated angiomas dis- tributed over the lower thorax, abdomen, sides of trunk, buttocks, thighs and genitalia. The mucous membranes of the lips, cheeks, and soft palate were also involved, but not the tongue. Spinal fluid and blood Wassermann tests were weakly positive. No reports of the blood platelets, blood chemistry, basal meta- bolism, radiograph of the sinuses, skull and teeth are included. No hemorrhages from the nose or mouth are mentioned. Archer con- sidered the hemiplegia due to bleeding from a similar (angiomatous) varicose and degener- ated condition of the vessels in the brain. He mentions, further, that such mental sluggish- ness is a frequent symptom in lichen planus, adenoma sebaceum and hypothyroidism. McKinstry’s patient (May 1927) was a girl aged 19 years, with advanced bilateral pulmonary tuberculosis. She bled from the nose and had 5 or 6 punctate subcutaneous hemorrhagic spots on the tips of her fingers, and “spider webs” (telangiectatic) in the an- terior part of the nasal septum. Her father was a “bleeder”. Laffont (Oct. 1909) mentions the observa- tions by Kopp, Chauffard, Rendu, Steiner- Voerner, Blaschko, Joseph, and Hanes, and reports his own cases. He divides the cases into hemorrhagic and non-hemorrhagic types. Hart-Drant (May 14, 1923) reported an atypical case of acquired multiple punctate telangiectases of 7 years’ duration in a white woman aged 40. Epistaxis is not mentioned. I shall not review in this paper the interest- ing cases reported by Guthrie (1902), Aitken (1909), Legg (1876), Hutchinson and Oliver (1916), Gundrum (1919), Osier (1901, 1907, 1911), Hanes (1909), Steiner (1917), F. Parkes- Weber (1907), Fitz-Hugh (1923), East (1926), Griffin (1927), Balph (1927), L. N. Boston (1930), Van Gilse and Postma (1928, 1929), and others. Recently (January 1930) there was a pa- tient (Max G. 1930-15) in the service of Professor Alfred Stengel, University of Pennsylvania Hospital, who died as the result of persistent severe hemorrhages, shock from repeated large blood transfusions, toxic hepa- titis, and cholemic nephrosis. The man was 64 years old. For many years he had severe April, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 321 recurrent attacks of nosebleed, and many telangiectatic lesions in the nose, roof of mouth, trachea, left bronchus, and rectum. In September 1927 he had “black stools”, and in Tune 1929 he had very profuse nosebleed, re- quiring blood transfusion. Bleeding and clotting time and blood-platelets were normal. He had an enlarged spleen.. At necropsy the spleen was found to weigh 660 gm. Size 19x3x7 cm. ; slate gray in color ; areas of hemorrhage were noted. No gross evidence of telangiectases was found in the stomach and intestines. Seven other members . of his family including 1 brother, 2 sisters, 1 son, 3 daughters and his mother, all bled from the nose. Dr. Goldstein — Telangiectasia. Osier’s Paper: Quarterly Jour, of Med., 1907. Treatment As the condition is due to some hereditary defect of the vascular system, little can be •done. • For the local bleeding, the chromic acid bead, electric cautery, carbon dioxide snow, astringents and radium have been tried. Ad- ministration of calcium by mouth and intra- venously, parathormone injections, viosterol ; ultraviolet ray and x-ray therapy, liver, liver- fraction, iron, arsenic, and endocrin therapy have given varying results. In severe hemor- rhages, whole-blood injections, blood serum, blood-transfusion, coagulen, stryphnon (Mey- er and Albrecht), thromboplastin, afenil and calcium gluconate may be useful. Professor B. Niekau (Tubingen) and Pro- fessor F. Llopis (Madrid) recommend the use of Nateina Llopise, a mixture of vitamins A, B, C and D, of vegetable origin, to which calcium phosphate and lactose have been add- ed. Five tablets are chewed before meals. This is considered a good remedy in hemo- philia. Taylor (July 1929) has apparently cured purpura hemorrhagica by the use of bothropic antivbnin. Rendu suggests cold compresses to the head and neck, lifting the arms, decoction of walnut leaves, or a little alum, tamponing when neces- sary, and the administration of opium. Gubler believes opium is the best remedy in some cases when epistaxis is excited by excessive nerve stimulus. Pagueguy (Paris, 1831) recommends the introduction of a piece of hog’s intestine pre- pared in the form of the finger of a glove and this can be filled with fluid by means of a syringe after which a ligature is applied to prevent escape of the fluid. Thus, the mucous membrane of the nose is compressed and the hemorrhage arrested. Wicks of lint moistened with alum solution were used for tamponing. He used wine of quinin and iron as tonics. G jessing uses calcium lactate regularly and as a prophylactic remedy. Osier used calcium chloride. Emile- Weil suggests using carbon-dioxide snow ( June 1926) and has obtained some good results. Leeches applied to the back of the neck and to the buttock was advised by Scharin, of Russia. Compression of the nose with thumb and index finger is at times a useful procedure. Stenger (1915) in his thesis for the University of Wurzburg, discusses, most thoroughly, the various forms of treatment for nasal hemor- rhages. He suggests the use of cauterization with chromic acid crystals or silver nitrate for the telangiectases, followed by loose tampon- age with 10% bismuth ointment. He has also tried styptol, secacornin, coagulen and the gelatins. McBride (University *of Penna. Med. Mag. II, 1889-1890, pp. 424-426) reports 2 fatal cases of nosebleed and 1 case that was nearly fatal ; the last patient, a law student, aged 17, who bled for many days. D. Hayes Agnew 322 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 19 31 suggested 2 cylinders of bacon so as to tightly plug the nostrils. This stopped the bleeding for awhile. Later, McBride used a cylinder of ham fat which “acted like a charm”. Ed- ward Martin and the late J. William White, of the University of Pennsylvania, also saw this patient. In the hypertensive, arteriosclerotic cases angioxyl may he given by injections and by mouth, and also iodides. Conclusions (1) A review of the literature of the world on the subject of familial epistaxis and hered- itary telangiectasia is here briefly discussed. (2) There are probably a total of 65 fam- ilies and about 3oO individuals suffering with this clinical entity— “hereditary (familial) epistaxis with multiple hemorrhagic hereditary telangiectasia” — on record in the entire avail- able medical literature of the world. (3 ) Many cases, no doubt, have been over- looked bv the otolaryngologists, dermatolo- gists, and pediatricians. A more careful study of cases of epistaxis and of those com- plaining of various forms of telangiectases and angiomatous lesions of the skin and mucous membranes will bring to light additional cases of this disease entity. (4) Cases of familial hematuria, hemor- rhagic nephritis, hemoptysis, “gastrostaxis”, intestinal and gastric bleeding, and some of the so-called essential idiopathic hemorrhages, are probably different forms of this disease. (5) Reports of cases of familial epistaxis, with and without skin and mucous membrane (vascitlar) lesions, are included in this paper. During the past 21 years I have met with 3 families in whom epistaxis occurred repeat- edly and profusely. The first family (W.) \\ as a typical instance of multiple hemorrhagic hereditary telangiectasia with familial epi- staxis; 11 members of this family, were so af- fected. This family was reported by me in 1921 (Arch. Int. Med.). Recently one of the patients was treated in the Atlantic City Hospital. In 1918, at the age of 42, she had a ’‘stroke”, due to bleeding from a cerebral telangiectatic lesion. Blood Wassermann test was negative. Renal func- tion tests, blood chemistry, blood platelets, coagulation and bleeding time, and blood pres- sure, at that time, were normal. There was no evidence of embolism, hemophilia, purpura, arteriosclerosis, hypertension, endarteritis ob- literans, syphilis, uremia, or vascular crises. During her recent stay (April 1930) in the Atlantic City Hospital, in the service of Dr. Barbash, her condition was very poor, and blood transfusion was necessary. Laboratory studies, made at the hospital, showed as fol- lows: April 3, 1930, R. B. C., 1,410,000; W. B. C., 12.750; hemoglobin, 35%; color index, 1.2 plus; polys., 89%; s. lym., 9%; 1. lym., 1%; baso., 1%. Large amount anisocytosis, macrocytes predominate; slight poildlocytosis ; marked achromia and polychromasia. April 7, 1930, after transfusion, R. B. C., 1,910,000; W. B. C., 22,750; hemoglobin, 35%; color index, 0.9 plus; polys., 85%; s. lym., 13%; baso., 1%; mono., 1%. Slight poikilocytosis ; marked anisocytosis; macro- cytes predominate ; marked achromia and polychromasia; occasional nucleated red cell. Apiil 15, 1930, W. B. C., 12,500; hemo- globin, 30%; color index, 0.7 plus; R. B. C., 1,690,000. April 16, 1930, R. B. C., 2,010,000; W. B. C. , 8,300 ; hemoglobin, 20% ; color index 0.5. April 7, 1930, reticulocyte count 1.2%; \\ assermann and Kahn negative. Coagulation tune, 5 minutes; icterus index, 2. April 15, 1930, platelet count, 66,000. April 16, 1930, percentage of banded W. B. C., 16/o , blood calcium, 8.4 mgm. % ; fragility test, minimal hemolysis, 0.40% ; maximal, 0.34%. Report of Author's Cases First Family (1918-1921) Case 7. Mrs. R. W., aged 42 years, white, married, has had severe persistent and recur- ring attacks of epistaxis since childhood. She has 2 daughters and 2 sons. One daughter, aged 20 years, has bled from early childhood. The other daughter, aged 11 years, has bled from the nose nearly all her life. The pa- tient has telangiectatic lesions on the nose, nasal septum, lips, tongue, chin and cheek. There are a few lesions on the left side of the neck, and 1 on the middle finger of the left hand. None are seen on the thighs and April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 323 legs. The larger spots on the tip of the tongue have bled on several occasions. Bleed- ing from lower lip occurred once. Sometimes the hemorrhages from the nose are very pro- fuse and uncontrollable. The patient received ferrous carbonate, sodium arsenate, calcium lactate -and calcium chloride at various times. She also used thyroid and lutein for a brief period. Secondary anemia is present. Her eld- est daughter has a few spots on the tongue, 1 over the right clavicle and some on the fore- arms. The younger daughter has none on the lace or body, and only 2 very small ones are seen on the tongue. The patient’s mother, Dr. Goldstein — Telangiectasia. Osier’s Paper: Quarterly Journal of Medicine, 1907. who is dead, also had recurring attacks of epistaxis and red spots. Three sisters are mar- ried ; 2 have nosebleed ; 1 sister, 34 years of age, bleeds profusely from the nose. Her 4 children, J. H„ 13 ; A. H„ 11 ; M. H„ 6, and I. H., 3; all suffer from epistaxis. An- other sister, A. L., aged 32, bleeds from the nose. Her son, M. L., aged 8, does not bleed. A third sister, Mrs. M. C., aged 30, and 2 children, J. C., aged 10 and E. C., aged 5, apparently do not bleed. Mrs. R. W. (the oldest daughter) had a “stroke” and hemiplegia January 20, 1918, after a little giddy spell. This attack was due to defects in the small vessels, like those oc- curring in other parts of the body, or a peri- pheral sclerosis. Blood Wassermann tests were negative on several occasions. Blood chemical tests showed urea nitrogen 18 mg. in 100 c.c. blood ; nonprotein nitrogen, 35 mg. ; creatinin, 2.20 mg. Urine. Jan. 26, 1918, trace of albumin; sugar less than 0.1% ; chlorides, 0.5% ; specific gravity, 1.005; granular and hyalin casts; flat, round and caudate epithelial cells; urea, 1% ; acid. March 11, 1919: Albumin present; urea, 0.5%; amorphous urates present; total solids, 16.3 gm. ; faintly acid; specific gravity, 1.009; no casts ; no sugar. July 24. Acid; specific gravity, 1.015: no acetone; no diacetic acid; slight excess of in- dican 1 5 times normal ; urea, 0.6% ; no diazo reaction ; slight excess of urorosein ; no casts and no cylindroids ; many red blood cells ; many renal epithelial cells ; large number of leukocytes (pus) ; 35 oz. urine voided in 12 hours. Eyes: April 30, 1919. Posterior polar catar- acts in both eyes. Blood : Coagulation and bleeding time nor- mal. Feb. 15, 1918. Erythrocytes, 3,980,000; leukocytes, 12,600; hemoglobin, 61%. Differ- ential count : polymorphonuclears. 64% ; transitionals, 2% ; eosinophils, 3% ; mast cells, 1%. July 24, 1919. Erythrocytes, 300,000; leukocytes, 14,600 ; hemoglobin, 68% ; poly- morphonuclears, 60% ; large mononuclears, 12% ; small mononuclears, 24% ; transitionals, 2%; eosinophils, 2%. The phenolsulphonephthalein renal function test was practically normal. The blood pres- sure varied during the past 3 years between 128 systolic and 90 diastolic, and 110 systolic and 80 diastolic. Comment. At the time she had the stroke it was difficult to decide as to the cause. One could not easily differentiate between em- bolism, thrombosis and hemorrhage. There was no evident source of an embolus. A faint murmur could be heard over the heart, and at times it was faintly audible at the apex, but it could be attributed to the anemia. Shortly after the cerebral hemorrhage, the systolic blood pressure was 140; however, at no time during the past 3 years has it been higher than the normal average, often below. 324 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 She complained of a heavy feeling and numb- ness in the limbs, and “heaviness with giddy or dizzy feeling in the head”. She had crying spells occasionally, worrying over her condi- tion. She was seen by Dr. O. H. Perry Pep- per at my request, who reported also that her dotting and bleeding time was normal. There is no history of hemophilia in the family and none of the family bleed exces- sively from cuts. One son, A. W., aged 12 years, has several small telangiectases, and a large pale reddish nevus on the back of the left shoulder and 1 telangiectatic lesion be- low the right lower eyelid. He does not bleed from the nose. The eldest son, L. W.. aged 23 years, apparently has neither epistaxis nor many telangiectases. There are a few over the scapular regions (supraspinous), and 1 lesion about 4 in. below and to the left of the left nipple. At the time of the “stroke”, and since, the patient, Mrs. R. W., has been seen by A. E. Roussel, F. X. Dercum, Charles Potts, W. G. Spiller, A. Gordon, of Philadelphia; T. D. Taggart, of Atlantic City; S S. Butler, of Camden, and others, during the past 3 years; however, none of them made the diagnosis of hereditary telangiectasia with recurring hemor- rhages, and did not associate the nosebleed and the cerebral complications with the hered- itary weakness of the vascular system. Dr. Pepper agreed with me in my diagnosis. Case 2. Mrs. Anna L., aged 32 years; mar- ried 7 years, had one miscarriage at 6 months, and 1 premature birth at 8 months, the child living only 24 hours. Her husband had a positive Wassermann test. The patient had a positive Wassermann 9 years ago. She has 1 boy, M. L., aged 7 years, living and well, who does not bleed from the nose. The pa- tient has had nosebleed since early childhood; very frequent; bleeding stops of itself. Had influenza and pneumonia and measles. She bleeds very profusely from the left nostril. Her hands are cold, and she gets short of breath on exertion. Occasionally, she bleeds from hemorrhoids. She has 7 or 8 small spots over the back, on the shoulders, 2 small spots back of ears, several on the left side (anteriorly) of septum of nose and 1 or 2 on right side of septum. There are a few radiating dilated capillaries around the alae of the nose. She also has clubbed fingers; these are cyanosed and cold; the lips are cyanosed and get “blue” very often. Blood pressure: systolic, 95 ; diastolic, 70. No cardiac mur- murs were heard at time of the examination but the heart sounds were not of good quality; they were weak and muffled. She is a sister to the above patient (Case 1) Mrs. R. W., and to Mrs. E. H. (Case 3). Numerous Was- sermann tests have been negative, following specific treatment taken up to a few years ago. Case 2. Mrs. Eliz. H., aged 35 years, has 4 children. She had 1 miscarriage. One in- fant, aged 1 month, died of whooping-cough. She was operated on 4 years ago for ruptured gastric ulcer with intestinal obstruction. She has been bleeding from the nose almost daily since childhood. She says her mother bled “terribly” from the nose for a great many years, and she thinks her death was due to these severe nasal hemorrhages. She has a pin-point lesion above the right eyebrow, 3 or 4 spots on the right cheek over the malar hone, 1 pin-point lesion on the left cheek 1 in. to left of the outer angle of the left eye; 3 or 4 lesions on right half of the lower lip; 1 spot on the under surface of the upper lip; 1 on upper gum; 1 spot on neck at base (right side). She gets attacks of nosebleeding even during her sleep. Case 4. Marvin H., aged 5 years, was al- ways well, except for severe nasal hemor- rhages. He has had nosebleed daily, and dur- ing sleep, since 2 years of age. He has 1 spot on left cheek, 1 in. below outer angle of left eye, and 1 on right cheek, 1 in. below and in front of right ear. Several dilated capillaries are noted on right side of septum of nose. He had measles. Mother says boy “bleeds in streams from nose” daily, which stops itself after bleeding for 5 or 6 minutes. While the hemorrhages have been severe and prolonged; there is only a comparatively mild secondary anemia. Sometimes washing the face, or us- ing a handkerchief, or other very slight trauma is sufficient to bring on an attack of epistaxis. Blood examination, Oct. 11, 1920: Hemo- globin, 70%; erythrocytes, 2,900,000; leuko- cytes, 8000; polymorphonuclears, 51%; small April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 325 lymphocytes, 45% ; large mononuclears, 3% ; eosinophils, 1%. Marked poikilocytosis. Blood Wassermann negative. Cases 5 and 6. Aaron H., aged 11 years, and Jeannette H., aged 13 years, the children of E. H., have bled very profusely from the nose since 2 years of age. They have “spots”. Blood examination, Oct. 11, 1920. Jean- nette: Hemoglobin, 75%; erythrocytes, 3,- 350,000 ; leukocytes, 7400 ; polymorphonu- clears, 72% ; small mononuclears, 25% ; large mononuclears, 2%i; eosinophils, 1%. Some anisocytosis and poikilocytosis. Blood Wasser- mann negative. Aaron : Hemoglobin, 80% ; erythrocytes, 3,250,000; leukocytes, 11,000; polymorphonuclears, 61% ; small mononu- clears, 36%; large mononuclears, 2%,; eosin- ophils, 1%. Some poikilocytosis and anisocy- tosis. Blood Wassermann negative. Boggs Test Tube Marvin H. 5 min. 6 min. Jeanette H. 6 min. 7 min. Aaron H. 5 min. 4 min. Second Family (1922) (1) Mr. C., aged 33 years, white, adult, male. Autoparts mechanist. Past history negative, except that he has had frequent at- tacks of nose bleed for many years. In the past 3 or 4 years he has been complaining of severe headaches, particularly a left hemi- crania. He is married, has 4 children, 2 boys and 2 girls. His wife has not had any mis- carriages. Venereal disease denied. One son and 1 daughter have had repeated attacks of nosebleed a number of years. General ex- amination negative. The x-ray findings are as follows : Peri-apical abscess at the root of the last upper left molar; should be extracted. An incipient abscess at the root of the last lower left molar; this tooth, I believe, can be saved by early treatment. Sinuses : distinct clouding of the left antrum and right frontal due to presence of a fluid exudate or pus. The other accessory sinuses are normal. Nose and throat examination showed free discharge of a mucopurulent nature from the left nostril and a degenerated middle turbi- nate of a colloidal character with obstruction to free drainage from the ethmoid and frontal sinuses. There is distinct evidence of a frontal sinusitis and disease of the left an- trum of Highmore. (2) Dorothea C., aged 8 years. White girl, daughter of the above patient. Has had measles , chicken-pox and whooping-cough. Enlarged tonsils and adenoids. General ex- amination negative. Has had repeated at- tacks of epistaxis; more often than her little brother. On examination 37 small brownish spots were found scattered over the trunk, neck and legs. One small telangiectatic spot about 2 in. below the right ear on the side of the neck and the left ear. Numerous very fine and dilated capillaries (arborescent and spider-like) over both cheeks. A few dilated capillaries are seen over the left nasal ala. One dilated capillary visible over the sternal end of the right clavicle and 1 over the right shoulder. There are some visible capillaries over the space between the left scapular spine and vertebras. (3) Harry C., aged 6 years. White boy, brother to the above patient. Has had measles, chicken-pox, grippe, and whooping- cough. Has attacks of hemorrhage from the nose; not very frequent of late. General ex- amination negative. Has a pale pink nevus on the back of the neck, 2x1 J4 in. and another “birth-mark” over the middle of the back 1 in- He has 28 brownish spots scatter- ed over the body, resembling dark pigmented freckles. There is visible one area of dilated capillaries over the left cheek. The father had several telangiectatic lesions, 1 or 2 on the neck and 35 or 40 dark pigment- ed spots, dark brown in color, scattered over the neck, trunk and arms. His tonsils were removed about 8 months ago. Third Family (1929) Mr. H., aged 29. Suffering from migraine and headaches for past 15 years. Had diph- theria. typhoid fever, pneumonia, 3 attacks of acute articular rheumatism. Now has occas- ional pains in the joints. Had nosebleed fre- quently and nearly bled to death following tonsillectomy. Is “drowsy” and “fatigued” and cannot concentrate. Mother has diabetes. Father and 2 brothers affected by nosebleed. Blood Wassermann tests were negative. Urin- 326 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 alysis negative. Bleeding time, 2 J4 minutes. Clotting time, 11 minutes (hypocalcemia). Blood calcium, 7.9 mgm. per 100 c.c. blood. Blood sugar, 90 mgm. per 100 c.c. blood. Blood count: R. B. C., 4,390,000; platelets, 290,000; W. B. C., 10,000; polys., 59%; small lymps, 39%. Radiograph of sinuses showed clouding of left antrum. Sella turcica, normal. Teeth negative. Eye examination, low amount of far-sighted astigmatism. Basal metabolism minus 25%. Removal of the tonsil stump, cleaning the antrum, the administration of thyroid ex- tract, calcium, parathormone, and ultraviolet ray therapy brought about rapid improvement. Blood calcium rose to 11 mgm. Blood uric acid, 3.8 mgm. Creatinin, 1.4 mgm. Basal metabolism became normal. One brother, aged 23 years, bled severely after tonsillectomy. An- other brother, aged 25 years, bled profusely after tonsillectomy (1924) ; followed by pneu- monia. Another brother, aged 42 years, used to bleed from the nose. His 3 sons do not bleed. The father, aged 68 years, had severe nosebleed when younger. One sister and 1 brother do not have nosebleed. These instances of familial epistaxis re- semble the type of cases reported by Giffin, of the Mayo Clinic, in the American Journal of Medical Sciences, 1927. Diagnosis The differential diagnosis must be made from “pseudohemophilia,” hypertensive epis- taxis, purpura hemorrhagica, hemophilia, per- nicious anemia, tuberculosis, deficiency dis- ease, or “hemorrhagic diathesis”. Blood plate- lets, bleeding and clotting time are usually normal. Men and women are affected, and both sexes may transmit the condition. REFERENCES Acknowledgment is made of the privilege to use the illustrations — by permission of Archives of Internal Medicine (Chicago) and Quarterly Jour- nal of Medicine (Oxford, Eng.). 1. Goldstein, H. I. Archiv. Int. Med., Jan., 1921. 2. Flandin and Soule, La Presse Medicale, Jan. 2, 1929. 3. Erdheim, S. H., Brit. Jour. Dermat. and Syph., Feb., 1929. 4. Van Gilse and Postma, Nederl. Tijdsch. v. Geneesk, Vol. 72, 1928. 5. Schwartz, Minnesota Med., Aug., 1925. 6. Kofler, Wien. klin. Wchnschr., 21:570, 1908. 7. Emil-Weil, Bull, et Mem. Soc. Med. d. hop. de Paris, 50:1135, June, 1926. 8. Meltie, Brit. Med. Jour., March 5, 1927. 9. Rendou, Gaz. d. hop. Paris, 69:1322, Nov. 24, 1896. 10. Goldstein, H. I., Jour. Med. Soc., New Jer- sey, 19:50, 1922. 11. Gillin, Am. Journal Med. Scs., 174:690, Nov., 1927. 12. Harper, Newcastle Med. Jour., April, 1929. 13. Schoen, Deutsch. Archiv. f. klin. Medizin, p. 156, 1930. 14. Arrak, Deutsch. Arch. f. klin. Med., p. 287, 1925. 15. Williams, Arch. Dermat. and Syph., Julv, 1926. 16. Boston, L. N., Medical Times (N. Y.), March, 1930. 17. Fitz-Hugli, Am. Jour. Med. Scs., Dec., 1923. 18. Edel, van Gilse & Postma, Acta oto-laryng., 13:525, 1929. 19. Becker, Acta Dermato-Venereologica, 8:117, Sept., 1927. 20. Parkes-Weber, Brit. Jour. Childrenjs Dis., 21:198, July-Sept., 1924. 21. Thomson and Mason Lamb, Birmingham Med. Rev., Sept., 1928. 22. Hoffman, Medic, rational, systemat. Pars II, Sect. I, Cap. I u Opusc. Physicomedica, p. 196, 1740. 23. Sutton, Medical Mirror (London), Pages 769- 781, 1864. Hanes (1909) defines this clinical entity as an hereditary affection manifesting itself in localized dilatations of capillaries and venules, forming dis- tinct groups or telangiectases which occur espe- cially upon the skin of the face, nasal and buccal mucous membranes and give rise to profuse hemor- rhage either spontaneously or as the result of slight trauma. Discussion Dr. Matthew S. Ersner (Philadelphia) : I wish to congratulate Dr. Goldstein upon the splendid manner in which he presented his paper. The bibliography and analysis will remain as an ac- cepted record for some time to come; I feel that he has left no stone unturned for he has covered the subject most thoroughly. Epistaxis, commonly known as “nosebleed”, oc- cupies an important place in the practice of rhin- ology. The average individual who loses blood from any source, irrespective from where it comes, loses his general sense of proportion, becomes frightened, and so annoys himself, his family and the attending physician. When one stops to con- sider that the most precious of life’s fluids is pour- ing forth and leaves in its path a pale, asthenic, anemic and an almost helpless individual, one real- izes that “blood is blood” in any language and we must deal with epistaxis from a general as well as from a local standpoint. Hereditary hemorrhagic telangiectasia may be defined as an hereditary abnormality which upon endonasal examination reveals localized dilatations of capillaries and venules. These telangiectatic areas can also be found in other parts of the body. The most prominent bleeding points in the nasal region are the Kesselbach area, middle of the sep- tum, near the root of the turbinate and floor of the posterior portion of the nose. The important blood vessels that we encounter in these areas are the internal sphenopalatine and the superior coro- nary arteries. Upon careful perusal of history, one will learn April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 327 that this condition occurs both in the male and female and is hereditarily transmitted both from the maternal and paternal sides. In some cases, however, it is difficult to prove that heredity fol- lows the Mendelian law. The 3 cases which I have in mind are of heredi- tary origin. The first, a male, was transmitted through the mother; the second, a female, through the father; the third case represents a close inter- marriage of blood relations, the father having a history of gastric bleeding and the mother of nasal bleeding. The question of atavism, therefore, seems positive at least from these cases which I am about to quote. Case 1. D. G., male, aged 6. In 1918 patient was first examined by me for a nasal hemorrhage. His chief complaint was profuse recurrent nasal bleed- ing which would occur upon slightest provocation or ■without any apparent cause. Family history revealed that his mother and sister were the bleed- ers in the family. As he grew older the epistaxis of the nose became less frequent. Although, it has been necessary for him to remain under my care for treatment at different times. Case 2. S. M., female, aged 20, came under my observation in 1924 for recurrent nasal bleeding. Endonasal examination revealed a septal spur and dilated blood vessels. These would bleed exces- sively at different intervals. From the family his- tory we learned that the father had gastric hemor- rhages. His Wassermann and blood picture were negative. He died at the age of 40 from hemi- plegia, probably due to a telangiectasia of the lenticular artery. About 4 months ago I again was called to see the patient who had another attack of epistaxis. Case 3. M. B., male, aged 5. From the family his- tory we learned that the father and mother were closely related, that the father had gastric hemor- rhages and that an exploratory abdominal opera- tion was performed but there was no abatement of the symptoms. The mother gives us a history of recurrent nasal bleeding and informed us that at the. time of delivery she almost bled to death. Eight days after delivery, the infant was circum- cised, and profuse hemorrhage followed the proce- dure. The child at the age of 5 was brought to me for tonsillectomy and because of the history of familial hemorrhage all precautions were taken. The blood coagulation, bleeding time, blood plate- lets and complete red and white count were taken and were found to be normal. As a further pre- caution, we administered calcium lactate by mouth and thromboplastin and parathormone hypodermi- cally. Irrespective of all these precautions, a severe postoperative hemorrhage occurred which neces- sitated a 10 day hospitalization for the child. At the present time she is 11 years old and frequently gets nasal hemorrhage. Dr. Henry C. Barkhorn (Newark) : It is obvious that Dr. Goldstein is a “professor” on this subject and that it is hopeless for me to discuss even the bibliography. We have all seen telangiectasia with nosebleed. We have all seen families who said they were familial bleeders. The important thing to emphasize in this paper, and undoubtedly it is in the context, is that this is not related to hemo- philia. It is not handed down through the female, nor are the blood changes of hemophilia present, but it occurs with these nevi which Cushing, for in- stance, has devoted a whole section in his book on intracranial vascular tumors — to the coincidence of nevi of the skin and nevi of the dura and mucous membranes. It occurs, as the doctor says, in pro- tein locations. We have found that in handling these cases the best proposition perhaps was to infiltrate with novocain under the nevus and then to cook it with the Bovi apparatus, or some ap- paratus, of that type, rather than to cauterize it with the actual cautery. The cooking current takes care of it without hemorrhagic manifestations; with the cautery you just go from one mess into a worse one and get more and more bleeding. One must remember that if the bleeding comes from the middle turbinate region it comes from the anterior ethmoidal, which is a branch of the internal carotid, not the external, and you have to tie the internal carotid artery. If it comes from the septum it is from the external carotid and tying the external carotid will be adequate. This is for the dangerous cases. I think it is very gratifying for this section to have had a real piece of research of this sort brought to our attention and to have it published in the Journal under the auspices of this section. It is most unusual, it is different, it isi something that leads us to think, and it is something I am sure that will make all of us go into the history of the next patient who says, “Oh, yes, I used to bleed also”, and see if we can find any hereditary connection and any nevi anywhere on the body. MEDICOLEGAL ASPECTS OF DIS- ABILITY IN INDUSTRIAL LEAD POISONING Max Kummel, M.D., Member New Jersey Bar Newark, N. J. The most difficult and perplexing problem in connection with lead poisoning is the ques- tion of prognosis and disability. A careful search of general literature and text-books, both old and new, fails to disclose definite conclusions as to the amount and character of disability following industrial lead intoxica- tion. For this reason I include no bib- liography and confine my conclusions solely to actual cases that have come under, my obser- vation and study during the last few years, including not only those whose cases are pending before the compensation bureau and who suffer from an additional morbid psychic state, but also those whose claims have been adjudicated. It is the latter, who may gain no further benefits by their complaints, whose cases have been acted upon and “finally” ad- judicated, that can serve as a criterion and, by way of example, demonstrate what disability and physical incapacity may result from lead poisoning. That lead poisoning will occur among indus- trial workers no matter what preventive 328 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 measures are adopted or precautions taken goes without saying. Under favorable cir- cumstances, with most modern safeguards the incidence of lead poisoning is greatly re- duced and the disability in existing cases minimized. However, there is danger of over-confidence in safeguards. The attending physician of a recently built storage battery plant, with all the modern devices that safety engineering can provide, assured me that no cases of lead poisoning could possibly occur in their plant. There are hoods, gloves, res- pirators, ventilators, shower-baths and even a change of linen. The workers are carefully scrutinized, foreigners are generally rejected, physical examination made at frequent inter- vals, and even ordinary illnesses are treated by the plant physician at the company’s expense, in order to detect and arrest incipient cases. Yet, aftct a comparatively short time, a great many men were taken acutely ill and have since been undergoing treatment for lead poisoning. The explanation lies in the very nature of the in- dustry and its inherent hazards. Industrial lead poisoning is a very costly affair. The annual wage loss attributable to this disease amounts to millions of dollars and the annual total loss to about 5 or 6 times that amount. In this are included the cost of medical care, the over-head cost in connection "ith payment of claims, and the important in- direct cost of loss of production. Formerly, the affected workingman footed the entire bill because the disease was not compensable. At present, lead poisoning has been entered upon the statutes of, I think, 12 states but the worker still pays the bill in pain and suf- fering, impaired productive power, workless and wageless weeks and years, and consequent lowered standard of living. It has been es- timated that the injured workman assumes from three-fourths to four-fifths of the finan- cial loss attending his incapacity even under the most liberal compensation laws. Industry has already learned that it is “good, business” to prevent accidents, but it has not learned that it pays equally to prevent occupational disease. However, among the more enlightened of industries, where inten- sive and sustained efforts for prevention of lead poisoning are maintained, it is consider- ed more than sound business to put up the money for elimination of lead poisoning from modern industry, or at least to minimize, if it cannot entirely abolish, the disability resulting from the insidious poisoning. The experience of a few of these plants where a fair degree of safety has been obtained points to a de- ' cided economic advantage, for safe working conditions bring about efficiency and increased production, reduce over-head, improve labor relations and place rival industries at a com- petitive disadvantage. It is rather interesting, though regretful, to observe the methods employed by a goodly portion of the lead industry to avoid payment of compensation for lead poisoning instead of preventing it and curing when it does occur. A New Jersey plant where safety measures were few and the hazard great employed a system of signing up each employee as an in- dependent contractor at the time of applica- tion for employment. Another plant would discharge grumbling Portuguese and employ satisfied Negroes. A third would reject the ungrateful Negroes and engage the meek, but thankful Portuguese. It so happened that there was a mutual exchange of poisoned em- ployees. I have also observed some men being ill with lead poisoning and who were given certificates for grippe, influenza and gastritis. However, industry as a wdiole is willing to co- operate and eradicate lead poisoning from its midst piovided it is given the proper incen- tive and guidance. 1 hat a true case of lead intoxication usually leaves an indelible imprint upon the human system and causes permanent pathologic changes no one disputes. Nor is it denied that poisoning by the same metal may terminate fatally. It is. furthermore, generally conceded that a mild case may produce some temporary discomfort without permanent pathologv. Tes- tifying before the Newark, New Jersey, Com- pensation Bureau, Dr. Joseph C. Aub stated that encephalopathy and peripheral nerve changes may be permanent in nature, but he had no evidence to prove or disprove other or- ganic changes. The following week I spoke to Dr. E. R. Hayhurst who assured me that chronic lead poisoning invariably produces nephritic changes and may result in a con- April, 1931 JOURNAL OF THE MEDICAL SOQIETY OF NEW JERSEY 329 traded kidney. Subsequently, at a symposium on occupational diseases, Dr. Harrison S. Martland stated that, in treating cancer with colloidal lead, patients were all cured of their cancer but died of lead poisoning. Professor Chaves and Dr. Levin of the Berlin-Lank- owitz Hospital made a study of 1500 cases diagnosed as lead poisoning and came to the conclusion that “organic changes in the blood, the kidneys, nervous system, intestinal canal and liver can rightfully be attributed to the action of lead”. The conditions enumerated in the preceding paragraph illustrate some of the factors en- tering into the computation of disability, the true measure of which is the amount of im- paired function and physical incapacity re- maining after all acute manifestations have disappeared. It has been established that in true cases of lead intoxication the lead is stored in the long bones of the body. After an apparent recovery the accumulated lead is subject to sudden liberation and mobilization into the circulation by so slight an agency as the common cold, change in diet, or ordinary fatigue which, while having no effect on the every day worker, is sufficient to disturb the acid-base equilibrium and reactivate the lead poisoning long after cessation of exposure. This condition lessens the worker’s earning capacity, increases the number of workless days per year, reduces the period of “work expectancy” and with other sequels contributes to a shorter span of life. Temporary Disability. In lead poisoning this is the period during which the affected in- dividual is incapacitated from any work on account of acute manifestations of the disease. The most distressing symptoms at this time are the severe colic, intense headache, and gen- eral asthenia. Duration of this period is ex- tremely variable, depending upon many fac- tors, such as age and sex of individual, length of exposure, compound exposed to and, above all, the susceptibility and idiosyncrasy of the individual. This period of disability varies greatly with the particular systems or organs involved in the exposed individual. If the poison attacks the brain or the nerves and their endings, the period is longest, while in cases with predominating cardiovascular disturbance the period is shorter, and it is still further re- duced if the symptoms are confined to the gastro-intestinal tract. Generally speaking, the period of temporary disability in industrial lead poisoning varies from 2 or 3 weeks to several months, and considerably longer in cases of encephalopathy. P ermanent Disability. This is the residual damage or permanent pathology left after the individual is removed from further exposure, and medical and physical measures instituted, and sufficient time has elapsed to allow the or- dinary consequences of the disease to disap- pear by medication and elimination. Generally speaking, this residual damage is greatest in the cerebrospinal type of cases, because of the nature of brain tissue. Injury by the lead di- rectly, or through the damaged blood vessels indirectly, is permanent in character because damaged brain tissue does not regenerate. This is the most distressing form and may be characterized by headache, tremors, neuras- thenia, hallucinations, convulsions or epilepti- form seizures, or even insanity. Similarly, the neuromuscular type exhibits muscular weak- ness, atrophy and even muscle group par- alysis. The permanent pathology in the car- diovascular group is referred to the second- ary anemia and to local changes in the organs supplied by the sclerotic vessels. The gastro- intestinal form is milder in its permanent ef- fects, the individual suffering at most from a persistent constipation and recurrent colic. To determine the permanency of the path- ology and its resulting disability I have follow- ed a great many cases from inception until the present date. The following data are based on a study of over 200 cases of indus- trial lead poisoning that have come under my observation during the last few years. No cases were included in the series unless, at the onset of the disease, they presented the fol- lowing cardinal signs of lead intoxication : History of exposure to lead, colic or epigastric distress, stippling of the red blood cells, and usually presence of lead in the urine. It is ap- parent that the deductions as to permanency of the pathology would not apply to all cases of alleged lead poisoning because, as a rule, those not presenting the cardinal signs were regarded as temporary in nature and excluded from the series. About 50% of these cases 330 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 have cleared up and left no appreciable disa- bility, or have not reached the stage where permanency could be established. Due to lack of space and time, the details of 12 cases and a resume of about 85 others constitute the basis upon which the conclusions are reached. These have been under my observation from 1 to Al/> years. Case 1. February 22, 1929. J. S., male, white, single, 31, Portuguese, lead furnace worker, working 7 days a week. Cramps in stomach, vomiting spells, dizziness, headache, weakness in hands and feet. Blood: Hb., 76%; R. B. C., 4,000,000; W. B.C., 6500; 85 stippled cells per 100 leuko- cytes ; moderate poikilocytosis ; anisocytosis and polvchromophilia. Urine: Sp. Gr. 1.013; occasional hyaline cast ; lead present. February 30, 1930. Persistent constipation; occasional cramps ; headaches ; dizziness ; loss of sight; general weakness, particularly hands and feet; loss of memory. Physical examination : Lead line on gums ; blanched membranes ; tenderness over epigas- trium ; pupils react but very sluggishly, right more than left; diminished knee jerks; masked facies ; blepharospasm ; triceps reflex diminish- ed ; retinal hemorrhages ; arteriosclerosis ; sclerotic vessels in retina. Case 2. March 18, 1929. J. C., male, white, married, 33, Portuguese laborer, furnace worker in smelting plant. Cramps in stomach, vomiting, headache, dizziness and muscular pains. Blood: Hb., 58%; R. B. C., 2,900,000; W. B. C., 6800; stipples 200 per 100 cells; poikilocytosis ; anisocytosis ; and polychromo- philia. Urine: Lead present; trace of albumin; hyaline casts numerous ; occasional granular casts. July 21, 1930. Cramps, persistent constipa- tion, fatigue on moderate exertion, occasional attack of colic, recurrent headaches and im- paired vision. Physical examination : Remains of blue line on upper gum ; dull facial expression ; pupils widely dilated; tremor of tongue and extended fingers. Blood shows a mild second- ary anemia. Urine: Albumin, hyaline and granular casts ; negative for lead. Case 2. December 6, 1928. P. McR., male, colored, married. 33, American laborer, clean- ing tanks where colors and paints are mixed, worked 9 hr. a day, 5% days a week. While working, was taken suddenly ill with severe cramps, vomiting, headache, dizziness, and general weakness. December 22, 1928. Blood: A few stippled cells. Wassermann negative. January 12, 1929. Urine: Faint trace of albumin ; many hyaline and granular casts ; lead present. Blood: Hb., 45%; R. B. C., 3,250,000; W. B. C„ 5250. April 9, 1929. Blood : 'Stipples — 36 per 100 cells ; marked poikilocytosis ; moderate aniso- cytosis and polvchromophilia. Urine: Strongly positive. September 6, 1929. Weakness, occasional colic, pains in joints and back, general pallor. Urine: Lead present; hyaline and granular casts. Blood : Hb., 68% ; R. B. C., 3,600,000 ; W. B. C., 4200; occasional stipples. Physical examination: Arcus senilis; left disc pale ; pupils react ; tachycardia ; diminish- ed knee-jerks; hypesthesia of lower extrem- ities. June 30, 1930. Cramps, pain in back, weak- ness of muscles, particularly wrists, persistent constipation, easily fatigued. Case 4. March 1929. J. R., male, single, white, 28, Portuguese laborer, working on lead furnance in smelting plant 7 days a week. Severe cramps, vomiting spells, dizziness, weakness, constipation and severe pains in both legs. Blood: Hb., 78%; R. B. C., 4,100,- 000; W.B.C., 7400; 40 stipples ; polychromo- philia. Urine: Lead present; occasional hya- line cast; Wassermann negative. January 24, 1930. Headache, dizziness, ver- tigo, diplopia, defective memory, weakness of arms and legs, particularly left arm. Physical examination : Irregular, intermit- tent heart ; enlarged liver ; normal reflexes and gait ; very slight tremor of fingers ; slight hy- palgesia ; hypesthesia ; good general muscular response to electric reactions. Case 5. January 1929. M. N., male, white, married, Portuguese, 41, laborer working on lead furnace 11 hours a day and 7 days a week. Pains in stomach, very weak and tired in legs, vomiting, “funny taste in mouth”, “head- ache that makes everything turn around when April. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 331 standing up”. Blood : Hb., 70%; R.B.C., 4,- i 00, 000 ; W. B. C., 8000; marked polychromo- philia ; slight poikilocytosis ; anisocytosis ; 18 stippled cells. Urine: Negative for lead. January 14, 1930. Headache, dizziness, weakness of arms and legs, poor vision in one eye, loss of weight. Physical examination : Blue line on gingival margin; cyanosis of hands and feet; general tremulousness and general increase in deep re- flexes ; electric reactions show the upper ex- tremities to react well while the lower, espe- cially the right leg, does not react so well ; eye-grounds reveal some signs of optic atrophy which may be due to the lead poisoning. Case 6. March 23, 1929. A. M., male, white, married, 38, Portuguese, lead furnace man in smelting concern, worked 7 days per week. Cramps in stomach, loss of appetite, dizziness, headache, vomiting, dry throat, generalized weakness and persistent constipation. March 20, 1929. Blood : Numerous stip- pled cells. March 26, 1929. Blood: Hb., 60%; R. B. C., 3,000,000; W. B. C. 5200; 100 stipples; poikilocytosis ; anisocytosis, and polychromo- philia. Urine: Positive for lead. December 29, 1930. Loss of vision which is periodic in nature, nervousness, weakness of extremities, difficulty of speech and con- stipation. Physical examination: Waxy yellow skin; restless eyes ; fine tremor of extended fingers and protruding tongue ; dyspnea ; abdominal reflexes equal 'and active; right ankle- jerk ab- sent ; hypalgesia and hvpesthesia over all ex- tremities ; extensor weakness ; eye-grounds re- veal optic atrophy. Case 7 . December 1929. A. B., male, white, 35, Portuguese, married, lead furnace worker for 3 years, worked 7 days a week. Sudden attack of dizziness, weakness, pain in stomach and fell unconscious while at work. Blood: Secondary anemia and marked stippling. Physical examination: Well developed in- dividual ; pale ; sallow expression ; gait, steady ; abdominal tenderness ; exaggerated reflexes ; extensor weakness. January 1931. Constipation, headache and insomnia. Physical examination : W ell-nourished and muscular; somewhat anemic; frightened facies; expression pinched; waxy skin; un- steady gait ; general . tremors ; pupils slightly unequal, right larger than the left ; discs pale ; vessels over-filled and tortuous ; throm- bosed veins in center of right disc ; all reflexes exaggerated tremendously. B. P. 142/80. Tuning fork, air conduction less on left side. Loss of tuning sensation. Marked tremor of tongue and extended fingers. Case 8. October 15, 1929. A. D., male, white, 32, married, lead furnace tender, work- ed 7 days per week. Headache, dizziness, pain in abdomen, weakness in extremities, nausea, vomiting, impaired vision. Blood: Hb., 65%; R. B. C., 3.900,000; W. B. C., 6500; color in- dex, 0.9; polynuclears, 57%; small lympho- cytes, 33 ; large lymphocytes, 8 ; endothelial cells 2 ; 125 stippled cells per 100 leukocytes ; R. B. C., achromatin ; anisocytosis; poikilo- cytosis ; and polychromophilia. October 15, 1929. Physical examination: Pallor of skin and mucous membrane 'of mouth and conjunctiva; epigastric tenderness; extensor weakness. January 1931. Physical examination: Pale; unsteady; atrophy of left arm; Romberg posi- tive; exaggerated knee-jerk; practically no plantars; slight optic neuritis; retina pale (on both sides) ; vessels congested; hvpesthesia of left side of chest and legs; general tremors; atonic facies ; corneal anesthesia ; epigastrium still tender. Case 9. April 27, 1928. J. C., male, white, married, 36, Portuguese, previous occupation agricultural laborer, taking molten lead and copper from the furnace. Became ill in April 1928. Date of last exposure — April 27, 1929. Cramps, dizziness, nausea, vomiting, general weakness; subsequently faintness followed by unconsciousness. Blood: Hb., 83%; R. B. C., 4,600,000; W. B. C., 6800; 32 stipples, nor- mal as to size and form. Urine: Negative, ex- cept for few blood cells. Wassermann nega- tive. November 2, 1929. Epileptiform seizures growing more frequent in duration and lasting longer. Had attacks on street and once in sub- way. Epigastric tenderness, tearing head- aches and general weakness. Physical examination : Pale waxy skin ; 332 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 cadaverous mask-line facies; appears indiffer- ent and phlegmatic ; heart sounds below par ; B. P., 115/90; slight involvement of the up- per left chest, subcrepitant rales; sclerosis of retinal vessels ; abdomen-epigastric tender- ness and right rectus rigidity. Reflexes — in creased triceps, biceps, ulnar and radial ; mark- edly increased knee and Achilles reflexes; left Babinski. Bilateral papillitis. Extremities cyanotic, skin dry — diaphoresis. Blood: Nu- merous stippled cells. Urine: Albumin, hya- line casts; R. B. C., and W. B. C. Case 10. July 1929. A. F., male, white, 36, Portuguese, single, tap man in lead furnace, worked 7 days a week. Loss of appetite, muscle weakness, headaches, cramps, vomit- ing. Blood: Marked stippling. Hb., 43%. Urine: Positive for lead. Physical examina- tion : Well developed ; rather pale ; waxy, pinched expression ; tender over epigastrium. May 31, 1930. Physical examination: Ap- pears aged ; hair gray ; masked facies ; slow arid unsteady gait; cadaveric skin; pale con- junctiva; slight facial paralysis. Blood: Hb., 50%; R. B. C., 3,250,000; W. B. C„ 5000; color index, 0.8 plus ; polynuclears, 50% ; lymphocytes, 48% ; endothelial cells, 2% ; 35 stippled cells per 100 leukocytes ; red cells show anisocytosis ; poikilocytosis and poly- chromophilia. January 1931. Headache, dizziness, weak- ness, impaired vision, deafness in right ear, progressive constipation and facial paralysis, loss of weight, insomnia. Physical examina- tion : Anemic ; lacks initiative ; pupils react to light and accommodation; slight nystagmus; eye-grounds distinctly blurred ; retinal veins tortuous and engorged with a definite optic neuritis. Facial paralysis very marked. All reflexes sluggish except right knee which is exaggerated. Hands tremulous ; station un- steady ; speech defective. Case 11. November 1928. P. R., male, white, single, 48, Ukrainian, grinder and weigher in color and pigment plant for 5 or 6 years. Working 11 hours a day and 7 days a week. Cramps in stomach, back and chest, itching over whole body, vomiting, dizziness, sweet and bitter taste in mouth, constipation and shaking. Blood: Hb., 87%; R. B. C., 4,400,- 000; W. B. C., 7000; no stippled ceils or poikilocystosis ; normal as to size, form and staining. Urine: Negative for lead; albumin and casts present. Wassermann negative. Feces positive for lead. February 1930. Physical examination: Masked facies ; general and muscular develop- ment fair ; heart and lungs negative ; defective speech ; persistent nystagmoid movements of the head ; pupils react normally ; generalized tremors ; marked intention tremors ; general weakness of extensors; sensory areas of anes- thesia, in upper extremities and hypesthesia in lower ; mentally retarded ; hyperemotional and too excited to answer simple questions. This man is totally incapacitated for any kind of work although part of his pathology may possibly be attributed to a head injury he sustained about 15 years ago. However, he did not lose any time from work during the preceding years. Case 12. February 1926. I. B., male, white, married, 54, American, painter for 15 years. General weakness, colic, dizziness, dropped to the ground while at work and unable to work. Blood : Large amount of stippling. Urine : Lead present. April 1926. Began to feel lazy, had no am- bition, lost appetite, was constipated, had pe- culiar nasty taste in mouth every morning, constantly increasing headaches, dizziness and nausea. Both wrists were losing strength so that he was unable to hold brush. April 19, 1926. Felt sick at stomach, had sharp cramps, got red in the face, and had pains in arms and legs. Collapsed and taken to the hospital where he remained for 6 months. January 2, 1929. Physical examination: Pa- tient developed advanced encephalopathy. Nystagmoid movements of head; generalized tremors; paralysis of extensors of both fore- arms ; weakness of extensors of legs ; unable to do work of any kind. January 22, 1931. Physical examination: Condition unchanged ; double wrist drop ; legs weak, tremors more pronounced; unable to do any work. In addition to the 12 cases cited, about 90 others have been followed periodically and the findings recorded. While a series of 102 cases is far too small a number upon which to base April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 333 definite conclusions, nevertheless, the repeat- ed clinical manifestations and objective find- ings as disclosed in the periodic examination clearly point toward definite pathology as shown in the following table : The subjective and objective symptoms of this group in the order of their frequency and their percentages were as follows : Subjective Persistent headache 70% Dizziness 60% Obstinate constipation 52% Muscle group weakness 48% Premature fatigue 36% Epigastric pains 35% Visual disturbances’ 33% Arthralgia 32% Shakes 32% Insomnia 20% Periodic vomiting 18% Loss of weight 14% Objective Anemia 60% Eye-ground changes 33% Tremors 32% Unsteady station 25% Hypesthesia and hypalgesia 20 % Nephritis 18% Arteriosclerosis (premature) 16% Lead line 16% Cardiac lesions 12% Retinal hemorrhage 11% Facial palsies 10% Dyspnea 9% Wrist and ankle drop 5% Convulsions 2% While the subjective symptoms may have been exaggerated wilfully or as a result of an anxiety neurosis, nevertheless, the physical signs, ophthalmoscopic findings and laboratory examinations, demonstrated the physiologic basis for their abstract complaints. In reply to a questionnaire sent to the medi- cal officers of 30 life insurance companies scattered throughout the United States and Canada we received the advice that a man who had suffered from industrial lead poison- ing would not be issued ordinary life in- surance and would be “rated” up for a sub- standard form of insurance. Practically none would issue health insurance or attach a disability clause to the policy. While this is not conclusive, it is rather significant, in view of the attitude of the insurance companies that base their opinions on past experience. Observations (1) Wrist drop was comparatively rare, with the exception of the painter who used his wrist muscles more than the others. (2) The blood picture is of diagnostic sig- nificance and is indicative of the intensity of the disease in the acute and subacute stages. It is of no import in the chronic stage since the most seriously affected of that group — those who are permanently and totally dis- abled— displayed a practically normal blood. (3) Persistent headache, dizziness, consti- pation, general weakness, visual disturbance,, muscle and joint pains, in their respective or- der, are the chief complaints of the patient suffering with chronic plumbism ; the other symptoms are just as definite, but less fre- quent. (4) Workers in different industries, where different compounds or processes are used, display different clinical pictures and blood findings. The white lead workers showed a persistently low hemoglobin ; the smelters a low red blood cell count; and the lead battery workers an arthralgia and myalgia. (5) Workers with chronic plumbism are ready victims for intercurrent diseases, par- ticularly tuberculosis. Incised or lacerated wounds “fester” and the duration of the or- dinary cold is out of proportion to its severity. (6) Over-worked men have a longer period of temporary disability and are subject to most residual damage. The more seriously^ affected of the group were those who worked 7 days a week and 10-12 hours a day. Appar- ently in these individuals elimination did not keep pace with absorption and the accumu- lated balance resulted in permanent disability. (7) The length of exposure was of no- material significance. Some men with 2 or 3 weeks’ exposure suffered from a more in- tense attack and were left with greater disa- bility than those with long years of exposure. Conclusions (1) A mild case of lead poisoning may leave no permanent disability. (2) The gastro-intestinal type of lead poisoning is of a temporary nature and the resulting persistent constipation is not disab- ling in character. 334 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 (3) The cerebrospinal form of lead poison- ing is the most distressing in its fnanifesta- tions, most destructive in nature, most per- manent in character and may result in total permanent disability. (4) The kidneys usually show the most degenerative changes. (5) Long hours and over- work are con- ducive to greater disability. (6) Chronic lead poisoning sufferers have a lowered resistance, are poor risks for health insurance, and have a shorter life expectancy. May I mention, in closing, that our follow- up work and examinations of this group, though by no means perfect, have revealed that these men have been suffering intensely and persistently. 1 could not escape the feel- ing, although I cannot produce the legal proof, that once a man suffers from a severe indus- trial lead intoxication he never completely re- covers from it and carries the sequels to the end of his days. DIFFERENTIAL DIAGNOSIS OF LEAD POISONING Joseph S. Mark, M.D., Woodbridge, N. J. Of late years, during the development of industrial medicine and surgery as a specialty, much has been written concerning lead intoxi- cation, and attention of the profession has been clearly drawn to consideration of this condition when facing indefinite complaints by workers employed in lead hazardous occupa- tions. In fact, the emphasis has been so great that there exists a very definite danger of overlooking the fact that a man can be so employed, even show evidence of lead ab- sorption, and yet his complaint may be patho- logically due to some other, intercurrent con- dition. This danger is enhanced by the fact that often the symptoms of lead intoxication are manifold and indefinite, and may so easily be confused with chronic conditions the symp- toms of which are similar. ' As lead intoxica- tion is the diagnosis of least resistance, in- tercurrent conditions can easily be neglected, and it requires, an exceptional amount of zeal and diagnostic acumen to pursue investigation further, when a lead hazard employee com- plaining of indefinite symptoms, showing basophilic stippling and some anemia, pre- sents himself for diagnosis. And yet, quite frequently, if sufficient time is allowed to elapse to allow his pathologic condition to be- come diagnostically definite, any one of a num- ber of chronic diseases may establish its presence. In order -to discuss differential diagnosis more intelligently, I would like to enumerate briefly the salient signs, symptoms, and labora- tory findings in lead intoxication. Clinical picture. As a rule, the symptoms are rather indefinite and gradual in their on- set. The patient first notices that his appetite is diminishing. There follows some sleepless- ness, headache, constipation, easy fatigue, ir- ritability, nervousness, inability to concentrate and, occasionally, indefinite abdominal pains and nausea. These symptoms might mani- fest themselves a few weeks after the begin- ning of exposure, and sometimes not for years, depending on individual susceptibility. As a rule, if a man works for 6 months in the presence of a lead hazard without any of the prodromal signs just described, his sus- ceptibility is rather high, and with care he will not develop lead intoxication. As the con- dition advances, there appears a characteristic pallor. There is a uniformly grayish color- of the face, like the appearance often noticed in miners, or people working constantly at night occupation where little exposure to sunlight is obtained. It is often surprising how slight is the loss of hemoglobin as compared with the pallor of the face. It is difficult to avoid be- ing misled by Spaniards, Portuguese or other people whose color is normally grayish and pallid. There develops a very fine tremor, in- tentional in character, beginning around the ocular and buccal sphincter muscles, especially noticeable when the patient is requested to bare the upper gums or approximate the eye- lashes without shutting the eyes entirely. Later, there is a tremor of the fingers and hands, demonstrable when the patient is re- quested to hold out the arms and hands straight and separate the fingers, and to main- April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 335 tain that position for a few minutes. Also there is a gradually increasing weakness of the tensor muscles of the fore-arm demon- strable by having the patient flex and extend the wrist against resistance measured by spring scales or weights. In far advanced cases, as is well known, there is a wrist-drop, and foot-drop. Meanwhile, loss of appetite is in- creasing; he will carry his lunch home un- touched. Constipation, which only very large doses of cathartics will remedy, becomes severe. There will be indefinite collicky pains and marked fulness in the epigastrium; metallic taste is often complained of ; head- aches and insomnia increase ; fleeting pains along the peripheral nerves and joints but no real arthritis or neuritis. In some cases, con- junctival jaundice is in evidence, and the well known Burtonian line, or lead line, develops. Sometimes there is a mental change ; irritabil- ity, forgetfulness, nervousness. I need hardly mention lead colic, for it has been often de- scribed and well impressed on the clinician, except to say that it is usually a late symptom ; but when present it clinches the diagnosis. In fact, lead colic is not present so frequently as general opinion would indicate. Encephalo- pathies occur, manifested by epileptiform seizures, convulsions, and even coma, but these are fortunately rare and late manifesta- tions. Ocular disturbances also occur, rang- ing from paralysis of the external muscles to real optic atrophy. There are some symptoms mentioned in text-books which have never been proved to be due to lead, and which, clinically, I have never been able to accept as such; i.e., arteriosclerosis, hypertension, or- ganic kidney changes, organic joint changes. The symptoms above described may all co- exist or may be present at different times. In the majority of cases, some of these symptoms are strikingly in evidence, others negligibly. It is by a combination of symptoms and signs, and by their extent and correlation, that we are guided to a diagnosis. Laboratory findings. The blood picture is very distinct. There is a diminution of hemo- globin, which is rarely lower than 65% ; anisocytosis and poikilocytosis ; diminution of the red cells, but rarely lower than 3,500,000 ; the white cell and differential counts are not altered. Basophilic degeneration or stip- pling of the red blood cells is present to a varying degree. I have been in the habit of estimating these cells quantitatively in rela- tion to 100 white blood cells, and less than 6 stippled cells is not considered pathologic. There exists considerable difference of opinion as to the prognostic value of the number of stippled cells present. I am convinced that the presence of stippled cells in the blood in excess of 6 to 100 leukocytes, when the primary anemias, leukemias, malaria and benzol poisoning can be excluded, is indica- tive of just one thing — absorption of lead into the system. Whether or not the lead thus absorbed is causing poisoning, stippled cells will not tell us. In a frank case of poisoning it will not tell either the severity or progress. Attaching any further significance to the presence or quantitative determination of stippled cells is the one great stumbling block of the. differential diagnosis of lead poisoning. I have followed men who have shown consistently stippled cell counts, vary- ing from 10 to 300, for years, who have not lost a day from work because of illness nor shown any other symptom of lead poisoning. Men can have severe cases of lead poisoning, and show very few stippled cells. The absence of stippled cells, on repeated examinations, is a distinct evidence of freedom of the system from lead; or to put it differently, no lead poisoning can be present if no stippled cells are found on repeated examination. Presence of lead in the feces shows the en- try of lead into the gastro-intestinal tract. Whether it has been swallowed and passed through, or reabsorbed from the blood stream, it is impossible to state. Presence of lead in the urine shows that lead has been absorbed and passed through the system. The presence of lead in either feces or urine or both simply shows absorption, not necessarily poisoning. Further symptoms and signs are required to diagnose poisoning, with these laboratory findings as corroborative evidence. The diagnostic value of the lead line is in the same category as the laboratory findings. Its presence indicates lead in the system, but not necessarily poisoning. Its absence does not preclude lead poisoning. It must be noted, 336 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 in passing, that Arabs and Turks have natural bluish spots or their gums which must not be confused with a lead line. Differential diagnosis must be discussed in relation to 3 distinct groups: (1) Frank cases where no unusual difficulties are present. (2) Frank cases where lead poisoning is claimed but the indications are clearly negative. (3) Borderline cases, where it is necessary to use extreme care to arrive at a diagnosis. Group 1. Lead colic is relatively simple to differentiate, although there are a few con- ditions with which it might be confused. Ap- pendicitis shows more localized pain, tender- ness, and rigidity. In lead colic, the signs are referable to the upper abdomen, as a rule, and rigidity is generalized and intermittent. There is seldom more than 1° elevation in temperature in lead colic, and no leukocytosis. It is possible to have acute appendicitis in cases where stippled cells and lead line are present. Peptic ulcer about to perforate the serosa will give symptoms resembling lead colic; the on- set of pain is more abrupt, and tenderness and rigidity are localized to the right side of the -epigastrium, while in lead poisoning they are more generalized. Cholelithiasis, nephro- lithiasis, tabetic crises, and kinks of the ureter, must also be considered, but they have charac- teristic signs and need no further discussion. Hypodermic injections of morphin sulphate in adequate doses will relieve these conditions, but are not so apt to relieve the pain of lead colic. Intravenous injection of calcium chloride or gluconate will relieve lead colic but will have no effect in the other conditions. Atypical cases of angina pectoris must also be considered, but the direction of the pain, being referred to the left shoulder and arm, the facies, the absence of abdominal rigidity, his- tory of previous similar attacks and hyper- tension will clarify the diagnosis. Wrist-drop and foot-drop are easily diagnosed, but in some cases alcoholic neuritis, slowly develop- ing polyomyelitis, and progressive muscular atrophy must be considered. Group 2. Workers in factories where propaganda has been undertaken to prevent lead poisoning often come to the medical ad- viser with the home-made diagnosis of lead poisoning but with conditions which may be anything from acute follicular tonsillitis to eczema. I mention these cases only to warn the clinician not to accept readily the diag- nosis just because the patient has been ex- posed to a lead hazard. Group 3. It is in cases where indefinite symptoms with no distinct physical signs are present that the greatest care must be exer- cised. Every case must be decided on its own individual merits and diagnosis arrived at by correlating the symptoms, by careful valua- tion of the significance of prominent symp- toms present, by taking into consideration the suggestive help of less striking symptoms, and the corroborative evidence of the laboratory findings. As a rule, where gastro-intestinal symptoms are present, a lead line is evident, pallor is striking, constipation marked, and the blood picture is positive, the condition must be treated as lead intoxication until disproved. Among conditions most closely resembling lead intoxication, chronic alcoholism is most frequent and must be seriously considered. It will produce the gastro-intestinal signs and symptoms, the tremors, headaches, insomnia, and nervous manifestations. It will cause peri- pheral neuritis, often blamed on lead. Chronic alcoholism predisposes to lead intoxication, and for that reason alcoholics should be removed from where lead hazard is present. When in doubt, consider the condition as alcoholic, secure thorough elimination, and the patient will be relieved ; if not, the case should be considered positive for lead and treated ac- cordingly. Alcohol and lead do not mix; al- coholics show signs of poisoning early and from relatively small amounts, and so they seldom develop bad cases of lead intoxica- tion and can be deleaded promptly. Tuber- culosis in its incipient stages may be easily mistaken for lead poisoning. The gastro-in- testinal complaints, weakness, loss of appetite, debilitation and pallor are common to both conditions and very often radiographs, posi- tive sputum, and temperature records are necessary before a definite diagnosis can be made. Syphilis, as the greatest imitator, has a rival in lead poisoning, which also can mimic a great many indefinite conditions. General paralysis will be ruled out by the positive Wassermann reaction; which reaction April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 337 in lead poisoning is always negative. Per- nicious anemia, leukemias, and secondary anemias can be ruled out by the blood picture, although they might be combined with lead ab- sorption. Malingering in lead poisoning. No paper of this character would be complete, without some consideration of malingering. The ma- jority of workmen exposed to lead for a long time will absorb a certain amount, varying ac- cording to individual susceptibility, the length and character of exposure, health of the in- dividual and precautions exercised. This ab- sorption might be temporary, recurrent, or permanent. It can be easily demonstrated by the lead line, stippled cells, and presence of lead in the feces and urine. Only a small per- centage of workers will develop lead poison- ing, if proper precautions and care are exer- cised. Practically any of these men can, how- ever, claim the presence of lead poisoning if their laboratory findings are positive, and if they can enumerate enough subjective symp- toms which no one can disprove or deny. If a lead line is present, they can strengthen their case accordingly. The motive for malingering is the money which the compensation court might award for temporary, partial or per- manent disability. The immediate cause for malingering is either some grievance against the employer, a large award recently made to some friend, the persuasion of some lawyer’s runner, or transfer to some other work which is disliked. It has been my experience that a good many men, discharged at any one time, will promptly find their way to the compen- sation court, being represented by the same lawyer, complaining of the same or similar symptoms, in spite of the fact that their em- ployment and medical records are free of com- plaints, or noted absences from work because of illness. It is not easy to explain this oc- currence on the basis of coincidence. The fol- lowing instances may be of interest. In a cer- tain lead plant 2 men were discharged be- cause of acute alcoholism. On the same day one of the furnaces was shut down for re- pairs, and 2 men were discharged for lack of work. All 4 men filed claims for compensa- tion, claiming permanent disability because of lead poisoning. In another instance, a man filed claim for compensation because of a slowly developing hernia. The case was de- cided against him and he promptly changed his plea to partial permanent disability be- cause of lead poisoning. All of these men had medical certificates to back their claims, the diagnosis in each case being based on the lab- oratory findings. The medical men did not take into consideration the clinical findings, because stippled cells were present. In most of these cases the men do not consult the physician in search of treatment; the object is medical testimony. They are not in search of health but of easy money. If successful, remarkable cures are accomplished ; their strength and health returns as if by magic, and they find that they are able to take up the same work once more, although often in a different locality. There have been cases un- earthed where the men were receiving partial permanent disability awards from one factory, and working steadily and full time in another. In doubtful cases of this category, I have adopted the following procedure. Thorough hospitalization for a complete study of the condition and measures used for relief of con- ditions complained of ; if negative for inter- current pathology, deleading and supportive and building-up treatment. This method seems to me ideal, for the patient is given the bene- fit of the doubt, and if it is a true lead case deleading and supportive treatment will cure him ; if some other disease, it can be brought' to light and accordingly treated; if the con- dition is imaginary, hospital routine and in- tensive study will bring it to light. In fairness to the patient, temporary disability should be paid during the period of hospitalization, and afterward until declared again able to work, if the debility is due to lead. LIVER CYSTS; REPORT OF CASE John H. Hermann, M.D., and Guy B. Griffin, M.D., Orange, N. J. Owing to its comparative rarity the follow- ing case is being reported with some detail. The Massachusetts General Hospital records 338 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 (1870-1905) show that in 1858 operations on the liver only 6 simple cysts were found. Case Report Mrs. K., American, aged 32, was taken ill at 7 a. m. August 8, 1930, with a continuous sharp pain arising in the right upper quadrant and radiating across the epigastrium; pain so severe that she fainted. After she revived the pain, still present, was accompanied by vomit- ing and retching. A. stomach sedative cur- tailed both vomiting and retching but the pain persisted. At time of attack the temperature was 102°F. (oral), pulse 92, and respirations 20. Patient slept that night, after taking a narcotic. The following day she was seen at 10 a. m. by Dr. Hermann, at which time she presented the following features : Temperature 101°F. (rectal); pulse 100; respirations 30; blood pressure 140/82 (aus- cultatory, prone). General examination re- vealed nothing. Abdomen was rounded, some- what due to fat and flatulence ; right upper quadrant particularly prominent. Upper ab- domen was tender to palpation, accentuated over a small area just below costal margin in the right mid-clavicular line. A mass was palpated there, approximately 7 cm. in diam- eter which seemed to extend up under the liver; it was neither elastic nor was a hydatid thrill elicited. Percussion note was dull over this area. Auscultation revealed nothing. Past history. Measles as a child. Influenza in 1928. Two months ago (June 1930), after returning from an automobile ride, she had an attack of “chills and feA^er” which lasted through the night. Again, 1 month ago (July 1930), noted some “vague pain” in the upper abdomen which lasted a few hours and was followed by a sensation of soreness over the whole upper abdomen, which persisted for 8 hours accompanied by some nausea and vom- iting. A burning epigastric pain lasting an hour has been caused by anything eaten since that time. Has had occasional spells of dizzi- ness during the past month — no particular time or relation to meals. Gravida ii ; Para ii. Nothing unusual noted during periods of ges- tation. Mother died of a liver carcinoma. Laboratory findings. Blood count showed 16,600 polymorphonuclear leukocytes; the dif- ferential was 88% neutrophiles, 10% lympho- cytes and 2% monocytes. Urinalysis showed 1 + albumin. Stool was negative for blood. Roentgenogram showed a distorted duodenum and a filling defect in the pylorus which was irregular and suggestive of malignancy. Due to the foregoing data, and because of the persistent pain, an exploratory laparotomv was decided upon. Operation: On August 15, 1930, under gas- oxygen induction and ether maintenance, a right rectus incision was made. The mass was seen to be cystic and extended inferiorly from the porta hepatis to about 4 cm. below the liver border; laterally from about 5 cm. left of the round ligament of the liver to approxi- mately 9 cm. to the right of that structure. It was firmly attached to the round ligament and contiguous liver surface; the gall-bladder was not adherent. The pylorus and duodenum were compressed and inflamed. When the pressure was removed, contour of both stom- ach and duodenum was normal ; no adhesions were noted. The cyst was incised and found to have 7 connecting secondary sacs A^arying from 2-6 cm. in diameter. The sacs Avere evacuated of 250 c.c. clear, serous fluid and 5 c.c. inspissated pus. A portion of the wall Avas resected for pathologic examination. There was no visible connection with either the common bile duct or the gall-bladder. Tavo cigarette drains were placed into the cyst and the opening sutured to the peritoneum. A similar drain was placed in the abdominal cav- ity terminating near the porta hepatis. Reten- tion sutures were taken and the layers of the abdominal wall were closed separately. There was little blood lost and the patient stood the intervention Avell. Laboratory report. The pus was sterile and neither booklets, scolices nor biliary elements were found. Pathologic report. From the portion re- sected, Dr. Harrison Martland could find no evidence of malignancy or hydatid disease, and he diagnosed the tissue as coming from a simple cyst of the liver. Convalescence was uninterrupted. The wound closed cleanly and the patient was dis- charged August 30, 1930. She has since been April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 339 seen at frequent intervals and is apparently in the best of health. The former abdominal pain and discomfort after meals are entirely gone. Liver Cysts It is almost as difficult to give a satisfactory discussion of cysts as it is of general tumors ; there are so many varieties and so many ex- ceptions. A cyst may be defined as a well cir- cumscribed, pathologic collection of fluid, tending to persist and increase (McFarland). Not including cysts of the gall-bladder or ex- trahepatic ducts, those found in the liver may he classified as follows : Hydatids. Due to infection of the larval form of the Tenia echinococcus; the diagnosis being based upon a minimum of symptoms. Brum considers the reaction of Weinberg of no practical value and although a 2-5% eosino- philia was confirmed at operation as echino- coccus infection in 80% of 147 cases, he places little importance upon this finding. In only 2 cases was the hydatid thrill elicited and he observes that : ( 1 ) There are no clinical symp- toms manifest so long as the cyst remains small and hidden. (2) When it does become exteriorized there is only 1 symptom : tumor. (3) The biologic reactions have no practical value. Intrahepatic biliary cysts. From continued obstruction the intrahepatic ducts may be widely dilated. The contents may be thick, inspissated bile with a healthy gall-bladder, or colorless bile when the gall-bladder is unable to cause concentration. This condition has been termed “hydrohepatosis” by Rous and McMaster. Occasionally small retention cysts are seen associated with cirrhosis. Cysts due to multiple adenomas. These are small and develop at the expense of the epi- thelial cells of the intrahepatic biliary canalic- uli. Because of this they are thought (Scalone) to be the most important of all cystic new-formations in the liver. Simple cysts. These may be single or present in small numbers and may be due to biliary retention, although when large the bile may disappear and the fluid then become ■colorless. Constantine and Duboucher con- sider their origin the same as cystic disease. A single cyst not parasitic or due to change in an adenoma of the bile ducts may contain much fluid ; in Bayer’s and Winckler’s cases 6.5 liters. Cousins reported an instance in which a cyst of the liver contained 2 % gal- lons (11.3 liters) of clear, limpid, yellow fluid. Like simple cysts of the common bile-duct females provide the vast majority of the cases; out of 56 cases, 44 were females (Jones). The clinical symptoms are essentially those of hydatid cysts (q. v.) from which they can be distinguished by an examination of their contents. Jaundice has sometimes been noted (Doran and Munk). Very severe symptoms may be caused by extensive hemorrhage into or rupture of a cyst. Pseudo-cvsts. These are due to softening down of sarcomatous or carcinomatous nod- ules; here the contents may be blood stained or clear but the former occurs in the majority of cases. In either event a microscopic ex- amination of the cyst wall should show some evidence of malignancy. In general, diagnosis of liver cysts is ex- tremely difficult and depends almost wholly upon a microscopic examination of the con- tents and a section of the wall. According to Jones, Ivilvington of Melbourne, where hy- datid cysts are common, made the correct pre-operative diagnosis in an instance of non- parasitic cyst, his criterion being that the fluid tension was less than in the ordinary hydatid cyst. Clinically, apart from hepatic enlarge- ment or the presence of cysts which have been known to simulate ovarian cysts or a dilated gall-bladder, symptoms pointing to the liver are usuallly wanting. In a series of cases of liver cysts reviewed by Caylor, of the Mayo Clinic, pain was a common complaint. Jaun- dice may be present if there is pressure on a bile-duct. In cystic disease of the liver the symptoms are those of chronic renal disease from the usually accompanying megalo- cystic kidneys, such as uremia. It is to be noted that in large tumors of the liver the colon is displaced downward and to the left, while in large kidney tumors the colon lies over the swelling (Hofmann). Excursion of the diaphragm producing change in the position of the tumor may aid in ascertaining the site of the mass ; however, large cysts may produce sufficient pressure to practically in- hibit diaphragmatic excursion. 340 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 Treatment. Cysts that occur particularly in connection with bilateral polycystic disease of the kidney, as a rule, require no treatment. If marked, they may be aspirated or resected. The type of cyst one finds may alter the op- erative procedure, but there are some points that should always be observed: (1) Where the mass is large, shock is to be guarded against. Here, quick evisceration may result in an acute fall in blood pressure. By slowly decompressing the abdomen or by the sub- cutaneous administration of pituitary extract, prior to the sudden release of intraabdominal pressure, shock may be avoided. (2) The cyst should be walled off from all other abdominal contents. This is most important in the event that the structure is of the hydatid variety. (3) When and if opened the contents, with a section of the wall, should be examined im- mediately under a microscope ; operative pro- cedure may then be altered to accommodate the findings. Mortality statistics would indicate that the most favorable procedure is to incise the cyst, draw off the contents, and suture the cyst wall to the peritoneum or skin. This may be done in 1 or 2 stages and is commonly known as marsupialization. The first stage, consisting of suturing the unopened cyst to the per- itoneum or skin, is followed by (second stage) incision and drainage after sufficient adhesions have formed. In some cases one may enucleate the cyst in its entirety and this, of course, is always desirable. TREATMENT OF ACTIVE MEASLES BY INTRAMUSCULAR INJECTION OF RECENT CONVALESCENT WHOLE BLOOD Jacob Piller, M.D., Paterson, N. J. Medical literature contains many articles on the use of immune serum for the prevention or modification of measles, but little has been written on the use of recent convalescent blood in the actual treatment of active measles. Kellogg (Jour. A. M. A., Dec. 21, 1929, p. 1927) states: “Convalescent serum has been found to be effective in preventing measles, but it is useless as a cure, once the disease is established.” Rowland G. Freeman, Jr., of New York, states : “It has been attempted to abort the disease (measles) by the injection of 20-30 c.c. of serum during the period of invasion, but we have had no results that would indi- cate any benefit from this measure.” Kato (Amer. Jour. Dis. Children, Sept. 1928, pp. 526-573) summarizes: “Convales- cent serum has been employed in the active treatment of a few patients with malignant measles; when a large amount of the blood is used, as in transfusion, the effect seems to be beneficial.” The following two case reports illustrate this treatment, demonstrating the practical abortion of fully developed measles, and im- mediate convalescence. Whether these treated children have developed a personal immunity, I cannot say. Case 1. Baby W., aged 18 months, is the youngest of 4 children. The oldest, aged 10 years, came down with an average case of mea- sles. About a week later the second, and then the third child, became ill with typical measles. The mother was reluctant to have the young- est injected with immune serum; but when it, too, developed the rash, after 4 days’ sneez- ing and red eyes, she requested the treat- ment. By this time the eldest patient was entirely convalescent and I withdrew 10 c.c. of his blood and immediately injected it into the buttock of the infant. Within 24 hours the rash was entirely gone, temperature was normal, and the child in usual good spirits. There was no relapse or complication. Case 2. Baby J., aged 11 months, is the youngest of 3 children. The oldest, aged 6 years, became ill with measles complicated by a purulent dacryocystitis. About 10 days later, the second child, aged 4 years, and the 11- months old infant both exhibited the rash, af- ter the usual prodromal symptoms. I with- drew 10 c.c. blood from the 6 year old con- valescent boy and immediately injected it into the buttock of the infant. The next day the rash and fever were gone and the child was entirely well. The 4 year old girl ran the usual course of uncomplicated measles. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 341 In the first case I had little hope of any result, as the rash was already present ; and was surprised, as well as pleased, to see the disease promptly checked within 24 hours. In the second case the circumstances were also propitious for this therapy, and the favorable result was expected. THE ANEMIA OF PREGNANCY Robert A. Kilduffe, M.D., Director Laboratories, Atlantic City Hospital, Atlantic City, N. J. Possibly as an aftermath of studies in pre- natal care, the fact that pregnancy per se may be the cause of a varying degree of anemia is attracting increasing attention. The phrase “anemia of pregnancy” is more usually applied to the severe, acute hemolytic anemia infre- quently encountered, or to that form which, both cytologically and symptomatically, may present more or less resemblance to the per- nicious form. These, however, are so symp- tomatically evident that they are seldom over- looked. Of greater importance, both because it is more common, and because without particular effort it is easily over-looked, is a definite sec- ondary anemia without obvious symptoms but occurring in a large number of cases. Bland and Goldstein1, for example, report 50 cases in which the hemoglobin varied from 42 to 78%, and the erythrocyte count from 2.36 to 3.98 millions. Of these 92% made spontan- eous recovery after delivery. Lyon," in about one-third of 200 cases studied, found a hemoglobin of less than 70% and similar findings have been reported by Galloway3, Moore4, Kerwin and Collins5, and others. That these studies are of practical importance is readily apparent, for it is ob- vious that a woman with a definite secondary anemia cannot be expected to stand a prolong- ed or arduous labor as well as one whose blood picture is normal. If, as would seem to be the case, this condition is a common concomitant of pregnancy, then its occurrence must be taken into account in the conduct of prenatal measures. The present report records the findings, as regards hemoglobin and erythrocyte counts, in 300 women registered in the Obstetric Dis- pensary of the Atlantic City Hospital. The cases were unselected in any way. The report is based upon a single examination but, never- theless, presents findings of distinct interest as shown in the tables below. TABLE I. HEMOGLOBIN AND ERYTHROCYTE COUNTS ARRANGED IN ACCORDANCE WITH DURATION OF PREGNANCY Average Average Erythrocyte Duration o{ Number Hemoglobin Count: Millions Pregnancy: Months of Cases % Gm. % per cu.m.m. 1 — 3 12 73 10.07 4.50 4 — 6 72 72 9.93 3.73 7 — 9 216 66 9.10 3.73 From these findings it is not only apparent that a secondary anemia was encountered in a high proportion of the cases studied, but also that the anemia varied in degree in pro- portion to the duration of pregnancy, being more marked in the last than in the first or second trimester. In this table both hemoglobin readings and erythrocyte counts were averaged. If 75% is arbitrarily taken as the lower limit of normal, and 4,000,000 erythrocytes similarly accepted, it is seen that in the 12 patients in the first trimester the findings taken as an average are approximately nor- mal. As a matter of fact, however, one of these patients whose Wassermann (Kolmer quantitative) was 444 0 0, had a hemoglobin of 70 and a red cell count of 3,820,000; and another, a hemoglobin of 69 with a red cell count of 3,720,000. In the second trimester the individual variations were somewhat more marked, rang- ing from 45-82 hemoglobin and from 2,- 640,000 to 4,300,000 red cells. Nevertheless, evidence of anemia was found in 65, or 91% of the 72 cases examined. In the third trimester only 34, or 15%, had readings within the arbitrary normal limits outlined above, well marked anemia being present in 87% of 216 cases. These results, which are in uniformity with 342 those reported by others, leave little room for doubt that pregnancy per se is a cause of a definite degree of secondary anemia, the sever- ity of which bears a somewhat proportionate relation to the duration of the pregnancy. While the occurrence of secondary anemia in pregnancy is no longer disputed there has been, and still is, much discussion concerning its etiology and mechanism. Among the more prominent theories which have been advanced are: that the anemia is the consequence of hy- dremia with subsequent reduction in the iron content of the red corpuscules — in other words that it is a chloro-anemia ; that it is the expression of an “individual disposition” in accordance with the general physical well- being of the particular patient; that it results fiom the action of a syncitial hemolysin; that it is the product of poor hygiene or such dis- eases as nephritis, syphilis, tuberculosis, and so on ; that it is a continuation of a preexisting anemia ; or that it depends upon the presence of focal infections. While it is quite true that any of the factors listed may be the cause of secondary anemia, such factors are neither present with sufficient constancy nor found in a sufficiently large number of cases to be accepted without re- serve. There seems little reason to doubt that a well-marked secondary anemia is a frequent occurrence in pregnancy; that its etiology and mechanism are as yet undetermined and obscure ; and that pregnancy per se is a definite factor in its production. The establishment of these facts indicates the desirability of blood examinations as an important part of prenatal study and care in order that patients presenting hemoglobin leadings of less than 75% and erythrocyte counts of less than 3,000,000 may be detected and subjected to suitable therapeutic measures. Bibliography 1. Bland, P. B., Goldstein, L. and First, A., Ane- mia In Pregnancy, Jour. A. M. A., 1929, 93:582. 2. Lyon, E. C„ Anemia In Late Pregnancy, Jour. A. M. A., 1929, 92:11. 3. Galloway, C. E., Anemia in Pregnancy, Amer Jour. Obs. & Gyn., 1929, 17:84. 4. Moore, J. H., Anemia in Pregnancy, Prelim- inary Report of 100 Observed Cases, Amer. Jour Obs. & Gyn., 1929, p. 424. 5. Kerwin, W. and Collins, L. L., Hemoglobin Estimations in Pregnancy, Amer. Jour. Med. Sc 1926, 172:4:548. April, 1931 HIGH LIGHTS IN THE LIFE OF ROBERT KOCH Harry Subin, M.D., Atlantic City, N. J. Robert Koch, of IClausthal, was educated in the gymnasium of his native town, and took his medical degree at Gottingen, where he was very much influenced by the teachings of Jacob Henle, whose theory of contagion may have started Koch upon his life-work in science. After serving in the Franco-Prus- sian Y\ ar. he became district physician at Wollstein, where he varied the monotony of long journeyings over rough country roads by private microscopic studies. He began with anthrax, and in 18/6 wrote to the eminent bot- anist, Ferdinand Cohn, at Breslau, to the efi ect that he had worked out the complete life history and sporulation of the anthrax bacillus. About a week later, at Cohn’s in- vitation, he gave a demonstration of his cul- ture methods and results at thq Botanical In- stitute in Breslau, in the presence of Cohn, Weigert, Auerbach, Trube, Cohnheim, and others. Cohnheim declared that Koch’s was the greatest bacteriologic discovery yet made, and Cohn immediately published his paper in his Beitrage. d his report demonstrated that the an- thrax bacillus is the cause of the disease, and that a pure culture grown through several generations outside the body can produce the disease in various animals. Koch’s results were very much opposed by Paul Bert, but completely confirmed by Pasteur. The next year Koch published his methods of fixing and drying bacterial films on cover-slips, of staining flagellae, and photographing bacteria for identification and comparison. Then his great memoir on the etiology of traumatic in- iectious diseases appeared, in which the bac- teria of 6 different kinds of surgical infection are described, with pathologic findings, each microorganism breeding true through many generations in vitro or in animals. These 3 memoirs elevated Koch to the front rank in medical science and, through Cohnheim’s in- fluence he was appointed to a vacancy in JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 343 the Imperial Health Department, with Loef- Her and Gaffky as assistants. Here, he pro- duced his important paper upon the method of obtaining pure cultures of organisms by spreading' liquid gelatin with meat infusion upon glass plates, forming a solid coagulum. When Koch demonstrated his plate cultures at the International Congress, in London, Pas- teur vehemently declared his approval of Koch’s great progress. The next year was marked by discovery of the tubercle bacillus, by special statement of “Koch’s postulates”, establishing the pathogenic character of a given microorganism, which had already been adumbrated by Henle and Edwin Klebs. About the same time Koch and his assistants introduced sterilization by dry heat. Then, Koch at the head of the German Cholera Com- mission, visited Egypt and India, discovered the cholera vibrio, its transmission by drink- ing-water, food, and clothing, and incidentally found the microoorganisms of Egyptian oph- thalmia or infectious conjunctivitis, which is the Koch-Weeks bacillus, for which results he received a donation of 100,000 marks from the Prussian State. Then he was appointed professor of hygiene and bacteriology at the University of Berlin, where his laboratories became crowded with bright pupils from all over the world, among whom were Gaffky, Loeffler, Pfeiffer, Welch, and Kitasato. At the Tenth International Medical Con- gress, at Berlin, Koch announced his belief that he had found a remedy for tuberculosis; the introduction of tuberculin, his one mistake, in that it was prematurely considered, was hailed all over the world as an event of the. greatest scientific moment, and honors and felicitations of all kinds were showered upon him. Although he himself had limited his claims to the possible cure of early cases of phthisis, the great hopes which had been entertained of the remedy were not realized in time, and the number of failures and fatal cases impaired the confidence of the profession, but abated little of Koch’s great reputation, especially after discovery that tuberculin is the most re- liable means of diagnosis. In 1891, the In- stitute for Infectious Diseases was founded in Berlin, and remained under his direction until he resigned in favor of his pupil Gaffky. While directing the institute his ideas were applied in fighting the cholera epidemic at Hamburg, and during this time he wrote an important paper on water-borne epidemics, showing how they may be largely prevented by proper filtration. He investigated rinder- pest in South Africa at the request of the English government, devised a method of pre- ventive inoculation, and made valuable studies of Texas fever, blackwater fever, tropical ma- laria, surra and plague. The next year he produced his new tuberculin, and after that investigated malaria fever in Italy. At the London Tuberculosis Congress he announced his view that the bacilli of bovine and human tuberculosis, which had been separated and studied by Theobald Smith, are not identical, claiming that there is little danger of trans- mission of the bovine type to man. These views were reiterated at the Washington Con- gress, and on both occasions aroused violent controversy, the general trend of opinion be- ing in favor of Koch. Next, he studied Rho- desian red-water fever, horse-sickness, tryp- anosomiasis, and recurrent fever in German East Africa, and in the same year established methods of controlling typhoid which have been adopted almost everywhere. Koch received the Nobel Prize after resign- ing the directorship of the Institute of Infec- tious Diseases and then visited Africa again at the head of the Sleeping Sickness Commis- sion, introducing atoxyl for the treatment of the disease. Although he was honored by a membership in the Prussian Academy of Sciences and the title of Excellenz, he was not happy in the later years of his life. Certain changes in his domestic arrangements es- tranged many of his friends, and subjected him to harsh criticism, which he bore with stoicism and dignity, but which told upon him in the end. He died of heart failuie at the age of 67, thus ending the life of one of the greatest men of science that his country has produced. 344 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 ETIOLOGY, DIAGNOSIS AND TREAT- MENT OF PEPTIC ULCER* George H. Lathrope, M.D., Member Medical Board Morristown Memorial Hos- pital; Consulting- Physician to All Souls Hospital, Morristown, The Dover General Hospital The New Jersey State Hospital at Greys’tone Park, and the New York Stock Exchange. Newark, New Jersey Introduction The terms peptic and pyloric ulcer are used here inclusively to denote both gastric and duodenal ulcer, which in the majority of cases occur within l1^ in. on either side of the pylorus. Some ulcers occur fairly high on the lesser curvature, and the English, and now many American writers, use the term peptic ulcei as descriptive of both groups. Some American writers always distinguish between gasti ic ulcei and duodenal ulcer on the ground that theii course differs, their management \aiies, that surgery is more commonly needed in one than the other, and even that there may be differences in pathogenesis. Anatomic and physiologic considerations, however, are so much the same as to make it reasonable to think of the pyloric area as embracing the dis- tal \y2 in. of the stomach and an equal por- tion of the proximal duodenum. There seems no reasonable justification as yet for a divid- ing line between stomach and duodenum, with differing indications, prognosis, and thera- peutics on the two sides. It seems simpler and more sensible at present to include the en- tire area in a single conception, and the terms “pyloric ulcer” and “peptic ulcer” will there- fore be used interchangeably to denote the same condition. An exposition of pathology and symptoms has not been attempted in this discussion, as they are partially and, it is hoped, sufficiently dealt with in the sections on etiology and diag- nosis. Etiology I he etiology of ulcer of the stomach or the duodenum is still one of the befogged areas of medical controversy. Various ideas ’(Read before Warren County Medical Society October 21, 1930.) have been and still are current, all largely hypothetic, and backed up only partially and incompletely by experimental work or exact knowledge. We know much about the physi- ology of the stomach ; we are on the eve of knowing more about distortions of that phvsi- °logy ; but as to how an erosion of the mucous membrane begins, or why in some cases it should go on to form a chronic ulceration which upsets the digestive economy, and too often threatens the victim’s life, is still some- thing of a mystery. The problem, according to Aschoff (and in this he is followed today by most observers), centers around the ex- planation of 2 phenomena: (1) the primary bieak in continuity of the mucous membrane, i.e., the acute ulcer phase; and (2) its failure to heal, the chronic phase. Rehfuss has offered evidence that acute ul- cer may be produced by extraneous toxic sub- stances introduced into the stomach, and Bol- ton believes that metabolic toxins can pro- duce the same effect. Durante has shown very definitely that trophic disturbance can cause acute ulceration which may persist as a chronic lesion. He concluded the report of his experimental work thus: “***** ujcer may be produced by any agent capable of damaging the sympathetic nervous system (the median splanchnic nerve in particular), as it is on the integrity of this system, which con- trols circulation, secretion, and profound sen- sibility in the stomach, that the very life of the gastric cell may be said to depend. The theory of trophic ulcer must be taken in this sense.” Judd, reviewing the etiology of ulcer in the 1927 Mutter Lecture, while mentioning Rosenow’s work, places most emphasis on the research of Mann demonstrating in animals the invariable development of ulcer whenever the duodenum was sidetracked so as to keep the biliary and pancreatic fluids away from the pylorus ; and likewise the cure of ulcers so produced by restoring the normal admix- ture of gastric and duodenal juices at the py- loiic region. Rosenow offered evidence in 191d that streptococci injected into the blood stream may have a selective affinity for the gastric mucosa and produce acute ulcer. In a later publication (1916) he stated that to sup- port the idea that gastric ulcer in man is due April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 345 commonly to a local hematogenous strepto- coccal infection, it would be necessary to show : first, that in such ulcers streptococci are usually present to the exclusion of other types of bacteria; and second, that streptococci iso- lated from the ulcer wall, as well as those from foci of infection in the same patient, will produce, when injected into animals, ul- cers of, the stomach or duodenum resembling those in man. He then retails the experimen- tal work by which he supports these postulates. No one of these ideas has been substantiated as yet by a sufficient number of other work- ers to make it universally acceptable as the established etiologic factor ; but there is slowly accumulating considerable evidence that the primary necrosis of the mucous membrane is caused in some such manner as these various lines of research indicate, with a preponder- ance of evidence in favor of some form of bacterial activity. Only recently (1928) Nickel and Hufford have reported an exhaustive study of the elective localization of streptococci ob- tained from peptic ulcers, and declare their complete agreement with Rosenow. They state a further important conclusion, that “the over- whelming number of patients suffering from peptic ulcer harbor * * * septic foci”. Given whatever causation of an area of ne- crosis on the mucous surface of stomach or duodenum, most observers agree that action of the hydrochloric acid or the pepsin, on the raw surface thus produced, plus traumatism from peristaltic unrest, will tend to make and keep the ulceration chronic. Whether bacterial action can continue in the presence of the gas- tric juice is doubtful, for only a few active bacteria can be cultured out of the gastric con- tents, or from a base of such ulcers postmor- tem ; and the consistent growth of bacteria in vitro in an acid medium equivalent to that of the gastric secretion, has not been success- fully accomplished. The factors making for chronicity of an ul- cer once begun are probably numerous. It is quite possible that many ulcers arise and heal spontaneously, without perhaps ever having been recognized. The irritating quality of the gastric juice may be the largest single fac- tor making for chronicity; but peristaltic un- rest, irritating foods, toxins of metabolic origin, successive bacterial invasion, and low- ered vitality and resisting powers on the part of the patient, must all be taken into consider- ation. Another factor may be that the dis- turbance of gastric physiology which results from the presence of an ulcer, or from con- ditions which produced it, causes a fatigue or depression of the local healing forces inherent in the gastric mucosal cells. Holman stresses the importance of fatigue, particularly a local- ized fatigue of those cells concerned in the pathology of the condition, and then makes this sensible and conservative statement : “The frequently satisfactory results of simple means of giving rest certainly speak against the primary dominant importance of bacteria in the etiology, but should not blind us to their extremely dangerous role in complicating the condition, and where their source is in other infected foci these should certainly be attend- ed to.” An important and common clinical obser- vation is that ulcer is a condition prone to re- lapse. It would be better perhaps to use the word “recur” ; for it is quite likely that the ulcer heals, and a fresh ulcer forms later on, due to the same factors which brought about the original ulcer and which have not been removed. It has been a striking fact in our own cases that several patients who have for periods of 3-5 years shown no tendency to re- currences, are cases in which were found very bad tooth root infections, which were cleaned up soon after instituting treatment. If this observation has any etiologic significance it tends to support the idea that bacterial activity of some sort has to do with the inception of ulcer. In summarizing this question of etiology. Nickel and Hufford say: “It is universally agreed that the fundamental change per se in the gastric or duodenal mucosa is impaired nutrition in a localized area, with subsequent necrosis, sloughing, and digestion in the in- jured area by the corrosive action of the acid gastric juice. The mechanic, corrosive, throm- botic, embolic, and neurogenic factors are em- phasized by the exponents of the different theories.” Conclusion. For clinical purposes, then, it seems a fair assumption, on the basis of pres- 346 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 ent day evidence, some of which is factual, while other is hypothetic and from analogy, that ulcer is induced primarily by blocking of the terminal vessels in the gastric or duodenal mucosa, possibly due to bacterial invasion, which thus causes a localized area of necrosis; that this probably occurs most readily, or per- haps only, in a patient whose general resist- ance is lowered, and whose local resistance also is fatigued ; that, an ulcer once establish- ed, its chronicity is determined by the diges- tive action of acid gastric juice, peristaltic un- rest, and the influence of toxins from without or within the organism, as well as other ill- understood factors. This offers a very practical working hypo- thesis to the clinician ; for it leads him logi- cally to his most important measures for treatment, namely, physiologic rest, and the eradication of infective foci. * Diagnosis There is one and only one indisputable method of accurate diagnosis ; and that is di- rect visualization of the ulcer by the surgeon or pathologist at operation or at autopsy. These gentlemen maintain a certain Presby- terian smugness on this question of diagnosis, because they are so sure of their position as the final arbiters. Nevertheless, the prac- titioner must do the best he can to determine, as nearly as may be, an accurate diagnosis for the patient who he hopes will come neither to operating nor autopsy table ; and it is as- sumed that this discussion deals with the earlier and more benign stages of ulcer, and not with lethal or near lethal conditions. Prior to and apart from either of these re- grettable procedures the nearest approach to accuracy is that of the roentgenologic demon- stration of a constant niche on the outline of either stomach or duodenum. If the roentgen- ologist is not happy in his choice of angle at which the films are exposed, or if he is impa- tient, or if he just does not happen, with all *A very complete resume of the various theories of etiology and pathogenesis of ulcer appears in The Medical Clinics of North America for Septem- ber 1930 — by Held and Goldbloom, of Beth Israel Hospital, N. Y. Beyond its value as a review, how- ever, it leads nowhere; and it is felt that the theories outlined above are the most practical and therefore constructive. his care and skill, to show the ulcer in outline, he will miss this demonstration of its presence. But to show a niche on a single film does not constitute a diagnosis. That evidence should be the same on 2 or more films taken at appre- ciable intervals. If it is present on more than one of several films taken minutes — not sec- onds— apart, it means something. The niche of ulcer may be simulated on a single film, or on successive films taken within a few sec- onds of each other, by the vagaries of peri- staltic action combined with an adhesion on the peritoneal surface ; and with niches that are not deep and pronounced this is a most con- fusing diagnostic factor, and failure at proper interpretation may destroy the differentiation between ulcer and gall-bladder disease. A constant incisura only indicates some irritative lesion in the gastro-intestinal wall ahead of it; and while that lesion is most commonly ulcer, because ulcer is the common condition, yet it may be due to cancer, or to gall-bladder dis- ease. A 6-hour retention in the stomach ex- presses much the same thing, and, while us- ually due to ulcer, may be caused by other obstructive lesions. Hyperperistalsis must be interpreted with due regard for the physiology of the gastro-intestinal tract, and the reasons why such a phenomenon presents itself. Ulcer is not its sole cause. It is an evidence either of irritation or of obstruction. Turning to other laboratory aids there is but little that is helpful ; nothing that is pathog- nomonic. Urinalysis may be dismissed with- out comment. Blood chemistry offers no help. The white cell count may reveal evidence of a chronic infective process — nothing else — but it is of importance in that a leukocytosis or poly- nuclear increase should emphasize the need of a search for focal infection ; and, without either leukocytosis or polynuclear increase, an abnormal number of immature forms of polvnuclears is in itself an index of chronic infection. The red cell count may demon- strate an anemia, suggesting seepage of blood from an ulcerated surface ; and, if it can- not be satisfactorily accounted for otherwise, may prove an important finding. Examination of the stools for occult blood is valuable, and should be a routine procedure. If care be taken, a positive test for occult blood should April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 347 be regarded as abnormal and its significance carefully weighed, especially if accompanied by anemia of any appreciable degree. Blood, occult or gross, in the gastric content, demon- strated either in test meal or in vomitus, should be treated skeptically, remembering that it may be the result of traumatism. Gastric analysis has not proved itself anything but dis- appointing so far as the diagnosis of peptic ulcer is concerned. Hyperacidity is not a diagnostic finding in ulcer. Ryle has shown that it occurs too frequently in otherwise per- fectly normal individuals; that it occurs in too many conditions other than ulcer ; and that both hypo-acidity and normal acidity, may be demonstrated in too many ulcer pa- tients. The method is wasteful both of the physician’s time and of the patient’s money, and not worth in its results the time, discom- fort, or expense to both patient and physician that are required for its careful performance. Lastly, we must consider the diagnostic data obtained by the clinician himself ; and as a matter of fact these should be the most im- portant of all. Upon his intellectual capacity, his ability to gather and weigh evidence, his genius for correlation of all the facts pre- sented by his own investigation and that of his laboratory and x-ray helpers, depends the welfare of his patient. He has before him a question fundamentally of differential diag- nosis. Periodic pain is an evidence probably of tonic over-contraction of the gastric muscu- lature. It may occur as a result of lesion in the stomach or outside it. It may be due to toxic substances such as those from excessive use of tobacco, or from bacterial action, as in tuberculosis and focal infections. It may be an evidence of gall-bladder or appendix disease quite as truly as of ulcer. All these and many other conditions the clinician must keep in mind, carefully gather his bits of evidence, and evaluate them from every possible angle. There may be a fair certainty of ulcer ; but before it is written down and treatment be- gun, is there reasonable assurance that it is not an appendix, that it is not gall-bladder dis- ease, that it is not due to excessive smoking, that there is no chronic infection, or any other of the conditions which may reflexly or di- rectly give rise to gastrospasm? The same statement applies even more forci- bly to the symptom of hyperacidity or acid dyspepsia. While that symptom appears fre- quently with ulcer, it is also part of the symp- tom complex of other disorders, and must be regarded diagnostically with more than the proverbial grain of salt. The need for care- ful differential diagnosis was indicated in a recent experience of analyzing 255 of our own cases which presented these symptoms. Vomiting of blood is strongly suspicious, but may occur in cancer, blood dyscrasias, cir- rhosis of the liver, and is said to occur in chronic appendicitis. Tenderness in the epigastrium may be pres- ent in any case which exhibits periodic pain or an excessive acid dyspepsia. Rigidity is a sign of ulcer near perforation, or at any rate of a near surgical condition. Conclusions. The serviceable diagnostic criteria may then be summarized as follows : (1) Niche on x-ray examination. (2) Incisura on x-ray examination. (3) 6-hour gastric retention. (4) Hyperperistalsis. (5) Secondary anemia without other ex- plainable cause. (6) Occult blood in the stool. (7) History of acid dyspepsia and of peri- odic pain. (8) Vomiting of blood. (9) Tenderness in the epigastrium. (10) Rigidity in the episgastrium. (11) Exclusion of other conditions which might present the same picture in whole or in part. The first and the last mentioned would ap- pear to be the points to be especially stressed. Diagnostic criteria individually are uncer- tain, and only a careful balancing and weigh- ing of all acquirable evidence will bring satis- factory diagnostic results. In the limited time at our disposal the high spots only of this sub- ject can be touched. No effort at refinement of detail can be attempted. The purpose of this paper is served if it but indicates to the clini- cian that it is his job to diagnose ulcer; that he cannot sidestep that task nor safely or fairly shift the burden to the shoulders of the roentgenologist or the surgeon. Were diag- nosis easy we would not be discussing it. It is 348 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 the type of problem which makes medicine in- teresting and attracts men of intellect to the ranks of the profession. Dean Quinn, in a recent number of the Yale Review, concludes his essay with this sentence which is a propos of our own discussion : “The difficulties them- selves make the pursuit attractive, for its un- certainties arise from the very qualities that make it fascinating.” Tire positive Wasser- rnann, the Widal reaction, the finding of ma- larial plasmodia in the blood, are examples of a few — and they are very few — of the pathog- nomonic types of diagnosis. Were all medi- cal diagnosis on this basis it might be turned over to technicians. The fault of clinicians is that they are too often looking for short cuts to save both time and intellectual energy. This is a lazy trait and does not belong to good medical practice. The work of diagnosis in ulcer rests with the clinician and can neither be evaded nor imposed on the technical worker in laboratories and operating room. It must be assumed by the man to whom it belongs, and whether he will or no, the clinician, if he be honest, must accept his responsibilities, ad- mit if need be his own ignorance, but not try to shirk a task primarily his own. Treatment Distinctions between the management of gastric ulcer on the one hand and duodenal ulcer on the other have been attempted, and more or less satisfactorily maintained, by var- ious writers. There seems to have been work- ed out, however, no clear cut indication either way, and it is probably safest to handle all cases, in the beginning at least, according to the same definite routine. The attending physician will discover sooner or later that some departure from the routine must be made in a fair number of his cases, dependent on individual peculiarities, requirements, or reactions. The essence of medical treatment may be summed up in the one word — rest. This means primarily and always rest for the ulcerated organ ; for an era continuously in motion and constantly called upon to work or func- tion at full speed is not in an ideal condition for reparative work. Rest is essential to save time and bring about the best results, or even any results whatever. Peristalsis in the stomach can no more be made to cease en- tirely than can the cardiac beat ; but it may be reduced to a distinct minimum, first, by giving the stomach as little work to do as pos- sible, and, second, by putting the entire body at rest, and so quieting down to the lowest ebb vascular and nervous tension in stomach and intestine. To this end the first requisite is rest in bed for 1, 2, or 3 weeks according to in- dividual need; and the second a carefully regulated diet, so arranged that for a few days a bare sufficiency is allowed to keep body and soul together. This diet should be simple and given at frequent intervals; for if any amount of hunger contraction is allowed to develop it will aggravate in the gastric wall the very condition of muscular tension, to- gether with increased vascularity and activity, which it is so requisite to keep at a low level. Therefore, a temporary even though brief complete starvation is not desirable. Lenhartz, Sippey, or Von Leube dietaries may be followed exactly or with modifications arranged according to the fancy and exper- ience of the physician. These plans are all based on the reasoning outlined above; and of a dozen different physicians treating ulcer, no 2 may work out the same detail, and yet all will secure equally good results. Indeed, the same man may treat a dozen different cases with a dozen variations of his scheme. Milk and white of egg constitute the bulk of the diet for the early days ; then whole eggs are added, and gradually cereal gruels, bread and butter, cream soups, cream cheese, pureed vegetables, etc. By the end of 3 or 4 weeks the patient should be on a diet which in qual- ity and quantity will suffice him daily for the ensuing year. It will be noted on inspection of these var- ious dietaries that the essential element is ex- clusion of anything which cannot be readily broken up in the stomach or is not easily soluble. There is no roughage or indigestible residue. This is for 2 reasons : first, that by giving things easy of digestion the stomach has less work to do ; second, that scratchy foods may unduly irritate or mechanically injure the gastric mucosa. The second is a poor reason, April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 349 but the first is probably good — to save the stomach from being over-worked and its re- sistance therefore lowered. So much for dietetic principles. What of drugs? They play a minor but important role. Alkalies alone or combined with bismuth may be given before or after every feeding or in relation to alternate feedings only. A powder of heavy oxide of magnesia gr. 10, bismuth subnitrate gr. 5, and saccharum lactis gr. 5, 3 or 4 times a day is very useful. It is usually given after meals, but one sometimes finds the patient likes it better when given just before the feeding. This powder apparently controls the sour taste and heart-burn, alleviates the pain to a considerable extent, checks formation of gas, and keeps the bowels open. Tincture belladonna may be given in 5 or 10 gtt. dose with each powder, and probably does much to relax the gastrospasm which is perhaps the great pain producing factor in ulcer. There is little or no place for any other drugs in the routine handling of these cases. Some pa- tients who are definitely hypothyroid are slow in healing ulcer, and their reparative processes will be hastened by judicious feeding of thy- roid up to their metabolic needs. Alcohol is a distinct irritant to an ulcerated mucosa and must be rigidly excluded. Tobacco, through the effect of nicotin on the vagus, excites gas- trospasm and is best discarded for the time being. An ice bag to the epigastrium may alleviate pain and tenderness. Some patients find it soothing. Others prefer not to be bothered with it. Rest in bed with bathroom privileges should be enforced for at least 2 weeks, or until pain has disappeared. This is especially requisite •during the first week when the intake is low, running from 1000 to 1500 calories, and is not sufficient to admit of any unnecessary ac- tivity without dangerous loss of vitality and great over-draft on reserve strength. Again, and it cannot be insisted on too often, bodily rest will secure greater rest for the stomach, and the more completely the stomach is quieted the sooner and more readily will the diseased area be restored to normal. Such is the general scheme of medical care of ulcer, and it will suffice for the largest num- ber of patients. It is highly probable that, treated in this manner, the ulcer which reacts favorably is well started on its way to healing in 10 days or 2 weeks ; certainly deep niches into which the end of a lead pencil might be thrust in. or more show nothing to mark their site when filmed at the end of 2 or 3 months, and the smaller erosions perhaps heal in a very short time, almost comparable to the aphthous ulcers one sees in the mouth. Confusion comes occasionally in the second or third week of treatment when the patient begins to complain of returning pain. Inquiry may show that it is rather different from the former pain — not definitely periodic, but sharper in character, and located lower in the abdomen. This is probably due to the mag- nesia, which may be cut down or stopped for 24-48 hours, when the pain disappears. Re- currence of real hunger pain, as the patient’s diet is more extended, is not uncommon. It is probably due to slow healing of the ulcer, or to recrudescence, and is simply met by a re- turn to first principles, and working the diet up again from the beginning. Inability to handle milk or eggs sometimes causes trouble. Substitution of malted milk, cocoa, or butter- milk will usually relieve the situation. If the bowels do not keep satisfactorily open, a daily enema is used. There are certain intractable cases, and some of the cases with hemorrhage, which are best handled by passing a duodenal tube and leaving it in situ for a period of 1-3 weeks, feeding peptonized milk and eggs through the tube at 2 hr. intervals. A longer period in bed is necessary for this type of patient. And finally there is the case which relapses persistently ; or shows no tendency whatever to heal ; or which bleeds persistently ; and for this the answer must be supplied by the sur- geon. Perforation and definite organic ob- struction at the pylorus are, of course, sur- gical as soon as diagnosed. How to prevent recurrence? No one knows the true answer to this question but a care- fully restricted diet for 1 or 2 years is essen- 350 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 tial, and as soon as the patient is around and on his feet after the preliminary rest period, all infective foci must be searched out and so far as possible eradicated. If there is anything in the theory of bacterial influence in this dis- ease; if there is any reasonable analogy from other conditions f amiliarily associated with focal infection ; a house-cleaning of bad teeth, sinuses, tonsils, etc., is in order for every pa- tient who has had ulcer. ANNUAL CONVENTION Medical Society of New Jersey Asbury Park, June 3*5 Are you preparing to attend the 165th Annual Meeting of your State Society? We hope to publish, as usual, in the May Jour- nal, a complete program. Meanwhile, accept our assurance that it will be attractive, and make your reservation for self and family — for the Woman’s Auxiliary is making enticing plans for your wife or nearest female relative — at the Berkeley-Car- teret Hotel. Our confreres in Monmouth County, collectively and individually, are striving to make the Asbury Park convention a big success. Give them your loyal support. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 351 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J. Entered at the post office at Orange, N. J., as second-class matter PUBLICATION COMMITTEE HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J. EDITOR: HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J. Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact. NOTE. — The transaction of business will be expedited, and prompt attention secured if: All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to The Editor, Atlantic City, N. J. t All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements, or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication Committee, (address above), Newark, N. J. DOCTORS ARE “EASY MARKS”! At the very moment when we were de- nouncing the American Tobacco Company for broadcasting the statement that more than 20,- 000 physicians had signed endorsements of Lucky Strike cigarettes ; and while we were expressing doubt that so large a number could have “fallen for” the method employed to se- cure their signatures — and doubt whether any ever signed the phrase alleged (that Luckies .are less irritant to the throat than other cigar- ettes) ; some of our own state society mem- bers were doing their level best to prove that even physicians of considerable experience with public affairs can be induced to sign most anything. The Atlantic City Daily Press, of February 2, 1931, carried a quarter-page advertisement of a certain cigar, and the central feature of that “ad” is a letter signed by one of the best known city health officers of the state. A few days later the Newark Evening News con- tained a similar advertisement with a similarly featured letter signed by another equally well known city health officer. These special let- ter advertisements have appeared in other newspapers inside and outside of this state, and each of them so far observed says that almost 57 varieties of health officers have furnished the tobacco company with such let- ters. The advertisements referred to not only publish the health officer’s letter but they make the most of his official position by displaying in large type headlines, his name, title and location ; disclosing very clearly what the ad- vertising company was after and to what it attributed any value his testimonial might have. The letters, themselves, are worth reading by any one interested in advertising methods or in medical and business ethics. In the first place it will be noted that each letter contains a clause — we suspect dictated by the com- pany’s agent — designed to relieve the com- pany of any responsibility for publishing the signer’s opinion ; “any use you may care to make of this letter will be agreeable to me”, is a phrase that must have been supplied by the company, for it could not possibly have originated spontaneously in the minds of more than 50 letter writers in different parts of the country. That last sentence in each letter — even though it is varied slightly — not only justifies the above mentioned suspicion; it even arouses our suspicions as to authorship of other portions of those letters. Did the doctors really write the letters, or did they merely sign — on the line — letters presented to them? Not that the answer matters; they made themselves responsible for the letters, in either event, but an answer might contribute something toward a determination of just how “easy” they were. It is difficult to assume that these health officers independently constructed and volun- tarily submitted the letters to the cigar com- pany or its advertising agency, but let tis try to adopt that assumption and read their let- 352 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 ters in that light. The naivete exhibited — of purpose and phraseology — will certainly en- tertain you. Each congratulates the company upon its noble health crusade or commends the company for conducting a war against pos- sible infection from spit. One such letter we have seen actually becomes rather slobbery in its effusive endorsement. The combination of health officers and cigar manufacturers threatens to annihilate the “friends of spit’’, whoever they may be. Well, a crusade by a tobacco selling company against spit and spit- ting would surely be another noble experi- ment, and would possibly be deserving of com- mendation by those doctors were it not for the fact that a moron confronted by the con- ditions existing when the letters were signed could scarcely have avoided noting that the company was not half so much interested in protecting the health of smokers as in having the letters convey to the public the impression that all other cigars than this one brand are manufactured in a filthy manner. That is the proposition those men actually signed ; that is the object of the advertisements in which their letters are embodied. Is it possible they were so simple minded as to suspect no ulterior purpose — so innocent as to believe this cigar advertising campaign to be a public health crusade ? The following Associated Press item ap- peared in newspapers all over the United States on February 16: • "Cigarette Advertising Assailed. Washington, February 15, (AP). — In an editorial in its weekly clip sheet attacking the ‘tobacco companies’, the Methodist Episcopal Board of Temperance con- demned the creation of an ‘impression that the use of cigarettes by youftg women is socially nec- essary’, and the testimony ‘bought’ from physi- cians and others concerning the effects of tobacco.’’ We submit that this is not a nice thing to have said about our profession ; especially as we are compelled to admit that technically the charge is true. The physicians who signed cigarette or cigar testimonials probably did not realize that they were being bought, but the company probably felt it was paving for the act when delivering to the signers a car- ton of cigarettes or a few cigars ; incidentally, a pitifully small price considering the use made of the testimonials. THE PHYSICIAN AN IDEALIST At a time when the medical profession is being “knocked” on every side and the honest physician hesitates to open any monthly magazine lest he shall be greeted by another printed attack upon himself or his confreres, it is interesting to run across words of praise from an unexpected source. The Bulletin of the Medical and Chirurgical Faculty of Mary- land (the Maryland State Medical Society) for March contained a short article setting forth the views of a distinguished trainer of college athletes, Knute Rockne, who has had contact with thousands of young men at the age when they are making choice of a career. As stated bv the Bulletin, his observations and bis philosophy are not only refreshing but they should carry weight. In tracing the career of one of his former gridiron stars, who had elected to study medi- cine, he said : “No other profession is nearly so exacting. I have been wondering what makes young men want to go into the prac- tice of medicine with all its grief, endless hours, long preparation and what not. It has been my observation that the good doctors have a sort of spark in their eyes, whereas many other professions interest men from the? standpoint of monetary reward, easy liveli- hood, soft berth, prestige or a stepping-stone to something else. This can never be said of medicine. Medicine apparently is all-absorb- ing and occupies all of a man’s wakeful mo- ments, and even some of the others. I have tried to analyze some successful doctors and I find that all of them have personality, abil- ity, honesty, capacity for work, a burning zeal toward perfection in their chosen specialty, and intense responsibility regarding the human lives they are taking care of.” STATE MEDICINE In the February Journal we published an interesting original article by Dr. Haigh, of Worcester, Massachusetts, author of the Bill presented to the legislature of that state pro- posing the establishment of state medicine on a plan modeled from that in use by the United States Navy; an article in which Dr. Haigh succinctly explains why he thinks some form April, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 353 of state control of medical practice is inevit- able and why he considers the Navy Medical Corps a suitable model for adoption. In the March Journal we presented, in the course of a “travel talk”, a summary of the British National Health Insurance Law, and our impressions with respect to its working, together with an explanation of a new propo- sition recently made by the British Medical Association for extension of that law — state medicine in its complete form — to the entire population. This month, again in the “travel” article, we have described what is so far known of the new law which took effect in France so recently as July last. Also, in this month’s Collateral Reading Department, we have told what little accurate information we have con- cerning Soviet control of medicine in Russia. We have in hand several documents from Canadian provinces yet to he abstracted for publication, and we hope to digest that for our readers next month. As stated elsewhere, and upon other occasions, the object in publishing this ma- terial is that members of this society may have ready access to facts concerning the ex- istence of and progress being made by state medicine. Within the past month, a Bill has been introduced into the New York State Legislature that would provide for com- pulsory health, accident, life and unemploy- ment insurance and old age pensions ; an ex- pansive combination. The day is certain to come when New Jersey will have such legisla- tion to consider. Let us be well informed and prepared to meet the situation in a proper manner. PERSONAL INTEREST AND ACTIVITY Spring is in the air and the time approaches when state and national medical associations command attention. Throughout the autumn and winter months county societies have held sway and the Journal has not only published accurate reports of their proceedings but has served as an additional medium for providing information — scientific and general — concern- ing matters of special import to medical prac- titioners. The county society is the basic unit of medical organization. The state society constitutes the forum where all the county representatives may meet for conference with a view to effecting concerted, unified action upon important problems. During the past, or rapidly passing, year our members have been supplied with a vast amount of informa- tion relating to economic problems with which organized medicine at present has to deal. In all probability, some of those questions will be discussed, possibly acted upon, at the state so- ciety meeting in June. Possibly because that thought was in mind we were impressed by an editorial in the Ohio State Medical Journal for November 1930, and we quote it for your consideration : “Frequent inventories are advocated by leaders in industry and business as quite nec- essary to the continued life and well-being of any business ; as a practical method of keep- ing the concern economically sound. The same procedure might well be followed by members of the medical profession, de- clares the Bulletin of the Medical Society of Milwaukee County (Wis.), to determine, if possible, to what extent each member may be responsible for some of the conditions which now exist in the medical field. The Milwaukee Bulletin suggests that each physician ask himself the following questions in attempting to analyze just how much he has, or has not, contributed to his profession and to organized medicine : (1) Have I cooperated with my fellow practitioners as I should, or. do I criticize them when the opportunity presents itself ? (2) Flave I given serious thought to the activities of the County Medical Society, and organized medicine as a whole? (3) Have I offered a constructive thought in the cause of medicine, or do I resort to carping and useless criticism? (4) Have I taken proper interest in pub- lic health and preventive medicine? (5) Flave I cultivated the vision which embraces public welfare and sees beyond the present, and includes the possibilities of the future?” 354 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 Special Article MEDICAL TRAVEL TALK A Physician’s Vacation in Ireland, England and France Henry O. Reik, M.D., (Continued from March Journal) Most of our journeying through Ireland, Wales and Northern England had been ac- companied by cool and rainy weather, but in London we encountered a heat wave, and we sought relief on a terrifically hot day, August 29, by proceeding onward to Paris. The Golden Arrow Express, which has been op- erating between London and Paris, by way of Dover-Calais, with a special boat service, for the past 3 years, is about “the last word” in luxury, speed and comfort. Americans are accustomed to boast of their own railroads and special trains but we could profit by an honest appraisal of English, French and Ger- man railroads and by adoption of their best features. In general, our service compares fa- vorably with that of Europe, but in some re- spects Europe leads us — and that is particu- larly true in relation to comfort. The Golden Arrow (Fleche d’Or, in French) just re- ferred to, the Oriental Express from Paris through to Constantinople, and the new Ger- man-equipped train that starts in Holland, at Rotterdam, and runs down through France to Switzerland and thence eastward, are all superior in beauty of construction, luxurious equipment and travel comforts, to any trains in the United States. Some of you may be surprised to learn that we no longer hold even the speed record. That is a record which we need not worry over, but as we boast of our speed in most things it seems odd that this particular blue ribbon should have been al- lowed to pass along to others ; yet, the fastest train in the world is said to be the “rapide” from Paris to Bordeaux, and the longest dis- tance nonstop run (393 miles) is made by the Flying Scotsman connecting London with Edinburgh in 8j4 hours. On this particular occasion we lingered in Paris but a few days — only long enough to arrange for an autobus trip through Brittany — and September 8 found us at Vannes ready to start upon a tour of that quaint portion of France. On the way to Vannes we had paid short visits to Rennes and Josselin; the lat- ter an ideal place for acquiring the proper “background”, the proper “state of mind”, for absorbing medieval history. To reach Josselin we had to make use of both modern and ancient types of transportation: a fast express from Paris to Rennes, passing through the beautiful “granary of France” ; a local, “way train” (omnibus, as the French call it) to Ploermel ; a typical “Toonerville jerk- water”, drawn by a small, wood-burning en- gine, upon a narrow guage track, traversing a beautifully forested country; and, finally, on our own feet from the station, situated upon the edge of the old fortified town, to the hotel about an eighth of a mile away, and all of it up-hill, in the center of the town, facing the old cathedral, close beside the castle. But, having arrived, we felt repaid for all the trouble and exertion ; we had been miracu- lously, as it were, lifted out of modernity and set down in the midst of medievalism. Our guide book furnished the information that: “The superb castle of Josselin, compar- able to nothing else so much as Warwick Castle, in England, was founded about the year 1008, on a site very defensible and very holy; for more than 3 centuries it was a pil- grimage shrine of great sanctity and renown.” We found the castle still an imposing and fascinating institution, whether viewed from across the river or from inside its enclosure, and the town is still the focal point of great religious pilgrimages; one of the most in- teresting being those curiously picturesque “Breton Pardons” which have been held an- nually, unchanged in character, for several hundred years. Clara Laughlin describes such celebrations, as follows: “Usually a pardon has 3 phases: the eve ; the religious ceremony ; and the merrymaking. The eve is devoted to confes- sion and prayer, the pilgrims flocking in from every direction. They come bareheaded, bare- footed, and usually fasting, followed by crowds of the lame, the halt, and the blind. There is a sermon, drinking at the holy well or other miraculous source, and a torchlight proces- sion. Next day there is the ceremony which is the distinctive feature of that special par- don— the blessing of the sea, of the boats, of the cattle, or whatever it may be — followed by the procession wherein every one wears the rich, picturesque costumes that have been handed down for generations and are kept stored in old carved chests, except on such occasions as these. And in the afternoon there is a fair, followed by dancing and drink- ing and courting.” We were not so fortunate as to be there on Josselin’s greatest feast day but a similar event of lesser importance was held on the Sunday morning succeeding to our arrival on Saturday evening and we had full opportunity to enjoy our first observation of the quaint April, 1531 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 355 dress and customs of the Bretons. Armed with Kodak and Filmo, we began at once to acquire snapshots and movies of people, events and dress entirely new to our experience. Of the castle much might be said but we must be content to locate it in your memory cells by recalling some historic events with which it was connected. It was from here that Jean de Beaumanoir issued his challenge to the English which resulted in the famous Battle of Thirty — 30 knights on each side to meet on a certain Saturday in March 1351 and settle their disputes by mortal combat. The opposing forces met between Ploermel and Josselin, at a point still marked by a cross and pyramid, and of the 30 Bretons only 3 Avere slain, while the English suffered a loss of 12 on the field and those left alive had to beg for quarter and accept imprisonment in the castle at Josselin. The glory was all to Beaumanoir, but he was seriously wounded and it was not long thereafter when the great Olivier de Clisson married his widow and be- came master of this castle, reigning there until 1407 and his remains resting now in the neighboring church. “His son-in-law and suc- cessor began the transformation of the for- tress into the most elegant residence in all Brittany. And through the courtesy of the widowed chatelaine, the Duchesse de Rohan, mother of the little Duke, we are permitted to visit the castle. A fine old servitor, burst- ing with pride in the great lineage and the true noblesse of the family he is attached to, shows us the imposing dining-room with the great equestrian statue of Olivier de Clisson, done by Fremiet; the salon, with its superb mantelpiece ; the library, with the table where- on the edict of Nantes was signed. The rever- ent guide will show us a photograph of the late Duke, killed in the Great War; and perhaps one of the young lad who now bears the title. It may be that we shall catch a glimpse of the duchess, in her garden, writing letters or read- ing. (We did see her, quite by accident, Sun- day, September 7, in the morning sitting in the shade of a tree knitting, and in the after- noon leaving the grounds for a drive.) Her mother-in-law, who died in the early part of this year wherein I write, was a great lady of many distinctions; her salon in Paris was one of the most distinguished, of recent years, and her ardent interest in the arts is carried on by her daughter, Princess Murat, whose little art exhibition and tea room you have probably visited in Paris — on the Ouai d'Horloge and Place Dauphine, where Manon Roland grew no. Few of the great old feudal names of France are more familiar in American and English ears than that of Rohan.” With the kindly aid of the hotel proprie- tress— who would not permit an imposition upon her guests, but insisted on the garage man fixing a fair fee (considerably less than his first named price) for the trip — we were driven Sunday afternoon, in an ancient Ford car much worse worn than the Eleventh Cen- tury Castle, 20 miles to Vannes where our real Brittany trip was to commence next morning. But, in that glorious country one is constantly meeting surprises, and that Sunday afternoon we arrived in Vannes just in time to witness its annual festival and church parade in honor of St. Vincent ; an impressive eA^ent which Ave were fortunate enough to record on the film of our small moving picture camera. It would take up too much space to tell you all the joys of our trip through Brittany, joys 1. Menhirs — Ancient Memorial Stones at Carnac. 356 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 about which we have reminisced many times since and of which we do not tire talking; so, we shall have to confine our ravings here to the “high spots”, after expressing a general summary in the single statement that any traveler can find entertainment, instruction and pleasure in that arcadian area. The arche- ologist, the historian, the antiquarian, the humanitarian, or just the plain tourist, will secure incentive for research and happiness in his findings. The Bretons are a simple, honest folk who learned centuries ago a satis- factory philosophy of life and they do not disturb themselves today to chase after false gods. Just one example will illustrate our meaning. Brittany (Bretagne, in French) is that sec- tion of France which projects into the Atlantic Ocean, in the form of a peninsula, from the northwestern corner of the country, with the English Channel bathing its northern shore and the Bay of Biscay on the south. Some of you who served in the A. E. F. will re- member it well because of having disembarked or reembarked at the port of Brest ; and if you spent any time in the “rest camp” of Pon- tanezan Barracks just outside that city you will recall that because of the geographic lo- cation it rains there during some portion of nearly every day— no matter which way the wind blows. France is divided into, or is composed of, Departments, just as our own nation is composed of States. Bretagne is the ancient name for that portion of French ter- ritory which comprises present political depart- ments of Finistere, Morbihan and the Cotes- du-Nord. The total area of Brittany is ap- proximately that of our state — New Jersey— and the city of Brest, on the extreme western boundary, is less than 500 miles from Paris. Now, remember that Paris has been for many centuries the fashion center of the world, and that the great mass of so-called civilised people of Europe, Asia, Africa, North and South America follow the dictates of the Parisian dressmakers and milliners ; and yet, Brittany — French to the core, and located at the very door of Paris — has re- mained through all these centuries unaffected by the changing styles in dress. When “dressed up" the men wear black velvet coats ornamented with silver buttons, knee breeches, long stockings, silver-buckled shoes, and flat derby hats with long silk ribbon streamers hanging down their backs. The women, too, still adorn themselves in the ancient cos- tumes of black silk dress and starched white linen caps ; and it is said that if familiar with the variations in shape and form of these caps you can tell from what portion of Brittany — even from what parish — the wearer comes. How sensible ! Costumes that meet all the essential requirements: comfort, beauty, util- ity, economy. Clothes are worn so long as they remain presentable ; not cast aside be- cause some arbiter of fashion has decreed a change ; and the fascinating linen or lace caps are washed and ironed and utilized for an in- definite period of time, instead of being thrown away because the seasonal calendar lias moved from spring to summer. In our opinion they show more sense than those of us who deem it necessary to change hats and dresses as rapidly as new styles can be de- \ ised. Do not imagine that because these people adhere to the old style costumes they are “backward” in all respects. You will find that they live well, know how to use telephones, radios and automobiles, make use of modern machinery, and are fully awake in the trans- action of business. They simply follow the excellent advice given bv St. Paul — “Try all things, and hold fast to that which is good.” We sincerely wish our own people would emulate the example. And, if you doubt whether a people living so simply can still produce virile physical specimens and gigan- tic intellects, remind yourselves that Foch and Clemenceau both belonged to Finistere and were duly proud of the fact. On the circular tour we kept close to the coast-line so as to observe the world-famous sardine fishery ports on the south shore, the rugged, x'ock-bound, western shore, and the summer resorts and bathing beaches strung along the north coast all the way to Mont St. Michel ; running inland occasionally to visit the renowned cathedrals and “calvaries”, some of which date back to the eleventh, tenth and even the eighth century. Among the many curiosities and artistic monuments encounter- ed were the menhirs (Fig. 1.) (tall single stones) and dolmens (huge, flat, table-like ar- rangements) to be seen on the first day at Carnac ; acres of otherwise barren land cov- ered by stones (some of enormous size), more or less regularly distributed, as if this may have been an ancient tribal burying ground. Of prehistoric origin, these orderly collections of monoliths have been discovered in various parts of the world and we had on this very trip already seen similar specimens in Ire- land. Concarneau and Douarnenez are the chief French ports for collection, canning and dis- tribution of sardines, and we had the good fortune to arrive at each port just as the fishing fleet was coming home — one of the most picturesque scenes imaginable. The boats are not unlike our own fishing smacks as to size and shape, carrying 1 or 2 masts and April, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 357 sometimes equipped with gasoline engines, but the appearance of the fleet is quite distinctive and far more beautiful because of the colored sails and nets. The net used for sardines is naturally of very small mesh, and it is colored sky blue to match the deep sea water, ren- dering it less easily distinguishable when im- mersed, and thus to fool the fish. The sails are stained by a coating of ochre dissolved, or suspended, in gasoline ; the sail-cloth being spread upon the ground, a bucket of paint is sloshed upon it and spread over the surface rapidly by a workman with the aid of a broom ; the oily mixture soaks into the canvas and the excess of oil evaporates, leaving its stain. The result is sails that vary in color from light or- ange to red-brown, and when the boats come will further recall, an Italian salvage crew was successful in locating the sunken gold and its divers had so far advanced the work of rescuing the money as to be hauling up the safe in which it was deposited, when a new storm intervened, destroyed all the care- fully developed plans and works, and drove them from the scene; leaving the golden for- tune still somewhere in Davy Jones’ locker. We were, naturally, greatly interested in read- ing about that storm because it occurred only a week after our visit to that coast. The ter- rible damage done by such storms, the terrific loss of life they impose upon the fishing fleet, and the sorrows inflicted upon the women and children of fishermen's families, were forcibly brought to our attention at the time. At 2. Sardine Fleet at anchor at Douarnenez. into harbor with nets hanging from the masts and booms to dry, and sails spread with a background of sky and the setting sun, a picture is produced that will long be remem- bered. From Quimper we made a side trip to Pointe-du-Raz, a wild, rocky promontory of the western coast which is the bane of all sailors and deep sea fishermen compelled to navigate that section of the Atlantic Ocean. As a means of locating it for you, we may re- mind you that it was in this vicinity that the British ship sank, during the World War, with $5,000,000 in gold coin locked in her coffers ; and, also, that it was at a lighthouse upon one of the many dangerous rock islands off this coast that the lightkeeper and his as- sistant were practically marooned for 60 days in the winter of 1929-30 because continuous stormy weather prevented any boats approach- ing the spot with supplies. Last year, you Douarnenez we had commented upon, and taken pictures of, the womenfolk — some with babes in arms and older children playing around them — sitting in groups on the piers, industriously engaged in knitting and gossip while awaiting return of their husbands and lovers with the sardine fleet. One week later a terrific storm suddenly arose, demolished a score of boats upon the rocks and took a heavy toll of human lives. We could men- tally picture those same groups of women and children weeping, pathetically scanning the horizon for signs of their particular boats, praying for the return of husbands, lovers and fathers who would never be seen again upon this earth ; and memory reverted to that touching poem — “For men must work and women must weep." The castles, cathedrals, religious monuments and ceremonies to be visited or witnessed on such a tour are numerous and of great inter- 358 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 est. The records of historic characters beset one on every hand. At Saint-Malo we slept and ate in a hotel one section of which was once the home of Chateaubriand. At Treguier we could pay our respects to the birth-place of Ernest Renan and inspect the room where he wrote some parts of his Life of Jesus; and an excellent statue of him stands today in the public square. Returned to Paris, we made it our business to inquire into the new National Health In- surance Law which had just become effective on July first. Because the law is so new and only beginning to come into effect, we cannot make for you an analysis of conditions com- parable to that we made last month for Eng- land. We can only present at this time a brief abstract of the French law, setting forth the main features of interest. In France, even more markedly than in England, the government has been for the past 20 years under control of the labor party or of political parties having a strong social- istic leaning, and the very natural effort to enact legislation of this character has pro- gressed slowly but steadily until the law reached its present form. Also, in France as in England, the medical profession has fought an obstinate, losing battle. Although the law, as finally promulgated, was modified at the behest of the profession, it is by no means satisfactory and there is much complaining on the part of practicing physicians and very little evidence as yet of an inclination to co- operate or even to submit gracefully. In ad- dition to the orthodox form of organization for scientific discussions, the medical profes- sion in France is organized into “syndicats” — on a basis similar to labor unions — for deal- ing with the government and with economic problems in general. In consequence, it is the Syndicats Medicate , rather than the Academy of Medicine, that engage in the con- troversy and that enter into contract for medi- cal service to those insured under the health law, or — Loi sur les Assurances Sociales. The insurance law is applied compulsorily to all employees, of both sexes, less than 60 years of age who earn not more than $600 per annum ; to any employee having 1 depend- ent child and whose salary does not exceed $680 — or $800 if living in a city of more than 200,000 inhabitants; to any employee having 2 dependent children, and whose salary does not exceed $760 — or $880 if in a city of more than 200,000 population ; to any employee hav- ing 3 or more dependent children, whose in- come does not surpass $1000 — without regard to distinction of locality. Such insurance is available to, but not compulsory to, children who perform salaried work not forbidden by law ; children who work at home without spe- cific salary but for the benefit of the family ; and, all members of the family of an agricul- tural worker so long as they work and live with him without receiving remuneration in money. In order to become compulsorily insured it is necessary to be salaried. The earning capac- ity of the optionally insured, with reference to insurability, is measured by the same scale as given for the compulsory classes. The insured person chooses his assessment according to the benefits he wishes to obtain, but this may not exceed 10% of his annual salary nor be less than $9.60 per annum ex- cept where he desires only to cover the old age pension provision, when the low figure is $4.80 a year. The insurance fund is used to provide for medical attention during illness, for absence from work on account of disa- bility resulting from sickness, for a maternity period commencing 6 weeks prior to delivery and continuing until the mother is restored to normal health, and, for old age pensions - — health benefits terminating and pensions be- ginning at the age of 60. There is special provision for optional insurance of non- salaried wives of compulsorily insured men, and for women who may become widowed or divorced. There are also special rulings ap- plicable to veterans of the World War, with special reference to other aid they may be receiving in the nature of medical care or disability pensions ; in other words, the “law of social insurance” is coordinated with pre- viously enacted laws for medical assistance, maternity aid, free service to ex-soldiers and pensions. Sickness insurance covers all forms of ill- ness— without distinction between accidents and so-called natural causes — surgical opera- tions, dentistry, and even care at thermal baths and “spas” when considered indispens- able. If the patient is to be treated at home, he has “freedom of choice of doctor, surgeon, specialist, dentist, druggist or midwife, under the sole condition that the attendant selected shall be properly qualified”. The patient who must be hospitalized has free choice of the institution he will enter but thereafter is sub- ject to the qualified members of the staff of that establishment. All legally qualified prac- titioners of medicine in France may enroll for insurance practice but no physician is com- pelled to accept such service, save in so far as common decency would dictate in cases of emergency. As in Great Britain, negotiations between the insured, the physicians and hos- pitals, and the government are carried on chiefly through insurance companies ; the in- sured selecting the “association” with which he desires to be affiliated, with the sole limita- April, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 359 tion that it must be an association doing busi- ness in the local section or department where he is employed ; and, such an association may be formed by spontaneous grouping of in- sured persons. There is a council of admin- istration to supervise the insurance associa- tions, composed of 18 members, of whom at least 2 must be physicians elected from a list submitted by the medical profession*. General control of the insurance plan is vested in the Minister of Labor, with certain definite re- lationships to the Minister of Finance. Elaborate machinery is proposed for recording and checking reports of cases, and severe penalties are imposable for malinger- ing or false statements regarding illness or disability; advantage having been taken of ex- perience with such laws for a number of years in the section of Alsace-Lorraine. We can imagine a number of questions you would like to ask and we regret not being able to volunteer the answers now, but, as pre- viously stated, the law has been in operation for a few months only and we are not suffi- ciently wise to predict with certainty how it will work. The probabilities are that time and experience will effect some changes in the law, and that physicians will come to feel less antagonistic to the whole scheme than they have been. With this letter we terminate our report of last year’s travel observations but we may, possibly, because dealing with development of health insurance laws in other countries, sup- ply one more letter to present you with some information that has drifted into this office from Canada. Medical Ethics “WHO STEALS MY PURSE STEALS TRASH” John Hammond Bradshaw, M.D., F.A.C.S., Orange, New Jersey What is there in a name? None can say. If your name is for sale, you must know its value. It is surprising to see the low value of some appraisals. The owner is himself to blame when he holds his name too cheap. It should give us pause to think how thought- lessly and how carelessly we sometimes lend it. And like other loans, we may not get our name back ; and even when it is returned, it may be tarnished, and in that case we surely do not get it all back. Or, on the other hand, when we get it back it may be unduly in- flated or it may be polished to an undeserved lustre. In this case also the ledger shows profit and loss ; although the writing may be hidden, it is in red ink just the same. This can be true even when the name becomes a very noisy one. But, you will say, anyone can write a few abstract platitudes; they are not real facts. Let us now look at some concrete statements which are facts and are surely not falsehoods. A prominent New York City Judge blandly admits even this winter on the witness stand receiving $1000 cash for endorsing a much exploited brand of yeast. The value of this endorsement is much enhanced by its accom- panying photograph of the judge in all official robes ; the underwriting gives the name and official title. Was the price $1000 too cheap or too dear? Who knows? “Nuxated Iron” once had an extensive sale as a tonic and strengthener because it was en- dorsed by Jess Willard, the prize-fighter. We are not told how much Jess got for his name. But the advertisement fell flat (after telling the public it was the cause of Willard’s strength) when the fighter was knocked out. Possibly in this case Willard got more than his name was worth. Was it not a racket? Almost a half-score supposedly nose and throat men are now pictured in the daily press, each wearing a head mirror with not one patient in sight and the invaluable infor- mation is given that nose and throat doctors endorse a certain brand of cigarettes. Do they? Another racket? Furthermore, we are told (the voice invading even our firesides) that over 20,000 doctors endorse another brand of cigarettes because “they are toasted”. Do they? Is this still another racket? The writer with hundreds of others (per- haps thousands) received, gratis, a very large package of cigarettes from a certain manu- facturer of a popular brand with request for a written statement of the enjoyment afford- ed thereby. Did the manufacturer get it? It is flow getting almost too common to read endorsements. It is quite funny to be- lieve or ask if people are really taken in and if they think that the endorsements are given “on the merits” of the goods. Do not we know that they are given for cash or value received? All the cults have their endorsers, even by the thousands — then just consider the beauty creams and the number of patent medicines that are endorsed over the signature “it cured me”. There is no end to this, “racket” game — it pervades not only evil doers but all our mod- ern life. The spirit pervading our “modern- istic” morals, like our present day modern- istic art, is after all nothing but a racket. It is distorted, grotesque and unlovely, and we 360 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 come into the picture when we give it our own names. There is the usual trite (but true) warning ior us to avoid putting our property in jeop- ardy by our endorsements. But many an honorable name has in this way been inno- cently dishonored and much property has been lost. Pressure of friendship, social, political, and even of family influence leads us to give our name to certificates of ability or disability or of some promised benefit. This we are told will be of great benefaction if not to our- selves, to others. Even our charity is made a weakness. Hid- den away almost out of sight is some diabolic joker to keep all concerned within the law, whereas, if justice were served, the law should take its course. Esthetics CONSIDER THE DREAMERS (From the Kalends, Williams and Wilkins Co.) Behold, this dreamer cometh. And Joseph’s brothers laughed — until they were hungry. Then it was that they discovered that Joseph had all the corn — cereal, be it understood. And he had the corn because he dreamt dreams that were worth the dreaming. Be not too severe upon the dreamer, for dreams are part of all achievement. The course of our present civilization itself was charted by dreamers ; by men with clear vision and simple sincerity, who dared strive and fight in the face of all opposition with a tenacity that would not be subdued. Jesus was a dreamer, and his dreams have inspired men to heroic deeds and influenced the course of history in a manner such as no other man’s life has ever done. And* yet his dreams even today are but half interpreted. Columbus was a dreamer, but his castles were not built in Spain. Pasteur was a dreamer, but his dreams were not of gold and renown. Ah, no! The dreams of such dreamers were rooted, deep rooted, in ideals and purposes. Such dreams* and their dreamers’ achieve- ments gave the World a doctrine of hope, gave America to the world, and helped vastly to make all of the world a better place to dwell in. Sad it is, in a way, that so few dreamers live to see their dreams come true! Most of the greatest of them, as is attested by history, were halted midway between conception and realization. Life is too short, it seems, to realize many of the dreams that are worth while; the best most of us can do is to fling the torch to others, and cry the age-old chal- lenge of “Carry on” ! To many of us may and will be denied the incomparable thrill that comes with complete fulfilment of a life’s dream. Few are so for- tunate as an Edison. Yet, if we have dreamed dreams wo’rth dreaming, our dreams will not have been in vain; for we will have kindled a spark of inspiration in the hearts and minds of those who follow in our paths — our sons, our daughters,- and their children. No life, no business, no nation, and no civilization but what, after all, is built al- most entirely of the stuff that dreams are made of — ideals, intangible strivings, long- time dreams, and adherence to self-sacrificing principles, all of which must be paid for in advance with no assurance of return. Our dreams, our hopes, and our aspirations may not be, relatively, as vital as those of the mas- ter dreamers of the ages, but as individuals our dreams are no less important. While it is true that all things for us will fade into in- significance with the coming of tomorrow, it is also true that tomorrow never comes unto our children and their children until our yes- terdays are but a memory— -the stuff of dreams. Collateral Reading . SOME NEW BOOKS (Reviewed by the Editor) Having explained in our last article that Santa Claus had supplied us abundantly with reading matter for the winter evenings, it seems necessary to report at this time upon the pleasure and satisfaction already derived from those gifts. Perhaps we ought to be ashamed to say that we found ourselves reach- ing first for the smallest sized volumes in that collection, but we are delighted to report that the very smallest book proved to be' a treasure. Doctor and Patient by Francis W. Peabody. M.D. Having thoroughly enjoyed this book our- selves, we are strongly inclined to recommend it to physicians or members of physicians’ families who have occasion to make a small gift to some practitioner of medicine. The book costs but $1.50, comprises fewer than 100 pages, and consists of 4 essays written by the late Francis Peabody and collected recently April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 361 lor publication by some of his friends. As he was a distinguished physician and a well loved teacher, active practitioners will delight in the sane advice offered in these essays and the sound judgment displayed in everything that he has heretofore recorded. This group of papers deals particularly with his views upon the relation of the physician to the public, proper care of patients, interest in scientific laboratory work and the attitude of medical teachers, calling upon each such teacher to be what he indicates as “the soul of the clinic”. The last essay, alone, is worth the price of the book, as it consists in an expression of his personal views through the medium of a let- ter to his close friend. Professor Longcope, of Johns Hopkins University. Our New Progress by James Bayard Clark The second smallest book in the collection proved also to be extremely interesting though it dealt with quite another aspect of medical interest. Our new progress is essentially a study, an analysis, of the recent period of “great prosperity” and attempts to answer the question — What is our new prosperity worth and what hope for happiness and con- tentment does it hold? As most of the alleged prosperity seems to have vanished, interest in answering the question now is to be found mainly in the hope that in the future such a calamitous prosperity may be avoided. Re- viewing the effect upon different classes of society produced by the modern craze for financial success, the author makes a very hapnv reference to our profession as follows : “As civilization stands today, the profession of medicine has a great deal to do. It has, in- deed, made it possible for civilization to take on the form it now' parades in. Whether this is entirely creditable is another matter. The iact remains, however, that large cities, in- dustries, wars and commerce as they are at present conducted could not he maintained without the aid of this profession. And to its credit it has stood out pretty well against the enveloping movement of the industrial forces. It is a profession fiercely jealous of its in- dividuality, for it knows that two-thirds of its therapeutic value lies in the influence of personality. As a class it is no more inter- ested in the amassing of money than is the teaching profession. This collection of cir- cumstances has made the medical profession an exceedingly awkward segment of society for industry to embosom ; yet industry has not been without accomplishment in this re- gard, thanks to its ally, charitable endow- ments.” Having gained somewhat in strength, spiritual as well as physical, we felt able to tackle an 800 page novel with a fancy wrap- per done in red, blue, green and yellow and carrying a title that was at least intriguing. Women and Monks by Joseph Kallinikov The jacket blurb describes this book as a tremendous panorama of Russian life during the period between the years 1905 and 1917, including in the last portion of that period events attending upon the revolution. It pur- ports to reveal “the low down” on life in monasteries and convents in Russia, student life in St. Petersburg with particular refer- ence to development of revolutionary fire brands, the brutal character of life among peasants, and the effects of commencing in- dustrialism in the Russian cities. It must be admitted that, from the literary standpoint, the book is well written, but one may very well ask zvhy it was ever written. Fully 50% of the book consists in recording the licentious relationships between the monks and the women with whom they came in contact, either within or outside of the monasteries, and the similar loose life of the university students. If a small fraction of the statements herein presented be true, one may better understand the present determination of the Bolshevik Government to antagonize in every way re- ligion and religious institutions. It is highly probable that the basic factor of truth has been grossly exaggerated in the construction of a novel designed to set forth such truth. At any rate, inasmuch as the author and his backers insist upon the truthfulness of the picture written, we may accept it as in some respects measurably descriptive of conditions precedent to and conducive of the revolution that took place. And in that respect reading it helped to put us in a better position to ap- preciate the next book in the collection. Soviet Russia by William Henry Chamberlin Here we have a book that deserves to be read by every American who has any wish to know what has happened and is happening in Russia. Chamberlin was for many years, and we believe still is, an American newspaper reporter of exceptional talent stationed in Russia. He seems to know intimately the people and their language and he reviews the progress of events from the downfall of the monarchy, through the Kerensky period and establishment of the Soviet Republic, up to the commencement of 1930. We shall not at- 362 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 tempt to review the book — not even to quote from it extensively — because you will want to read it in full if you are at all interested in ascertaining what progress the Soviet has made up to date. It is by all odds the most authoritative, and the most satisfactorily writ- ten, exposition of the plans, efforts and de- gree of success attained toward the establish- ment of a government based upon and abso- lutely controlled by the proletariat — which as used here is but another name for the union of working men. One phase only shall we specifically refer to, and that because it deals with medical prac- tice under the Bolshevik Government. Regard- ing medicine we may quote from Chamberlin as follows : “Nikolai Semashko, a country doctor be- fore the Revolution, has built up an extensive socalized health service. He is especially proud of the achievements of his Commis- sariat in the field of preventive medicine, and in reducing the formerly high rate of infant mortality. ***** The Commissariat for Health plays an important role in the Soviet Union, because medical aid there has been largely transformed from a private to a pub- lic function. The Commissar for Health, N. E. Semashko, stated that during 11 months of the year 1927 a total of 49,435 workers and employees went to private hospitals as against 14,000,000 who received treatment in state hospitals and dispensaries. The worker’s av- erage expenditure for medical aid during this time was 23 kopecks (11)4 cents) most of which sum went for home medicines. During the year 1926-1927, the state spent,' on the average, 30.84 rubles ($15.42) on medical aid to each worker’s family. The Health Commissariat is inclined to take special pride in its work for the prevention of disease. At the time of the celebration of the tenth anniversary of the establishment of the Commissariat for Health, in the autumn of 1928, Dr. Semashko declared that 2000 doctors were employed in the field of protect- ing the health of children through regular physical examinations of school pupils, in- spections of the sanitary condition of the schools, encouragement of physical training, etc. A good deal has been done in the way of investigating occupational diseases of fac- tory workers, and a number of experimental sanatoriums are maintained in this connection. In medicine, in the provision of hospitals, clinics, and sanatoriums, as in so many, branches of Soviet life, one is forcibly struck by the impression of leveling. Existing accommodations are, as a rule, inferior to what wealthy or even middle class people would command before the Revolution. But work- ers and the poorer classes who could not in pre-war times have afforded to pay the fees of private doctors and hospitals now receive a much larger share of free medical attention. The health of the population as a whole seems to be better than was the case before the war, if mortality statistics represent a fair criterion. The death rate in European Russia in 1913 was 27.4 per thousand. In the European part of the Soviet Union in 1926 it was 19.9 per thousand. There has been an especially marked decline in infant mortality, due to legislation for the protection of mothers and babies. The country has also been free dur- ing recent years from the terrible scourges of cholera and typhus, although this may be due in part to the fact that these epidemics were so widespread during the period of civil war that a considerable part of the population ac- quired relative immunity through contracting the diseases.” Chamberlin refers to physicians being over-worked under the new system but gives us little information upon which to base even a guess at the effect otherwise upon the pro- fession. In Lighter Vein Breaking Up "What is the best thing to do when the brakes of one’s car give way?” asks a motoring corres- pondent. Hit something cheap. — Everybody’s Weekly. They Don’t Satisfy A New Jersey doctor says there are fewer girl sopranos since women started smoking. That’s the greatest argument we’ve heard in favor of women smoking.— -Southern Lumberman. Labor- Saver “Wouldn’t you be surprised if I gave you a check for your birthday, Henry?’? “I certainly would, dear.’’ “Well, here it is, already made out, ready for you to sign.” — Chicago News. Honk! Honk! Driver — “I wasn’t going forty miles an hour, nor thirty, nor even twenty.” Judge — “Here, steady now, or you’ll be back- ing into something!”— Rammer-Jammer. Economy Plus “Here comes the parade, and your Aunt Helen will miss it. Where is she?” “She’s up-stairs waving her hair.” “Mercy! Can’t we afford a flag?’?- — Kennebec Journal. Jamboree in the Jam Two little boys were talking. One said to the other: “Aren’t ants funny little things? They work and work, and never play.” “Oh, I don’t know about that,” replied the other. “Every time I go on a picnic they are there.”— Boston Christian Register. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OP NEW JERSEY 363 Current Events MINUTES OF THE WELFARE COMMITTEE The regularly called meeting of the Welfare Committee was held at the Hotel Stacy-Trent, Sunday, March 1, 1931; being called to order by the Chairman, Dr. A. Haines Lippincott, at 3 p. m. The following members were present: Clayton, Conaway, Costill, Dandois, Davis, Disbrow, Ely, Green, Hagerty, Haggerty, Hunter, Lee, Lippin- cott, Londrigan, McBride, McGuire, McMahon, Morrill, Morrison, Morrow, Nafey, North, Quig- ley, Schauffler, Schlichter, Sommer, Tracy, and as guests, Drs. Charles B. Kelley and Marcus W. Newcomb. Excuses were received from Drs. Don- ohoe, Haussling and Sherman. The Chairman called upon the Executive Secre- tary for the reading of his report which was pre- sented by Dr. Reik. Report of the Executive Secretary to the Welfare Committee March 1, 1931. Since we last gathered in consultation a new legislature has come into existence and we now have to consider an entirely new crop of proposed laws; a new crop, but most of the propositions growing from seeds of the same old hardy peren- nials. The procedure this year of closing the door against submission of new bills after February 10 resulted in an avalanche of documents on that date, and the Legislative Index lists 243 Senate and 429 Assembly Bills, a total of 672 propositions for new laws or amendments to existing laws. Out of this number we have culled for study 3f (14 S. and 17 A.) which, from their titles, seemed to have some possible bearing upon medical prac- tice or upon public health. We secured and have read all of these Bills and have found that 25 of them should be reported to this committee. Before taking up the Senate list, we should say that with adjournment of the General Assembly of 1930, the Abell Commission Bills, so-called, in the form originally presented, passed out of ex- istence. There was an agreement, however, that the same or similar bills should have “right of way’’ in the opening days of the new Assembly. During the interval between the Assemblies of 1930 and 1931, members of the commission and the prospective officers of the new legislature held several conferences concerning this general subject and, as a result thereof, some of the old bills now appear in modified form and some have disappeared entirely. The proposal to combine all of the pro- fessional examining and licensing boards under a bureau in the State Board of Education has been dropped; at least, for the time being. Among the recently submitted bills, S. 22 and S. 24 take the place of S. 260 and S. 262 of last year; that is, they provide for the appointment of a State Budget Commissioner, for paying into the state treasury all moneys received by government departments and agencies and for the method of appropriation of funds to be expended by such departments and agencies. The State Board of Medical Examiners is not specifically mentioned but it would appear to be covered in the provision for state commissions and boards handling dedi- cated funds. The Secretary of the Medical Ex- amining Board will probably inform you today whether this is a correct assumption. S. 63, S. 137 and A. 61 propose amendments to the Workman’s Compensation Law, and all seem worthy of endorsement; the first named attempts to clear up differences of opinion in regard to compensation for “traumatic hernia”, making the requirements more liberal; the second combines 2 existing laws, which have at times occasioned con- flict, regarding contracts for employer insurance to cover liability imposed by accidents to em- ployees; while the third extends the time iimit for filing claims. We see nothing to complain of in any of these bills. S. 147 applies to the State Health Department and is said to be for the purpose of providing local boards of health with power to control sanitary conditions beyond the minimum requirement of the general state law. S. 170 requires the use of distinctive poison labels for containers of wood alcohol or prepara- tions made up in part of wood alcohol. S. 201 seems to be a health department provision to control the importation of milk and cream into this state. S. 202 refers to manufacturers and wholesalers who supply drugs, medicines and poisons to gen- eral merchants who have no legal right to sell such articles at retail. None of this last group of 4 bills calls for ac- tion on our part. S. 161 and A. 63 relate to the hospital lien law that was passed last year. The first named would amend that law by striking out, in reference to hospitals, the words “supported in whole or in part by private charity”; the second is a new law outlining the method of procedure for release of the hospital’s lien against the patient. We have submitted these to Dr. Londrigan for an opinion. S. 186 and S. 207 have to do with laws that pro- vide for the care of war veterans. The first amends the existing law so as to permit surgeons of the United States Army, Navy or Marine Corps, or surgeons in the employ of the Veterans’ Bureau, to sign certificates of insanity for veterans uncler observation, and thus to facilitate the handling of such cases; the second provides additional con- valescent care for sick veterans upon the “recom- mendation of reputable physicians”. S. 221 is an annual registration bill for pharma- cists but includes provision for limiting use of the terms pharmacy, drug store, etc., “to places super- vised by registered pharmacists”. Assembly Bill No. 1 would make permanent the temporary commission that was provided 2 years ago to investigate the number and condition of crippled children in New Jersey, and provides that the 9 members of the commission shall consist of the Director of the State Department of Health, 1 representative from each of the organizations known as Elks, Rotarians, Kiwanians, Masons and Lions, and, “3 other citizens of the state” to be selected by the Governor. Inasmuch as this bill constitutes a commission “for the care and treat- ment of crippled children”, we suggest the ad- visability of providing for at least 1 physician in its personnel. The bill says about the com- mission: “They are empowered to inquire into and ascertain the number, distribution and condition of crippled children throughout the state, and are further authorized to provide for the care, treat- ment, education, and general welfare of such children.” A very large portion of the work of such a commission must necessarily deal with the physical and health conditions of the children, with the diagnosis, prognosis and treatment of medi- cal conditions, and yet no one seems to have thought it necessary to provide for the opinion of a trained medical man. The bill is in committee 364 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 and might be amended if you consider it wise to make that suggestion. A. 29 was introduced by Dr. Newcomb and would amend the school health laws so as to pro- vide for the physical examination of school chil- dren, by school physicians, “with the head, neck and chest exposed”, under proper conditions. The bill is on the third reading file and should be passed. A. 36 is a proposition to establish an old age pension system, limited here to those over 65 years of age and unable to support themselves or to secure support from relatives. Whether or not it is a good bill depends upon your personal opinion of socialistic movements. A. 104 and 105 determine the procedure for con- solidating 2 or more hospitals, and we are inform- ed that it is intended to apply to a situation in Newark where amalgamation of 2 institutions has become desirable; A. 160 would authorize courts of law to order, before or at the time of trial, x-ray examinations for the purpose of using the radiographs as testi- mony in cases based upon alleged injury to the person. A. 229 gives school physicians, school nurses, and school authorities (under varying conditions) the right to exclude from the class-room children in an abnormal state of health who might spread contagious or infectious diseases to other pupils. We have reserved until the last, 5 bills of more specific interest to the medical society, mainly be- cause of their bearing upon the Medical Practice Act. They are as follows; A. 370 is another at- tempt to establish a Board of Examiners to select and license barbers. This bill is without the old reference to beauty parlors, but it still authorizes barbers to “remove superfluous hairs, warts, moles or other blemishes from the scalp, face, neck or upper part of the body. We think it should be opposed on that ground, though we must say, in addition, that we see no good reason for its passage even as an attempt to make bartering a profession — as seems to be the object of its pro- moters. A. 205 is our old friend, the bill to increase the rights and privileges of osteopaths, to permit them to use anesthesia and antiseptics, and to practice surgery and obstetrics; though these items are more or less cleverly hidden behind provisions al- legedly planned to raise the standards for future osteopaths. It is noteworthy that the term osteo- pathy receives a new definition and that through- out the law, amendments would insert the word surgery wherever reference is made to the type of practice permitted. The new bill is no improve- ment over its predecessors, and must be opposed. A. 207, also introduced by our friend, Mr. Muir, and S. 155, presented by the distinguished attorney who once gave us an enlightening address upon cult practice, Mr. Leap, provide for the licensing of so-called naturopaths. Mr. Leap still desires a license for that personal friend whose great knowl- edge and industry he so fervently expounded in this room. A. 207 is more liberal in that it would provide a medical license for almost any applicant. It provides for a special board of examiners, to consist of 5 members who may have been for 3 years defying the laws of New Jersey by prac- ticing without a license, and it defines a naturo- pathic school as an institution "giving resident courses in physiotherapy, physicultopathy, sani- practic , phy somedicine , or any other system whose curriculum is “recognized by the proposed State Board of Naturopaths”. A. 264 is an amendment to the Medical Practice Act that would make it mandatory upon the Board of Examiners to issue a license to a person of a certain type — we take it to mean that individual who has been striving so long for this special license. A. 349 requests the appointment of another member to the State Board of Examiners — a chi- ropodist. It is not a bad bill, in itself, and per- haps our action ought to rest upon the opinion of the Board; whether its members desire this ad- dition to their number. Respectfully submitted by, Henry O. Reik, M. D., Executive Secretary. Chairman Lippincott : Inasmuch as there are numerous items in the Secretary’s Report, it would seem wise to consider them one at a time. Dr. Reik\ Taking up these legislative bills as nearly as possible in their proper order, we have recommended that A. No. 1, providing for the ap- pointment of a permanent commission on crip- pled children, should be amended in such man- ner as to require the appointment of at least 1 physician on that commission. Dr. Morrison: I move that the Welfare Com- mittee shall seek the adoption of such an amend- ment. The motion was seconded and after some dis- cussion, during which Drs. Quigley and Costill ex- pressed disapproval, and Drs. Morrison, McBride and Newcomb urged adoption, the motion was unanimously adopted. Dr. Reik: S. 161 and A. 63, amendments to the hospital lien law, were referred to Dr. Londrigan as Chairman of the subcommittee in charge of that subject. Dr. Londrigan: I am under the impression that both bills are satisfactory and should receive our support. Dr. Schauffler offered a motion authorizing the subcommittee to follow up these bills and to use its own discretion in regard to further amend- ments; which motion was unanimously adopted. Dr. Reik: S. 186 and S. 207 authorize army and navy surgeons to sign certain certificates for veterans. After some discussion it was decided not to oppose those bills. Dr. Reik: S. 63, S. 137 and A. 61 all refer to the Workman’s Compensation Law and seem to be worthy of endorsement. Dr. Morrison explained that the Advisory Board, appointed by the Commissioner of Labor, and of which he is a member, approved the passage of those amendments. Upon his motion, seconded by Dr. McBride, approval was given to all 3 measures. Dr. Reik: Attention was called to A. 370, the so- called barber’s bill. Drs. McBride and Morrison pointed out that this bill might constitute sufficient authorization for barbers to perform minor surgery, and upon mo- tion of the former, seconded by the latter, it was unanimously voted to oppose enactment of this law. April, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 365 Dr. Reik: Y'our attention was next directed to A. 205, the osteopathy bill, and A. 207 and S. 155, the naturopath bills. Dr. McBride moved that all 3 bills be vigorously opposed, and his motion was unanimously adopted. Dr. Reik: A. 264 is a bill that would provide a special license for a particular individual who has not been able to meet the requirements of the State Board of Examiners. Dr. Newcomb stated that the author of this bill had publicly made the statement that this bill has been endorsed by the Board of Medical Examiners — and he asked if that statement was true. Dr. McGuire denied the allegation. After some discussion, participated in by Drs. Hagerty, Morrison, Kelley, McBride, Newcomb, McGuire and Lippincott, as to the best method of procedure to counteract the statement reported by Dr. Newcomb, Dr. McGuire accepted a suggestion made by Dr. McBride — that the Secretary of the Board of Examiners should write to Assemblyman Rothermel denying that the Board or its Secre- tary favored enactment of this bill. Dr. Reik: A. 349, providing for the appointment of a chiropodist to membership in the Board of Examiners, we thought should also be submitted to that Board for an opinion. Dr. McGuire announced that the Board is op- posed to an increase in its number, and thereupon a motion was adopted to oppose the passage of this bill. Dr. Reik: A. 29 is a bill submitted by Dr. New- comb, which we assume he would like to have en- dorsed by this committee. Upon motion of Dr. McBride the committee unanimously approved Dr. Newcomb’s bill. Dr. Reik: There remain for consideration only the 2 bills, S. 22 and S. 24, which take the place of the 2 budget bills originally presented by the Abell Commission, and about which we have in- quired as to the correctness of our interpretation that they adequately protect the Board of Medical Examiners in treating the Board’s income as dedi- cated funds. Dr. McGuire explained that he understood this to be the case. Chairman Lippincott: That concludes our con- sideration of legislation. Is there any further business? Dr. Hagerty: I would like to present the report of the subcommittee appointed to consider what action should be taken with regard to control of the practice of surgery. Dr. Hagerty read his report (placed on file) and moved that it be held for publication if and when any bills should be offered providing for the legal control of surgery or the surgical specialties. His motion was seconded by Dr. Londrigan and unani- mously adopted. Dr. McBride called attention to the fact that President Sommer had expended the sum of $100 in the engagement of counsel to represent the State Society, in conjunction with other organiza- tions, at the Public Hearing on Abell Commission Bill A. 304, and moved that the committee author- ize reimbursement of Dr. Sommer for that amount from the committee’s budget. The motion was duly •seconded and unanimously adopted. The meeting then adjourned. Henry O. Reik, M.D., Secretary. School Health Department NOTES OF GENERAL INTEREST Allen G. Ireland, M.D., Director of Physical and Health Education, State Department of Public Instruction, Trenton, N.J. School physicians are asked to make a note of Wednesday, June 3, which is the date for the Sec- ond Annual Conference of School Physicians held under the auspices of the State Medical Society. The meeting will be held in the afternoon at the Berkeley-Carteret Hotel, Asbury Park. The pro- gram will be announced in a later issue. No doubt many school physicians are including examination of the feet in their annual health ex- aminations of school children. From information recently received, it is apparent that Dr. Donald B. Hull, of Ridgewood, is devoting close attention to this item. Dr. Hull reports that he is finding a larger percentage of potential foot troubles than we would suppose existed. This Department would be glad to hear from other physicians doing sim- ilar work. At least several school physicians are under- taking the annual examination of teachers. The exact number is not known, but it is evident from the trend of opinion that some day greater con- cern will be shown, for the health of the teacher than is exhibited at present. There is much to be said in favor of this activity. A news clipping just received announces that Ames, Iowa, has won for the third consecutive year the silver cup awarded through the National Tuberculosis Association to that city in the United States of more than 10,000 population which has the best school health program. The interesting point in the announcement is the fact that the physican’s examinations are conducted annually, only in grades 1, 3, 6, 9, and 12. In other grades the physical inspection is given by the school nurse. The Trenton Board of Education announces the appointment of Dr. R. Grant Barry, Psychiatric Physician, to the Directorship of the Division of Medical Inspection in the public schools. , Dr. Barry comes from the State Hospital where he was a member of the staff. Cape May County is the first county in New Jer- sey to have the services of a Helping Teacher in Health Education on the staff of the County Su- jjerintendent of Schools. Although this appoint- ment is in the nature of an experiment, there have already been achievements reported which lead to the conclusion that the plan will prob- ably be adopted permanently for other counties. Monmouth County followed a few months later with appointment of a Helping Teacher in Health Education who is also a well qualified, experienced school nurse. The prospects for development of the school health program through the work of these young women are very bright. From Union County comes word that a dentist has been invited by the County Superintendent of 366 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 Schools to act as an involuntary and unpaid su- pervisor of school dental clinics. This seems to be a move in the right direction, and the experi- ment will be watched with interest. During the winter the writer accepted an invita- tion to serve as Chairman for Child Health, for the State Congress of Parents and Teachers. The plat- form as accepted by the Congress is as follows: (1) To compose a “Bill of Health for the New Jersey Child” and to establish its provisions as the fundamental health objectives in the work of the Congress and its affiliated units. (2) To encourage the appointment of an ac- tive Chairman for Child Health in every unit. (3) To make available for county and local chairmen type programs and suggested projects, and eventually, to have available a handbook on the conduct of health programs. (4) To make available for county and local chairmen a synopsis of an ideal school health pro- gram in order that local school needs and attain- ments may be more accurately estimated and bet- ter understood, thus making for better cooperation between local chairmen and local school au- thorities. (5) To bring about through the state chair- man, acting as a clearing center, and with the aid of the county chairmen, an exchange of ideas, plans, programs, etc., successfully tried by local associations. (6) To serve the units and individual members with respect to information concerning child health, sources of professional advice, available current literature, and child health studies. “The School Physicians' Bulletin” is the title of the monthly journal of the American Association of School Physicians. This bulletin and the asso- ciation are called to the attention of school physi- cians in New Jersey, and recommended for con- sideration. Although the association is only a few years old, it has a large membership from all over the country. We believe that it is filling a great need and doing a remarkable piece of work for an infant. The dues are $2 a year, including sub- scription to the bulletin. The business manager is Dr. William A. Howe, State Department of Edu- cation, Albany, New York. Governor Larson has called a Conference of Child Health and Social Welfare Workers for the purpose of carrying on in New Jersey the recom- mendations of the White House Conference on Child Health and Protection. The New Jersey Con- ference for Social Work has been asked to sponsor the organization of the state conference. Com- missioner William J. Ellis, President of the Con- ference for Social Work, is general chairman. The meetings will be held at New Brunswick, in the buildings of the New Jersey College for Women, and probable dates are April 16-18. Attention of school physicians is also invited again to 2 state publications dealing with the com- municable disease problems in schools. One of these is Circular No. 191 of the State Department of Health, called “Communicable Diseases Among School Children": the other bulletin is “Standards for the Prevention and Control of Communicable Diseases in Public Schools”, by the State Depart- ment of Public Instruction. These are available without charge, and it is hoped that every school physician will find them useful in constructing local programs. State Health Department LABORATORY TESTS IN I'NDl'LANT FEVER D. C. Bowen, Director of Health New Jersey State Department of Health Trenton, N. J. Ever since undulant fever was first recognized in New Jersey, 2 years ago last month, its diag- nosis has challenged the medical profession just as control measures have aroused health depart- ments. Recognition of 39 cases in the 2 years’ period indicates that physicians are keeping this disease in mind as a possible cause of prolonged, unexplained fevers. The further fact that the laboratory of the State Department of Health now examines each month for the undulant fever re- action from 12 to 25 specimens of Dlood shows that many physicians are seeking laboratory tests in cases which they suspect may be undulant fever. Possibly the number of such tests would be greater if all members of the medical profession knew that this service is at their command. The undulant fever reaction is given by the blood of a moderately advanced case when tested with a suitable antigen. The antigen used in the State Laboratory is the widely accepted one made from Brucella abortus organisms, strain No. 80. A specimen submitted for the undulant fever test should consist of 5 to 10 c.c. of the patient’s blood, prepared in the same manner as a specimen for the Wassermann test for syphilis. In fact, the outfit furnished for Wassermann specimens should be used. However, the request that a test for the undulant fever reaction be made should be writ- ten conspicuously in blue pencil or red ink, diag- onally across the accompanying yellow slip; other- wise the special request may be overlooked when the specimen is received and handled with the daily mail, which often includes 200-300 Wassermann containers. Reactions frequently occur in dilutions as high as 1-1280 in advanced cases. Among 21 New Jersey cases, the titre reached 1280 in 12 instances and ranged from 500 to 1000 in 5 others. Agglutination in dilutions of less than 1-80 are usually not re- garded as significant. Of the 39 cases on record in New Jersey (up to March 15, 1931) 22 have been recognized since July 1, 1930, when undulant fever was made re- portable to local boards of health. These 22 re- ported cases were distributed among the counties as follows: Bergen, 1; Essex, 4; Gloucester, 6; Mercer, 3; Middlesex, 1; Monmouth, 1; Morris, 4; Salem, 1; Somerset, 1. Those who have studied this diseasie are in general agreement that the source of infection is animals, particularly cows, hogs and goats, infect- ed with the causative organism of contagious abortion. They are also generally agreed that mankind is infected through close contact with such infected animals, or their carcasses, and also by the use of raw milk containing infection from the cow. Pasteurization of milk is, of course, an easy way to safeguard users of this food against the infec- tion. Contact with infected animals or meat is not so simple a problem to solve. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 367 Woman’s Auxiliary NOTE from tile editor In The February Journal, pages 172-173, we re- produced an article from the Journal of the Indiana State Medical Association and suggested that auxiliary members express to the Delineator .their condemnation of such advertisements. The President of the State Society Auxiliary, Mrs. John Nevin, acted upon that recommendation and wrote a letter to the Editor of the Delineator, which she graciously allows us to print here- with. If all members of the Auxiliary and all members of the Medical Society would follow this excellent example and denounce newspapers, magazines and radio broadcasters for spreading false, misleading and dangerous information or advice there would surely result an improvement in advertising and a saving of innumerable lives — lives that are now sacrificed through the blind faith of readers in their favorite papers and magazines. Thousands of readers accept as gos- pel the deceptive and fraudulent statements pub- lished as advertising matter by fakers and charla- tans, and newspaper and magazine publishers are, in our opinion, equally culpable with the quacks, because they know that many of the ad- vertisements handled are false and dangerous, and they accept for publication, and lend their support to such fraudulent claims only because their sense of moral responsibility has become prostituted to their cupidity. We hope many of you will rally to this cause. This is a “cause” large enough to supply every auxiliary with work to do. Rid your community in so far as possible of lying advertisements through the local radio station, and help to clean up the advertising pages of the newspapers and magazines to which you subscribe. Mrs. Nevin's letter was as follows: Editor of Delineator Dear Sir: The members of the Woman’s Auxiliary to the Medical Society of New Jersey are justly indig- nant over an article which appeared in the De- lineator of September 1930, and which has been reproduced in the February issue of the Journal of the Medical Society of New Jersey. The offending article, written by Celia Caroline Cole, and purporting to advance a remedy for puffing eyes and wrinkled lids, advises an as- tringent for the puffiness, cream for the lids, eye exercises, etc. All to be followed by an adjust- ment of the nerves in the back of the neck and backbone by an osteopath. As President of the Woman’s Auxiliary to the Medical Society of New Jersey, I voice the senti- ments of hundreds of members who resent the spreading of such fraudulent information, know- ing the harm it could wreak on unsuspecting readers. May I suggest that, in order to restore the confidence of discerning wives and families of reputable physicians, a disclaimer or explana- tion should come from the Delineator in order To abate this widespread comment. Respectfully, (signed) Mrs. John Nevin. PANORAMIC VIEW OF THE WOMAN’S AUX- ILIARY TO THE AMERICAN MEDICAL ASSOCIATION IN 4 ARTICLES No. 2. — North Central States i Mrs. James Blake According to the Constitution and By-Laws of the Auxiliary to the American Medical Association, the organization program is carried on by the ac- tive work of the Vice-Presidents. Mrs. Southgate Leigh, of Norfolk, Va., is First Vice-President and automatically Chairman of Organization. Due to her location on the map, the Second Vice-President finds herself interested in the destinies of the north central group of states. Looking backward, with pleasant memories, to Detroit, and forward with delightful anticipations, to Philadelphia, we find this group of states all doing something of common interest. In the January Journal of the Indiana Medical Society, the Auxiliary President stresses the im- portance of more constructive work on the part of her organized county groups. “Physicians’ wives,” she says, in her New Year’s Address, “hold an enviable position in being privileged to have a part in a world-wide health program, and I would urge every physician’s wife to bring before other women dependable knowledge, and a just appreciation of the real spirit and purpose and actual achieve- ments of the medical profession.” So, from In- diana we know we are to have constructive work during this year. Physicians as a class are not prone to participate in legislative matters but when 4 separate bills, which affect the profession di- rectly, are presented during one session of a state’s legislature, it is time to be up and doing. Such is . Indiana’s situation this year and the doctors of the seventh district have thought it worthwhile to instruct their Auxiliary members on these subjects that their influence may be properly used. The In- diana Journal never fails to give the Auxiliary space, and it is little wonder the Indiana women are up and coming, when they have such Editorial Notes to enlighten and guide them in their con- structive program work, as one finds in this same Journal. Kansas is slowly getting a few things accom- plished. A world-wide depression has rendered prophets quite fameless abroad as well as at home, but the doctor’s wife in Kansas is coming into her own, and we prophesy that the Auxiliary will climb to the top because of the indomitable spirit of the leaders in that state. In Illinois the motto might well read: “Builders we are, and builders we must ever be. Builders, not in stone that shelters life’, but builders in life.” We find good constructive programs of well-bal- anced educational value, we find a Journal ever ready to broadcast Auxiliary news, and best of all we find a healthy organization line-up, and an ad- visory board from its medical society. Several of its county groups are having the members get busy with the “Health Audit Program.” One project of worthy mention comes from Vermillion County on the Eastern boundary of the state. The county auxiliary put on the “Health Insti- tute” in Danville last November. A member from every agency in the county working out any kind of a health program was included in the person- nel of the speakers. It was for just 1 day, but it was worth 365 as a rouser for auxiliary work. It really was sort of a Christmas Seal Campaign opening, a get together of Club Women, and P. T. A. groups in the county. And what a wise idea for 368 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 a medical auxiliary to have the headlines in the plans for such a “Health Day”. Wisconsin, Iowa and South Dakota are among the latest states to join the National Auxiliary. Or- ganization is the key note for their work, and the National Study Envelopes are offered as program material. Right now if the modern doctor’s wife needs to get one thing more than another from her organization, it is the knowledge of what is going on in this world; especially the world of medicine. Women are discriminating more care- fully in the clubs they are joining. They are ask- ing what membership will mean to them, what they will get out of it. For that reason the sub- jects for study should be more carefully chosen, and the roll call should be made to count for something more than jokes and quotations from forgotten poets. It isn’t a pleasant feeling for a busy mother who rides miles to a meeting to say when it is all over: “I can’t say I know any more now than when I started.” And so we find these 3 states getting themselves established on a firm foundation, with the national program envelopes scattered far and wide to aid and encourage Aux- iliary members, already in, and prospective mem- bers. Montana and North Dakota are debating pro- and-con but as Mrs. Hoxie said in her Detroit re- port: “I believe it will be a mistake from now on to organize a new state unless it appears reason- ably certain that there is interest enough among the doctors who want the Auxiliary so that they will foster it and stand back of it.” And so we leave Montana half-hearted about forming an Aux- iliary, and North Dakota in the air. We find Michigan giving intelligent cooperation with state and county officials. Women, like men, are interested in the improvement of civic affairs and healthful living and are realizing that they need to be armed with a definite knowledge of health laws and public health practices. Missouri is in a very healthy condition. We find that Mrs. A. B. McGlothan, the President-Elect of the Woman’s Auxiliary to the American Medical Association, will attend President Hoover’s White House Conference for Child Health and Protection to be held in Washington, D. C„ February 19 to -1. Mrs. G. H. Hoxie, the President for last year, will also attend the White House Conference. Mrs. A. W. McAlester tells us the women of Missouri are finding the Study Envelopes, pub- lished by the Education Committee of the Woman’s Auxiliary to the American Medical Association, most interesting and instructive. The studies on “Common Defects in Children”, and on “Diph- theria”, “Small-pox” and “Typhoid Fever” were recommended by the Department of Health in the Missouri Branch, National Congress of Parents and Teachers for use on Parent-Teacher Programs; 800 copies of each were distributed for use in Parent-Teacher Units; 300 were requested and supplied for use in Parent Education Classes; re- quests are constantly coming in for additional copies of the studies for use by teacher^ and Parent-Teacher Units. The Department of Public Information of the Extension Division of the Uni- versity of Missouri is including these studies in its suggested programs for clubs in the Missouri Federation of Women’s Clubs. This department requested back numbers of Hygeia for use in such programs. Three hundred copies of Hygeia were supplied by women in the state and by the circu- lation manager and are being extensively used in club programs. The Missouri Chairman of Pub- lic Relations is planning to have a copy of each of the studies, “Common Defects in Children", and “Communicable Disease Control”, sent to each county school superintendent in the state. Several of the county auxiliaries are using the study en- velopes in their programs. Mrs. M. P. Overholser, of Harrisonville, Mo., has been appointed chairman of Public Relations in the Missouri Auxiliary. This Auxiliary maintains a scholarship for a medical student, per capita quotas being assigned to each county auxiliary. They also have sent in 30% of the total number of Hygeia subscriptions recorded from all auxil- iaries from January 1, 1930, to January 1, 1931. Some county auxiliaries provide Hygeia for all their teachers. Among these are Buchanan, Gen- try and Lafayette. Cape Girardeau County Aux- iliary has just finished paying a $1000 pledge to a hospital in the city and is now ready for another kind of work. It is a live group and certainly works hard to be able to accomplish so many won- derfully worthwhile things. Minnesota, the North Star State, has had a busy and successful year on organization. The Presi- dent and Organization Committee Chairman have visited over the state and planned meetings and educational programs with many county groups. In October the International Medical Assembly met in Minneapolis, and at this time the Hennepin County Auxiliary celebrated its twentieth anniver- sary, by being hostess for 5 days to the visiting doctors’ wives. A great many social affairs and an Educational Day, which included a speaker on public health, were features. Hennepin County is having a year with a definite program. Each month a speaker is scheduled, and 1 meeting dur- ing the year is reciprocity day and each auxiliary in the state is invited to send visitors. This group features philanthropic work for T. B. patients at Glen Lake and does much for the library at the sanatorium. It has helped the Medical Society furnish its library and club rooms, spending $1000. Ramsey County does much the same work. It has a Scholarship Fund for Medical Students. St. Louis County is noted for work in the Public Relations Field. The State Medical Journal gives a page to Auxiliary news. One of the other coun- ties takes care of a Nurse’s Scholarship. The Min- nesota Auxiliary has a splendid Advisory Board and a page in the State Journal. The President will be one of the speakers on the program for the Annual Conference of Secretaries of the Compon- ent Societies of the Minnesota State Medical Asso- ciation, to be held in St. Paul the first week in February. This is the first time the Auxiliary has been asked to take part in this annual affair. Mrs. Hesselgrave’s talk will be, “Uses of the Auxiliary”. And so, closing my review of the work of the North Central Group of States, may I say again — Builders we are, and Builders we must ever be Builders not in stone that shelters life but, Builders in life itself — ever remembering the fu- ture of the world for generations to come de- pends upon what we think and will and do today. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 369 Atlantic County A Report from Mrs. W. Blair Stewart Since the first of the year the county reports have come in very slowly, with but 9 counties heard from — and but 2 have sent in reports for January, February and March. Of course some of our counties only have quarterly meetings. Atlan- tic and Union Counties have had reports each month. Every Auxiliary should have an active reporter. Many attended the open Executive Committee Meeting and Luncheon at Trenton, which was a very enthusiastic meeting, as plans were discuss- ed for both the A. M. A. Auxiliary Convention in Philadelphia — June 8-12; and also for the State Medical Meeting in Asbury Park, June 3 to 5 at the Berkeley-Carteret Hotel. Among the activities reported are — welfare work — the deficient child — scholarship funds — Hygeia subscriptions. There have been flowers and plants sent to the sick or to those in trouble. Card parties have been given to raise funds. Among those who have addressed the various Auxiliaries were Dr. Harveys Green, Mrs. Taney- hill, Mrs. A. Haines Lippincott, Dr. Ellen Potter, Mrs. John Nevin, Mrs. Russell Shirrefs, Dr. Leo Haggerty, Dr. George N. J. Sommer and Dr. Reik. Funds are being raised to assist in the enter- tainment of the Auxiliary Convention in June in Philadelphia. Friday, the thirteenth, was not in any way a hoodoo day, for the Atlantic County Auxiliary gave a very successful and delightful musicale- tea in the Solarium of Hotel Claridge on the twentieth floor (a sure enough sky-scraper for the seashore!) given to honor our beloved Presi- dent of the New Jersey Medical Auxiliary, Mrs. John Nevin, of Jersey City. Mrs. James Hunter, a Past-President, was also a guest, both giving us helpful addresses. The musical program was given by Claridge Orchestra, with Mr. William Stokking as leader. An hour’s program of vocal and instrumental numbers was given by Atlantic City talent, mostly from those related to the profession. Delicious refreshments were afterward served. Claridge Hotel should be called the House of Hospitality, for the management did everything possible to make our musicale a success, even giving the use of its fine orchestra. Dr. H. O. Reik, Editor of the Journal of the Medical Society of New Jersey, was the speaker at a meeting of the Atlantic County Auxiliary, Friday evening, March 6, in the Blue Room of Chalfonte Hotel. Arrangements were made for a card party about the middle of April to raise funds. Mrs. Joseph Poland, Vice-President, presided. After a short business meeting, a social evening with bridge was enjoyed. This year the Atlantic County Auxiliary mourns the loss of 3 valued members from its family. With Mrs. Beckwith, our President, we mourn the loss of Dr. J. T. Beckwith, who was taken away suddenly. Mrs. Mark Haley was the next whom death called, and now we are deeply distressed at the passing on of our friend and member, Mrs. Samuel Barbash. She had assisted in the organ- izing of the Atlantic County Medical Auxiliary and was always graciously willing to give of herself and of her talents. MRS. SAMUEL BARBASH The Atlantic City Press published on March 15 an editorial, on the passing away of Mrs. Barbash, of such character that we use it here as a memorial tribute. The unexpected death of Mrs. (Ann Tomlinson) Barbash yesterday created genuine sorrow in no small group of native Atlantic City folks. The reason was perfectly plain. She had been so gracious and generous in her personal devotion to friendships, to all worthy endeavors in the social, church and musical life of the city, and to the interests of those who were either her friends or for any reason sought her help. While exceedingly active in the historic, fraternal and patriotic societies of all New Jersey, Mrs. Bar- bash's greatest single contribution to this com- munity perhaps was her success in gathering, keeping alive and helping to preserve the inter- esting historical facts and traditions of Atlantic City and this immediate section of New Jersey. In this task her energies were tireless and her achievements will . endure as of substantial value tc this and succeeding generations interested in local history and local genealogic research. Bergen County Reported by Mrs. Michael Sarla The regular monthly meeting of the Woman’s Auxiliary to the Bergen County Medical Society was held at the Nurses’ Home of the Hackensack Plospital on the evening of March 10, with 16 members present. After the business meeting interesting motion picture films of California, Panama Canal, and Honolulu were shown by Mrs. George Finke of her recent travels there. Delightful refresh- ments were served in which the Bergen County Medical Society joined us. A public card party took the place of the February meeting and the sum of $100 was real- ized. The money will be divided between the 4 county hospitals. Essex County Reported by Mrs. F. J. Conley The Woman’s Auxiliary to the Essex County Medical Society has concentrated its efforts of the past month on the Scholarship Fund. The Theater benefit held on March 9 and 10, at the Lyceum Theater in East Orange, was a most en- couraging affair. Our doctors attended in goodly numbers so that social success was added to financial. At our March general meeting, we hope to be enlightened on the work done by the Visiting Nurses’ Association; an address by one of the Association’s members. We were honored by an invitation to attend the March meeting of the Essex County Medical Society at the Library Building in Newark. Gloucester County- Reported by Mrs. Henry B. Diverty The meeting of the Gloucester County Medical Society Auxiliary was held at the Woodbury Country Club, Thursday, March 19, at 9 p. m., 370 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 President, Mrs. Elwood Downs, in the chair. Con- sidering the stormy weather our members were very well represented. Mrs. James Hunter, of Westville, a member of our auxiliary and also of the State Board, brought to us in detail the program of entertainment by Pennsylvania, New Jersey and Delaware Auxiliaries to the A. M. A. Convention, to be held in Philadelphia, June 8 to 12. A letter from headquarters regarding circula- tion of Hygeia was read and discussed. After transacting the routine business, we adjourned. With the coming of the auxiliary and its work a new and greater friendliness has come to us. The atmosphere of our medical people is entirely changed. The doctors held a meeting at the same hour in another part of the building. After they ad- journed, we joined our forces and went to the dining room where a fine collation was served by the Country Club steward, and a very enjoy- able social hour followed. Hudson County Reported by Miss Anne Hetherington The February meeting of the Woman’s Auxili- ary to the Hudson County Medical Society was held in the Jersey City Y. W. C. A. on Friday, F'ebruary 27. It was voted that $100 be distributed among local charities. After the business meeting, a talk by Mrs. E. C..Taneyhill, Field Secretary of the Medical So- ciety of New Jersey, on “Mental Hygiene’’ was enthusiastically received, proving the lively in- terest this subject is arousing everywhere today. Mrs. Taneyhill graciously discussed many points of her address with the members during the in- formal tea hour which followed. The President, Mrs. John Nevin, again made a plea for a large attendance at the State Medical Society Convention to be held in Asbury Park, June 3 to 5, reminding the members of the attrac- tive plans made for their entertainment. Mrs. Nevin also presented the social, scientific and historic advantages to be enjoyed at the American Medical Association Convention at Philadelphia, June 8 to 12, concluding her talk with the reminder that every member should consider it a personal obligation to play her part as hostess on the New Jersey Day assigned to the State Auxiliaries. Somerset County Reported by Mrs. Abram Levy The Woman’s Auxiliary to the Somerset County Medical Society held the third meeting of the year on Thursday afternoon, February 12, at the Nurses’ Home of the Somerset Hospital. It was decided to hold a card party in April, ihe proceeds of which would be used for enter- taining at the A. M. A. Convention in Phila- delphia. Delegates were elected for the State Society Convention at Asbury Park. The first delegate is Mrs. Edgar Flint, of Raritan, and her alternate is Mrs. R. K. Adams, of Skillman. The second delegate is Mrs. E. G. Brittain, of Bound Brook, and her alternate is Mrs. Abram Levy, of Somer- ville. Union County Reported by Mrs. C. A. Hoffman The first of a series of afternoon meetings was held by the Woman’s Auxiliary to the Union County Medical Society in the Winfield Scott Hotel, Elizabeth, on February 16. Nearly 40 guests and members sat down to the luncheon. The President and President-Elect of the Aux- iliary to the State Medical Society, Mrs. John Nevin, of Jersey City, and Mrs. H. Roy Van Ness, of Newark, were guest speakers. Mrs. F. A. Kinch, of Westfield, a Past-Presi- dent of the Union County Auxiliary, outlined the spring program. Mrs. George L. Orton, another Past-President, reported plans for entertainment of the Auxiliary members at the meeting of the New Jersey Medical Society, in Asbury Park, June 3, 4 and 5, and those of the American Medi- cal Association, in Philadelphia, June 8-12. Mrs. H. V. Hubbard, of Plainfield, President of the Union County Auxiliary, presided. At the close of the meeting the following officers were presented: President-Elect, Mrs. Harold Cor- busier, of Plainfield; Vice-Presidents, Mrs. Nor- man Currie, of Plainfield, and Mrs. George L. Or- ton, of Rahway; Secretary, Mrs. Charles A. Hoff- man, of Plainfield, and Treasurer, Mrs. Denis McElhinney, of Elizabeth. County Society Reports ATLANTIC COUNTY John S. Irvin, M.D., Reporter The regular monthly meeting of the Atlantic County Medical Society was called to order at 8.30 p. m., March 13, by the president, Dr. Norman J. Quinn, at the Chalfonte Hotel. The minutes of the previous meeting were read and approved by the secretary, Dr. Joseph H. Marcus. The names of Drs. Timberlake, Roark and Kline having been approved, they were declared elected to membership. Public Health and Sanitation Committee: Dr. W. Blair Stewart said Don D. Modica, convicted of practicing without a license, was fined $500 or 200 days in jail. He brought up the question of advertising patent medicines over Radio Station WPG. This station now broadcasts nightly at 11.30 a talk on patent medicines. The matter will be taken up with Mr. Spence who is in charge of the station. Last Tuesday evening the Atlantic City Auto- mobile Club took up the question of drunken driv- ing. The general medical profession of Atlantic City has been blamed very seriously upon this question. Any member of the medical society who pronounces a man drunk should stand by his point. Dr. Scott, one of the oldest practitioners in the city, is ill, and it would be nice if the committee would communicate with Mrs. Scott and offer the services of the society. Dr. Senseman said it was a disgrace to the medical profession the way drunken driving is handled in this city. The Atlantic City Hospital interns cannot pass upon whether a person is drunk or not, as they are not registered physi- cians, and secondly the hospital isn’t a police sta- tion. The drunken man should not be sent to the hospital just because the present police surgeon April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 371 refuses to do that work. In regard to the broad- casting, the committee will be very willing to take the matter up. Since WPG was taken over by Columbia it is a commercial proposition and we must take this into consideration. A motion was passed that the society go on record as protesting against this radio broadcast- ing of patent medicine. The treasurer’s report was declared to be cor- rect, by Dr. Homer I. Silvers, who audited it. A letter of appreciation was received from Dr. Henry O. Reik, who was elected an Honorary Member at the last meeting. A motion was passed that the society purchase a copy of “American Physicians and Surgeons” and present it to the library. Dr. Harvey spoke about a plan which is on the order of “Know Your City Day”; the idea being to sell Atlantic City to Atlantic City and the com- munity. The members of the committee could meet with the Chairman of the Chamber of Com- merce. He said that the doctors could join in by giving exhibits of child welfare, an exhibit of x-ray work and baby welfare clinic, tuberculosis and red cross work, etc. The doctors can do nothing as individuals but as a body they could show the health work that is being done here in the city. It must be done under the auspices of the County Society. Booths are being sold in the Convention Hall for this purpose at $10 per 100 sq. ft. The question that comes into our minds is, do we want to enter it? A motion was passed to appoint a committee to consider the advisability of this. The president appointed Drs. Harvey, Conaway and Silvers. Dr. Stern spoke about a so-called “racket” being practiced by the insurance underwriters. He said they are sending patients to get treatment at the state rehabilitation clinic at $1 per patient. He complained bitterly of physicians’ fees being ar- bitrarily reduced by the insurance companies, and made the charge that some members of the society are doing compensation work at cut-rates by con- tracts with the companies. He thought that the insurance companies should not determine the fees that the doctor shall charge. Dr. James Mason, who is the State Compensation Commission’s doctor for this district, spoke. He said he is in charge of the state clinic and that treatment is given there at the price of $1 per treatment. In the Rehabilitation Clinic they re- ceive cases referred from other doctors. Cases are also sent from the Workman’s Compensation Court, which is a part of the Department of Labor of the State of New Jersey. He read the Act which was passed by the legislature of the state of New Jer- sey. He then explained that a committee is ap- pointed under this Act to pass upon all disputed medical fees in compensation cases. Dr. Allman is on this committee as a representative of this society. Dr. Pilkington is on it as a representa- tive of the insurance companies and Dr. Mason represents the state. The committees were ap- pointed with the idea of avoiding legal complica- tions. If a physician is not satisfied with the rul- ing of this committee he has recourse to the Com- mon Law Court. The insurance company doesn’t • dictate the fee. The Act itself states the fee. Dr. Mason went on to say that as far as contract work is concerned he does a great deal of this compen- sation work and he has no contract with any in- surance company or with anybody and that he charges his own fees. Dr. Allman : The companies treat you right if you go about it in the right manner. There are some doctors who try to rob insurance companies. I, personally, know that some members of this so- ciety have charged for visits that were never made, and that is why the companies are prone to send their patients to doctors whom they can trust. We do not try to favor the insurance com- panies nor do we try to “gyp” them. It is much better to go along with them in a friendly man- ner than to try to get an exorbitant rate and so throw unjust reflection on the whole society. Dr. Senseman said there is no reason why an in- surance company should be robbed. Quite often it receives large bills for negligible services. Therefore, the dishonest doctors make it bad for the honest doctors. The trouble is more often with us than with the insurance companies. Dr. Marcus announced that on April 10, there will be no regular meeting. Instead, there will be a meeting of the Fifth Councilor District of the State Medical Society at Haddon Hall at 4 p. m. The speakers at this session will be, Dr. John A. Hartwell, President of the New York Academy of Medicine, who will speak on, “The Continued Edu- cation of the Doctor”, and Dr. Joseph Doane, Di- rector of the Jewish Hospital in Philadelphia, who will speak on “What the Public Thinks of the Present Day Practice of Medicine”. The after- dinner speaker will be Dr. H. Sheridan Baketel, Professor of Preventive Medicine in the Long Island College of Medicine, and he will speak on “The Personal Element in Medical Economics”. At 8.30 p. m. there will be a Clinic at the Atlan- tic City Hospital where interesting cases will be shown. Refreshments will be served after the clinic. Dr. Quinn hopes the members will turn out 100%. Then followed a talk by Dr. Ernst P. Boas, Associate in Medicine in the Mt. Sinai Hospital, New York, on “Rheumatic Fever”. Dr. Boas. The subject I have chosen to speak about is such a vast one that it is difficult to know what to put in and what to leave out. I felt that rheumatic fever is such an important prob- lem to all of us, in view of the fact that one-half of all cases of heart disease and nearly all cases of heart disease in children are caused by it. Definite knowledge as to its cause is still very scanty. First of all, I should like to emphasize the fact that rheumatic fever is an infectious disease like meningitis, poliomyelitis and pneumonia. What evidence have we to substantiate this point of view? Rheumatic fever, in its seasonal distribu- tion, resembles many infectious diseases. Over a period of 30 to 40 years this incidence may be high and then again the incidence decreases. There are definite waves that occur, due to an. un- known fact. In this latitude the disease exists and begins to get scattering in the fall, but from March to May the incidence reaches its greatest. At the present time we are receiving many cases in our hospital in New York. There is a very interesting problem about the contagiousness of rheumatic fever. Most of us have not thought about it as an infectious disease. It can be trans- mitted from one person to another. Yrears ago cases were described of one child developing arthritis and then the mother or some other mem- ber of the family contracting the disease. Then some 30 odd years ago there was pointed out the marked frequency of rheumatic fever in families, due to hereditary predisposition. Environment, rather than heredity, determines the high inci- dence of many cases in a family. In the brothers and sisters and parents who attend my cardiac clinics I found that in their families multiple cases 372 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 occurred. Rheumatic valvular heart disease was much more prevalent in rheumatic families. Finally, very definite epidemics have been ob- served and described. During the War, the French noted definite evi- dence of epidemics in regiments. It was not con- ditioned by environment, as only the originally in- fected regiment kept on having the disease. I have had the good fortune of observing 2 epidemics in the children’s wards of the Montefiore Hospital. In the first one there were 18 boys with old rheu- matic heart disease in a ward. One child began with an acute rheumatic infection and then after a month about 8 other children became infected, and several died. The second epidemic was sim- ilar. However, this disease hasn’t a high degree of contagiousness, like measles. It is like polio- myelitis, in which infection occurs but which is not very common. Environment also plays an im- portant part. The disease is found among the poor. It is like tuberculosis in this sense, where the economic status of the people makes it hard to prevent the disease. The first point to remember then is that it is an infectious disease partaking of the general character of the general infectious diseases. If you study the incidence of the disease in the L^nited States and compare the *North with the South you will find that going from Boston south it diminishes tremendously. It will suffice to say the disease is rare south of Virginia. In the tropics the disease is almost unknown. I have been interested in studying the incidence in Porto Rico. A large settlement of Porto Ricans live in the vicinity of the Mount Sinai Hospital. Among them we have seen cases of acute rheumatic fever, but with very few exceptions they all contracted their infection after arriving in the United States. I took pains to check up the morbidity and mor- tality statistics. What is true of Porto Rico is true of the tropics in general. Not alone rheu- matic fever but other diseases, such as scarlet fever of streptococcic origin, do not tend to spread. Mouth cultures have shown that the streptococcus is very common there. So the matter is not as simple as it sounds. Recently some, physicians in the Presbyterian Hospital made an experiment. They sent some rheumatic patients to Porto Rico and while they were down there their symptoms subsided. This points to a very practical conclusion in regard to children especially. It may be very wise to ad- vise parents to send their children South. I would send them south in September or October and keep them there until June. This measure is a practical method of treatment of the disease where the patient’s means will allow. The heart needs little comment. We know that when the endocardium is attacked the myocardium is attacked as well. Not the heart itself, but the large vessels are attacked too, even lesions of the pulmonary artery have been described. The lungs are commonly involved in rheumatic fever. A few years ago Nace described rather characteristic rheumatic pneumonia. Rheumatic pleurisy we are all familiar with. Rheumatic pneumonia is associated with other manifestations. Physical signs are very definite. The brain is also at times involved. Cerebral rheu- matism is probably an encephalitis. The perito- neum may' be involved. I would like to call your attention to the frequency of severe abdominal pain and rigidity. It is not at all uncommon for a child to be taken with chill, rigidity and pain in abdominal region. Appendectomies have been per- formed and within a week the patients developed arthritis. This has been overlooked in recent years, and we seem to have forgotten about it until in the last few years papers have appeared upon the subject. The skin is frequently involved. We have all types of skin eruptions. The sub- cutaneous tissues are also involved. The anemia of the disease may be due to involvement of the bone marrow. I have enumerated all of these items to impress upon you that rheumatic fever is an infectious disease which may involve any part of the body. In any case the virus is widespread. What is the etiology of the disease? Very little is actually known. While many observers have been believed to isolate the germ (streptococcus) we cannot reproduce the disease in animals. We do know that it is often associated with tonsillitis. Glover observed a tonsillitis epidemic among 3530 soldiers — 427 cases. Within 2 weeks following on- set of the tonsillitis he found some 40 cases of rheu- matic fever. Schlesinger also made similar ob- servations. It usually occurs from a period of from 10-21 days after the onset of the tonsillitis. The tonsils have been accused of being the por- tal of entry. The whole respiratory tract, the nose, nasopharynx, lungs and tonsils are all portals of entry for the rheumatic virus, but I do not be- lieve that any one particular tract is more of a portal than another. I have seen rheumatic fever very frequently in people who had no tonsils but who had attacks of pharyngitis, so I think we are mistaken when we localize too strictly. Dr. May Wilson and some associates in New York followed the course of 400 children from 1 to 10 years. Over half of these children had their tonsils carefully and completely removed, yet 48% developed rheumatic manifestations. It was found that as the children became older the rate of infec- tion became less. As children grow older they become less susceptible to rheumatic infections. We must regard the whole respiratory tract, upper and lower, as a possible portal of entry, and that even after the tonsils have been removed the pa- tient may get pharyngitis. Under what conditions and when should tonsils be removed? I believe that the history is impor- tant. Not in the hope of preventing heart dis- ease but in the hope of preventing severe follicular tonsillitis. You cannot tell by looking at the ton- sil whether it is infected. Tonsils and adenoids that are so large that they make breathing diffi- cult are indications for removal of the tonsils; also otitis media. In years to come there will be less removal of tonsils than there is at the present time. What lesions may we expect in the heart? The first of these is the immediate heart lesion accom- panying the acute infection, an acute myocarditis and endocarditis. In the acute stage of the dis- ease we need not worry about any dynamic effects of valvular lesions. We have to worry about the actual effect on the cardiac function. The heart in order to maintain its work, even when the pa- tient is actually at rest must be quite rapid. These patients react very poorly, even to the very slight- est effort. To complete these children’s immobil- ization. I should not have such a child move about in bed or even feed itself, and would watch very closely to prevent even the most minimum effort, as I have seen such children suddenly sit up in bed and drop dead from the effort. These children should be placed in bed for a long period of time. Once the fever has gone down, we send the chil- dren home. This is a mistake, as after the fever has been down 10 or 15 days these children should be kept in bed at least a month longer to make sure that their fever will stay down. This is the April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 373 only way we can minimize to a slight degree the serious effects. Then, of course, we have a large number of late heart lesions, the after-effects of acute heart lesions. Are there any cases which recover com- pletely? There are, undoubtedly. There are some who are spared any cardiac involvement whatso- ever. There are some who have a definite valvular disease who are fortunate in having only one re- infection, but since they are spared further re- infection there is slight incapacity and as the heart grows with the growth of the child this never again bothers the individual. However, in these cases in which the original valvular defect is slight such defect may in later years be the site of sclerosis sufficient to give symptoms of heart disease. Such cases, I believe, are not at all uncommon. 1 said nothing at all about the myocardium. There apparently is no permanent damage here. The acute inflammation leaves a few small scars, the so-called Aschoff nodules. The function of the heart is not impaired. A few brief words as to treatment and prophyl- axis. There is no other disease in which treat- ment is so unsatisfactory. We have no means of counteracting the rheumatic virus. We have a few facts that are sufficiently suggestive to use as a plan of therapy. I wish to repeat that wherever it is possible for a patient, send him south, with the fairly good assurance that the dis- ease will be arrested after a few months. I believe that the time is coming soon when the sanatorium treatment of rheumatic fever is going to be adopted just as for tuberculosis. I should like to repeat one word about the tonsils. In some cases it is not only futile but dangerous to re- move them. As for medication, there is no medi- cation. Give the patient absolute rest. While there is an acute myocarditis, digitalis is of no earthly good. It acts as an additional toxin. Salicylate is often given in too great doses. We must remember that it is a chronic disease and that the fever may con- tinue for weeks or months and we must support the patient and feed him. Don’t keep these pa- tients on a liquid or soft diet, but give whatever they can stand — anything within reason. What is the criteria for recovery? When he shows no longer progressive wasting and anemia. The return of the sedimentation time to normal may help. We have no accurate method of attack- ing the disease. Just as tuberculosis is decreasing, so is the incidence of rheumatic fever decreasing because of the better economic conditions of the public. We know that it is a poverty disease to a great extent and when we have better housing conditions the disease will be less prevalent. Discussion Dr. Scanlan. As regards the removal of tonsils, our hospital staff would be glad to hear your talk, so that they would have fewer tonsils to take out. A few cases never prove anything, but we had a case of a girl suffering from acute nephritis and she didn’t show any signs of improvement as time went on. Upon removal of her tonsils her temperature dropped to normal. The same thing happened with a case of rheumatic fever; the girl got better as soon as her tonsils were removed. We had the case of a nurse who was suffering from this same illness, who went home in February to Ot- towa, Canada, and I believe that the climatic change killed her. I decided to have my 4 chil- dren’s tonsils taken out at once. The healthiest child in the bunch, and who is still the healthiest, had hers taken out, only because the rest were having theirs out. When they took hers out they found that she had an abscess with a green foul smelling pus that no one would have ever dreamed was there. Dr. Stewart. I was just wondering whether Dr. Boas noticed whether during the epidemic of in- fluenza there was any coincident increase in cases of rheumatic fever. I have come in contact with more acute rheumatic conditions in adults than I have with children. I know of a patient whose kidneys were very bad and whose tonsils were supposed to be the best by otologists and laryngologists, and upon operation a very marked purulent condition was found, just as in the case of Dr. Scanlan’s child. Some of these bad after- results would be prevented if the children were put to absolute rest. I wish to thank Dr. Boas per- sonally for a most interesting talk. Dr. Andrews. In my undergraduate work, where I studied in a school at the mouth of the Missis- sippi River, we didn’t see a case of this kind among 1000 men and we were curious to know why. We were following a lot of Cabot’s work and we didn’t know those diseases when we saw them. We learned that they didn’t have these cases to deal with much in the South. When I went to Bos- ton I found that out. Dr. Davidson asked Dr. Boas what his opinion is of Small’s serum. Dr. Barbash. One thought that struck me as Dr. Boas went over the field in discussing the treat- ment was that he gave very little encouragement as to any particular treatment. At one time you talked about using serum and you immediately be- gan to brag about the results you got with that particular form of treatment. I saw one case in particular that got better with mercurochrome in- travenously and we all know that we have never been able to find one specific cause if there is one specific cause. We shouldn’t throw out the var- ious forms of treatment merely because they haven’t been of benefit in a specific form of the disease. The idea of sanatorium treatment for rheumatic fever is an excellent one and I believe there is one such institution in Philadelphia and the particular form of treatment as outlined by Dr. Boas is being given there. Dr. Quinn asked Dr. Boas to give some of the school nurses present some hints as to the treat- ment of chorea and about the various forms of exercise for school children. Dr. Boas. I over-emphasized my attitude about the tonsils in order to drive my point home. As for Dr. Stewart’s question, I am not sure that there was a definite increase of rheumatic fever following influenza. We see patients who, following sinusitis, develop clinical instances of heart murmurs and we don’t know whether to call them rheumatic. Small’s serum has not been found useful by any of the men in New York who are interested par- ticularly in rheumatic fever. Just how we are go- ing to treat these patients will depend upon our temperaments. Some will try to keep the patients in good shape and bide our time. Others will get restless. It is perfectly legitimate to experiment around as long as we are not radical. One can speak for hours of the relationship of the school to the rheumatic child, and it is difficult to bring out the view points that are of the great- est importance. We are faced with 2 alterna- tives. We must not make the child too heart con- scious. On the other hand, we must not allow the child’s lesion to go on unchecked, and so these children require very careful handling. The teach- 374 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 ers should be aware they are dealing with a rheu- matic child. Great care should be exerted to seg- regate these children from other children suffering with colds and tonsillitis. As far as handling of the acute infection, it can only be a matter of constant attention. What are we going to do with the children who have regular heart disease? In New York they have special cardiac classes. The drawback of this is that the children have their attention fixed upon .their illness. Yet, in New York, where the children have to be rushed up and down stairs, it is better that these children be segregated in special classes. The important thing to teach these children is leisure. lrou can stop pushing the child. In general, children are under too much of a strain. A child with a mild heart lesion should climb leisurely up the stairs, and if he lives too great a distance from the school should not go home for lunch. He should avoid competitive games. When he does play in games and becomes a little short of breath he should sit down. A child like this usually knows when he has had enough. Children don't need regular sys- tematized exercise. This means with the excep- tion of a few older girls between the ages of 12 and 16 who sit around most of the day and don’t do anything much at all. Setting-up exercises are a waste of energy. Children with chorea certainly don’t belong in school. Chorea starts in with an acute rheumatic infection and it winds up as a habit spasm and you don’t know when infection is over and when the habit begins. Many people believe that only children who have predispositions to nervousness will acquire this habit spasm. I had the case of a boy of 15 who couldn’t even talk, or drink water, as his tongue would go con- tinually. After 2 months we gave the boy a very large dose of chloral and when he came to he tried to move, but as soon as he did so the nurse would quiet him and tell him to lie still, soothing- ly. He became cured in this way. Yrou will have to look into the conditions of these children at home. They set up a very bad example to other children. Atlantic City Hospital Staff Joseph H. Marcus, M.D., Secretary The stated monthly meeting of the General Staff was held in the Auditorium of the Hospital on February 27. The meeting was called to order at 8.30 p. m. by Dr. Milton S. Ireland, President. The Scientific Program was presented by Dr. Walt Ponder Conaway, Chief of the Gynecologic Ser- vice, and Dr. J. Carlisle Brown, Assistant. Dr. Conaway. I submit herewith a report of the work performed in the Gynecologic Service of the Atlantic City Hospital, from August to Decem- ber 1, 1930. During that time 133 patients were admitted; ^92 white and 41 colored. Of these pa- tients, 117 were subjected to operations. If a patient had both major and minor operations, it is counted in this report as one. Seven declined to accept our offer of assistance by surgical means arid 8 were cured or improved by medical care; a patient with inoperable general pelvic and ab- dominal carcinomatosis, referred from the Medi- cal Service, died while arrangements were pend- ing for removal to her home in Philadelphia. An itemized list of operative work is appended. Of the 117 operative cases, 107 patients were con- sidered as cured, 6 improved and 4 unimproved. There were no postoperative deaths. Eight patients were given radium treatments; in 4 the diagnosis was carcinoma of the cervix, confirmed by biopsy. In the other 4 patients, radium was used for the control of uterine bleeding and in 2 of these it was used as a palliative measure only. The average number of days spent in the hos- pital was 11.5 for the white and 15 for the colored patients. One patient from the previous service remained in our ward for 102 days; 1 of our own patients remained 80 days and another 57 days, which increased our average of hospitalization t ery materially. Gas-oxygen was used routinely and only in a few cases was this anesthesia supplemented by ether. Two patients were given spinal anesthesia on account of pulmonary and cardiac conditions, which rendered inhalation anesthesia more haz- ardous. Dr. Johnson, of the Surgical Service, ad- ministered the spinal anesthetic very skillfully and both patients made an uninterrupted re- covery. Two patients proved to be of much more than usual interest and I have asked my assistant, Dr. Brown, to report these cases to you more in de- tail. Thirty-one consultations were held with mem- bers of the Medical and Surgical Service and we were asked to see 13 patients in consultation. During the last few weeks of our service, we used sodium amytal in 3-6 gr. doses instead of morphin and atropin preliminary to anesthesia, and I am inclined to think the patients were less apprehensive and that they were afforded some protection against the undesirable psychic ef- fects of the operating room. They seemed equally as comfortable and relaxed before operation and theie was less postoperative nausea and vomiting. The X-Ray Department and the Department of Radiology cooperated with us in every possible manner, and I desire to add a special word of commendation for their very prompt and efficient service. The rather plethoric condition of the finances of our Radium Fund is also deserving of ’some comment. The Hospital Laboratory was of veiy great assistance. Our requests were an- swered promptly and the desired reports never delayed. Our service the past year was the largest we have ever had. The work of our interns was very satisfactory and I was very happy indeed to give them an opportunity to operate whenever pos- sible. Dr. J. Carlisle Brown : We have selected 3 cases which have unusual features that may be of in- terest. The first case is of a nulliparous married woman who came to the hospital with history of pain of 2 months’ duration in the left lower quadrant. Temperature was 100°, pulse 110 and there was a mass 5 cm. in size in the adnexal legion. She was able to walk about the wards and did not have an extreme amount of pain. Diagnosis of salpingitis was made, with a possi- bility of ectopic gestation. The next morning I was called from the delivery room when the day nurse came on duty and the diagnosis was then obvious; she had all the symptoms of severe in- traabdominal hemorrhage. The night nurse had apparently failed to notice the condition. She was immediately taken to the operating room and the operation begun, but she almost immediately became pulseless. An intravenous injection of saline was starred and 1000 c.c. given. As the pulse was still imperceptible the injection was continued. At 1300 c.c. the pulse became per- ceptible and the injection was stopped after 1500 c.c. had been given. The operation was finished April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY *75 as quickly as possible and the patient reacted promptly in the ward. At 2.30 p. m. she was given a blood transfusion. When 250 c.c. had been given the patient woke up and remarked that hei heart had stopped beating. She stated that she felt alright but insisted that her heart had stopped. Vfe believe that the large amount of saline was definitely life-saving in this case, and that if we had stopped the injection when a spe- cific amount had been given and before return of the pulse, that she would have died. The pa- tient’s own observation of the relief of the car- diac distress due to a low blood volume is also interesting. The second case is one of those remarkable recoveries of a patient for whom we hold a most discouraging prognosis. We acknowledge that the credit for the recovery of this woman should be given to the splendid cooperation of our con- sultants on the medical side. This patient had all the classical symptoms and signs of fibroids and pus .tubes, with a hemglobin of 30% and a mitral stenosis which was compensated. She was given a transfusion of 6 00 c.c. whole blood from which she had a very severe reaction. Rest in bed, tonics, general hygienic measures and a blood transfusion brought her hemoglobin up to 50%. Although she was still a poor risk we decid- ed to operate. What we found was considerably more than we had expected. The omentum was adherent to the front of the uterus, the bladder and the anterior surface of the broad ligaments. The broad ligaments were markedly edematous. The tubes were densely adherent to the ovaries and to the posterior surface of the broad liga- ments, and contained pus. The uterus was ap- proximately 12 cm. in diameter and studded witn small fibroids. Between the fibroids the uterus was soft and fluctuating; having the consistency of a pregnant uterus with fibroids in its wall. When the omentum was released by blunt dis- section a small amount of colon bacillus pus was found beneath each adhesion. As the patient was doing poorly any sort of radical operation was out of the question. Most of the adhesions were released so that a drain could be put in the cul- de-sac. A stab wound was made in one of the fluctuating areas of the uterus and enlarged radi- cally by the finger. A large amount of colon bacillus pus flowed out of numerous pockets in the uterine wall. The cavity of the uterus did not seem to be a part of the abscess cavity. Two cigarette drains were placed in the cul-de-sac and a rubber tube in the uterus. For 2 days this woman had no pulse at the wrist, her extremities were cold and her condi- tion was extremely grave. She was stuporous and apparently had little pain. On the third day she developed an appetite which I think saved her life. After that third day there was never a day when she could not take a full house-tray. Several times during convalesenc-e she showed signs of cardiac failure which were taken care of by the medical chiefs. When we consider that this woman had a postoperative hemoglobin of 30%, mitral stenosis, bilateral pus tubes and an abscessed uterus which were left in her, I believe that you will agree with us that her recovery was remarkable. The last case presents several interesting com- plications. This was diagnosed fibroids and an ovarian cyst. Her hemoglobin was 3 0%. A blood transfusion did little good. The operation was a supravaginal hysterectomy, right salpingectomy and left oophorectomy. Part of the ovarian cyst was so densely adherent in the cul-de-sac that it seemed a part of the peritoneum. A gauze pack was placed in the part of the cyst wall that it was necessary to leave. On the second day after op- eration she suddenly developed pain in the chest, especially severe over the heart. The tempera- ture rose abruptly from 101° to 105°; pulse from 100 to 135; respirations from 20 to 30. Shortly after this, the patient became markedly stupor- ous. Embolism was suspected. On examination Dr. Scanlan found no signs of emboli in the lungs but a definite pulmonic stenosis and mitral in- sufficiency. The temperature, pulse and respira- tory rates gradually returned to normal. On the tenth day the temperature suddenly rose to- 101.6° and signs of thrombosis developed in the left leg, which subsided gradually. On the twen- ty-first day the temperature again rose to 102° and thrombosis developed in the right leg. She had no further distress with her heart. In the light of these later complications it is interesting to speculate if she did not have a shower of small emboli in spite of negative physical signs. Much has been written recently concerning thrombosis and embolism. In a paper from the Mayo Clinic it was reported that in a series of 1712 abdominal hysterectomies there were 5 cases of fatal embolism — 1 .in 342. There are several factors which seem to predispose to the forma- tion of thrombi in the veins. It occurs, most frequently in gynecologic and obstetric operations, especially those involving the hemorrhoidal and pampiniform plexuses of veins. Operation per se, by lowering the blood pressure, slowing the rate of blood flow, and increasing the leukocytes and blood platelets, predisposes to this condition. Pa- tients over-weight, of 40 years or older, seden- tary habits with evidence of poor circulation, such as edema of the legs and and varicose veins, seem especially prone to the formation of thrombi. In- fection, too, seems to play a major part. Polak found the incidence of thrombosis and embolism in 12,000 obstetric and gynecologic cases in his clinic to be 0.5%. On the other hand it is well known that patients with high blood pressures, with very active circulations, seldom suffer from embolism. Working -on the problem from this angle, the Mayo Clinic has suggested that efforts should be made to increase the metabolic ac- tivity and stimulate the circulation in all patients who show signs of circulatory weakness. They prescribe small doses of thyroid extract before and after operation and believe that they are lowering the incidence of this very disastrous complication. BERGEN COUNTY Charles Littwin, M.D., Reporter The- regular meeting of the Bergen County Medical Society was held Tuesday evening, March 10, at the Hackensack Hospital, 60 members at- tending, presided over by the, president, Dr. Joseph R. Morrow. The minutes of the last meeting and also of the executive committee meeting were read and ap- proved. Dr. Morrow reported that, as a result of the .registered letters and his own personal telephone calls to delinquent members, they had all signi- fied their intention of paying. He asked that the matter of suspension be laid over. The advisability of giving up collations was discussed by Drs. Harryman, H'allett, Levitas, 376 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 Vroom and Littwin. It was the consensus of opinion that these should not be dispensed with. Dr. Sarla reported $1631.60 in the checking account and $981 in the savings account, with all debts paid. Dr. Wolowitz reported on the broadcasting over stations WBMjS and WOR and also stated that the post-graduate committee would soon have the details of the course for May. Dr. Kilts stated that a plan for collections was being formulated. The applications of Drs. Joseph A. Rowe, of Ridgewood; Thomas F. Reid, of Cliffside; and Ivan A. Mader, of Hackensack, were read. The following were elected to membership; Drs. J. Willis Demarest, of Hackensack; Franz Kastler, of Rutherford; Trevalyn W. Omstead, of West- wood. The transfer of Dr. Calvin C. F. Bosch, of Iowa, was approved. Dr. Snedecor explained the coming Councilor District Meeting which will be held at the Ori- tani Club, in Hackensack, on April 29, Hudson, Passaic and Sussex Counties joining us. The pur- pose of the meeting and the agenda as listed in the Bulletin were explained. Dr. E. P. Essertier gave a very interesting ac- count of the Child Welfare Conference recently held in Washington. Dr. Frederick Bancroft, Director of Surgery at the Fifth Avenue Hospital, read a paper on “Thrombosis and Embolism”. (To be published in the Journal later.) BURLINGTON COUNTY Roscius I. Downs, M.D., Reporter The regular meeting of the Burlington County Medical Society was held Wednesday afternoon, March 11, at St. Mary's Guild House, Burlington. There were 24 members and guests present, with President Joseph Kuder in the chair. The guests included Drs. George N. J. Sommer, President of the State Society; Irwin E. Diebert, of Camden, and Professor Bryan, of Rutgers University. The minutes of the previous meeting were read and approved. Dr. P. H. Corpening, of Marlton, who was elected to membership at the last meeting, was present and signed the Constitution. An application of Dr. J. George Wagner, of Delanco, for membership to the society, was read and referred to the Board of Censors. The Board of Freeholders will not now pay the usual medical fee of $5 for commitment of in- digent applicants to the county asylum until it is proved that the applicants are destitute. This has been discussed in several meetings with little progress. Dr. Tracy was asked to write to the secretaries of the other societies for their meth- ods of collecting these fees. Professor Bryan, Drs. Sommer and Newcomb presented the program and the advantages for post-graduate lectures for Burlington County. If 15 men will subscribe a general course of lec- tures will be given at the hospital at Mt. Holly. There was immediate response from 14 members with the possibility of several more, so the above lectures are assured for Burlington County. Dr. Newcomb reported that the societies com- posing the Fourth Councillor District, including Monmouth, Ocean, Burlington and Camden, will have a joint meeting in April. This probably will be an evening meeting at the Pine-tree Inn, Lakehurst. D-r. Sommer spoke of the valuable help from the Woman’s Auxiliary. In Burlington County Ilygeia was placed in the high school libraries by the auxiliary. Dr. Hammell P. Shipps, Chairmah of the Sec- tion on -Surgery, announced the following scien- tific program: “Newer Anesthetics and Their Use in General Medicine”, by Dr. Irwin E. Diebert, of Camden, and “Office Reduction of Fractures under Local Infiltration Anesthesia”, by Dr. Hammell P. Shipps, of Delanco. Dr. Diebert said the ideal anesthetic has not been found. Hypnotics are not free of danger. They must be placed in the blood stream to produce re- sults. Ethylin gas is the safest of gas anesthetics. The patient must have a long period of induction as in ether. Its best use is in surgery of the ex- tremities and the thyroid gland. Good relaxation and less bleeding are noted. Ethyl chloride is the most rapid acting anesthetic and more dangerous -than chloroform. Somnoform is a similar pro- duct. Spinal anesthesia is fine for most cases but not for the nervous type. Of the common anesthetics the technic of the rectal use of ether in oil is complicated. The toxicity of novocain, both used locally and intra- spinally, is a definite picture. Convulsions or syn- copy results. It is terrifying but not dangerous. It is due to the paralysis of the vasomotor system and not from paralysis of the cardiac or res- piratory center. This produces relaxation of the blood vessels. Blood, like water, seeks its own level. Keeping the head lower than the feet pre- vents the catastrophe. Of the newer preparations percaine or new- percaine was mentioned. Sleep will last from 4 or 5 to 24 hours. These hours of relaxation are beneficial in cases of fracture of femur. Avertin, given rectally 15 minutes before an operation, produces a profound sleep. It is necessary to supplement this with other anesthetics. There is no vomiting and the patient needs less attention after operation. A chemically pure drug is not possible, however. Pernatin is similar to sodium amytal. It is made chemically pure and is given preliminary to ether. Intravenous solution of sodium amytal is not on the market. It is in- jected slowly like neoarsphenamin producing sleep in 3 minutes. Now sodium amytal is given by mouth before operation. It is given at 9 p. m. the night before and 6 a. m. before the oper- ation. Before this 15 gr. of luminal were given in 2 doses of 7 % gr. each. This is beneficial in vomiting of pregnancy and alcoholism. Dr. Shipps’ method of local anesthesia in re- duction of fractures is an infiltration above and in gap of fracture with the local anesthetic used. The technic is as follows: With careful aseptic and antiseptic preparation the skin, subcutaneous tissue, muscles (little in muscle) and blood-clot between the gap of fracture are infiltrated; 20-150 c.c. of V2 % solution of cocain, procain or novo- cain are used. Wait 15 to 30 minutes and re- duce the fracture. A marked relaxation is pres- sent which makes reduction simpler and painless. It is indicated especially in the aged and debili- tated and for skull fractures. It is contraindi- cated in compound fractures and in the presence of infection. It is a safe procedure in the office. Following an excellent meal, the meeting ad- journed to reconvene in May. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 377 CAMDEN COUNTY Robert S. Gamon, M.D., Reporter The regular monthly meeting of the Camden County Medical Society was held on March 3, 1931, President W. J. Barrett in the chair. The chairman of Committee- on Post-Graduate Instruction for this society reported that courses would start on Wednesday, April 1, and con- tinue each successive Wednesday over a period of 8 weeks. Gloucester County will com- bine with Camden County in supporting these lec- tures. The application blanks are now in the hands of the members of the society. The Committee of Resolutions presented its report on the recent death of Dr. John W. Donges, an honorary member of this society. (See obituary columns.) The Scientific Program consisted of 2 excellent papers. Dr. R. K. Hollinshed, of Gloucester County, by invitation, rendered a paper on “A Review of Some of the Recent Literature on An- gina Pectoris and . Coronary Artery Disease”. The paper was well received and was discussed by Drs. Shafer, Goldstein, Browning, Reik and Hol- linshed. The second paper was given by Dr. S. Snedecor, of Bergen County, by invitation, on ‘‘Shall the Doctors Advertise?” The speaker’s re- marks were illustrated with lantern slides. The paper was discussed by Drs. Reik, Lippincott,' Lee and Del Duca. Among the guests from the other societies were: Dr. H. O. Reik, Editor of the State Journal; Dr. Tracy, Secretary of Burlington County So- ciety; Drs. Diverty and Hollinshed, of Gloucester County. The meeting was well attended. ESSEX COUNTY E. LeRoy V/ood, M. D., Reporter Dr. George J. Holmes, Director of the Depart- ment of Health Education of the Newark Public Schools, was the principal speaker at the meet- ing of the Essex County Medical Society, held Thursday evening, March 12, in the auditorium of the Academy of Medicine, taking for his sub- ject “What is Medical Inspection of Public School Children Doing for the Child and for the Physi- cian?” When Dr. Holmes took office in 1901 his main work was the detention of infectious and contagious diseases among the pupils. Now the work has developed to embrace instruction in preventive medicine and hygiene. At the present time emphasis is laid on disease prevention and on the prevention of bad results of physical de- fects. The school authorities do not propose to enter the practitioner’s field of treatment al- though their work with mental defectives, crip- ples and undernourished children may verge on such field. He outlined the development of the Medical Department of the Public School System, with its many ramifications through assistant physicians, consultant specialists, dentists, nurses, nutritionists, gymnastic instructors, oral hygien- ists, child guidance specialists, and said that the objective is complete instruction in conservation and improvement of health. Dr. Holmes display- ed charts showing the organization of his de- partment. Dr. George T. Palmer, D. P. H., Director of Division of Research, American Child Health As- sociation, opened the discussion, saying: There are 3 clear-cut reasons for medical service in the schools. In the first place, the state, in compelling people to send their children to school, is in duty ■bound to furnish reasonable protection against the hazards of school life; for there are hazards in going to school. The possibility of contracting communicable disease is increased when large numbers of children are brought into close con- tact. In going to school the preschool child passes from the shelter of his mother’s wings into a new world where he must begin to take care of himself, and schools should do their best to see that his health is not injured in the process. The schools need medical advice in planning pro- tection against the spread of communicable dis- eases. This means the encouragement of im- munization against smallpox and diphtheria, close daily observation of children to detect signs of disease in their incipiency, and rules on the re- admittance of children after illness. In the second place, schools very properly should protect their investment. If some children can’t hear the teacher, or see the blackboard, or are absent a great deal because of colds, and if some of these conditions can be improved by medical attention, then it is good business on the part of the schools to help direct children to places where corrections can be obtained. It is certainly proper ffcr the schools to help parents make children receptive to an education; it saves the expense of repeated grades and is of definite service to the child and his family. For children more severely handicapped, medical advice is needed in selecting such children as are in need of special instruction methods. In short, the schools are justified in establishing some system of physical and mental appraisal of their pupils. In the third place, education consists in part in assisting the child to develop and take care of himself. Care of health is a proper subject in the curriculum, as much so as arithmetic. One of the ways of teaching health preservation is through the medical examination. If painstak- ingly done and if the parent is present, the school physician has the opportunity to convince the parent and the child that there is something in the medical examination that will be useful in later life. If the examination is superficial the parent and child are quick to detect it. In the school examination the medical profession is on exhibit before the school child and his parent. It is within the school physician’s power to either make converts to preventive medical service or to lessen popular faith in this service. I think that organized medicine has not sufficiently real- ized the extent to which the kind of a perform- ance that the physician puts on in the school may affect medical practice later on. These 3 uses of medical service are proper for the schools and are a matter of public in- terest transcending private interest. What are the problems of medical service in the schools? The first is to find physicians who will do medical inspection for the salaries offered and who will take the job seriously. The next prob- lem is administrative — how to deal with children in the mass. This differs from the work of the private practitioner who is dealing with indi- viduals. What can 1 physician, on part-time, do for 2500 children? His first inclination is to look for short cuts, for some simple way of reducing this task to manageable proportions. This is a perplexing problem; how to reach the children 378 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 that need medical attention without himself slowly and laboriously examining the whole lot. Another problem facing the school authorities is how to get the children, whom the school physician, after much effort, has discovered as needing further professional attention, to actually get this attention. This is a question that has to do with the parent, the private practitioner and the public clinics. In some cities, in order to meet the needs for corrective attention, schools have established their own corrective clinics. There may be good reasons for doing this in some localities. In principle, however, I would say that the schools should not go beyond the point •of discovering and referring cases for outside pro- fessional attention. It would seem much better policy to depend on the private practitioners and the hospitals to provide such facilities. But, in so far as this service cannot be obtained either because of expense or other reasons, the schools are tempted to supply this demand. Naturally, the schools, after efforts to discover physical handicaps, are anxious to see that such handi- caps as are correctable do receive proper atten- tion. This is a problem that organized medicine ought to help the schools to solve. How has school medical inspection worked out in practice ? An enormous number of inspections and examinations have been made. Many physi- cians have .given splendid service, with little or no recompense. But, generally speaking, for the country as a whole, the school medical inspection or examination program is inclined to be some- what sketchy and superficial. Frankly, some of it is probably worthless, and might better not be done. Some states require annual medical inspec- tion of every child. These laws might better be changed, for they, as much as anything else, are responsible for superficial work. If to comply with the law the physician has to inspect every child annually he is forced to work very fast super- ficially on each child. He can’t do otherwise. The schools want a high medical service that will be educational as well as effective, but they haven’t been willing to pay the necessary price. It is difficult to get and hold sufficient competent physicians to enter and stay with this work long enough to solve some of the perplexing difficul- ties. There is no professional prestige for the physician in such a position unless the physician is under a health department or a medical in- stitution and assigned to the school work as part of his job. It is hard to find men willing to de- vote their full time to this medical administra- tion in the school. There is very great opportunity for improvement in this field. What has medical inspection done for the child? In spite of its administrative short comings it has stirred great numbers of parents to seek medical advice for their children; people who probably would never have sought such attention otherwise. This advice has been sought from the private practitioner as well as from public clinics. A note from the school physician started me to the oculist with my child about 2 years ago. The net results of medical inspection in terms of improved national health are difficult to measure but that benefits have resulted is hardly disputable. What has medical inspection done for the prac- ticing physician? It has increased his practice, it has opened his eyes to the wide prevalence of physical handicaps existing even among pre- school children, and it has turned the more pro- gressive men back to the medical school for post- graduate work. In the last few years one of the medical schools of the middle west has had many men register for post-graduate work in pedia- trics and these physicians say that they want ad- ditional training because their patients are de- manding a type of service that they are not pre- pared to give. How can school medical inspection be improved? One way is for organized medicine to take a greater interest in the subject and lend serious aid in trying to solve some of the difficulties. Hospital staffs might assign a number for ad- visory service. One of the most hopeful signs is the recent meeting of the Medical Section of the White House Conference, in Washington. Here were assembled hundreds, of physicians, many representing different specialties together with physiologists, anatomists, biometricians, deans of medical schools, dentists, nurses, hospital social workers, nutritionists, lexecutives of voluntary health associations and of official health agencies, each meeting the other on equal terms, each recognizing that each group has something to contribute to the question of health service for children. It means a great deal when people recognize the limitations of their own special field and are willing to contribute their bit to the solution of problems that need social as well as medical correction. School medical inspection can be improved if schools and school medical officers will keep certain objectives clearly before them, definitely fix responsibility, and not overstep the bounds into fields better conducted by others. It can be improved by repeal of compulsory annual inspection laws which would entail pro- hibitive costs if properly carried out and by schools getting away from the idea of quantitative service and substituting in its stead service of a better quality. Service should be extended only as funds are forthcoming to permit this extension at no sacrifice of quality. The relations of the schools to the private prac- titioners can be improved if extensive programs involving the practitioners are adopted only after consulting the organization representing the practitioners concerned; instead of adopting pro- grams and then expecting practitioners to fall into line. The application of medical service to schools can be improved if foundations will con- tribute funds for administrative research to help work out reliable methods and routines, and scientific ways of measuring results. The height- weight-age tables have had great vogue in the schools as a means of picking out under-nourish- ed children. Recent research has shown us that underweight is largely due to skeletal variations such as narrow hips, narrow and shallow chest. Weight is determined very largely by skeletal build. The heavy child, as a rule, has a broad and deep skeletal framework; the lightweight child a slighter framework. Nutritional status is better measured in terms of girth and condi- tion of subcutaneous tissue, and yet an enormous amount of attention has been showered on under- weight. We need better methods of discrimi- nating which children need this special attention. It is frequently said that medical knowledge is 20 years ahead of the application of this knowl- edge. I am inclined to doubt this in the field of school health work. I have a feeling that prac- tice is catching up, if it is not getting well ahead of knowledge; that some things are being done for which there is very inadequate justification. April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 379 Research is needed to bring scientific knowledge abreast of current practice. I have tabulated the results of a survey of the use of medical and dental service for pre- school children in 146 cities of the country. The results came from inquiries at the individual homes of 140,000 children under 6 years of age. These surveys were carried out during the past 8 months under direction of the Medical Section of the White House Conference on Child Health and Protection. This inquiry covers 4 types of service — health examinations, dental examina- tions, vaccination and immunization. Six New Jersey cities are included. In the average city the proportion of children under 6 years of age who at some time in their lives have had a health examination — while well — is 48%. The percentage in Newark was 49, or just above the average. East Orange was 71%, Trenton 67%, Elizabeth 51%, Passaic 40% and .Camden 32%. In Newark only 3% of preschool children have had a dental health examination; 19% have been vaccinated, and 23% immunized. These figures for Camden were, 32% health ex- amination, 3% dental examination, 13% vaccin- ated, 5% immunized. For Elizabeth, 51% health examination, 5% dental examination, 12% vaccin- ated, 23% immunized. For Trenton, 67% health examination, 7% dental examination, 27% vac- cinated, 10% immunized. For East Orange, 71% health examination, 22% dental examination, 24% vaccinated, 36% immunized. No city of our state was included in the groups of the 5 cities ranking highest among the 146 cities in each of 4 health measures. Dr. Henry C. Barkhorn, President of the Essex County Medical Society, then introduced Miss Janet M. Geister, R. N., Director at Headquarters, American Nurses Association, who spoke on the subject “Nursing Mr. Middle-Man’r and reviewed some of the present day economic problems of organized nursing. The high cost of sickness is attracting considerable attention and the middle class family with limited means finds difficulty paying a day and night nurse $7 each, plus board, for any length of time. Miss Geister said that this per diem charge could not be reduced by the nurse because she only has work 8 months each year and is only paid for 7, and she must be al- ways available. Miss Geister suggested as reme- dies part-time nursing in the home according to the needs of the patient, and staff nursing in the hospitals, giving the patient only the amount of actual special nursing he needs and charging him proportionately, saving him from paying for the nurse’s idle periods. Drs. M. Weinstock Bergman, Giovanni Fasano, and. Nicholas L. Pollis, all of Newark, were elected members of the society. Eye, Ear, Nose and Throat Section Academy of Medicine of Northern New Jersey E. LeRoy Wood, M.D., Secretary Dr. J. Wallace Hurff, Chairman of the Eye, Ear, Nose and Throat Section of the Academy of Medicine, devoted the meeting held Monday eve- ning, March 9, to reports of interesting cases. Dr. B. M. Hawley, of New Brunswick, reported a case of “Mastoiditis wi,th Complications”. J. M., colored, aged 34, came to see me on September 23, 1 9 30, suffering with suppurative otitis media on the right side. His trouble began 3 weeks pre- viously following a cold for which he had been treated by his family doctor. Severe pains had been with him for about 48 hours. Paracentesis was done at once, with immediate relief and a free flow of pus. I saw him 2 days later when the discharge was very profuse and he was feel- ing very well. A week later his family doctor phoned me that he had a chill, but otherwise was all right. I advised his removal to the hospital for an x-ray examination and observation. In- stead of going to the hospital he called at my of- fice saying that he was feeling well excepting for a severe headache. Examination showed no dis- charge in the canal; drum membrane was red- dened and suggestive of pus or infection still there; absolutely no pain on pressure over the mastoid. X-ray examination showed mastoiditis with most of the trouble in the attic. At operation on October 6 the mastoid was found badly in- fected; pus was plentiful from the attic to the tip; lateral sinus was uncovered showing an in- fective thrombosis. The sinus clot was removed and the wound packed with iodoform gauze. He was discharged from the hospital in a week, hav- ing run a perfectly normal temperature from the day of operation. He came to the office for his mastoid dressings and about October 28 com- plained of some headache, which became more severe the next day, and on the following morning at 2 a. m. I received a telephone call stating that the man was unconscious. I ordered his removal to the hospital and saw him about 7 a. m. when he was absolutely unconscious; pupils moderately dilated, and a slight stiffness of the neck. Spinal puncture was done; the fluid was cloudy. The old wound being re-opened and cleaned out, the sinus held a clot but no free pus was found until a probe was passed through the dura in the region of the sinus. This was opened wider and con- siderable pus escaped. A probe passed into this abscess cavity about 1 % in., so an iodoform gauze drain was inserted and the rest of the wound packed. The Wassermann had been nega- tive, but he acknowledged a specific infection acquired 7 years before, and for which he had received treatment. In spite of negative Wasser- mann I felt that his previous syphilitic state had something to do with the present sickness, and gave him on the day of operation an injection of sulpharsphenamin. It looked very much as if the man was going to die and I did not think the injection would do any harm. The next day the patient was very much better, answering ques- tions and understanding most everything that was said to him. Pus obtained from brain abscess and cultures of the spinal fluid J>oth showed the Friedlander bacillus. The patient showed steady improvement com- plaining mostly of weakness in the legs, not being able to walk very far, and at the end of 4 weeks he was discharged from the hospital and 3 weeks later went back to work. The question, that I would like to present to you is — -“Do you think the sulpharsphenamin did any good or was it a useless effort?” Personally, I think it did good. Examination of records shows that infection of the meninges by the Friedlander bacillus is rare and that when such infection occurs it is gen- erally fatal; there being only 2 or 3 authentic re- coveries on record. Dr Nathan Zvaifler, of Newark, reported 3 cases 380 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 from the Beth Israel Ear, Nose, and Throat Ser- vice. Case 1. M. S., first seen in the clinic with diag- nosis of left optic atrophy, cause unknown. Ex- amination was negative except for a deflected septum and hypertrophied middle turbinates; the left antrum was slightly cloudy but irrigations were negative. Radiogram of the sinuses reveal- ed no further pathology. He was admitted to the hospital and a submucous resection and double turbinectomy were done. The operation was per- formed with no special difficulty and nose was packed with vaselin gauze. Next day at 8 a. m., about half of packing was removed; temperature 100.2°; patient had no complaints. At 10 a. m. complained of headache, 'which became pro- gressively worse, and by 3 p. m. he was very restless, slightly irrational, and picked the re- maining packing from his nose. Temperature at this time was 102.6°. At 9 p. m. he was delirious; temperature 103°; stiff neck and suspicious Ker- nig. Lumbar puncture revealed a cloudy fluid under pressure; reported later to be pneu- mococcus type 4. Blood culture done at same time showed the same organism. Lumbar punc- tures were done twice daily. ; he also received some antipneumococcus serum. Condition became steadily worse and Dr. Barkhorn and I did a wide decompression for frontal head sepsis. The frontal sinus showed hyperplastic mucous mem- brane from which the pneumococcus was obtain- ed on culture; there was no bony erosion nor any localization of the process revealed in our wide exposure. Autopsy did not disclose clearly any route of in- fection from nose to brain and we thought most likely that the meningitis and abscess were sec- ondary to a septicemia caused by osteothrombo- phlebitis of one of the smaller veins. Case 2. J. T., 3 years old, was admitted to the hospital with diagnosis of meningitis. The his- tory went back 3 weeks to a sore throat with tem- perature of 102° in the morning and in the even- ing normal. On December 27, about 10 days be- fore admission, a swelling was noticed on back of left thigh. Both father and mother were syphil- itic and the child had a -)- 2 Wassermann. Ex- amination showed a swelling of the left thigh and a suspicious Kernig; no stiff neck; no abnormal reflexes; temperature 101.5°. Lumbar puncture showed fluid under marked pressure and about 30 c.c. were removed. Examination of the fluid at this time was entirely negative except for posi- tive Wassermann and Kahn. Immediately after the lumbar puncture the child shot a temperature of 105° and on this date the pediatrician noticed a red ear drum on the right side. The child daily became worse and another lumbar puncture was done which showed markedly cloudy fluid with 380 white cells to the field, and on smear streptococcus hemolyticus; at that same time the ear was bulg- ing. I saw the child and advised an immediate mastoid operation, which was done the same evening. Mastoid was completely necrotic and a wide exposure of the dura and sinus was made. The child did badly and died 2 days later. Autopsy examination and review of the his- tory led to the conclusion that the cerebral con- dition and the abscess of the thigh were secondary (the latter metastatic) to infection of the blood stream from otitis media at the time of the re- ported sore throat. Case 3. Child, J. S., with history of having as- pirated a pin 1 year before and been for past few months treated by various physicians for a per- sistent cough. Finally, one day she coughed up what appeared to be part of a pin. X-rays showed rest of pin in the left lower bronchus. In New Y’ork she was bronchoscoped unsuccessfully and came back to Newark. That night she suddenly developed a severe pain in the chest with cyanosis and rapid respirations, and was brought to the hospital where diagnosis of traumatic pneumo- thorax was made. Radiogram revealed a com- pletely collapsed lung with pin in the lower left bronchus and an infection of the pleural cav- ity. It seemed inadvisable, and was probably im- possible, to reach the foreign body through a bronchoscope with the lung in that condition, and a thoractomy was done to relieve the empyema. The lung failed to expand and she had a per- sistent fistula from the operation with a thick- ening of the pleura and an encapsulated empyema. In January of this year, 3 months later, she sud- denly coughed out the rest of the pin from the collapsed lung, in spite of the fact that it had been collapsed for 4 months or more. She was recently operated on again to break up the ad- hesions in the pleural cavity and to drain the re- maining collection of pus. Dr. James B. Shannon A, of Montclair, reported a case of “Brain Abscess with Pneumococcal Menin- gitis and Recovery. May 9, 1930, P. P„ male, aged 19, admitted to Mountainside Hospital on the service of Drs. Richardson and Moore, with a provisional diagnosis of bilateral chronic mas- toiditis complicated by intracranial extension. His- tory of discharge from both ears for 17 years; some transient pain in ears and headache since 1917. Three days prior to admission, developed in- tense pain over the right mastoid region, which became progressively more intense. Day before admission had a chill, followed by high tempera- ture, mental depression, unbearable headache and vomiting. On admission, temperature was 105°, pulse 100; W. B. C., 16,100; 82% polymorphonuclears. Spinal fluid cloudy and under increased pressure (no manometer reading made); 8400 cells per c.c. Positive pneumococcus smears; and cultures showed pneumococcus, type 4. Blood Wasser- mann 4 + . Radiograph showed infantile sclerotic mastoids with no detail; far forward sinus. Patient was very listless but could be aroused, moaning with pain. When strenuously aroused, cerebration was slew, but patient seemed tran- siently oriented. No motor aphasia. Pupils- small, sluggish; right larger than left. No nystagmus. No paralysis. Hyperemia of left fundus. Blur- ring of right disc. Foul discharge from both ears, more profuse from right. Tenderness over both mastoids, more pronounced on right. Canal on right side boggy, obscuring view of drum. Left drum depressed; high attic erosion with cavitation, containing cholesteatomatous ma- terial. Hearing loud voice at auricle. Marked re- traction of head, with rigidity of neck, which could not be overcome. Good coordination con- sidering patient’s lethargic state. No clonus, geniculars absent. Positive Oppenheim and Babinski. A few hours after admission a right radical mastoidectomy was done; the sinus exposed and examined, appeared normal; middle fossa ex- posed and dura found covered with unhealthy granulation tissue. Incised and more than 2 oz. of thick, foul pus evacuated from a large en- cysted temperosphenoidal abscess cavity. Drain- age with soft rubber dam; wound packed open April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 381 around drain. Culture from mastoid and ab- scess cavities showed pneumococcus. The following 6 days presented a rather stormy period, patient having to be kept under restraint, irrational, garrulous, and taking off bandage. Spinal taps were carried out twice daily with difficulty. There was a progressive decrease in cell count in subsequent specimens of spinal fluid. The last positive pneumococcic culture was ob- tained 4 days after operation. Temperature ranged from 100°to 104.6°; pulse 60-100. On the seventh day postoperative the temperature and pulse returned to practically normal and remained so. Six weeks after the initial operation a sec- ondary flap and closure operation was done. The radical cavity being packed with iodoform gauze around the wick of rubber dam, draining the ab- scess cavity. Drain permanently removed 2 weeks later and patient discharged to out-patient de- partment. Complete healing of radical cavity 10 days after discharge.' I do not consider this an unusual case, nor a permanent recovery. A recent review of some 5 0 brain abscess cases of otitic origin, with varying degrees of meningitis, reminds me our bubble of elation over apparent success is all too often ruptured at a subsequent autopsy. In the case of this patient, I feel that the future is very uncertain; a potentially dangerous ear needing operation, for which he has not, been willing to give consent; an established syphilitic infection; an encysted chronic temperosphenoidal abscess, which has not been obliterated and which may or may not be sterile; and some residual signs of encephalitis. At least no meddlesome surgery has been done to date. What the even- tualities of the future may be, I am not *prepared to say. Dr. Lyndon A. Peer, of Newark, reported “Plastic Repair After Radical Frontal Sinus Operation and 2 Cases of Rhinoplasty’’. The first case which I am presenting tonight is that of a young girl who came to the City Hospital 1 % yr. ago with an acute left frontal sinusitis. The sinus was oper- ated on externally and free drainage given into the nose and outside over the brow. Improved slowly for 2 weeks and then began to have fronto- occipital headache, chills and a high temperature. A second operation was performed in which a large portion of the frontal bone adjacent to the left frontal sinus, including the inner plate of the sinus and entire brow, had to be removed in order to reach healthy bone. The wound was left wide open, exposing the dura. The patient left the hospital 2 months later cured of her osteomyelitis, but there remained a wide scar in the forehead closely adherent to the dura and a deep depression over the left brow. As the young lady was very sensitive about her deformity I performed a plastic operation. The scar first had to be removed carefully from the external sur- face of the dura. I then rotated the deeper tis- sues so as to fill in the depression and approxi- mate the skin edges. As you may see by com- paring her present appearance with this photo- graph taken before operation, she has a very satisfactory result. Case 2. This patient had a hump over the bony bridge of her nose which caused it to appear twisted to the right. The line of the dorsum of the nose exclusive of the hump was straight and all that the patient required was removal of the hump. This was accomplished through an alar incision in the vestibule to prevent an external scar. In these cases it is best to remove the periosteum first before chiseling off the bone, and if a groove remains it is necessary ,to refracture the nasal processes and squeeze the bone together to fill in the groove. Case 3. An examination of the original photo- graph taken before operation shows the bony bridge displaced to the left and a saddle in the re- gion of the cartilagenous bridge. A submucous re- section had been performed 15 years ago, but the cartilage support remaining was twisted to the left and prevented setting the bones in a mid- plane. It was first necessary to remove part of this obstructive cartilage bar. The bones were then fractured and set in correct position and the sad- dle filled with strips of lower lateral cartilage taken from the alar regions and transferred to fill out the depression. Dr. Henry C. Barkhorn, of Newark, reported 3 cases of “Head Sepsis’’. He discussed the path- ways of infection in intracranial sepsis, describ- ing a case of pia-arachnoid abscess from the frontal sinus, a temperosphenoidal brain abscess from the ear, and a meningitis from the petrous tip and labyrinth, to illustrate anterior, middle and posterior fossal types. Dr. Dennis F. O’Connor read the report of the Nominating Committee, which was composed of Drs. Elbert S. Sherman, Chairman, Dennis F. O’Connor and Henry C. Barkhorn, naming for the new officers: Chairman, Dr. C. W. Buvinger; Sec- retary, E. LeRoy Wood. There were 40 present, and the meeting ad- journed at 10.45 p. m. Academy of Medicine of Northern New Jersey E. LeRoy Wood, M.D., Reporter The Annual Meeting — and Twentieth Anniver- sary— of the Academy was held at 91 Lincoln Park, Newark, Thursday evening, March 19. The Nominating Committee recommended for consideration the following list of officers: Presi- dent, Wells P. Eagleton; First Vice-President, F. DuBois Bunting; Second Vice-President, Walter B. Mount; Secretary, Adrian R. Kristeller; Treas- urer, Henry C. Barkhorn; Trustee, John F. Hag- erty; Library Committee, Frank W. Pinneo; Cor- responding Secretary, Harvey Herald; Committee on Admission, B. E. Failing. Dr. H. J. F. Wallhauser, Chairman of the Nom- inating Committee, paid tribute to Dr. Newman, who has served as Secretary of the Academy more than 15 years. He suggested the position of Secretary Emeritus, be created for Dr. Newman and this was done. Speakers at the meeting were Ferdinand Pe- cora, former assistant district attorney of New York County, and Prosecutor Joseph L. Smith, of Essex County. Mr. Smith declared an undesir- able tendency on the part of the public to criticize public officials has sprung up recently. Mr. Smith paid tribute to Dr. Harrison S. Martland, chief Essex County Medical Examiner, as “the greatest member of his profession in the county and one of the greatest aids we have in the prosecution of many criminal cases”. Mr. Pecora, speaking on “Social Responsibility for Crime”, declared the legal profession, as lead- ers in the "handling of crime, could learn a lesson from medical practice in this work. He pointed 382 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 out that physicians have come to realize the value of preventive medicine and have developed health codes and practice to prevent epidemics, in addition to the usual curative procedure and quarantine measures after disease appears. “The legal profession has done too much legis- lating, given too much attention to penal laws, spent too much time dealing with the criminal, the diseased person. It has not given enough at- tention to the social agencies that can eradicate crime, that can eradicate conditions which breed crime germs and convert otherwise healthy boys and girls into criminals. It is better to prevent the making of criminals than to deal with them afterward.’’ The former New York prosecutor pointed out that criminals every year are appearing in younger groups. He declared the solution to crime must be found in training of the young either by their parents or otherwise. “Stricter laws”, he said, “have deterred professional crim- inals from continuance of crimes of violence, but have not stopped the making of young gangsters.” Mr. Pecora attacked the growing complication of law, declaring legislatures “have been tinker- ing with the penal law continually for more than a century”. “In the penal code of New York”, he said: “There are dozens of sections devoted to the crime of larceny. The student of law must read hundreds and hundreds of pages of judicial opin- ions also in order to understand the law on lar- ceny. The same is true in regard to homicide or perjury or any other felony. And yet each of these 3 could be summed up in one of those older laws, so much simpler, so much plainer. Larceny law is no more than a development of 'Thou shalt not steal’. The others, too — homicide — ‘Thou shalt not kill’, per- jury— ‘Thou shalt not bear false witness.’ How much simpler this is, how much wiser.” The Academy of Medicine of Northern New Jersey Ralph Kristeller, D.D.S., Assistant Secretary At the twentieth anniversary meeting, Dr. Er- win Reissman entertained the Honorable Fer- dinand Pecora who was the essayist of the even- ing. Honorable Ferdinand Pecora presented a new outlook to many of us, especially as to the close relationship between our relative professions. He stated that the legal profession would do well to follow our example of finding the cause for the disease rather than the cure for the one already afflicted. In summarizing his lecture he went back to the Ten Commandments, saying that much legal phraseology and interpretation could be condensed to “Thou shalt not kill”, “Thou shalt not steal”, and “Thou shalt not bear false witness”. If these were taught more diligently in the home, all children of tender years would understand their meaning. Prosecutor Smith was called from the audience to deliver a short address. Prior to the former assistant district attorney’s talk, the Chairman of the Nominating Committee, Dr. J. H. F. Wallhauser, read his report. For President, Wells P. Eagleton; Vice-President, P. DuBois Punting; Corresponding Secretary, Har- vey Herald; Secretary, Adrian Ralph Kristeller, D. D. S.; Treasurer, Henry C. Barkhorn; all the above nominated for the term of 2 years. Trustees for 5 years, E. Reissman, J. F. Hag- erty; Committee cn admission for 3 years, B. E. Failing; Library Committee for 3 years, H. R. Livingood. Following this he paid a most glowing tribute to the efforts of Dr. E. D. Newman, who for the past 18 years has held the post of Recording Sec- retary, and by resolution favored creating the post of Secretary Emeritus, which was passed unanimously. He then nominated Dr. E. D. New- man for the position which report was greeted with tremendous applause. The past year has been one of very great pro- gress in the annals of the Academy of Medicine. Dr. Reissman has achieved the distinction of ■having large audiences at the stated meetings. He has had as his guests essayists from far and near, even going so far as Montreal in quest of them. During the present regime, many beneficial changes have been made in the building of the Academy. Two plaques have been erected in ap- preciation of gifts previously given, one to the Dean of the Newark Medical Profession, Dr. E. .1. Ill, and the other in memory of Dr. William Disbrow. GLOUCESTER COUNTY Henry B. Diverty, M.D., Reporter An especially interesting session of the Glou- cester County Medical Society was enjoyed at the Country Club, Thursday evening, March 19. Dr. Thomas C. iStellwagen, professor at the Jefferson Medical College, took for his subject “Some Phases of Genito-Urinary Surgery of In- terest to the Genera] Practitioner”. Dr. George J. Mullershon, a former resident of this community, also spoke. Lectures concerning the post-graduate courses in cardiac diseases and gastro-enterology to be conducted by the Medical Society of New Jer- sey, in cooperation with the Rutgers University of New Brunswick, were discussed at great length. The course will start Wednesday, April 1, at the Camden Dispensary, 729 Federal Street, The Educational Committee from Camden and Gloucester Counties includes Drs. A. H. Lippin- cott, Benjamin F. Buzby, Paul Mecray, Thomas K. Lewis, of Camden; R. K. Hollinshed, West- ville; H. B. Diverty, Woodbury; and S. F. Ash- craft, of Mullica Hill. Those attending the meeting were: Drs. I. W. Knight, W. J. Burkett, J. Harris Underwood, O. R. Wood, James Hunter, Jr., A. B. Black, Dun- can Campbell, Ralph Hollinshed, E. E. Downs, Harry Nelson, Paul Pegau, H. W. Stout, C. I. Ulmer, and H. B. Diverty. Guests included Drs. Corson, of Bridgetown; Reik, of Alantic City, Editor of the State Medi- cal Journal; Casselman, of Camden, and Church, of Salem. HUDSON COUNTY E. G. Waters, M.D., Reporter The monthly meeting of the Hudson County Medical Society was held at the Carteret Club, Jersey City, March 3. The paper of the evening was by Dr. Wells P. Eagleton, of Newark, who spoke on “Complica- April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 383 t;ons of Cranial Injuries”. The first part of the paper was accompanied by a lantern slide demon- stration in comparative anatomy of the central nervous system, with especial reference to pro- gression of the higher centers and retrogression of the olfactory areas in the ascending scale of development. The presentation was enhanced by Dr. Eagleton's charming personal observations of developmental changes of special importance, and of many of the physiologic experiments marking mile-stones in our understanding of what are now accepted as facts. Dr. Eagleton then discussed fractures of the frontal and temporal regions of the head, con- trasted with regard to their resistance to infection, and the effects of direct trauma. Fractures of the frontal region are of importance because of the anatomic configuration which permits the rapidly growing mucous membrane of the nose and air sinuses to invade a rent in the dura before the latter has had a chance to grow. Thus, when the dura has been broken, or the -blood sinuses in- volved in a frontal fracture, there is an excellent chance for either immediate or late infection. The patient may apparently recover, yet die months later when he contracts a head cold, the infective organisms of which invade the brain via the mucous membranal tract laid down long before. When the dura is not broken, there is seldom danger from this source. Fractures in the temporal region present quite another problem. Here, the dura, less intimately adherent to the bone, is less frequently torn by a fracture. Also there is no rapidly growing epithelial surface to invade the fracture line, as the area is well cov- ered by the temporal muscle and fascia. But here we have something else of importance. The mid- dle meningeal artery courses this region and is usually involved in linear fractures. When it is torn, it is unable to retract as most arteries do, for it is firmly held by the dura, and bleeding con- tinues. Dr. Eagleton stressed repeatedly the so well known but so easily forgotten “free inter- val” symptom of this type of fracture, where the patient gets up after the injury, and subsequently becomes unconscious as the accumulating sub- dural blood causes increasing intracranial pres- sure with progressive embarrassment of the vital ■centers. This type of fracture requires imme- diate operation to save the patient’s life. Its treatment is quite in contrast with other types of fracture, where the fracture is unimportant, the cerebral trauma being the important and unfor- tunately irremediable factor. Dr. Eagleton talked on fractures involving the auditory apparatus, emphasizing the necessity of not interfering or washing out the ear, lest a bad condition be made worse by inducing infection. Slides depicting various types of skull frac- tures with their all-important attendant brain in- jury were shown. After all, a fracture is nothing, unless brain injury accompanies it. And when the brain -is injured, no man may say how or when the patient will recover, for permanent changes all too frequently follow. Dr. Eagleton discussed at some length the medicolegal difficulties encountered in defining the effect of brain trauma, which effects are often profound without having any serious objective findings. When he concluded, many questions were asked and a lively discussion brought out many points of practical interest and stressed many of those which had been mentioned in the presentation. Clinical Society of North Hudson Hospital J. Africano, M.D., Reporter The regular monthly meeting of the Clinical Society was held Tuesday, March 10, with Dr. Pellegrino D’Acierno acting as chairman; 52 members and guests were present. Dr. Tannert read the hospital report for February: 195 ad- missions; 244 discharges, 17 deaths, of which 5 were medical, 5 surgical, 1 new-born, 1 E. E. N. & T., and 5 pediatric; 4 autopsies were performed. D-rs. Klaus and Pcarlstein discussed plans for the Annual Staff Dinner to be held on Wednesday, March 25, at 9 p. m., at the Paramount Grill, New York City. Dr. Klaus discussed the death of a patient with final diagnosis of ileocecal intussusception and edema of the lungs. A male child, aged 5 V2, complained on the first day of abdominal pains, vomited on the second day, and had more severe colicky pains on the third, when he was admitted to the hospital, February 22. There was tender- ness in the R. L. Q., with some rigidity and -slight distension; temp. 102°; W. B. C. 13,000; polys, 80%. The picture was that of acute ap- pendicitis. Dr. Losche suggested Intussusception when he did a rectal examination and believed he felt a mass, but there were no gastro-intestinal symptoms except the vomiting — no diarrhea or bloody stool. At operation an intussusception of the ileocecal type was found, the ileum entering with the valve into the cecum for a distance of 8 in.; the bowel itself was not gangrenous; how- ever, the appendix was kinked and bound down by adhesions, and intensely inflamed. It was re- moved because so severely diseased, and the in- tussusception reduced. The child developed a distended abdomen and expired on the fourth day postoperatively, from paralytic ileus. Dr. Klaus felt that this child should have gotten well, and emphasized certain points regarding the surgical aspects of intussusception, gleaned from exper- ience and not often referred to in text-books: the surgical treatment usually consists of reduction of the intussusception, thus restoring the con- tinuity of the bqwel; if the intestine is gan- grenous, a resection is indicated, but these are bad subjects for such a procedure; an intus- susception is one of the most disastrous catas- trophies in a child, analagous to perforated gas- tric ulcer or to acute pancreatitis in an adult; the appendix is practically in all cases found to be congested, edematous, and 2-3 times the normal size—actually it is part of the same condition, i. e., secondary to the intussusception, and there- fore it should not be removed, as the ligature is apt to blow off from relief of the edema; regard- ing the question of recurrence in the same pa- tient, after recovery, there are no cases on record; immediately after reduction the parts are so ede- matous and swollen that they could not possibly telescope into each other again; in the case of adults sometimes an intussusception forms from a polypoid tumor of the intestine — a recurrence here would be in the form of intestinal obstruc- tion from angulation or adhesions. Dr. Luippold stated that this case impressed him with the difficulty of diagnosis of the acute ab- domen in the child; the patient gave a fairly typical history and signs of appendicitis, and yet at operation 2 conditions were found present, either of which presumably might have been primary. Dr. Tannert brought up the question of mobile 384 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 cecum, sometimes found in these cases; it is claimed by one author that in the ileocolic type, unless the ligaments are shortened at operation, there may be a recurrence of the intussusception. Dr. Schuhnan asked concerning an enterostomy — not done in this case because there was only slight distension pre-operatively. Dr. W. Braunstein gave the pathologic findings in the appendix: peri-appendicitis confined to the serosa, without involvement of the mucosa and lumen; regarding recurrence, he stated that theo- retically it might happen; often an intussusception is found postmortem, but without signs of con- gestion. Dr. William Braunstein reported a case of “Spontaneous Pneumothorax". M.H., male, aged 26, onset of present illness 5 weeks before admis- sion, when the patient noticed that he was be- coming short of breath, particularly after slight exertion. At the same time he began to complain of a cough which he attributed to an ordinary cold. He also became conscious of a rapid heart beat after slight exertion or excitement. These sym- toms continued without any marked progression. In addition, he complained of hoarseness for several weeks before admission, and the cougn had become productive of yellowish material, but there was no hemoptysis. The family history was negative to tuberculosis. His parents, 6 brothers and 3 sisters, were living and well. The past history showed the usual children’s diseases, measles and mumps. Venereal diseases denied. Surgical history negative. Weight was 128 lb. as compared to 135 lb. 1 year ago. The essential findings were in the chest; heart was not displaced but the sounds were very rapid; no murmurs; right upper chest anteriorly ind posteriorly gave a slightly tympanitic per- cussion note; left upper was dull; right axillary space dull; tactile and vocal fremitus increased over the right upper but breath sounds slightly diminished and respiration gave a definite me- tallic sound; the left upper and middle right, an- teriorily and posteriorily, presented patches of bronchial breathing and numerous persistent rales. At times there was amphoric breathing in the right upper chest. The abdomen and ex- tremities were not remarkable except for clubbing of the fingers. Roentgenogram of the chest revealed a pneu- mothorax of the upper right anterior lobe; inter- lobular band radiographed; infiltration of the middle right lobe; fibrosis of the upper left lobe with cavitation; heart and mediastinum normal. Sputum positive for tubercle bacilli on 2 occas- ions. Blood count: Hb., 78%; R. B. C., 4,540,- 000; W. B. C„ 10,500; P. 76; L. 24. Urine and Wassermann negative. The patient had an up and down temperature varying between 99° and 100° a. m. and 102° and 104° p. m. Pulse varied between 100 and 140. Respirations 25 to 40. Blood pressure 102/68. Shortly after the diagnosis was made, arrangements were made for transfer to Laurel Hill. Dr. Braunstein explained the x-ray findings, the signs of pneumothorax being quite evident; there was no effusion. Dr. Pearlstein said that dyspnea had been pres- ent for a long time, and that the ultimate prog- nosis was grave from the standpoint of chronic pulmonary tuberculosis; ' he cited an article in a recent issue of the Jour. A. M. A., in which a similar case is discussed. Dr. Justin pointed out that while the pneumo- thorax was on the right side, the lung involve- ment was on the left, hence it appeared that the perforation was of long standing, an attempt perhaps of nature to rest the lung on the same principle we resort to in creating an artificial pneumothorax. The physical signs were not typical of pneumothorax, but could have been due to a large-sized cavity. Dr. Luippold discussed the etiology: The com- monest cause is tuberculosis of the lung, from rupture of a cavity or a caseous focus in acute phthisis; he considered Dr. Justin’s hypothesis of nature’s attempt to rest the lung quite plausible, but it occurs also in an active tuberculous process, and most times by an accidental perforation of the pleura. Dr. S. Africano suggested changing the title of diagnosis to read “Chronic Pulmonary Tuber- culosis Complicated by Pneumothorax’’ to differ- entiate the spontaneous type. Dr. S. Braunstein. “Ulcerative Colitis”. F. D., male, aged 41, usual occupation bar-tender, at present iron worker, was admitted to ward on January 20, 1931, with the chief complaints of swelling of right leg and ankle, dyspnea, and pain across the back. For the past week he has noticed bright red blood in his stool. Had a marked pallor of the face and mucous mem- branes. Heart markedly enlarged in all of its di- ameters; soft blowing systolic murmur with max- imum intensity over the apex, transmitted up- ward to the axilla; also a rough systolic over the aortic area transmitted to the right nipple. The rhythm is regular and the sounds of fair quality. The liver palpable midway between the umbilicus and the right costal margin; not ten- der nor nodular. Spleen also enlarged and easily palpated. No ascites; no palpable masses. Rectal examination showed several soft internal hemor- rhoids. Roentgenogram of chest showed the heart en- larged in all diameters. Gastric series was re- ported as “ulcerative colitis of the descending colon". The striking features of this case are the marked anemia, profuse rectal bleeding, enlarged liver with a smooth edge, markedly enlarged spleen, enlarged cardia with murmurs, and x-ray findings of colitis. We feel that we can account for the clinical manifestations of this patient on the basis of cirrhosis. The marked anemia is of secondary type and is due to bleeding from the hemorrhoids. We do not feel that there is any ulceration of the bowel in the nature of a non-specific ulcerative colitiis because all the symptoms of colitis are missing. There may, however, be a solitary ulceration on the basis of venous engorgement, of the same etiologic factor as the hemorrhoidal bleeding, which is secondary to portal obstruction. Treatment in this case was a bland diet and rest in bed. He also received 2 transfusions which brought his hemoglobin up for a few days but due to his profuse rectal bleeding, it was at one time as low as 19%, with a relative decrease in red cells. He has had dilute HC1 and calcium lactate and his blood picture has improved, the Hb. on March 10 being 41%, but prognosis is poor. Dr. Green had considered a diagnosis of throm- April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 385 bocytopenia, but this was ruled out when the platelet count was persistently a low normal. Dr. Justin first saw this puzzling case on his service in January, when he had 20% hemo- globin, an enlarged heart and a bloated appear- ance pointing to an acute Bright’s disease; the history, however, pointed to cirrhosis, and the findings up to this time place him as a case of hypertrophic cirrhosis more definitely. Dr. Stein believed that a cardiac origin of a chronic passive congestion of the liver should be considered the probable diagnosis till proved otherwise. Dr. S. Braunstein, in closing, stated that Hanot’s type of biliary hypertrophic cirrhosis was ruled out on the basis of no fever jaundice, early as- cites, and the negative history of biliary or other infectious diseases, and that the absence of gas- tric or intestinal symptoms did not rule out cir- rhosis. Atypical Pneumonia — 2 Cases Dr. Tidivell reported 2 “Cases of Atypical Pneu- monia’’. A. P., an infant 7 months of age, ad- mitted to the hospital in what appeared to be a moribund condition. Feeding was from the breast, and recently cooked cereals had been added to the diet. Orange juice or cod-liver oil had not been given. Had been perfectly well until 4 days before admission, when a dry cough was noticed; this became persistently worse and 2 days later was accompanied by fever and cya- nosis. The urinary output was diminished at this time. On the fourth day of illness the child be- came much worst; dyspnea and cyanosis were marked and he had been in coma for several hours before being brought to the hospital. On percussion, the chest revealed dullness in the right base posteriorly, where crepitant rfiles were heard, accompanied by bronchial breathing. Mucous rales were heard throughout the chest, amounting almost to a pulmonary edema. The heart sounds were normal but rapid. Temperature 101.4°; pulse 144; respirations 20 and of the Cheyne-Stokes’ variety. Inhalation of oxygen was instituted and 1/300 gr. of atropin sulphate given for 3 doses. Lum- bar puncture was performed and 35 c.c. clear fluid obtained under marked pressure. Two hours later the child seemed to react and cried con- siderably. Next morning the character of breath- ing was much improved. Temp. 102.8°; P. 160; R. 60. He seemed to be aware of his surround- ings and followed objects. As the fontanelle was still bulging, another spinal puncture was done and 18 c.c. of fluid removed under 14 mm. Hg. pressure. The chest findings remained about the same, with the exception of possibly fewer crepi- tant rales. Lumbar puncture was done on the next 2 days, the first under 20 mm. pressure and the last at 10 mm. From this time on there was no more bulging of the fontanelle. The spinal fluid was negative, as was the Wassermann. The x-ray report on admission was negative. The day before dischai’ge, both upper lobes re- ported as hazy. On February 13, 10 days after admission, tem- perature rose to 104° and next day the left ear drum was found to be 'bulging. Double para- centesis was performed and followed by a pro- fuse discharge of pus from the left. ear. Within 3 days temperature reached normal and remain- ed so until he was discharged as cured on Feb- ruary 20. Case 2. K. K., a male infant, 16 months of age, admitted to the hospital February 6, 1931, with fever, cough and irritability. He had no convulsions nor muscular twitch- ing, but a discrete macular rash was noted on the chest. In the chest there were scattered mucous r sties with some dullness in the right base; a blowing systolic murmur heard at apex of the heart. Tem- perature, 104°; pulse, 168; resp. 64. This picture continued not much changed ‘or 6 days, when the temperature dropped suddenly from 104.6° to 99° and the child seemed improved. However, the next day it was noticed that there was some neck rigidity, Brudzinsky positive but negative Kernig. Temperature again rose to 104°. Lumbar puncture was- done but no fluid obtained. This was repeated the next day with similar re- sults. A tap on the following day yielded a few drops of clear fluid, which was negative on cul- ture. Twelve days after admission the child started to vomit; the character was not pro- jectile, but continued once or twice a day. Two weeks after admission there was still dullness, crepitant rales and bronchial breathing in the right base. X-ray of the chest showed nothing significant. The Mantoux test was negative. At this stage he appeared quite drowsy, and it was felt that we were dealing with an encephalitis. On February 22, the left patellar reflex was absent. The next day a tap was again attempted and 5 c.c. of slightly viscid, yellowish fluid was removed under decreased pressure. Examination of this fluid was unsatisfactory. February 25 a cisternal puncture was performed and 12 c.c. of cloudy fluid removed under pressure. The cell count was 10,200; no organisms were seen in the smear. After a few hours, culture showed definite meningococci. Antimeningococcic serum (15 c.c.) was given by the cisternal route. The general condition became much worse, and in spite of stimulation the child expired. Autopsy was re- fused. ■ Final diagnosis was bronchopneumonia com- plicated by meningococcic meningitis with sub- arachnoid block. Dr. Stein stated that these cases were interest- ing from the standpoint of cerebral manifesta- tions; the first suffered from a temporary men- ingismus and coma, and was relieved by spinal tap; in the second case there appeared to be an independent infection of the cerebrospinal sys- tem, with blockage, so that repeated attempts at relief of spinal pressure failed in both cases; the pulmonary signs were marked enough but the radiographs did not bear them out. Dr. Bailyn saw the second patient on the out- side, and described the events leading up to his order of hospitalization — beginning with slight fever, cough and few chest signs on the first day, he found the child in coma on the second day with lungs so full of rales that the heart sounds were inaudible, and a trismus of the oral cavity prevented a throat examination; later in the day cyanosis supervened and the cerebral symptoms became more manifest; a spinal tap was attempt- ed at the home before removal to the hospital. Dr. J. M. Stein. “Chronic Vaginitis with Acute Pyelitis in Infant.’’ V. L., aged 11, admitted Feb- ruary 12, with the complaints of dysuria, chills and fever, headache, anorexia and offensive vaginal discharge. For the past 3 years has had an offensive vaginal discharge; treated by various 386 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 physicians, using permanganate douches with temporary relief. Three days before admission, patient com- plained of pain in the right side of the abdomen and nausea. The following day she vomited and complained of dysuria. Following a douche she had a considerable flow of blood from the vagina; the following morning similar hemorrhage. The only significant finding was a positive Murphy sign on the right side. Temp. 105°. Laboratory findings — Blood count: Hb. 70%; R. B. C., 3,900,000; W. B. C., 8800; P. 67; L. 33. Urine: Many large clumps of W. B. C. Patient had an irregular fever with peaks at 104-105° and with remissions and occasional in- termissions. The longest period of normal tem- perature was from Mai-ch 3 to 7, but next day the temperature rose to 106°. On March 10 tem- perature dropped to normal again. On March 3, 1931, Dr. Hekimian made a cys- toscopic examination; the bladder and ureteral orifices were normal; catheterized urine of the right kidney contained a few white cells; it was sterile on culture. Report of pyelogram; right pelvis normal in shape; calyces distorted and pressed to the midline; right ureter dilated; no evidence of stone; right kidney not outlined. On March 6 the urine contained a large amount of albumin (16%) and many R. B. C. Examina- tion of vaginal ulcer scraping showed an acid- fast bacillus; could not be determined whether it was smegma or tubercle. A guinea-pig was in- oculated for accurate determination. The Wasser- mann and von Pirquet tests were negative. Treatment for the vaginitis was daily swabbing with 10% argyrol. Response was good. At this time there is no discharge. The ulcers have healed. Treatment for the pyelitis was not so satisfactory. She was on a restricted diet and potassium citrate. On March 6 she showed evi- dence of a pyelonephritis. The interesting features of this case are: The chronic vaginitis which probably was the cause of an ascending infection and subsequent pyelo- nephritis. Severity of the disease is rather un- usual. Anorexia was a marked feature during the entire course. Dr. Hekimian did the cystoscopy and saw large flakes of pus welling around in the bladdei cavity; culture proved to be sterile; he suggested methylene blue for treatment. Dr. Tidwell concluded that not enough alkali had been given the patient, from a comparison of the urinary findings with the temperature curve; it was found that 15 gr. every 4 hr. caused only a partial drop in temperature, while on complete omission of alkali the fever rose to 106°; when readministered the fever remitted to normal; the vaginitis is cured, while the nephritis still per- sists, and on the latter the prognosis of the cases hinges. Dr. Kolb saw this patient in private practice before admission to the hospital, and considered possible ulcerative tuberculous vaginitis, or some yeast infection; the von Pirquet was negative. Dr. Pcarlstein mentioned as another possibility the presence of an infection due to an organism similar to the spirochete of trench-mouth dis- ease, which thrives in an alkaline medium. Dr. Lulppold suggested a means of differentia- tion between the smegma and the tubercle bacil- lus by prolonged immersion in acid-alcohol; in case of the smegma bacillus the carbol-fuchsin would eventually fade away, while the acid-fast organism would hold the stain indefinitely. Dr. Kooperman has found that a low leukocyte count does not mitigate against a diagnosis oi pyelitis; the reaction of the urine per se does not determine the absence or presence of infec- tion, but if the urine is alkaline the patient is more prone to infection. Dr. Hekimian reported an “Interesting Case of Hematuria’’. The presence of blood in the urine, either microscopic or macroscopic, may be due to lesion of the genito-urinary tract, systemic condition, or pathology of organs in close ana- tomic relation to the tract. Among the systemic causes are blood diseases, such as leukemia, hemo- philia, polycythemia, Hodgkin’s disease, purpura, analine dye poisoning. High protein diet ana physical exertion may give rise to temporary hematuria. Acute lesions of the appendix, female adnexa or colon can be responsible for traces of blood in the urine. Although the method of transmission of infection from adjacent organs to the urinary tract by continuity is a possiblity, the usual chan- nel is by the lymphatics. Blood in a specimen of urine in a case of suspected acute appendicitis needs investigation to rule out a coexisting path- ology. Hematuria as precarious menstruation and from tumors of the adrenals has been re- ported. Of all hematurias, 75% are due to lesions of the genito-urinary tract, and 70% of these are found in the upper urinary tract. Establishment of diagnosis of conditions involving the bladder and urethra is comparatively easy, because these parts are brought under direct vision by the aid of the cystoscope and urethroscope. However, the same is not true in case of the kidneys and ureters, because the method is an indirect one; it depends upon the visualization of an opaque medium in the tract. Variations in outline of normal renal pelvis, irregularity of the outline due to blood clots and exudates may easily lead to erroneous diagnosis. Consequently, repeated complete urologic examinations may be necessary to arrive at a correct conclusion. The following case is of interest from a diag- nostic standpoint: W. C., male, aged 41, truck driver, admitted with the complaints of weakness, generalized pains, epigastric pain, bloody stools, hematuria, urgency, dysuria and frequency of 4 months’ duration. Past history: Gonorrhea at 17 and 34; gonorrheal arthritis with the last infec- tion. Operated upon for repeated hemorrhages from gastric ulcer, 7 yr. ago. The patient was kept under observation for a week. Laboratory findings: Blood count: Hb., 65%; R. B. C., 4,000,000; W. B. C., 6000; P., 60. Wassermann negative. Urine, daily specimens: alkaline, bright red or smoky with blood; sugar negative; albumin from trace up to 14% by volume; phosphates; and R. B. C. Of course blood will give an albumin reaction, but on later dates albumin was still reported when there was no blood. X-ray was negative for calculi. First attempt at cystoscopy was unsuccessful on account of the marked irritability of the ure- thra. He came under my care a week later. There was no visible discharge; external geni- talia negative; first .urine blood-tinged; prostate and seminal vesicles congested and extremely tender; moderate amount of debris after mas- sage. A small observation cystoscope was intro- duced into the bladder after passing several stric- April, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 387 tures of the anterior urethra. Bladder mucous membrane normal; no growth; no blood observed from the ureters; posterior urethra deeply con- gested and bleeding. The urinary symptoms continued, and 3 days later ureteral catheterization was done under spinal anesthesia. A jet of blood was seen from the left ureter. Pyelography on that side showed no abnormality; catheterized specimens were found sterile on culture. He was transferred to the Urologic Service with the medical diagnoses of grippe, chronic gastric ulcer, chronic cholecystitis and chronic glomerular nephritis. Urinary symptoms were re- lieved with medication of methylene blue and prostatic massage. To date there has been no recurrence of hematuria or urinary distress. The tource of hematuria in this case was from 2 different areas. Observation showed some of the specimens contained blood only at the start of the stream, the rest of the flow being clear. The origin of this was at the posterior urethra, as confirmed by cystoscopic examination, result- ing from chronic prostatitis and vesiculitis and further aggravated by strictures of the anterior urethra. Most of the specimens with smoky hue were of renal origin, most likely due to glomer- ular circulatory disturbance. The possibility of fibrous or angiomatous change in one of the renal papilla must be kept in mind. Dr. Tataryan related a case of “Hyperemesis Gravidarum’’. The essential cause of liyper- emesis gravidarum is toxemia, although in cer- tain cases neurosis and reflex excitability are strongly in evidence. No satisfactory distinction can be made between toxemic and neurotic vom- iting as the neurotic states more frequently re- sult from than cause hyperemesis. A disturbance of the carbohydrate metabolism is a common feature. The toxins originate from the fetus or from endocrine dysfunction or focal infection in the mother. There is profound necrosis of the central portion of the lobules in the liver; and in fatal cases, the liver undergoes fatty degenera- tion. N. B., female, aged 28, gravida iii, para i, ad- mitted to hospital on August 3, 1930; state of gestation 2 months. She had pleurisy in 1928; pernicious vomiting through her first pregnancy, giving birth to a living child; vomiting in second pregnancy, which ended in spontaneous miscar- riage in the third month of gestation. One month before admission she started to vomit; at first only in the mornings, then after each meal, and finally 20-30 times a day. Tenderness all over the ab- domen, more marked near the umbilicus. Blood pressure 175/70. Urinalysis negative except for acetone and diacetic acid. Blood count: Hb., 80%; W. B. C., 6300; P., 50; L., 49; M., 1. Blood chemistry; NPN, 54 mgm.; creatinin, 1.9; sugar, 60; urea, 20; carbon dioxide, 60. The usual treatment was instituted but no im- provement was noticed for the first 5 days, so on the sixth day cystoscopy was done, which revealed moderate congestion of the trigone, some trabeculation, apparently normal ureteral orifices. The right ureter was easily catheterized; the urine cloudy and microscopically revealed W. B. C. free and in clumps, some R. B. C., and staphylococcus on culture. After catheterization she showed marked improvement; did not vomit for 6 days and was discharged as cured. Follow- up: After her discharge, she was very comfort- able except occasional emesis through the preg- nancy until full term. Comment. In hyper emesis gravidarum, if the patient does not respond favorably to the routine treatments within a week, cystoscopic examina- tion should be done to determine the possibility of a symptomless pyelitis, regardless of the urin- ary findings. It should be done early in order to prevent an active pyelitis, as this complication will make the prognosis much graver. In patients suffering from hyperemesis in repeated preg- nancies, ad interim, the condition of the kidney pelvis and ureters should be carefully investl- ated. Dr. Kolb referred to Duncan’s work on this form of toxemia. He regards all cases as po- tentially pernicious and uses emenin, an en- docrine product which he claims acts as a spe- cific, and concludes that some condition of the mother prevents the formation of an antitoxin to circulate in the maternal blood to overcome the normally formed toxins of pregnancy, so that the vomiting is progressive; whereas the emenin supplies this deficit. Dr. D’Acierno emphasized that all cases of vom- iting of pregnancy are not amenable to treat- ment in the same manner, and advised that, be- sides the taking of a careful history and doing a detailed physical examination, stress should be placed on the following 5 points: (1) The neurotic element: many cases will re- spond solely to rest in bed; isolation, good nurs- ing, and a mild sedative like luminal gr. 2 by hypodermic injection 2-3 times a day, or simply by chloral 10 gr. daily by rectum. (2) The reflex element: for practical purposes this should not be disregarded, as in some cases the vomiting is actually terminated by replacing a retroverted uterus, or by the cure of a rectocele by pessary. (3) The endocrine factor: Hirst, of Phila- delphia, still advocates corpus luteum as the drug choice; others recommend thyroid extract, or pituitary and parathyroid in more intractable cases. (4) Coincident focal infections: not only teeth and tonsils but also a latent sinus infection, or a pyelitis, cystitis or pyelonephritis, may be the original toxic focus; Poliak of the Austrian school designates 98% of the vomiting of pregnancy pa- tients to this class. (5) The most important, the factor of meta- bolism, and conveniently divided into 3 stages: (a) The dehydration stage: as a result of vomiting, water is lost to the maternal organism, and this may be made up by the injection of glu- cose solution, Titus using up to 3 liters, or 3000 c.c. of a 3% solution, daily, either subcutanteously under the breasts or by intravenous infusion; if gotten early, this may tide the patient over in 1 or 2 weeks. (to) The starvation stage: if severe vomiting still persists for over 2-3 weeks, there results de- struction of serum proteins; this destruction may be counteracted by the intramuscular injection of phosphoplasmin-lecithin solution; 75%, in Dr. D’Acierno’s experience, react favorably and per- manently to this treatment. He suggested trans- fusion in this stage, though he has not tried it. (c) The stage of hepatic degeneration, as shown by bilirubin in the urine, a positive immediate direct Van den Berg, and the other increasing signs of toxemia which may finally end in coma; no case should be allowed to reach this stage; Van Wyck is using lately a continuous phlebocly- 388 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 sis adjusted at about COO c.c. per hour o£ a 3% solution, for 5 hours daily; also a high caloric diet is being advised in the form of duodenal feeding, as 3 oz. each of skimmed milk and 10% glucose; finally, when no improvement occurs in this stage after 4-5 days under intensive treat- ment, the uterus must be emptied. MERGER COUNT Y A. Dunbar Hutchinson, M.D., Reporter The Mercer County Medical Society met in the Carteret Club on the evening of March 11, Presi- dent Swern presiding. Dr. I. W. Held, of New York, delivered an ad- dress on “Modern Conception of Jaundice and its Clinical Treatment”, giving a detailed account of numerous laboratory analyses attending arti- ficial production of the several constituents found in the blood stream during a period of jaundice. The various methods employed in differential diagnosis of jaundice were specifically defined, and the determined manner in which Dr. Held expressed himself proclaimed his thorough ac- quaintance with this subject. Dr. H. D. Rellis was elected an annual dele- gate in the place of Dr. M. W. Reddan, who, by virtue of his office, is a member of the House of Delegates. Dr. Harry J. Majeski was elected to associate membership in the society. MIDDLESEX COUNTY Samuel Gordon Berkow, M.D., Reporter The regular meeting of the Middlesex County Medical Society was held March 25, 9 p. m„ at the Perth Amboy City Hospital, Dr. William H. McCormick presiding. Drs. George N. J. Sommer and Henry O. Reik were welcomed by the president, who expressed the pleasure of the society in the visit of these distinguished guests. Drs. Irwin, of Matawan; Alexander Fishkoff, of Perth Amboy, and Dieker, of South River, were voted to membership. The application of Dr. Rothfuss, of Woodbridge, was referred to the Membership Committee. Dr. M. S. Goldberger, of Mount Sinai Hospital, New York City, read a paper on the “Ascheim- Zondek Test for Pregnancy”. Of 368 tests, correct results were obtained in 95%. This is slightly less than Ascheim and Zondek’s figures, which show 98.6% correct results, but is a higher per- centage of efficiency than is claimed for the Wassermann test in the diagnosis of syphilis. Dr. Goldberger cited 2 cases of chorio-epi- thclioma in males, in which female sex hormone was obtained from the blood. Dr. Morrell, Director of Endocrine Research at Squibb’s Laboratories, New Brunswick, opened the discussion. He inquired as to the efficiency of a pure pituitary preparation in producing a positive skin reaction on injection intradermally, and as to the nature of the cases in which the Ascheim-Zondek would be of clinical value. Dr. Sommer spoke on urine tests for pregnancy as carried out on his surgical service. He stated his high regard for the methods elaborated by Frank and his co-workers. employed by the County Society in acting upon applications for membership and stressed the necessity of abiding by the by-laws which have been adopted by the State Society. He then called attention to the value of an active Woman’s Aux- iliary to the county society, which can be in- termediary between the society and the public; it can influence legislators; it promotes better un- derstanding between physicians. Dr. Reik spoke entertainingly and informatively on various subjects important to the members of the society. He spoke of the Journal and its many features, including original articles, scien- tific data, and reports of scientific meetings; and its pages devoted to medical economics, esthetics and forensic medicine; he urged the members to read the Journal for information vital to their welfare. He scored the endorsement of cigarettes and cigars by physicians and health officers. Rising vote of thanks was tendered to Drs. Sommer, Reik, Goldberger and Morrell. Medical Section of Rutgers Club February Meeting John H. Rowland, M.D., Secretary Regular meeting of the Medical Section of the Rutgers Club was held on Thursday evening, Feb- ruary 26, at the Campus Tea Room. Dr. Klein pre- siding, with 32 members, friends and guests present. There being no business to transact, the speaker of the evening was immediately introduced. Dr. Walter Dannreuther, Director of the Department of Gynecology at the Post-Graduate Hospital, New York, spoke on “Diagnosis and Treatment of Local Infection of the Uterus and Adnexa”, pre- senting his topic interestingly with aid of lantern slides. He stressed particularly the modes of in- fection, demonstrating the lymph channels and other paths of infection, and differential diag- nosis, and also the difference between good sur- gical judgment and bad practice. The paper was discussed freely by members. After the meeting the members adjourned to the porch dining room where they were enter- tained by Drs. Klein, King, Leonard and Mer- rill. March 6 Meeting The regular monthly meeting was held Friday evening, March 6, at the Campus Tea Room, where about 35 members, friends and guests were present; Dr. William Klein presiding. Dr. John Morehead, of the Post-Graduate Hos- pital, New York, spoke on the subject of “Trau- matic Injuries", cautioning against mistakes in injuries particularly of the head, back, pelvis and knee joints, where external appearance or super- ficial examination wrould not suggest any serious trouble. Dr. Morehead spoke of wounds with particular relation to disinfection, suturing, drainage, dress- ings, and tetanus antitoxin; also of wounds that that were already infected, and stressed treatment in early, intermediate and late stages of infection, with indications for treatment. He also referred to injuries to the joint, particularly synovitis and dislocations, stressing early recognition, prompt reduction, retention and early motion, and return to function. The paper was discussed by many of the mem- bers, to the advantage of all. April. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY After the meeting the members adjourned to the porch dining room, where they were enter- tained by Drs. McGovern, McKiernan, Nieman, and Nafey. March 20 Meeting The annual meeting of the Medical- Section of the Rutgers Club was held on Friday evening, March 20, at the office of Dr. Howley, Dr. William Klein presiding. There were 15 members present. The minutes of the previous meeting were read and approved. Reports of Committees: Dr. Faulkingham, in the absence of Dr. Merrill, Chairman of the Audit- ing Committee, reported on the auditing of the books of the Treasurer up to February 6, 1931. Committee on Visiting Nurses: In the absence of Dr. McGovern, Chairman, Dr. Johnson report- ed that the committee met with Miss McLeod, of the Visiting Nurses’ Association, and discussed the efficiency of nursing and cooperation of physi- cians. It was moved by Dr. Johnson, and passed, that the Secretary be instructed to write a letter to the Visiting Nurses’ Association commending the good work they are carrying on. Application for membership to the Club from Dr. Tilton was read. Resignation of Dr. King was accepted. At this point Dr. Nafey brought up the ques- tion of closed meetings for members only. Refer- ence was made to Article III of the Constitution which covers that point. Applications for membership of Drs. Rona, Chester T. Brown and Marshall Smith were voted upon. Drs. Brown and Smith were voted in as members of the Club. There being no other new business, the members proceeded to the election of officers for the en- suing year. Dr. Howley, Chairman of the Nom- inating Committee, read the nominations of Dr. Johnson for Chairman, Dr. Gutmann, Vice-Chair- man, and Dr. Rowland, Secretary and Treasurer. A motion was made and passed that the nomina- tions be closed, and that the Secretary cast a ballot for the election of the above-named officers. Next, a report was made by the Treasurer up to March 20, 1931. At this point Dr. Klein thanked the various members of Committees and others who aided in making this past year so successful. Dr. Nafey made a motion that a vote of thanks be given Dr. Klein for his excellent services dur- ing the past year and for the refreshments about to be served. On motion the meeting adjourned. MONMOUTH COUNTY William H. Von Oehsen, M.D., Reporter The February meeting of the Monmouth County Medical Society was held at the Berkeley-Carteret Hotel, Asbury- Park, Wednesday evening, Febru- ary 25, with Dr. William K. Campbell presiding. Communications were read and ordered filed. A letter was read from Dr. Henry O. Reik. Executive Secretary of the State Society, asking for information as to historic data our 'society may possess which would be of use to the His- torian. On a motion from Dr. G. V. Warner, of Red Bank, seconded by Dr. H. Brown, of Free- hold, the Secretary is ordered to let Dr. Reik know that the minutes of this society are avail- able since the date of its organization in 1816 and are now in possession of Dr. Warner, who 389 is writing a history of the medical profession in Monmouth County. Dr, Warner also moved that the minute book dating from 1885 to the present time be bound. Motion seconded by Dr. Brown and carried. Dr, Brown was appointed by the President to take charge of the binding. Application of Drs. Woronoff, Matthews and Niemtzow, for membership, were referred to the Board of Censors. Dr. Frank Altschul, reporting for the Radio Committee, said a list of subjects was to be made from which those members who have not already broadcast will have an opportunity of selecting a subject and arranging for a date. It was also moved and seconded that a record be made of the talks which have already been given and incor- porated in the minutes. Dr. Altschul was also asked to try to find out the reaction of the pub- lic to these talks and whether there have been any letters or questions sent in which would help us arrange a program. The Committee on Education reported that those men who were interviewed regarding the Post-Graduate Course were mostly opposed to en- rolling. Dr. Fisher, of the Program Committee for the coming State Society Convention, gave a brief re- sume of the meeting held in Trenton to arrange the different features of the program. Mr. William Couse, President of the Asbury Park Trust Company, gave a very interesting talk on the “business and economic side of the practice of medicine”, which brought forth some lively discussion. Dr. James Fisher read a paper discussing the same subject from the doctor’s point of view. This was also very well received. A buffet lunch was served. MORRIS COUNTY Marcus A. Curry, M.D., Reporter A regular quarterly meeting of the Morris County Medical Society was held the evening of Thursday, March 12, at the Elks’ Club in Dover. President Sutphen presided over an attendance of about 45 members and guests. Routine business was suspended to give oppor- tunity to insurance representatives to present their propositions. Mr. Heard, of Hornblower & Heard, Newark, explained concisely a policy to cover the physician against all claims for mal- practice, except criminal acts, at a low rate; and recommending it for consideration by any physi- cian not already covered or not adequately cov- ered; and expressing a willingness to have a rep- resentative call at the physician’s office to ex- plain the contract further. The society was ad- dressed also by a representative of other com- panies affording protection against other than malpractice: the Manufacturers’ Casualty Insur- ance Company of Philadelphia, writing automo- bile insurance, liability, property damage, col- lision and fire, at special low rates: also explain- ing a life policy, a special contract to members of the medical profession; the Commonwealth Cas- ualty Company, a Pennsylvania concern, with a contract specially written up in conference with Dr. Pinneo, of Essex County. Minutes were read and approved, including the proceedings of the- Executive Committee, the 390 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY April, 1931 i latter Indicating that Drs. Costello and Plume will report on the death of Dr. Adsit. Favorable men- tion was made of the first annual meeting of the First Councilor District, at the Academy of Medi- cine in Newark, February 12. Drs. Campbell and Horn were reported as dropped for non-payment of dues, in accordance with the by-laws. Treasurer Emory reported a balance of $1202.28, and that 5 members have not as yet paid their clues for 1931. Dr. Ruth Ferris, of Morristown, was duly pro- posed for membership, the proposal taking the usual course. To prepare a roster of officers for the ensuing year, to be submitted at the June quarterly meet- ing and voted on at the annual meeting in Sep- tember, the following Nominating Committee was duly appointed: Drs. Young, Frost and Costello. The scientific chapter of the meeting was a symposium on “Asthma’’ by Dr. Lathrope and his confreres, who read the following papers: “Some Difficulties of the Asthma Problem’’, Dr. George H. Lathrope; “Allergic and Bacterial Phases’’, Dr. Royce Paddock; “The Role of Focal Infection in Asthma”, Dr. Lyndon A. Peer. The papers (promised for Journal publication! indicated careful and painstaking preparation and elicited an unusual degree of interest, and con- tributed to making this meeting live up to the high standard that has been set in past years for the Dover meeting. The papers were widely discussed by Drs. Costello, Krauss, Spencer, Haven, Plume, Matthews, F. Grendon Reed, Pinckney, Julia Mutchler, and Howard S. Hatch, Resident Physician of the Morris County Tuber- culosis Hospital and Tuberculosis Specialist at the New Jersey State Hospital at Greystone Park. After adjournment refreshments were enjoyed in the club dining rooms. PASSAIC COUNTY Wayne W. Hall, M.D., Secretary The regular meeting of the Passaic County Medical Society was held at the Passaic City Club, Passaic, March 12, with Dr. Carlisle pre- siding. There were about 100 members present. The minutes of the February meeting were ap- proved as read. The Board of Censors presented its report to the society. This report contained the approval of the applications of the following doctors: Al- bert S. Irving, Radburn; M. G. Joelson, 122 Pater- son Street, Paterson; and James M. Allen, 657 Main Avenue, Passaic. A discussion was held as to the question of ad- mission to the society of physicians doing con- tract practice. At present this matter is deter- mined by the local society, although the subject is now in the hands of a committee of the state society. Our society was greatly honored by the pres- ence of Dr. George Sommer, of Trenton, Presi- dent of our State Medical Society; Dr. John F. Hagerty, of Newark, Vice-President of the State Society; and Dr. Reik, of Atlantic City, Editor of the Journal. Dr. Reik gave a report on the progress of the State Medical Journal, and called attention to some of its special features. The Executive Office has available medical movies and a projector which are offered for the benefit of society pro- grams. Dr. ,T. B. Morrison, of Newark, Recording Sec- retary of the State 3ociety, read a paper on “The Menace of State Medicine”. He advocates pre- paredness on the part of the medical profession. The scientific paper of the evening was pre- sented by Dr. Royal C. Van Etten, Attending Gynecologist to the Sloane Hospital, New York City. His subject was “Modern Obstetric Meth- ods at Sloane Hospital”, illustrated by slides and movies. Adjournment followed a collation. Obituaries COLHOUN, Charles, of 24 West Passaic Avenue, Rutherford, died at his home February 23, 1931, at the age of 67. Dr. Colhoun was born in North Carolina, ac- quired his medical education at the College of Physicians and Surgeons, Columbia University, and practiced in Rutherford for 30 years. For 16 years he served as a member of the Rutherford Board of Health. DONGES, John W., of 805 Cooper Street, Cam- den, born of Jacob and Sarah Donges, September 18, 1844, in Strochsburg, Pennsylvania, died Febru- ary 4, 1931. Dr. Donges attended Strochsburg Academy and was graduated in medicine from the University of Pennsylvania in the Class of 1866. He was a mem- ber of the Camden City Council, U. S. Pension Board, Camden Board of Assessors and Camden Board of Health. He belonged to the Odd Fellows, Masons and was an Honorary member of the Camden County Medical Society. Resolutions on the Death of Dr. Donges Adopted by Camden County Medical Society WHEREAS, John W. Donges, a medical prac- titioner for many years, and a valued member of the Camden County Medical Society, has left his earthly labors and passed on. therefore, BE IT RESOLVED, that in his death the so- ciety has lost not only a faithful and skilled mem- ber of the profession, but also a distinguished representative in the community at large; one who has added dignity to the profession by earnest work as a plain citizen, in both peace and war times. Dr. Donges* entire life, as a man, was spent in the service of his fellow-men, and spent unselfishly. He was at the front, and in the line of fire, when the destines of our National Govern- ment were at stake, and when peace returned he served his home community in various positions in the local government. His example will be cherished by his fellow practitioners who have adopted this resolution, and ordered that a copy be sent to his family. Alexander MacAlister. A. Haines Lippincott. W. H. Pratt. ERROR IN OFFICIAL LIST (Letter from Dr. J. B. Morrison.) To the Editor: Will you kindly insert in the April issue of the Journal the following note: Through an error in the office of the Treasurer of the Cumberland County Medical Society, the name of Dr. H. Garrett Miller was omitted from the list sent in for publication in the “Official List” of members of the Medical Society of New Jersey. Dr. Miller is and has always been in good standing- 391 journal of The Medical Society of New J ersey Under the Direction of the Committee on Publication Vol. XXVIII., No. 5 ORANGE, N. J., MAY, 1931 Subscription, $3.00 per Year Single Copies. 30 Cents PREVENTING THE TRANSMISSION OF SYPHILIS BY CONTROL OF IN- FECTIOUSNESS* John H. Stokes, M.D., Philadelphia, Pa. The United States Public Health Service lias recently released, as reasonably trust- worthy, an estimate of nearly 500,000 new infections with syphilis annually in the United States ; and irrespective of its cost in dis- ability, syphilis has varied in different esti- mates, between first and fourth place among the causes of death in man, since Osier’s re- vision of British mortality statistics. Syphilis is now definitely known to lead tuberculosis and scarlet fever in incidence ; it is reported one-third more frequently than diphtheria, 3 times as frequently as small-pox, 5 times as frequently as typhoid fever; 600,000 patients with it are constantly under medical care in this country, an estimate which takes no ac- count at all of the enormous number of latent infections for the moment neither under ob- servation nor treatment. What more im- portant subject could a medical society choose for consideration, in the face of these facts, than this — in very truth the critical health problem of the present day. The prevention of syphilis is not only important in itself, but it is important because the past 2 decades of medical history with respect to it have been a sovereign illustration of fundamental max- ims in the control of disease in general as a ♦(Read at the Passaic County Medical Society meeting, Dec. 10, 1930.) public health problem. At one and the same moment (and the fact is one of deep concern to us as individual medical practitioners), the syphilis problem is significant because it fur- nishes the ideal illustration of the value of controlling infectiousness chemotherapeuti- cally by germ-destroying drugs, and also is the outstanding example of the greater effective-, ness of state as compared with individual ef- fort in the suppression of disease. Through socialized effort, directed at the control of infectiousness, the incidence of new infections with syphilis has apparently decreased since 1919, 5/6 in Great Britain, 2/3 in Germany, and 9/10 in Belgium. From France, whose individualism of medical practice compares with our own, and whose incidence of syphilis is, at least for the time being, on the increase, comes evidence as to the reasons for the con- trast. An individualistic system for the con- trol of an infectious disease lacks a coordinat- ing force, a program control through central authority which follows through a plan of at- tack without regard to temperamental vagary, individual notions based on negligible exper- ience, therapeutic impressionism, prejudices, self-interest and the activities of the pharma- ceutic detail man. France and, to some ex- tent, this country suffer from ailments with respect to the treatment of syphilis which Jeanselme and Brunier have clearly enumer- ated ; a disposition to substitute bismuth for the arsphenamins ; non-recognition of the in- fectiousness of syphilis in the woman; aban- donment by both private physician and pa- tient of all treatment as soon as signs disap- pear; the tendency of the practitioner to try new fads in both diagnosis and treatment; 392 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 and, among special influences of a social and economic character, an increase in prostitution and an influx of foreign labor. This country, in which, in contrast with the larger part of the Old World, 2/3 to 4/5 of all syphilis is in the hands of the practitioner, may well con- sider the maxim — “whom the shoe fits, let him wear it”. Of the various ways of de- veloping cooperation of the state and other social agencies in aid of the practitioner, with- out eliminating him from this field, I have written elsewhere, and have there recorded my belief that such a combination of interests, with preservation of the inestimable advan- tages of individualism in medicine, can be brought about. I should not, therefore, im- pose on your good nature and time in mere repetition, but should rather proceed to point out as clearly as I can how you and I, and all others who deal with syphilis, can assist in achieving the alpha and omega of its public health control, and ultimate extinction — the prevention of its transmission from person to person. Once given ideal accomplishment of this aim, as Parran has pointed out, and the disease should, in theory at least, disappear within the life of a single generation. Even though no such ideal consummation be reach- ed at once, your effort and my effort toward this end will assuredly bring nearer that Uto- pian day. I propose first to present to you certain biologic facts about syphilis, which condition our control of it as an infection. I do this without apology, because I know you agree with me that insight into first principles is the first essential to inspired attack on a problem. I shall next consider the control of transmis- sion through the older, and always hopeful if not often helpful, method of the patient’s co- operation ; then its control by treatment, which is the distinctive and immeasurably more sig- nificant contribution of modern knowledge to the problem ; and to certain special aspects of the general thesis, including the technic of con- trolling infectiousness in early syphilis; in syphilis involving the problem of mar- riage; in pregnancy; in industrial, social hygiene and public health fields ; and finally, that the problem may come home to you di- rectly among physicians, nurses and dentists. Fundamental biologic considerations ; the life cvcle of the Spirocheta pallida. There is a certain amount of clinical evidence that the spiral form of the organism of syphilis, with which we are all familiar, is not the only form taken by the virus of syphilis; and now that experimental study is beginning to lend tangi- bility to the matter one can be pardoned for introducing this phase of the subject with a somewhat speculative turn. Paternal transmis- sion of syphilis, difficult to imagine if the or- ganism be conceived as riding a spermatozoon to its destination in the ovum, to produce an infected child from an uninfected mother, could easily be explained if there were a rest form of ultramicroscopic or granular type. It is well established that the semen of the syph- ilitic male is infectious though spirochetes have rarely been seen in it. So, too, is the macerated and ground tissue of the lymph- node of the rabbit though no spirochetes can be found with the darkfield examination. Here, then, is the possibility of an unseen enemy in the problem of control of the dis- ease by prevention of infectiousness. Levaditi and his co-workers, and of late Warthin, have lent an unexpected seriousness to the much ridiculed attempts of MacDonough and others to describe a life cycle for the organism of syphilis. While we need not expect a “Leuko- cytozoon syphilidis”, we must be prepared to find that syphilis may achieve an unexpected and perhaps therapeutically inaccessible latency through the discovery of a rest form which is not recognizable by clinical laboratory meth- ods, and hence difficult to test for, and per- haps to destroy by spirillicidal agents. Such considerations may seriously affect many of the generalizations about to be set forth in regard to syphilis in marriage especially. Viability of the Spirocheta pallida. The or- ganism of syphilis is an anaerobe, requiring, furthermore, the presence of tissue for cul- tural growth, and of moisture and protein so- lutions for survival. These facts make clear important rules governing the infectious transmission of the disease. The organism does not survive on dry surfaces, whether of May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 393 the body or elsewhere. Hence, closed lesions, such as the macular and papular secondary syphilid on the free skin, exposed to air and dry, are not infectious, though just beneath the epidermis the organisms are abundant. The doorknob, the dry clothing, the room occupied by such patients, the dust, are en- tirely harmless. On the other hand, let the epidermis be rubbed or macerated from the surface of a macular or papular lesion, and in the presence of exudate and the relative ab- sence of air, a dangerously infectious lesion results. These conditions are met in the orifices and folds of the body, and in dis- charges or secretions emanating from them. Hence the extreme danger attaching to con- tact with the mouth and throat, the anal and genital regions, the axillary, inguinal and sub- mammary folds of the patient with early syphilis. Dressings moist with such secre- tions, since they protect the organism from air in the presence of a protein medium, and instruments, including those of physician, den- tist, and nurse, which are used in such sites, are dangerous. Contacts with such regions (and note that these are, like kissing and sex- ual intercourse, the intimate and emotionally controlled rather than the reasoned contacts of life) are the prime sources of transmission of the disease. While these facts are being emphasized, let it be noted that the older con- ception of an abrasion of the receiving surface as essential to infection, which has given rise to much false sense of security, is an error abundantly disproved by experimental evi- dence in even a relatively resistant animal like the rabbit. Opinion now leans as far in the other direction, in the suggestion of Kolle, that there is a definite type of human carrier, who, like the mouse, has acquired his infec- tion without abrasion or reaction, and who re- distributes it perhaps without open or obvious lesions. It is possible to acquire syphilis with- out an abrasion, and without a chancre, and to become a focus of distribution without being- aware that one has the disease. This is the role apparently played by an unknown pro- portion of those patients, discovered by routine application of the serologic tests to general medical examination and diagnosis, who truth- fully deny infection and have never realized until late symptoms appeared that they had the disease. The action of disinfectants upon the or- ganism is significant. While the Spirocheta pallida is easily destroyed by weak disin- fectants. it is only too frequently protected by the protein tissue constituents of solutions by which it is carried or surrounded. Failure to thoroughly wash before applying prophylaxis may, therefore, be fatal to effectiveness. There is a tragic absurdity in the spectacle of of an assistant putting tincture of iodin on a deep needle puncture obtained in operation on an active syphilitic, or of a nurse rub- bing in calomel after a similar accident in drawing infectious Wassermann blood. The needle prick is the chief source of direct blood stream inoculation without chancre, unless nowadays negligent blood transfusions may outrank it. There is an additional disconcert- ing thought connected with chemical prophy- laxis. In the recent International Congress at Copenhagen, Zurhelle showed that application of prophylactic ointments may simply act to prolong the incubation period rather than to prevent infection of the individual with syph- ilis. It is a matter for serious question, whether prophylaxis apparently successful, because no lesion appears, may not have simply cloaked rather than actually prevented infec- tion. In practical work then, soap, water, and boiling, stand first, as with other disinfection, and false security from questionable precau- tion is more often a pitfall than anything else. As I shall say over and over, a sense of se- curity and a low index of suspicion are the chief sources of infection with syphilis. Localization factors. The association of syphilis with genital contacts is not purely fortuitous. The recent observations of Raiziss, to the effect that Spirocheta pallida, if in- troduced into the cerebral ventricle of the rabbit, does not give rise to a neurosyphilis as such, but results after a time in the appear- ance of a testicular chancre, suggest that the genital structures are real centers of elective localization for the organism. Similarly, from our own recent study of relapse phenomena, it appears that recurrent infectious lesions have a pronounced tendency to localize on the genitalia, 68% appearing there or in the 394 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 mouth, and 75% of the genital recurrent lesions being on the penis and vulva, ideally situated for spread of the disease. The tes- ticle, too, is notable among the elective sites for localization of the organism. The ten- dency to perivascular localization, so im- portant to the future of the victim of syph- ilis, is the result of the fact that blood carries the organism especially during the early weeks of the disease, but also during its course in later years. Fruhwald showed a decade and a half ago that the blood of a seronegative prostitute could be infectious; and the recur- rence of spirochetal showers in the blood stream is the best available explanation of the fact that a syphilitic woman may give birth to a syphilitic infant between 2 preg- nancies resulting in healthy offspring. Con- trol of the hematogenous distribution of the organism within the body is then an item in preventing prenatal transmission of the dis- ease to children. Perhaps the most important of all the bio- logic influences affecting the transmission of syphilis, and one of the least appreciated, is time. The acutely infectious period of syph- ilis covers the first 5 years of the disease. In fact, infectious recurrences are largely over by the end of the second year, 93% appear- ing within this period. On the other hand, time can never guarantee the non-infectious- ness of a person with syphilis, for there are authentic reports of infectious mucosal lesions appearing as late as 24 years after onset of the disease. It is true, none the less, that sparring for time is important in preventing the spread of syphilis, whether in permission to marry or otherwise. Every month and every year that can be allowed to elapse be- tween the onset of a syphilitic infection and a possible transmitting contact, decreases the risk of infection. The chancre, the moist lesions of the secondary period, and the re- lapses on the mucocutaneous surfaces and the genitalia, are the chief sources of dissemina- tion of the disease. The relapse factor. We all recognize readily enough, perhaps, the primary infectiousness of sy^philis during chancre and secondary periods. Most patients can be made to ap- preciate the danger they are to the community in these stages. But relapse as a source of the disease has never been fully appreciated by the practitioner though the syphilologist has harped upon it since the days of Ricord. In- fectious relapse is relatively unobtrusive, pain- less, and very easily overlooked. It occurs in sites invisible to the patient, and rarely ex- amined by the physician. While numerically 1/5 as important as the chancre in transmis- sion of the disease, the recurrent lesion is al- most equally important as a source of infec- tion because of the considerations just men- tioned. Here, again, a false sense of security, engendered by a little treatment, and a low index of suspicion, spread syphilis. The serologic factor. The response of the Wassermann and precipitation tests to treat- ment for syphilis has led us to one exceed- ingly dangerous and unwarranted generaliza- tion— that cure and non-infectiousness pro- gress hand in hand. The facts regarding the use of the Wassermann tests as a guide to infectiousness are these: Infectious lesions may appear immediately following the obtain- ing of a negative blood test on patients as late, in my own experience, as 6 years after infection. They may appear while the blood Wassermann reaction is negative, and the Spirocheta pallida may even be demonstrated from them by darkfield, as in a case I pre- sented to an army class during the war. I have known a physician to authorize inter- course between a Wassermann negative hus- band and an uninfected wife, without the use of a condom, and 3 months later the wife was brought to me with early secondaries. The syphilitic chancre is never so infective, and it literally swarms with Spirocheta pallida, as at the precise period in the disease when the actively and acutely syphilitic patient is Was- sermann negative. The sharpening of the sen- sitivity of serologic tests has not helped the sit- uation because, although as high as 96.5% of clinically recognized relapses give positive Wassermanns, these positive tests are obtained in the presence of the full blown lesion, after the damage is in all probability done, and not as anticipatory warning that the patient is about to become infectious. There is, therefore, only one course for the physician to pursue in practice. Dismiss the Wassermann or any May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 395 other serologic test from the mind as evidence of the infectiousness or non-inf ectiousness of a patient with syphilis. Tt has literally nothing to do with the question, and only ultimate dis- aster can follow any attempt to use it as proof of the presence or absence of the infectious state. The syphilitic carrier. All sorts of inter- esting problems surround the syphilitic car- rier, and I have already alluded to them in quoting Kobe’s views on the prophylaxis problem in relation to the production of asymptomatic carriers. An extremely serious phase of the carrier problem concerns the production of chronic infectious relapsers by insufficient modern treatment. Morton Smith some years ago called attention to the dis- appearance of early lesions of the conven- tional primary and secondary types under the regime of a few doses of arsphenamin. He might well have stressed their replacement by the arsphenamin recidivist, the product of an era of inadequate treatment. In the old days, the patient, under pills, relapsed and relapsed until the cumulative immunity reaction plus the slow effect of the drug brought the process to a symptomless latency. Conditions were as bad as they could be with respect to trans- mission. The immeasurably greater potential benefits of the new era, however, have not been realized, because not only does the amount of arsenical generally used by the practitioner in a given case fall far short of what is needed for cure, but his interference with, and defeating of the immunity reaction by insufficient treatment converts the patient the more easily into a chronic recidivist. This generalization applies especially to the group of seronegative primary cases in which treat- ment is begun in the chancre stage before secondaries appear, for it is now definitely apparent that development of full-fledged secondary lesions tends to protect the patient from subsequent relapse. The patient whose early symptoms have been abolished by a few doses of neo-arsphenamin, enters on an in- determinate period of danger to his commun- ity, represented by the general statement that approximately 10 to 13 times as many patients relapse after 8 injections of an arsphenamin, as after 28 injections. I shall apply this ob- servation again, later, to the principles of treatment for the prevention of early relapse. Meanwhile, let us not forget the infectious relapse. Control of infectiousness through coopera- tion of the patient. In the days of mercury and iodide as the sole agents for the treat- ment of syphilis, the disease, as I have said, ran its course through a series of infectious relapses in which the control of transmission was largely in the hands of chance and the patient. The results of this state of affairs are before you in the wide spread prevalence of syphilis today. No system of control which depends on chance and the patient can hope to accomplish much. Real self-denial on the part of the patient with syphilis is rarely to be obtained, not because he is syphilitic but because he is human. He is the victim of a disease which is prolonged, insidious and in- conspicuous in its most dangerously transmis- sible phases. His cooperation must be im- plicit, blind, irksome, and protracted. Yet, in the face of such considerations, plus some knowledge of human nature, we still continue to lay down rules for his guidance without regard to the realities of the situation. In order that you shall not judge me de- ficient in respect for the proprieties sanctified by tradition, I set before you here a tabular presentation, both of the facts of infectious- ness and the rules to be observed by the pa- tient for their control. God bless and prosper your efforts to secure their observance. I still preserve enough faith in mankind to make every patient who comes to me with an early infection read them through. Summary of the Facts of Infectiousness ( 1 ) The more recent the infection, the more dangerous. (2) The blood Wassermann is not a guide to infectiousness or non-infectiousness. It may be negative with infectious lesions pres- ent and positive in non-infectious cases. (3) The most infectious lesions are: chancre, mucous patch, condyloma, moist papule (flexures). (4) The places to look for infectious re- current lesions in inspection are: lip (outer 396 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 and inner surface), angles of mouth, faucial pillars and tonsils, sides and bottom of tongue, axilla, nipples, inguinal folds, labia, penis, scrotum, anus (piles). (5) All open or eroded lesions in early syphilis are dangerous. (6) Infection is also transmitted by semen and by benign non-syphilitic lesions (herpes) in patients with syphilis. (7) Syphilis is transmitted mainly by in- timate contact of moist surfaces; i.e., by kiss- ing or sexual intercourse. (8) Moist articles and discharge-bearing dressings and articles of common use can also carry infection. (9) Thorough washing in hot water and soap disinfects contaminated objects. The ad- ditional precaution of boiling dishes, utensils, and such articles as douche nozzles, instru- ments, etc., in soda solution may be used. (10) Dry objects, and dry (not crusted) lesions are non-infectious. (11) Pyogenic infection reduces the in- fectiousness of the local lesion. (12) Trauma by an infected object (knuckle striking teeth, needle prick) makes infection almost certain ; it may be hema- togenous and without chancre. (13) Transfusion is a means of trans- mitting syphilis. A single negative blood Wassermann test in the donor does not pro- tect. (14) There is a distinct infectious relapsing type of syphilis that must be watched for. To such a patient, no assurances can be made. (15) Local irritation favors infectious re- currence; dirt, sweat, discharges, friction (in- tercourse) tobacco (smoked or chewed). (16) Time diminishes the infectiousness of syphilis. After 5 years few cases are infec- tious ; desultory, non-curative treatment, with relapses, may prolong infectiousness many months or years. No treatment can guarantee the non-infectiousness of syphilis indefinitely. (17) Secondary relapses have been seen with general paresis after 20 years. Inade- quate treatment favors infectious relapse. ( 18) Late syphilids are not infectious even though open lesions are present. Do not con- fuse with recurrences. (19) Mercury does not control infectious- ness. (20) Bismuth, while more effective in this respect than mercury, is probably less so than arsphenamin. (21) Arsphenamin controls infectiousness, probably as long as 1 month from the last dose. Summary of Personal Hygiene Instruc- tions for the Syphilitic Patient (1) Do to others in this matter as you would wish them to do to you if you were well and they sick. (2) Don’t kiss. Change your disposition if you have been effusive. (3) Sleep alone. (4) Trust wife or husband with the facts. (5) Have your own towels and dishes at home. When away, eat where you know they scald the dishes. (6) Never use another person’s shaving tools, his cup or dipper, his spoon or other eating tool, his pipe or cigarette holder, his toilet articles, and never let him use yours. (7) Consider every open sore infectious until you have seen your doctor. Burn the dressings. (8) Watch for “patches”, cold sores, cankers, pimples, chafes and piles, and see your doctor if they appear. Consider yourself infectious. (9) Get your doctor's instructions rela- tive to sexual matters, and follow them. (10) Don’t smoke, if you are within 5 years of the beginning of your infection. (11) Don’t worry. Keep free of mental strain as much as you can. (12) Sleep 8 hours a night. (13) Avoid over-work, but keep reason- ably busy. (14) Gain weight unless your doctor says not. (15) Exercise as usual in the open air, unless otherwise instructed. (16) Avoid chilling and getting wet. (17) Report all colds, coughs, sore throats, and other infections to your doctor while you are under treatment. (18) Avoid injuries. They may start May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 397 trouble. Be especially careful to avoid sprain- ed joints and blows on bone. (19) No alcoholics. (20) Realize that your chances are good for recovery, and make the most of them. There is one way in which the physician can further the value of the patient’s cooper- ative effort in the prevention of infection. This is through thorough examination and re- examination at every possible opportunity during the early years of the disease, to de- tect the presence of a relapsing tendency, and of actual relapse lesions as such. In spite of what I have said about the unreliability of the Wassermann test as evidence of infec- tiousness, it does have a certain significance in the early months of treatment. Moore and Kemp have shown, that a relapsing tendency is indicated by the too early decline of the Wassermann to negative under treatment. It is also well known that recurrence of a posi- tive after a series of negatives in an early case is a warning of the existence or pros- pect of relapse in some group of structures. It is, moreover, known that seronegative primary syphilis which becomes positive with- in a few days after the first injection of an arsphenamin, behaves much as does seroposi- tive primary syphilis with respect to an in- creased tendency to relapse when treatment is stopped. Finally, there exists in man as in animals, a definite relapsing type, which does not accumulate resistance to the disease ex- cept at the expense of repeated cutaneous re- actions, most of them in potentially infec- tious form, during the first 5 years or so of the disease. These are the patients with de- layed secondary eruptions especially. To utilize these considerations in practice calls for frequent repetitions of the serologic tests within the first weeks or months of the dis- ease (Moore and Kemp performed them once a week) ; and systematic search for the re- currence of infectious lesions about the mouth, throat and genitalia, especially after treatment is suspended. It is impossible to over-empha- size the necessity for thoroughness in such re- examination of treated patients. No swivel- chair examination and “Oh you look all right” technic will do the work. It is necessary to burrow into the corners with light and tongue blade ; to evert the prepuce, paw over and in- spect the scrotum, especially the posterior sur- face, and see the anal opening; to attentively study the flattened palms and soles. I know from experience how irksome and time-con- suming this is, but you will be rewarded by some startling discoveries among your sup- posedly cured patients. Look especially for mucous erosions, supposed fissures with grey- ish pellicles, “warts”, supposed hemorrhoids, “herpetic” lesions on the penis, and the ringed recurrent lesion of the scrotum. Control of infectiousness by treatment. An understanding of a few fundamental prin- ciples here aids in the application of rules and standards to the individual case. Contrast for the moment the situation of public health con- trol with respect to syphilis and tuberculosis. In the latter disease, education, isolation, and hygienic attack are still our chief weapons. In syphilis, while these methods have their worth, they are of minor import because they cannot stem the countercurrent of the basic urge which underlies the prevalence of the venereal diseases. Without a new weapon, we would be as we are with gonorrhea, at a standstill. Our new weapon is chemotherapy, as yet un- known in tuberculosis, but already far advanc- ed with respect to syphilis. It is not too much to say that it is arsphenamin, and arsphen- amin alone, that makes hopeful the ultimate extinction of the disease. It is essential, there- fore, to understand the action and peculiari- ties of the arsphenamins if we wish to do our utmost to control the disease. Action of the antisyphilitic drugs. Action of the arsphenamins is clarified by a comparison with that of mercury and bismuth. An arsphenamin acts upon the spirochete through the medium of its oxidation products, and de- stroys it outright with comparatively little ef- fect on the tissues. Mercury, on the other hand, in the body, has little effect on the spirochete, but acts rather by stimulating tis- sue resistance to the organism, and perhaps by stimulating the cell to make its own slow and only partially effective resistance to the disease. Bismuth is intermediate between these types of action, a better spirillicide than mer- 398 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 cury, but a much poorer one than arsphena- niin. The action of an arsphenamin upon in- fectiousness may he summarized by saying that an effective arsphenamin in adequate dosage destroys every surface organism, and hence renders the patient non-infectious with- in 24 hours. The duration of this sterilization is short, and is made permanent only by repe- tition of the doses at intervals not greater than a week, for a long series. The action of mercury with respect to infectiousness is summarized by saying that condylomas swarm- ing with spirochetes may develop around the anus, right in the middle of a course of the most popular insoluble mercurial salt (mer- cury salicylate). Bismuth will sterilize, but its action is 3 to 8 times as slow as that of an arsphenamin. Arsphenamins vary in their spirochete- destroying power. Neo-arsphenamin. though so popular, is notably uncertain in this regard, and Dale and White were able to show that a good deal of what was labelled and sold as neo-arsphenamin in Great Britain during the war, was powerless to destroy the Spirocheta pallida. Voegtlin confirmed some of these observations for neo-arsphenamin made and used in this country. It is important to real- ize that the spirochete-destroying power of an arsphenamin is not due to arsenic as such. For that reason, other arsenicals, especially the pentavalent drugs such as tryparsamide, and the cacodylates, have no value in tracing infectious syphilis, for they are feebly or not at all spirillicidal. It is the valence of the arsenic-linkage to the dye base that counts. The complete dependence of the prevention of infectiousness, not to say even the so-called cure of the disease, upon the arsphenamins is perfectly illustrated by a number of recent clinical observations. Moore and Kemp found a definite decline in the frequency of recur- rent secondary syphilis proportional to the number of arsphenamin courses received by their patients. Of 196 patients receiving from 1 to 8 injections of an arsphenamin, 80% had potentially infectious recurrences; of 89 re- ceiving 6 to 12 injections, 10%, or only half as many, relapsed; of 46 receiving 13 to 20 injections, 10%, and of 71 receiving 21 to 40 injections, only 5.6% relapsed into potential infectiousness. Besancon, Schoch and I found in my own clinic that 85% of our patients who relapse with the appearance of infectious lesions have had less than 12 arsphenamin and 10 heavy metal injections, a figure which exactly confirms the 88% found by Moore and Kemp. The study presented before the International Congress of Dermatology and Syphilology this summer showed with clear- ness and exactitude based on large numbers of cases collected from 5 cooperating Ameri- can clinics, that the critical point for a large proportion of patients with reference to the prevention of potentially infectious relapse, lies between the fifth and the ninth injection of “606”. Even with identical amounts of heavy metal in both groups, those who re- ceived only 1 to 5 injections of arsphenamin relapsed 5 times as often as those who re- ceived 5 to 9 injections. Modern treatment, then, depends for the prevention of infectiousness, on the arsphen- amins, and not on either mercury or bismuth, essential though these elements are in the successful outcome and “cure” of the indi- vidual. The patient in the first 2 or 3 years of a syphilitic infection who receives from his physician less than 20 arsphenamin in- jections, remains a vastly greater danger to his contacts and the public health, than does the patient who receives more than 20 injec- tions. My time allotment must have consideration — so that I know you will pardon the didac- ticism of a succession of short summaries setting forth application of the foregoing principles to various special phases of syph- ilis, to which we shall now proceed. Control of infectiousness in early syphilis ( first 3 years). This is “Today’s World Prob- lem in Disease Prevention”. Let me stress to you the vital importance of 2 factors, time and arsphenamin ; time , because every hour gained in putting an early infection under treatment nips future contacts, and increases the proportion of radical cures ; arsphenamin, because, as I have shown you, it is the only quick destroyer of the organisms, and the ab- May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 399 solute leader in the field of infection control. On the question of time, I might harangue you on the darkfield, as all of us have done ; and leave you without the knowledge or equip- ment to use it. I recognize the individual im- practibilities of the darkfield, and I therefore urge you not to buy the instrument and use it, but to require of your state laboratory that it develop a darkfield service comparable to its present Wassermann service, and supply you with the pipettes and mailing cases to secure for your patients with suspected chancres darkfield examination of the chancre serum within the first few days of the life of the lesion, while the blood is still negative to Wassermann and Kahn. If your state will not provide the service, get it from the hos- pital or pathologist in your neighborhood. Develop a local darkfield man who knows his spirochete when he sees him, and try for cure in the seronegative phase. Refuse to listen, first of all, to those of the “Old Guard” who advise you to wait for secondaries to appear, in order to “give the patient a good reaction”. There is absolutely incontestable evidence that though this may affect somewhat the tendency to recurrence, it reduces the prospect of cure for the individual 25 to 40%. More than that, withholding arsphenamin maintains for days and weeks a focus of dissemination of the disease in the community, not subject to quarantine, and unquarantinable even if regu- lations existed, that spreads syphilis broad- cast as of old. Throw the detail man out of your office who advises you to try his firm’s intravenous preparation of bismuth alone on an early case — or any other preparation but an arsphenamin compound. The French have tried bismuth this way, to their sorrow. Even the contrast between an arsphenamin and an arsphenamin-bismuth compound is illuminat- ing in this particular, for an arsphenamin alone in adequate dose is 3 or 4 times as fast a sterilizer of active lesions, as is the ars- phenamin-bismuth compound — bismarsen ; though properly used, bismarsen is apparently the superior from the curative standpoint. It is possible without in any wise sacrificing the interests of your individual patient to pre- serve fully and further the public health con- cern in the early effective use of an arsphen- amin. Of the subsidiary principles involved in the control of infectiousness in early syphilis, I would offer these. Allow no rest periods in the first 18 months, for these lead to relapse. Use a heavy metal, preferably now-a-days bis- muth, side by side with and in the intervals between arsphenamin courses. Be moderate in dosage, but effective, for less than 0.3 gm. of an arshpenamin is of doubtful utility, and more than 0.5 gm. of “606” or 0.6 gm. of “914” may destroy tolerance and cut treat- ment short. Mass the patient’s treatment early, giving the injections closer together at the start, and getting all the treatment you can into the patient within the first 3 or 4 months. Then keep on, and try in every early case to reach 36 to 40 injections of an ars- phenamin in courses of 12, 10 or 8 injections, plus the accompanying bismuth. Never, no matter what the stage or circumstances of the case at the start, give abortive cures, a single course of 8 injections or less, and put the pa- tient on pills or any other form of treatment than a continuance of his arsphenamin. Abor- tive cure has disappeared from the practice even of Germany, which originated it. Treat every case to a maximum, determined, not by your personal experience with a few patients, or your detail man’s experience with none, but by that of the syphilis clinics of the world as presented in the literature and through your state and national venereal disease services. Control of infectiousness in late syphilis. Here the time factor is paramount. Lose your dread of the gumma and the tabetic patient if you have any, for transmission of the dis- ease does not lie at their door. I believe it was Hoffman who reported the famous ex- ample of a man with gumma of the penis, who, though by no means abstemious in un- protected intercourse, did not transmit the disease to his uninfected partner. Latency in marriage, is, of course, a special problem, to be presently mentioned, but, in general, one need not fear the infectiousness of late syph- ilis nor make life unduly hard even for pros- titutes who have had the infection for a dec- ade or more. Control of infectiousness in sexual relations 400 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1031 and pregnancy. You will notice, of course, that I have not said “marriage and preg- nancy’’ ; for I would wish you in considering this matter to be realistically rather than mor- alistically minded. Marriage is only a part of the problem, as one well realizes when a seemingly intelligent young man replies to his doctor's warnings by saying, “Why of course I would not stay -with any nice girl, Doctor, while I have this thing’’. Whether for better or for worse, the niceties have faded out of the modern situation with decline of the double standard, and the instructions to the patient and the course to be pursued in refer- ence to possible sexual contacts must be the same for the married and the unmarried. Therefore, I suggest that you lay before all patients, in the first interview after diagnosis is made and the first treatment given, the facts I have recounted to you, regarding time-treatment relations in the transmission of the disease. I suggest you set 40 ars- phenamin injections, rather than 5 years, as a probable landmark in the resumption of sexual activity. Then, if you live in a state or community where enlightenment is pos- sible, remember that infectious recurrence in- volves especially the penis, the vulva, and the mouth parts, and that the semen may be in- fectious. Keep them apart by impervious protection rather than chemically. Though I speak in terms of almost urologic barbarity, I would not belittle the influence and worth of ethical pressure, and would spar for time be- tween infection and my patient’s resumption of sexual activity by every device known to the temple, the court and the sawdust trail. I fear to seem facetious or cynical, for these issues are critical, and a religious or moral appeal that holds even an occasional man to arsphena- min and keeps him from women, has public health worth. Remember again not to base decisions as to infectiousness on negative serologic tests, lest you wreck some innocent woman or child by premature permission to a husband. And, once you have in your best judgment authorized sexual activity, keep constant check upon it in the early years, limiting it to the times when the patient is under arsphenamin control, if possible. The problem of preparation of the intelli- gently cooperative man or woman for the con- ception or bearing of a child is still on a theoretic basis, for so few patients can be kept under the necessary control for the pur- pose. In theory one should prepare both the syphilitic man and woman for the conception of a child with an arsphenamin and bismuth course. More frequently we are called upon to deal with the situation and prevent infec- tion of the child only after conception has oc- curred. On this matter there can no longer be 2 opinions. I cite you simply for concrete- ness the notable statistics of Boas and Gam- meltoft (Nabarro, Brit. Jour. Vener. Dis. 1928, 4:107). In a total of 201 cases of syphi- litic mothers receiving no treatment for the disease, 96.5% of the children were syphi- litic, and 3.5% healthy. Of 87 syphilitic mothers receiving mercury before pregnancy but none during, 90% of children were syphi- litic and 10% healthy. Of 15 mothers receiv- ing arsphenamin before pregnancy, but none during, 80% of children were syphilitic and 20% healthy. Of 111 mothers receiving mercury only during pregnancy, 72% of chil- dren were syphilitic and 28% normal. Of 26 mothers receiving arsphenamin before and mercury during pregnancy, 27% of children were syphilitic and 73% normal ; while of 105 mothers receiving arsphenamin during or both before and during pregnancy, from 15 to 20% of children were syphilitic, and from 80 to 85% normal. It is unnecessary to point the moral of these figures. Translated into prac- tical terms, every pregnant woman, regardless of age, social status or other circumstances, should have a serologic test for syphilis as soon as she is first seen by her obstetric at- tendant, and this test should be repeated by the seventh month. Every mother who has or has had syphilis, regardless of the age of her infection, of her serologic findings, whether positive or negative, and almost of her general state, can and should have some arsphenamin, preferably both before and during, but .at least during, her pregnancy. The prescription may vary in individual cases, for a syphilitic heart or liver, for example, modifies the rule; but in general, the arsphenamin should be be- gun early, given through the larger part of May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 401 the pregnancy, and be combined with bismuth at least part of the time. The dosage can be moderate, but should not be picayune, and the follow-up of mother and child must be com- plete and protracted. An enormous harvest of prevented infection with syphilis awaits the adoption of these rules by the profession at large. Control of infectiousness in industrial re- lations. My time and your patience are hardly lengthening, so that I devote only a word to this interesting subject. The crux of the syphilis problem in industry is recognition of the infected person. Perhaps I might place ahead of this the problem of getting the issue before the czar-like official autocracies that too often bar the way. The principles in- volved are these, as I learned them in my study of railroad men. Syphilis is overwhelm- ingly acquired in youth. It is infectious in its early years, and coincidently it is apt to be serologically positive during this period. The appropriate mass measure, aside from detailed periodic physical examination, is the taking of the blood Wassermann test on all persons be- tween the ages of 17 and 31, on entering em- ploy, and at such intervals thereafter as may be practicable within the age period named. Understand that this Wassermann is taken not to detect infectiousness but to identify the presence of syphilis. Further medical exam- ination is then essential to determine the status of the detected case, which may, of course, not be infectious at all, even though serologi- cally positive. As a matter of fact, with disappearance of the common drinking cup (if it has disappear- ed), the transmission of syphilis in industrial relations as such, is probably of small moment. When both sexes work in contact, it is more important to attack the social hygiene problem than the epidemiologic one, through the instru- mentality of matrons, effective shop discipline, and education. Even in food handlers, and cosmetic workers, the risk of transmission of syphilis may be exaggerated, though it is true that one sometimes shivers when one watches the technic of barbers, dining-room, kitchen, and soda fountain help, from behind the Scenes. Periodic serologic testing of such persons is probably desirable for detection purposes. The most tragic aspect of the mat- ter is the least known — the children infected by irresponsible and immoral servants in the home. I have seen everything from tabes in the house-mother of a great girls’ school dormitory, to a chancre on the penis of a 2- year old baby, traced to the activities of the crooked and infected nurse. Here at least is a field that merits genuine effort at study and control. Social hygiene and public health aspects. The reservoir of syphilis, up to the War, was prostitution, organized and unorganized. It is impossible to quote the vast mass of figures from every source demonstrative of this fact, but in the study of prenatal syphilis and of the infected father and mother which I made preparatory to the chapter of my text on this aspect of the disease, the realization was most clearly brought home to me. Of the fathers of my little syphilitic patients, 90% had ac- quired the disease extramari tally. Just what role the so-called emancipation of women is likely to play in the dissemination of syphilis, is as yet largely material for speculation. I question if the role will be a large one — the worldly-wise maiden is beginning to under- stand the protective virtues of caoutchouc too well to take unnecessary chances, if my im- pressions from the venereal confessional are any guide. At the same time, Jeanselme and Burnier seem to feel that increasing prostitu- tion is a significant force in the wrong direc- tion. Two or 3 things do seem to stand out, that deserve mention. The younger a prosti- tute, or a free lance, the more dangerous, for obvious reasons, and hence the more in need of control. This word raises at once the question as to whether there can be such a thing as control. Some very interesting ex- periments have been tried recently in this di- rection, among them Kolle’s effort to keep prostitutes non-inf ectious by the injection of what he called “bismuth plugs” intramuscu- larly, which he hoped would prevent the de- velopment of infectious lesions. Nothing not- able has been published thus far to my knowl- edge on the matter. I may tell you that my lifetime’s experience with syphilis, such as it 402 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 is, has made me an abolitionist. No one who knows the disease seriously expects to control or influence its incidence by the provision of segregated districts and inspected girls. Public health control of venereal disease as it con- cerns the infection focus centers around the tracing of the source of each and every early infection identified, and the immediate steril- ization and supervision of that infectious source by every available means, but most of all by making treatment not so much forced as attractive and easy. Every practicing doctor can contribute to this end by trying to bring in the source from which his patients are infected and by demanding of the state that it inter- fere here, instead of in the treatment of tabes and paresis, the mere non-infectious end-re- sults. A state social service could do won- ders in backing the doctor by bringing in for treatment the foci that spread the disease among his patients. The report and the quar- antine, while orthodox weapons, have helped me far less than the 2 or 3 socially minded and intelligent women that used to trace sources for Irvine in Minnesota during the war. The entire policy of a great nation, England, in dealing with the venereal dis- ease, is founded on cooperation and education rather than compulsion — not without some protest, however. Let us do what we can, too, to spoil the business of the druggist who prescribes and dispenses to venereal patients. He ruins the early detection of the disease too often. And let us not expect too much of personal chemi- cal or packet prophylaxis. I see something of it among men of more than average intelli- gence, and I doubt if among the average it is worth anything at all. A half-drunk man and a prophylactic packet are no match for the spirochete. Remember that it is station prophylaxis under organizational conditions that worked the wonders on the venereal situ- ation in the War. Control of infectiousness in physicians, dentists and nurses. You remember the an- cient saying that “curses like chickens always come home to roost”. My closing paragraph is the appropriate place for such a consum- mation. No one who deals with syphilis day in and day out can fail to realize the tragic in- cidence and the deplorable outcomes of the disease among those whose professions bring them into contact with it. Several facts have high significance here. Syphilis is the danger- ous unexpected. It is not the svphilologist who acquires it, even from a lifetime of potentially dangerous contacts. It is the practicing doc- tor, secure in ignorance, of a low index of sus- picion, of a mistaken casualness and bravado, and irresponsible in treatment who meets ruin in this way. It is a legitimate demand on the public in protection of professional attendants, that patients submit to a routine test for syphilis as a part of every medical examination. Now that the precipitation tests are coming to the requisite simplification (as witness the presumptive Kahn and the finger-test Kline), it is no longer necessary to remain in ignor- ance of a patient’s condition on this important point. One can know that one is dealing with potentially infectious material within 20 min- utes. where such facilities are available. No- where will such a help be more important, if I may digress momentarily, than in the pre- vention of transmission of the disease by blood transfusion, one of the most shocking and regrettable miscarriages of modern thera- peutics that can befall a hospital or a medical staff. Two additional items calculated to protect the profession from accidental syphilis are an adequate light in examination of patients in the office ; and, an absolutely unbreakable habit of inspecting orifices. If the examina- tion of the fourchette and labia before passing the palpating finger ; of the commissures, buc- cal mucosa and throat before introducing dental instruments ; of the anal and vaginal openings before passing tubes and thermome- ters ; were conducted with a good flash lamp, many a finger and many a life would be spared. Good gloves, new gloves, and condign punish- ment for pinholed gloves handed to an ex- aminer, would mean much. The habit of warn- ing the patient not to cough ; the learning of that difficult art of looking at not merely, through or past the small things one encoun-. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 403 ters on an orificial inspection; these would help. Special realization of danger on the part of those who deal with the woman’s in- visible genital tract in diagnosis and treatment, and those who operate upon the nose, throat and anus, where danger is always imminent and always unexpected, would help. And when infection occurs, some medical knowl- edge of the extragenital chancre — which is not a felon, not a boil, not a sarcoma, not “just an infection”, would help, too. Indura- tion, indolence, and satellite adenopathy, the 3 keystones to physical diagnosis of the chancre, could help us to an early darkfield, and early diagnosis, and a probable cure, much oftener than they do. I would recommend it to you as a pro- tective procedure, that your patients with recognized and not recently treated syphilis who are up for operation, receive, if no emergency or special aspect of the disease contraindicates, 1 or 2 injections or 0.45 gm. neo-arsphenamin before they are operated on. At least ask the advice of a syphilis man on the matter. I know the risks of surgical in- fection with syphilis are small in some as- pects of the work ; that there are hoary-headed masters of the surgical art who have come through 40 years of operating untouched so far as they know. But I have seen too many men marred. Writing this paper in my study, I picture my audience as hearing with patience and comprehension — perhaps, too, with some con- siderate indulgence — the effort of one who was once kindly called a crusader, to bring this subject home to you. Being generously disposed to strangers, and, as your records show, genuinely concerned over this aspect of the public health, your enlightened outlook will accept, I know, the conclusion of the whole matter. The responsibility for the modern control of the infectiousness of syphi- lis is not in the hands of the church with its preaching, the law with its mandates, or the laboratory with its drugs. It lies today, to be met or ignored, with the everyday doctor. VALUE OF BLOOD SEDIMENTATION TEST IN GYNECOLOGY John Huberman, M.D., Newark, N. J. During the past few years a great deal has been written on the clinical significance of the sedimentation test, which has been on trial for some years in this country and abroad. Its value has been emphasized by the following investigators : Popper and Kreindler find - the test a valuable aid in diagnosis and prognosis. Netschman uses it in differential diagnosis, especially in conjunction with a complete blood count. Frosch believes the sedimenta- tion test more delicate than the blood count can be. Barr and Reis, from Michael Reis Hospital, in Chicago, and Friedlander, of Detroit, advocate it in gynecology. Some workers report unsatisfactory results, such as Cherry and Schmitz, whose difficulty would seem to be one of interpretation. The figures obtained by them and on which they base their condemnation of the sedimentation test are so at variance with the rates obtained in the various gynecologic case types by practically all other workers in this field as to warrant the impression that their cases were compli- cated by undetected remote foci of infection or were of mixed pelvic pathology. Men like John Osborne Polak have had tests made on every patient admitted to the gynecologic wards of the hospital and 1000 readings have been made from which the rates of sedimenta- tion have been tabulated and definite deduc- tions drawn. In gynecology a large proportion of our operative work is elective, and we must strive to eliminate every possible factor which may contribute toward a prolonged convales- cence, especially factors involving the recogni- tion and elimination of infection. It might be well to emphasize at once that we are clinicians and not laboratory tech- nicians. We are treating patients and not simply making tests, and of course the clini- cal course is the outstanding factor in hand- ling our patients. We use the leukocyte count, temperature curve and, in addition to our 404 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 clinical data, the proper interpretation of the sedimentation test. This investigation was undertaken by our service in order to deter- mine whether the blood sedimentation test offers additional information of either diag- nostic or prognostic value. If this test adds something to our clinical knowledge that may help us to determine the presence of latent infections, and when to operate and when not to interfere, it is worth using routinely, con- sidering its simplicity. Let us briefly review the history of the sedimentation test. The hastened settling of inflammatory blood has been known to physi- cians for centuries and was considered a par- ticularly important clinical sign, both theoret- ically and practically. With cessation of , blood letting and the advent of cellular path- ology, it practically had become forgotten and is now observed again independently by a modern investigator with a new meaning and in a new light. Many writers credit Galen as the first to call attention to this phenomenon under the name of “Crista Phlogistica”. John Hunter studied the phenomenon of blood sedi- mentation in 1791. He not only observed that the erythrocytes settled more quickly in their own plasma, but he was also the first to demonstrate that the red cells of normal blood when separated and transferred to the plasma of inflammatory blood, settled with greater speed, the rapidity of this process being in direct relation to severity of the infection. In 1918 Fahrens rediscovered the phenomenon of blood sedimentation in pregnancy and started the present wave of investigation. It has since been observed and studied in tuber- culosis, cancer, various forms of joint dis- ease, pneumonia, scarlet fever, pelvic inflam- matory disease, syphilis, anemia, and many other conditions. It is not within the scope of this paper to discuss the various theories advocated to ex- plain the sedimentation phenomenon. It is safe to say, however, that out of the host of theories propounded, from auto-agglutination, electrophysical reaction and increased fibrogen content of blood plasma, down to the presence of some specific ferment in the plasma, there is not one universally acceptable explanation. Regardless of theory, the ultimate cause ap- parently depends upon the degree of cellular destruction going on in the body. The sedi- mentation reaction is generally regarded as a measure of pathologic activity and therefore as a symptom of a general kind. It is a fine quan- titative measure of the change in the blood, produced by a destructive process somewhere in the body. It does not diagnose, nor does it localize the infection. It does not indicate the state of the diseased organ, hut it does re- flect the disturbance produced in the organism through the absorption of products of infec- tion. There are 2 recognized methods of sedi- mentation reading. The first, time method, is advocated by Linzenmeier. This method fixes the distance and observes the time, recording the results in minutes. The second, distance method , employed by Westergren, where he fixes the time and measures the distance recording the results in millimeters. Although most investigators in this country choose the Linzenmeier method, we felt that the Wester- gren method was easier for reading and more exact for results. The Westergren technic, as employed by us, is as follows: To prevent blood coagula- tion, a 2 c.c. syringe is filled with 0.4 c.c. of 3.8% sodium citrate solution. The cubital vein is punctured and 1.6 c.c. blood is with- drawn, which means that the syringe is filled up to the mark of 2 c.c. and the blood sodium citrate mixture is then put into a test tube. By shaking, we attempt to get an equal distri- bution of the blood cells. The blood is sucked up into a pipette which shows a scale of 200 mm. The content between the zero mark and mark 200 equals 1 c.c. It is not necessary to fill the pipette immediately after the ven- ous puncture, as the citrated blood gives the same sedimentation after standing in the test tube for a few hours. The pipette is fixed then into a frame and time noted. After a certain time the sedimentation of a red column in the pipette is noticeable. We read usually after 1 hour, a second time after 2 hours, and finally after 24 hours. The most important reading is the first hour. The important question to be answered is whether the sedimentation test has a practical application. Its practicability so far as technic May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 405 is concerned is obvious for the test is simple and requires very little laboratory equipment. The fact that in normal individuals the sedi- mentation is between 2 and 5 mm. in the male and 3 and 7 mm. in the female individuals, while sedimentation in inflammatory cases varies according to severity of the process, indicates the value of the test. It is a more precise reagent than the thermometer, for ab- sorability of infected material is promptly recorded by variation of blood sedimentation even when the temperature remains normal. We cannot always claim that increased sedi- mentation indicates an infection in that part of the body upon which we are directing our attention. We know, however, that there is an infective process in some part of the body and that we must try to . eliminate all error in diagnosis; i.e., when the infection is not found where it was suspected a thorough search may locate the infection elsewhere. We read a rapid sedimentation and operate suspecting diseased adnexa, but instead we find normal adnexa, and if we search further we may find a diseased appendix or gall-bladder to account for the rapid sedimentation. The sedimentation test is especially valu- able in those cases of adnexal disease where there is a latent infection with a normal tem- perature and normal blood count. Very often the surgeon operates and finds such a latent infection, which lights up and causes a stormy convalescence, or even jeopardizes the life of the patient. We consider an increased sedi- mentation, above 50, a sign of latent infection and although temperature and blood count are normal, postpone operation until tests indi- cate a sterile field so far as operation is con- cerned. Whenever sedimentation is used, operations have not been complicated by the presence of unsuspected latent infections, which indicates that the test succeeds in show- ing the existence of such a condition. Because it is known that operations increase the mor- bidity and mortality in such infected cases, the exclusion of a latent infection is only possible when the sedimentation is not more than 10 to 15 mm. Too much emphasis cannot be laid on the importance of repeated readings. The clinical picture and physical findings may seem to re- main unchanged, the temperature curve and leukocyte count may show no significant vari- ations, while the sedimentation time is chang- ing in direct relation to the changing condi- tion of the patient. This holds good not only in determining safe operability, but even more strikingly in making a prognosis. In the opinion of most authorities and this is borne out in our experience, it is possible to classify all gynecologic conditions according to their sedimentation. Normal sedimentation test occurs in the following: (1) Malposition of the uterus; (2) polyps; (3) plastic opera- tions. The readings will not exceed 10 mm. for the first hour. Cases of pelvic pathology whose sedimen- tation comes nearest to normal are : ( 1 ) Simple ovarian cysts; (2) dermoid cysts; (3) hydrosalpingitis; (4) uncomplicated myoma. As a rule, they never exceed 15 to 20 mm. within first hour. In the presence of an active infection, i.e. acute salpingitis, de- generated fibroid or mixed pelvic infection, the test shows a strikingly increased sedimen- tation ranging from 70 to 120 for the first hour. An individual interpretation is required in malignancy and ectopic pregnancy. An un- ruptured ectopic shows only a slightly in- creased sedimentation. A ruptured extra- uterine pregnancy shows an increased sedi- mentation which is in direct proportion to the amount of bleeding and destruction of red cells. The larger the amount of free blood in the abdominal cavity, the higher the sedi- mentation. Of course the safety limit of 50 mm. for the first hour does. not apply in the case of ruptured ectopic, any more than it would apply in cases of obstruction where operation is vitally indicated. Another special consideration must be given to malignancy. Here the sedimentation read- ing is directly proportional to the amount of tissue destruction. An early malignancy shows slow sedimentation which increases as the destructive malignant process goes on. I will now try to illustrate the value of this test by reading a few typical case histories. To begin with, in our group of normal or low readings — ovarian cysts, malposition of uterus, and plastic operations with a reading 406 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 of about 10 — we found the white and differen- tial count in the majority of cases to conform with the sedimentation test. Where a dis- crepancy existed we gave preference to the sedimentation test. We might add here that where the sedimentation was normal or low we did not find at operation any latent infec- tion and the patients made an uneventful re- covery. The first case for illustration is a patient in the hospital now. Mrs. S. Lien, admitted with the diagnosis of left salpingitis, tempera- ture 101°, pulse 120, blood count 8900, and differential only 69%. Sedimentation taken and found 98 for first hour and 129 second hour, which is rather high. After a few days’ rest, first hour reading 84 and 121 second hour. In spite of the low blood count and dif- ferential of 69%, we are inclined to believe that the diagnosis is acute salpingitis, with possibility of pus. We examined this patient vaginally 2 days later and her temperature rose to 103°. In this case the sedimentation tests is in conformity with the clinical picture and tem- perature curve, while the blood count and dif- ferential would tend to mislead us as to the existing pathology. In such a case we post- pone operation until the sedimentation is be- low 50 for the first hour although the temper- ature and pulse may become normal. By doing this we hope to avoid a stormy convalescence. As a counterpart to the preceding history, the following case might be of interest. Mrs. J. R. was admitted with the following history : For the past 5 weeks she had experienced a pain in the right lower abdomen, radiating to the right extremity and the rectum. Later, the pressure on the rectum was the most pro- nounced symptom, causing a constant tenes- mus. Bimanual examination showed a palp- able mass in the posterior cul-de-sac, which was not fluctuating, and a tentative diagnosis of pelvic abscess was made. Temperature 102°; pulse 100; leukocyte count of 26,250, with 89% polys ; but the sedimentation was normal. We did a posterior colpotomy. No evidence of pus being found, she was treated conservatively and went home within a week without any pelvic pathology, and she is ap- parently still well ; proving that the sedimenta- tion test result was correct in spite of the clin- ical and laboratory findings. A third interesting case follows. Mrs. Ray Petesky, admitted with diagnosis of “possi- ble ectopic’’. History of vaginal bleeding, pain in lower abdomen, difficulty of micturition and defecation. She had missed 2 periods. Had been previously operated on at Royal Victory Hospital, in Montreal, for ruptured right ec- topic. Temperature on admission 101°; pulse 100; white count of 1400 and 76% differential; Hb., 68%. Vaginal examination showed uterus enlarged, with an indefinite mass on left fornix. So far, the diagnosis of ectopic appeared to be amply justified. Sedimentation was taken and found to be 134 for the first and 137 for the second hour; which is maxi- mum rapidity. We reasoned as follows : Unruptured ec- topic would give a low reading; not higher than 40. Ruptured ectopic would give read- ing in direct proportion to the amount of free blood in the abdominal cavity. In this case there was no evidence of internal hemorrhage and we therefore came to the conclusion that we were dealing with a superactive salpingitis. The operative findings disclosed a left tubo- ovarian abscess, and that was substantiated by the pathologic report. Another interesting group is that of malig- nancy. Mrs. G. was admitted with diagnosis of tumor of left ovary. For past few months she had occasional sharp pains in left lower abdomen, radiating downward. Moderate vag- inal discharge and regular menstruation until last month, when she menstruated twice, the second time very profusely. Temperature 98.4°; pulse, 80; leukocytes, 13,200; polys, 76%. On bimanual examination, large cystic mass felt on left side. Diagnosis was made of left ovarian cyst. The sedimentation test showed 72 for first and 96 for the second hour, and our diagnosis was accordingly changed to malignant cyst. Operative finding and patho- logic report showed a papillary cyst, adeno- carcinoma of the ovary. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 407 The value of the sedimentation test can be summarized in the following manner : (1) It is an aid in differential diagnosis and prognosis. (2) A sensitive means of recognizing the presence of inflammation and tissue destruc- tion. (3) The only guide in determining the most favorable time for operative intervention. (4) In pelvic inflammatory conditions we consider a reading of 50 or less as a favorable time for operation. (5) The test is a more sensitive means of indicating inflammatory changes than is the white cell count or temperature curve. (6) In malignancy the sedimentation cor- responds with the degree of tissue involvement. (7) In fibroids the test will show in what cases we may expect inflammatory complica- tion, for an uncomplicated fibroid shows a normal sedimentation. In conclusion, it is hardly necessary for me to call attention to the importance of correlat- ing the sedimentation reading with the history, the clinical picture and pelvic signs. I merely assert that it is easier to do a sedimentation test than to make a blood count, and that you will sret more information out of a sedimen- tation test than from a blood count in the presence of a latent infection. This applies not only in gynecology but to a variety of other pathologic conditions in other branches of medicine and I would make a plea at this time to the other services that it be used routinely and they become convinced of its value in their own branch of work. To quote Dr. Polak: “The sedimentation is not a panacea, it is valuable because a high read- ing means infection — a low reading means that infection can be excluded ; for the sedi- mentation test never lies.” I desire, at this time, to thank Dr. Yaguda for his kind cooperation in introducing this test as a routine measure in our hospital ; and also Dr. Glass, who was assigned to this work on our service. THE ACUTE ABDOMEN* John B. Deaver, M.D., Philadelphia, Pa. I hope the experience of many years of active work in study of the pathology of the living, solving many riddles and disentangling many alliances, may be of help to you in un- ravelling some of the difficulties that concern diagnosis and treatment of acute disease of the abdomen. I will confine my discussion to the “idiopathic” abdomen. Before proceeding, let me remark that in no emergency is clinical acumen a more valu- able asset than in the “acute abdomen”, for much as I value aid of the laboratory in the diagnosis of certain diseases, I am free to state that in acute abdominal disease, such as a perforated appendix, perforated gall-blad- der, perforated duodenal ulcer, ruptured ec- topic pregnancy or a twisted pedicle of an ovarian cyst, the laboratory has little if any place, with exception of the blood picture and the sedimentation test in acute pelvic infec- tion, in the diagnosis ; but that diagnosis de- pends most upon clinical facts and clinical ex- perience, and since diagnosis to a large extent affects prognosis, it is sound clinical knowl- edge that counts in the end. The first thing to be considered when con- fronted with an acute abdominal condition is to determine, if possible, the underlying cause, the momentous question of operation, and eventually the most favorable time for op- eration. Sometimes all these questions can be decided by the appearance of the patient; that is, the evidence of hemorrhage, syncope, shock, cyanosis ; the position of the patient, whether fixed or restless ; the type of peristalsis ; the history, if available, of previous attacks; the nature of onset, character and site of pain, presence of nausea and vomiting ; and the se- quence of these 3 items — the site and the de- gree of tenderness and the rigidity. When approaching the bedside the common causes of the acute abdomen should be borne *(Read before the Atlantic County Medical So- ciety at Atlantic City, Dec. 12, 1930.) 408 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1031 in mind. First and foremost is appendicitis. Next in order are cholecystitis, perforated peptic ulcer, intestinal obstruction, acute pel- vic inflammation, ruptured ectopic pregnancy, pancreatitis, twisted pedicle of an ovarian cyst, diverticulitis, occasionally partial or complete torsion of the great omentum, mes- enteric thrombosis, and especially one should not overlook a small lump at the site of one of the hernial orifices, or at the site of a scar the result of a previous operation, that may be a strangulated hernia. In spite of the fact that appendicitis heads the list of causes of abdominal infection, it is not at all unusual to be misled in the diagnosis and to mistake it for some of the other dis- eases, and vice versa. Every busy surgeon, no doubt, has had the experience of opening the abdomen for a supposed disease of the gall-bladder or a peptic ulcer, to find that a diseased appendix has assumed the role of the upper abdominal condition, the other organs being intact. Thus, an acute fulminating ap- pendicitis may present the familiar signs and symptoms of acute perforative cholecystitis or perforating ulcer or acute pancreatitis. The source of this error is due to the power of mimicry of the appendix, which in turn rests largely on the different positions the appendix may occupy. An appendix in a position higher than normal is especially prone to simulate disease of the gall-bladder, and if perforated at the base and the perforation is large, simu- lates a perforated peptic ulcer. I have operat- ed under these circumstances, believing the case to be one of perforated ulcer, to find a high-lying perforated appendix and a periton- itis with no attempt at walling off, making me fearful of further surgery; therefore, I closed the wound, placed the patient on anatomic and physiologic rest, and later, when the periton- itis had subsided or become localized, I have taken out the appendix. While the power of mimicry of the appendix applies particularly to the chronic ailment, it is not at all unusual for a high acute appendix so closely to simu- late an acute cholecystitis, especially in the ab- sence of a definite history of gall-bladder dis- ease, as to make it impossible to differentiate between the two, at least not until the early muscular rigidity has somewhat subsided, so that by palpation the point of greatest tender- ness can be determined and the diagnosis more nearly approached. In the early stage of the acute abdomen the rigidity is generalized, and palpation, usually so significant a physical sign, loses much of its value, so that the ques- tion of immediate operation depends largely on what can be learned by questioning the pa- tient or his family, the patient’s general con- dition, and last, but not the least, upon exper- ience with similar cases. We all know, how- ever, that operation at this early stage, before peritonitis has advanced, will give the best results when the peritoneal involvement is usually confined to the site of the lesion and the surgeon is able to protect the peritoneum against contamination. In this stage, patho- genic organisms are rarely found in the smears taken at and beyond site of the lesion. Later on, however, the infection becomes diffused, especially if nature has not been able effec- tively to place her barriers. Diffusion makes for confusion and adds to the seriousness of the situation. To operate in the presence of a diffusing or a localizing peritonitis may be likened to stirring up a hornet’s nest. Gen- eralized abdominal rigidity is due to peritoneal irritation, the fore-runner of peritonitis, while when the rigidity is more pronounced at a given point it is a sign of incipient periton- itis. Rigidity, not general, together with cir- cumscribed tenderness, is the finding in per- forated appendix and perforated gall-bladder, as against generalized rigidity significant of perforated ulcer with the absence of decided tenderness confined to a circumscribed area. In ulcer the bacteriologic findings of smears in the first few hours after perforation, at the site of the lesion and beyond, are negative. Here we have the explanation of the well- known fact that practically all cases of per- forated ulcer recover if operated upon early. The exceptions are a perforated carcinoma- tous ulcer and a perforated marginal ulcer. In the former there is infection, the result of necrosis, and in the latter infection the result of the position of the ulcer in the jejunum. Fortunately, as a rule, perforated peptic ul- cer presents few diagnostic difficulties to any May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 409 one of average experience. The board-like rigidity is so typical as to be indelibly im- pressed on the average observer. The first observer, as a rule, is the practitioner and it is upon his prompt recognition of the situa- tion and his prompt action in the emergency that successful surgical treatment largely de- pends— for surgery is the only treatment. Ex- pectant treatment in these cases is much like the instance in which the wife of a very sick man said to the doctor: “Is there no hope?” — - to which he replied : “It depends upon what you’re hoping for, madam.” The vast amount of profitable study which has been accorded to diseases of the gastro- intestinal tract, including peptic ulcer, has brought with it many advocates of medical treatment for the chronic ulcer. In my exper- ience this has resulted in an increased number of perforated ulcers. The internist and the gastro-enterologist both seem to lose sight of the fact that at least 15% of chronic ulcer? sooner or later perforate ; that anywhere from 7 to 35% of gastric ulcers are the fore-run- ners of carcinoma ; and that a small percent- age of gastric and duodenal ulcer patients bleed to death. This, to my mind, is a valid argument against too prolonged medical treat- ment of chronic indigestion with ulcer symp- toms. The chief pitfall in the diagnosis of per- forating ulcer lies, as has already been indicat- ed, in the mimicry of the appendix. The main points of difference are in the history and the physical signs. The history of ulcer is one of long-standing indigestion while this is not so in appendicitis. In the perforated ulcer seen early, there is neither fever nor increased pulse rate, as in perforated appendicitis. In ulcer there is killing, unbearable pain ; while the pain of appendicitis, though severe, is more bearable. The ulcer patient assumes a fixed position, while the appendicitis patient is restless and rolls from side to side. In ul- cer there is a general board-like rigidity of the abdominal walls ; while in appendicitis the rigidity is limited, as is also the tenderness that in ulcer is general. In a few words, the ulcer patient is the more desperately ill of the two. To this audience all this may be like carrying coals to Newcastle, but I am present- ing this discussion in what I should like to think a practical manner. Acute perforation of the gall-bladder may present symptoms similar to those of ulcer, although the history of gall-bladder disease should give the proper clue. In the absence of this information, however, the differentiation is not always clear — except that perforating cholecystitis is rather unusual. Nevertheless, it occurs with sufficient frequency to be borne in mind in the presence of an acute abdominal crisis. Besides the usual syndrome of an acute perforation, jaundice is sometimes present. In both acute and chronic cholecys- titis jaundice is the result of cholangitis, us- ually a lymph-borne infection. The differen- tiation between acute perforating and acute nonperforating cholecystitis is in the severity of the symptoms and the physical signs, both of which are more pronounced in the former. Differentiation is important because while acute non-perforating cholecystitis usually sub- sides under anatomic and physiologic rest, acute perforating cholecystitis demands imme- diate operation. If acute perforating chole- cystitis is not operated upon early it will rap- idly develop a vicious, dangerous and too: of- ten a fatal peritonitis, the severity of which depends on the virulence of the pathogenic or- ganism. In most instances it is the colon bacillus, and not infrequently the infection is streptococcal. In a very small percentage of cases nature takes care of the infection by im- prisonment, so to speak, so that the peritonitis becomes circumscribed and the patient may recover from the acute attack and may carry on for a considerable time in reasonable com- fort ; but, finally, operation becomes inevitable and the findings then consist of a walled-off abscess, the bed of which is the great omen- tum, which contains stones that escaped at the time of the perforation. Acute pancreatitis, consisting of 4 varieties, as I have been able to demonstrate at opera- tion— the ultraacute, acute, subacute and the focal — presents differential difficulties, in that with exception of the subacute variety it oc- curs without warning and is accompanied by profound shock. It is probably more fre- quent than is generally supposed and many deaths from “acute indigestion” are no doubt 410 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 actually due to acute pancreatitis. Even when the diagnosis of acute pancreatitis is made, it is usually too late for successful operation be- cause of the injurious effect of the escaping powerful pancreatic ferments on the sur- rounding tissues. The ultraacute variety is rare and so rap- idly fatal, because of the massive hemorrhage around and within the pancreas and the lesser peritoneal cavity, that there is little chance of successful operation. The acute variety is more common. In the acute there is hemor- rhage beneath the serosa and within the pan- creas. Subacute pancreatitis is probably the most frequent of the 4 varieties of acute pan- creatitis. In this, the pancreas is enlarged and edematous, and occasionally a small amount of fat necrosis is present. This is often diag- nosed and operated on for acute cholecystitis. A more frequent error, however, is the con- fusion of acute pancreatitis with intestinal ob- struction. Why this is so I am at a loss to understand, as the differential points seem to me so conspicuous. Acute pancreatitis, with few exceptions, occurs in middle life or after. The patient is usually stout, a heavy eater and often a fairly heavy imbiber. The onset is sudden and overwhelming. There is persistent vomiting, which fails to yield to lavage, hic- cough and cyanosis. The pulse is rapid, there is marked abdominal distension, especially in the epigastrium, rigidity of the abdominal walls and hypoperistalsis or the absence of peristalsis. In acute intestinal obstruction, on the other hand, the pain is intermittent and the pulse is of normal volume and rate ; vomiting is temporarily relieved by lavage ; peristalsis is stormy and there is no distension until late in the disease. If vomiting persists it becomes of fecal odor — an unmistakable sign of what is going on. Unfortunately, acute intestinal obstruction is not always recognized in its early and most favorable stage for operation. One reason is that so often it follows a dietary indiscretion and is treated with home remedies before the doctor is called. The onset of sudden, sharp, colicky pain, followed by sick stomach and vomiting, is mistaken for severe bellyache. Giving a pur- gative, as is sometimes done, is disastrous. Unless the suffering is very severe more time is lost by giving enemas, which even when fol- lowed by a stool accomplish nothing but delay in sending for the doctor, and when the doctor finally sees the patient the picture will have undergone a marked change and will have as- sumed the second stage of obstruction. The belly walls have lost their rigidity, abdominal distension is marked and in some instances coils of bowel are seen, although not so fre- quently as in chronic obstruction, where the abdomen presents the ladder-rung appearance. Now the vomitus has the characteristic fecal odor, there is hyperperistalsis, rapid pulse and temperature. In the third state — the stage of approaching dissolution — the pulse is rapid and weak, the abdomen is greatly distended and tympanitic throughout, the belly is either silent or merely a tinkling peristalsis can be heard, the pulsations of the aorta are ab- normally loud and there is constant regurgita- tion or fecal vomiting. Operation offers little at this stage, being a last resort, yet it should be done. Acute obstruction due to intussusception or to volvulus of the sigmoid should, as a rule, be recognized early ; intussusception by colicky pain, rectal tenesmus and mucoid bloody stools, and, as a rule, the presence of a tumor detected by abdominal palpation and digital examination of the rectum ; volvulus by sud- den onset of very acute pain immediately fol- lowed by sudden and great distension of the lower abdomen. I impress upon my interns to think first, last and always of the appendix, if it has not been removed, when seeing an acute abdomen, and if absent to think next of acute intestinal obstruction caused by ad- hesions. At this point we must again turn to the ap- pendix. As already indicated, the mimicry of this organ depends to some extent upon the position it occupies. The term pelvic appen- dicitis thus is self-explanatory. It is also sometimes a very convenient diagnosis for disease of the pelvic organs. Owing to the close proximity and lymphatic relationship of the appendix to the pelvic organs, it may be difficult at times to tell exactly where the trouble lies, or at least where it originated. Nevertheless, differentiation between a true pelvic appendicitis from suppurative condi- May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 411 tions such as acute salpingitis, salpingo- oophoritis, twisted pedicle of ovarian cyst, and sigmoidal diverticulitis, is essential, for upon the diagnosis will depend the line of treat- ment, and if surgery is indicated, the best method of approach. Acute salpingitis, for example, will subside under anatomic and physiologic rest. The error of overlooking an acute suppurative salpingitis can be avoided by a careful history, vaginal examination, making the sedimentation test, the presence of a vaginal discharge, the relative tenderness in the adnexal regions with perhaps some fixa- tion of the uterus, the attempt to move which by pressure against the cervix evokes pain, and the presence of a small palpable mass to both vaginal and rectal touch. An important point in the history is the gradual onset, with the pain in the lower abdomen, unless the les- ion be a leaking or ruptured pus tube, in con- trast to the suddenness of the appendiceal at- tack. Bilateral abdominal rigidity with pain referred to the left side and marked tender- ness to deep pressure by 2 finger tips on the outer side of the lower-third of the right rec- tus muscle directed downward and to the left, bespeaks pelvic appendicitis more often than salpingitis. The history of a recent abortion and of gonorrheal infection is decisive. Some authorities depend on the sedimentation test which in appendicitis is normal, and decided in acute pelvic infection. I attach consider- able importance to this test, popularized by our colleague, Polak. Twisted pedicle of a right ovarian cyst is often mistaken for acute appendicitis. There is the same sudden onset of abdominal or pelvic pain, nausea, vomiting and more or less exquisite local tenderness and rigidity. The distinguishing feature is the presence of a palpable tumor, usually in a low position. In view of the fact that opera- tion is indicated in either case and also that the appendix should be removed even if the condition is ovarian, the clinical diagnosis is not of primary importance. In a pelvic sup- purative appendicitis, the route of approach will depend on the condition and sex of the patient and, if a female, her age. In the fe- male, occasionally the best incision is one through the vault of the vagina behind the cervix ; while in the male much depends upon how sick the patient is, the exact location of the collection, whether above the pubic bone or Poupart’s ligament or deep in the pelvis and if fluctuation is evident to rectal touch. The aim of the surgeon should always be to open the abscess by extraperitoneal approach. The symptoms of ruptured ectopic tubal pregnancy, it seems to me, are so distinctive as to be almost unmistakable. But I admit I have been guilty of an occasional erroneous diagnosis. The history is without doubt the most important diagnostic aid. But this is not always reliable. The similarities of the two conditions, acute appendicitis and a ruptured right tubal pregnancy, lie in the sudden pain, tenderness and rigidity, together with the evidence of shock and syncope due to the hemorrhage. The association of tubal preg- nancy and acute appendicitis, though rare, should be borne in mind. Again, operative in- terference is indicated; refinement of diag- nosis is not essential if the best interests of the patient are to be served. An acute sigmoidal diverticulitis oftentimes simulates an acute pelvic appendicitis. A point in favor of the former is that the signs be- gin in the left lower abdomen, in fact it is often spoken of as left-sided appendicitis; the pain later may or may not become general- ized, and there is a history of antecedent pro- nounced constipation and discomfort from the accumulation of gas. Etiologically, the disorder is rare in the female, occurring more often in the male at or past middle life. The physical examination is of much moment. Dis- tinguishing points are: tenderness on the left side that is more pronounced and superficial as compared with right-sided tenderness in pelvic appendicitis ; due to the distance be- tween the appendix, when in the true pelvis, and the abdominal wall ; and finding by rectal touch of a mass or induration in the region of the sigmoid. If acute perforated diverticulitis of the sig- moid is seen and operated on early, before abscess formation has taken place, a transperi- toneal approach is best. In the presence of an abscess, however, especially if it is very low down in the pelvis, it is better to make the approach through an incision in the an- terior rectal wall — or, if the patient is a fe- 412 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 male, through the vagina. But fortunately, in nearly all cases of suppurative diverticulitis the collection is above Poupart’s ligament, where through an incision above the outer- third of the ligament and carried upward and outward, dividing the aponeurosis and sep- arating the fibers of the external oblique muscle, and cutting through the internal ob- lique and the transversalis muscles, the col- lection can be evacuated without opening the peritoneum. The other conditions I have mentioned are rare but they must be thought of if we are to sharpen our diagnostic acumen. Mesenteric thrombosis is characterized by very abrupt and acute agonizing pain immediately follow- ed by abdominal rigidity. Volvulus of the great omentum is only diag- nosed at operation. Its clinical manifestations are those of the acute abdomen in general. When the torsion is complete the signs and symptoms, as I have already stated, are those of intestinal obstruction, but when incomplete they may suggest acute appendicitis. Right-sided pyelitis in the female is not infrequently diagnosed as high-lying postcecal or postcolic appendix. This is inexcusable, if the surgeon is alert. When discussing the acute abdomen I am occasionally asked how to differentiate be- tween right-sided pneumonia, right-sided pleurisy — especially subdiaphragmatic — and heart disease, all 3 of which may cause pain referred to the mid-upper and right-upper ab- domen. This is a pertinent question, and I am always glad to make an attempt to answer it. In the early, the developing, stage of right-sided pneumonia or of pleurisy, the question of a high-lying appendicitis very fre- quently arises, and if operation is consider- ed the differential diagnosis is all the more important. In both pneumonia and pleurisy, the former usually being ushered in by a chill, there is pain on breathing, increase of pulse rate and temperature, increased respirations, the presence of a slight cough, as a rule, ab- dominal rigidity and tenderness of the upper right and mid-abdomen. Increased respirations with or without respiratory discomfort or slight cyanosis, especially in the presence of a high leukocyte count, say 40,000, will cer- tainly make the careful surgeon apprehensive, to the extent at least of postponing operation for some hours in order to await development of physical signs. Portable x-ray examina- tion, when this is feasible, is of moment. Per- sonally, I have seen enough of these cases to put me on my guard about advising surgery. In subdiaphragmatic pleurisy the differentia- tion, while not so difficult, is still difficult enough to make one cautious. In cardiac dis- ease with attacks of angina, the pain may be referred to the epigastrium and to the upper right abdomen. This, together with the fact that there is a much disturbed circulation, may suggest the diagnosis of an acute gall-bladder. 1 he surgeon of experience, knowing full well that under anatomic and physiologic rest the gall-bladder condition will, with very few ex- ceptions, subside, will counsel against opera- tion in such instances. The surgeon who has a good working knowledge of general medi- cine, particularly if he was a doctor before becoming a surgeon, has the advantage of erring less often than he who has not this knowledge. While in no way claiming any originality or completeness for this discussion, I hope I have succeeded in crystalizing in your minds some of the essentials in the diagnosis and treatment of the acute abdomen as they have presented themselves to me in the course of my work. RUPTURED GASTRIC ULCER; ROLE OF THE INTERNIST* Edward C. Klein, Jr., M.D., Newark, New Jersey Rupture of a gastric ulcer is not only the most formidable of the acute complications attending this disease but it is also of the greatest concern to the internist because he is usually the first to see the case. Prognosis depends almost entirely upon his decision, since cases submitted to surgery within 6 hours are expected to recover, whereas with ♦(Read as part of symposium before Surgical Section of Academy of Medicine of Northern New Jersey, Oct. 28, 1930.) May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 413 every hour of additional delay the outlook darkens until there is scarcely any hope after 24 hours, notwithstanding that now and then someone records a recovery. By ruptured ul- cer is meant a perforation of all the anatomic coats of the stomach into the free peritoneal cavity and extravasation of its contents into the peritoneal sac. The more gastric disten- sion with food, the greater the danger. How- ever, as long as the contents are sterile the danger is minimized by early operation ; but if there be a previous stomach infection the general experience is that a serious peritonitis will inevitably follow. Diagnosis, as a rule, is easy. The first and most important sign is sudden agonizing pain in the upper abdomen. However, Stohr re- ported a case in which the pains instead of being in the classical position radiated to the right shoulder, thus giving the impression of gall-duct spasm. The pain which follows per- foration has been described as one of the most violent and atrocious forms of suffering known. It often occurs after a heavy meal, during work or after some trauma, with evi- dences of peritoneal shock, fever and a leuko- cytosis. In the very beginning there may be no abdominal distension, merely board-like rigidity. Very often temperature and pulse show little or no modification at first but with- in 6 hours, as a rule, the characteristic peri- toneal facies appears followed by symptoms of peritonitis with vomiting, distension, fever, rigors, rapid pulse and shock. The appearance of a patient in shock, yet with little or no temperature and a correspondingly low pulse rate, is an invaluable sign in early diagnosis. Since only 45% of patients give a clear ulcer history, one must rely on eliciting a story of periodic digestive disturbances, of obscure or atypical symptoms, with periods of euphoria intervening. Reperforation occurs at times and is apt to be overlooked unless one keeps the possibility of such a contingency in mind, the symptoms of aggravation being laid to progressive peritoneal inflammation ; Lewisohn has even noted a third perforation of the same ulcer. In acute ulcer, fortunately representing only 10% of perforations, there may be no warning symptoms at all. Never- theless, they constitute a serious contingency, especially when silent perforation occurs. An interesting case was recently reported by Gregoire ; perforation of a gastric ulcer with free fluid and gas in the abdominal cavity but at the same time without any distinctive clini- cal signs. The patient, a woman 35 years of age, was able to walk to the x-ray department, 100 meters away from the ward, and it was only after fluoroscopic examination had disclosed presence of air in the peritoneal cavity that a perforated duodenal ulcer was suspected. As to whether the initial distress attending perfor- ation is due to the giving way of the gastric wall, or to irritation of the adjacent peritoneal surfaces, there would seem to be no longer any doubt. During the discussion of Gregoire’s pa- per, Rouhier related 2 cases occurring in his practice in which the operative findings showed localized peritonitis before there had been time to completely perforate all the walls of the stomach. Guimbellot added 2 similar exper- iences, and his first case is worth study from a symptomatologic standpoint because of the in- itial location of the pain ; a 40 yr. old man was suddenly seized with severe pain in the right lower abdominal quadrant, and vomiting last- ing 24 hr. before the patient was submitted to surgical intervention. The anterior surface of the pyloric region was found to be covered by the transverse colon. No perforation had occurred but a whitish plaque of about 1.5 cm. showed on the pyloric aspect, as well as a similar one on the apposite colon. The physical signs of localized tenderness with board-like rigidity of the abdominal wall becoming generalized with the progress of in- fection, dulness in the flank or flanks indicat- ing fluid in the peritoneal sac, augment the diagnosis. In this connection, it is of im- portance to remember the value of radiology in the diagnosis of perforated peptic ulcer. Vaughan and Singer demonstrated pneu- moperitoneum skiagraphically in 63 of 72 pa- tients having ruptured peptic ulcers as proved by laparotomy. Another diagnostic point of value in difficult cases or when radiographic examination is not available has been brought out by Neller. The patient lying flat upon the bed, the finger of the- examiner is placed over the naval while pressure is exerted and released. When the naval is loosely closed 414 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 this pressure produces a peculiar crepitation which indicates air in the peritoneal cavity. In immediate postoperative care nothing, as a rule, should be allowed by mouth for 24 hours. On the return to bed, pantopon gr. 1 3 is suggested to insure rest for some hours after the operation; it is less apt to induce vomiting than morphin. Eight to 10 oz. of 5 to 10% glucose in normal saline solution is given per rectum every 4 hours. If these rectal taps are not retained, the Murphy drip may be resorted to. In formulating dietetic management, the mode of surgical treatment whjch has just been employed ought to be considered ; for instance, in the simple suture case, the patient’s condition being so serious as not to warrant added risk of the supple- mental short circuit procedure, it is wiser to be cautious with mouth feedings. Half hourly drinks of % oz. barley or plain water may be allowed on the second or third day. On the other hand, food deprivation must not be car- ried too far as Carlson has shown that the fast- ing stomach is never quiet. Ivy’s recent studies in the experimental causation of peptic ulcer in animals have shown that the mechanical factor of strong muscular contractions is quite as important as the acid factor. The justifica- tion, therefore, for such feedings is that strong gastric contractions are apt to occur if the patient gets hungry, which might lead to injury at site of the suture. Peptonized milk 1 to 2 oz. hourly up to the fifth or seventh day may be used until cessation of nausea and vomiting. The gastro-enterosto- mized stomach has seemed to me comparable to the physiologic state of complete relaxa- tion, as the rectum is after divulsion of the sphincter ani, but by the fifth day gastric motility has recovered again and food passes through an unobstructed pylorus as well as through the stoma. This is the time that the ulcer bed begins to granulate and surely none but the blandest food ought to be allowed for the next 4 weeks. However, on questioning patients with unsatisfactory end-results, one finds that this rule is honored more in the breach than in the observance. In my opinion, it is necessary to determine at the time of op- eration whether atony is present, for this is the type of case that always has stormy post- operative experiences and is apt to go on to acute dilation. Careful gastric aspiration, using a small Rehfuss tube, is often necessary to remove the accumulating material and oft- times at the end of the day will remove stag- nant, decomposing food stuffs. Rectal feed- ing should be employed exclusively under such circumstances. Where marked dilation of the stomach is found at the time of oper- ation nothing should be allowed by mouth for 2, 3 or more days. There is no danger of strong gastric contractions to such cases be- cause of the severely atonic state of the mus- cular coat. Rectal and intravenous alimen- tation will serve the patient's immediate needs. Here again, repeated aspirations will prove of value. This is all the more necessary be- cause the material is usually in a state of de- composition causing elevation of temperature and uneasiness, often vomiting. In a case recently reported by Dixon, aspiration was done daily for 16 days and as much as 1000 c.c. removed at times. When there is per- sistent vomiting, due to the attendant periton- itis, and danger of recurrent hemorrhage or where there is considerable postoperative dila- tation, glucose solutions intravenously and lavage with hot water 12CTF. will often tide the patient over until rectal or gastric feedings can be resumed. If rectal alimentation is em- ployed, certain details must be observed. For instance, peptone solution should not be made stronger than 10-20%. If it is, irritation of the mucous membrane occurs and defeats ab- sorption. The same substances should not be given every time. Von Leube showed that the addition of pancreatic extract to the white of egg enema resulted in much better absorp- tion. Pancreatized diluted cream has been shown by Straus to be very easily absorbed through the bowel. Those having a disincli- nation to retain the aliment can be helped by adding a small amount of laudanum to the mixture. The addition of lactose should not be forgotten, because of the ease with which this carbohydrate is absorbed. In general, during the first few days milk will be suf- ficient unless there happens to be a specific allergic state. Right at this point it is im- portant to determine from the dietetic his- tory of the patient whether there is any food May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 415 allergy, especially in reference to milk or egg, in order to prevent stormy reactions. Vallone’s studies in anaphylaxis and gastric ulcer in sensitized animals showed that healing of the lesions is much slower. He concludes that change in the quality of mucus secreted to- gether with the changed constitution of the cells of the gastric mucosa, and insufficiency of antipepsin in these same changed cells, are some of the conditions which account for the failure of ready cicatrization. If these views are correct the great importance of discover- ing alimentary sensitization in some cases be- comes apparent. In the gastro-enterostomized patient the prevention of 'jejunal ulcer must be consider- ed from the time of operation. We all know that the gastrojejunal ulcer at the line of suture is, as a rule, due to faulty technic, but in the typical jejunal ulcer the altered physi- ology is a factor that is too often neglected. On account of the excluded duodenal juices either in whole or in part, the main bolus of food enters the jejunum thoroughly mixed with the acid chyme of the stomach. To coun- teract this exaggerated acidity mild alkaliniza- tion and soft bland food should be used for at least a month. Small doses of calcium phos- phate and carbonate are effective for this pur- pose, but where there is a suspicion or a knowledge of multiple ulcers, or a history of many relapses, bismuth in large doses must be added and seems more effective in bringing about a symptom- free state. Furthermore, the bismuth by its chemotactic action undoubt- edly aids cicatrization, as has been shown by the use of bismuth paste in the treatment of refractory sinuses. After the eighth day a regular “ulcer cure” should be instituted. The ulcer patient has an ulcerous proclivity as a defect in his con- stitution. The only known way now to con- trol that is by placing the body in as near a state of health as possible. Since nearly all perforating cases occur in individuals of poor resistance, the general condition must be raised in order to prevent possible reactiva- tion or reperforation. The erethistic type, which is distinguished by the greater tendency to painful peristalsis and hyperacidity, should be thoroughly atropinized and kept that way for many weeks when only suture with in- clusion has been practiced, for the simple reason that the gastric muscle must be kept as quiet as possible in order not to delay cicatrization. In all cases where a peristently high hydrochloric acidity continues, atropin should also be used for its effect on the vagus in lessening acid secretion. In these latter cases, experience with much material indi- cates that there are also extrinsic causes for the continued hyperchlorhydria. Continuous intensive alkalization of the stomach is still employed to a considerable ex- tent, notwithstanding that Hardt and Rivers, in a study of 48 selected cases with peptic ul- cer observed in the Mayo Clinic from April 1921 to April 1922, showed toxic manifesta- tions following the alkaline treatment. Al- though these findings were not positive, they were nevertheless suggestive of the injury that might result from the persistent alkalosis resulting from such a method of therapy. Recently, however, Westphal and Kuckuck have shown that alkalinization with sodium bicarbonate is a more serious affair than one would suppose. Considering how long the use of antacids has been in vogue, it is strange that the baneful local effects have not been disclosed before now. They noticed, as have many others, that instead of the usual hunger pain of ulcer, those who had been on large doses of bicarbonate of soda eventually re- turned complaining of a feeling of fulness and weight in the epigastrium and belching of gas. Fractional gastric tests showed an achylia which in some cases was histamin re- sistant. Furthermore, by the employment of Berg’s method of interpretation of Roentgen topography of the gastric mucosa, the folds were found broadened and thickened to a de- cided degree. Histologic examination of specimens of the gastric mucosa removed at operation showed the usual structural changes of hypertrophic gastritis. Continued roent- genologic observations on cases exhibiting the broadened folds of mucous membrane were made after cessation of the intensive alkaliza- tion, and this method regularly showed a de- cided reduction in breadths of the folds. The induction of alkali-achylia is thereby proved to be a serious therapeutic blunder in that it 416 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 replaces an ulcer with what is regarded in some quarters as a precancerous disease. Ex- act observations have proved that the heavy alkalization is found to be followed by a cor- respondingly heavy response of the acid glands of the stomach and the continued stimulation of them eventually leads to func- tional or organic exhaustion of their secretory activity. It, of course, gives relief and there- fore is popular. But is it justified in view of these observations ? Another fact, that all of you must have noticed who are in the habit of studying the clinical and therapeutic history of ulcer cases, is that patients recover on all sorts of dietary systems. Consider, for example, those used by Von Leube, Lenhartz, Sippy, Alvarez, Ja- rotsky, Smithies, etc. The more material one sees, the more the principles laid down more than 20 years ago by Hans Eisner appear to comprehend the philosophic reasons. They are in brief : (1) Caloric values must be sufficient to properly nourish that particular individual. (2) Daily volume should not be too large nor too small in order to avoid contractions from over distension on the one hand and from hunger on the other. (3) Nutrient material must be nonirritat- ing, both chemically and mechanically. There- fore, spices and roughage must be avoided. (4) Articles comprising the diet should be such as to combine easily with the hydro- chloric acid. Herein lies the advantage of the modified Lenhartz diet of milk, eggs and meat. So then, to my mind, the successful management of the diet of ulcer patients calls for careful individualization. For instance, in one case the only thing tolerated by a patient was the old fashioned “mandelmilch”. Rectal feedings had failed entirely, and the stomach refused everything for 8 days excepting this “mandelmilch”. Recurrent postoperative ulcer is a stubborn problem very rebellious to surgery, the patient usually experiencing many revisions. Here we have found that 20 weeks’ rest in bed with ap- propriate dietetic and medicinal measures is the only method offering real recovery to the sufferer; always providing, of course, that the operative mechanics have been properly done. Indeed, the value of sufficient physical repose in rebellious cases seems to have attracted little interest. The usual period according to the histories of patients coming in with re- lapsing ulcer is one of 2 to 6 weeks. This amount of time suffices in the usual run of acute or superficial ulcerations, but is never sufficient in deep or relapsing cases. The indur- ation around an old ulcer often requires at least 10 weeks for absorption before cicatrization commences. Anyone can verify this state- ment by observation of cases submitted to surgery. The reason is that the stomach is never at rest. It can not be splinted like a broken bone, but the respiratory excursions can be lessened and slowed, fhus giving the lesion such an amount of rest that the local reparative powers can do their work. The warrant for this view is the same as with the heart, the lungs and other organs. Why not give the stomach the same opportunity? Be- sides, and this applies with especial emphasis to old and rebellious cases, not only does physical repose lessen the respiratory excur- sion of the diaphragm, thus giving the stomach more rest, but every one must have noticed that ulcer patients are of a peculiarly nervous type, characterized by nervous tension, and that atropinization is often unable to reduce the hyperchlorhydria. Providing that there are no extrinsic causes for the continued hy- persecretion of acid these same cases will show a low acid curve after sufficient bodily rest. There is no need of heavy alkalization where sufficiently long physical rest is carried out. And when these things are explained to the patient together with the gravity of his lesion there is seldom serious objection to submission. All that has just been said ap- plies with even more force to those trouble- some cases that continue to have pylorospasm even after the best of surgery. A personal case had had 4 surgical revisions without the slightest relief, but was entirely relieved by a 20 weeks’ rest cure. The same advice is necessary in those cases of posterior ulcer which invades the pancreas as well as in those more rare ones that cannot tolerate any form of alkaline treatment at all. In conclusion, all ulcer patients, after sur- gical intervention and discharge, should be May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 417 given active clinical supervision, not only dietetically but otherwise as well fo’- at least 1 year. Then, after a symptom-free state arrives, the patient must be impressed with the necessity of avoiding dietary and other indiscretions, of the need of sufficient sleep, and of the avoidance of unduly hard labor. In short, he must be reminded that he has an ulcer diathesis and that his future depends upon maintaining more than the average standard of health. ACUTE PERFORATION OF PEPTIC ULCERS* Royal A. Schaff, M.D., Newark, N. J. In the whole field of abdominal diseases there is no more sudden, dramatic or danger- ous catastrophe than an acute perforation of a gastric or duodenal ulcer. By such an acci- dent a patient, apparently in good health up to the moment of its occurrence, is felled as if by a bullet; and, unless prompt and effi- cient surgical intervention is instituted, his condition progresses rapidly from bad to worse until death almost invariably super- venes within a few days. Upon early recog- nition and immediate operation, the victim’s life depends more than in all other abdominal emergencies, not excepting ruptured tubal pregnancy, acute pancreatitis, traumatic rup- ture of solid viscera or even gunshot wounds.. In all of these, the percentage of recoveries without operation will be considerably higher than in the overlooked or neglected cases of acute perforation of a peptic ulcer, in which the mortality is almost exactly 100%. It is therefore essential that, from time to time, the subject be reviewed in order that the general practitioner, as well as the sur- geon, may constantly bear the condition in mind, and be familiar with those symptoms and signs which in the early hours, at least, make its recognition usually so easy. Classification. Perforation of peptic ulcers ♦(Read as part of a symposium at the Academy of Medicine, Newark, October 28, 1930). may be classified as: (a) Acute; (b) sub- acute; (c) chronic. In the acute variety, with which the dis- cussion this evening will be primarily concern- ed, the perforation occurs suddenly, com- pletely and often without premonitory signs, the contents of the stomach or duodenum being discharged directly into the general peritoneal cavity, Morison’s pouch, or the lesser peritoneal sac, depending upon the lo- cation of the ulcer. In the subacute variety, perforation occurs almost if not quite as quickly ; but, owing to the small size of the opening, the emptiness of the affected viscus and the fortunate dis- position of the natural protective forces of the peritoneum, extensive leakage into the peritoneal cavity does not occur. In these in- stances, the surgeon finds the opening plugged with a tab of omentum or sealed with lymph, making a cover for the ulcer and preventing the extravasation of any considerable quantity of stomach contents. In chronic perforation the ulcer slowly but progressively extends through all the visceral layers, allowing ample time for development of a plastic peritonitis at its base or for ad- hesion of the stomach or duodenum in the region of the ulcer to neighboring organs or to the anterior abdominal wall. The leakage is therefore slight and limited to a small area, but it may lead to the formation of a peri- gastric or subphrenic abscess. As one might expect, the great majority (90%) of acute and subacute perforations are found on the anterior surface of the stom- ach or duodenum, while only a few (10%) occur into the lesser sac or retroperitoneal tissues. On the other hand, however, of chronic perforating ulcers, more than 75% involve the posterior wall and lesser curva- ture of the stomach. Etiology. Perforation, either acute or chronic, is a natural event occurring at some time in the course of 5% to 28% of all cases of peptic ulcer, according to different statis- tical studies. Its etiology may briefly be said to be that of peptic ulceration in general, with, in addition, a greatly increased activity of the ulcerative process, due to unknown causes immediately preceding rupture, or to 418 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 the strain of over-distension or sudden exer- tion upon a much weakened gastric or duo- denal wall. The majority of cases are seen in males in the third to the fifth decades, but no age is immune. Symptoms. The symptoms of acute perfor- ation may be grouped under 4 heads: (a) Antecedent; (b) premonitory; (c) early; (d) late. The antecedent symptoms are those of in- digestion, of the ulcer type, often extending over a period of months or years. A care- fully obtained history will rarely fail to dis- close definite subjective evidence of the ex- istence of an ulcer, especially when viewed in retrospect, but one does occasionally encoun- ter a case which has been quite symptom- free up to the moment of perforation. Even then, however, upon being pressed, the pa- tient will usually admit that he “may be troubled with a little gas now and then”. Be- cause of gravity of the patient’s illness, ques- tions bearing upon the antecedent history are often omitted. One cannot emphasize too strongly the necessity for care in this par- ticular, for an accurate history will not in- frequently make obvious an otherwise uncer- tain diagnosis. Premonitory symptoms are often absent, but, when present, they have great sig- nificance. If a patient known to have peptic ulcer begins to suffer in the present attack much more than in the past, if the pain be- comes more severe and less amenable to treat- ment, if localized tenderness appears or be- comes more acute, then are the danger signals of impending perforation being flown and then should surgical treatment be undertaken to fore-stall approaching disaster. In the early hours following perforation, the patient usually exhibits a striking attitude and appearance. He is most often found lying in a position of fixed immobility, com- plaining piteously of excruciating epigastric pain and resenting the touch of the examining hand upon the abdominal wall. The ashen pallor, beaded brow, anxious facies, rapid, shallow breathing and the prostration combine to give him the appearance of shock, but in one most important respect the picture is incomplete. The circulation shows little if any change — the pulse remaining slow, volume full and blood pressure but little altered. The body temperature is usually normal or slightly below and, in common with the pulse rate, rises only with the onset of peritonitis. The abdominal muscles at once become inflexibly rigid producing in thin subjects a scaphoid abdomen. With the lapse of a few hours the disease makes rapid progress. The pulse rate and temperature increase, muscular rigidity per- sists, the abdomen becomes much distended, vomiting occurs repeatedly, and the picture thereafter differs in no essential respect in its course and termination from that of acute generalized peritonitis from any other cause. Pain is the one constant symptom of acute perforation. It is sudden in onset, excruciat- ing in character and prostrating beyond ex- pression in its effects. It is generalized throughout the abdomen, but it is often greater in the epigastrium, the right hypo- chondrium, or the right iliac fossa, depending upon the site of perforation or the point of maximum accumulation of extravasated fluid. It does not radiate and it is much aggravated by motion or by palpation of the abdominal wall. It is variously described by different patients, but all agree upon its agonizing in- tensity. It is said to rival in severity the pain of coronary thrombosis or that of acute pan- creatitis, and at times its violence is so great as to cause sudden death. Vomiting of stomach contents and, rarely, of blood, occurs as an initial symptom in a fair proportion of the cases, but it is not a prominent feature until after the onset of peritonitis. The shock so commonly spoken of is much more apparent than real. True shock connotes a grave change in the circula- tory mechanism, which in the case of acute perforation in the early hours, is peculiarly conspicuous by its absence. Moynihan aptly describes the patient as “having the appear- ance of shock”. Physical signs. Rigidity of the abdominal muscles and tenderness upon palpation are the only physical signs always present. The rigidity affects all of the abdominal muscles including the diaphragm which, in conjunction with the distension of the stomach, causes the May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 419 rapid, shallow type of breathing usually noted. It is board-like in character and generalized throughout the abdominal wall, but often dis- tinctly more marked in the region of the per- foration or of the maximum accumulation of extravasated fluid. Muscular spasm of the same degree is not encountered in any other condition except sudden and complete per- foration of other hollow viscera due either to ulceration or traumatism. It is remarkable how rapidly and completely the rigidity disappears following closure of the perforation. Distribution of the tenderness follows closely that of the pain and rigidity, its point of maximum intensity often serving to locate the site of perforation with considerable ac- curacy. Disappearance of liver dulness, when ob- served, is a sign of the greatest importance, indicating, as it does, the presence of gas in the peritoneal cavity. It is quite constantly noted in late cases, where it serves as one of the most valuable points in the differential diagnosis of the various forms of acute gen- eralized peritonitis. In the early hours, how- ever, this sign is so often absent that failure to elicit it should in no way influence one against the diagnosis of perforation. Elicita- tion of the sign requires great care. With the patient in a semi-sitting posture, percus- sion is made in the right midaxillary line in- stead of over the anterior surface of the liver which is so uniformly practiced, and which is so misleading in cases with marked tympanites. A roentgenogram, taken with the patient sit- ting up, will demonstrate a bubble between the liver and diaphragm when any considerable quantity of gas has accumulated in the peri- toneal cavity. As positive evidence, this find- ing is invaluable ; as negative, worthless, for many of the early cases will have but little if any leakage of gas. Incidentally, this pro- cedure constitutes the only laboratory exam- ination of any value in the diagnosis of per- foration of peptic ulcers. It is not pathog- nomonic, however, for a collection of gas in the peritoneal cavity from any source will give the same picture. The method should be employed only as an aid in the diagnosis of •doubtful cases as it involves loss of time and additional handling of the already too sick- patient. It is impossible to overstress the condition of the circulation in the first hours following perforation. No other abdominal crisis leaves the pulse rate and blood pressure so little al- tered. The tranquility of the pulse with its full volume and the sustained blood pressure seem quite incompatible with the otherwise obvious gravity of the patient’s condition. Failure to appreciate and remember this most vital fact has led to many disastrous errors in diagnosis and delays in operation. Only the recent writers, notably, Moynihan, Finney and Babcock lay sufficient emphasis on the point. All the older text-books mention a rapid and feeble pulse as an early sign of perforation, and the error is perpetuated in an article by one of America’s leading surgeons in a work on “Surgical Diagnosis” published within a few months. One must remember that in- crease in the pulse rate and elevation of the body temperature occur only with the onset of peritonitis. Diagnosis. The typical early case of acute perforation of a peptic ulcer presents no diffi- culty in diagnosis to one who has seen the condition once or twice before. The ante- cedent history of indigestion, sudden onset with violent pain and prostration, appearance of shock with unaltered circulation and the board-like rigidity of the abdominal muscles make a clinical picture difficult to confuse with any other abdominal emergency. It is worthy of note that the junior intern on duty in the receiving ward of the City Hospital rarely fails to make the correct diagnosis in this type of case. Only in the presence of coexisting “acute alcoholic intoxication is the diagnosis apt to be diffiuclt. In such cases it may be quite impossible to arrive at a cor- rect conclusion without an exploratory incis- ion. Should the doubt arise, one must not hesitate to operate at once, for an unnecessary operation will do little harm, while a delayed one may easily result in disaster. Differential diagnosis. Although the typical early case of acute perforation is easy of recognition, there are many less obvious ex- amples which require differentiation from other emergencies, thoracic as well as ab- 420 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 dominal. Perforation has been mistaken for everything ranging from renal colic to sun- stroke, but as a rule, distinction need be made between only a relatively few conditions. One most often must distinguish between perfor- ation and acute appendicitis, and the task is not always easy. The question arises usually as the result of perforation of a duodenal ul- cer, the extravasated fluid from which first fills Morison’s pouch, then runs down on the outer side of the ascending colon, and finally accumulates in some quantity in the pelvis and right iliac fossa where it may produce ex- quisite pain with locally increased tenderness and muscular rigidity. The mimicry of acute appendicitis may be complete except for pres- ence of the generalized board-like rigidity and the appearance of shock with unchanged cir- culation and body temperature. The ante- cedent history, story of the onset, presence or absence of rigidity of the muscles of the left upper quadrant and possibly the disap- pearance of liver dulness, will usually suffice to settle the problem. Biliary colic with or without acute cholecy- stitis may give rise to the suspicion of perfor- ation, but here the sex, age and stature of the patient, the history of previous similar at- tacks, character and radiation of the pain, ceaseless motion in the search for relief and absence of the appearance of shock and of the generalized muscular rigidity, should serve to make the differentiation clear. The onset of acute pancreatitis is often quite as spectacular as that of acute perfora- tion, but, again, the age of the patient, ante- cedent history of biliary disease, very rapid, feeble pulse, uncontrollable vomiting and early development of an epigastric mass, together with the less generalized and less inflexible muscle spasm, will be helpful in distinguishing between the conditions. Acute intestinal obstruction affecting the small intestine occasionally simulates an acute perforation ; but the intermittent colicky type of pain, prompt vomiting of stomach follow- ed by intestinal contents, and absence of gen- eralized rigidity of the abdominal muscles should clarify the diagnosis. In each of the other abdominal emergen- cies, such as acute salpingitis, rupture of a tubal pregnancy, rupture or twist in the ped- icle of an ovarian cyst, intussusception, acute gastro-enteritis, strangulated hernia and renal colic, the syndrome is so characteristic that the differential points distinguishing these from an acute perforation should suggest themselves without special elaboration. Of thoracic conditions, only 2 are apt to be confused with an acute perforation : Lobar pneumonia, affecting the right lower lobe and causing a diaphragmatic pleurisy, sometimes produces severe epigastric pain and rigidity of the muscles of the right upper quadrant of the abdomen. In such instances, however, the chill, high fever, rapid pulse and respiratory rates, and perhaps a pleural friction rub, should enable one to rule out the question of perforation. An occasional case of coronary thrombosis in which the pain is referred to the epigas- trium instead of following its usual distri- bution, may bear a strong superficial resem- blance to an acute perforation of peptic ul- cer, but absence of the characteristic rigidity of the abdominal muscles together with the disorganized heart action, low blood pressure, and early appearance of a pericardial friction sound should enable one to recognize the true state of affairs. One other pitfall requires mention in pass- ing. A gastric crisis of tabes dorsalis has more than once resulted in operation for a perforation which did not exist. One need only remember the possibility of the existence of such a condition to be able to exclude it by an examination of the pupils and the knee- jerks. Incidentally, these steps should be part of the routine in the diagnosis of all surgical conditions within the abdomen. The rare in- stance of a perforation of an ulcer occurring in a sufferer from locomotor ataxia cannot be differentiated from a gastric crisis without op- eration, unless one. is fortunate enough to ob- serve the disappearance of liver dulness or to find a gas bubble in the roentgenogram. The late cases of acute perforation of pep- tic ulcers may present insuperable diagnostic difficulties. Often the most one can say is that a generalized peritonitis of unknown ori- May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 421 gin exists. It is here that the close scrutiny of a carefully obtained history may furnish a clue to solution of the problem. At this stage there are no manifestations upon which much reliance may be placed. Perhaps the most constant and trustworthy sign is the presence of gas, free in the peritoneal cavity, as shown by disappearance of liver dulness or by demonstration in a roentgenogram of a gas bubble between the liver and diaphragm. Even such evidence is inconclusive, however, for it merely proves the existence of a perforation somewhere in the alimentary tract — a perfor- ated peptic or typhoid ulcer, leaking cecum, perforated sigmoid diverticulm or, perhaps, even a gas bacillus infection within the peri- toneal cavity. In such a situation the surgeon is justified in making a small suprapubic in- cision. The character of the escaping fluid will then enable him to locate the perforation, to which he may gain access through a second incision appropriately placed, the first being used for drainage purposes if desired. Prognosis. The prognosis in an acute per- foration of a peptic ulcer depends largely upon promptness of the diagnosis and the speed and skill with which operative treat- ment is rendered. It is an emergency of the first magnitude, admitting of nothing but the least possible delay. When feasible, the patient should be taken directly from the am- bulance to the operating room to save time and unnecessary handling. Patients operated upon within the first 6 hours will nearly all .recover, but after that time the death rate rises about 3% per hour until at the thirty- sixth hour it reaches practically 100%. Here, if anywhere, may the mortality be said to be that of delay. The tyro in surgery may suc- cessfully close a perforation in the early hours — the most skilfull will be powerless to stay progress of the advanced case. No cloud is without its silver lining, and an acute perforation of a peptic ulcer may prove to be a blessing in disguise, for it seems to be an established clinical fact that a large number of the fortunate survivors gain permanent relief from their ulcer symptoms following their return from the Valley of the Shadow. Supplemental Note Dr. Herbert A. Schulte and Dr. Robert H. Hill have analyzed with meticulous care the statistics of cases of acute perforation of pep- tic ulcers treated in the Newark City Hospi- tal in the period beginning January 1, 1920, and ending December 31, 1929. During this time 168 patients were observed, the diag- nosis in each instance being verified by opera- tion or autopsy. Of this number, 62 (37%) died. The majority of the recorded previous histories mention one or more symptoms in- dicative of ulcer, such as epigastric pain or distress. There are many examples of the un- altered pulse rate and body temperature in the early hours following perforation. A correct preoperative diagnosis was made in 120 cases, while in 27 instances the condi- tion was confused with acute appendicitis. Perforation of an ulcer was mistaken for acute cholecystitis and acute intestinal obstruc- tion, each 4 times ; acute pancreatitis, 3 times ; renal colic and heart disease, each twice ; rup- tured ectopic pregnancy, tuberculous periton- itis, cancer of the stomach, influenza, lead colic and constipation each once. There is ample and convincing evidence of the need for early operative treatment and, after care- fully reviewing all of the available data on the fatal cases, one is reluctantly led to the con- clusion that earlier operation, greater gentle- ness and speed, more thorough exploration and better closure of the perforation would have saved a definite number of those who succumbed. TREATMENT OF PERFORATED PEPTIC ULCER* Herbert A. Schulte, A.B., M.D., F.A.C.S., Newark, New Jersey In considering the treatment of this condi- tion we shall hold to the classification of per- foration as given by Dr. Schaaf, i.e. acute, subacute, and chronic. Acute and subacute perforations are treated identically and we will discuss these first. The *(Read as part of the symposium at the Newark Academy of Medicine, Oct. 28, 1930.) 422 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 treatment is surgery, which might be written in large letters, with emergency emphasized in even larger letters. There are few problems which the surgeon has to face that demand emergency measures more than perforation of a peptic ulcer, and few conditions in which delay of a few hours may make such a differ- ence in the result. I should like to repeat the statement made by Dr. Schaaf that “the .mor- tality rate rises about 3% with every hour’s delay after 6 hours”, therefore, it is a dis- tinct blot on the records of my surgical ser- vice to delay operation any later than is ab- solutely essential to make provisional diagnosis and preparation for the surgical procedure. These patients are always seriously ill and great care should be taken in transportation to and in the hospital. It would be more ideal to have them enter the hospital directly to the shock room connected with the operat- ing suite. There can be no doubt that recovery by medical treatment alone is possible in certain forms of perforated ulcers for there are cases on record of undoubted perforation where surgery was not immediately available, but where later operation proved the point. So, patients may recover but their recovery can- not be urged as a reason for the delay or with- holding of surgical help in all cases, for the possibility of spontaneous recovery, though not denied, is yet so remote as to make it im- perative to adopt operative treatment at the earliest possible moment. Attention to the lesser details in guarding the patient against greater shock during the operation is exceed- ingly important and maintenance of proper temperature of the table and room, avoidance of delay in the operating room, posture of patient during operation, and a carefully chosen and administered anesthetic may play important parts in the ultimate results. The upper abdomen is usually opened to the right of the midline by an ample incision. It has been suggested that because perfora- tions of longer duration frequently create diagnoses, especially of appendicitis, that in these cases a small suprapubic midline in- cision be made. Gas and the type of fluid en- countered would be helpful in more accurately locating the lesion. The upper incision could then be made and the suprapubic incision used for drainage purposes. On opening the peri- toneum one encounters gas and fluid which is a mixture of stomach contents containing semidigested food particles and the secretion poured out by the peritoneum as a protective measure, and is not only sterile but actively antibacterial. The ulcer is not always readily found, but it is recognized by the escape of gas and fluid and by a thick deposit of lymph around it. If the perforation does not readily present itself, a search should be made in the region where it most frequently occurs, namely, in the neighborhood of the pylorus and along the lesser curvature. Remember, that about 90% are on the more easily acces- sible anterior surface of stomach and duo- denum. It has been stated previously that in about 10% of cases the site of perforation is not readily found because the ulcer is situated on the posterior wall and in these cases it is necessary to open the lesser peritoneal cavity and continue search of the posterior wall of the stomach. An ulcer of the posterior duo- denal wall will sometimes rupture into the re- troperitoneal tissues and produce an edema of the area, which serves as an excellent guide in the search. As soon as the ulcer is localized, the in- volved part is drawn, if possible, well up into the wound, and precaution should be taken against further soiling of the peritoneum. One must not neglect a careful search for other ulcers, for there have been cases reported of simultaneous or almost simultaneous rupture of 2 ulcers. The surgeon is then presented with the problem of procedure, and it should be emphasized here that every case is a law unto itself and the problem is to apply to this particular case that particular form of opera- tive procedure which in his judgment is most suitable to the condition. It is bad practice and worse surgery to attempt to adapt any one course to every case. One must be guided by the location of the ulcer, size of the area in- volved, degree of chronicity and effect of any procedure on the future function of the organ ; always remembering that the operation is an emergency procedure, and the patient a relatively poor risk. Therefore, depending on the factors involved, the ulcer may be cauter- May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 423 ized or excised before proceeding with re- pairs. There seems to be good evidence that an ul- cer which perforates and heals does not recur. If this is true in all cases, then treatment by cautery or excision is a useless procedure and time misspent. For simple closure of the perforation, a single stitch through all coats will suffice, or a mattress suture, which is of particular value where edematous tissue is encountered. The site is then buried by infolding the stomach or duodenal walls with double layers of con- tinuous sutures. To make the sealing-off complete, an omental flap is of great value. Many surgeons recommend turning up the great omentum to lie between the anterior stomach surface and the parietal peritoneum. If the stomach is full, as it frequently is, it is wise to pass a stomach tube and empty it of contents. A gentle lavage may also be per- formed. Some authorities, Deaver for in- stance, insist upon closure of the perforation followed by gastro-enterostomy, as a routine procedure, while others, headed by Moynihan, practice this only when the exigencies of the case demand it. Let me quote Moynihan on this point : “The question of the performance of gastro-en- terostomy has excited great controversy. The fac- tors which require consideration are many, and they refer not only to the various attributes of the ulcer in respect to position, size and lapse of time since perforation, nor to the degree of peritoneal contamination, but also and perhaps chiefly to the experience, the judgment and the technical skill of the surgeon. Statistics which have been furnish- ed in large numbers do not help in the solution of the problem.’’ Certain definite indications of procedure can however be given. If the suture of an ul- cer lying in the stomach or the duodenum has caused a definite obstruction, then gastro-en- terostomy will certainly be necessary or at least extremely desirable. If obstruction seems inevitable in the future because of the contraction of a scar, or if there are other ul- cers present, a short-circuiting operation must be considered. A gastro-enterostomy per- formed in a case of recent perforation does not add appreciably to the danger of opera- tion, but the mortality increases steadily in cases operated on after 12 hours. The con- dition of the patient in the late hours— 24 to 36 hours after perforation — is such that the thought of prolonging the operation even for a few minutes must be rejected. Deaver has recorded a mortality rate of only 6.8% in a series where gastro-enteros- tomy was performed after infolding the ulcer. For ulcers situated in the duodenum or stomach near the pylorus, the pyloroplasty as modified by Finney, with excision of the ulcer, seems ideal for it has the added advan- tage of not exposing other areas to contamina- tion. Differences of opinion are to be found among surgeons of experience with reference to the toilet of the peritoneum. Authority can be found for almost any method that one may employ. It is a serious question whether or not more harm than good may be done by attempting more than the removal of gross food particles and other material readily ac- cessible. Here, again, the element of elapsed time enters. If more than 12 hours have elapsed since perforation and if gross food particles are free in the peritoneum, greater care and longer time must be spent in ensur- ing that all is clean. Moynihan recommends hot moist sponges passed into all parts of the abdomen, with especial care to the subdiaphrag- matic areas, for the risk of subphrenic abscess or spreading of a septic inflammation through the diaphragm, giving rise to a pleurisy or empyema, is by no means inconsiderable. Fin- ney and others suggest flushing the peritoneal cavity with hot sterile saline through multi- ple incisions to be used for drainage. But this procedure should be reserved for the severe cases of longer duration. The question of drainage is a debatable one. Some authorities advise drainage as a routine practice, others oppose it. After all, the question of drainage can be decided only by the surgeon himself in each case. The time elapsed since perforation and the type of peritoneal fluid must be the guides. It is stated that if less than 12 hours have elapsed, drain- age is seldom necessary. After 12 hours, it is probably necessary to drain at least one- half of the cases. If one drains at all, it is a good rule to drain thoroughly. This means multiple drains placed in dependent portions 424 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 as indicated and brought out through stab wounds in the flanks and above the pubis, or even through the vagina in the case of women. Drainage through the incision is to be avoided if possible. Rolled rubber drains in pairs are preferable, split rubber tubing is often em- ployed, but gauze is not advisable because of its tendency to act as a plug. Early removal of drains is to be encouraged. The most dreaded complication during the postoperative course of a perforated ulcer is formation of a subphrenic abscess or exten- sion of a septic process into the chest as an empyema. These conditions must be recog- nized promptly and dealt with accordingly. The treatment of chronic perforation is also definitely surgical, but the great need for hasty intervention is not so imperative. In these cases we find that there has been a limit- ed area of peritoneal involvement, usually fixing the ulcer to an adjacent organ, or a well limited perigastric abscess has formed. The same general principle governing the sur- gical procedure can be used here as in the acute varieties, but the type of operation em- ployed will be the same as for any chronic ulcer uncomplicated by perforation. In reviewing the cases of perforated pep- tic ulcers admitted to the Newark City Hos- pital for the 10 years 1920-9, we have accum- ulated a lot of statistics which are of doubt- ful value, and if presented here I am sure would be a bore. There are, however, some figures which I feel might be of some interest to you. There were 106 patients who recovered, operated upon by 24 surgeons ; 74 were op- erated upon within 12 hours after perfora- tion; 15 within 12 to 24 hours; 3 within 24 to 48 hours, and 14 within 48 hours to 14 days. In 2 surgical cases no perforation was found, but all evidence suggested a ruptured ulcer. In 72 cases, the surgeon infolded the ulcer ; 7 ulcers were cauterized and 8 ex- cised ; 13 posterior gastro-enterostomies were performed. In 10 cases the appendix was also removed. Only 5 cases were not drained; these made uncomplicated recoveries, the av- erage stay in the hospital being 19 days. In 19 cases stab wounds were used for drainage, and 3 of these developed the postoperative complications of subphrenic abscess. If these 3 patients whose hospital stay ran up to 73 days, be excluded, we found an average con- valescence time of 20 days. Of 72 cases drained through the wound either alone or with stab wounds, 4 were complicated by subphrenic abscesses. The average hos- pital stay was 25 Rj days. There were 62 deaths ; 58 were operated on, and 4 who were moribund on admission, and the diagnosis was made at autopsy. In analyzing 58 deaths we found that there were 6 cases in which no perforation was found at operation but which were definitely diagnosed “ruptured peptic ul- cer” by autopsy or operative findings. In 3 cases the ulcers were cauterized ; in 3 excised ; no gastro-enterostomies were performed ; 4 added removal of the appendix and in 1 case jejunostomy was done. These patients lived from 1 to 36 days, an average of 5-}4 days. The causes of deaths were: peritonitis, 46; peritonitis and evisceration, 2 ; peritonitis and diabetes, 2 ; peritonitis and hemorrhage, 1 ; subphrenic abscess, 2 ; postoperative pneu- monia, 6; and 7 had some cardiac complica- tion. It is interesting to note that of the 58 deaths 16 were patients who had been oper- ated on within 12 hours. The causes of death in these cases: peritonitis, 6; peritonitis with no closure of ulcer, 2 ; hemorrhage, 1 ; pneu- monia, 3 ; cardiac, 4. There were 12 deaths in cases operated on 12 to 24 hours after perforation; 12 cases, 24 to 48 hours, and 23 were operated upon after 48 hours. I wish to express my appreciation to Dr. Robert Hill for his help in going over the City Hospital records. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 425 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J. Entered at the post office at Orange, N. J., as seccnd-class matter PUBLICATION COMMITTEE HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J. EDITOR: HENRY O. REIK, M.D., P.A.C.S., Vermont Apartments, Atlantic City, N. J. Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact. NOTE. — The transaction of business will be expedited, and prompt attention secured if: All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to. The Editor, Dr. Henry O. Reiic, Vermont Apartments, Atlantic City, N. J. All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements, or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication Committee, (address above), Newark, N. J. THE PASSING WESTWARD OF OSMUN AND LAWRENCE That small group of officials comprising the Secretaries and Reporters of County Medical Societies mourns the recent loss of two members whose departure creates vacan- cies difficult to fill. Lawrence, as a Reporter, exemplified the adage that it is the busy man who finds time always to perform the extra task demanded ; he rarely failed to report promptly the proceedings of his county so- ciety. Osmun, as a Secretary, was in like manner, a prompt, reliable and efficient worker in the interests of his profession ; and it was partly in recognition of his faithful attendance upon meetings that he was last year promoted to the office of Trustee in the State Society. The officers of the state organization and the Editor of the Journal will miss Lawrence and Osmun as keenly, perhaps, as will their as- sociates in Ocean and Warren Counties. ADVANCE NOTICE OF ANNUAL MEETING Owing to the near approach of the 165th Annual Meeting of the Medical Society of New Jersey, this issue of the Journal is limit- ed somewhat in size and devoted in part to publication of the Presessional Reports and the Preliminary Program. In as much as the Journal material must go to the printer by the middle of April for appearance in the May issue (made necessary by changing the meeting date to the first week in June), and the fiscal year of the Society does not end until June first, it is difficult if not impossible for some officials and committee chairmen to prepare a satisfactory presessional report; i.e. satisfactory to those who are doing the work. For that reason, and because it would have seriously damaged her schedule, we take the responsibility for having excused the Field Secretary from submitting such a report this year, and trust you will be satisfied with the Executive Secretary’s assurance that her re- port in June will show an excellent record of performance and accomplishment. Our own report cannot be a complete one but will cover most of the important items. The Treasurer will probably have to resort to a leaflet for distribution at the opening ses- sion. The Welfare Committee Chairman supplies his report, as the. committee’s work is probably terminated for the year ; and we shall include herewith as many other com- mittee reports as may be received. Monmouth County members are doing all they can to make things attractive, even spon- soring an “All Day Handicap Golf Tourna- ment” for Wednesday, June 3, at the Asbury Park Golf Club, to which men and women, both, are invited. There will be prizes for “low gross, and low net, 18 hole scores; and special prizes for winners and runners-up in a Scotch 4 ball four-some for men. Do not overlook the fact that the Woman’s 426 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 Auxiliary is meeting at the same time and that provision has been made for social entertain- ment in which all may participate. Come out and help make this Annual Meet- ing an exceptional success. Make your hotel reservations “right now”. COUNTY SOCIETY AND HOSPITAL REPORTS; WE PLAY NO FAVORITES On a number of different occasions the Edi- tor has expressed the belief that much of the material published by this Journal in its Sec- tion, or Department, of County Society Re- ports is of as great value to our readers, scien- tifically, as the more carefully prepared ma- terial presented through the channel of Orig- inal Articles. That is notably true of the Atlantic City, Bayonne, Elizabeth General, Jersey City and North Hudson hospital staff reports, and the Eye, Ear, Nose and Throat Section of the Academy of Medicine of Northern New Jersey. Our county society reports are fundamentally for the purpose of recording the transactions of such bodies, as component parts of the organized profession, giving incidentally abstracts of scientific papers read, and of the discussions that fol- low, at their meetings. It is in hospital staff meetings that most clinical reports and dis- cussions are now presented, and such reviews of hospital work, including comparison of au- topsy investigations with clinical records, furnish the best kind of material for post- graduate study. Conceiving it to be one of the functions of this Journal to record the professional work, especially the clinical performances and scien- tific achievements of the physicians of New Jersey, we have constantly urged county so- ciety reporters regularly to furnish us with complete reports of all happenings at their sessions and, whenever they considered any paper on the program of sufficient merit to justify its wider dissemination, to procure it for publication in the Journal in full; and if that could not be done, then to submit to us an abstract of the paper. In like manner we have repeatedly invited other local societies and all hospitals to send us reports of pro- ceedings. A glance at the last page of the index to last year’s Journal will show to what extent the invitation has been accepted. Now, on several occasions, we have heard that some member or group of members of the state society felt aggrieved that his or their city or county had been receiving less space in the Journal than some other localities. The Editor desires to dispose of such griev- ance hv stating most emphatically that no par- tiality whatsoever has ever been dispensed from this office. The reason why the so- cieties and institutions of Atlantic, Hudson and Union Counties, and the one section of the Academy, have filled so much space is that they have alert and competent reporters. The Editor does not “write up” those reports ; he does curtail some of them editorially. And he wishes to add the following message to all whom it may concern : If the proceedings of your county society, or the doings of your hospital, are not re- ceiving an appropriate amount of space in the Journal, the fault lies in your own organisa- tion. Send us as good reports as do the men- tioned institutions and you will be accorded the same amount of space. IV e play no favorites. STATUS OF STATE MEDICINE The concluding letter of the series in which we have reviewed so-called state medicine — legally called national health insurance — ap- pears in our travel talk this month. We have endeavored to collect for you reliable informa- tion concerning the laws and the working of such laws in other countries and to suggest the advisability of giving serious thought to the problems involved, so that we may not be caught unprepared if some radical legislation appears, and that we may more intelligently strive toward a solution of those unsatisfac- tory conditions that possibly give rise to dis- content and to threats of governmental con- trol. May we now recommend that you read carefully and ponder seriously upon the 3 special articles appearing consecutively in the March, April and May Journals. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 427 Special Article MEDICAL TRAVEL TALK The Editor Returns from Vacation Henry O. Reik, M.D., Atlantic City (Continued from April Journal) Through the months of January to April, hoth inclusive, we have written of observa- tions made while vacationing last summer, making use of such travel talk as a medium for conveyance of oicked-up information re- lating to the operation of state medicine in Great Britain and France. Returning to the editorial desk on the first of October, and looking over accumulated journals, we were amazed to find that during the previous 6 months not less than 40 articles dealing with one or another aspect of state medicine had been published in American Journals issued by State Medical Societies ; many of those ar- ticles being in the form of a State or County Presidential Address. We knew that the topic was a live one but had not realized that quite so much concerning it had been written. At first glance it appeared to have become really a burning issue, but that was an un- justified inference. Further investigation has led us to believe that the apparently wide- spread interest in this topic is limited to — at least the articles mostly emanated from — of- ficers of medical societies and that small group of physicians that may be called “lead- ers” of medical opinion. It is very difficult, indeed, to ascertain to what extent the profession at large is inter- ested, but we can safely say that practically every physician holding an organizational offi- cial position that carries any degree of respon- sibility, and every physician in the organiza- tion’s ranks who has given serious thought to the situation, is deeply concerned about changes that have been effected or that seem to be impending. Probably the condition is similar to that which confronts us with regard to governmental affairs. In political matters — city, state or national — we find only a few leaders or statesmen earnestly and intelli- gently striving to solve problems of state ; a larger number, but still all too few, that are awake to the importance of some of those problems ; and a vast congregation that re- mains utterly indifferent. If we may from our necessarily limited personal observation draw similar inferences bearing upon this point, we feel that a comparatively small per- centage of American physicians are at pres- ent reasonably well informed regarding the economic changes that have been and are tak- ing place in the practice of medicine; that a larger percentage — fortunately a rapidly in- creasing number — is showing some interest in the situation and beginning to study these problems ; but that considerably more than 50% of active members of the profession ex- hibits only indifference. Whatever befalls the profession will affect all of its members, and what we fear is that indifference on the part of the majority may result in something dis- astrous to the whole number. That feeling explains our decision to ex- tend these travel talks to cover state medicine reports from some other countries, so that in the light of knowledge as to what has happen- ed elsewhere we may become better prepared to deal with our own troubles. So, having reviewed conditions in England and France let us collect what information is available from other sources ; we wish it were possible to accompany such data with an en- tertaining round-the-world travelogue, but at present can only supply material gathered from various publications. It would be natural to commence with a consideration of state medicine in Germany because that was the first nation to adopt com- pulsory insurance against sickness ; back in 1883. Unfortunately, at the present moment conditions in Germany are so topsy-turvy that outsiders cannot with any degree of ac- curacy estimate the situation. Prior to the World War we were given to believe in a general way that the socialistic medical laws in Germany were highly developed and in the main satisfactory to physicians and the people alike. Since the war we have heard much grumbling and neither the people nor the pro- fession seems satisfied. Some of the discon- tent may be attributable to the changed state of affairs growing out of the governmental revolution; some may arise from the post- war period of bankruptcy and the slow re- covery that is taking place in all professions and general business 'throughout Germany; but a large part of the trouble may be due to faults inherent to the original plan, that have been made worse by recent developments. If we correctly understand it, the German system has always been defective in some im- portant respects ; for instance, that health in- surance practice was not open to all qualified physicians, and, that control of such practice did not rest with a medical body but with lay officials. At any rate, we are not able at this moment to give out authentic information con- cerning the working of state medicine in that country, and it is appropriate to add here that our state of knowledge is little or no better 428 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, I'J31 concerning Austria, Hungary, Bulgaria and other countries embraced in the broad term of “Middle Europe”. Belgium was last year passing through the same agony that France had previously en- dured, in broadening the scope of compulsory health insurance and the organized medical profession (Federation medicale Beige) was fighting the radical provisions of a law then pending in the Senate, and was demanding amendments that would, in effect, produce a law comparable in the main to the one proposed by the British Medical Association. The last information we had relating thereto was that the original Bill had been withdrawn and a new one— granting the requested amendments — introduced. Holland, which, like all other European countries, has long had voluntary health in- surance, passed in 1930 into the group of 24 nations that provide for compulsory insurance of employees or wage earners of limited in- come ($720 for single and $1080 for married persons). We usually give the Dutch credit with exercising a deal of “common sense”, and it is noteworthy that under the Nether- lands law physicians have themselves organ- ized “Association Funds” (their name for the health insurance companies), and thus control the situation so well that any member of the national medical association is eligible to treat such insured persons, and all shall be paid regulation fees for such services. Among the Scandinavian countries, Den- mark is reputed to have the most satisfactory scheme of insurance against sickness — a scheme which links health insurance with other “necessities of life”, especially provision for invalidism and old age pensions, and which requires “repayment of all expenses in- curred by public assistance, if in the future the individual can”. Russia comes to mind now whenever one thinks of any state social problem ; and con- cern for the people’s health is no exception to that rule. In the April Journal, page 361, we reviewed Chamberlin’s book on Soviet Russia, in so far as the author referred to the practice of medicine. Of much greater value to us, as physicians, is a small book — Health Work in Soviet Russia — published among the Vanguard Studies of Soviet Russia (price 50 cents), edited by Jerome Davis of Yale Uni- versity. The book was written by Anna J. Haines, a trained nurse, graduated from the Philadelphia General Hospital, who has spent a great deal of time in Russia since 1917 doing relief work, and establishing a Nurse’s Train- ing School in Moscow, under the auspices of the American Friends Service Committee. Miss Haines’ work should be doubly inter- esting to us because she is a product of New Jersey; having been born in Moorestown and lived a goodly portion of her life in this state. We recommend as strongly as possible that you purchase and read Miss Haines’ book ; it is worth many times the small investment re- quired. Here, of course, we can only provide you with selected portions to indicate what is happening to medical practice in Russia. In the first place, both these authors, Cham- berlin and Haines, agree in opinion that Lenin was fotunate in the selection of Dr. Semashko for Commissar of Health, and that Stalin has been wise in keeping that officer in charge of all health affairs. It appears also that the Commissariat of Health has made greater substantial success than any other department of the Soviet regime. Nikolai Alexandrovich Semashko was a plain, country boy, born in the Orlov district and educated through his youthful period in the nearby schools. Country life under primi- tive conditions and among the peasants de- veloped his rugged health and strength and his understanding of and sympathy for suf- fering humanity. Country origin probably accounts also for his characteristics of self- reliance and practical ability to deal with emergencies. Before his schooling was finish- ed, the death of his father compelled the boy to procure his university education by his own efforts. His independent spirit got him into trouble with “the authorities” during his stu- dent days in Moscow, although he was never a populist nor violently radical, and he seems rather to have been forced into socialism by a chain of circumstances. Banished from Moscow for a time, he completed his medical studies at Kazan University, where he met Rykov. later to become the Soviet Prime Min- ister, and at Geneva, where he met Lenin. When the revolution occurred he returned to Moscow, from a country practice somewhere in the Balkans, and was chosen to serve as Director of the City Health Department. His reorganization of what constituted “a jumble of private hospitals without funds, a few wretchedly equipped public hospitals and a dwindling staff of disgusted doctors and nurses” attracted Lenin’s attention and when the Soviet government moved to Petrograd he was asked by Lenin to draft a public health scheme on a nation-wide scale. His present official position, as Commissar of Health, cor- responds to that of a member of the Presi- dent’s Cabinet — what would be called at Washington “Secretary of Health” if we had such a cabinet post ; to that extent, at least, Russia is more advanced than the United States. Miss Haines gives us a detailed description, May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 429 with explanatory diagrams, of the health de- partment organization, of the present state of medical education, including the full cur- riculum for medical schools and nurses’ train- ing schools, and points out many difficulties yet to be conquered in the vast scheme outlined. Evidently much has been done but much re- mains to be done, and as in all other divisions of the new Russian government it remains to be seen whether the idealism of Soviet leaders can be transmuted into successful practical realism. The Commissariat of Health controls everything and everybody associated with the prevention or cure of disease, acting largely through or in cooperation with the All-Rus- sian Medical Workers’ Union, whose mem- bership embraces medical personnel from the august super-specialist to the lowly hospital- ward scrub woman. The following sentence quoted from the historic sketch of this move- ment has a familiar sound; i.e., “Of all the groups of medical workers, the doctors were the slowest to see the advantage in an asso- ciation which would include them on the same footing with other workers for the people’s health.’’ The Russian Medical Association fought state medicine in general and resisted all overtures for affiliation made by the Medi- cal Workers’ Union from 1917 to 1920, at which time it was forced by legal procedure to surrender; securing, however, by way of compromise, the privilege of retaining its own organization for scientific purposes. Now, a few words as to the aim of soviet- ized medicine and the accomplishments so far recorded. Semashko published in 1926 an essay on the Foundations of Soviet Medicine, in which he declared: “Soviet Government is a government by the masses in the cities and the country. This fundamental fact deter- mines the entire character of soviet sanita- tion and medicine. The health of the workers is the responsibility of the workers them- selves. The nationalization of medicine does not mean, as some think, the closing of all private hospitals and prevention of all private practice, but the actual socialization of medi- cine ; the taking over by the state of the re- sponsibility of providing for everyone, at his earliest need, free and well-qualified medical treatment. Only then will disappear, like a shadow before sunlight, all private hospitals and all commercial private practice. This is the perspective of communist medicine.” The goal is to be achieved by application of 5 basic principles : ( 1 ) The unification of medicine. (2) Accessibility of medical aid to all citi- zens. (3) Medical treatment by qualified per- sons. (4) Free medical treatment for all citizens. (5) Emphasis on preventive medicine. That does not appear to be a very terrify- ing program; indeed, with the exception of item No. 4, it sounds not unlike an American State Medical Society Welfare Program. One other significant variation is found in an ac- companying explanation that: “The present- day Russian considers physical health as im- portant a factor in life as education. There- fore, medical service has been put in the same category as the public school system, the state aiming to provide both for practically all citizens.” Among the results so far attained we note some interesting features : (1) Limiting the working day of physi- cians to 6 hours, and the opportunity afforded them to carry on research work or any avo- cation they please during their ample leisure time. (2) Free diet kitchens to which the physi- cian may send patients who require scientific- ally prepared food, just as they are sent with other prescriptions to the pharmacy for medi- cine to be furnished freely. (3) The formal school life of children be- gins with the kindergarten, to which applicants are admitted after the age of 3 years. The ma- jority of children enter public schools at the age of 7. and upon entrance they are given a thorough physical examination by physicians trained for and assigned especially to this work. Then, these school physicians are ex- pected to treat, or send to specialists, all chil- dren exhibiting defects that can be remedied ; so that there is prompt correction of all faults that might handicap the child, and there is no wasted energy or loss of time such as at- tends our own school inspections. (4) Health and sanitation are taught ob- jectively in the schools and the children learn to assume responsibility for- personal and pub- lic health. (5) Special schools or classes are being provided as rapidly as funds become available for education and care of mental defectives or those whose poor vision or hearing prevents them traveling along the standard education route. (6) Campaigns against venereal diseases and tuberculosis are well organized and every facility for treatment is offered the victims of those diseases. Special “night sanatoriums” have been opened for the reception and care of persons with incipient tuberculosis who must, nevertheless, work during the day ; this is an innovation which is said to be producing surprisingly good results. 430 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 (7) The Insurance Fund pays full salary to women for the 6 to 8 weeks of absence from work before and after child-birth. (8) An allowance in place of salary is awarded to any worker during a protracted illness, but this does not encourage malinger- ing because it is limited to about 20% of his regular salary. (9) Since the physicians have accepted the “new order of things” formerly famous specialists have gradually been restored to their old university and institutional positions, regardless of their political beliefs; Pavlov, for instance, is chief of the Institute for Pre- ventive Medicine, and Speransky directs the Institute for Protection of Motherhood and Infancy. (10) Incidentally, and surprisingly, distinct propaganda for specialization is being carried on among young physicians, urging them to continue their studies and investigations along special lines, and offering assistance in post- graduate work; a striking contrast to most of the talk in this part of the world, and another interesting experiment to watch. It would certainly be an ironic result if higher special- ization should prove to be the solution of our troubles arising from the increase in number of specialists. In her concluding remarks about sovietized medical practice, Miss Haines says : “Russia’s nationalized health system offers one method of solution, neither more revo- lutionary nor more expensive than our public school system. We may not care to adopt this solution but it can do us no harm to watch it.” Coming now to the Western Hemisphere we find Chile the only South American coun- try so far listed as having adopted compulsory health insurance — and of that law we regret to say we know nothing— though Brazil and the Argentine Confederation are considering the matter, and Canada, in North America, is on the verge of accepting state medicine. In 1928 the Canadian national government was asked to adopt some form of health in- surance, and with that request was linked the question of insurance to cover unemployment. More attention was paid at the time to the subject of employment, and then the Depart- ment of Justice ruled that control of health, like education, belonged to the provinces — -not the nation ; a decision of importance to us because, by comparison, we believe in the United States that control of health matters and the practice of medicine is a “state’s right” problem. In consequence of that rul- ing, the matter of health insurance was re- ferred to the several provinces, and during the past 3 years extensive and intensive study of state medicine has been made by the pro- vincial legislatures of Alberta. British Colum- bia, Ontario and Saskatchewan. Through the courtesy of Dr. W. Harvey Smith, Presi- dent of the Canadian Medical Society, we have had the privilege of reading the records of the preliminary investigation by a Royal Commission of the Canadian House of Commons, and reports of the studies made in Alberta and British Columbia; all very in- structive documents. It looks now as if the greater part of Can- ada will adopt a plan of health insurance simi- lar to that of Great Britain in the immediate future. President Smith has advised the pro- fession to recognize its responsibilities and to devise plans for placing medical service on a par with medical science, saying : “The state, having granted the medical pro- fession legal authority to control licensure and to pass upon the qualifications of men seeking authorization to practice, must un- questionably possess the right to exact a quality of professional skill and service that will meet the needs of the age, and to require adequate facilities for their distribution to every section of the community. If corporate medicine cannot or will not recognize and meet the demands so insistently made for the development of a system under which compe- tent medical aid will be available — for rural districts especially— no protest can be raised if governments or municipal bodies take steps to inaugurate a system of medical service of whatever type and character may seem best.” And now, at last, we return from this theoretic voyage to foreign countries and are confronted by conditions at home which seem to demand some consideration with relation to the necessity for opposing, or accepting and guiding, state health insurance — otherwise known as state medicine. As has been point- ed out, nearly every other nation on earth has either voluntary or compulsory health insur- ance for those citizens who earn less than $1200 a year; and it seems highly probable that the few nations yet depending upon vol- untary insurance will change to the compul- sory form within the next few years. The possible advent of state medicine into some one of our states is by no means a new thought ; its coming has been repeatedly pre- dicted, promised or threatened. It does, how- ever, seem to be at this moment more im- minent than ever before ; an opinion based upon the fact previously referred to, i.e., that throughout our country those who are most closely in touch with current events believe that state medicine is due to arrive shortly unless the profession can forestall it by sup- plying something in lieu thereof — some im- provement on present methods that will May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 431 satisfy the demand for better and cheaper service to the mass of citizenry. In support of that opinion let us remind you that for the third successive year the Legislature of Massachusetts has been pre- sented with an Act to create a department of public medicine and health for the purpose of furnishing a free and complete medical ser- vice to the people of the commonwealth of Massachusetts, patterned upon the bureau of medicine and surgery of the United States Navy. That Act will probably not become a law this year but it is a noteworthy fact that each year it has gained in the number of adherents despite determined opposition on the part of the medical profession ; and its author tells us he is encouraged to believe it will ultimately be adopted. Further, we may direct your at- tention to an Act now pending in the New York Legislature: an Act which covers the entire field of health insurance, unemployment insurance and old age pensions. Again, we feel certain this proposition will be defeated this year ; but, what about next year or the year following? These are but single instances, but they may be considered as very definite indications of the direction of the wind; and they are of special import because they have appeared in 2 of the most conservative and most important states in the Union, and be- cause neither Act emanated from a “radical” source ; one was drawn by a thoroughly re- putable physician, and the other was sponsor- ed by a legislator in good standing— whether or not aided by a physician we do not know. On our desk there are 28 original articles that appeared in state medical society Jour- nals between May and October 1930, articles not searched for but which were observed in the routine course of inspecting the tables of contents as exchange copies passed through our hands, all dealing with this question of prospective state medicine. Among the au- thors of those articles we note 3 Ex-Presi- dents of the American Medical Association ; 7 presidents of state societies ; 2 presidents of county societies ; and the others are all men of orominence in the profession; no “reds”, no paid writers, no one “with an axe to grind” —but each and everyone speaking in the in- terest of his medical confreres. We may add, too, that these writers represent all sections of the nation from Maine to California — in- cluding, as it happens, both those states. We will not bore you now with lengthy ab- stracts from those articles, but to show that there is no material difference of opinion be- tween physicians of the east and the west, the north and the south, who are awake to the situation, and that there is among them a uni- versal demand for preparedness, let us refer briefly to 3 or 4 articles arising from widely separated points. Dr. S. H. Boyer, President of the Minne- sota Medical Society, said: “What the attitude of the medical profession shall be in relation to the changes taking place affords food for serious thought. That paternalistic encroach- ments have taken place is only too apparent. * * * The movement appears to be well nigh world-wide in its scope and its tentacles are reaching hungrily into our own country. It has gathered such impetus now that only a solidly organized and militant profession will be able to ward it off or so modify it as to eliminate its most pernicious features.” At the Annual Meeting of the California Medical Association, April 28, 1930, the Chairman of the Committee on Medical Eco- nomics, reporting to the House of Delegates, deprecated the lassitude of the major portion of the organization and scolded them for scant courtesy shown another member who had spent 2 years in study and preparation of a 'report upon economic conditions. In conse- quence, in the July issue of the State Society Journal (California and Western Medicine) you will find 3 excellent papers by Drs. Rex- wald Brown, of Santa Barbara, John H. Graves, of San Francisco, and John C. Rud- dock, of Los Angeles, reviewing the whole subject. W. G. Richards, of Billings, Montana, says : “The danger of our present attitude is that while we stand off and quibble the public may take the matter into its own hands and im- pose upon us some scheme of its own de- vising.” C. A. Harper, President of the Wisconsin Society, says : “These facts strongly empha- size a popular demand for certain changes that will comply, more or less, with the wishes of the general public. Is it wise for the medi- cal profession to remain indifferent to the problem while these agencies are developing certain lines of activity, or would it not be far better for the medical profession to ap- preciate the evolution that is now taking place, and become a prominent factor in guiding these various lines of procedure?” From the New York State Journal of Medi- cine (Dec. 1, 1930, page 1424) we quote part of an editorial written by Dr. William H. Ross, President of the New York State Medical Society, referring to the program of the Annual Conference of State Society Secretaries : “It indicates that the day of iso- lation in medicine is over and that medicine must soon undertake a self-appraisal of its own organization to see if its own public medical relationships are such as to enable it 432 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 to make proposals for the solution of unsolved and unmet public medical service problems, chiefly just 2 — the availability of medical knowledge for limiting illness, and provision for adequate medical care at a cost that can be met without involving the individual in debt from which he can hardly ever recover. It is the obligation of medicine to propose methods for these things, and, also, to work out a solution of how the doctor may be paid for his services to the indigent or near in- digent, either in private practice or hospital. * * * There may come another revolution in medical practice, as it has come in the past, as the result of great social needs and social changes; and who knows that it is not be- ginning? We may be nearer than we know to such things as unlimited old age pensions, provision for adequate medical care by the state, and the inclusion of sickness benefit in Workman’s Compensation and Health Insur- ance as in other countries. It should make us think !” These Things "Should Make Us Think” That is the note upon which we would close this series of letters. Medical Ethics PATIENTS MUST NOT BE NEGLECTED John Hammond Bradshaw, M.D., F.A.C.S., Orange, N. J. A physician is free to choose whom he will serve. He should, however, always respond to any request for his assistance in an emergency or whenever temperate public opinion expects the service. Once having un- dertaken a case, a physician should not aban- don or neglect the patient because the dis- ease is deemed incurable; nor should he with- draw from the case for any reason until a sufficient notice of a desire to be released has been given the patient or his friends to make it possible for them to secure another medi- cal attendant. — Sec. 4, Principles of Medical Ethics, A. M. A. We should never forget we are dealing not only with the sick but with human nature and sometimes the human nature we treat is worse than the disease that accompanies it. If we attempt to treat the disease alone we are in trouble and the patient does not get the full benefit from our treatment. It often takes more skill to treat weak human nature than a weak stomach. What the patients some- time forget is that we are human beings our- selves. A few years ago the press was full of com- ments upon a case where allegedly, in one of our cities, a patient had tried in vain among more than 20 physicians to secure any one of them to respond to his call. Like most of such reports, when the story was investigated it was found to be not only greatly exagger- ated, but mostly false. But, the story having been spread about in the papers, many people had believed it to be true. Years ago, the writer remembers a man in his office who boasted that he had never paid a doctor’s bill in his life, because if one doc- tor refused to take the case there were al- ways several who would be ready to respond ; and probably he was right. Do we mark this as a credit or a discredit to the profession? Just as the physician should be free to choose whom he would serve, so should the patient be free to choose whom he desires to treat his case. This needlessly often leads to wailing and gnashing of teeth. Much enmity and harsh criticism of our fellow-man can be avoided if we will all have a heart-to-heart talk with each other about our differences. Personally, I have never known a physician to abandon a case because he considered it in- curable ; but I have known many instances where, after he had expressed an honest opin- ion that he had done all that he could, the pa- tient had secretly slipped into the case other doctors who, not being quite so honest, had seemingly worked the case for all it was worth, even up to the bitter end — even giving the family and patient the idea that “if only, etc.”, much to the discredit of the first physi- cian. But doctors are no more perfect than men in other professions, and we have even heard of some lawyers doing shady things! After some especially unkind and uncalled- for treatment, on the part of the patient, to a conscientious and faithful physician — for a sick body often makes for a sick mind — it is only human nature for the doctor to exclaim to himself that he “will never make another call”, and he can legitimately do this and re- tire from the case if he sees to it that he makes it possible for the family to secure the services of another physician. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 433 Collateral Reading REVIEW OF SOME MEDICAL BOOKS During the past 6 months we have received complimentarily from the medical book pub- lishers a considerable number of new books for placement in the library of the Medical Society of New Jersey. Pending provision by the society of a suitable place for housing its library, and proper facilities for a reading room available and convenient to all our mem- bers, we have placed these books in the Library of the Atlantic County Medical So- ciety at the Atlantic City Hospital. The Journal has not space for elaborate re- views of all these books, so we can only ex- press the thanks of the State Society to the donors and in listing the books make brief comments upon the character and contents of a few books that merit special consideration ; and commend them to all members as they may be individually interested. If we may be pardoned for beginning near home, we take pleasure in praising “Clinical Interpretation of Blood Examinations” by Robert A. Kilduffe, of Atlantic City ; publish- ed by Lea and Febiger, price $6.50. Observa- tion of his work inclines us to the belief that everything done by Kilduffe is well done ; and this book is no exception. He has covered the subject in a comprehensive, all-inclusive, man- ner and readers may safely rely upon his ad- vice in the matter of interpreting laboratory reports. As a book of reference, for the solv- ing of “blood pictures”, it seems to us in- valuable, and we extend to author and pub- lisher thanks for providing such a complete, accurate and reliable source of information. Another neighbor and friend, Dr. Robert N. Iveely, of Philadelphia, has turned litera- teur and gives us “Paris and All the World Besides” ; a biographic story of great interest. Those physicians who, as students of medicine in the last decade of the nineteenth century, went “abroad to study in European clinics” will appreciate Keely’s description of the many nonmedical attractions that interfered with prescribed curricula even though they afforded opportunities for scientific investi- gation. Many of his experiences were unique, however, and very few men have had half so many chances to witness or participate in un- usual events. It seemed his fate to step from one rare adventure into another, and if we guess correctly he has not yet finished, for in a personal chat within this month he announc- ed the intention to “return to Paris” for a visit this summer. If you want a few hours of communion with a rare soul, and one who has seen life with the eye of a physician as well as an adventurous traveler, read Keely’s book. “The Baby’s First 2 Years” is the title of a small book written by Dr. Richard M. Smith, of Boston, published by the Houghton Mifflin Company (price $1.75) for the purpose of providing young or inexperienced mothers with sage advice. It is particularly useful in the matter of infant feeding and family physicians could do worse than to recommend this book to mothers who need an adviser ready at hand. “Easier Motherhood”, by Constance L. Todd, gotten out by the John Day Company ($2), is a lay writer’s evaluation of Gwath- mey’s obstetric analgesia by colonic injections, and if it attains a wide circulation physicians will doubtless soon have their patients pre- scribing the technic to be followed in de- livery. We doubt the propriety of public education by this method. The publisher states that: “One wholesome result of such an informal demand (for Gwathmey’s techinc) among women would be to make less popular the operative interference with the normal birth process which is now in vogue”, etc. Operative interference is always wrong ; op- erative intervention, even, may sometimes be wrong, and we also feel that too many de- liveries are being expedited by aid of forceps or by cesarean section, but that situation can- not be corrected by the patients. It is not many years since some popular magazine writers were insisting that all prospective mothers should demand “twilight sleep”. To- day we know that had the profession suc- cumbed to that demand a goodly number of women would have, in consequence, passed into the next world. There is great need for improvement in obstetric practice ; possibly there is some need for closer attention to the “humanities” on the part of some obstetri- cians ; but no single method of inducing analgesia or anesthesia has been discovered that is applicable to all cases of child-birth, and when a safe and reliable technic is dis- covered its suitability for employment in given instances must still be determined by the doctor in attendance rather than by some one in a distant literary office, or even by the patient herself. We do advise physicians to read this book, if only to ascertain what their patients are being taught to expect or de- mand. “Suggestion for Contraceptive Practice”, published by the Holland-Rantos Co., is a booklet offered to physicians free of charge; containing in condensed form much practical information. “Treatment of Diseases of Children”, by 434 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 Lust, published by J. B. Lippincott, price $8, is a modern treatise that appears to lie well worth its cost. The same publisher has re- cently issued the following excellent books: “Clinical Nutrition and Feeding in Infancy and Childhood”, by Kugelmass ; “Burns”, by Pack; “Tropical Medicine”, by Reed; each at the price of $6. For up-to-date information concerning these several subjects we know of no better literary sources of supply. “Treatment of Epilepsy”, by Talbot, pub- lished by Macmillan, $4, is a timely and very useful book. The general practitioner has not been over-supplied with authentic text-books upon the subject of epilepsy, and this work should find a welcome niche in many office libraries. Equally practical in character is Carl Beck’s “Crippled Hand and Arm”, for in this machine age industrial accidents are fre- quent and industrial surgery has few more important problems than those concerned with treatment of injuries to the hand. For practical consideration of such injuries we commend Beck’s book. In this connection, we can also recommend Boehler-Lorenz’s “Treat- ment of Fractures” which has been translated from the German by Steinberg, of Portland, Oregon, and sells for $5. C. V. Mosby has sponsored a group of new books that seem worthy of wide circulation : “Infant Nutrition” ($5.50), by McKim Mar- riott; “Physiology and Biochemistry in Mod- ern Medicine” ($11), by J. J. R. Macleod; and “Minor Surgery” ($10), by Hertzler and Chesky. Again, industrial surgery has created a demand for such books as the last men- tioned above. “The Challenge of Chronic Disease”, by Boas and Michelson, and the “Clinical As- pects of Venous Pressure” by Eyster; both published by Mosby, $2.50 each, are quite ap- propriate to the present demand for closer study and better treatment of conditions that affect us after 40 years of age and which tend to curtail life. And, in association with these books one may profitably read Gurd’s “In- fection, Immunity and Inflammation”, and Wyatt’s “Chronic Arthritis and Rheumatoid Affections”, for most chronic affections have their origin in some form of infection that establishes a focal point from which to carry on its devastating work. If compelled to judge from manuscripts submitted for publication we would say that not so many physicians as should possess a medical dictionary. So, to those in need of such a desk companion we can say that Sted- man’s, sent to us by the William Wood Com- pany, will be found useful and valuable. Finally, Johnson and Johnson, of New Brunswick, offer to send any physician a copy of a very serviceable book, 136 pages, on “First Aid and Medical Service in Industry” ; a helpful guide to those called upon to set up infirmaries in shops and factories. In Lighter Vein Reversed Pimple Definition of a dimple: A dimple is a lump in- side out. — Carolina Buccaneer. Wrong Label “A spoonful of water contains 270,000 potential horse-power”, says a scientist. That isn’t water.— Life. Losing Step with the Joneses ‘‘My dear, I can’t get a nurse for love nor money — my baby-carriage is last year’s model!” — Passing Show. Latest Efficiency Wrinkle Jaywalker — "So many people are struck by autos while alighting from street-cars.” Street-car Official — “Well, yes; but those people have paid their fares. It’s this running over peo- ple who are waiting to get on that makes me mad.” — -Pathfinder. Sorting 'Em Out Soused Voice: “Hello, is this the city morgue? Well, this is the Medical School. We want you to come out and pick out the stiffs so the rest of us can go home.” — Pitt Panther. A new musical instrument, resembling a saxo- phone, is said to be so simple in design that a child can play it. It is a great pity. — The Humorist. Government chemists have found a new way to make alcohol unfit to drink, but the bootleggers really didn’t need a new way. — Publishers Syn- dicate. “What may be a certain cure for one person is often utterly useless in the case of another”, says a doctor. It is no good, for example, advising a kleptomaniac to try to take things quietly in the future. — The Humorist. Customers That Come Back We have served people in widely varying cir- cumstances. We have conducted many very costly funerals. The fact that those we have served once return again, and recommend us to their friends, is, we feel, a high endorsement of the service we render, regardless of cost. — Ad in a Downsville (N. Y.) paper. Biggest Boss “Rufus, did you go to your lodge meeting last night ?” “Nah, suli. We dun have to pos’pone it.” “How is that?” “De Grand All-Powerful Invincible Most Su- preme Unconquerable Potentate dun got beat up by his wife.” — U. P. Magazine. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 435 Preliminary Program MEDICAL SOCIETY OF NEW JERSEY The 165tli Annual Meeting, Berkeley- Cartaret Hotel, Ashury-park June 3, 4 and 5, 1931 ANNOUNCEMENTS Credentials and Certificates The Committee on Credentials will meet at the hotel on Tuesday afternoon, June 2, and on Wed- nesday morning, June 3. Its office will be open constantly during the meeting. The Constitution requires that all Fellows, Offi- cers, Delegates, and Reporters shall register with this committee. Delegates must present to this committee a certificate of election signed by the President and Secretary of their respective component societies. Without such certificate they cannot sit as mem- bers of the House of Delegates. Each member of the Nominating Committee should present his certificate to the Secretary before the opening of the afternoon session so that the names of the Nominating Committee may be announced, as indicated on the program. The Nominating Committee will meet on Thursday, June 4, at 5.30 p. m., in the committee room. Papers and Reports All papers read before the society or appearing by title on the program, whether read or not, thereby become the property of the society. The author of each paper is required to give the Secre- tary a legible copy of the same before reading. The expense of alterations in a paper after it is in type, and the cost of illustrations are borne by the author. All manuscripts should be typewritten, double-spaced, and on one side of the paper only. Excepting orations, addresses of special guests, and the Address of the President, the time to be occupied in the actual reading of a paper is lim- ited absolutely to 20 minutes. Those opening the discussion are allowed 10 minutes each, others 5 minutes each. Members desiring to present voluntary papers or reports of cases should first have their papers ac- cepted by the Committee on Scientific Work and then apply to the Committee on Program for a position. Papers and reports not presented when called for by the President cannot be presented at a later time unless the regular order of business is completed. All members of component societies who are in good standing are entitled to sit as associate mem- bers and have the privilege of discussing papers in the general session, but have no vote nor the right to take part in the discussions of the House of Delegates. On arising to discuss a paper, the speaker will please walk forward to platform and announce his name and address clearly for the benefit of the society. No member may speak a second time in any discussion. All sessions will be opened promptly at the hour set, in order that the program may be carried out as planned. The Board of Trustees will meet at the Berke- ley-Carteret Hotel, Tuesday, June 2, at 8 p. m. Committees or Boards desiring meeting rooms will please notify the Committee on Arrange- ments, M. W. Reddan, Chairman, or W. D. Olm- stead, Secretary. The Berkeley-Carteret is operated on the Euro- pean plan and the following special convention rates are available to our members: $5 per day, single room, bath or shower. $8 per day, double room, twin beds, and bath or shower. All rooms are priced alike. Make hotel reserva- tions direct. The Berkeley-Carteret serves very splendid table d’hote meals at the following prices: Breakfast 60c to $1 Luncheon $1.50 Dinner $2 In addition to the above, a la carte service is available at all times for those who prefer it. Exhibits Exhibits of instruments, books, pharmaceutic preparations, x-ray apparatus, etc., will be shown in the “Exhibit Hall’’ of the hotel and members are urged to avail themselves of this opportunity to examine the very latest improvements in these various departments. The degree of interest shown by the visitors in these exhibits mathematically increases or de- creases the revenue to the society. It’s up to you to help. HOUSE OF DELEGATES Wednesday, June 3, 1931, 10.30 A. M. Call to Order. Report of Committee on Credentials. Reading of Minutes of 1930 Meeting. Report of Committee on Arrangements and Pro- gram. Report of Committee on Scientific Work. Report of Committee on Publication. Report of Secretary. Report of Executive Secretary. Report of Field Secretary. Report of Welfare Committee. Report of Board of Trustees. Report of Judicial Council. Report of Treasurer. Report of Committee on Finance and Budget. Report of Committee on Honorary Membership. Report of Board of Medical Examiners. Report of Committee on Post-Graduate Instruc- tion. Report of Committee on Hospitals and Medical Education. Report of Committee on Indemnity Insurance. Report of Committee on Group Health and Acci- dent Insurance. Report of Delegates to the American Medical As- sociation and to State Societies. Afternoon Session Wednesday, June 3, at 2.30 P. M. (1) Unfinished Business. (2) New Business. SECTION OF SCHOOL PHYSICIANS Wednesday, June 3, at 2.30 P. M. Chairman: Allen G. Ireland, Director of Physical and Health Education, State Department of Public Instruction, Trenton. 436 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 (1) Foot Examinations in Public Schools Donald B. Hull, Ridgewood (2) Physician’s Part in Training of Teachers Grace M. Kahrs, Jersey City (Physician for the State Normal School at Jersey City.) (3) Facts in a Child Health Program of Com- mon Interest to School and Community Health Officials I. W. Knight (District Health Officer, State Department of Health.) (4) Health in Education from the Point of View of a School Administrator Winton J. White, Englewood (Superin- tendent of Schools.) GENERAL SESSIONS Scientific Program Thursday, June 4, at 10 A. M. (1) Surgical Aspects of Biliary Tract Disease John B. Deaver, Philadelphia Discussion opened by Max Danzis, Newark. (2) Value of Duodenal Tube Drainage of the Biliary System and Treatment of Various Diseases and Disorders of the Liver B. B. Vincent Lyon, Philadelphia Discussion opened by Geo. IT. Lathrope, Newark. Thursday, June 4, 2.30 P. M. (1) Fusospirochetal Diseases of the Lung (Illustrated with lantern slides) F. J. Altschul, C. A. Pons, and W. G. Herrman, Long Branch Discussion opened by William P. Belk, Phila- delphia. (2) Cardiac Irregularities, their Clinical Recogni- tion Philip Marvel, Jr., Atlantic City Discussion opened by Harvey M. Ewing, Newark. <3) Silent Mitral Stenosis; its Detection and Significance J. Polevski, Newark Discussion opened by A. E. Jaffin, Jersey City. (4) Epitheliomas of the Skin; Differential Diag- nosis and Treatment (Illustrated with lan- tern slides) Bart M. James, Newark Discussion opened by H. J. F. Wallhauser, Newark. Friday, June 5, 10 A. M. (1) Radiation of Bladder and Prostatic Carci- nomas Benjamin S. Barringer, New York City Discussion opened by Stanley R. Woodruff, Jersey City. <2) New Views on Pathogenesis, Diagnosis and Treatment of Ulcer and Cancer of the Stomach, Cholelithiasis and Diseases of the Digestive Organs in General A. L. Soreci, New York City Discussion opened by Joseph Samenfeld, Brook- lyn. (3) Findings of the Governor’s Conference on Child Welfare and Protection. Frank C. Johnson, New Brunswick Discussion opened by Henry O. Reik, Atlantic City. (4) Role of the General Practitioner in Conserva- tion of Vision Elbert S. Sherman, Newark Discussion opened by Elias J. Marsh, Paterson, and Lewis H. Carris, Managing Director of the National Society for the Prevention of Blindness. Special Order — 12 Noon Presidential Address George N. J. Sommer, Trenton Friday, June 5, 2 P. M. (1) Election of Officers (No other business). Scientific Program at 2.30 P. M. (2) Fees, Specialists, and Kindred Annoyances. Elias J. Marsh, Paterson Discussion opened by George H. Lathrope, Newark, and Ephraim R. Mulford, Bur- lington. (3) An Etiologic Conception of the Disease Entity H. B. Logie, New York City (4) The Conditioned Reflexes of the Cerebral Cortex. (Pavlov’s epoch-making investi- gations of the physiologic processes under- lying the phenomena of thought, feeling and conduct. Clinical problems of various functional psychoneuroses his work eluci- dates.) William H. Hicks, Newark (5) Manganese Poisoning F. P. Wilbur, Franklin Discussion opened by Christopher C. Beling, Newark. (6) The State’s Provision for 3 Types of Deaf Children Ethel Warfield, Trenton Junction, Field Worker, New Jersey School for the Deaf SECTION OF OPHTHALMOLOGY, OTOLOGY AND RH1NOLARYNGOLOGY Chairman; Elbert S. Sherman, Newark Thursday, June 4, 9.30 A. M. (1) A Muscle-shortening Operation Harry V. Hubbard, Plainfield Discussion opened by George F. Sullivan, Ho- boken. (2) Clinical Management of Heterophoria John H. Dunnington, New York City (3) Combined Orthoptic and Operative Treat- ment of Convergent Squint Linn Emerson, East Orange Thursday, June 4, at 2 P. M. (1) Tumors in the Neighborhood of the Optic Chiasm, with Special Reference to Eye Symptoms Thomas H. Johnson, New York City Discussion opened by Wells P. Eagleton, Newark. (2) Ocular Manifestations of Focal Infection Samuel T. Hubbard, Hackensack Discussion opened by Charles Zehnder, Newark. (3) Non-traumatic Hemorrhage in the Vitreous of Young People Charles Franklin Adams, Trenton Discussion opened by Wallace Pyle, Jersey City. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 437 Friday, June 5, at 9.30 A. M. (1) Some Cases of Facial Paralysis E. P. Cardwell, Newark Discussion opened by James A. Fisher, Asbury Park. (2) Important Factors in Surgery of Congenital and Acquired Facial Deformities Jacques W. Maliniak, Newark Discussion opened by H. C. Barkhorn, Newark and H. H. Kessler, Newark. General Session Room Special Order — 12 Noon Presidential Address George N. J. Sommer Friday, June 5, at 2.30 P. M. (1) Allergy as a Factor in the Etiology of Dis- eases of the Nose and Paranasal Sinuses Royce Paddock, Newark (2) Accessory Nasal Sinus Infection in Children G. W. Strickland, Roselle (3) The Credulity of Rhinologists Anent the Sinuses Charles S. McGivern, Atlantic City Discussion opened by Charles H. Schlichter, Elizabeth, and Henry C. Barkhorn, Newark. SECTION OF PEDIATRICS Chairman: Elmer G. Wherry, Newark Thursday, June 4, at 10 A. M. (1) Tonsil Problem Chester R. Brown, Kearny Discussion opened by Henry C. Barkhorn, New- ark. (2) Symptomatology and Treatment of Thymus Gland Conditions in Children Paul Hosp, Newark (3) Clinical Evaluation of a Palatable Concentrate of Vitamins A and D Joseph A. Marcus, Atlantic City Thursday, June 4, at 2.30 P. M. (1) Treatment of Heredosyphilis F. J. McCauley, Newark Discussion opened by Robert R. Sellers, Newark. (2) Blood Transfusion as a Therapeutic Agent in Pediatrics Dewis W. Brown, Newark Friday, June 5, at 10 A. M. (1) Results Obtained in 40 Cases of Eczema on a Milk-Free Diet Julius Levy, Newark (2) Importance of Differential Study of the White Blood Cells, as Illustrated by Certain Cases Royce Paddock, Newark (3) Influenzal Meningitis; Report of a Recovered Case. F. C. Johnson, New Brunswick Special Order — 12 Noon General Session Room Presidential Address George N. J. Sommer WOMAN’S AUXILIARY TO THE MEDICAL SOCIETY OF NEW JERSEY FOURTH ANNUAL MEETING Berkeley-Carteret Hotel, Asbury Park. Wednesday, June 3 Golf Tournament for both women and men at the Asbury Park Golf Club. Wednesday, June 3, at 1 P. M. Luncheon (subscription) and Executive Board Meeting. Wednesday Evening, June 3 Dutch Treat Supper Dance at Monterey Grill. Thursday, June 4, at 9.30 A. M. North Solarium Call to Order Mrs. John Nevin, President Prayer : Ecclesiasticus 38: Honor the physician for the need thou hast of him: for the most High hath created him. For all healing is from God, and he shall receive gifts of the king. The skill of the physician shall lift up his head, and in the sight of great men he shall be praised. Minutes of Last Meeting Mrs. Dan S. Renner, Recording Secretary Financial Statement Mrs. Edward Clarke, Treasurer Report of Standing Committees Report of County Presidents Speeches limited to 2 minutes Appointment of Nominating Committee Report of Committee on Revision of Constitution New and Unfinished Business Thursday, June 4, at 1 to 5 P. M. Entertainment by Monmouth County Auxiliary Boat trip on steamer leaving Long Branch at Pleasure Bay dock about 1.30 and returning about 5 p. m. Trip will cover the Shrewsbury River out past Atlantic Highlands, Twin Lights, and along Sandy Hook into Lower New York Bay. Buses will , leave Berkeley-Carteret Hotel about 1 o’clock and will return guests to hotel after the trip. Luncheon will be served at Fort Hancock. Thursday Evening, June 4, at 7.30 P. M. Crystal Room Dinner Dance (Subscription). Friday, June 5, at 9.30 A. M. North Solarium President’s Report Mrs. John Nevin, President Report of Nominating Committee Election of Officers Unfinished Business Installation of New Officers Friday, June 5, at 1 P. M. Auxiliary Luncheon (Subscription). Guests of Honor: Mrs. John O. McReynolds 438 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 Mrs. John Nevin Mrs. H. Roy Van Ness Dr. George N. .1. Sommer Dr. John F. Hagerty GENERAL ENTERTAINMENT The following entertainment has been arranged for by the Committee on Program and Arrange- ments in cooperation with the Program Committee of the Woman’s Auxiliary and a Special Com- mittee appointed by the President of the Mon- mouth County Medical Society. Wednesday, June 3 Golf Tournament, all day, sponsored by the Mon- mouth County Medical Society, at the Asbury Park Golf Club, for men and women. All members of the Medical Society of New Jersey, and all mem- bers of the Woman’s Auxiliary to that Society, are cordially invited to participate. Prizes will be awarded for low gross and low net scores — 18 holes — for both men and women play- ers. Also, there will be 4 prizes for winners and run- ners-up in a Scotch 4-ball foursome for men. Wednesday, June 3, at 8 P. M. Dutch Treat Supper Dance at the popular Mon- terey Grill; special music furnished by the management. Thursday, June 4, at 8 P. M. Dinner Dance in the Ball Room of Berkeley- Carteret Hotel. A splendid dance orchestra and a hostess entertainer will be provided. Beautiful prizes will be furnished by the Woman’s Auxiliary. Reservations must be made at the registration desk. Everyone is invited. Friday, June 5 Golf for those who wish to play. Special entertainment for the ladies for Friday afternoon will be announced later. Splendid meetings, teeming with interest, have been arranged for and all members are urged to attend. Committee on Program and Arrangements. Presessional Reports ANNUAL MEETING Presessional Report of the Welfare Committee The newly appointed Welfare Committee held its organization meeting at the Stacy-Trent Hotel, Trenton, November 9, 1930. A. Haines Lippincott was reelected chairman. The report of the secretary, reviewing the work of his office during the past summer, was present- ed. Radio broadcasting of medical programs in those sections where proper facilities exist was thought to be worth while and it was decided to continue the practice. The report covered briefly the programs of the Field Secretary, Mrs. Taney- hill, whose work has enlarged very much. The demands on Mrs. Taneyhill’s time are constantly increasing, due to the excellent cooperation of the State Board of Education, whereby she has ar- ranged contacts with all the school organizations of the state. Dr. Leo Haggerty, of Trenton, again volunteered his valuable assistance in keeping us in touch with proposed legislation that might need our con- sideration, and the status of such bills. The pro- fession and the people of New Jersey owe a great debt to Dr. Haggerty for giving his valuable time to this task. There were many bills dumped into the hopper this year that might be classed as medical legisla- tion. After careful study of this proposed legisla- tion by Dr. Reik, he concluded that there were about 20 Bills that required consideration by the Welfare Committee. These bills were carefully considered by the Committee and a plan of ac- tion decided upon. It was decided that the Executive Secretary should send a letter to every member of both houses of the Legislature informing them of the action of the Committee and the reasons for ap- proval or disapproval in each instance. Under the watchful eyes and convincing argu- ments of Drs. Newcomb and Hargraves, in the Assembly, and Dr. Cole in the Senate, supported by the many friends of the profession who are members of both Houses, at this writing we seem to have checked or defeated all proposed legisla- tion that had not the stamp of our approval. We cannot be too optimistic, however, regard- ing the future. We have learned our lesson from past experience that there is not always safety in quiescence. The politicians this year had a diversion that has taken up a great deal of their time and thought. The great mass of bills that came out of the report of the Abell Commission has possibly drawn their attention from other matters in which we as physicians are particularly interested. The Abell Report dealt with many changes and methods in state government, and we were to a certain extent drawn into the whirl. We are interested in the appointment of physicians to Boards and Commissions where medical counsel will benefit the state. While it has not been neces- sary to call the Welfare Committee together but 3 times, the members responded to those calls magnificently, with an enthusiasm and a willing- ness to serve their profession and their state in such manner that makes me proud of the honor of having been chosen chairman of this group of physicians. A. Haines Lippincott, M.D., Chairman. PRELIMINARY REPORT OF COMMITTEE ON HEALTH & ACCIDENT AND AUTO- MOBILE INSURANCE Since our annual report to the House of Dele- gates in June 1930, published in the Transactions (Sept. Sup. 1930, p. 27) progress in the favorable reception by members of our Health and Accident policy, offered them through the society, has been gratifying, and the settlements by the claim de- partment have been extraordinarily liberal and, without a single exception, satisfactory to claim- ants. Our keenness to make avail of any opportunity to improve the contract, in coverage, or in pre- mium rates, has resulted in successful negotiations by which the term for indemnity for total disa- bility from illness, is now increased from 4 to 6 weeks, and the requirement that the total disa- bility must be “house-confining", is abolished. Prior May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 439 to this change, the committee often secured a liberal adjustment for a member, in this matter of house-confinement, beyond the terms of the policy, but now we have it secured in the con- tract. We strenuously urge more consideration by our members of the advantages of this policy on Health and Accident insurance (which all doc- tors should carry) for the reason that an in- creased number of policy-holders will materially help our negotiations for even more benefits. The policies on automobile insurance are, as be- fore, standard policies, offered our members at a discount of 15 to 30%. These also have been well received and are universally acceptable. At the June convention an agent will be on hand, with an exhibit, and ready to interview members and answer inquiries. Frank W. Pinneo, M.D., Chairman, for the Committee. PRESESSION Al/ REPORT OF THE EDITOR AND EXECUTIVE SECRETARY Our society rules require publication of annual reports at least one month prior to the annual meeting. The period of time that must intervene between the writing of this report (April 10), for inclusion in the May Journal, and the end of our fiscal year, compels us to present a message that is preliminary and incomplete in character, and to request the privilege of making alterations and additions when preparing our final report for pre- sentation to the House of Delegates in June. Such tasks as have been completed can be reported in full; those having 2 months yet to run will neces- sarily have to be revised. We ask that this docu- ment be considered as only a preliminary report. (1) The Journal. If a president of the United States may without injury to his native modesty “point with pride” to the accomplishments of his administration, surely a mere editor may be ex- cused for directing attention to the things he has done or attempted to do during his reign. While serving in France with the American Expeditionary Forces, we learned some of the principles of suc- cessful warfare: (1) Over the top and dash for the first objective! (2) Hold it! (3) Consolidate your gains! (4) Prepare to carry along all you have won and to jump off from the advance post at the next zero hour for a new objective. Thus, step by step, never relaxing hold upon any point attained, and always reaching toward new attain- ments, our efforts were crowned with success. Pershing’s tactics were justified in war, and his battle principles seem applicable to most pro- gressive affairs in civil life. So, we have endeavor- ed to apply them to journalism. In 1924 the Journal of the Medical Society of New Jersey was practically a replica of all other state medical society journals; that is to say, it regularly consisted of about 6 sections, or de- partments, covering original articles, editorials, an occasional special article or case report, county society reports, obituaries and news items. The total of reading matter for the year making 400 pages. In 1930 this Journal exceeded 1000 pages — with an incidental increase of page size — embrac- ing not 6 but 16 distinct sections or departments. One at a time, commencing with Lighthouse Ob- servations and running through Ethics, Esthetics, Economics, Public Relations, Collateral Reading, School Health, Public Health, Current Events, and Woman’s Auxiliary, 10 new departments have been introduced and by constantly adding and never abandoning any established project, we have reached the present admirable monthly edition, to which we dare “point with pride”. May we say that this degree of success has not been attained without many hours of hard labor — many hours more than the labor union re- striction of an 8-hour working day — for our day never shows less than 12 and seldom less than 16 hours, and, as we suppose must be true, the editor of any periodical often wishes he might know whether his clientele is 1 sufficiently well pleased to justify all this expenditure of time and energy. Occasionally someone thinks to express general approval or to praise a particular feature of the journal; and on such days there is much joy in the editorial office. Recently we had a “red let- ter day”. While attending a Cumberland County Society meeting one member voluntarily stated his pleasure in reading this Journal and his pride in it as the organ of his own state society. We asked what he liked best about it, and we were somewhat surprised by his response: “I like it best because you are giving us such a variety of interesting matter, all bearing on medicine or re- lated to our professional lives, and yet much of it being material that I never before saw nor ex- pected to see in a medical journal.” It is scarcely necessary to say that we were rendered very happy, for he was the first to have mentioned dis- covery of the goal toward which we have been striving. It is the present purpose of the Journal to record the scientific work of New Jersey physi- cians, to supply them with information concerning medical progress, to constitute itself a monthly medium of post-graduate instruction, and to keep its readers in touch with any and every thing that can be serviceable to practitioners too busy to read extensively in the field of general knowledge. Returned home from that meeting we hastened to compare your Journal with those of other states, and we find that no other journal in this country, state or national, offers anything comparable to the wide variety of regular, monthly literary pabulum of high grade that is contained in the Journal of the Medical Society of New Jersey. A few of the other state journals are “better dressed” and make a more striking appearance because they use a better quality of paper — especially import- ant in the reproduction of illustrations — but in most other respects we excel. Not only do we surpass other publications in variety but we are providing a much greater quantity of first class medical reading. As repeatedly pointed out, we consider many of our regular hospital staff and county society reports fully equal to the average of original articles published in any journal. By way of comparing our own progress in re- spect to quantity of scientific matter published, our office secretary. Miss Mahoney, tabulated the material in the bound volumes of 1924 and 1930. The resulting figures showed 62 original articles in 1924, and 124 — exactly double — in 1930; 13 pages of editorials in 1924, against 29 pages in 1930 ; 62 coun- ty society reports in 1924, and 124 in 1930; 48 pages of society and hospital reports in 1924, and 163 pages last year. And this does not take into con- sideration the wealth of excellent original material now annually contributed through the Tristate Conference. That you may have personally an opportunity to make some comparisons, we are, following the plan of last year, exhibiting in the adjoining room the regular May issue of some 30 other state so- ciety journals, and we invite criticism and sug- gestions for further improvement of your own 440 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 magazine. The only recommendation the editor has to offer at present is that as soon as the financial situation permits, we may be instructed to contract for a heavier grade of paper with a good reproducing surface. As stated before, we fully appreciate any word of praise accorded our work but we reached the pinnacle of happiness a few days ago, when the monthly bulletin of the Middlesex County Society, issued as a call for the April meeting, carried the following announcement: “Hereafter, the Satur- day Evening Post stays on the shelf; the Journal comes first.” We thank the secretary of that so- ciety. (2) County Societies. During the fiscal year it has been our privilege to visit all but 2 of the 21 county societies at least once, and to have made 2 visits to one county and 3 to another. It is a pleasure to report that all of the component so- cieties are active and most of them are func- tioning in a praiseworthy manner. Following the custom established by his immediate predecessors, President Sommer has also attended regular meet- ings of each and all (we believe) of the county organizations, and we note with increasing satis- faction, the good results of these presidential visits and the visits made by the secretary of the state society. Dr. Morrison. It is not solely that the county members and the officers enjoy an ex- change of pleasantries and sociability, but each county unit feels that it is an important integral part of the state and national organization. With state officials present to be quizzed, the county members have brought up for consideration some of the problems that beset them and which vary in different communities. Especially is this true of economic problems, and this year it has be- come manifest that the state society must help to solve some of these problems, particularly those relating to the Workmen’s Compensation Law, and those growing out of industrial medicine as it is developing in a variety of forms all over the state. We respectfully suggest that the House of Delegates shall take some action with reference to these matters. The Annual Conference of Secretaries and Re- porters of County Medical Societies was held at Trenton, November 5, 1930, and this proved to be the most interesting session so far held. The pro- ceedings were published in full in the December Journal, pages 1000 to 1020. It was at that con- ference that Dr. Walter F. Donaldson, Secretary of the Pennsylvania Medical Society, spoke of the advantages of Councilor District Meetings, and it was out of the discussion following that of our own secretaries, lead by the presiding officer, Dr. George H. Lathrope, devised the plan for trying such district meetings in this state. Our 5 dis- tricts have all held meetings during the past few months and while different plans were used, ac- cording to the needs or the wishes of different sections, or as experiments in some regions, we believe that all proved successful; and we antici- pate that the society will be asked to give official endorsement to the general scheme. It was at that conference, also, that Dr. Mor- rison read his paper on the possible imminence of state medicine; calling attention to its rapid spread in foreign countries, its appearance in Canada and its threatened advent here as evi- denced by bills introduced into several state legis- latures. Tbe conference, at the suggestion of Dr. Fuhrmann, of Hunterdon County, adopted a reso- lution to ask the state society at this annual meeting to appoint a special committee to investi- gate the working of so-called state medicine in other states and countries, to collect all available data, and to report the results at some future date. In passing we desire to report that these con- ferences have had a very beneficial effect upon many of the county societies; one very noticeable improvement showing in the character of pro- grams now being issued. (3) Woman's Auxiliary. This organization con- tinues to thrive and we think has made definite progress this year. The editor is lending such aid as he may through the Journal and continues to hope that an effective organization will ulti- mately develop in every county. Cooperating with the president of the state aux- iliary, Mrs. Nevin, he has suggested, as a task for the auxiliary, an effort to control some of the obnoxious advertising being published in papers and magazines and broadcast by radio. Mrs. Nevin will probably present that question for considera- tion by the auxiliary and by the society during this meeting. (4) Educational Work. Our program during the year has been even more extensive than usual. The field secretary will report personally upon that part of the program entrusted to her. We would only say here that she has, with the as- sistance of the State Department of Education, reached a very large number of desirable audiences and that she has accomplished the fulfillment of a huge program. That her work has been of su- perior character is evidenced by the number of commendatory letters received from each of the counties visited by her, and by the almost uni- versal request that she return again next year. Our radio program has been carried this year mainly by the county societies, and in our com- plete report to the society in June we will furnish a statement of the broadcastings from Atlantic Bergen and Monmouth county societies. (5) Public Relations. Among the larger move- ments participated in this year were the Hoover Child Welfare Conference in Washington and the similar state conference called by Governor Lar- son. We were invited to speak at the last men- tioned gathering on the subject of cooperation, and we endeavored to make clear to lay organiza- tions the relationship of the medical profession to such movements and the conditions upon which we must insist if there is to be effective coopera- tion in public health work. Through an editorial in the February Journal we took exception to some of the advertising re- cently put out in printed form and by radio, which in our opinion was insulting to the medical pro- fession. The instance cited was not the only one that might have been used. The radio threatens to become more of a nuisance than a blessing un- less a curb can be put on objectionable forms of advertising. Wre feel that the profession should object to, and should actively oppose, a number of things now being done under the cloak of radio entertainment. For instance, Amos and Andy are being employed to veil an advertisement that has passed from endorsement of a tooth paste into actual prescribing of an alleged powerful anti- septic for sore throat and colds in the head. We suggest that the society give thought to this mat- ter and consider what action may or should be taken. (6) Tristate Conference. The proceedings of each successive conference have been published in full in our Journal and we recommend continued support of this project. (7) Legislations State and national legislation has occupied much of our time during tfie past May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 441 winter and spring but we are happy to report that nothing detrimental to public health got past us. More details will be supplied in our complete re- port in June. Respectfully submitted, Henry O. Reik, M.D., Editor and Executive Secretary. Lighthouse Observations HEAD INJURIES OF MODERATE DEGREE In a general review of 100 cases, including 50 In which ventricular studies were made, George W. Swift (Northwest Med., 30:16, January 1931) aays : “One-third of all head injury cases seen in in- dustrial surgery fall into a group of minor in- juries. Perhaps there is some temporary loss of consciousness, but the patients are strong indi- viduals and to them it is more or less trivial. As soon as the lacerations, if any, are healed, they are ready to resume their work. With these we have no further interest except to call attention to the fact that a strong, robust individual who receives a minor injury to his head, with no ac- tual injury to the brain tissue, almost universally returns to work at the earliest possible moment. On another side we have that group of patients who constitute perhaps another third of the sum total, who receive a perfectly obvious total per- manent disability, which is so recognized by the attending physician and the Department of Labor and Industries. This group of cases does not in- terest us in the present discussion. The remaining third is that group of patients who, after a period of time, do not adjust them- selves to their present condition. The factors in- volved in thisi failure of readjustment are, of course, first of all the injury itself. The more severe the injury without total disability, the more easy it is to observe physical findings which will correspond to the subjective symptoms. This, one might say, would constitute the upper margin of disability in this particular group, while the true malingerer, the man who feels that the state owes him a living and uses a head injury merely as a subterfuge, would be found at the other end of the list. A great many patients are found be- tween these 2 extremes and the factors which might be noted as contributing somewhat to their inability of readjustment are: Suggestion on the part of the doctor, the relatives or other patients, particularly those suffering from a similar injury, perhaps of a more severe degree. An unstable or nervous temperament almost universally leads to failure of readjustment, even though the injury may be very slight. Lastly, repeated injuries of the same character to the same individual, each causing a more lasting impression upon his men- tal processes. It is this group of cases which causes the great- est difficulty both to the State Department of Labor and Industries in arriving at a just com- pensation or to insurance companies in estimating the amount of compensable disability, and to the physicians who are called upon to make these esti- mations and evaluations. With these facts in mind, a study has been made of 100 cases falling in this last group, that is, those who have suffered injuries to the head and have not been able to readjust themselves to the conditions found following the injuries. In this are included 50 ventricular studies, used as a check on the general physical examination. These examinations were all made at the request of the Department of Labor and Industries (Washing- ton State) and wherever there was a reasonable doubt that there was actually a physical lesion which could be the cause of the failure of read- justment, a ventricular study was done. The average age of the patients was 42 and the average time between the injury and our ex- amination was 8 months. Only 12 of the 100 pa- tients showed positive fractures in the roentgeno- grams which were taken. We have, then, a com- posite picture of a man approximately 42 years of age, who 8 months prior to our examination had suffered an injury to the head which had caused subjective symptoms, such as severe headache, dizziness, general weakness, disturbances in hear- ing and vision, loss of memory and localized pain, who presented practically no neurologic findings except increased reflexes and passive congestion of the vessels of the retina. In only 12% of cases did roentgenograms show fracture of the skull, yet this average individual has been unable to ad- just himself to his surroundings. In tabulation of the roentgenograms, showing displacement of the ventricles, we find bilateral displacement in 2 cases, dilatation of the ventricles in 4 and compression of the ventricles in 4. In 13 cases, or 26%, air showed over the cortex. In glancing at the subjective symptoms, we find disturbance of hearing, disturbance of vision, localized pain and general weakness in about the same percentage of cases as we find distribution of air over the cortex. Practically all patients showing air over the cortex complained of these symptoms. There does not seem to be any rela- tion between the degree of headache and dizziness and the ventricular findings of air over the cor- tex or disturbance in the ventricular system. As practically all of the patients on whom a ventricu- lar study was made complained of both headache and dizziness and only 25% showed cortical air, it is fair to assume that only 1 in 4 actually were suffering from severe headache and dizziness. This brings us, then, to discussion of the rela- tive value of the history, physical examination and ventricular study in these cases. Obviously, the history, while important, if combined with the pa- tient’s statement as to symptoms, is of value in only 25% of the cases. Nor does the physical examination yield much more information. The ventricular study is more accurate and gives posi- tive tradings. Particularly is this true in the case of a general edema and it also suggests the treat- ment which is of greatest benefit to these patients, namely, dehydration followed by limitation of fluid intake. It is not going to be possible to secure ventric- ular studies on all questionable cases, nor will it be possible to estimate exactly the degree of com- pensable injury, but it will be possible for the medical profession to give better treatment at the very beginning of the injury. This, no doubt, will do away with many actual disabilities. It will not help in those cases in which there is a tear of the arachnoid with accumulation of cerebrospinal fluid about the cortex, as first noted by Naffziger. Secondly, we must look forward to the time when all those engaged in active industry shall have to submit to a physical examination and have noted the actual condition present at the time of securing the position. An injury subsequent to this examination can be checked by the previous physical condition of the patient. Lastly, there must be in industry, just as there is in our colleges today and in the business world, a reclassification 442 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 from the standpoint of temperament and adapta- bility. Men who are constitutionally psychopathic to begin with cannot be permitted to enter hazard- ous occupations, where the slightest injury will bring about claims for complete and total disa- bility. Public Relations GOVERNOR LOOKS AT CHIROPRACTIC (From Jour. A. M. A., 96:1148, April 4, 1931.) Governor Buck, of Delaware, has returned to the legislature, without his approval, a bill to create a board of chiropractic examiners and to regulate the practice of chiropractic. His summarization of the reasons for his veto is so clear and terse that it should be read by the legislators and governors of every state that is threatened or already afflicted with this cult. His statement follows: The purpose of the act, as I understand it, is to legalize the practice of chiropractic in this state. Practitioners of this cult are not recognized now. Do they profess to be doctors in the same sense of the term as is commonly understood to apply to men and women of the medical profession? In- sofar as I am able to determine, there is not a recognized medical school in the country that in- cludes in its curriculum a course in chiropractic. This fact in itself seems singularly significant. Even to the lay mind the idea that all disease of whatever character is due to spinal displacements of a mild sort, and that cures of such ailments as tuberculosis, small-pox, diphtheria, scarlet fever and others can be effected by manipulation and fingering of the spine is preposterous. Before returning this bill to you I have satisfied myself that the training and education a chiro- practor, or a drugless healer, needs to practice his art does not fit him properly to advisedly treat the sick, inasmuch as he is not qualified to diagnose ailment nor recognize communicable diseases and to take measures to control them. He is there- fore an opponent to the department of health. Wherefore, it seems to me it would be incon- sistent for the legislature to appropriate, as it will do, money for the state board of health, which board is trying to eradicate communicable diseases, and at the same time legalize the practice of a cult which does not believe in the germ theory of disease but does teach and believe that such dis- eases as scarlet fever, etc., are due to a distracted vertebra and the method to prevent and cure such disease is to see that everybody has a normal spine. (Italics supplied by Editor.) NEWARK TOPS CLASS IN HEALTH RATING V. S. Chamber Also Cites Three of Oranges For Conservation Work (Washington Bureau. Newark News) Newark last year was the leading city of its class in health conservation in the United States. The city received first rating today for cities between 250,000 and 500,000 population in the na- tional health conservation contest conducted by the Chamber of Commerce of the United States with cooperation of the American Public Health Association. East Orange, West Orange and South Orange were among 30 “honor” cities named by the judges in addition to 6 class winners. In last year’s con- test, East Orange won first place among cities of 50,000 to 100,000 population. The 5 winners, in addition to Newark, among 149 entrants were: Above 500,000, Detroit; 100,000 to 250,000, New Haven; 50,000 to 100,000, Racine, Wis.; 20,000 to 50,000, Alhambra, Cal., and less than 20,000, Chestertown, Md. Reports from entrants were submitted several months ago and analyzed by a grading committee. Personal inspection by the committee was made of winning cities before awards were announced. Contest points included water supply, sewage disposal, protection of milk supply, preventive measures, medical conferences and clinics, pro- grams for prevention and early care, life loss sta- tistics for preventable diseases and support for local health work by official and unofficial agencies. Awards will be presented April 28 to May 1 at the annual meeting of the national chamber in Atlantic City. REPORT TO THE COMMISSIONER OF LABOR BY THE WORKMEN’S COMPENSATION ADVISORY COMMISSION Newark, N. J., March 11, 1931. Honorable Charles R. Blunt, Commissioner of Labor, Trenton, N. J. Dear Sir : The undersigned, constituting an Advisory Com- mittee appointed by you to examine into the op- eration of the Workmen’s Compensation Bureau of the Department of Labor and the administration of the laws relating to the same, beg to report as follows: The Workmen’s Compensation Act, which was originally enacted in 1911, was designed to secure to injured workmen or their dependents, definite amounts of compensation for injuries suffered and pecuniary loss sustained, irrespective of the ques- tion of fault and negligence on either part of the employee or employer, and it was intended that the statute should be liberally construed in order that the economic loss resulting from injury to the employee should be reduced as much as possible. Amendments to the law have been made from time to time, increasing the amount of compensa- tion awarded for the term for which the stated compensation should apply, and in other respects as experience demonstrated defects and weak- nesses in the original Act. In order to obtain as wide and as thorough in- vestigation as possible you have appointed as members of the Advisory Commission representa- tives of labor, industry, law, medicine and insur- ance, and in the conduct of our investigation we have extended invitations to various groups repre- senting these various interests, and have been favored with their views on a number of questions relating to the Act itself, and to the operation of the Bureau. We find at the outset that, while the cases re- ported to the Bureau during the first full year of its operation numbered 11,922, during the year 1930 the total number of cases had increased to 28,269. These figures would seemingly indicate the neces- sity for enlarging the administrative staff, as well as the equipment and facilities necessary to proper administration of the law, but we find that there has been no increase in personnel, equipment or May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 443 other facilities proportionate to the increase of the business of the bureau, and this fact has been the cause of a number of criticisms which have been addressed to us. The old headquarters of the Bureau at No. 9 Franklin Street, in the City of Newark, were notoriously inadequate and removal of the department to the new headquarters in the Industrial Building- has eliminated one of the chief causes of complaint to which our attention has been called. A majority of the various interests that have given us their views with reference to the opera- tion of the Bureau, are of the opinion that the Bureau has not a sufficient personnel in the way of referees and examining physicians, in order to examine and pass upon cases in full fairness to the injured employee, the employer, or the insur- ance carrier. The evidence before us indicates that in some cases, owing to the pressure of busi- ness or the limited time available for the work of the State Physicians, the physical examina- tions are not as thorough as they should be. A criticism has also been made of the practice of notifying claimants, employers, insurance carriers and other interests in a large number of cases to appear at the Bureau at a stated hour in the morning, and that by reason of the large num- ber of cases set down for a particular tim,e, and the length of time necessary to get through the list, the time of the interested parties is largely wasted in waiting to be heard. This seems to us to result partly from the lack of sufficient per- sonnel, as above indicated, as well as from the practice of assigning more (too many) cases for hearing at a stated hour in the morning instead of being scheduled for different hours during the day. It seems to be the consensus of opinion, and we so find and report, that at least 2 additional referees should be appointed and that the medical staff should be enlarged correspondingly. As to the medical staff, we have had additional criticisms to the effect that certain physicians em- ployed by the Rehabilitation Clinic, have also at various times become interested in compensation cases either on behalf of an injured workman or in behalf of an employer or insurance carrier. It is our belief that the physicians employed by the state should be prohibited from engaging in such practice. It has been suggested that the work •of the Bureau would be expedited and rendered more effective by the employment of a physician or physicians on a full-time basis, at an adequate salary, and we have been advised that a com- petent physician can be obtained, whose full time could be given to the examination of cases coming before the Bureau, at an adequate salary. We do not doubt that if such a physician were employed and would attend at the Bureau every weekday for the purpose of making examinations, and that such physician be precluded from engaging in practice on behalf of any injured workman, em- ployer or insurance company, that the work of the Bureau and its results would be materially enhanced. The Commissioner of Labor should also be authorized to engage as many as 3 inde- pendent physicians to make examinations and ad- vise the Deputy Commissioners of any important case where it appears to the Deputy Commission- ers that the testimony of the physicians obtained by the parties is in irreconcilable conflict. There seems to be also a very strong sentiment among the majority having contact with the Workmen’s Compensation Bureau, that in no case should a case be set down for a formal hearing “until the matter has been examined into at an in- Tormal hearing, and a recommendation made there- in by the Referee or Deputy Commissioner, so that the parties involved may have the opportunity of speedily settling or adjusting these cases if they so desire. It has been urged upon our attention that there have been many cases which could be informally adjusted by a Referee without delay and to the entire satisfacion of all parties con- cerned, but that owing to the intervention of cer- tain lawyers and doctors whose chief interests seem to be in obtaining the allowance of fees, these cases are not permitted to be informally ad- judicated by a referee but are set down for a formal trial. This practice necessarily suspends and delays the payment of compensation when it is most needed, and in the long run seems to work more to the benefit of the doctors and lawyers who become interested in cases rather than to the claimants themselves. We, therefore, believe it would be in public in- terest that in these cases the claimant should at the earliest possible date report to the Bureau for a physical examination, and that at such time claimant should be examined by a Referee as to the time and place and circumstances of the acci- dent and extent of the injury, and the present condition of the claimant stated, and duly record- ed with the recommendations of the Referee, and a docket, file or other record kept for that pur- pose. It has also been suggested and we recommend that, if at places like Newark, Jersey City, Pater- son, Camden or wherever a large amount of work falls on the attending referee or examining doc- tor, he be provided with a stenographer to make a record of the facts elicited instead of the long- hand method now in use, and that such record be made a permanent file, and that such file should in all cases be made part of the cases to be submitted to the Deputy Commissioner on final hearing. The procedure in practice in Jersey City appeals to us as that which should be adopted generally. We have had considerable evidence indicating that the practice before the Bureau on the part of certain attorneys and physicians is becoming commercialized; that there is a certain amount of “ambulance chasing” on the part of the doc- tors, lawyers and runners, and that this practice is carried on in the quarters of the Department of Labor, and this charge has been made with re- spect to cases which, although being satisfactorily handled by the referees, might be made the oc- casion of obtaining professional fees by throwing the matter into a formal hearing. Another matter with reference to which we have had considerable criticism, is- the practice of State physicians recommending to the Referee and Deputy Commissioner the allowance of some ar- bitrary percentage for assumed permanent dis- ability, in cases where there has been or is indi- cated a complete recovery from a temporary dis- ability. Doubtless there are cases of fracture fol- lowed by a complete union which may cause fu- ture recurring pain or disability, but we do not believe that the letter or spirit of the Workmen’s Compensation Act justifies general allowance of permanent disability percentage where the injury is of a temporary nature. Much criticism has also been expressed before us in the matter of making allowances for at- torneys fees and medical fees. The statute au- thorizes in contested cases the allowance of at- torney fees not exceeding 20% of the amount of the judgment except in cases where compensation has already been paid, in which event the at- torney’s fee is based upon the excess compensation 444 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 awarded on the final hearing. The criticism in this connection is that some of the deputy com- missioners have in the past frequently awarded the full 20% of the judgment or of the excess, as the case may be, without recognizing that the amount suggested by the statute is a maximum amount and not an arbitrary percentage to be ap- plied in all cases. The same criticism is directed to the allowance for medical fees. The statute directs an allowance of a maximum of $50 to any one physician, not exceeding $150 in any one case, and it has been stated that, as to these allowances also, the practice of the deputy commissioners is to allow $50 to each physician, notwithstanding that the same physician may appear in 3 or 4 cases before the same deputy commissioner on the same day. We believe that if the design and purpose of the law were kept in mind by the deputy commissioners, and the legal and medical fees based on the actual work done, it would dis- courage to a great extent the apparently growing practice of commercializing compensation cases by doctors and lawyers. Requests have been made, in which we concur, that the rules of the Bureau be amended to provide for 5 days’ notice to both parties of the dates of informal hearings, and that the time for filing an answer to a formal petition be extended to 20 days instead of 10 days after service of the pe- tition or bill of particulars. It has been called to otir attention that fre- quently a case is repeatedly set down for hearing, and the petitioner does not appear or notify the Bureau in advance of the fact that he will not appear. This may be due partly to the fact that the petitioner’s address does not properly appear in the records or that the petitioner may have moved from the the address given at the time of the injury, and it is suggested, and we concur in the recommendation, that where a case has been set down for hearing, and ample notice is given to the petitioner, and the petitioner does not ap- pear, such case should not be again assigned for hearing except on the request of the petitioner. We also concur in the suggestion that in every case either the employer or insurance carrier be authorized to accept and endorse acknowledgment of service of petitions, as this is a common method used in civil suits of law. We have given consideration to numerous sug- gested amendments to the Act, many of which seem to be desirable, particularly the following: Repeal the provision relating to penalty for failure to file accident reports, and extend the period of limitation in which petitions may be filed to 2 years. AJso to extend the time for filing a petition by a widow or other dependents until 1 year after the date of death of the in- jured. That all nonresident employers engaged in work and hiring labor within the state of New Jersey should be required to provide security for any liability they may incur in New Jersey under our Workmen’s Compensation Act, or, that the ser- vice of process upon the Secretary of State be made a valid method of service in all cases where nonresident employers cannot otherwise be served. To abolish the appeal to the Common Pleas Court and provide for review by writ of certiorari in the Supreme Court. Amend the hernia section of the Act so as to provide for a 48 hour notice whenever an accident occurs on a day preceding a Sunday or legal holi- day. Substitute for Section 23F a new Act providing that the employer or insurance carrier may in- stitute an action against third persons in the event that the injured employee refuses or neglects to institute such action within a limited time. While it might be desirable to make a number of other changes in the laws, we do not believe that further amendments of the statutes should be attempted. We urgently recommend, however, that the entire body of the Workmen’s Compen- sation Laws should be entirely revised. The act of 1911 has been amended 15 times, and the sup- plement of 1918 has been amended 7 times, and other supplementary acts have been passed, so that the law as a whole is now in a state of corn- fusion, and in many instances of inconsistency. In our judgment, it is impossible to adequately amend the law so as to provide an harmonious, understandable and workable code covering the matter of workmen’s compensation. The whole matter should be revised, modified and clarified to afford a better understanding and proper ad- ministration of the law. In conclusion, we would like to take the oppor- tunity to express our commendation to the Com- missioner of Labor, as well as to the personnel of the Bureau, for the satisfactory manner in which most of its affairs are being conducted. Notwith- standing the criticisms offered in the foregoing pages, we find that everyone in the Bureau is making a conscientious and determined effort to better the general efficiency. As a matter of fact, noticeable improvement has been made, in our opinion, during the past 8 months while the Com- mission was functioning. We wish to express our thanks officially, also, for the cooperation of the Deputy Commissioners and Referees, whose com- ments and explanations have been very helpful. Respectfully submitted, Thomas B. Eames Maximilian M. Stallman W. S. Landes J. B. Morrison, M.D. A. Duncan Reid. School Health Department . NOTES FROM LOS ANGELES Allen G. Ireland, M.D., Director of Physical and Health Education, State Department of Public Instruction, Trenton. The Los Angeles school system has won deserved fame for its health and physical education pro- gram. From its last annual report the following excerpts have been taken. Importance of exclusion. “It has been discovered by experience that it is much better to exclude a number of pupils for 1 day or 2 with minor ail- ments, than to allow 1 child with suspicious symp- toms to attend school until a positive diagnosis of communicable disease can be made. This is es- pecially important in view of the fact that measles and scarlet fever, for instance, are more con- tagious for several days before the diagnosis is usually made. The exclusion of every child from school who suffers from an acute cold has re- duced the number of cases of influenza, pneumonia, measles, whooping-cough, mumps, meningitis, diphtheria, scarlet fever, septic sore throat, and bronchitis. Most of our communicable diseases be- gin with symptoms simulating the common cold. By control of acute colds among school children, we have gone a long way toward aborting most of our epidemics. These symptoms are very easily May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 445 detected by the teachers, and they have been in- structed to exclude all such children.” Keeping schools open. ‘‘It has been agreed among health officers that a properly inspected school room is the safest place for a child during the outbreak of an epidemic. By school inspection, the children acutely infected are excluded and thus separated from the other children, at the same time reducing the number of contacts.” The School Physician The following is an excerpt from an article by Dr. John L. Goflin in the March, 1930, issue of School Life. Dr. Goflin is Assistant Health Super- visor of the Los Angeles Schools. “This situation points unmistakably to the ne- cessity of special training for school physicians, both medically and educationally. Authorities in school health work are now pretty generally agreed that the prospective school physician needs special instruction in pediatrics, orthopedics, sani- tation, contagious-disease control, and in the prin- ciples of health education and the organization and administration of health education. There is also a growing feeling that the school physician should be a full-time worker, who enters school health work as a specialty with the idea of ad- vancing himself steadily and making it his life work. If we are to make school health work a dignified and useful profession, we must provide professional and economic incentives. Profession- ally, the school physician must be assured a steady and progressive growth; economically, he must be rewarded commensurately with his knowledge and skill. I can see no valid reason why the specialty of school health can not be made as attractive professionally as any other specialty in medicine. As at present organized, a very large amount of routine work is required and too little time is allowed for research. There is very little opportunity for keeping children under close ob- servation for long periods. There is practically no opportuntiy for treatment in the medical sense.” Minimum Standard This resolution was adopted by the American Public Health Association and the American As- sociation of School Physicians. Whereas school physicians as a class have not heretofore been adequately prepared for the work which our complex educational systems now de- mand, and Whereas school physicians have not heretofore been paid a salary sufficient to justify this ad- ditional training, and enable them to devote their full time and best efforts to this work, and Whereas it has become necessary to take definite steps to improve this situation, therefore, be it Resolved, That the American Public Health As- sociation and the American Association of School Physicians, in convention assembled, do recom- mend consideration of, and action upon, by the various states, the following minimum require- ments for new school physician applicants: (1) Graduation from an acceptable medical school, 1 year of acceptable internship, and a license to practice medicine in the state. (2) Six semester hours of graduate training in medical subjects relating to school health work. (3) Six semester hours in a school of education of work embodying the principles of health edu- cation, and the organization and administration of same. (4) This 12 hours of graduate work must be completed within 3 years after certification by the State Board of Education. And that they further recommend: (1) The establishment of a salary rating equiva- lent to that now granted the high school principals in their respective localities. (2) That this salary be subject to automatic in- crease according to length of service. (3) And that it be subject, also, to an increase commensurate with educational merit and pro- gressive professional development. Communications ONE REASON WHY PATENT MEDICINE VENDORS THRIVE (Parody upon a Hospital Staff Meeting, sub- mitted by one of cur members who vouches for the truth of the essentials and declares this ac- tually happened in one of New Jersey’s large cities.) A type-written card came to Dr. Deutsch’s office: Consultation — meeting at the General Hospital on Tuesday, February 17, at 9 p. m. Subject: Obscure conditions of the liver. These consultation-meetings were held once a month in accordance with the regulations of the College of Surgeons. Primarily, they were held to discuss cases treated in the hospital in which a fatal ending had not been averted. But even the doctors do not like to hear of death more than they have to — so, in our hospital the Committee on Program was obliging and tried to offer something of interest to nearly everybody. The evening of the seventeenth of February was given over by the chairman to a doctor who pre- sented 4 patients, all males, whom he, to the best of his ability, had cared for until such time as surgical intervention seemed the only way out. In his zeal to make the evening attractive he had asked all 4 men whose cases were to be discussed to be present at 9 o'clock to show that they were very much alive. The doctor exhibiting these patients was of the antediluvian type; he still sported the mustache and goatee so popular a quarter of a century ago, and it was only recently that he had changed from an open-air horse-drawn vehicle to a closed automobile — a Ford. He still prescribed Lloyd’s Specifics, Echinacea, and other - remedies of which he did not know the composition; but he could tell stories entertainingly, and all grandmothers liked him because he never “queered” them in their use of poultices or home-remedies. He had easy-going manners and a laugh resem- bling the exuberance of a goat. He was a strictly medical man, not a surgeon. Dr. Pushemover, whom he had asked to operate on his patients, was also present. Dr. Goatee opened the meeting: “Gentlemen, we have here present with us 4 patients who have been operated on in this hospital. The first, Mr. Hiram Bunk, was here — let me see — was it in 1928 — that’s right?” “Yes”, said Mr. Bunk, “I was operated on June 21, 1928.” “And are you entirely well”, asked the doctor. “I was never better in my life”, answered Mr. Bunk. “Gentlemen”, spoke the goateed doctor, “to-night Mr. Bunk is celebrating the twenty-fifth annivers- ary of his wedding to one wife and I think, on a 446 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 day like this, we ought to excuse him.” Exit Mr. Bunk. The second victim of surgery was then present- ed. He, too, stated that he was well — and so did the third and fourth patients. They were excused and allowed to depart. Now came the interesting part of the evening — discussion of the state of the livers of these pa- tients who had really never been made acquainted with what ailed them. Dr. Goatee read all the data from the charts — it took him a long time to search through the records to find what he wanted but at last, with infinite patience, he was able to tell the audience what, in his opinion, each patient was not suffering from. One of the men, Mr. Liverwell, had been sick quite some time with fever and jaundice; there was no end to the fever and nothwithstanding the quinin and the Lloyd’s Specific’s given to him, the man did not improve. Dr. Goatee decided to call a consultant. This eminent doctor, living in New York City, would condescend to come to our town for $500. That was too much. Another consultant telephoned to say he would come out for $100. His fee was agreed to. After examination, this New York specialist said: “Do you know what you have there? An abscess of the liver. Yrou’ll have to take him to the operating room.” “If the man is willing, will you operate on him?” asked Dr. Goatee. “Certainly”, replied the consultant, “but that will be $150 extra.” The man was willing. The consultant opened the abdomen, saw nothing abnormal with the liver, and proceeded to pierce that organ with long needles in direction perpendicular, oblique and tranverse, but no pus was found. The operator finally gave it up as a bad job and closed the ab- domen. The patient’s temperature after operation remained the same as before — around 101° in the morning and 103° in the afternoon — but after some 4 weeks or more the temperature dropped to nor- mal and gradually the man got well. Mr. Bunk’s case excited the most interest. After nearly a year’s ailment, with lack of appetite and a slight pain over the liver region, he developed a fever which arose sometimes to 104°. Dr. Goatee, who saw that the man was jaundiced, thought that he was possibly suffering from gall-stones, and with this idea in mind he called in Dr. Pushem- over who agreed with him and suggested an op- eration. At operation the gall-bladder was opened but no stones were found. The liver was enlarged about 2 finger-breadths; there was no tumor, but some peculiar spots, white, and of the size of a pin-head, were present on the liver’s surface. Dr. Pushemover, who was a protege of the Hos- pital’s Board of Governors, perhaps wasn’t quite as experienced in dealing with livers as he should have been. He had never seen a liver with spots like those of his patient. He therefore called them cancer — which was a risky thing to do because time would ultimately prove him right or wrong. Anyway, it was then declared to be cancer and the patient was sewed up and put back to bed. The fever continued as before but, strange to say, Mr. Bunk recovered in about 8 weeks notwith- standing the operation. His disease condition had been called cancer, and the family had been told. A drowning man catches at straws, and this pa- tient, made aware of his condition, wrote to Mus- catine, Iowa, for information regarding a certain Cancer Specialist. The most interesting part of the meeting was now to begin. Dr. Goatee had presented his cases — all 4 patients had come to operation but the op- erations had not cured them — all 4 had continued to have high temperatures for weeks until at last nature, or their own resistance powers, had put them back on their feet. The Chairman of the meeting announced that the report was open for discussion. A surgeon of the staff asked whether a piece of liver tissue had been removed for examination, from the man who was supposed to have had can- cer. “No”, answered Dr. Pushemover. “Why, then, was the condition diagnosed as can- cer?”— asked the Staff Surgeon. “We supposed that those white spots on the sur- face of the liver were metastases from cancer in some other parts, but evidently we were wrong.” Another doctor spoke up and said that he could not understand how a diagnosis of cancer could have been made if the temperature curve had been taken into consideration — he had never seen a cancer of the liver exhibit that particular curve, which looked more like a septic temperature record than anything else. Another man arose and said: “I am very glad that this case of supposed cancer has come up for discussion. I have often wondered if this man Bunk, whom everybody in this town seems to know, really had a tumor or a cancer at the time of his operation. The facts of the case have now come to light. Whenever I see a case of cancer, in my practice, someone invariably mentions Hiram Bunk who, as the whole town is told, ‘has been cured of cancer by taking patent medicine after the doctors who had operated on him, had given him up to die’. I am, and always have been, thoroughly disgusted when hearing the praises of this patent medicine, knowing well enough that no such medicine has ever yet cured real cancer. I listen to the talk of superstitious gullible people, but it is a conundrum to me how a certain doctor on the staff of this hospital, and who is also a member of the American Medical Association, can be so naive as to advocate use of that patent-medicine because it is said to have cured Mr. Bunk. What is more, there is also a nurse in this hospital who recommends this medi- cine to all victims within her reach. And now, I will read to you, from the Cancer Specific booklet, Mr. Bunk’s testimonal. ‘To whom it may concern: I was operated upon on June 21, 1928, for a gall-bladder condition but the surgeon found an advanced cancer of the liver. After the shock of the operation had passed, I started to take your Cancer Specific and have continued it right along. I now feel better than I have for years. All signs and symptoms of the condition seem to have passed away. Hardly a week goes by but what I have 2 or 3 inquiries about your medicine and I heartily recommend it to all. Y'ours very truly, Hiram Bunk.’ ” Dr. Pushemover made himself as small as pos- sible. He -was evidently embarrassed. Bunk’s can- cer medicine sold like hot cakes in the town, because of the living testimonial walking the streets “after 2 able doctors had condemned him to die of cancer”. Another man got up and said: “Not only does a doctor recommend this medicine but we have in our midst a minister of the gospel who thinks he is very close to our heavenly father — and he, too,. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 447 ‘knows that Bunk has been cured by the Cancer Specific’ and he tells all the members of his con- gregation that it is foolish to call in a doctor in any case of cancer.” On motion, the meeting was adjourned and the refreshments brought in. The refreshments consisted of coffee, diminutive sandwiches and heavy slices of ice-cream with cream-puffs, lady-fingers and chocolate-coated sweet things. “How can you sleep?” asked the President of the Staff of Dr. Deutsch, “after a cup of strong coffee?” “I am a Dutchman”, said Dr. Deutsch, “I am a drinker, but not an eater — for instance, I don’t eat ice-cream — I don’t touch those dou-dahs in which you are so interested, but I like my cup of coffee.” FIRST COUNCILOR DISTRICT MEETING (A letter from Dr. S. Rubinow, of Newark, of- fering suggestions of value to committees arrang- ing for meetings at which economic problems are to be discussed.) To the Editor: The February meeting of the Essex County Medical Society, a joint meeting with 4 other county societies, was devoted to medical economics. It was, we believe, arranged at the suggestion of the Conference of County Secretaries, which rightfully considers this topic at the present time of the utmost importance to the profession. Nearly every leading man in state and national medical organizations is aware of the grave problems facing the profession and is deploring the indifference of its members to these problems. The object of these meetings is to overcome this indifference, to arouse the pro- fession’s interest and to create a unanimous, strong, medical opinion and a definite attitude to- ward the issues involved. From this point of view one is compelled to say frankly that the above mentioned meeting did not fully accomplish its purpose. To begin with, the meeting was not sufficiently advertised to as- sure a large attendance. The presence of a num- ber of members from the other counties some- what saved the situation but even so the attend- ance was poor. The addresses were excellent, though somewhat too long, too academic. What is to be regretted most, is the fact that the mem- bers at large were not at all encouraged and hardly given an opportunity to participate in the discussion, very likely on account of the late hour. A few officers of the state and county societies were called upon for discussion, but one is of the opinion that these members have other oppor- tunities for expressing their views. The writer of these lines believes that such a meeting, if its importance is sincerely felt, should have been conducted in 2 sessions, 1 de- voted exclusively to discussion. The meeting was held on Dincoln Day and an afternoon and even- ing session could have been arranged with a dinner between. The meeting could have been adver- tised more efficiently by announcements at all preceding medical meetings, by placing reminders on the boards of all the hospitals; by postal cards on the day of meeting, and so forth. These remarks are written with no intent of fault finding, and solely with the desire to be helpful to other county societies, which may contemplate similar meetings. ACTIVE IMMUNIZATION AGAINST ME A SDKS (Letter from Dr. Felix Baum, of Newark) The article of Dr. Piller in the April number of this Journal reminds me of an experiment in my own family which might be of practical interest. In April 1918, my second son developed measles at the age of 3 years. In order to protect my older son, 6 years old, who had just entered school, I vaccinated him on the inner surface of the right fore-arm in the usual way, making a few scratches superficially and rubbing in a drop of nasal secre- tion from the nostrils of the sick child. Vaccination of the healthy boy took place at the bedside of the patient during the stage of eruption. I watched the fore-arm of the older boy, who attended school and slept in the same room with his brother. A few days after the vaccination I noticed a slight redness and a soft movable mass, not larger than a cherry, just under the skin of the fore-arm, which disappeared after about 5 days. There was no fever nor pain. The boy continued at school without showing any signs of measles. During the epidemic in the same month the entire class of which my boy was a member developed measles but he stayed well and remains immunized until today, though he is 19 years old and has been exposed to measles repeatedly. How long the immunity will last I do not know. In looking over the literature, I find that numerous attempts have been made to immunize children actively against measles. Herrman (Arch. Pediat., 39:607) took the nasal mucous discharge of pa- tients before appearance of the eruption, mixed it with saline solution, centrifuged the mixture, added tricresol as a preservative, and applied a few drops to the nasal mucous membrane of 4 to 5 months’ old infants to be immunized. It seems to me more logical to use the skin, the organ of protection, as the site of inoculation. Moreover, direct vaccination with the virus, unchanged by chemical or mechanical means, seems preferable because we know that the virus is very sensitive and can be transmitted only by direct contact. I admit that 1 case does not prove anything, but it indicates that an artificial, localized skin infection with measles probably is harmless and deserves further study in a large number of cases. ERRORS IN “OFFICIAL LIST” (Letter from Dr. J. B. Morrison, Secretary of the Medical Society of New Jersey.) Hofer, C. J. M., of Metuchen, is alive and in good standing. The deceased physician, Dr. Clarence A. Hofer, was also a resident of Me- tuchen, hence the mistake. Through a printer’s error, an asterisk was placed before the name of Dr. Francis E. Proc- tor, of Trenton. Dr. Frank C. Johnson, of New Brunswick, wishes to have reference made to the fact that he has an office in New Brunswick and also one in Elizabeth. 448 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 Woman’s Auxiliary WOMEN AT THE A. M. A. PHILADELPHIA JUNE 8-12, MEETING (Submitted by Mrs. Walter Jackson Freeman) The Woman’s Auxiliary to the American Medical Association has been placed in charge of all en- tertainment of women visitors, and began its lab- ors on June 27, 1930, by engaging the whole Roof Garden of the Bellevue- Stratford Hotel for the period of the Convention. All women’s activities will center in this hotel — -registration, meetings, luncheons and supper dance, and all excursions will start from the Broad Street entrance. Invita- tions and tickets must all be procured in the Roof Garden in advance, as nothing but programs will be obtainable elsewhere. Members of the A. M. A. are invited to join all excursions, and should register for them in advance. Rooms for State Headquarters have also been reserved in the hotel, and sponsors will be appointed to look after all women registered from their own states. The list of sponsors will be printed in the program. The Chairman of the Women’s Hotel Committee is Mrs. Frederick S. Baldi, 2117 Porter Street, Phila- delphia, who will be glad to make any desired reservations. The Convention will open with a subscription buffet luncheon in honor of all National Auxiliary Presidents from Mrs. Red to Mrs. McGlothlan, immediately followed by 3 “round tables” of 35 minutes each, with 10 minutes intermissions, each under expert leadership. The subjects will be: (1) Programs for County Auxiliary Meetings. (2) Technic and Value of a Committee on Pub- lic Relations. (3) History and Archives. These informal gatherings will be a sort of pre- liminary canter, designed to bring together those interested in special phases of auxiliary work and give them opportunity to discuss the subject thoroughly during the following days. The Na- tional Board Dinner and Pre-Convention Meeting are scheduled for Monday evening. A new and, we hope, helpful feature will be a Question and Suggestion Box to which we beg all with good ideas to contribute. This seems the most practical way of finding out what our mem- bers want continued, what discarded, and what plans are indicated for the future. The regular business session will be held on Tuesday and Wednesday mornings. National chairmen will be allowed 10 minutes for their re- ports, State Presidents 3 minutes. Reports to be printed may be as long as desired (within reason), but let no one reporting on the floor imagine these limits an idle jest. Nor will the hours an- nounced on the program be found to mean “about”. Have your watches cleaned and regulated, and practice your wrist drill before leaving home. You will need it. Thursday morning, too, will be a busy one, the post-convention Board meeting, a special meeting for State and County Treasurers desiring further elucidation fo the treasurer’s receipt blanks, and at 10.30 an informal round table presided over by the new president: the subject, “What Have I Gotten Out of the Convention?” At this meeting Mrs. McGlothlan will announce her comJmittee chairmen and outline her plans for the coming year, and the subjects in the Question Box will be discussed, a sort of stock taking, closing the year’s business and opening the new books. Philadelphia, as an historic and culture center. is the key-note of the entertainment planned for our guests. Except Monday, all afternoon and evenings will be devoted to pleasure, and a variety of excursions is offered to suit all tastes, all physi- ques, and all weathers. They include bus trips to Valley Forge and to Longwood, the beautiful es- state of Mr. and Mrs. Pierre S. du Pont; a boat trip on the Delaware, and visits to the Fairmount and Rodin Museums and to the Historical Society of Pennsylvania. The Museum authorities are de- lighted to provide decent service for those desirous of more than a passing glance at their treasures, and the Historical Society will arrange a special exhibition for the week — including portraits, prints, engravings, documents, silver, etc. — from its unsurpassed collection of Americana. There will also be a brief history address by Dr. Charles W. Burr, of Philadelphia. Wednesday will be a field day, the big auxiliary luncheon, with guests and speakers from the A. M. A., and a beautiful musical program, the gift of the Delaware Auxiliary. In the afternoon, the Philadelphia County Medical Society will invite the women to be guests on a bus trip through historic Philadelphia (a 10 minute’s stop at Independence Hall), Fairmount Park and Germantown to “Sten- ton”, where the New Jersey Auxiliary invites us all to tea. “Stenton”, the home of James Logan, Penn’s friend, Secretary of the Colony, still stands just as it was built in 1728, with furniture of the period, and garden laid out as described by con- temporaries. On Wednesday evening, the Pennsyl- vania Auxiliary invites all visiting ladies to a reception in the superb Chinese Rotunda of the Lhiiversity Museum, a setting probably unsurpass- ed in any museum anywhere. This meeting of the A. M. A. is the first in Philadelphia in 30 years, and the county medical society, desiring to mark so auspicious an occasion, and also in appreciation of the work of the aux- iliary, invites all members of the A. M. A. and the visiting ladies to be its guests at a supper dance in the Ball Room of the Bellevue, following the big meeting of the A. M. A. on Tuesday even- ing at the Academy of Music. The President’s ball at the Benjamin Franklin Hotel on Thursday evening, to which all are invited, will close the formal festivities. To those still able to rise from their beds on Friday morning there are offered a tour of Wana- maker’s with luncheon in the Crystal Tea Room; or an all -day bus trip to Atlantic City, where the New Jersey Auxiliary will meet them for luncheon at the Claridge. This Atlantic City program in- cludes also a visit to the new Convention Hall, an hour in a chair on the boardwalk, and plenty of time for window shopping or a swim. And finally, every day and all day there will be a booth in the Roof Garden inscribed “As You Like It” — where those wishing to golf, shop, go to Garden Days, or carry out any other pet pro- ject not elsewhere provided for, may find in- formation and assistance in making a profitable use of their opportunity. Will you not reward our efforts by the largest and most enthusiastic woman’s attendance in the history of the American Medical Association? EXECUTIVE BOARD MEETING Reported by Mrs. W. Blair Stewart. The Executive Board of the Woman’s Auxiliary to the Medical Society of New Jersey met at the Stacy-Trent Hotel, Trenton. Prior to the business meeting a luncheon was served which added to the general friendliness of the occasion. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 449 The program for the State Auxiliary meeting at the Berkeley-Carteret Hotel in Asbury Park, June 3-5, was read and discussed, and the proposed re- vision of By-Laws read and discussed. Those attending were: Mrs. John Nevin, Presi- dent; Mrs. H. Roy Van Ness, President-Elect; and Mrs. Dan S. Renner, Mrs. Edward Clarke, Mrs. A. Haines Lippincott, Mrs. George Orton, Mrs. Theo- dore Teimer, Mrs. William Preile, Mrs. John F. Hagerty, Mrs. H. H. V. Hubbard, Mrs. W. C. Raughley, Mrs. Emanuel Newman, Mrs. George N. J. Sommer, Mrs. W. Blair Stewart. The guests were treasurers or secretaries from the various county auxiliaries. Gloucester County Reported by Mrs. Henry B. Diverty The regular meeting of the Woman’s Auxiliary to the Gloucester County Medical Society was held at the Woodbury Country Club on Thursday, April 16, at 9 p. m. The president, Mrs. Elwood Downs, was in the chair and the membership was well represented. Mrs. D. Miller, of Millville, was a guest. After disposing of the regular business, Mrs. Downs read the wonderful program for the enter- tainment of Auxiliaries attending the American Medical Association convention to be held in Phila- delphia June 8 to 12. This program was arranged by Mrs. Walter Jackson Freeman, who knows Philadelphia and knows women, and the best Philadelphia has for a sight-seeing trip of 3 days is on this program. Social functions as well. Head- quarters for Auxiliary members will be at the Bellevue-Stratford Hotel, where 2 rooms will be at their service for the entire time — gratis. If it is your privilege to belong to the Auxiliary to Gloucester County Medical Society, don’t miss it. Professor Beardsley, who had addressed the doc- tors in an adjoining room, was presented to us and other visiting delegates. After a short social session we were invited into the dining room where a fine collation was served by the Country Club chef. Hudson County Reported by Miss Anne Hetherington The Woman’s Auxiliary to the Hudson County Medical Society met March 27 in the Jersey City Y. W. C. A., with Mrs. John Nevin presiding. A Nominating Committee for the coming elec- tion was appointed: Mrs. J. S. McDede, chairman; assisted by Mrs. W. Duckett, Mrs. P. Maras, Mrs. A. Ruoff. Delegates to the State Medical Auxiliary Convention at Asbury Park in June are: Mrs. IT. Klaus, Mrs. W. Duckett, Mrs. S. Barishaw, with Mrs. Freile, Mrs. F. Nicholson and Miss Anne Hetherington as alternates. After the business meeting the Auxiliary was addressed by Mr. J. Coleman, Secretary of the Jersey City Health Council, whose subject was “New Developments in the Field of Tuberculosis’’. The Hudson County and Jersey City Boards of Health are distributing pamphlets on tuberculosis in the schools, stressing early diagnosis and pre- ventive hygiene to the older boys and girls. They have tried to make this literature as appealing as possible to arrest the attention of the young. Some pages are given to items of varied interest with an occasional biographic sketch. In the last issue appears the Life of Laennec, inventor of the stethoscope. Mr, Coleman cited many of the causes of tuber- culosis, among them being the scanty dress of the modern girl; industrial occupations; crowded living conditions; but declared malnutrition, in- duced by Hollywood diets and the craze for slen- derness, to be the most fertile source of the dis- ease. Fortunately, this destroyer of the young, even in its advanced stages, responds to nutrition- al therapy. Tuberculosis is found in varying degrees among different races; the lowest death rate is held by the Jewish people, who have developed an immun- ity to this disease which is offset by a proneness to nephritis and diabetes. The Italian death rate is the next lowest; the highest is suffered by the Irish and colored races. In his native south, the negro shows comparative freedom from this dis- ease, but transplanted to other cities, he becomes easy prey. The health boards intend to make great efforts to educate the negro in preventive measures. After Mr. Coleman’s address an open discussion was held. Tea and the usual social hour followed. Hunterdon County Reported by Mrs. J. D. K. Tompkins The spring meeting of the Woman’s Auxiliary to the Hunterdon County Medical Society was held at the home of the President, Mrs. F. A. Thomas, in Flemington, on Tuesday, April 21. Following the meeting a delicious luncheon was served by the hostess. Union County Reported by Mrs. C. A. Hoffman The regular quarterly meeting of the Woman’s Auxiliary to the Union County Medical Society was held in the Nurses’ Home of the Elizabeth General Hospital, Elizabeth, on April 8, with Mrs. Hubbard presiding. There were 24 members pres- ent. Minutes of the previous meeting were read and approved. Mrs. McElhinney, Treasurer, reported a balance on hand of $35.36. Monthly" reports were called for. Delegates were appointed to the American Medical Association Convention to be held in Phila- delphia the first week in June: Mrs. Harry V. Hubbard, of Plainfield, and Mrs. G. S. Laird, of Westfield; Alternates, Mrs. H. D. Corbusier, of Plainfield, and Mrs. F. A. Kinch, of Westfield. Mrs. John Nevin, of Jersey City, President of the Woman’s Auxiliary to the State Society, was present and gave a review of a book by Gertrude Atherton, “The Conquerer”, and also commented upon other authors, including Sinclair Lewis and Booth Tarkington. An interesting address on “How to Make a Small Garden’’ was given by Mrs. R. A. Shirrefs, of Elizabeth. A door prize was given, and was won by Mrs. De Cesar, of Bozelle Park. A delightful afternoon at cards, following lunch- 450 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 eon, was enjoyed by more than 20 members at the Clare Louise Tea Shop, in Plainfield, on March 1G. Members were present from Elizabeth, Westfield, Cranford, Rahway and Plainfield. Pour prizes were awarded, the first going to Mrs. G. S. Laird, of Westfield. The door prize was won by Mrs. F. A. Kinch, of Westfield. County Society Reports ATLANTIC COUNTY Fifth Councilor District, Medical Society of New Jersey John Irvin, M.D., Reporter The third annual meeting of the Fifth Councilor District of the Medical Society of New Jersey, comprising Atlantic, Cape May, Cumberland, Gloucester and Salem Counties, was held in Atlan- tic City April 10, with Dr. Joseph H. Marcus act- ing as chairman. Dr. Marcus welcomed members and guests from the other counties, and went on to explain the purpose of the meeting. Extension of the Councilor District meeting plan to the entire state was proposed at the November meeting of County Society Secretaries and Reporters. The purpose is in part to discuss the economics of medicine and state medicine in order to inform our members what is going on and in order to keep them in touch with ever-changing conditions. So, it is my very great pleasure to introduce Dr. Hartwell, who is President of the New York Academy of Medicine, and whose topic will be “The Continued Education of the Doctor”. (To be published in the June Journal.) Dr. Marcus: Dr. Hartwell has presented to you facts that have been gathered from years of ex- perience. Our next speaker brings with him a wealth of experience, from a clinical as well as an institutional point of view. He is a clinician of note in Philadelphia and it is my great pleasure to introduce Dr. Jospeh C. Doane, Medical Di- rector, Jewish Hospital, Philadelphia, who will speak on the subject: “What the Public Thinks of Present Day Practice of Medicine.’’ Dr. Doane: It goes without saying that I con- sider myself able to speak about the current prob- lem that is confronting the medical profession. If I am a trifle vitrolic, a trifle caustic, in regard to our own profession, let me say it isn’t time for platitudes when one is trying to find out who is muddying the water. One can hardly go into a Pullman car without hearing someone relate some unpleasant experience that a relative or friend has had at the hands of a physician. We are passing through a changing economic and political exist- ence. Perhaps the doctor and society will have to have adjustments from the standpoint of finan- cial relationships downward or upward to suit the needs of the individual. Certainly there is some- thing in the water which is muddying it. Whether the fault lies with the patient or the physician it is hard to say, but we will have to purge our ranks of the unethical, the pretenders, those whose names may carry the M. D. but who do not have the welfare of the patient or the physi- cian at heart. It seems to me that the profession must separate itself from those who are doing it harm, and the public cannot judge and will not judge on generalities. The people desire to deal in specific instances. Medical Societies should as- sume a more militant leadership. In Pittsburgh, for example, no Medical Director is appointed without approval of the medical so- ciety. In many other localities, where leadership is needed, rarely do they turn to the medical so- ciety for advice. The Philadelphia County Medi- cal Society has been asked by 2 of the city’s lead- ing papers to censor all medical advertisements. Certain broadcasting stations have promised that all members advertising, whether it be about medi- cal appliances, apparatus or anything to do with medicine, will be submitted for careful censoring by the local medical society. (Dr. Doane’s paper will appear in the June Journal.) At the close of the afternoon session all mem- bers and guests attended dinner in the hotel, at which the principal speaker and Guest of Honor was Dr. H. Sheridan Baketel, Professor of Hygiene in Long Island Medical College, and Editor of “Medical Economics”. (Dr. Baketel’s address to be published later in the Journal.) In the evening a Clinical Session was held at the Atlantic City Hospital, where members of the staff exhibited patients and discussed a wide variety of disease conditions. The attendance at this District Meeting was greater than in preceding years and was stated by Dr. Reik to be larger than the number reached at any other District Meeting in the state. Among those present was Dr. George N. J. Sommer, President of the State Medical Society, who responded to a call from the chairman and delivered a short talk at the banquet table. This meeting was considered in every way suc- cessful. BERGEN COUNTY C. H. Littwin, M.D., Reporter The regular meeting of Bergen County Medical Society was held April 14, at the Englewood Hos- pital, with Dr. Joseph Morrow presiding. The minutes of the last meeting, and also of the meet- ing of the executive committee, were read and ap- proved. Dr. Morrow announced the appointment of the Public Health Nursing Committee: Drs. Edward W. Clarke, Chairman; Payne, Pallen, Sarla, James and Knowles. The membership application of Dr. Neil McL. Whittaker, of Hackensack, was read. The follow- ing were elected to membership: Drs. Thomas F. Reid, Joseph A. Rowe, William F. Fitzhugh, and A. Ivan Mader, Jr. The Secretary announced the omission of Dr. Herman Trossbach's name from the program through an oversight. Dr. Trossbach attended the meeting of the American College of Physicians at Baltimore as the first member from Bergen County. A communication from Wm. J. Ellis, Commis- sioner of Institutions and Agencies, urging atten- dance at the Child Welfare Conference in New Brunswick, was read. Dr. Wolowitz announced the progam for the Post-Graduate Course in Gynecology and Obstet- rics, which is to be given at the Hackensack Hos- pital on Friday afternoons beginning May 1. Mention was made that Dr. Levitas had given a May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 451 dinner before the meeting to the speaker of the evening and a number of his friends on the occasion of his 25th anniversary of practice in Bergen County. He was presented with a silver cocktail shaker by the Medical Board of Hacken- sack Hospital. For the scientific program, Dr. Burton J. Lee, Professor of Surgery at Cornell University Medi- cal School and Attending Surgeon at Memorial Hospital, spoke on the “Indications for Surgery or Irradiation in Treatment of Cancer”; illustrating his talk with lantern slides. As a member of the American College of Surgeons’ Committee on Establishment of Cancer Clinics, Dr. Lee’s par- ticular plea was for establishment of a Cancer Clinic in Bergen County for earlier diagnosis and better treatment. Drs. Pallen, Levitas and A. W. Ward discussed the question, and on motion of Dr. Levitas the president was ordered to appoint a committee to consider the formation of such a clinic. CAMDEN COUNTY Robert S. Gamon, M.D., Reporter The regular monthly meeting of the Camden County Medical Society was held in the Camden City Dispensary on April 7, with Dr. W. J. Bar- rett presiding. Dr. E. A. Y. Schellenger was sworn in as a member. The Scientific Program was given by 5 mem- bers who are qualified oculists. Dr. Pierce Shope read an article on “Refraction and Health”. An interesting paper was presented by Dr. A. T. Eaton on ‘‘Eye Grounds in Some Medical Dis- eases”. This was illustrated with lantern slides. “Squint in Children and Its Effect in Later Life” was read, and illustrated by lantern slides, by Dr. W. G. Mengel. Dr. Shipman presented a paper entitled “Significance of a Red Eye; with Some Remarks on Glaucoma”, using lantern slides to illustrate his remarks. “Some Com- mon Conditions in Industrial Ophthalmology” was given by Dr. G. J. Dublin. Moving Pictures of Cataract Operations, taken by Dr. Frank Par- ker of Wills Eye Hospital, were also presented. Each paper was well presented and received favorable comment from the members present. CUMBERLAND COUNTY E. S. Corson, M.D., Reporter Newcomb Hospital, Vineland, again opened its hospitable doors to the Cumberland County Medi- cal Society, on April 14, when 2 distinguished physicians addressed the society, and a resolu- tion was adopted advocating a county hospital for tuberculosis patients. -One of the first things was introducing new members: Drs. G. A. Davies, Elmer; Charles Cunningham and H. B. Walker, of Vineland; Charles B. Neal and Fred V. Ware, of Millville. A resolution endorsing a movement of the County Committee of the American Legion, to petition the County Freeholders to provide a hos- pital for tuberculous patients, was passed. “The difficulty in securing places for these patients, the cost of transportation and visiting them, the delay in entering them until it is too late for a cure, and the infection of associates, make it necessary to seriously consider taking care of our patients at home”, it was stated. Dr. Reba Lloyd, president, felicitated herself in a gracious manner on being able to present as guest speakers, 2 professors of her Alma Ma- ter, the Women's Medical College of Philadel- phia. Dr. Catherine MacFarlane, Germantown, dis- cussed “The R61e of Focal Infections in Disease of the Urinary Tract”. Focal infection is an out- standing discovery of American doctors. It is now readily determined that infected tonsils and teeth may cause infection of the kidneys and bladder. The findings in 100 cases clearly evi- denced this statement. Several speakers gave personal illustrations of how cures of rheuma- tism, bladder disease and neuritis had promptly disappeared on removal of the causes as stated above. Dr. J. Stewart Rodman, Philadelphia, traced the growth of the efforts to cure and prevent “Cancer of the Breast”. The female breast, owing to its function, is more liable to become affected. A simple inflammation of the milk ducts may eventually end in cancer. Attention to this condition should be given at once. At present a 5 years’ delay of fatal terminations has been secured in 50% of the cases operated on, and less loss of function has resulted than form- erly. With the extensive investigation that is in progress, the discovery of a cure cannot long be delayed. He explained a modification of the Hal- sted operation, to prevent contraction of the scar. A vertical incision, a few inches from the insertion of the pectoral muscles is made, in- stead of carrying to the usual point. ESSEX COUNTY E. LeRoy Wood, M.D., Reporter Considerable attention was given to economic problems at the Essex County Medical Society meeting held Thursday evening, April 9, at the Academy of Medicine, Newark. The president. Dr. Henry C. Barkhorn, first called attention to an ethical and economic problem involving the re- lationship of one physician to another. There is great complaint by many doctors against physi- cians employed by insurance companies operating under the Workmen’s Compensation Act. An in- jured workman places himself under the care of a doctor of his choice. Shortly, another doctor, employed or influenced by an insurance company, “lifts” the patient from the care of the first one. The idea was expressed that such conduct is just as unethical as the taking of other than compen- sation patients from another doctor. It was stated that while the patients may be influenced by in- surance company agents to change from an out- side physician to an insurance or company doctor, the latter is party to an unethical act, and such conduct was condemned by the society through passage of a resolution. In the discussion, it was pointed out that con- duct by a physician contrary to the ethical stand- ards of the County Society might cause that physi- cian to lose membership. As many hospitals and other organizations require County Society mem- bership of staff members, the result of unethical conduct might be far reaching in its effects. Con- duct contrary to code principles, by insurance doc- 452 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 tors, may cause them to take a place outside of organized medicine. Dr. Barkhorn then introduced Dr. Linn Emer- son, who read a paper entitled “Economic Phil- osophy for the Present Day Doctor”. Dr. James S. Plant, Director of the Essex County Juvenile Clinic, taking as his subject “The Essex County Juvenile Clinic and the Medical Profes- sion”, spoke as follows: The Essex County Juvenile Clinic was organ- ized in 1923 by the Board of Chosen Freeholders of Essex County. It is supported by that Board and is cpunty-wide in its work. It is not fair to judge the Clinic without know- ing something of the philosophic trends which were back of its construction. There were at least 2 distinct movements of which this was a result. Beginning in 1900. with establishment of the Juvenile Court in Chicago under Judge Julian Mack, and flowering out of this in 1911 into estab- lishment of the Psychiatric Clinic in conjunction with that Court, we have developed in the legal field the psychiatric point of view. Psychiatrists are physicians and if they are interested in con- duct disorders (delinquencies, maladjustment, crime) they look upon such disorders as simply symptoms of some deeper trouble. The lawyer is always interested in the exact degree of delin- quency or crime. We have in psychiatry assumed the attitude of wanting to know why a delinquency occurred, and this involves such a study of the patient and his environment as will show the de- linquency to be just the natural outcome of funda- mental stresses in the child’s life. An entirely different movement was running parallel with this in the field of mental disease. With the birth of modern psychiatry, in 1890, with the work of Pinel, there developed a group of better mental hospitals, but there was a growing conviction that such hospitals were simply treat- ing end-results. Thus, when Beers, in 190G, popularized the notion of the understanding and prevention of mental difficulties he found the psychiatrists in a receptive mood. Here began the notion that we should try to understand people who were disturbed, before they became sufficiently disturbed to go into a mental hospital. This is not true prevention although it has often been called so. That is, there is no true prevention in simply trying to get a disease process just a little bit earlier than you had before. We have seen in the matter of physical disease the ultimate neces- sity (in true prevention) of ameliorating those en- vironmental conditions which give rise to the dis- ease. That is true prevention. We prevent typhoid by watching our water reservoirs and the cows at the dairies. We prevent tuberculosis by building better houses. I submit that we can only really prevent mental breakdown of one sort and an- other by an understanding and control of all those great cultural forces which give rise to such diffi- culties. As I picture these social applications of psychi- atry, may I draw your attention to an interesting correlated development in the field of biology. The biologist is today definitely accepting the cell and its environment as a continuum. In other words, it is more and more recognized even in the biologic field that individuality in the sense that we have thought of it in the past, does not exist: that there is such a set of reactions and interactions be- tween the individual and his environment as makes it utterly impossible to think of them as in any sense separated. This gives you a picture of the philosophic basis. The work is carried on in such way that after a youngster has been referred to us we try to make a thorough physical, psychologic, psychiatric and social study of him in an effort to find out why he got into his difficulty. Roughly, in about Vs of the children we find a physical source of difficulty that is primary; i.e., primary in the sense that it is the important causative factor. For instance, we have a truant who doesn’t want to go to school because he can't sit still there. We find, even in our own county, that many times such a child has been given a seat in the front of the room facing the other children so that -he will stop his everlasting wiggling. So, we often find chorea, bad tonsils, bad teeth, or constipation as the sole major source of the difficulty. I should like in addition to call to your attention what I might term physical factors as “indirect” causes. I am referring to such matters as short stature, birth-marks, being “plain”, unusually large stature in girls, and that sort of thing — where the physical difficulty is of itself not im- portant but where it makes the child feel that he has much to compensate for because he has thus been set apart as different, odd and strange. Per- haps the most desperate criminal I have ever known was a boy who grew up as a “runt”. He compensated for all of this feeling of inferiority by a series of amazing crimes. In something like 30% of our cases mental de- fect in one form or another is a major factor. Here, of course, we have chiefly the inability on the part of the child to successfully meet the academic requirements of the school. One of the most interesting of problems arises out of the fact that as we mechanize and automatize our culture, we rather tend to place a premium upon feeble-mindedness. That is, we must remember that the job which has little of satisfaction in it- self, as a job, is perhaps peculiarly adapted to the handicapped youngster. This leaves us some 55% of children who are pretty normal individuals physically and mentally, with whom the problem is that of adjustment. I tend, with this group, to think of 3 steps of com- plexity of adjustment. Of course you cannot schematize life but perhaps it isn’t too mechani- cal to follow this outline. In the first adjustment, we have what we would call the “family” period; they come to us with the problems of thumb- sucking, enuresis, temper tantrums — all of those affairs which have their basis in poor habit train- ing by the parents. The parental dissatisfactions, the parental disappointments, the parental rest- lessness, nervousness and artificiality, here play an important part. We have the feeling that these habit problems that go to the pediatrician are very difficult of understanding if the pediatrician looks at the problems solely from the point of view of the child. It is so difficult to understand, for in- stance, the mother’s overweaning interest in the child’s development if we do not understand the relationships which she has with her husband and other members of the family. Secondly, there is the period of socialization — that period beginning at the age of 4 or 5 years, when the child leaves his family to compete with the child of the street and the school. There come all of the problems of shyness, poor companion- ship, of the effort to establish one’s self in the com- munity in whatever way seems easiest. So many of the problems of the court and school, problems of mischief, problems of making faces, of antics, May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 453 of raising the devil, are only the child’s simplest way of making himself the center of attraction. Thirdly, we have the period of sexualization — all of those problems that come from the child’s at- tempt at solving the difficulties arising from de- velopment of his or her sexual life. A boy started to stammer at 13, and came to me at 16 because he simply couldn’t talk to any other person. He was a shy and rather difficult boy, rather typi- cally a Froelich’s syndrome, who suddenly dis- covered at 13 that his genitalia were very unde- veloped in comparison with other boys. He was, of course, simply beside himself, felt that he would never be a success, that he could never make his way with others, and the stammering appeared, and got worse, because he couldn’t bring himself to make any sort of social adjustment. What is the relationship of this work to the medical profession or to the County Medical So- ciety? Only opinion can be given and in what further I have to say to you I should like to have you realize that I am giving only my own plan. It has been my good fortune during the past year to be working on a committee of the White House Conference on Child Health and Protection which has been interested in precisely this problem. We have come to certain conclusions and these, in part, I am presenting to you; but they are again, of course, presented purely as one way only of looking at the problem. The psychiatrist’s work can be rather easily di- vided into that which forms a technic and that which is a point of view. The psychiatric point of view involves: (1) seeing a conduct problem as purely a symptom of deeper stresses in the per- son’s life. (2) having a high regard and respect for the child himself. I am amazed at the number of children who come to me after having been to many other physicians and who find in me the first person who has really interested himself in the way the child looks upon his own physical and social problems. I am interested, in the younger child, with the number of times that the pediatri- cian seems to forget that it is the child himself who is wetting the bed. One would think from the work of many physicians that it was the mother who was the person to be worked with in the matter of the enuresis; seeming somehow to forget that it is not she but the child who is presenting the difficulty. Frequently it seems never to have occurred to anyone to talk with the child about it and to find out the way that the child looks at it. (3) Placing of high value upon non-verbal modes of communication; I mean to cover all of that group of fallacies built on the notion that a child understands only what is said to it. As a matter of fact the child rarely is interested in what is said to him, and is almost entirely governed by the way in which the thing is said and the man- ner of conversation that is held about him. It is startling to recognize the extent to which physi- cians discuss a young child with the mother, in the child’s presence, saying of course that the child doesn’t “understand the language”. It is our experience that in this situation the child is often the only one in the room who really acutely and tragically catches the meaning and the import- ance of the stresses involved. (4) Accepting the notion that the parents and others who surround the child so much live out their lives in the child’s life. These are some of the factors in what I would call the psychiatric point of view; what Dr. Meyer calls “being psychiatrically intelligent”. It is my hope that all physicians will be trained in these matters and it is my belief that the task of the Essex County Juvenile Clinic is to further the spread of “psychiatric intelligence” in the medical field. This is all rather in contradistinction to the various types of psychiatric technic that have de- veloped; highly complicated modes of psychiatric treatment. Probably such an institution as the Juvenile Clinic will turn to the psychiatrist as a specialist just as it turns to the surgeon or the orthopedist. I am trying here to make the clear- est distinction between a way of looking at things and a highly specialized technic in psychiatric treatment, with, of course, the hope that in time such an institution as the Juvenile Clinic will not be needed, as we gradually bring into our medical practice the psychiatric point of view which is its chief aim at the present time. May I briefly say to you that there is a move- ment in the medical schools toward getting away from specialties as specialties. That is, there is a growing tendency to get back to the point of view of the general physician, where the patient is looked upon as an integrated, acting whole. In 2 of the medical schools, Harvard and Johns Hopkins, there is a very definite tendency to give all stu- dents some conception of the environmental stresses in human relationships that play upon the patient. These are very hopeful signs. To these I may add my own hope that the medical man of the future will more and more understand the wide usefulness of the social worker. The family goes to the physician for advice about its most sincere problems. To these problems the physician is now to a large extent blind because he is not interested in his patient as a working, reacting mechanism, but only as a group of viscera, skin and bones. I make this appeal, that you look toward a situa- tion which will find you giving help to parents in matters of the total social adjustment of their children, and of themselves, simply because you are the logical persons to do it, because the family looks to you to do it, and because if you don’t do it you will find that in the field of conduct dis- orders, just as in many other medical fields, the quack, the charlatan, the poorly-prepared person, will come in to help the family simply because you will not accept a tremendously challenging and interesting burden which the family would very much prefer that you carry.” The following 7 new members were elected: Rose W. Bass, Bernard Fein, Philip Grossblatt, Gil- christ B. Matheson, John J. Reilly, James H. Trainor and Maurice M. Weinberg. Academy of Medicine of Northern New Jersey Eye, Ear, Nose and Throat Section E. LeRoy Wood, M.D., Secretary At the meeting of the Eye, Ear, Nose and Throat Section of the Academy of Medicine of Northern New Jersey held Monday evening, April 13, the Chairman, Dr. J. Wallace Hurff, announced the following committee to investigate and consider the problem of the high cost of eye-glasses and to recommend a solution: Drs. Dennis F. O’Connor, Dinn Emerson, Brayton E. Failing, William H. Hahn, Elbert S. Sherman, Andrew Rados, William F. Krone, Charles W. Buvinger, George J. Holmes 454 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 ancl Lee W. Hughes; the first named being chair- man. The following officers were elected for the en- suing year: Charles W. Buvinger, Chairman; E. LeRoy Wood, Secretary. Dr. Hurff then introduced Dr. John McCoy, of New York City, who spoke on “Successful Treat- ment of Chronic Discharging Ears and Nasal Ac- cessory Sinuses by Means of Zinc Ionization". Dr. McCoy : My object in presenting this paper is to give my results and conclusions after using the method of zinc ionization during the past few years. It was first practiced by Dr. Le Due, of France; later, by Dr. Friel, of England.. If we review briefly what takes place when zinc ionization is practiced, we find that ionization is a chemical decomposition effected by means of an electric current. There are certain laws govern- ing this decomposition. Ions are groups of atoms which result from the electrolytic decomposition of a molecule. These ions are either electro-nega- tive or electro-positive. The electro-negative ions are called anions; electro-positive ions are called cathions. Hydrogen and the metals generally are cathions. The electro-positive ions, or cathions, tend to flow toward the negative pole. It has been found that by use of a solution of sulphate of zinc at the positive and the ordinary saline solution at the negative pole, it is possible to drive zinc ions into the exudate and into the membranes of the ear cavities. Some have gone so far as to claim that such a procedure will cure chronic necrosing mas- toiditis. Our observations have not borne this out. They have proved to us, however, that this method will cure many cases which generally are regard- ed, from their symptoms, as being chronic middle- ear and mastoid necrosis. In cases where there exists a posterior marginal perforation, or one in Shrapnell’s membrane with bone necrosis and foul-smelling pus, this method should not be used. It has proved exceedingly use- ful, however, in cases of subacute and chronic discharge where the perforation is central or near the margin, and where numerous other methods used for chronic suppuration have failed. Before resorting to its use we believe that symptoms of extension to structures adjacent to the middle ear and mastoid should be ruled out, as far as possible, by means of x-ray pictures of the mas- toid and by careful examination of the labyrinth. The ear is thoroughly cleansed with warm water. A pledget of cotton containing 4% cocain solution is then applied to the middle ear for a period of 5-10 minutes. The patient is then placed upon a table with the diseased ear upward. After the pledget of cotton has been removed, the ear is filled with a 1% or 2% zinc sulphate solution and the zinc electrode attached to the positive pole is placed in the ear through a vulcanite speculum (McCoy’s modification), so that the zinc electrode and the zinc sulphate solution are in contact. The patient is then given the other pole to hold in the hand, or it is applied to the arm, being very wet with saline solution. Current is then turned on very gradually until a strength of 3 m.a. is reached. This is continued for 10 minutes, when the current is very gradually turned off. Un- pleasant effects sometimes take place in the shape of slight dizziness or slight pain in the region of the eustachian tube, but they are very evanescent. By this method the writer has treated a number of cases with results that were surprisingly gratifying, the patient’s ear condition drying up in 2-6 treatments, the treatments being adminis- tered once every 4 or 5 days. Zinc ionization of the nose is practiced in the following way: The nose is cleansed with warm saline solution, a solution of 4% cocain is applied to the part to be treated for a period of 5-10 min- utes, usually with a pledget of cotton. The cavity to be treated is then filled with a 2% zinc sulphate solution or cotton wet with 2% zinc sulphate is applied to the part to be treated. Now, the zinc electrode attached to the positive pole is placed in the nose so that the zinc electrode and the zinc sulphate are in contact. The patient is then given the other pole to hold in the hand. The current is then turned on very gradually until a strength of 4 to 8 m.a. is reached. This is then allowed to continue for 10 minutes, when the current is very gradually turned off. About 3 years ago, a doctor presented himself at my office for a discharge of mucopus from the antrum, with symptoms of focal infection, and this was after having had 3 major intranasal opera- tions. My advice was to have the antral opening made a little larger, but he said that he was through with operations and wished to try any other means. I then thought of zinc ionization and applied it to his antrum. This was subse- quently twice repeated, 4 and 8 days later, with the result that the antrum completely dried up and for 2 years or more it has remained dry. GLOUCESTER COUNTY Henry B. Diverty, M.D., Reporter At the Woodbury Country Club on April 16, physicians of the Gloucester County Medical So- ciety met in regular session. An informal inter- esting talk was delivered by Professor E. J. G. Beardsley, of Jefferson College, Philadelphia. Delegates present were: Dr. and Mrs. Miller, of Millville; Dr. Markes, from Woodstown, and Dr. Church, of Salem County. The following lo- cal members were present: Drs. I. W. Knight, R. K. Hollinshed, of West- ville; W. J. Burkett, of Pitman; H. M. Fooder, of Williamstown; J. Harris Underwood, Duncan Campbell, E. E. Downs, C. A. Bowersox, William Brewer, Paul Regau, H. B. Diverty, all of Wood- bury; H. L. Sinexson, of Paulsboro; C. I. Ulmer, of Gibbstown; A. B. Black, of Mickleton; C. C. Sheets, also of Paulsboro, and C. C. Krusen, of Mullica Hill. A luncheon was served by the caterer. HUDSON COUNTY E. G. Waters, M.D., Reporter The regular meeting of the Hudson County Medical Society was held on April 7, at the Car- teret Club, in Jersey City. Dr. J. M. Cassidy pre- siding. The minutes of the March meeting were accepted as printed in the Bulletin. The following communication from Dr. Cole- man was read, and having been favorably re- ported upon by the Executive Committee, was ap- proved: “The assumption by Congress, in the Volstead Act, of control over the practice of medicine in the United States has raised the most serious .May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 455 questions that have ever confronted the medical profession: (1) The right of the several states to regulate the practice of medicine within their borders; and (2) the right of the individual physician to treat patients according to his train- ing and experience. These questions have no relation whatsoever to prohibition as such; alcohol was merely the oc- casion of the assumption of the above-mentioned powers by Congress. Under other circumstances, Congress might forbid the use of toxin-antitoxin or forbid more than 3 grains of caffein a day. The right of the state to regulate the prac- tice of medicine within its borders concerns the members of the medical profession only as citi- zens. The right of the physician to the untram- meled exercise of his judgment concerns the wel- fare of his patients and his own freedom of ac- tion. There were 2 ways of meeting the attack by Congress on the medical profession. (1) By test- ing the constitutionality of the medical provisions of the Volstead Act in the courts, and (2) by di- rect demand by the members of the medical pro- fession upon Congress for relief. The first method was tried and failed. -A group of New York physicians organized the As- sociation for the Protection of Constitut'onal Rights consisting of 928 members in New York and neighboring states to light for the traditions and the rights of the medical profession. Dr. Samuel W. Lambert was elected president of the Association and under the auspices of the Asso- ciation brought suit against the Government (Lambert v. Yellowley). An adverse decision was rendered by the United States Supreme Court. If relief is to be had from the condition which exists, the individual members of the medical profession must now demand of Congress that the medical restrictions of the Volstead Act be repealed. Congress will probably listen to this. In order to promote this action the enclosed resolution, sponsored by the Association for the Protection of Constitutional Rights, is being sent to a number of organizations for consideration. The greater the number of medical organizations that adopt it, the sooner will the prerogatives of the profession be restored. It should be added that the Association for the Protection of Constitutional Rights is in favor of stringent regulations to control the use of al- cohol by physicians and of severe penalties for “violation of the regulations. This will afford pro- tection to those physicians who believe in, and use, alcohol in their practice and will at the same time restrain any physician who might be in- clined to abuse his privileges. If the resolution meets with your approval, would you be willing to present it to your State Society for action? Samuel W. Lambert, President James F. McKernon, Vice-President F E. Sondern, Treasurer Warren Coleman, Secretary John A. Hartwell Samuel A. Brown Harlow Brooks Charles L. Dana Nathan B. Van Etten J. Bentley Squier George David iStewart T. C. Chalmers Linsly R. Williams James T. Gorton Executive Committee. Association for the Protection of Constitutional Rights. PROPOSED RESOLUTIONS FOR PRESENTA- TION TO COUNTY SOCIETY WHEREAS The Congress has undertaken to fix doses of wine and whiskey and brandy by leg- islative fiat, thus taking ovqr the functions of pharmacologist and physician, and WHEREAS the Volstead Act compels physi- cians to betray the confidences of their patients by keeping a record of their diseases and ail- ments for inspection by Federal prohibition agents, thus violating the traditions of the medi- cal profession, medical ethics and the laws of a number of states, and, WHEREAS relief from these conditions has been sought in the courts and has been denied by the United States Supreme Court, and WHEREAS the Wickersham Commission has unanimously made the recommendation: (1) ‘Re- moval of the causes of irritation and resentment on the part of the medical profession by: (a) Doing away with the statutory fixing of the amount which may be prescribed and the num- ber of prescriptions. (b) Abolition of the re- quirement of specifying the ailment for which liquor is prescribed upon a blank to go into the public files, (c) Leaving as much as possible to regulations rather than fixing details by statute’. BE IT RESOLVED — That the Medical Society of the County of New York hereby formally ex- presses its disapproval of those portions of the Volstead Act which invade the right of the State of New York to regulate the practice of medicine within its own borders and which deprive the physician of his right to the free exercise of his judgment in the practice of his profession, and BE IT RESOLVED — That the Medical Society of the County of New York demands of Congress the repeal of said portions of the Volstead Act, and BE IT RESOLVED — That the Medical Society of the County of New York urge each of its mem- bers to demand of his Senators and Congress- man the repeal of said portions of the Volstead Act, and, BE IT FURTHER RESOLVED — That the Sec- retary of the Medical Society of the County of New York be, and hereby is, instructed to trans- mit a copy of these resolutions to the Senators from New York and to each Representative in Congress of the County of New York.” It was moved and seconded that the. papers for the evening be presented and discussed before the balance of the business session. Dr. Edward G-. Waters read a paper entitled “Plan for County Society Control of Periodic Health Examinations”. In presenting this plan of periodic physical examinations and publicity to the medical profes- sion, I do not attempt to advise medical men as individuals on how to handle their patients and business. I present it as a practical plan to meet serious and unfair competition, and to offer some- thing of real value to our public as a whole which must react favorably for the physician. It can be characterized even as a measure to re- store to us that degree of public confidence which our more vindictive critics believe we have lost. While this plan has been fomenting in my mind, I have heard myriads of complaints and read many papers about medical economics, but a paucity of practical advice or definitive sug- gestions. The thought has resolved itself into 456 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 a form which I believe is applicable to the vast majority of communities in this country, with hut few alterations. For the purposes of clarity and reference, I have divided the plan info 4 major component parts, which I will now present in some detail: (1) The adoption of a form of procedure for periodic physical examinations with delineation of minimum requirements for the examining doctor to meet. This is obviously the keystone. Any examination of this sort must be thorough and complete. A cursory examination of the heart and lungs, often through a half-unbutton- ed shirt, isn’t worthy of a name. Likewise, every thorough examination of the heart and lungs, but neglecting, for example, a rectal ex- amination, lacks completeness. The patient must be stripped and ready for a complete examina- tion, for halfway measures are not sufficient. To remove haphazardness and prevent omissions, a form of procedure is planned which constitutes a written list of examinations made from head to foot, but lists only those which any practicing physician should be competent to make. It does not include specialized examinations, as for ex- ample, a retinoscopic and sigmoidoscopic ex- amination, but would include visual eye tests, and a rectal examination. When specialized exam- inations are required, as for example, retinoscop- ic, sigmoidoscopic or cystoscopic, it will be feas- ible and highly practical to refer the patient for these examinations to qualified men, such exam- inations tc be part of the general examination and in no sense to constitute a "consultation”. The patient may thus be insured a thorough and adequate examination with "reference” but with- out “consultation”. The specialized examina- tions will of course add to the charge made, if the patient follows the general examiner’s ad- vice who suggests them, but he knows in ad- vance why they are requested and what the ex- tra work entails, apart from the regular form of examination. (2) The adoption of a standard fee for the community. It is imperative for the success of such a plan that a fee be charged which is not only compatible with the ability of the average examinee to pay, but which is also standard among those physicians who enroll as county medical examiners in given communities. The fee must at least meet or better that charged by lay-controlled groups and clinics operating for gain. It must be unalterable by the physician, and include all that the standard form of pro- cedure delineates. In addition, there must be definitely known charges for any additional ex- aminations, such as x-ray and blood chemistry, and these must be comparable with the scale of charge for the entire examination. If such a plan is to succeed, the patient must be given all he needs to warrant thoroughness and complete- ness in examination and diagnosis, but his fi- nances must be conserved and we must not per- mit his being mulcted through incidental exam- inations. There are plenty of good x-ray and diagnostic laboratories which will be only too willing to cooperate in this work, and furnish service at less than standard rates. (3) Publication of a list of members of the County Society of the district, indicating those members willing to give the examination at the standard fee. The public must be apprised of the adoption of such a plan, and must know what physicians are available for examinations. To avoid any possibility of confusion as to medical standing, the entire roster of the county society — which means the roll of men acceptable to the medical brotherhood — should be published. How- ever, as plan acceptance is elective with mem- bers, such published lists should clearly indicate those men who are willing to give examinations, as contrasted with men in good standing who neither subscribe to the form procedure nor the standard fee. The publication of such lists will prove of material assistance to the county so- cieties. The public will be enabled to ascertain the identity of medically-eligible men. Illegitimate practitioners will find the going harder, and twi- light practitioners will be refused the light of community acceptance. A reference list of com- petent physicians will be available in emergency. Physicians will profit individually and as a group, for an ethical type of advertising is available. The public will profit vastly from the oppor- tunity to distinguish the medically acceptable from those who are not, and through elimination of the undesirables in medicine. (4) Publication of the detailed form of pro- cedure. The public at large does not know what a’ complete medical examination means. The average person knows that for a cold his chest is examined, and for a sore throat his nose and throat are gone over, but he has seldom if ever gone to his physician for a complete examination when he was not sick. This fact doubtless ac- counts in large measure for the reputation for completeness and thoroughness acquired by lay- controlled clinics specializing in health examina- tions. A patient visiting the office for treatment of a head cold, or sebaceous cyst of the scalp, would think it very queer if the doctor tested the ocular movements and reflexes, took the height and weight, looked in the ears, tried the patellar reflexes, and so on. But the same pa- tient, subsequently taking a routine examination at a clinic specializing in such examinations, would doubtless widely advertise the thorough- ness of the going over he received. He would often compare critically his experience with his visits to his own doctor. Such a patient ignores the truth of the matter — which is, that he never went to his doctor for a complete examination when he was not in fact a “patient”. But, if he had gone to his doctor for a complete examination, would he have received one? And if he had, how would he know it to be adequate and thorough. In my opinion, the public should be acquainted with what may be expected in a complete exam- ination. If people know what is due them, the examining physician must render it to them. The physician conducts a complete examination, and the patient is satisfied. If it is not thor- ough, the patient will know it, and the physician will suffer in consequence. The form of procedure must be broadcast, and copies of the form made available on request. It will not take the average American citizen long to know exactly what to expect for his money, and we 'may be sure that he will see that he gets it. In addition to the 4 major component parts detailed above, there are numerous factors of less importance which require mention and con- sideration. I hardly need mention the value of the plan tc the public in early detection of con- ditions which are of serious import if neglected. Likewise, I need hardly detail the value of the May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 457 examinations to the physicians who detect those defects which require attention and treatment. But the Medical Society must police its own or- ganization, or have it policed for them, to insure the patients against unnecessary and expensive follow-up treatments hy the occasional commer- cial and dishonest examiner. When the examination is concluded the patient should be given a written report, with notation of defects which require attention. The detailed record of the examination is to be held and filed by the examiner; however, if the patient decides to take treatment elsewhere, a copy of the com- plete record of the examination must be for- warded to the physician treating the patient, should he request it. This is proper and ethical, and cannot fail to materially increase confidence in our efforts along these lines. In conclusion, I believe the publicity asso- ciated with this plan will be a strong welding bond between physician and layman. The pub- lic is entitled to know the names of competent physicians willing to give adequate health ex- aminations for a set fee. The public is also en- titled to detailed knowledge of the content of adequate health examinations. The education along these lines cannot help but make for bet- ter service to patients and cannot help but make tire average physician better in respect to detail and completeness in his work. There is bound to be an increase in the confidence and respect of the public toward physicians as a group, for a move which is so clearly for their betterment. The County Society may thus become a real fac- tor in the promotion of public health plans and in the protection of public health by the endorse- ment of means of bettering medical practice. In this paper, I have not discussed in detail the relationship of physician to patient, advice for treatment, disposal of examination forms, reference^ of patient elsewhere, care of laboratory and x-ray needs, etc. I have rather definite ideas upon these matters, but the one of prime im- portance at first is to pass and act upon the value of the plan itself. When the major issue is decided, the lesser ones are easily dispatched. Discussion This paper was discussed by Drs. Quigley, Nor- ton, Gordon, D’Acierno, and Waters. A motion was made and seconded that the president ap- point a committee to further and carry to a con- crete conclusion the ideas embodied in Dr. Wa- ter’s report. Dr. Merrill A. Sioiney read a paper — “Technic in Obstetrics”. Every physician will agree that an obstetrician may in one sense be skilfull, and yet he may have disastrous results. He will have a death rate of 1 in 50 from puerperal sepsis, unless he also at- tains skill in conducting his war against germs. During the last generation the germs have been holding their own in the battle. The doctors have not cut down the death rate from puerperal sepsis. In many cities a woman takes less chances of dying from infection if she goes to a midwife. The latter does not carry on her hands so many germs of infection as the doctor who is handling all sorts of cases. About 15 years ago I read a paper before this society on the use of iodin in obstetrics. I had then used it exclusively for 3 or 4 years. After a continual use of this method for over 15 years, I am still enthusiastic about it. It has proved its efficiency. We have delivered in my sanatorium in 18 years, 1292 women. Only 1 of those pa- tients died of puerperal sepsis. Before entering the sanatorium, she had been bleeding from pla- centa previa for 2 weeks. Many physicians had examined her. When she was admitted, her temperature was 102.8°; pulse, 140; Hb., 55%. A large pack was in the vagina and the lower uterine segment. She showed all evidence of in- fection, when admitted. iShe died of general peritonitis. In 4 engagement cases, forceps failed. Then I did cesarean section. These 4 women lived, and there was no sepsis, showing that iodized forceps carried no infection into the uterus. This is the proof I offer that my antiseptic technic is practically perfect. I gave up the idea of aseptic technic many years ago, as I considered it a delusion. The technic depends on 3%% solution of iodin. At examina- tion, the vulva and perineum are painted with it; the dry rubber glove is painted with it. At de- livery, the vulva and perineum are again painted, and all instruments are painted with it, I did use 7% solution of iodin, but occasionally it blis- tered the skin; the 3%% solution gives no trouble. One thorough vaginal examination is my rule. If it is complete, no other is necessary, until de- livery is decided upon. Some doctors make many examinations in the course of long tedious la- bors. I unreservedly condemn that practice. The rectal examination is unsatisfactory to me. My morbidity and mortality rates prove that a va- ginal examination can be almost perfect. The patient is put in the lithotomy position on the examination table; pubic hair is shaved; vulva and perineum are painted with iodin; a dry rub- ber glove on the left hand is also painted with iodin and careful vaginal examination follows. We delivered almost all patients in bed. We take only high forceps, cesarean section, or dif- ficult version cases, to the delivery room. We put flannel leggings on the patient and place her on an obstetric pan of my own design. This pan makes the delivery easy; the legs are in the best possible position to relax the vaginal outlet. Not much care is needed to prevent contamination, as the pelvis is elevated from the bed, and the drainage drops directly into the pan. If there is considerable leukorrhea, we use an instilla- tion of 4% mercurochrome, 15 minutes before the examination; we use it occasionally during prog- ress of the labor. The use of the pan prevents contamination in the third stage. After delivery, the binder is adjusted, the patient is covered, the pan is removed, and the bed is dry. There is a minimum of disturbance to the patient. My method is simple; it is much easier than delivery on a table, in ordinary cases; patient is not excited; relatives are not alarmed; it causes much less anxiety than taking the patient to a delivery room; requires a minimum of ether; and it needs but few assistants. This technic can just as well be carried out in the home. Nothing can be simpler; nor more nearly perfect. I urge the general practitioner who is handling obstetric cases to make note of and try this technic. It saves a great deal of time wasted in boiling gloves and instruments and waiting for them to cool. i 458 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 Discussed by Drs. Quigley, Norton, Gordon, D'Acierno and Waters. The following applicants having been favor- ably reported upon by the Board of Censors, were declared elected: Drs. Solomon Hirsch, William Yudkoff, and Eugene M. Kiely. The following new applications were received and referred to the Board of Censors: Drs. Nich- olas M. Alter and Lawrence V. Lindroth. Clinical Society of North Hudson Hospital J. Africano, M.D., Reporter The regular monthly meeting of the Clinical So- ciety was held Tuesday, April 14, with Dr. Hekim- ian acting as chairman; 47 members and guests present. Dr. Tannert read the hospital report for Mai eh 1931: 233 admissions; 238 discharges; 20 deaths (13 under 48 hours), of which 11 were sur- gical, 5 medical, 2 new-born, 1 urologic, and 1 pediatric. Dr. Klaus discussed a fatal case of “Mesenteric Thrombosis writh Gangrene of the Intestines”. The patient was ill for 3 days with symptoms of intes- tinal obstruction, especially vomiting, distension and fever; though the history suggested nothing to account for obstruction. Small intestine was found to be gangrenous in segments, with almost healthy loops in between, for a distance of 15 feet, while the mesenteric vessels were definitely throm- bosed; nothing could be done for the patient, and he expired 18 hours postoperatively. Dr. Comoro, reported a “Bilateral Detachment of the Retina”. M. C., white, aged 42, admitted Oc- tober 13, 1930, with symptoms of well-developed toxemia of pregnancy and renal insufficiency; had 9 children, and 2 miscarriages; B. P. on admission, 224/156. Right eye showed a beginning choked disc with edema of the surrounding area; several small fresh hemorrhages, and detachment of al- most the entire lower half of the retina, which ballooned out into the vitreous cavity. Left eye showed detachment involving both upper and lower portions of the retina, without damage to the macula. Vision was limited to perception of fingers at 2 feet. Tension of both eyes normal or slightly less. On October 25, 1930, the edema of both fundi was more marked; exudative patches larger and more numerous; bulbar conjunctiva of both eyes edema- tous and greyish in color. Vision of both eyes limited to Anger perception. On October 27 labor was induced by the Voor- hees’ bag and a dead macerated, male fetus, of 8 months’ gestation, was expelled. On October 30, the fundi showed marked improvement; detach- ments in both eyes had receded remarkably, and the upper detachment of the left eye had dis- appeared entirely. Choked disc increased however; there was more tortuosity of the vessels, more venous congestion, and greater number of exuda- tive and hemorrhagic spots. Vision improved. Dr. Selinger. “Multiple Intra-ocular Foreign Bodies”. E. D., boy, aged 7, playing with detona- tion caps, caused an explosion which produced the following results: Face was peppered with copper particles, left eye perforated, lens displaced, and traumatic iridec- tomy was accomplished; the lens was cataractous, vitreous lost, tension gone, vision limited to light perception and poor light projection; also detach- ment of the retina, and retention of 2 foreign bodies. The right eye, supposedly good, showed point of entrance of a foreign body at about 5 o’clock position. Examining the fundus, with pupil dilated, a shiny piece of copper was clearly visible in the vitreous at about 4 o’clock position. The question arose as to the best line of procedure for saving the patient’s vision in the only good eye. After consultation it was decided to leave the right eye and its foreign body alone, and watch it carefully for the possibility of any reaction; secondary effects, or sympathetic results. The vitreous hanging out of the left eye was cut Aush with the cornea and allowed to recede; otherwise both eyes were left alone surgically, and medi- cally they were kept under atropin. Vision in the right eye is 20/15 with a -j- 1 sphere combined with a 0.50 cyl. ax. 90°. L. E. vision limited to light perception and poor light projec- tion. The everlasting question now arises: “What will happen to the right eye, with its contained foreign body?” Time alone will tell. Dr. Comoro. “Sublingual Cyst; 2 Cases.” H. L. and A. S., each aged 15, giving vague history of trauma followed by swelling under the tongue gradually increasing, and causing difficulty in swallowing and pressure on the larynx, not as- sociated with pain or other discomfort. Examina- tion showed a Arm, cystic, oval tumor, the size of a small egg, with long diameter anteroposteriorly, slightly to left of the median line; inferior to the submaxillary gland and rather freely movable. Un- der general anesthesia, an incision was made in the Aoor of the mouth, from before backward, and with dull dissection the tumor, in each case, was shelled out intact; wound closed with silk sutures. Cysts found in the sublingual area are usually dermoid in character, and are sometimes er- roneously diagnosed as ranula or sebaceous cysts. Dermoids are congenital but often do not develop until late in life. The great majority occur be- tween the ages of 12 and 25. They are benign until they encroach upon other organs, when they become dangerous. Exploratory puncture will usually make the diagnosis, for aspiration of the sebaceous contents points either to dermoid or tliyroglossal cyst, and they cannot be differentiated clinically; diagnosis depending on pathologic study of the cyst contents or wall. Dr. Ash. “Chronic Mastoiditis Complicated by Brain Abscess.” M. B., female, aged 17, was ad- mitted October 24, 1930. complaining of chills, headache, and vertigo; slightly irrational; temper- ature 99.2° in morning and 104° in evening; pulse, 120-140. Had the usual children’s diseases and a discharge from both ears at intervals for years. Present illness began on the morning of October 12, when she awoke with dizziness and vomiting. These symptoms continued for about a week, then she developed chills and fever. Physical examination showed moderate amount of rigidity of the neck; positive Kernig and Oppen- heim; knee-jerk absent; pupils regular and re- acted to light; retinal veins full and tortuous, with double papilledema; purulent discharge from the right ear with slight edema over mastoid and mod- erate amount of tenderness. Radical mastoid operation revealed choles- teatoma in the middle ear with unhealthy dura exposed in the middle and posterior fossas; lateral sinus was also covered with dark, unhealthy gran- May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 459 illations. Within 24 hr. the fever had disappeared and the pulse rate dropped to 100. The drowsiness, headaches and vomiting gradually subsided and in about 4 weeks following operation the patient was feeling quite normal. Two weeks later, or 6 weeks postoperative, fever rose to 101°; the patient be- came slightly delirious, had some headache, vomit- ed frequently and had 3 convulsions in 24 hr. Spinal puncture showed clear fluid and normal pressure, 24 cells per c.mm. ; slight increase of globulin and decrease of sugar. Culture negative. Drawing spinal fluid apparently relieved the intra- cranial pressure and the patient’s symptoms grad- ually subsided. The mastoid wound was too small for the amount of discharge and since the head- aches and vomiting attacks were returning, it was decided to complete the radical mastoid operation by making a flap. The dura was also inspected and incised. This gave vent to some clear spinal fluid. The headaches and vomiting ceased and the patient left the hospital about 1 month later. Five months following operation the patient shows a gain of 14 lb; the discharge has lessened, has no bad odor, and appears to be coming from a subdural abscess in the posterior fossa. Dr. Ash. “Pansinusitis Terminating in Menin- gitis.” W. R., male, aged 13, admitted with con- siderable sw'elling, edema and tenderness of the forehead extending into eyelids; intense pain; pro- fuse purulent discharge from both nostrils and both ears. Present illness began with grippe 2 weeks before admission. Considerable tenderness, swelling and edema with fluctuation over the frontal bone. Entire mucous membrane of the nose swollen; right eye deviated outward, with limitation of movement; fields, vision and optic nerve heads normal. No signs of meningitis. Tem- perature 103°; P. 110; R. 20. Culture from nose: Staph, aureus. A diagnosis of pansinusitis, mainly involving the right side, was made. The right middle turbinate was removed and the anterior ethmoid cells open- ed, which released 2 V2 oz. of thick pus. The open- ing into the right frontal was enlarged; and also an opening was made into the right antrum. Thin, foul-smelling pus escaped from the frontal sinus and antrum. Incisions IV2 in. long were made above the inner part of each brow, which gave vent to 3 oz. pus. It was thought that this would be sufficient drainage to allow the patient to re- cover his strength before having a more radical operation. There was gradual improvement in condition, until about a week later, when fluctuation was noticed at the outer end of the left eyebrow. This area was incised, with escape of considerable pus. A left antrotomy was performed and considerable pus was washed away. The swelling in the mu- cous membrane of the nose had subsided, nasal breathing had become quite free and the amount of pus from the nose and frontal region had les- sened considerably; but as the frontal tendernesss disappeared, it spread along the left parietal region to the occiput. Pain in the head became more severe. During the next 3 days pulse dropped to 72, became weak and irregular. Projectile vomit- ing occurred; the patient became drowsy and ex- pired. In reviewing this history I am convinced that the patient was doomed to die from the very be- ginning, yet a more careful examination of the central nervous system, e.g., testing of reflexes, searching for evidences of muscular spasms and paralysis, record of hearing, examination of the spinal fluid, a greater exposure of the frontal bone, etc., would undoubtedly have simplified the diag- nosis. Dr. 8. Braunstein. “Case of Trichinosis.” H. H., male, aged 19, white, employed on a swill truck in Secaucus, admitted because of pain in the calves, thighs and elbows; more severe with the arm ex- tended. Venereal denied. He developed pains in the muscles of the lower extremities and he noticed that his face, eyes and hands became swollen, so much that he could hardly open his eyes. A chain of glands palpable on both sides of the neck in the postcervical region; fairly firm, dis- crete, freely movable and not tender. Tenderness at both elbows and fore-arms; no swelling or red- ness of joints. Epitrochlear glands palpable and also the axillary glands. Tenderness over both calves and thighs; no edema. Blood count, 5,632,000; W. B. C., 16,600; polys., 30%. A test for the Bacillus mellitensis was nega- tive. The Widal showed a partial agglutination 1-40. and 1-80. The striking symptoms in this case are the edema of the eyes and face, fever, muscular phe- nomena, adenopathy, enlarged spleen and heart murmur. With these findings we considered this a case of trichinosis with the following to be con- sidered in the differential diagnosis: Glandular fever, aleukemic leukemia, typhoid and lues. The history of eating pork over a long period of time, the fact that several of his friends with whom he worked were also taken sick about the same time with similar symptoms, the swelling of the eyes and face and the muscular pains all gave evidence for the diagnosis. Just 2 days before the patient was discharged we teased the deltoid muscle with a 28 gauge needle and were rewarded with a beautiful speci- men of the trichina on the slide. Later a biopsy was done and this also showed the trichina on frozen section. Dr. Kaplan. “Strangulated Non-descended Testes.” J. O., aged 32, white, occupation milk- man ; admitted writh the chief complaint of pain in the right inguinal region. After an alcoholic bout, the patient started vomiting, which con- tinued all the next day. Then experienced a sud- den sharp, lancinating pain in the right inguinal region, constant and radiating upward along Pou- part’s ligament to the iliac crest. The pain be- came cramplike after a few hours. The next day, he went to work but was unable to continue be- cause of another attack of sharp pain. There was a marked tenderness on palpation over the right inguinal region, and a mass about the size of a walnut, not reducible. No impulse on coughing. Scrotum did not contain any testicles. The right inguinal canal was opened and the tes- ticle found edematous and gangrenous with the spermatic cord twisted upon itself 4-5 times. He made an uneventful recovery. Dr. Eckert. “Bilateral Chocolate Ovarian Cysts — ■ Ruptured.” Chocolate cysts of the ovaries are be- nign cystic formations closely allied to and fre- quently spoken of as a form of extra-uterine endo- metriosis. Chief characteristics are either cystic formations or cavities, frequently bilateral, filled with a chocolate colored tenacious fluid. According to Bailey, endometrial tissue finds lodgment on the ovary and implants itself; then invades the ovarian 460 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 tissue and excavates and proliferates. The pro- liferated tissue degenerates and this, with the blood from menstrual activity, results in a pe- culiar cyst. The diagnosis is very difficult and generally made at the time of operation, or by aid of the microscope. It may be easily con- founded with chronic adnexal disease although the condition itself is not inflammatory. Medical Center of Jersey City Joseph Binder, M.D., Reporter The regylar monthly meeting of the Medical Staff was held on Thursday evening, April 9, in the Out-Patient Department of the Hospital, Dr. C. B. Kelley presiding. Among those present were: Drs. O’Hanlon, Binder, Peters, Houghton, Braun- stein, Hashing, Alter, Perkel, Fineberg, Street, Scially, Ghee, Cohen, Riese, Rector, Benjamin, Harter, Christian, Rundlett, Variano, Fellman, Winter, Perlberg, Macchi, Burke, Sprague, E. Connell, Borshaw, Siegler, and Freile. Dr. Charles M. Peters presented 2 cases of “Tumor qf the Jaws”, both patients over 50 years of age. The growths were of the upper jaw, diagnosed adamantinoma and carcinoma. Particu- lar stress was laid upon a correct diagnosis as a means of planning a successful surgical procedure and conserving function and esthetics. Under radium and x-ray treatment the carcinomatous mass entirely subsided. The adamantinoma was treated by complete removal, cutting outside of the free border with cautery, and previously ligat- ing the carotid artery. Dr. Peters also presented different stages of operative procedure in cleft palate and cleft lip, emphasizing the importance of operating within 3 months to obtain proper correction of the bones. At this period the bones are treated in the same manner as one would a fracture. The early bone operation corrects to a great extent the lip and flattened nostril. The lip operation usually fol- lows in 6 weeks and the soft palate around 18 months, or before speech begins. The mortality is lowr providing the proper preparation of the in- fant is carried out. The advice given to parents to postpone these operations in infancy is de- plorable. These cases were discussed by Drs. Braunstein, Alter and Kelley. Dr. Rundlett presented 2 cases of “Diphtheria of the Penis, Following Circumcision”. In the Journal A. M. A., May 3, 1930, there was a case of penile diphtheria reported, and it was stated that only 15 could be found in literature. Generally, diphtheria of the penis is secondary to some other diphtheritic lesion in the body; nevertheless, sev- eral cases have been reported in which the infec- tion was primary in the genitals. A number of cases reported in the literature occurred a fewr days after circumcision. The case cited by the Journal A. M. A. is the only one which has ever occurred in the Municipal Contagious Disease Hospital of Chicago, out of a series of approxi- mately 14,000 cases of oral diphtheria. We present a case (by We, I mean Dr. Troost, who was with me at the time, and to whom much credit is due) as follows: A 9 months’ old child was admitted to the Medical Center for circumcision. Unfortunately, there is no record of a routine ad- mission ward culture. Baby was operated on, on January 8, 1930, and infection first suspected on January 15. Dr. Emmet Connell saw the child next day and suspected diphtheria. Culture was sent to the laboratory and reported negative for diphtheria. Case re-cultured, both glans and throat, and the report came back, positive for penis, negative for throat. I was requested to take him over to Isolation. He received 10,000 units diphtheria antitoxin intramuscularly and the glans was sprayed daily with diphtheria antitoxin. Wet com- presses of boric acid. There was extreme redness about, and the whole area of glans covered with thick grayish-white membrane. On January 19 there was a sudden rise in temperature, and within a few hours a sharply defined reddened area ex- tending well up on the abdomen and down on the thighs and scrotum. It was not the typical, brawny red of erysipelas, but it was raised and indurated. As this infant had received already a large dose of diphtheria antitoxin, we hesitated about giving another serum for the erysipelas. The dressing was changed to warm magnesium sulph., and there wras a slight recession up to January 25, when the area again began to extend. There was involve- ment of the buttocks, showing a sharply defined erysipelas with distinct line of demarcation. Ery- sipelas antitoxin was given (500,000 skin test units, equal approximately to 10 c.c.) but the lesion con- tinued and extended, and the child developed bronchopneumonia. Getting no results from the erysipelas antitoxin, we switched to the antistrep- tococcic polyvalent serum, 20 c.c., with gratifying results, proving that we had a streptococcic ery- sipelas. Apart from a severe serum rash the little fellow continued to improve and went home on February 12 cured. This was the second case we have had. The other, a 3 year old boy, was circumcised on De- cember 17, 1929, and discharged on December 19. He was re-admitted to the hospital through the G. U. Clinic 2 days later with what was supposed to be an infected circumcision. On December 28 child developed high fever, difficult breathing and swollen cervical glands: apparently very toxic. Examination revealed that throat was covered with grayish white membrane. He was given 20,000 units diphtheria antitoxin by the throat specialist who also requested isolation. The penis was sprayed twice daily with antitoxin and kept moist with warm Wright’s solution. Laboratory reports were positive for nose, throat and penis, until January 20, when we got our first negative. On January 24 temperature rose to 103°. Examina- tion of chest revealed bronchovesicular breathing in right median line, with limitation of breath sounds pointing to a bronchopneumonia. Child ex- pired on January 26. Cases were discussed by Drs. E. Connell and Siegler. Drs. Sprague and Doran presented 3 cases of “Paget’s Disease”. Case 1. Female, broke left leg 10 years ago. This united well, but patient still complains of pain, with bowing of left leg. Later on there was bowing of the right leg. About 8 years ago she noted that her hat did not fit head and also that her right shoulder bothered her. Paget’s disease was suspected, and diagnosis confirmed by x-rays. Case 2. Male, with history of disease of 12 years’ duration. The tibia and fibula showed definite changes with bowing which is so characteristic of the disease. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 461 Case 3. Female, admitted with fracture of femur. Radiograph showed evidence of Paget’s disease, in this case not extensive. Patient was allowed up after being in bed for 10 weeks. In spite of the fact that there was a large amount of callus thrown out at the site of fracture, this patient sus- tained a spontaneous fracture of the same femur 3 in. above site of previous fracture. Dr. Benjamin presented 4 cases of “Pott’s Dis- ease in Adults”, because of the relative rarity of the disease in the adult; 10% of cases. There were 2 male and 2 female patients, ages 27, 46, 35, and 17 respectively, the average age of onset being- over 20 years. The chief complaint was pain, acute and severe in 2, and gradual in the others. The girl of 17 had pain for 3 months. The man of 46 complained of paralysis. In contrast. Dr. Benjamin also showed 3 cases of ‘traumatic spondylitis” (Kummel’s disease). In Pott’s disease, x-rays early show body then cartilage destruction, with later increase in car- tilage width, and perivertebral thickening, show- ing as spindle-shaped shadow of thickened soft parts. If this breaks down abscess results. In the adult, acute onset with pain is more common, and 10% of these show paralysis due to inflam- matory mass, bony encroachment, or pachymen- ingitis. Dr. Harter presented a case of “Recurrent Car- cinoma of the Rectum”. Female, first seen in 1928, with mass in rectum,, protruding on excetion. Biopsy showed odenocarcinorna. Hemoglobin was 50% and patient was tranfused with 1000 c.c. whole blood. Tumor then removed by actual cau- tery. Stricture of rectum resulted. In April, 1929, treatment was with radium 1630 m.c. am- peres. Patient not seen until November, 1930, when she complained of bleeding from rectum. Digital examination elicited a tumor, the size of small lemon, on anterior wall of the rectum. Op- eration of colostomy. There was no evidence of metastasis. The tumor decreased in size to small hazel nut size. It was then removed by resecting the rectum. Proximal end cauterized and sutured, and levator ani closed over. Patient is draining- through colostomy wound. Discussed by Dr. W. Friele. Dr. Braunstein showed specimen of autopsied rabbit used in performing the Ascheim-Zondek test for pregnancy. Instead of using a series of immature mice, he used a young rabbit 10-12 weeks’ old, and injected 8 c.c. urine. The ovaries of this rabbit showed hemorrhage indicating that the patient from whom the urine was taken is pregnant. Dr. Hutchinson reported the autopsy findings of a case of “Ulcerative Staphylococcus Aureus Endocarditis” in which source of infection was not determined. Bayonne Hospital Clinical Conference Maurice Shapiro, M.D., Secretary The regular meeting of the Clinical Confer- ence of Bayonne Hospital was held Monday even- ing, April 6, with Dr. Brooke acting as Chairman and Dr. Shapiro as Secretary. Dr. Finger reported from the service of Dr. Brooke 5 cases of breast tumors, in which the microscopic diagnosis from a quickly frozen sec- tion was of immediate aid to the surgeon in de- ciding upon radical or conservative operation. Case 1. Female, aged 50, admitted March 3, with history of noticing 2 weeks previously a lump in her right breast about the size of a walnut; not painful and had not enlarged since then. Sister died of carcinoma. Mass easily palpable just be- low nipple of right breast; no fixation; no aden- opathy in right axilla. A semilunar incision was made on either side of the nipple, at the edge of the gland and the tumor was gradually dis- sected out. The skin was closed with silk worm and clips. Report of the specimen sent to laboratory showed a scirrhus carcinoma present, about 1.5 ctm. in diameter, without any lymph-nodes. Case 2. Female, aged 31, admitted March 22. Trouble began 4 weeks previously, when she noticed a painless lump in her right breast. She consulted a physician who advised its removal. A biopsy was done and the section immediately examined by frozen section method. After re- port was obtained from the laboratory the en- tire breast was removed and wound closed with silk worm and clips. Specimen was quite cellu- lar, with moderate amount of connective tissue in its meshes. The nodules were not encap- sulated and tumor tissue was present in the lymphatics. Diagnosis: Adenocarcinoma of breast. This case is interesting because of the patient’s age. According to Babcock, carcinoma of the breqst in women under 35 years of age is unusual. - Case 3. Female, aged 51, admitted March 22. About 5 months previously patient noticed a re- traction of the left nipple and a lump in the breast. Sometime later she began to suffer from shooting pains down the left arm and progres- sive swellings in left axilla. She consulted a physician, who sent her to The Memorial Hos- pital, in New York, for deep x-ray therapy. She received 5 treatments and was advised to have an operation. The skin in the region of the left breast was discolored from x-ray therapy. The breast was enlarged and the nipple retracted; firmer than normal and there was a nodular mass in the left axilla. Large elliptical incisions were made extending from axilla to a point well below the left breast, the underlying fascia and part of the pectoralis major were removed. The axilla was explored and some fascia and lymph- nodules removed. The wound was closed with silk worm gut and clips. Report showed a very scirrhous breast with numerous typical and irregular cells scattered about. Tumor tissue had invaded the surround- ing structures. Being an advanced stage of the jdisease, recovery, according to - statistics, is less than 20% chance. Case If. Male, aged 30, admitted March 5. Trouble began about 9 years before admission. He was rowing for an athletic club and received a se- vere blow with an oar, in the left breast. Two years after the accident, noticed a lump in the same breast, which was becoming progressively larger until it had finally reached the size of a lemon. The breast had been sore ever since the accident, but had never given much trouble. Re- moval was advised. An oval incision was made over the mass and tumor removed with surrounding fatty tissue. Report was a fibro-adenoma without any evi- dence of metastasis. Case 5. Female, aged 29, admitted December 3. About 8 years ago she noticed a lump in her right breast which gradually increased in size 462 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 until it reached the size of a lemon; a hard, freely mo\able lobulated mass. Incision made through skin, superficial fascia and gland sub- stance intervening between fascia and outer wall of tumor. Entire growth was excised, and cavity approximated by deep sutures followed by clos- ure of superficial wound. Tumor consisted of 9 small firm masses which were well encapsulated. Microscopically there was atrophy of the glandular tissue. Intracanal- icular fibro-adenoma. Dr. Antapol stated that diagnosis by frozen sec- tion, if the pathologist has been notified in ad- vance and can have things prepared in time, can be made in 5 minutes. Experience has shown that diagnosis made in the microscopic stage re- sults in the highest percentage of cures. He also stated that after operation on a malignant case, there is a metastasis of the growth by a milking or suction action of the lymph channels and that, therefore, it is necessary to institute x-ray or radium treatment immediately. These conclusions have been verified by laboratory ex- periments on animals. He stated that there are 3 reasons for diagnosis by frozen section. (1) The question whether the operation shall be radical or conservative. (2) Clinicians realize that the microscopic stage of the disease should be recognized. (3) To differentiate between be- nign and malignant tumors. Dr. Brooke suggested that all cases of malig- nancy where the diagnosis is made from clinical evidence, should have a chest x-ray plate made in order to see if there is any metastasis into the lungs. He believes that if cases show metastasis they should not be operated on, as it only has- tens death. Dr. Murray reported the very interesting case of a woman about 32 years of age who began vomiting with extreme pain in the abdomen, af- ter previously complaining of a dysmenorrhea. Dr. Brooke saw this patient in consultation and thought there was ovarian trouble. At opera- tion a tuberculous peritonitis was found and tuberculosis of the appendix, ovaries and tubes. The patient is now getting better. Dr. Brooke suggested that one should always bear in mind tuberculosis when there are ovarian and tubal symptoms. He thinks that panhyster- ectomy is indicated in this case because tuber- culous cases are always over-sexed, and the re- sulting artificial menopause reduces sex desires and helps toward improvement. Dr. Feinberg reported on the use of antitoxin in several cases of erysipelas. Two cases were confined solely to the face and the other ex- tended to the chest and other parts of the body. Treatment used, 5000 units of erysipelas anti- toxin in each case, plus the local treatment of magnesium sulphate, glycerin dressings and boric acid applications. In 2 cases temperature was normal after 48 hours following administration of the serum, while in the more extensive case the symptoms cleared up and condition abated after the fifth day. Local use of immune serum, after the methods of Rivers and Tillet, showed that the infiltration of skin with normal or immune serum renders the areas thus treated quite refractory to infection with hemolytic streptococci. In most cases it is found that the process extends to the infiltrated area and then stops. In Bellevue Hospital, New York, the largest erysipelas ser- vice in the world, the antitoxin treatment is em- ployed to" the exclusion of all other methods. HUNTERDON COUNTY Barclay S. Fuhrmann, M.D., Reporter The Hunterdon County Medical Society met at Flemington, April 21, at 10.30 a. m. The fol- lowing members and visitors were present: Drs. A. H. Coleman, M. H. Leaver, Francis Apgar, E. F. Purcell, L. C. Williams, G. B. Tompkins, W. E. McCorkle, E. W. Closson, George Henry, B. S. Fuhrmann, F. G. Scammell and H. O. Reik. In the absence of the president, the meeting was called to order by Dr. Coleman. After transacting the usual routine business, and hearing a report of the treasurer which showed the society’s finances to be in good con- dition, the president called on Dr. Ernest F. Pur- cell, of Trenton, to read a paper on “Potter’s Version’’. Dr. Purcell traced the application of “version’’ from its inception years ago, to the present day and showed the changes that had been brought about in the mechanics of the operation. The paper was very beautifully illus- trated with drawings and, at the close, by show- ing a "clinical movie” of actual cases, which illustrated better than words the actual opera- tions. The clear and concise manner in which Dr. Purcell presented his subject was much ap- preciated. After some discussion of the general opera- tive procedures in obstetrics, the meeting ad- journed and we were served one of the famous chicken and waffle dinners by the Union Hotel. MERCER COUNTY A. Dunbar Hutchinson, M.D., Reporter The Mercer County Medical Society met in the Carteret Club on the evening of April 8, with Dr. Swern presiding. The regular order of business was suspended, and the moving picture, “Spinal Anesthesia”, ex- hibited. The application of Dr. Gerold H. Miller was read and referred tc membership committee. A communication relative to the parking prob- lem was referred to a committee, with power to confer with the City Commissioners. The subject of contract practice again appeared on the floor, and following a lengthy discussion, the President appointed Drs. Samuel Sica, C. H. Mitchell, E. F. Purcell, A. D. Hutchinson and G. A. Corio, as a Committee to investigate the sub- ject and report to the society. Dr. C. H. Mitchell was elected a member of the Board of Censors, to fill the vacancy occa- sioned by the death of Dr. Charles J. Craythorn. Following discussion on the subject of suit- able quarters for the holding of meetings, the society having outgrown the present facilities, Drs. Schildkraut, Scammell and Sica were ap- pointed to obtain information relative to the pos- sibilities of making a change. The society mourns the loss, through death, of several of its members, who, by their active par- ticipation in the affairs of the society, promul- May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 463- gated the high ideals for which the society stands, and through their wise counsel, temperate attitude and broad vision advanced the organiza- tion of the profession in the welfare of the com- munity in which they labored: Dr. Raymond S. Seibert died February 23; Dr. William M. Strat- ton on March 23; Dr. Charles J. Craythorn, March 28, and Dr. Walter F. Madden, April 13, 1931. MIDDLESEX COUNTY Samuel G. Berkow, M.D., Reporter April meeting was held at Middlesex General Hospital, New Brunswick, April 22, at 9 p. m. The scientific program consisted of a paper on “Hay-Fever”, by Dr. Thommen, of New York City, and discussed by Dr. Leonard, Director of Squibb’s Immunogen Laboratories, in New Bruns- wick. Dr. Thommen, an outstanding authority on problems of allergy, presented his subject con- cisely but with an amazing amount of detail and the subject seemed to expand in scope under his capable elaboration; he vivified the subject. He developed 5 postulates which must be satisfied for a plant to be considered as an important cause of hay-fever. By means of lantern slides he illustrated these postulates, showing the plants that pollinate and whose pollen contains an irri- tant capable of causing symptoms of hay-fever; the importance of wind-born pollen in contrast to pollen carried by insects; the smaller pollens, capable of being carried long distances, as op- posed to those greater than 5 0 millimicrons in diameter; the quantity of pollen in various plants satisfying the previous requirements; and those plants having a large geographic distribution. He then discussed the treatment of hay-fever by means of subcutaneous injection of graded doses of the irritant, and emphasized the danger of in- jecting even minute quantities into hypersensi- tive patients, whom he graded into 4 groups. Dr. Leonard discussed the paper and called attention to 2 variations from the usual pre- seasonal treatment. One, which he termed the English method or “hurry-up” treatment, in which the patient is confined to bed, preferably in a hospital, and given graded doses at very short intervals, completing the treatment in 24 to 48 hours; the other consisting of injections given to hypersensitive patients at monthly in- tervals following the preseasonal treatment. Dr. F. G. Scammell, of Trenton, Councilor of the Third District, who visited the meeting, re- lated his own experience with hay-fever and in- quired as to the surgical treatment of local con- ditions in the nasal and oral cavities. A committee was appointed to draw up resolu- tions expressing sympathy of the society, to be sent to the families of Dr. Ellis, of Metuchen, and Dr. Gruessner, of New Brunswick, recently deceased. Both served their respective com- munities faithfully and well, and were loyal mem- bers of the County Society. A Committee on Public Health and Public Re- lations was appointed. Dr. Johnson spoke of the child health conference to be held shortly and asked for cooperation of the society in this im- portant state endeavor. The newly formed com- mittees were instructed to present a plan for such cooperation. The subject of by-laws governing the County Society came up for discussion, and a committee was appointed to revise the present constitution. MONMOUTH COUNTY William Van Oehsen, M.D., Reporter The monthly meeting of the Monmouth County Medical Society was held at the Garfield-Grant Hotel, Long Branch, Wednesday evening, March 25, with Dr. William K. Campbell presiding. Minutes of the previous meeting were read and accepted. A letter was read from E. Donald Sterner, State Senator, promising his support in opposition to Senate Bill No. 155. Dr. H. Brown, of Free- hold, moved that a letter of thanks be sent to Mr. Sterner ; seconded by Dr. Slocum, and carried. Dr. H. Brown, of Freehold, reported that the old minute book had been bound. It was voted that the cost of binding the minute book ($5) be paid. Drs. William Matthews, Frank Niemtzow, George S. Reynolds and Morris Woronoff were elected to membership. Dr. Campbell announced that the Woman’s Auxiliary is to hold a meeting on April 7, and urged members to assist in promoting attendance. An extremely interesting talk was given by Dr. Byron Blaisdell on “Urologic Conditions’’. A buffet lunch was served. OCEAN COUNTY Eugene G. Herbener, M.D., Reporter The Spring Meeting of the Ocean County Medi- cal Society was held February 24 at Murray’s Log Cabin, Lakewood, with Dr. Adolph Towbin presid- ing. The following members were present: Drs. Adolph Towbin, Abraham Goldstein, Alfred Wood- house, Frank Brouwer, V. M. Disbrow, Harold Disbrow, Robert Buermann, Herbert Willis, J. Hilliard,’ Frank Denniston and Eugene Herbener. Applications for memberships were referred to the Committee on Membership. The President appointed Dr. E. G. Herbener, Reporter, to fill the vacancy caused by the death of our fellow mem- ber, Dr. Geo. W. Lawrence. A committee consisting of Drs. Frank Brouwer and E. G. Herbener was appointed to draw up resolutions on the death of Dr. Lawrence. (See Obituary Section, this Journal), The guest speaker of the . evening was Dr. George N. J. Sommer, President of the State So- ciety, who spoke on the benefits to be derived by members attending their County, State and A. M. A. meetings, which tend to create a better fellow- ship among the members. He touched on “State Medicine”, the New Jersey Workman’s Compen- sation Law, and made some complimentary re- marks about the Woman’s Auxiliary to the Medi- cal Society. He also expressed his opinion freely on matters concerning the county societies, as it has been his pleasure to visit each of the County Societies during the past year. PASSAIC COUNTY Wayne W. Hall, M.D., Reporter The regular meeting of the Passaic County Medical Society was held at the Health Center, Paterson, April 9, at 9 p. m. Dr. Carlisle pre- 464 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 sided. The minutes of the March meeting were approved as read. The application of Dr. Francis Palmer, of 2 7 Monroe Street, Passaic, was received and referred to the Board of Censors. The paper of the evening was presented by Dr. William C. White, Attending Surgeon at Roose- velt Hospital, New York City, on the “Diagnosis and Treatment of Breast Conditions’’, and was illustrated by lantern slides and moving pictures. Considerable discussion was carried on by Drs. Leon De Yoe, Thomas Dingman, William Spick- ers and David Polow. It was stressed that in chronic cystic mastitis, pain is of little diagnostic value. The condition is likely benign if lumps are multiple. In lymph obstruction, the Con- dolian operation is a failure because the scar is too near the arm pit and all patients have some postoperative edema. Theoretically the ideal thing to do is to block off lymph by x-rays. One month is required for proper effect in this treatment. As to infection in the breast after this procedure, it does not favorably influence the result. Simple mastectomy was conceded the indica- tion in the ordinary bleeding nipple. Propa- ganda, it was felt, influences procedure, but if a small lump is found it should be removed. Multiple cystic mastitis warrants simple mas- tectomy, as there is more irritation from numer- ous scars than from simple mastectomy. Dr. White also stated that in 20% of cases with the Halsted incision, skin graft is done, the arm be- ing placed in abduction 3 to 4 days after opera- tion to prevent edema. SALEM COUNTY William H. James, M.D., Reporter The Salem County Medical Society met at the Memorial Hospital, in Salem, on Wednesday, April 8, at 2 p. m. The meeting was called to order by Dr. Frank Perry. The minutes of the last meeting were read and approved. The speaker of the afternoon was Dr. B. L. Fleming, of Jefferson Medical College. His sub- ject: “Diagnosis of Acute Abdominal Lesions’’. He gave a very interesting talk about the dif- ferent abdominal lesions, such as appendicitis, duodenal ulcer, and peritonitis. This paper was very ably discussed by Dr. George N. J. Sommer, President of the New Jersey State Medical Society, who went into de- tails, as did some of the other members of the society. Dr. Morrison, Secretary of the State Society, read a paper on “State Medicine"; and Dr. Reik, gave one of his usual interesting talks. Dr. Edward R. Prigger, of Pennsgrove, was elected a member of the society. The next meeting will be held at the Country Club where we have our famous planked shad dinners about the middle of May. SOMERSET COUNTY J L. Young, M.D., Reporter The bimonthly meeting of the Somerset County Medical Society was held at the Nurses’ Home of Somerset Hospital, on April 9, Dr. E. G. Brit- tain presiding. The meeting was held in the evening for the first time in many years to see if it would in- crease attendance. There was an unusually large attendance; so a motion was made and passed that the next meeting be held in the even- ing at the same place. In the absence of the chairman of the com- mittee on collection of fees for compensation work, the secretary read the report of the com- mittee. Motion made and passed that the sec- retary have copies of report printed and mailed to each member of society. Dr. Avidan, of the referee’s court, read an in- teresting paper on “Methods of Collection of Compensation Bills”. The meeting was also attended by Dr. George N. J. Sommer, President of the Medical Society of New Jersey, and Dr. F. G. Scammell, Councilor for the Third District; brief talks were made by these visitors. Dr. Henry O. Reik, Editor of the Journal of the Medical Society of New Jersey, and Dr. J. Bennett Morrison, Secretary of the New Jersey State Medical Society, were also present and made short addresses. UNION COUNTY Russell A. Shirrefs, M.D., Reporter. About SO members attended the regular quar- terly meeting of the society at the Elizabeth Gen- eral Hospital on the evening of April 8. Dr. M. Vinciguerra, who presided, introduced the guest speaker. Dr. Herman O. Mosenthal, Professor of Internal Medicine at the New lrork Post-Gradu- ate School. Speaking eloquently, without manu- script, Dr. Mosenthal lectured on “The Diagnosis of Bright’s Disease”, and explained in detail the pathology of the nephritic kidney, impaired renal function, edema, anemia, hypertension and uremia; carefully considering the significance and inter- relation of the above symptoms. Discussion was opened by Dr. H. R. Livengood, who was followed by Drs. Wilson, Stern, Banker. Shirrefs and others, who asked questions which Dr. Mosenthal answered. One resignation was accepted on account of re- moval from the state; 5 were proposed for mem- bership, to be voted on at the next meeting; the following were elected : Drs. Frederick Hnat, George Ladas, Charles Ferguson, all of Elizabeth; and Gordon A. Stephenson, of Summit. An enjoyable collation served by courtesy of the Hospital was followed by a pleasant social hour. Summit Medical Society William J. Lamson, Secretary The regular monthly meeting of the Summit Medical Society was held at Wallace Pines on Tuesday, March 24, with President Smalley in the chair, and Dr. Krauss entertaining. There were 21 members and 6 guests present. The minutes were read and approved. Dr. Dengler announced that the Board of Health was using a diagnostic test for whooping-cough, by means of the injection of a serum, and hoped that the members of the society would send sus- pected cases to him for trial of the test. May, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 465 The paper of the evening was read by Dr. Ivrauss on “Medical Economics from the Practitioner’s Standpoint”. Very few enter the practice of medi- cine as a means of amassing wealth. The rewards of a professional career are: interest in the work itself; the opportunity to know human nature thoroughly; and the satisfaction of a useful life. But a physician has a right to live as well as his ability warrants, and to provide the usual com- forts and luxuries for his family. Many factors militate against great financial returns. Prepara- tion for his lifework is long, tedious, and ex- pensive. His office equipment and overhead ex- penses are large if they are to be adequate. Va- cations or illness are a dead loss. Public health activities of all sorts are continually limiting his field of action. Free clinics are abused by those able to pay. Quacks and charlatans still further attract the ignorant or gullible public. Much char- ity work is expected of the doctor, and worthy charity is cheerfully done. Sound medical economics can help the prac- titioner to a better living. Dr. Krauss made many useful suggestions along this line. A sliding scale of varying charges, proportional to a patient’s finan- cial standing and the skill and experience re- quired, is not only warranted but should be care- fully established. Telephone calls for advice should be charged for. Night calls should cost the patient double the amount of a day call. When more than one patient is treated in the same house, an extra fee should be expected. Evening office hours are illogical and often unnecessary; no other profession holds them, and calls made at such hours should be at a higher rate. Much can be done by the physician in training his pa- tients to be more considerate of his time. Many other valuable suggestions as to the economic • betterment of the practitioner were made. The paper was so thoughtfully prepared and presented that there was no adverse discussion. Obituaries DEMAREST, Frederick F. C., until recently dean cf Passaic physicians, died on Saturday evening, March 28, at his home, 49 Willard Place, Rutherford, after a stroke of paralysis in his seventy-fifth year. He was a resident of Rutherford from 1870 un- til a few years ago, and a practicing physician there since 189 9. On Friday he was out in his car as usual, but on Saturday morning he spoke of being ill. Dr. Demarest was born in Bound Brook on June 23, 1856. He was the son of the Rev. Will- iam Demarest, a Dutch Reformed clergyman, who was a native of New York, and Sarah Eliza- beth Cornell Demarest, a descendo.nt of the Freylinghuysen family of New Jersey. He was graduated from Columbia Grammar School and from Bellevue Hospital Medical College, New YTork. Fie was a member at the latter of the “blizzard class’’ of 1888. He was a member of the American Laryngological, Rhinological and Otological Society and of the American Board of Otolaryngology, besides the American Medical Association and the Passaic City Medical Society. He was noted for his in- vention of several surgical instruments, the most notable of which is the Demarest tonsillotome. Resolutions Adopted by the Ocean County Medical Society “WHEREAS it has pleased Almighty Provi- dence to call by death from our professional circle, Dr. George W. Lawrence, a member of the society for 24 years, BE IT RESOLVED that we hereby give expres- sion of our sorrow at his departure, and do honor to his memory. Dr. George Washington Lawrence was a gradu- ate of the Y'ale Medical College and Chief of Staff of the Paul Kimball Hospital, Lakewood, N. J. He died at his home in Lakewood, of a stroke of apoplexy, while he was recovering from a 6 weeks’ illness from toxic poisoning. Dr. George W. Lawrence Dr. Lawrence, who was 6-1. years old, was a former President of the Ocean County Medical So- ciety and was nationally known in medical circles. He was considered dean of surgeons in this part of the state and was also well known in business circles, having been Vice-President of the Lake- wood Trust Company and of the First National Bank of Lakewood. He was Founder and Presi- dent of the Ocean County Building and Loan Association. During the World War he was a Major in the New Jersey State Militia and di- rected the medical work, following explosion of the Gillespie Ammunition Plant, at Morgan, N. .1.. when South Amboy and Perth Amboy were de- vastated. He was born at Roxbury, New Hampshire, on April 2, 1869, and has lived in Lakewood 24 years. His wife died 7 years ago. Two daughters, Mrs. Walter Brown, of Lakewood, and Mrs. Russell Scott, of Plainfield, N. J., survive. He was a member of several lodges, including the Lakewood 466 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY May, 1931 Masonic Lodge and of Saloani Temple, I. A. A. O. M., of Newark, N. J., also a member of the Lakewood Rotary Club and Surgeon for the Cen- tral Railroad of New Jersey for many years. Frank Brouwer, M.D., Eugene G. Herbener, M.D., Committee on Resolutions. OSMLTN, Louis Cook, of Hackettstown, died at the Dover General Hospital, Monday, March 30, 1931, after a brief illness with multiple abscesses of the spleen. He was 66 years of age, and had been practicing medicine in Hackettstown since his graduation from College of Physicians and Surgeons, of New York City, with the exception of 3 years practice in Newark. Dr. Louis Cook Osmun Dr. Osmun was born in Mendham Township and was the only son of the late Edward and Ruth Menagh Osmun. He was chosen as head of the hospital during the small-pox epidemic in 1901. He was recognized and held offices in both the Warren County and New Jersey Medical Societies, being a Trustee of the latter at the time of his death. Besides this he was a Director of the Dover General Hospital and a member of the visiting staff. He was a member of the Methodist Episcopal Church, Dover Lodge of Elks, Monitor Council, Jr. O. TT. A. M., and a charter member of the Hackettstown Club. MADDEN, Walter, 324 South Broad Street, Trenton, died at his home, April 12, in his 58th year, of cerebral hemorrhage. Dr. Madden was born in Tuckahoe, N. J., July 10, 1873, the son of Thomas Madden. His ances- tors came to this country from Scotland and settled in New Jersey. His great grandfather, Hosea Madden, operated in South Jersey a glass works, which was the first of its kind in America. Products of the factory were known in all parts of the world. At the death of the founder, the business was continued by his son, Hosea, Jr., who took an active part in South Jersey politics. On his mother's side, Dr. Madden was a des- cendant of the old Steelman family, of Pennsyl- vania. The Madden family came to Trenton in 1875. Dr. Madden received his education in the public schools and the Rider Moore Business College, and then studied medicine under the late Dr. William Rice. He attended Jefferson Medical College for a time and was graduated from the College of Physicians and Surgeons, Baltimore, in 1897. In politics Dr. Madden met with a success that would have turned the head of a man less bal- anced. He was elected to Common Council from the Third Ward in 1904, and in 1906 was re- elected by an increased majority. He also served 2 terms as city physician and in 1908 was the unanimous choice of the Democratic party for mayor. After a close race, he emerged as vic- tor over John E. Gill, Republican, by a majority of 889 votes, and was later reelected by a very large majority. In 19 00 Dr. Madden married Miss Minnie Metzler, daughter of Andrew Metzler. The form- er mayor was a member of Mercer Lodge, No. 50, F. .st A. M.; Trenton Consistory, Scottish Rite; Crescent Temple, A. A. O. N. M. S.; Royal Order of Jesters; Tall Cedars of Lebanon; Trenton Lodge, No. 105, B. P. O. E.; Trenton Lodge, No. 164, L. O. O. M.; South Trenton Encampment, I. O. O. F.; Mercer Circle, No. 40, B. of A.; Mercer County Medical Society, and the American Medi- cal Association. SCOTT, George, died at his residence 9 S„ Pennsylvania Avenue, Atlantic City, Friday March 27, 1931, after an illness of several months. Dr. Scott came to this city from New Y"ork in 1903 and had practiced here since that year. He was 80 years old. Born in Illinois, he graduated from ML Union College, Ohio, and from Bellevue Medical College, New York, in 1871. He practiced in New York prior to coming to Atlantic City. WEBSTER. D. King, died at his home in Lees- burg, N. J., at the age of 52, after an illness of 2 weeks with pneumonia. Dr. Webster is survived by a widow, Mrs. Janice Lee Webster. His stepmother, Mrs. Amelia Web- ster, is living in Philadelphia. His own mother, Mrs. Ella Webster, died when he was a child and his father, Daniel Webster, died several years ago. Dr. Webster was born in Delmont and was graduated from the University of Pennsylvania Medical School. He opened an office in South Seaville and later located in Cape May Court House with Dr. Dix. He spent several years in Kansas prior to 1912, when he came to Leesburg, where he entered into a partnership with Dr. George S. Spence which lasted until the World War, when Dr. Spence sold his share and enlisted. Dr. Webster was a member of the Cumberland County Medical Society and a member of Neptune Lodge, F. and A. M., of Mauricetown. He was medical examiner for the public schools of Maur- ice River Township. 467 Journal of The Medical Society of New J ersey Under the Direction of the Committee on Publication Vol. XXVIII., No. 6 ORANGE, N. J„ JUNE, 1931 Subscription, $3.00 per Year Single Copies, 30 Cents ALCOHOLIC PSEUDO-PELLAGRA; RE- PORT OF CASES, WITH NOTATIONS ON THE ETIOLOGY N. B. Heller, M.D., Newark, N. J. During the hot summer months we have an opportunity of observing a number of derma- toses at the Newark City Hospital and Dis- pensary all of them presenting certain fea- tures in common. This has been previously described by other workers as alcoholic pseudo-pellagra. A short history of some of the cases will bring out the salient features. Case 1. C. P., 39 yr. old, laborer, born in the United States, was admitted to the hospi- tal with the following history: Out of work for the past 3 months, and his diet consisted of coffee, cake, and an occasional frankfurter; no fresh meat, vegetables nor fruit during the entire period. For the past 2 weeks has been using the average of a quart of poor gin daily, which caused a persistently upset stomach and loss of appetite. During the last few days, when the weather was hot, he slept out in the park. The last time, asleep with arms out- stretched, he awoke with a burning pain in the hands and they were red and covered with blisters. Physical examination : Poorly nourished, anemic, with dark pigmentation of the face and neck. Speech slightly incoherent, but no other mental symptoms ; a slight tremor of the hands. The dorsal aspect of both hands ery- thematous, infiltrated, covered by a finely lamellated scaling; a few flaccid bullae and where they had ruptured the areas were cover- ed by thin crusts ; in between, there are small islands of dark-brown pigmentation and dry atrophy. These changes are sharply demar- cated and confined symmetrically to both hands arid lower third of fore-arms. Laboratory findings were entirely negative, except for a trace of albumin in the urine and an occasional cylindroid cell. Under a generous mixed diet rich in fresh vegetables and meat he made a speedy re- covery. Case 2. L. J., 42 yr. old, laborer, native of Italy, admitted with the following history : Out of work for 4 months ; diet very irre- gular and of poor quality. For the past 3 weeks slept outdoors and used cheap alcohol freely. During the last heat spell, while sleep- ing in the park, noticed swelling of both hands associated with a burning pain and marked redness. Physical examination : Markedly under- nourished; anemic ; an anxious look in his face; tongue swollen and dark-red. Both hands and up to the lower' third of the fore- arms symmetrical dark red swelling, with marked pigmentation, fine lamellar scaling with a few scabs where the skin denudation was deep. Laboratory findings showed FIbg. 65% ;. otherwise negative. Patient made a complete recovery on a gen- erous mixed diet. Case 3. A. C., 39 yr. old, housewife, native of Italy, admitted to the hospital with a nega- tive family as well as personal history. Has always been in good health. Gave birth to 8 children ; all living and healthy. Husband has 468 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1031 Case No. 1 Case No. 2 June. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 469 been out of work for some time. During the past few months diet consisted of starchy food, mainly spaghetti served in different ways. W ith this there was an abundant sup- ply of home made wine. They occasionally had some milk and eggs, but the children got most of that. She does not remember eating any fresh meat, fruit nor vegetables during the entire period. During the hot weather she has been sitting in the yard with sleeves rolled up, thus ex- posing arms to the direct sun. On one oc- cation she had a sharp burning pain in the plus ; blood sugar, 0.095 ; blood urea-nitrogen, 10 mgm. ; blood Wassermann, negative. Alcohol and pellagra. From the earliest days alcohol has played a prominent part in study of pellagra and pellagrous conditions. As far back as the days of Zeist. the European litera- ture abounds with case histories under the name of pseudo-pellagra where no history of maze consumption could be elicited. In those cases chronic alcoholism was frequently found to be a factor. Olo’zag describes chichism in Colombia as a disease clinically resembling pellagra, and by Case No. 3 arms and noticed a few blisters, after which the arms became dark-red. Physical examination revealed an apa- thetic, fairly nourished individual, with a light brown pigmentation of face and neck, but not more than would be expected of a member of the Latin race. The tongue was deep red, but no other abnormalities. The ex- tensor surfaces of both hands, fore-arms and arms to the upper third showed symmetric pigmentation, with atrophic skin and fine flaky scaling. Some of the areas showed bright red lesions where the epidermis had been denuded. Laboratory findings: Urine, albumin 3 many authorities accepted as such, and caused by abuse of a native alcoholic drink made from maze and called chicha. Lie believes that because of the increased use of chicha not enough animal protein is consumed in the diet, and we get pellagra-like symptoms. It is interesting to note that with the decreased use of chicha and corresponding increased in- take of other foods there was a marked dis- appearance of the disease in the city of Medellin. Y. C. Shattuck, reviewing 144 cases of pel- lagra, reports 78% as abusing alcohol. Joseph Goldberger considers alcohol to be a chance coincidence in pellagra ; one acting 470 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 mainly by causing a chronic gastritis, inter- fering with appetite and the proper food in- take, and thus causing a decrease of protein with an increase of salts absorption. With these we must also consider the lowered body resistance caused by alcoholism. Light and pellagra. Goldberger quotes Fra- pelli’s (177 1) first description of pellagra in Italy and attributes the disease to the sun rays. Gherardini (1877) held the same view as to the sun being the causative agent. They all succeeded in producing an erythema and pigmentation of the back of hands in the pel- lagrous by exposing them to the June sun for a few days. These experiments certainly were not well controlled, as lesions also occur on nonexposed parts, while protection of hands and fingers did not prevent appearance of the eruption. Neusser (1887), examining markedly pellagrous children in Roumania, found the lesions confined to the hands and feet while the rest of the body showed only increased pigmentation. Goldberger and Wheeler, in experimental production of pel- lagrous lesions in human subjects, showed cases where the first lesions were noted on the genitalia ; not on exposed parts like the hands and feet. R. Crawston Low quotes Volpitio and Ron- doni as causing hyper sensitiveness in pellagra patients by injection of maze extract and ex- posing them to the sun rays. Evidently some toxins are produced in the circulation which are activated on exposure to the sun. Summary During the hot summer months we meet certain skin lesions which clinically cannot be distinguished from those seen in cases of pel- lagra. Without any exception all of our cases were found in chronic alcoholics who exposed themselves to the direct rays of the sun. It is quite difficult to explain these skin lesions. It is the accepted view, thanks mainly to the works of Joseph Goldberger, Wheeler Svden- stricker, and others, that pellagra is due to a dietary deficiency in animal protein-amino- acids, together with an inadequate mineral salt supply, and that unknown quantity belong- ing to the vitamin B complex. We can explain the skin changes in alcoholic pseudo-pellagra as due to a deficiency of the same elements in the diet, but caused by the chronic alcoholism, which acts as a food substitute, thus causing a loss of appetite and diminshed protein intake. Most of the patients are suffering with chronic gastritis. Whatever food they do manage to take is not properly digested and we get a condition analagous to that found in pellagra. The direct sun rays act only as an exciting cause on a tissue which has been lowered in resistance by the dietary deficiency. A GROUP OF ENDOCRINE CASES* Frank J. T. Aitken, M.D., Bridgeton, N. J. There are few syndromes in medicine so interesting, curious and provoking as those which are brought about by perverted func- tioning of the glands of internal secretion. It ♦(Read before the Bridgeton Hospital Staff, Nov. 11, 1930.) June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 471 is regrettable that in the face of so many in- teresting facts and cases of this sort that there is so little teaching of this important subject in the medical curricula. It is true that the exaggerated claims of commercial physicians and fanatics, who treat everything with “glandulars”, have caused many of our conservative practitioners to remain skeptical, just as there are still many skeptics on the subjects of heliotherapy and nonspecific protein therapy. If common sense and sound judg- ment, backed by the comprehensive knowledge of endocrinology and metabolism, were applied to the administration of “glandulars”, there would be few disappointments in their use, and many delights. It is indeed an easy mat- ter to understand how many physicians bred to therapeutic nihilism, in such schools as Harvard and Yale, will become such ardent believers in endocrine therapy that they could be termed fanatics. All fanatics, however, have the best of intentions. It is the purpose of this paper to present an unselected group of 9 cases, all of which deal with a glandular dystrophy. For con- venience in discussion, I will first mention the gland involved and the name of the syndrome. It will be necessary to be brief. Case 1. Pituitary (diabetes insipidus). J. M., a girl of 17, first seen on January 17, 1930, complaining of vomiting for 2 months. No pain; no nausea; the vomitus was not bilious, acid nor offensive ; occurred especially on overloading stomach or under any excite- ment. She admitted a voracious appetite, with constipation, segmented stools, and a craving for sweets and coffee. Her speech was hur- ried and there was a marked tremor of the hands. Tentatively, I diagnosed a catarrhal gas- troenteritis or possible chronic appendicitis with a thyroid imbalance of girlhood. Her diet was restricted on carbohydrates and cof- fee, and she was placed on tincture of bella- donna in 5 minim doses, and anesthesin and menthol each gr. y2 t.i.d. On her return a week later she was improved in all respects ; no vomiting ; bowels regular ; tremor slight and abdomen negative. For want of some- thing better, I gave her Ignatia 6x, a remedy of the homeopathic school of much value, in hysteroid conditions. Two weeks later she returned and with triumph over modesty informed me of the tremendous amounts of urine she passed. The urine, on examination was normal, even as to specific gravity. The blood sugar, urea and Wassermann were negative. The male parent submitted to the taking of a blood Wasser- mann, which returned 3 plus. She was placed on potassium iodide solution and mer- cury by mouth. When seen on September 1, 8 months after the first visit, there were no symptoms of disturbed function. She is now taking Lugol’s solution 2 weeks on and 1 week off, and has not reported for observa- tion. Case 2. Pituitary (enuresis) . J. E., married man, 22 years of age, first seen October 1929. Father died of tuberculosis when patient was 8 years of age — implying a tuberculous in- heritance. Family history negative otherwise. Chief complaint : bed-wetting 2 or 3 times every month. Personal history negative; height, weight and nutrition ideal. No evi- dence of focal infection. Urine repeatedly negative. No history of excess in the good things of life. Genito-urinary examination negative ; no phimosis ; no prostatic enlarge- ment. Feeling there was little to lose in a trial of pituitary extract, and all to gain in retaining the cooperation of the patient, I placed him on capsules of pituitary body posterior lobe gr. 1 daily, with biweekly injections of 1 c.c. of the extract, and after 2 months dismissed him; requesting continuance of the gland by mouth and to keep a record of his embarrass- ing moments. The patient returned in June of this year as requested, and stated that for 3 months he had been without enuresis. The dietetic bans were withdrawn, as well as the medication, and he has been instructed to report again this month. Case 3. Pituitary and thyroid ( Frohlich’s syndrome) . M. L., American girl, 12 years of age, first under observation June 1 this year. Weight 160 ; pink, blooming and jolly. Her complaints were fatigue on exertion or mod- 472 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 crate walking and abdominal cramps. She started to gain weight at 10 years of age, as had her mother and her brothers in their child- hood. Has menstruated since 11 years of age at irregular intervals averaging 3 weeks apart. Has complained of fatigue since the onset of her menses, which were painless and moderate in amount, and has gained decidedly in the few months before this history was taken, in spite of a sensibly restricted diet. Physical examination revealed marked in- crease of fatty tissue, especially over the lower abdomen, bips and breasts. Legs were slender. Fingers long and tapering. Hands cold. Widely separated upper incisors and abnormal development of tbe lateral incisors. The heart and lungs revealed no pathology. Pulse rate 90; greatly influenced by exercise. Tbe urine, blood sugar, and Wassermann, the last of which it is advisable to take in all cases of obesity not influenced favorably by diet, were all negative. I placed her on a liberal diet and restricted .■all exercise. By way of medication, anterior pituitary 6 gr. ; thyroid gradually increased ■over 2 weeks to 10 gr. daily. In 2 weeks a loss of 12 lb. was reported, and almost imme- diate loss of abdominal pain, which I believe was a cardialgia. The patient at this date, 4 months after her first examination, has lost 30 lb., menstruates regularly at 3 week in- tervals, which to be generous I ascribe to the medication, and she can enjoy longer walks without fatigue. The thyroid has been de- creased to 1/10 gr. 3 times daily and there are no complaints. Case 4. Thyroid (thyroid asthma). This case I shall never forget because of the fear it created and the respect for adrenalin. The pa- tient was a girl of 14, 6 feet tall, precocious, who for more than 3 months had been sub- ject to almost continual paroxyms of dis- tinctly asthmatic character. On her first visit in March 1930 she stated she had been taking injections of sterile water for the asthma, but had never been treated for allergic manifesta- tions as shown by skin tests. Closer examina- tion objectively revealed widened palpebral orifices with a staring expression character- istic of exophthalmic goiter. Her mother had a marked unilateral enlargement of the thy- roid. An etiologic relationship of the hyper- thyroidism to tbe asthma, naturally suggested itself. Recalling the so-called Goetch test (which is widely used in Great Britain in dif- ferentiating toxic thyroid disease from simple goiters, by a dermal reaction and also blood pressure variations, from tbe injections of adrenalin), I injected 2 minims into the girl’s arm and in about 2 seconds she gave what sounded like a death rattle and went cold and flaccid. I reassured the mother and carried her to the mechanical table, where treatment was rendered. In a few minutes she regain- ed consciousness, and at the same time had the first complete freedom from paroxysms. She was placed on belladonna and Lugol’s solution. A week later she returned and said she had only one spell of dyspnea which was relieved by ys gr • of ephedrin. The next 2 weeks she had no attacks. She returned this November, after a lapse of over 6 months (although it was my desire to observe her at closer intervals while on such potent medica- tion), with a history of 3 days of paroxysmal dyspnea. At this time her neck was quite visibly enlarged and tense, and speech was almost impossible. She had abandoned medi- cation 3 months before this visit and had ap- parently returned to a toxic state of thyroid activity. Oral administration of antispas- moclics and adrenalin was ineffectual and after waiting 40 minutes, adrenalin 2 minims was administered subcutaneously. There was a marked reaction, approaching collapse and followed by profuse vomiting. After the vomiting the patient felt relieved and breathed normally. She was again placed on bella- donna and Lugol’s solution with admonition to lie regular in office attendance, and to the present date she has had no complaints. Case 5. Pituitary (myxedema and neuro- syphilis). This patient was referred to me on September 18, 1930. Fifty-four years of age, but presenile. Ocular examination revealed changes in the discs and lenses similar to those seen in arteriosclerosis, also a sagging in both upper lids, and a granular conjunc- tivitis. Complained of poor vision and diffi- culty in raising the upper lids ; severe boring pains deep in the eyes, and tugging on the eyes, worse on the left. In other spheres her June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 473 chief complaints were shortness of breath, failing memory, difficulty in locomotion, par- ticularly in the dark, and disgust with every- thing. Physical examination revealed a myo- carditis, subnormal blood pressure, moderate anemia, facial tics about the mouth and eyes, weakness of the grip in both hands, solid edema of the wrists and below the clavicles, sparsity of eyebrows, and a general yellow tint to the skin. Diagnosis necessitated care- ful consideration of the following conditions: cerebro-spinal syphilis, Parkinson’s syndrome, nephritis (Bright’s), pernicious anemia, and advanced myxedema with arteriosclerosis and myocarditis. I was inclined to favor the last condition, in as much as the urine was nega- tive, there was no history of progressive wast- ing, and facies and gait were not sufficiently characteristic for a Parkinson syndrome. The Wassermann report had not yet been return- ed. On the other hand, there were several symptoms previously noted that are character- istic of myxedema. History of influenza in 1920, from which it took the patient 6 months to effect recovery, was judged to have a pos- sible bearing on the present condition. The Wassermann and Kahn returned posi- tive. Treatment consisted of iodides and mercury. There is little doubt, however, that a pituitary dystrophy complicated this case. Case 6. Thyroid (myxedema). S. L., a single woman 44 years of age, was well until 1927, when she was operated upon for bleed- ing hemorrhoids. A year ago last June she had complained of progressive weakness, dizzy spells and fainting, and increase in weight. Her menses had ceased in 1928. On her initial visit, June 1930, she stated that she had been under the care of 13 physicians since the onset of her symptoms. Physical examination showed : Maximum systolic pressure SO, diastolic 60 ; heart centrally placed and of normal dimensions; pulse 130, easily compressible, but regular in force and interval ; cbest clear and resonant throughout ; no edema nor ascites ; no abdominal masses ; no splenic nor hepatic enlargement. Rectal examination revealed an inflamed mass the size of a large cherry with a tendency to pro- lapse between the external sphincters. There was no infiltration in the wall of the rectum, but there were smaller hemorrhoids in the op- posite longitudinal axis. Superficially, the pa- tient was slightly yellow; skin was very dry ; eyes muddy; face expressionless; hair brittle and sparse ; hands pudgy, with thickened joints; wrists enlarged with so-called solid edema. A diagnosis of concealed hemorrhage and myxedma was made. At this time her hemoglobin was 25%. A serious syncope attended the prick of a needle and transfusion was adjudged dangerous. Local measures were adopted for the rectal pathology, and after 1 month of thyroid ex- tract and iodide of arsenic her hemoglobin in- creased to 45%, and I removed her hemor- rhoids. A long and tedious recovery follow- ed. Microscopic examination revealed charac- teristic pathology. Continuing the use of thyroid with strych- nin and iron her hemoglobin in another month had risen to 65%, and on November 10, less than 6 months, became 80%. Along with the increase in hemoglobin she has lost all signs of myxedema, and is a very attractive woman with a renewed interest in her music and pastimes, a complete indifference to which she had manifested for nearly 4 years. She is the daughter of the patient with trophedema whom I shall next describe. The maximum dose of desiccated thyroid given to this patient was 30 gr. a day. At present she takes a 5 gr. thyroid tablet daily and no auxiliary treat- ment. Case 7. Thyroid (trophedema). Mrs. L. M., mother of the previous patient. In this case it is necessary to describe an unusual condition. Trophedema is a chronic neuropathic edema occurring in segmentary distribution, associat- ed with a hardening and pallor of the skin, not due to cardiac or renal disease. Its diag- nosis is made by exclusion of other diseases which possibly could cause a similar condi- tion of the limbs. Conditions which might require differentiation are filariasis, cardiac disease, nephritis, mechanical obstruction with- in the pelvis which would disturb the local venous lymphatic circulation to a marked de- gree, and a bacterial form of elephantiasis due to streptococcus. Lymphatic obstruction 474 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 in other cases is the result of severe or re- current inflammation, as in erysipelas, milk- leg, or other factors. Trophedema was first described in 1898, but the pathologic basis has never been clarified. It is evident that there must be a disturbance of the trophic centers within the spinal cord. In some cases neuro- logic symptoms are present, such as hemi- plegia and paraplegia, but this must be a coincidence, for as a rule all other evidences of organic diseases are absent. In r?ery iso- lated cases it has been ascribed to traumatic origin and interpreted as developing through the mediation of an ascending neuritis which climbs up and involves the spinal ganglion, and from here to the constituents of the near- by sympathetic ganglia. Some instances of chronic trophedema have been observed in which the swelling was associated with dis- turbance of the ductless glands in the form of more or less acromegaly or myxedema, and that is the type of case into which my pa- tient falls. The disease may be hereditary or congenital, the infirmity being present at birth, or it may be acquired, coming on at a variable age, usually around puberty. In any event, trophedema is to be interpreted as a familial disease. It has been noted that in cases that are hereditary, the disease is transmitted through the maternal line, and that in a gen- eral way men are not susceptible. Mrs. M. is 65 years of age and appeared older. Her features were acromegalic; stolid expression ; a general yellowish tint. She gave a history of having been treated for the past year or more for variable conditions — -dia- betes, myocarditis and chronic parenchyma- tous nephritis ; the last mentioned had been the favored diagnosis. She has been on a high protein diet, and has been given urea in doses of 30 grams daily without any reduction in her edema. Has never had any ascites. Unable to walk for over a year. On my first visit I tentatively classified her as a cardiorenal, having a great deal of re- spect for the opinion and therapy of my brother practitioners. However, at this time, her heart and blood pressure seemed normal. Both calves measured 20 inches in circum- ference at the widest portion. I continued the nephritin, also giving Niemeyer’s pills, and a Carrel diet. Four days later, on my second visit, aside from feeling stronger, she showed no other changes and had. in spite of the limi- tation of fluids, no increase in the amount of urine passed. It was then that I decided her condition might be trophedema, especially since I had treated her daughter for myx- edema. On the third visit, October 14, there was no change in measurements about the lower limbs, the pulse rate had not changed, and there was no noticeable difference in the gen- eral condition except rest had been better. Thyroid extract was the only medicine given at this time and that in the equivalent of 15 gr. daily of the fresh substance. Urinalysis on this occasion revealed a 2 -f- sugar which patient stated has been the case for many years. She has never had any diabetic symp- toms, and the condition will be regarded as a nondiabetic glycosuria, since these conditions are present in myxedema. However, I omit- ted sugar and limited carbohydrates, placing her on a diet liberal in sea-food. On October 26, the measurement about the lower right leg was 1 ?y% inches, a reduction of only % in. She stated that generally she was feeling much better. Thyroid continued 15 gr. a day. Attempt at digitalization produced nausea on lowering the pulse to 100. On November 4, there were no complaints. Had attempted to walk, but was unable to on account of pain. Leg diameter 19 in., an increase rather than a decrease. Medication : thyroid 10 gr. and strychnin 1/50 gr. t.i.d. On November 11, the leg diameter was 17 in. and considerable burn- ing was present in the limbs, which I thought was an encouraging sign ; a decrease of 3 in. since the first visit. Continued medication. No- vember 18 she complained of fatigue and re- versed sleep rhythm. Thyroid was diminished to 15 gr. daily. Leg diameter 17 in. Solid wrist swelling entirely gone. November 26, less fatigue. Leg diameter 16 in. Medication continued. It appears at this writing that the thyroid substance is a specific, and I am almost opti- mistic enough to predict that she will be able to walk within a few months. Case 8. Thyroid (myxedema). M. N., mar- ried woman of 42, who is introduced because June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 475 of an indirect but interesting blood relation- ship to the previous 2 patients, showing ma- ternal transmission of myxedema. This pa- tient’s grandmother, who had a goiter, was an older sister to the trophedema patient. This patient’s daughter has a hyperthyroidism, al- though I have not yet had the pleasure of studying this daughter. Mrs. N. was first examined on No- vember 10, 1930. She had complained for the past 6 months of a sensation of a “fist gripping her heart”, vertex headaches, dizzi- ness on arising, extreme fatigue and mental depression. She has gained in weight. Physical examination revealed a distinct pallor, solid edema of the wrists, absence of eyebrows, deafness, and obesity. The only significant clinical finding in a complete study was a hemoglobin of 40%. Drawn to question her relationship to our previous myxedema pa- tient, I was delighted to find such existed. She was placed on a liver diet, thyroid ex- tract, and iron and strychnin intramuscularly, and after 3 weeks of treatment presents no symptoms of ill-being, and shows a hemo- globin of 65%. The equivalent of 30 gr. of fresh thyroid a day was given. She has lost in that time 20 pounds. In reviewing these and considering other parallel cases the following thoughts pre- sented themselves : (1) In all so-called neurasthenic and hys- teroid states it is highly advisable that func- tional endocrine disturbances should be sought. In obtaining history along the line of endocrinology the family history should be very carefully inquired into, even beyond liv- ing generations, along the line of structural abnormalities, asocial tendencies, or peculiar diatheses. In dealing with children of any age, it has always seemed to me that a pre- scription given after interviewing the pa- tient in the presence of the parents gives bet- ter results than to prescribe for the child who is unattended. (2) In all chronic cases it should be as- sumed that there is a complexity to their syn- drome that has defied the routine forms of treatment given by other physicians of equal or greater intelligence (I believe all of us have a certain routine which we try first, and failing in that routine we really commence to draw out our latent talents). Therefore, I be- lieve we should at once, in these cases, elimi- nate the possibility of deeply seated metabolic disturbances of physiochemic nature. (3) In all cases suggesting endocrine dys- trophy the possibility of syphilis should be eliminated. SINUSITIS* E. S. Hallinger, M.D., F.A.C.S., Camden, N. J. When asked to present a paper on some pertinent subject incidental to the season, it followed that as the “common cold” is more or less in the limelight of present day scientfic investigation a complication of it would be a fitting and appropriate subject to discuss. You all know what sinusitis is, yet, like the old say- ing that “familiarity breeds contempt”, this very familiarity is often responsible for our negligence to recognize self-evident facts, and in the hope that some of you have acquired this mental attitude I presume to present this so common condition for your consideration: Briefly, sinusitis is an inflammation, either acute or chronic in type, affecting the acces- sory nasal sinuses. These, as you know, oc- cur in groups of 5, namely, the frontals, an- terior ethmoids, posterior ethmoids, maxillary antrums and the sphenoids. Each of these sinuses has direct communication with the nasal fossa by individual -ostei, and, anatomi- cally, all are in direct relationship with each other. Any or all of these cells may be in- volved at the same time, either as a bilateral, unilateral or unicellular infection, which primarily may be induced by the following causes, which for the sake of convenience may be divided into 2 classes — local and general. Under the first group we have the mechano- physical conditions, e.g., nasal obstructions, due to deflected or deviated septums, hyper- trophied turbinates, spurs, polyps, new *(Read at the Camden County Medical Society meeting Dec. 2, 1930.) 4713 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 growths or abnormalities of the nasal walls or bony structures ; while under the second group we have the acute infections. While it is true that an acute sinusitis may occur without apparent, generalized, systemic manifestations, it generally is the result di- rectly or indirectly of an acute infective pro- cess, or a complication of the same. Heading this list is influenza, which produces about 75% of all the cases, depending upon viru- lency of the epidemic. Next in order of fre- quency come pneumonia, typhoid fever, scarlet fever, measles, erysipelas, diphtheria and cerebrospinal meningitis. Of the acute infectious diseases scarlet fever takes the lead and is usually more virulent in that the patho- logic process is more destructive, even involv- ing the bony walls of the sinus cavities, with an ensuing involvement of adjacent parts. Bacteriologically, practically every' case of sinusitis is of the mixed type, although the in- fluenza bacillus is frequently found alone. The most common organisms, in addition to the influenza bacilli are the pneumococci, meningo- cocci, various varieties of staphylococci and streptococci, and to a lesser extent the colon bacillus and the diphtheria bacillus. Any or all of these occur in single or multiple com- binations, producing different types or degrees of infection, the virulency of the latter vary- ing with, the types of combinations. It is not my desire to present sinusitis in all of its many phases, as this would be a tre- mendous undertaking, and an impossibility in the time allotted, even if considered in but a superficial manner, but rather to consider it from a single standpoint, namely, that of the “acute type”. This develops as the result of an acute rhinitis or common head cold, or as a part of the symptom complex of one of our acute infections, the degree of involvement depending upon: first, the nose affected; and, second, the type of infection. It is primarily essential that we have some nasal pathology before we can have a sinus infection, and upon this factor also depends the degree or acuteness of the disease ; the greater the obstruction, the greater the sus- ceptibility of the patient to involvement. lake- wise, the symptomatology varies with these factors. The most pronounced symptom, ex- cluding of course a generalized entity' such as influenza, ty'phoid fever or pneumonia, is headache. In fact, headache can he looked upon as being the first symptom of sinus in- volvement which follows a train of other pre- liminary complaints, and it is of any type im- aginable, both as to site and character ; it may be spasmodic or constant ; neuralgic or hemi- cranial, and violent to such a degree that the patient is beside himself. It may begin first as a dull ache which, however, gradually in- creases in severity, and usually is present over the site of the trouble — particularly if the frontal sinuses are involved; in which case it will be referred to the supra-orbital ridge or to the nasal side of the orbit; or, if the pos- terior group of cells is affected, we may simply have a generalized type or the lower- half headache, as described by Sluder, with or without ocular manifestations, such as deep orbital pain, photophobia and involvement of the ocular muscles. What are the mechanics of sinusitis? We stated that the degree of involvement depend- ed upon the ratio of nasal pathology rather than upon the offending organism. One can readily conceive that where the nasal fossa is markedly narrowed or where the parts are in close proximity to each other, as soon as the mucous membrane of this fossa is congested how quickly the resulting edema will produce occlusion. It is but a step forward to imagine what next occurs. As soon as engorgement and edema have taken place there is an imme- diate blocking of the nasal orifices of the sinuses, particularly those of the frontals and the ethmoids, with the result that ventilation of these cavities is arrested. What happens? There immediately ensues an absorption of the residual air in these cells, and as the ab- sorption continues a vacuum results ; the greater this becomes the more pronounced and severe will he the headache. In addition, there is an increased flow of mucous secretion which bathes the parts in excessive moisture, heat is created and all air circulation is shut off. What do we then have? — An ideal in- cubating chamber. It is not necessary to take up your time with the mechanics of the ensuing pyogenic process ; suffice it to say that this is the next June. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 477 procedure, and, depending upon virulency of the infection, may occur in a few hours or within 2 or 3 days. Then is the time when, in addition to gen- eral symptomatology, the local evidence of sinus involvement appears ; likewise varying with the type of infection present, represent- ing all degrees or phases of the pathologic process from a simple benign condition, par- ticularly when local nasal obstructions are in the minimum, to the severest type met with, and usually these are the cases that present evidence of the greatest amount of mechanical obstruction. Headache, of course, is present, as previously mentioned, and at first is pro- duced bv development of the vacuum and later by the damming up of secretion and by the establishment of contacts. Local symptoms vary with the sinus in- volved ; particularly true in cases of unicel- lular sinusitis. For example, if the frontal is the particular one, our local signs are directed to it. These, in order of their occurrence, are pain, tenderness, swelling and hyperemia. The pain may be supra-orbital or may only be re- ferred to the nasal side of the orbit, or may include both areas at the same time. Pain naturally increases in severity as the disease progresses, while tenderness of the orbital plate of the ethmoid may indicate an extension of inflammation to the ethmoid cells. As swelling develops, generalized pain and ten- derness are found, particularly when hyper- emia enters into the picture. This edema usually affects the eyelid and the conjunctiva. In addition to these evidences, we have at first a fluent nasal discharge, which sooner or later becomes purulent, the amount flowing being dependent upon the drainage facilities and upon the nasal obstructive pathology. Where other than the frontal sinuses are diseased, external evidences may be lacking. Diagnosis then depends upon other signs. It is in this acute stage, however, that immediate active measures should be instituted; otherwise ser- ious and even fatal complications are apt to rapidly occur, with all of their concurrent symptoms. These include, as the result of a damming up of pus and increased intrasinus pressure, empyemia and a generalized pan- sinusitis, wfith an osteitis of the sinus walls, which, ultimately eroding, permit rupture, either into the orbit, with the formation of an orbital abscess, or, the rupture may occur through the cribriform plate via the olfactory nerve openings, producing meningitis and brain abscess. Optic neuritis and cavernous sinus thrombosis are apt to be the particular complications if the sphenoids are included in the pathologic process; w'hile if the frontal sinus is destroyed, in addition to rupture into the orbit, we may have a progressive osteitis of the inner wall of the sinus with a breaking down of the same, development of a menin- gitis and brain abscess ; or, instead of break- ing directly through to the brain covering, a suppurating, progressive osteitis may extend through the entire cranium, creating multi- ple pyogenic abscesses. This infection travels through the diploic veins and may rupture anywhere over the meninges, likewise result- ing in multiple brain abscesses or a purulent meningitis. What are we going to do with these cases? The first essential thing is, naturally, to create ventilation, open up the nose and establish or permit drainage. This holds good in any phase of the disease and is particularly indi- cated before sinusitis actually begins ; i . e . , in the stage of congestion or hyperemia. vHow can this be accomplished? By using a shrinking agent that will deplete the engorged or turgescent mucous membrane, and the best agent in my experience is a 10%' solution of cocain. Some prefer adrenalin or ephedrin, alone or in combination ; be that as it may, the essential thing to do is to shrink the mucous membrane, and if this is done early, an attack may be aborted. If seen later, it will occasion- ally also be necessary to use suction, but this must be done with care as we will accomplish nothing if our vacuum is great enough to pull out the mucous membrane of our sinus. Fol- lowing the shrinking, use of a 10% solution of argyrol on cotton tampons is indicated. To be effectual these should be placed as high up in the nasal fossa as is possible and allowed to remain for at least a half an hour. It is remarkable how quickly the flow’ of secretion is started when these tampons are applied, and more particularly upon their removal the amount of relief obtained from their use. 478 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1031 Naturally, the amount of secretion removed depends upon the degree of pathology present. It is also permissible, following the use of the argyrol tampons, to make light suction followed by a soothing, oily spray. There are some cases, however, which should be irri- gated. This also depends upon the sinus in- volved, and if the antrums are involved and empyemic, they should be punctured and irri- gated. Treatment will only be of use if our patient has not an excessive degree of nasal obstruction. If such exists it is frequently necessary, and imperative, that these deformi- ties and obstructions be removed before treat- ment can be undertaken. Many times a radi- cal operation upon your patient can be avoid- ed by having taken care of the nasal path- ology. However, in spite of what we do, either conservatively or surgically, we reach a point where every radical measure must be used if we are going to save our patient, and occasionally they die in spite of our efforts. I have avoided going into a description of the basic pathologic processes and likewise have omitted reference to age limits ; but I would like to say, in conclusion, that children are more prone to sinus involvement than is naturally suspected, and that all stubborn head colds in children should be investigated. There are many other factors to be considered, but these will depend upon the type of condition which was the underlying cause of the sinus involvement and need no particular mention here. ONE YEAR OF NEUROLOGIC SERVICE AT ST. PETER’S GENERAL HOSPI- TAL IN NEW BRUNSWICK, NEW JERSEY Karl Rothschild, M.D., New Brunswick, N. J. During the last 2 years of existence of the old St. Peter’s Hospital, I had tried to in- stal a neurologic consultation service and, in the course of time, had found that this ser- vice was not only a convenience but soon de- veloped into a necessity, especially since, at the same time, we had started a neuropsychia- tric clinic, the attendance of which grew with time. When our new 200-bed hospital was finish- ed a year ago, the staff found it proper to create a full neuropsychiatric service which takes care of 3 functions: (1) The neuro- psychiatric ward service; (2) consultation with other services; and (3) neuropsychiatric clinic. The 1 year of existence has proved so suc- cessful that I feel it not out of place to record what we have done, because it is my belief that such a service could be easily arranged in any community the size of New Bruns- wick. I feel sure that some member of the staff in every community hospital is especially interested in neuropsychiatry and could take charge of such a department. The nearness of New Jersey to medical centers, besides, will help to obtain consultation service whenever necessary. It is a well known experience that for no other kind of service does the public run oftentimes to far-off places, as they do with neurologic or psychiatric problems. This fact is due to a certain indifference of the pro- fession toward those problems which con- sume a great amount of time and yet, in the end, often turn out unsatisfactorily. Every qualified hospital certainly should be able to take care of the neurologic (with possible ex- ception of the neurosurgic) and a large num- ber of the milder psychiatric cases. When looking over the records of the hos- pital, we see that a great number of such cases had always been admitted. Many neurologic cases had been handled by the medical ser- vice, without consultation. The surgeons would frequently have liked to call in a neu- rologist if only the expense had not been too great. Many psychoneurotic patients had been admitted and kept for a while, only to be shipped away later to an insane asylum. Let us consider the 3 types of service. ( 1 ) Ward service. The neuropsychiatric service in our hospital has been established within the group of medical services but as a separate unit, just as the pediatric service. That means that we have admitted to this service all patients whose chief complaint was on a neurologic basis, and we have made this a matter of classification. Thus, a case of June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 479 tabes dorsalis is admitted to the neurologic service. If during stay in hospital a medical problem arises in this case, the medical ser- vice is called into consultation. If, however, a tabetic patient comes in complaining of trouble pertaining to the medical field, he is admitted to the medical service and the neurologist is called into consultation. In this way, our ser- vice has been very successful. We have seen and treated a large number of the milder neurologic and psychiatric prob- lems but, on the other hand, we have also had occasion to observe a great number of rare cases, the diagnoses of which presented us with great difficulties. Let us just mention the following types : occlusion of a branch of a vertebral artery ; traumatic pontine concus- sion ; acute multiple sclerosis ; streptococcic meningitis ; meningitis following a brain ab- scess and caused by Bacillus mucosus capsu- latus (Friedlander’s bacillus) ; Foville’s par- alysis ; poliomyelitis anterior, superimposed on syringomyelia; tumors of the cerebellum, 2 cases ; tumor of the thalamus ; pituitary tumors, 2 cases ; general paresis with syphil- itic disturbances of the circulatory system ; and others. Thus, it will seem that the diagnostic and therapeutic possibilities of this service have proved their value, even within 1 short year. (2) Consultation service. Quite often has this service been called in consultation by the medical service in cases where neurologic or psychiatric problems arose. I remember specifically a case of indefinite pain in the pel- vic region, which proved to be a pluriglandu- lar disturbance and cleared up under proper medication. We had a patient with chills, resembling malaria, whose trouble afterward turned out to be Korsakoff’s psychosis. We had another case of Korsakoff’s psychosis, which originally made us suspect sinus dis- ease and which cleared up and the patient has been healthy since. We have seen a great many minor cases of hysteria, and especially a large number of apoplexies where the medi- cal aspect of the case was the prominent one, and we were called in to determine the neuro- logic status of the case. We considered of special importance our consultations with the surgical services. Here, we had the opportunity to see a number of brain injuries in which it was advisable to make a definite, topical diagnosis as well as a prognosis. Several times it was a matter of differentiating between a central or peripheral disturbance that caused the surgeon to call our service in consultation. I remember one of those rare cases — a brain injury causing a flaccid paralysis, instead of the expected spastic one — where the patient was worried and our assurance that within a few weeks the paralysis would become spastic was of great mental and moral help to the sufferer. In an- other case where there had been a head in- jury, caused by an automobile accident, we were called in for the reason that there was flaccid paralysis of the arm with motor de- ficiency, and which we could clear up by diag- nosing a subcortical lesion ; and flaccid par- alysis and apraxia will remain permanent symptoms, accompanied by motor aphasia and motor alexia, without disturbances of the sen- sory functions. There were cases where a neurologic status after peripheral lesions was necessary, and here I remember a case where an apparently harmless injury to the shoulder had caused complete paralysis of the brachial plexus. There were other cases in which a concussion of the brain, without fracture of the skull, was the sole injury, and where the question of permanency of symptoms had to be decided. (3) N euro psychiatric clinic. In this clinic we have seen many more neurologic cases than straightforward mental ones, and a num- ber of the cases referred to in this review of the ward service were originally admitted through the clinic. This 'fact may be due to the presence of a State Psychiatric Clinic in our city. We have felt that although this state clinic was established we should not abandon the psychiatric part of our clinic be- cause: (1) We feel that handling of the aver- age patient is not a matter for the state but for the community or the hospitals ; the state should confine itsdf to the treatment of defi- nitely insane patients and not take up treat- ment of psychoneuroses, and patients who do not need hospitalization. (2) The state clinic psychiatrist can see a patient only once a month, and one does not need much imagina- 480 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 tion to figure out that this is not sufficiently frequent for proper treatment. Our clinic is held once a week, but it is possible to have practically continuous service. A number of school children with mental defects have been referred to us. The New Brunswick city school system employs a psy- chologist who gives advice to the special classes and classifies the children. It is a common experience that the classification by method of the Intelligence Quotient is very unsatisfactory, and all the teachers of such classes will agree with this statement. Besides, many children with an I. Q. of 100, or even higher, show defects in behavior and emo- tions which can only be handled by a psychia- trist. This is the reason why the number of those children was so considerable. We have diagnosed a number of them as glandular dis- turbances and some experiences of ours with thyroid deficiency cases have been extreme^ satisfactory. We have seen another series of children who were suffering from infected tonsils, obstruction of the nose, sinusitis, um- bilical hernia, and other such “minor” troubles, who were definitely benefited by removal of these impediments. We have been frequently in consultation with the pediatric and eye, ear, nose and throat clinics. In the organic neuro- logic class, we have seen cases of paralysis agitans, paralysis following apoplexy, epi- lepsy, postencephalitis, and tremors of various origins. I especially remember a child of about 14, with continuous shaking of her limbs and body, certainly a case of posten- cephalitis, who had gone to a number of agen- cies. She improved greatly under administra- tion of proper medication. This clinic has also been an excellent means tor the interns to see neurologic cases, as well as for the nurses, who in a general hospital usually have no opportunity to see patients of this type. It should also be mentioned that the writer gave weekly lectures to the seniors of the nursing school and that the nurses benefited greatly by the possibility of actually seeing cases of the various types, neurologic as well as mental, during the lectures, and at any time when such patients were admitted to the service the nurses could he called together for a “clinical conference”. It may also be men- tioned that the superintendent of the nurses’ school asked the writer to give the probation- ers a few introductory lectures on “every day psychology, and the psychology of nursing problems”. The hospital authorities have been very co- operative in helping us to establish and main- tain this service. They have gladly admitted milder mental patients who did not need special supervision. They have provided us with the necessary neurologic apparatus, but, above all, they have shown acknowledgment of the value of this service and done their good share in improving it. especially by classifying the ser- vice in its proper place and giving it a stand- ing with the other services. Looking hack over the first year of this service, we have reason to be very well satis- fied. This will not say, however, that satis- faction means stagnation. There are many problems to be solved. There are some of the more complicated pieces of apparatus to be installed. We are, at the present time, without a high-type perimeter, and we have not the possibility of using a permanent water bath. Those things, I am sure, will come within the near future. Outside of these mechanical features, there is one field in which, in my opinon, the ser- vice is not yet called in frequently enough. These are the cases of head injuries. We feel it should be the rule that any head in- jury admitted to the surgical service should he seen by a neurologist if, as is the case in our hospital, there is no special neurosurgic service at hand. The greater number do not present a serious surgical problem, most of these cases being concussions accompanied by scalp wounds. It is sad to say that most of the severe injuries of the brain are beyond medical help anyhow, hut in the remaining class mentioned a neurologist ought to he con- sulted, especially in order to determine the amount of permanent injury before the pa- tient leaves the hospital; this is especially im- portant in compensation cases. We have lately had 2 patients who had been properly diagnosed as having concussion of the brain, who had been discharged, but who had not been able to work. Both were considered June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 481 hysterics who did not want to work. In both cases, we found definite organic disturbances due to multiple and diffuse hemorrhages in different parts of the cerebrum. This paper has been written with one idea in mind : to demonstrate that a neuropsychia- tric hospital service in a community like New Brunswick is a possibility when the necessary cooperation between members of the staff and the hospital authorities is so well established as at St. Peter's Hospital. INDICATIONS FOR SURGERY IN DIS- EASES OF THE THYROID* William Barclay Parsons, M.D., Presbyterian Hospital Medical Center, New York City In treating diseases of the thyroid gland, various methods are employed, from doing nothing to the use of iodin, glandular ex- tracts, radiotherapy, and operation. Surgery probably has a wider application than any other single form of treatment, being called upon in the infections, tumors, and some of the disturbances in physiologic function. Infections. Acute infections of the thyroid gland may appear with any of the acute in- fectious diseases due to a streptococcus, but usually they are associated with a generalized pyogenic infection presenting abscess forma- tion. Sometimes the infection will be localized, appearing in a small abscess, but at times the entire gland is replaced by a bag of pus. All of these cases should be drained, but the more fulminating type is associated with an ex- tremely bad prognosis. In the chronic infections, syphilis and tuberculosis are occasionally encountered. The former is, of course, nonoperative; the latter, when discrete and localized, requires removal. However, the diagnosis of tuberculosis of the thyroid when it appears as a localized condi- tion is almost never made. These cases are frequently operated on for a suspected ade- noma of the thyroid, with the true condition *(Read at meeting of the Morris County Medical Society, December 18, 1930.) not being found until microscopic examination of the specimen has been made. The one chronic infection peculiar to the thyroid is the iron-hard struma, first described by Riedel in 1896. This condition is charac- terized by a marked replacement of glandular elements of the thyroid by an extremely hard, dense connective tissue with a scattering of lymphoid tissue throughout the tumor. Hashi- moto, in 1912, described a condition in which he noted a marked increase in the lymphoid elements with production of huge germinal centers and a decrease in the glandular ele- ment. It is thought that the condition he de- scribed represents the early stage, and that described by Riedel the end stage of the same process. The symptoms caused by the swell- ing due to this marked increase in connective tissue are mechanical in nature. Encroachment upon the lumen of the trachea, and fixation of- the latter, interfering with the rising of the thyroid cartilage during swallowing, cause dyspnea and dysphagia, which, with a visible swelling, represent the main symptoms com- plained of. The main indication for surgery is relief of tracheal obstruction. This may be obtained by removal of merely the isthmus, but at times a partial thyroidectomy is necessary to de- compress the trachea. As little as possible of the thyroid should be removed, because there is a tendency for the condition to sub- side, leaving the patient in a somewhat sub- thyroid condition in most cases. This may re- quire the use of thyroid extract for a period of time, so that it is most desirable to leave as much of the gland as is possible. Neoplasms. Malignant -neoplasms of the thyroid gland represent an incidence of about 2% in the surgically treated cases. Some clinics report a considerably higher incidence, and a correspondingly higher ratio of suc- cessful operations. One suspects that many of the virulent-appearing, so-called fetal adenomas, which are absolutely benign lesions, have been included, being mistaken for carcinoma. The malignant neoplasms seen are carcinoma, sarcoma, and malignant thymoma. The latter 2 types are relatively rare and are highly fatal. A fair percentage of carcinomas are found while still within the 4S2 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 capsule of an adenoma, and 94% of cases with carcinoma have a history of previously enlarged thyroid. When this condition ob- tains, partial thyroidectomy offers an excellent -chance of cure. When the malignant change is found diffused through the gland, even though it may not be obvious beyond the capsule, the prognosis, even with complete thyroidectomy followed by radium or x-radi- ation, is poor. To put it another way, if the diagnosis of malignancy of the thyroid can be made before operation, the prognosis is bad, but if cancer is found on microscopic examin- ation after an adequate operation for adenoma, the prognosis is reasonably good. Fortunately a fair percentage of cases with very hard, nodu- lar glands that have caused pressure symptoms, may have their hardness due to calcification, so that a mistake in the good direction is easily made in what appears to be carcinoma. Sometimes this calcification is relatively diffuse, and in such thin layers that a radio- graph of the neck does not clearly indicate the true nature of the condition. Adenoma. One of the extremely interest- ing conditions from both a theoretic and practical standpoint is the group of cases under the diagnosis of adenoma of the thy- roid, whether with or without hyperthyroid- ism. These are the nodular goiters, and there has been considerable discussion as to their etiology. Some believe that they arise from cell rests present in the embryonic stage, the so-called “cells of Wolfer”, cells similar in all respects to the other embryonic thyroid cells but not participating in the ordinary for- mation of acini. This theory visualizes these isolated groups of cells as living and growing to produce, in one or more regions of the thyroid, masses of tissue which in their ulti- mate form may present a cellular arrangement similar to that found in a normal thyroid gland at any stage from the earliest embryonic to a completely adult form, even to a degen- erative form of the latter. One does find adenomas in which the cellular arrangement may be a solid grouping of thoroughly fetal cells, an arrangement in cords, tubules, or small acini, the presence of definite adult acini, cyst formation, and lastly, calcification. All of these are quite definitely changes through which the thyroid cells pass from their earliest form as they grow downward from the tuberculum impar through the muscles of the tongue to attain their eventual site and adult arrangement in the lower part of the neck. The other theory as to their formation takes into consideration the fact that the thyroid gland increases its activity in re- sponse to any energy demand, with a resolu- tion to the resting stage after the energy demand has been satisfied. In certain individuals elasticity of the thermostat, as it were, is deficient, with the result that in areas groups of acini do not revert, but persist in a hyperplastic state. For a period of time this hyperplastic state is more morphologic than physiologic, resulting in the persistence of one or more areas of enlargement, which, when it has occurred numerous times, pro- duces a nodular goiter. Eventually, persist- ence of physiologic over-activity appears, and one then has a persistence of hyperthyroidism which proceeds until the clinical picture of the disease is in evidence. I find it hard to believe that this latter theory covers all of the miscroscopic findings, and feel that in all probability both methods obtain. Certainly the latter theory covers those cases in which de- velopment of symptoms follows tonsillitis, pregnancy, prolonged mental strain, psychic trauma, and the various other occurrences frequently associated with the onset of symp- toms of hyperthyroidism. This will ascribe an exciting rather than etiologic importance to these various strains ; which is reasonable in that all individuals are exposed to one or more of these strains, and yet only a relatively small percentage of individuals exhibit patho- logic or physiologic thyroid changes. The group of adenoma cases without hyperthyroidism may require surgery. Cer- tainly on the Atlantic seaboard the use of iodin is unsatisfactory in individuals over 20 years of age. X-ray treatment has no effect upon the size of these masses, so that if any- thing at all is done it must be surgical. A few years ago, several articles appeared upon the danger of so-called iodin hyperthyroidism, namely the development of hyperthyroidism in an adenomatous gland consequent upon the Jun?, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 483 use of iodin. In my opinion, such a circum- stance is entirely coincidental. So many indi- viduals have received iodin on the advice of friends, druggists, advertising companies and doctors, that it is not at all surprising to find a fair number in whom symptoms have ap- parently developed during the administration of iodin. The earliest symptoms of hyper- thyrodism in a patient with an enlarged thy- roid of many years’ standing might easily be worry over the goiter, and medical or other advice would be sought. Iodin would be taken, with control of the symptoms for a period of time. Escape from control of the iodin would then ensue, and there would be an apparent development of symptoms consequent upon the use of iodin. It also seems absurd that the same substance would cause and help the same group of symptoms. We do not use iodin for the nontoxic nodular goiters, not for fear of damage but because it would do no good. There are 5 reasons for operation : cosmetic, worry, the presence of tracheal ob- struction, or even deviation, whether due to enlargements above or below the level of the clavicles, the likelihood of the development of hyperthyroidism, and the likelihood of the de- velopment of carcinoma. In young indi- viduals with inconspicuous enlargements, I believe it is safe and wise to do nothing. In these cases the cosmetic effect, worry, and pressure considerations do not appear, and the likelihood of hyperthyroidism and carcinoma can safely be considered as remote. Also, following pregnancy or other energy demands, there is apt to be an increase in size in the small, impalpable masses which would be apt to make their definite appearance following operation ; and if operation is postponed at least 1 operative procedure may be avoided. In older individuals who have gone through pregnancies and other tests, one can perhaps consider that no further masses are liable to appear, and that they are nearer the possible development of hyperthyroidism of malig- nancy. The large, prominent nodules present no need for delay. If the patient is worrying over the goiter, operation is a small price to pay for mental comfort, and the scar is always less noticeable than the lump. Even moderate tracheal deviation represents a certain hazard with the development of upper respiratory tract infections, and where there is definite impairment of the airway, this hazard is a real one, in addition to the considerable discom- fort under which these patients labor. It is hard to know what percentage of simple enlargements will be later associated with hyperthyroidism. In my own operative experience, there have been 190 adenomas without and 131 adenomas with hyperthy- roidism, which represents, roughly, a ratio of 3 to 2 in the series. All one can say fronr these figures is that there is a high incidence of hyperthyroidism in nodular goiters. I have already mentioned the 2% likelihood of malig- nancy associated with this group of cases, so that when one adds up the various points in favor of operative therapy in this type of case, it far outweighs the disadvantages of surgery. The only deaths we have had in the nontoxic group were due to pneumonia con- sequent upon severe tracheal obstruction ne- cessitating emergency procedures, and a pneu- mococcus type III pneumonia in another pa- tient who had auricular fibrillation and chronic valvular cardiac disease. The individuals with adenoma of the thy- roid who have developed hyperthyroidism are in general the older group of patients, and represent a high incidence of cardiac impair- ment. In an analysis of the results of partial thyroidectomy in this group, 44% of the un- successful cases presented persisting cardiac symptoms. We feel that surgery is the method of choice for this group, and employ radiotherapy only for those patients in whom the cardiac damage is so profound that oper- ation would be almost certainly fatal. Even in the presence of congestive heart failure of considerable degree, prolonged rest will fre- quently improve patients so much that with an ordinary period of iodin preparation they will stand surgery; and it must not be for- gotten, as Lahey and others have frequently emphasized, that these individuals have a greater cardiac reserve than an ordinary straightforward medical case of apparently equivalent severity. However, it is of great importance that operation be done before the development of cardiac damage, not only from 484 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 the standpoint of diminished risk and short- ening of the period of disability, but as shown by the distinctly better results noted in the follow-up clinic in the second group of cases. A considerable degree of heart embarrassment, as shown by heart-consciousness, dyspnea, and even auricular fibrillation, may be consistent with irritation rather than actual damage. When this holds true, one would expect to find little if any enlargement of the heart, as shown by a teleroentgenogram, and but little evidence of myocardial damage, as shown by the electrocardiogram. A fair percentage of cases will reestablish sinus rhythm early in the postoperative course; in fact we have noted it, in the electrocardiogram, on the second morning after operation. If operation is delayed until actual cardiac damage has oc- curred, one can expect some improvement, to be sure, but a certain amount of cardiac disa- bility is certain to be present. We do not differentiate from the standpoint of treatment between the so-called adenoma with hyperthyroidism and exophthalmic goi- ter, considering that the hyperthyroidism is qualitatively the same in the 2 types of cases, and that the difference in clinical picture in typical cases is due to difference in degree of severity, and to difference in the ages of the patients. The younger group, as a general rule, presents a more fulminating hyperthy- roidism ; the older individuals are apt to pre- sent a higher incidence of cardiac involve- ment. Both groups react to the use of iodin, as evidenced by improvement in general con- dition, pulse rate, gain in weight on a high caloric diet, basal metabolic rate, and diminu- tion of creatinurea when on a test diet lacking in meat protein. In the typical exophthalmic group we feel that operation is ecpially the desired treatment, with the following exceptions. In children and at the age of puberty, mild hyperthyroidism will frequently be controlled by life in the country with forced feeding, rest, occasional small doses of iodin and in some cases radio- therapy. In patients around 20 years of age, with mild symptoms and only a slight en- largement of the thyroid, we frequently em- ploy radiotherapy, and effect a satisfactory percentage of cures. In the full-blown cases, in individuals who have had one or more bouts of hyperthyroidism in previous years, and in the vast majority of patients over 25, we feel that surgery is the method of choice. This is based on risk and the follow-up re- sults in relation to returned economic activitv and to control of symptoms. In relation to risk, it is worthy of note that the operative risk is far less than the expected mortality in the disease under medical supervision. Hyman and Kessel, at the Mt. Sinai Hospital, several years ago followed a group of 50 patients who had refused surgery. These patients re- ceived medical and psychiatric help, but in the course of 5 years showed a mortality of 14%. In all the clinics in the country where much thyroid work is being done, the operative mor- tality is in the neighborhood of 1%, which of course compares very favorably with the mor- tality just mentioned, and with other surgical procedures of similar severity. In a recent study of 18S cases, 90 % of patients had returned to full economic activity by 12 months. From the standpoint of symptom control, at 6 months, 74% were satisfactory in all particu- lars; at 12 months 80% ; at 24 months 82%; and at 36 months 89% were classed as satis- factory. The percentage at 4 years was even better, but the number of cases was too few to warrant the drawing of any conclusions. At these various periods of time, the unsatisfac- tory cases presented, in the main, persisting cardiac symptoms. Recurrences may be ex- pected in perhaps 4%. The balance are usually due to the persistence of one or more of the nervous symptoms complained of prior to operation. The use of iodin in these cases is of ex- treme importance • and unquestionably has been the largest single factor contributing to the lowering of operative mortality. It is essential that if operation is considered iodin should not lie used as a palliative measure ex- cept in real emergencies. Individuals who have received iodin for many weeks or months usually are back at the point where they started from, and one cannot hope for an- other pharmacologic reaction. Striking im- provement is noted in those patients who have not received iodin previously, and they may be operated on with every expectation of sue- June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 485 cess. The patients one fears now-a-days are those who give a history of 15 or more years, having received in that time all manner of glandular extracts and iodin, and who present a cardiovascular apparatus that has suffered much wear and tear. Another point not stressed sufficiently in text-books and articles is the question of marked exophthalmos. When the eyelids fail to close at night, corneal ulceration in the sec- tor below the iris may occur. If following thyroidectomy there is not a prompt lessening of the width of the palpebral fissure, a plastic on the lid should be done to protect the eye and to improve the appearance. Occasionally, unilateral exophthalmos may be present, and this has been helped by section of the cervical sympathetic on that side, which results in the production of ptosis on the operated side but has no effect on the position of the eyeball. Surgery, then, is indicated: (1) To drain an abscess of the thyroid gland. (2) Remove localized tuberculosis. (3) Relieve pressure from an adenoma or Riedel’s struma. (4) In carcinoma and other malignancies. (5) For adenoma without hyperthyroid- ism, to improve the appearance, to aid or pre- vent pressure, and to avoid development of hyperthyroidism and carcinoma. (6) In cases with hyperthyroidism, as a method with a high percentage of cure and a low element of risk, particularly as a safe- guard before cardiac damage has occurred ; or, in the presence of cardiac damage to effect improvement in symptoms and interrupt the vicious cycle. OBSERVATIONS IN THE VIENNA EYE CLINICS* A. Russell Sherman, M.D., Newark, N. J. In speaking this evening about the Vien- nese eye clinics, I should like first to describe, for those who have not visited Vienna, the general plan of instruction and the oppor- *(Read before the Eye, Ear, Nose and Throat Section of the Academy of Medicine of Northern New Jersey, Newark, Feb. 9, 1931.) tunities for attending clinics there; and, secondly, to mention some of their present day ideas and practices, particularly those that differ from our own. The teaching, as a whole, is excellent. One may at times object to the subject matter as being too elementary or too advanced, too practical or too theoretic, but it is usually diffi- cult to find fault with the manner in which it is presented. The chief reason for this high quality teaching is perhaps a financial one. With the exception of those holding the rank of “professor”, the average of Viennese prac- titioners connected with large hospitals has no private work worth mentioning. The relation between his hospital hours and office hours is approximately reversed, as compared with ours, which means that he spends 8-10 hours daily in the hospital. Of this time, some is devoted to the handling of patients and a small amount may be taken up by under- graduate medical students. For this work he receives, I believe, somewhat under $1000 a year and must, of course, pick up something additional. Therefore, he offers post-grad- uate instruction and, as a result of the man- ner in which such courses are conducted, the best teacher is most in demand and makes the most money. A popular instructor may be teaching 5, 6 or more hours daily, and by constant repetition, commencing another course as soon as he finishes an old one, he naturally becomes very proficient. There are a great many courses given in English, and all of them, according to an agreement wTith the University of Vienna, are under the auspices of the American Medical Association of Vienna; an organization of English speaking medical men from various parts of the world who are in Vienna for post-graduate work. Any one, therefore, who wishes to take any of the English courses, joins the Viennese A. M. A., which occupies rooms in a building across the street from the Vienna General Hospital. There, he finds posted on bulletin boards lists of all the avail- able English courses. These courses ordinarily cover 1 hr. of instruction daily for 6 to 25 days, and classes may be limited to a few men, or may be unlimited. They begin some- times on a definite date, sometimes as soon 486 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 as the quota is filled. The charge of $5 or $6 an hour is divided among the members of the class. There are 2 or 3 disadvantages connected with these courses, namely, delay while waiting for a course to begin, occasional conflict when one finds 2 courses that he wants scheduled at the same hour, and the very elementary character of much of the work. Besides receiving formal instruction in this way, one may also become a “hospitant”. This means only that he pays a monthly fee of $10 which entitles him to spend- as much time as he chooses in the clinic, the ward, and the operating room, examining patients and ob- serving treatments. For any one who already has an elementary knowledge of a chosen specialty this is probably the best way to pro- ceed, for at the same time he will probably have an opportunity to take a few courses that seem particularly desirable. Most “eye men” going to Vienna for the first time probably expect to find the patho- logic work very good, but many no doubt wonder if the Viennese may not perhaps prove to be a little backward in other respects. With 2 exceptions, nothing could be farther from the truth. The average American will be shocked at their ideas concerning muscles ; which include postponement of squint oper- ations until the age of puberty, and entire disregard of the existence of a fusion faculty; also at their use of proprietary drugs without knowing or apparently caring what is in them. In general, however, they are quite up-to-date in their ideas, adopting anything new which seems desirable, whether it be American, European or Asiatic, and developing usually their own modifications and improvements. The clinic equipment is also extremely modern and complete. One wonders how, in a country as poor as Austria, so many ex- pensive instruments can be had for his- pital use, while many institutions in this country have poorer equipment than a prac- titioner requires for his office work. For ex- ample, the 2 eye clinics at the general hos- pital have, besides a good supply of the or- dinary eye instruments for clinic work and teaching, 2 Gullstrand ophthalmoscopes, 3 or 4 slit-lamps, a machine which projects ordi- nary lantern slides, microscopic sections, and opaque objects such as drawings and charts ; and a surgeon works in the operating room with the aid of 3 Zeiss hammer lamps cluster- ed above him and has at hand a fourth which may be held by a nurse or assistant. The teaching in ophthalmology, having been under the control of the elder Fuchs for so many years, is probably on a higher plane than that in some of the other specialties. An- other good feature is that it is carried on al- most entirely in the General Hospital, so that one is npt compelled to take 15 or 20 minute trolley rides from one hospital to an- other. The eye work in the General Hospital is taken care of by 2 clinics, the first or Meller clinic and the second or Lindner clinic, each having its own examining, treatment and lec- ture rooms, its own wards and operating room, and also its own ideas about diagnosis and treatment, so that for all practical purposes they could be separated by a few hundred miles instead of the few hundred feet they are. Apparently, the one thing that in a way connects them is the Fuchs tradition, for al- most all the men studied under him, Meller having been first assistant in his clinic for 17 years. In accordance with the teaching of the elder Fuchs they emphasize the clinical rather than the laboratory side of ophthalmology, and their approach to a case is based always on anatomy and pathology. This tendency to get at and keep in mind the fundamental changes producing any particular clinical condition is, unfortunately, in striking contrast to our own often very superficial manner of considering our cases and is, I believe, the one feature of their work that is distinctly outstanding. Guesses are not made about the pathologic changes in eye disease. If microscopic sec- tions of the condition have been studied, they are described; if not, one is simply told that no cases with a pathologic examination are known. One would imagine that under such conditions, considerable lack of knowledge is expressed concerning cases seen in the clinics, but this is not so. There is a very complete cross index and follow-up system in the clinics, so that a patient with an interesting eye condition can be followed for years and June, 11)31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 487 if, as often occurs, he comes to the hospital to die, or his body is brought into the morgue, the eye will in all probability be examined under the microscope in comparatively short order. Only under such circumstances could anyone write the book which one of the mem- bers of the Lindner clinic is now preparing on fundus diseases, and which is to contain a history of each case, a drawing or photo- graph of the fundus, and one or more photo- graphs of microscopic sections of the enu- cleated eye. It is by means of this record system, too, that some remarkable fundus cases can be collected for the classes in ophthalmoscopy. A man who is giving a course in fundus dis- ease often has postcards sent to patients he wants to exhibit and is able to show on one day optic atrophy, the next day optic neuritis, the next chorioretinitis, detached retina, con- genital anomalies, or practically anything de- scribed in the average fundus atlas. Some of these patients receive their car-fare and an Austrian shilling for coming to the clinic; others nothing ; and practically all of them sit patiently in the dark room for an hour while they are examined and reexamined by 10 to 15 persons. The lectures will, in general, prove disap- pointing to the eye man of average experience who hopes to discover some miraculously new methods of diagnosis and treatment. They often contain very little of practical value, except to the beginner, but do touch on many subjects which can make the practice of oph- thalmology more complete and interesting — such as : Why does a patient with macular dis- ease see comparatively better at night than in the daytime? Why is a Morax-Axenfeld con- junctivitis in the angles of the conjunctiva? Why are catarrhal ulcers found in their characteristic location? Why is an iris blue, or green, or brown? It is possible, and highly desirable, for one who is going to Vienna to study ophthal- mology, to avoid some of the inconveniences of the short courses by taking the so-called Fuchs’ course. This is a rather concentrated series of lectures, practical clinical hours and laboratory periods which has been given dur- ing 8 to 10 weeks in the Fall for the past 7 years. It is intended for men who have had previous experience, such as an eye internship or other elementary training, and is under the direction of the younger Fuchs who makes a sincere and rather successful effort to have each subject taught by the best teachers avail- able. I want now to mention more specifically, though I am afraid it will be rather discon- nectedly, some of the ideas and methods in vogue at present in the large Vienna clinics and in the clinic of Elschnig, at Prague, who is, by many competent observers, considered the outstanding man on the continent. There is nearly always considerable differ- ence of opinion anywhere concerning opera- tive methods, and it is especially significant to find certain procedures followed routinely in 3 independent clinics, as they are in regard to cataract extraction. In each of these clinics the cataract operation is performed with round pupil, with a fixation suture in the superior rectus tendon, and with akinesis of the lids by novocain injection. In regard to other features of the operation there is less uniformity. Both Elschnig and Lindner do the intracapsular operation routinely, dilating the pupil before operation, suturing a rather large conjunctival flap, and instilling eserin after the operation. Lindner excises a small piece of iris peripherally after extraction of the lens, and Elschnig simply makes a small peripheral iridotomy with a sharp-pointed de- Wecker scissors immediately after the in- cision, without removing any iris or touching it with forceps. In the Meller clinic the capsulotomy opera- tion, with peripheral iridectomy and small conjunctival flap without sutures, is routine, the intracapsular operation being reserved for immature and hypermature cataracts. Meller lays stress on the importance of opening the lens capsule with capsule forceps rather than with the cystotome, in order to remove as much of the anterior capsule as possible, thus preventing, partly, the inclusion of cortical matter between the 2 layers of capsule and the formation of a secondary cataract. He also calls attention to the delayed healing which follows inclusion of a small tag of lens cap- sule, often invisible in the wound, and feels 488 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 that preservation of the round pupil tends to prevent this complication. It is interesting, however, that after discussing this and other advantages of the round pupil, he concludes by saying that in very old people and in one- eyed patients a complete iridectomy should be done. Preliminary iridectomy is done only in those cases where a swollen, cataractous lens is producing some secondary glaucoma; never preparatory to extraction of an uncom- plicated cataract. In the operative treatment of glaucoma it is the general practice to perform an iridec- tomy in acute cases. In chronic cases Meller uses the trephine, Lindner the iridencleisis, and Elschnig the cyclodialysis. Meller states that cyclodialysis is the best operation for glaucoma in the aphakic eye. In the Vienna clinics, attention is called to the frequency of late infection, i.e., 1 year or more after op- eration, in eyes which have had an Elliot trephining; Meller stating that in his cases it has been 7%. In the Lindner clinic late in- fections occurred in 16 cases out of a series of 342. A bacteriologic examination of the con- junctival sac before operation is not done in the clinics of the Vienna General Hospital. Lindner gives 2 reasons why they have stop- ped this procedure ; that there are always bac- teria in the conjunctival sac, and that simple examination of a smear from the conjunctiva is insufficient for certainly detecting organ- isms there. His investigations have convinced him that most bacteria in the conjunctiva en- ter into the cells and are, as he says, “epi- thelial parasites”. He believes very strongly in the efficacy of 1% silver nitrate, according to the method of Bell, of New York, which, he says, brings about coagulation of the super- ficial conjunctival cells. These cells, contain- ing most of the bacteria present in the con- junctiva, are then washed out by the routine irrigation upon the table at the time of op- eration. Considerable work is being done with the Gonin cautery operation for retinal detach- ment. This has been developed intensively in the Lindner clinic, where a rather elaborate method of finding and localizing the retinal tear is in use. The patient sits with his eye in the center of a large, heavy brass ring, graduated in degrees, to which is attached a semicircular arc with its convex side toward the observer. This arc rotates about the vis- ual axis of the patient’s eye, and carries an electric ophthalmoscope of die tubular sort. By rotating the arc, and sliding the ophthal- moscope along it, the observer examines sys- tematically the entire fundus, and indicates on a chart the position of any holes or tears found. The horizontal meridian of the eye is then marked by 2 dots of india ink, placed nasally and temporally, just outside the lim- bus. At the time of operation, a metal indi- cator, consisting of a ring concentric with the limbus, is sutured in place over the cornea. This ring carries one or more limbs which ex- tend out radially, following the curve of the sclera backward, and previous to operation they are adjusted and trimmed off so that the tip of each lies over a retinal tear. These posi- tions are then marked by touching the sclera with the cautery tip, the indicator is removed, and the operation performed. By this method, Guist, in the Lindner clinic, has found retinal tears in 95% of the cases ex- amined, and of those in which a tear is pres- ent, has found 2 or more tears in 90%. Very recently, because of the diffuse de- struction of chorioidal and retinal tissues by the thermocautery, they have substituted cau- terization of the chorioid by fused potassium hydroxide, after exposing the area by a scleral trephine. Nonsurgical treatment of eye conditions in the Vienna clinics is very much the same as here. In regard to diagnosis, their ideas are some- what different from ours, and their methods of examination occasionally better because they are more thorough and exact. Keratitis, iritis, chorioiditis, etc., that we frequently consider the result of some hidden focus of infection, are called tuberculous, and although the existence of such a thing as focal infec- tion is admitted, its importance is not con- sidered very great. At this point, it might be well to mention the views of Prof. Hirsch, the rhinologist, concerning the relation of sinus disease to June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 489 optic neuritis. He states that only 8 to 10% of cases of retrobular neuritis arise from sinus infection, and calls attention to the fact that a suppurative inflammation is not essential to optic nerve involvement; a catarrhal inflam- mation with the resulting osteoporosis being quite sufficient. In ophthalmoscopy, red- free light is fre- quently used for studying cases of retinitis and neuritis. The younger Fuchs says that in his practice, ophthalmoscopy with red-free light is almost of as much importance as ex- amination with the slit-lamp. Patients refracted under a cycloplegic are examined by the method of cylinder skiascopy elaborated by Prof. Lindner. This is an ex- tremely accurate objective method which de- pends essentially on the fact that when 2 cylinders are crossed at an oblique axis there is formed a sphero-cylinder combination with its axis lying somewhere between the axes of the crossed cylinders. It will be seen that if the astigmatic eye is considered a cylindric lens which we are attempting to neutralize by another cylinder of opposite sign placed in the same axis, some rather odd retinoscopic shadow will be observed when the neutraliz- ing cylinder is placed4 before the examined eye at an incorrect axis. Lindner has sys- tematized these skiascopic pictures and has put forth some practical working rules, so that this method is now used routinely both in his own and in the Meller clinic. LEUKORRHEA, ITS SIGNIFICANCE AND TREATMENT P. Brooke Bland, M.D., Philadelphia, Pa. In considering the symptomatology of mor- bid conditions of the reproductive organs of women, I have always found it a convenience, as well as a special advantage, to divide the subject into: (1) symptoms arising in the body at large, or what one might denominate systemic or general symptoms; and (2) those having their source in the genital organs them- selves, which I customarily refer to as pelvic or local symptoms. While the first group must be looked upon as of very definite clini- cal importance, the latter are infinitely more significant, not only from the standpoint of diagnosis but more especially from the as- pect of etiology. I have always felt that the association of numbers aided the student in not only grasp- ing but retaining certain fundamentals of the subject, and I have pointed out that numeri- cally in the second group, there are 5 out- standing symptomatic expressions of both physiologic and pathologic processes. One or all five symptoms may be present. In the order of frequency they may comprehensively be enumerated as: (1) Leukorrhea; (2) al- tered menstruation; (3) bleeding; (4) pel- vic discomfort, at times expressing itself in actual pain; (5) and finally, irritability or dysfunction of the adjacent organs, namely, the bladder and bowel. In order of frequency, leukorrhea occupies the foremost place. It is present in all patho- logic conditions involving the genital organs. It is not only the most frequent, but the most significant local symptom as well. Generally speaking, it is the first symptom to appear and the last to cease. Before discussing, how- ever, this clinical manifestation of pelvic dis- ease in detail, it seems incumbent that some utterance should be made with reference to the so-called natural secretions. I am led to adopt this plan because, first, there seems to be some misunderstanding regarding this fea- ture of genital physiology and, secondly, be- cause without an intelligent conception of the normal secretions it is obviously impossible for one properly to comprehend and interpret the abnormal. The vaginal secretion. Since there are no glands in the vaginal mucous membrane, the small quantity of fluid present must be gen- erated partially by the squamous epithelial cells lining the canal and partially by osmotic processes. Physically, the vaginal secretion is bluish white and resembles both in color and consistence ordinary skimmed milk. Generally, on separating the labia, it is found only in small quantities. Usually there are observed only a few droplets escaping from the vag- inal orifice. Chemically, the material is highly acid in re- f 490 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 action. This has long been ascribed to the presence of the vaginal bacillus of Doderlein, but, since the acidity pursues a more or less cyclical course, it has been suggested that the reaction may in some way be governed by en- docrine activity. At any rate it is assumed, and quite properly too, that the special chemi- cal character of the secretion is an exceed- ingly important factor in nature’s defensive mechanism. The cervical secretion. The secretion elab- orated by the cervical mucous membrane is frequently compared to the white of an egg. This is entirely erroneous, because it is wholely devoid of color. Strictly speaking, it is as colorless as the purest crystal and only assumes a whitish hue when coming in con- tact with the acid secretion of the vagina. In pregnancy, as a result of this chemical combination, a thick, white, tenacious mucoid plug, the operculum, forms in the cervix, blocking the external os and forming, there- by, another factor of noteworthy importance in the barrier of defense. It is the operculum — stippled or stained with blood — discharged with the onset of uterine contractions that constitutes the show, the first positive sign heralding the advent of labor. The uterine secretion. The secretion elab- orated by the endometrium is of small im- portance clinically, nor is it of special moment diagnostically. It is physically somewhat like water in color and consistence, and chemi- cally it is alkaline in reaction. It becomes of some importance when excessive, as for ex- ample, in that rather curious condition known as hydrorrhea gravidarum. With this rather sketchy introduction, I shall now try to answer a question that I am quite confident occupies the minds of the ma- jority of the members of this assembly, namely, my object for selecting a topic for discussion so elementary as leukorrhea. There are sev- eral reasons why I elected to discuss the sub- ject. (1) I believe that one should always en- deavor to consider a theme of practical value. (2) I am quite convinced the best inter- ests of all are served not by presenting a topic of ultrascientific proportions, but one commonly met with in every day clinical work. I have found that most of our scien- tific meetings are attended largely by inen in general practice and it is to these, provided one has a message, that the message should be conveyed. (3) I was persuaded to speak of leukor- rhea because one must recollect that it is fund- amentally a symptom ; not a disease, but an expression of disease. It, hence, becomes ob- vious that the cause of the symptom, rather than the symptom itself, must be determined and treated. (4) It is prudent to recall that leukor- rhea may have a simple etiology and respond to a simple therapeutic plan. On the other hand, its cause may be more or less obscure, not susceptible to recognition by ordinary means of examination, but only after pains- taking microscopic scrutiny. (5) It is important at this time to em- phasize that one of the most frequent causes of leukorrhea has heretofore only occasionally been recognized. (6) I further elected to consider the topic because the condition is treated, as a rule, in a most unscientific and perfunctory manner. (7) It is now quite generally conceded that many cases have been treated hitherto on the assumption that they had their source in gonorrheal infection. Patients of all ages, from infancy to senility, may be found in this category. (8) Because of the prevailing, if not per- nicious, habit of regarding most cases of en- docervical origin, and treating them as such. (9) Because a most frequent form, if not the most frequent form of all, though first described 95 years ago, has been until quite recently grossly overlooked. In our Antenatal Clinic we find this type of disease more fre- quent than venereal infection. (10) Finally, because to the cervix, in many cases, destructive cauterization has per- niciously been performed, with the infection resident in the vagina and not in the structure cauterized. It might be of interest at this time to say that historically one finds reference to leukor- rhea in the oldest medical literature extant ; recently I had occasion to peruse abstracts from Eber’s Papyrus, written some 1500 June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 491 years before Christ, and, parenthetically, you may be stirred to learn that at last this most celebrated record has been translated into English. Reference, moreover, to the symp- tom is found in the earliest biblical literature, literature which antedates the Egyptian docu- ment by some 35 centuries. I have already directed attention to the fact that there is scarcely a single disorder arising in the generative organs of women without leukorrhea as a conspicuous accompaniment. Considering the symptom from its purely pathologic aspect, one finds that its clinical character may be almost as variable as its causation. For example, in simple vaginitis the discharge is usually of a thin, watery, catarrhal or suppurative type. In venereal in- fection it is found as a thick, irritating, sticky, pyogenic discharge. In malignancy, involving either the vagina or the cervix, it appears as a serosanguineous, malodorous, burned-beef- juice material. In a form now recognized as exceedingly common, it manifests itself as a free, copious, thick, yellowish, offensive, irritating, bubbly or foamy discharge, and it is this variety that I have chosen to talk about tonight. It was first described by Donne, in 1836. The symp- tom may be experienced in individuals of all ages and it has been transmitted from woman to man. This type of leukorrhea is associated with lesions more or less typical, involving the vaginal mucous membrane, especially the membrane of the fornices and the surface of the vaginal portion of the cervix. These are found as small, punctate, hyperemic or granu- lar areas in the anatomic situations named. Bleeding is readily excited by any form of manipulation. It has been observed that the endocervix is singularly free from morbid alteration in this form of infection and it is almost, if not al- together, safe to say that the cervical mucous membrane is rarely, if ever, affected. This is a noteworthy feature of the trouble, so much so that one may be axiomatic and affirm that, with a discharge of the nature I have described and the cervix relatively normal, trichomoniasis may be looked upon with a fair degree of certainty as basically the pro- voking factor. In other words, with the dis- charge presenting the typical features enumer- ated and with the cervix visually free from trouble, one is justified in making a diagnosis, provisionally at least, of trichomonas disease. Confirmation as to the cause of the symptom is readily determined on microscopic study, by finding the field, literally, flooded with parasites of unmistakable identity, namely, the T richomonas vaginalis. Treatment. With regard to the therapy of leukorrhea, it is apparent that no form of medication ever should be instituted without first determining its cause. Since in many in- stances infection of the endocervical mucosa is the source of the trouble, therapy directed to this region, especially in the form of cau- terization, is almost invariably followed by amelioration. In this connection, however, I cannot too strongly emphasize the absolute futility of therapeutics of this type in Tri- chomonas vaginitis. I have already referred to the fact that the endocervix seems curiously immune to the ingress of the parasites. We, as well as many other workers, have never found the organism within the cervical canal. It can readily be perceived, therefore, that it would be wholely illogical to expect a favor- able response to medication directed to this structure. Here may I reiterate that no case of leukor- rhea should ever be treated without its ex- citing cause first being determined. Any other course in the long run will prove unsatisfac- tory and may even court embarrassment. In this respect, may I crave your indulgence while I recite the clinical record of a patient who recently came under my care. She is 34 years of age and the daughter of an em- inent physician. At the age of 2 years, she developed what was regarded as a gonorrheal infection of the vagina. Since that time, or for a period of 32 years, this young woman has been treated with more or less constancy, without permanent release from her most dis- tressing symptom. Since cervical cauteriza- tion has gained a wide popularity as the ac- cepted mode of treating leukorrhea, the patient had this type of therapy applied on 18 dif- ferent occasions. During the past 2 years, 2 cauterizations were performed under anes- thesia. At the present time, there is no ves- 492 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 tige of a cervix. It has been totally destroy- ed. The external os, or rather the mouth of what remains of the cervical canal, is on a level with or, rather, continuous with the vaginal mucous membrane. Three months ago, she came under our ob- servation with the clinical record cited. A local examination disclosed the typical thick, yellow, rather offensive irritating, bubbly dis- charge, with the typical lesions, consisting of turgescence of the labia, engorgement and hyperemia of the lower section of the vaginal mucous membrane, punctate areas of hyper- emia and granulation in the upper part of the vaginal canal, especially in the fornices and surface of the cervix. A tentative diagnosis of the cause of her annoyance was made im- mediately and confirmation was found on mi- croscopic examination, with literally hordes of trichomonads obscuring the microscopic field. Under treatment the patient, now for the first time in years, is not only free from the parasitic infection, but the annoying leukorrhea and the lesions have entirely dis- appeared. With reference to the type of therapy in- stituted in cases of vaginal trichomoniasis, one may say at the outset that there is no specific recourse. It is important, however, to men- tion that early cases are usually responsive, while old or long standing ones prove fre- quently most obdurate. USEFUL IRRIGATING FLUID FOR SEPTIC WOUNDS* H. H. Goldstein, M.D. Elizabeth. N. J. For the past 3 or 4 years, in cases with septic wounds, we have been using an irri- gating fluid which has been a source of great satisfaction to us in so far as clearing up the infection was concerned, and having been (juestioned frequently as to the method of pre- paring the solution, it appeared that a note on the subject would not be amiss. We have *(Read before the clinical society of the Alexian Brother’s Hospital, Elizabeth, N. J., Dec. 9, 1930.) reference not to superficial wounds, but to those deep-seated affairs which have a habit of draining foul pus for an extremely long time. It does not matter whether the sinus leads into the peritoneal cavity or whether it is extra- peritoneal. It has been used with gratifying success in ruptured appendices, tuboovarian abscesses, perinephric abscesses, and a host of other deep-seated septic conditions. The solution is never used until a definite sinus is formed. Usually, the surgeon will allow suffi- cient time for a sinus to form before the drains are removed. If, after the drains are removed, a sinus persists in discharging pus, then the irrigating fluid is indicated. The greatest benefits are derived in cases infected with pyogenic organisms ; our experience with the Koch bacillus has not been happy. The irrigating fluid is prepared by adding to warm saturated boric acid solution a suffi- cient quantity of ordinary U. S. P. tincture of iodin to give the whole an amber color. The solution must always be made up freshly, and strength of the solution will depend on the severity of the infection and location of the sinus. If the sinus reaches into a walled-off area in the peritoneal cavity, the solution should be made weak ; while in a foul peri- nephric abscess a fairly strong solution may be used. One never adds so much iodin that a burn may result. The best results are obtained by using a catheter for the irrigation. An ordinary two- holed, soft rubber catheter is inserted to the bottom of the sinus, and with a large 5 oz. asepto-syringe the solution is gently injected and allowed to run out along the catheter. Suc- tion will remove whatever small quantity of solution does not run out of its own accord. The irrigation may be repeated every 2-3 hours for the first 3-4 days, and then once a day until the infection has been cleared up. The irrigating fluid serves a double purpose. It mechanically washes away the pus and debris, at the same time acting as a bacteriocidal and bacteriostatic agent. These latter properties are still further enhanced by the evolution of nascent iodin from the warm solution (iodin being volatilized at room temperature) and from the splitting of the hydriotic acid which is formed in the boric acid solution. June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 493 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J. Entered at the post office at Orange, N. J., as second-class matter PUBLICATION COMMITTEE HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J. EDITOR: HENRY O. REIK, M.D., P.A.C.S., Vermont Apartments, Atlantic City, N. J. Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact. NOTE. — The transaction of business will be expedited, and prompt attention secured if: All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to The Editor, Dr. Henry O. Reik, Vermont Apartments, Atlantic City, N. J. All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements, or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication Committee, (address above), Newark, N. J. INTERESTING INFORMATION CON- CERNING “OLD GOLDS” In February we directed attention to the character of advertising matter used by the makers of Lucky Strike cigarettes. In April it was the “health crusade” to benefit the manufacturer of non-spit-tipped cigars, that concerned us. Now, you may be interested to learn something about the methods used — again reflecting upon the medical profession — - to force the sale of Old Gold cigarettes. You probably saw in your favorite news- paper a quarter or half page advertisement of “Old Golds”, consisting largely of a pic- ture allegedly portraying a group of physi- cians and nurses in a hospital operating room, capped and gowned as for a surgical pro- cedure but suspending the professional rou- tine while the surgeons tested the relative merits of certain brands of cigarettes. The surgeons were said to be throat specialists, who found Old Golds as kind to your throat as luckies ; in point of fact, kinder. The ad also bore the imprint of Ripley, of “Believe it or not” fame. We wrote to Mr. Ripley that we did not , and asked for proof that any throat specialist had participated in such a test and authorized such use of his professional character. No re- sponse has come from Mr. Ripley, but the newspaper from which our clipping was taken passed the inquiry on to the agency that had arranged for publication of that advertise- ment, and ultimately we were invited to in- spect the records. Accepting that invitation, we visited the agency’s office in New York and had a very satisfactory conference that resulted in ex- posing the fraudulent character of the Old Gold statement. We discovered, in the first place, that the picture was “faked” ; i.e., it was not taken in any hospital, but was staged in a studio. Next, we were shown the list of physicians’ names-— alleged throat specialists — - appended to the advertising contract. From the list of 7 names of “throat specialists”, we selected 3 (chosen because they happened to be the most legible, for investigation. One of those 3 names has not been found in any di- rectory; one is the name of a physician who is not a throat specialist, and not a member of his county or state society; the third is a member of his county society and, of course, of the American Medical Association, but is not recognised as a throat specialist. We re- gret now that we did not copy the entire list of 7 names, but the relative results would probably not have been different. So, as stated before, the advertisement seems to have been fraudulent ; the picture was faked and the posing physicians were not throat specialists. We are concerned about such advertising not only because it is so flagrantly dishonest, but because we object to such exploitation of the medical profession, and we think the time has come to expose all such schemes. If American “big business” is based upon such rotten practices, it is no won- der that it is now tottering. 494 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 Medical Ethics UPHOLD HONOR OF THE PROFESSION John Hammond Bradshaw, M.D., F.A.C.S., Orange, N. J. The obligation assumed on entering the pro- fession requires the physician to comport him- self as a gentleman and demands that he use every honorable means to uphold the dignity and honor of his vocation, to exalt its stand- ards and to extend its sphere of usefulness. A physician should not base his practice on an exclusive dogma or sectarian system, for “sects are implacable despots ; to accept their thral- dom is to take away all liberty from one’s ac- tion and thought”. (Art. I, Sec. 1, Principles of Medical Ethics, A.M.A.) There are many excellent physicians living not far from this vicinity who still think that a written code of ethics is altogether unnec- essary for our profession. Strict in their own personal relations to ethics, they cannot un- derstand why all doctors should not be gen- tlemen. But in the writer’s very limited ex- perience he has met with several physicians who were not gentlemen and, if they observed any golden rule, it was the rule to acquire as much gold as they could without too much nicety of observation of ethics. It is possible that readers of this article can think of in- stances when they themselves had like ex- periences. Others cannot be perfect (?) like ourselves! We have often heard speakers ex- claim that if other men felt and acted as they did about the liquor question, there would be no need of a Prohibition Amendment. Per- haps they are right. Nevertheless, the writer firmly believes in a written code of ethics, and the more he scans the little booklet called “Principles of Medical Ethics”, given to any- one upon request by the American Medical Association, the more he appreciates the wis- dom of its authors and the actual need of its study and its general adoption. We sometimes roll under (and over) our tongue a morsel of professional scandal. Should we not rather know that when doing this we are fouling our own nest? In other words, by avoiding doing this, we are up- holding the honor and dignity of our voca- tion. We sometimes would like to tell our friends and patients that our regard for old Dr. Bluff is so small that we ourselves “would not call him in to attend a sick cat” (but just why a sick feline should be singled out for this pub- licity, the writer actually never found out). The writer is proud to tell that he once knew William Osier and can affirm (with all Dr. Osier’s friends) that this great physician al- ways had some good thing to say about oth- ers, even about his enemy (if he ever had one, which is sincerely doubted). It seems so silly to stir up strife when by taking the opposite course one can keep all one’s friends, be healthier, wealthier, more contented, and even keep one’s blood pres- sure down around normal. Esthetics MAKE YOUR OWN MURALS (An article by W. R. Storey, reproduced from the New York Times Magazine, Sunday, Jan. 18, 1931.) A new form of wall ornamentation, the “photo-mural”, has recently been developed. Through photography, a drawing, a printed picture or a small photograph may be enlarged to the size of a wall panel or even extended to cover the four sides of a room. Already these photo-murals have been applied to interiors of homes, cafes, clubs and offices with marked success. Professional interior decorators have achieved some of these results, but any one using the method may ornament his walls with pictures of his favorite sports, historic scenes or landscapes. Although more expensive than most wall papers, the photographic murals are less costly than a similar decoration done by hand. They vary from about $1 to $2.50 a square foot, depending on the amount of detail involved, and can be hung by any paperhanger. The individuality that may be achieved by this new form of wall decoration is shown in a dining room in the New York home of Owen Winston. Jones & Erwin, pioneers in the new murals, covered the walls with photo- graphic panels by reproducing old prints of special significance to the owner. A scene picturing the New York postoffice about a hundred years ago serves as an overmantel decoration, while the old Grade mansion and the original Astor residence form subjects for panels. The early-American atmosphere of the room is carried out by a fine Colonial din- ing table and chairs. Following the eighteenth-century vogue of painting walls in imitation of fabrics, a dress- ing room in the Winston home has its walls covered with a photographic representation of drapery whose vertical folds are formally regular and decoratively flat. Two vases on pedestals — important details of a Directoire June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 495 room — have been cleverly photographed and made part of the wall covering. More picturesque is the wall treatment of a Chicago home, in which the giant sequoia for- ests of California furnish the motifs. The vertical lines of the huge trees, running from floor to ceiling in soft-toned enlargements along the whole wall, impart to the room a sense of dignity, quiet and spaciousness that only a forest can convey. Tables and chairs, constructed from the same redwood in rough woodman’s style, stand on the Indian rugs covering the floor. Man’s conquest of the air is depicted in full-length, black and white photo-murals in a private dining room of the Cloud Club, high in the Chrysler tower. From the first balloon ascension in Paris a century and a half ago to the latest giant plane hovering over the skyscrapers of New York, the history of aeronautics emerges graphically on the walls. The romance of oil, with views of picturesque oil fields with derricks and storage tanks, is portrayed in similar fashion in a second din- ing room of the club, while the making of steel, with furnaces, forges, and skyscraoer ■construction, forms the subject in a third. Restaurants also use the photo-mural effec- tively. Thus, the college inn room of the Hotel Sherman, Chicago, utilizes an original sketch by the Negro artist, Aaron Douglas. Although the sketch itself, which depicted the origin of jazz music and the modern dance, was only 12x20 in., the flat masses of the artist’s design enlarged so effectively that the murals for an entire room were obtained. Several business offices have adopted this ■original mode of ornamentation. A banking firm has covered 2 sides of a room with a large-scale map of the world ; a concern manufacturing electric motors has ornamented its showroom with heroic-size pictures of its product, hand-colored in the actual hues ; a business man who is also a huntsman has decorated the walls of his office with a pano- ramic picture of a hunt of the Genesee Val- iev Hunt Club. Other uses for photo-murals include the decoration of screens. Old prints of famous landscapes or park scenes — an old Saratoga print, for example — are appropriately em- ployed for this purpose. An amusing design was developed by enlarging an old-fashioned Spencerian pen sketch. Even personal exper- iences may be immortalized by the photo- mural process. A picture of an African big game hunt has been enlarged to adorn a screen in the office of George Eastman at Rochester. A photo-mural may be of almost any size. While the special paper employed is generally only 40 in. wide, sections of the picture may be printed on separate pieces and the com- position joined together when the strips are hung on the wall. If, during the enlargement, the image is projected through the coarse meshes of bolting cloth, a soft fabric texture will result. Quiet color effects are obtained by the use of gray or sepia paper, although other hues may be put on by hand. Color should be ap- plied clecoratively rather than realistically. Oils, pastels and water-colors have been found successful, but almost any painting medium workable with paper can be used for coloring the enlargement. The finished paper is some- times coated with varnish to protect it and provide a soft, antique effect; some loss of brightness and color, however, must be al- lowed for when this is done. Although sepia and black-and-white paper produce interesting and dignified results, more definite and livelier colors may be given to these wall decorations. A transparent tint composed of photo-oil color combined with turpentine may be rubbed over the enlarge- ments after they are hung. Some satisfactory hues are burnt sienna, lemon chrome yellow, deep chrome yellow, ultramarine blue, mad- der lake, tolicline red and Milori blue. In Lighter Vein For Sobriety, Try a Monocle She was only the optician’s daughter — two glasses and she made a spectacle of herself. — Pitt Panther. Tip for Travelers For a cure for seasickness A reader appeals. A plan he might try is To bolt down his meals. - — Boston Transcript. Dolled Up for Sun Bathing “Clothes do not make the man.” Observe the dandy’s— If further proof’s required Just gaze at Gandhi’s. — Boston Transcript. Sometimes we dally with the vagrant thought that birth control would have more to recommend it if it could be made retroactive. — Weston (Ore.) Leader. Archeologists have found a skeleton with the knees crossed behind the head; so the art of dressing in an upper be’"*'h probably isn’t new. — Toronto Star. If the wife laughs at your jokes, you can be sure that either you know some good ones or you have a good wife. — Los Angeles Times. 496 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 Annual Report of the Treasurer 193 1 PERMANENT FUND DR. June 1, 1930 — 2 M 1st Liberty Loan 3 V2 % bonds .. $2000.00 4 M 4th Liberty Loan 4 14 % bonds . . 4000.00 Mortgage Certificates, Investors’ Title & Mortgage Guarantee Company. 2700.00 June 14 — - Cash from Reserve 3000.00 $11,700.00 CR. May 31, 1931 — 2 M 1st Liberty Loan 3V2% bonds. $2000.00 4 M 4th Liberty Loan 4%% bonds. 4000.00 Mortgage Certificates, Investors’ Title & Mortgage Guarantee Company. . 2700.00 Mortgage Certificates, Trenton Mort- gage & Title Guarantee Company.. 3000.00 $11,700.00 GENERAL ACCOUNT Receipts Payments Balance, June 1, 1930 Assessment s — Atlantic $ 1815 Bergen 2880 Burlington 765 Camden 2040 Cape May 375 Cumberland 750 Essex 11995 Gloucester 480 Hudson 6570 Hunterdon 390 Mercer 2205 Middlesex 1785 Monmouth 1330 Morris 1245 Ocean 225 Passaic 3360 Salem 225 Somerset 660 Sussex 315 Union 3640 Warren 375 Interest Publication Health charts sold $17,947.52 43,425.00 914.57 8,850.46 5.20 For Publication Committee $14,748.30 “ Publication Special clerical 100.00 “ Welfare Committee 672.38 “ Credentials Committee 394.02 “ Executive Department: Salaries .... $14,000.00 Travel 2,645.82 Office 3,641.49 20,287.31 “ Treasurer’s Office 65.00 “ Secretary’s Office: Salary $ 1500.00 Expenses 2196.91 3696.91 “ Delegates to A. M. A., R. R. fares.. 187.28 “ Printing and Stationery 1884.81 “ Legal Services 988.47 “ Tristate Conference 126.62 “ County Secretaries’ Conference .... 150.90 “ Expenses of Guests, 1.930 Meeting . . 249.62 “ Flowers, Dr. Dickinson’s Funeral . 25.00 “ Subscription, N. J. Legislative News 25.00 “ Refund to Dr. Hillegas 20.00 Reserve 3000.00 Balance, May 31, 1931 24,521.13 $71,142.75 $71,142.75 RECONCILIATION Expected Income Actual Income Appropriations Expenditures Operating Net Balance WITH BUDGET $48,450.00 53,195.23 48,450.00 46,621.62 5,573.61 Respectfully submitted, E. J. Marsh, Treasurer June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 497 Lighthouse Observations MANAGEMENT OF ANGINA PECTORIS A very practical discourse on this topic was presented by A. E. Vipond, of Montreal (Amer. Med., 36:789, December 1930), from which we ab- stract the following- : “This name does not convey to one’s mind the agonizing pain, the mental anguish, and the tragic death. How many of our personal friends and re- lations have suffered from this, hopeless form of heart disease? This heart trouble may develop slowly and a patient might live for many years, an attack tak- ing place when he oversteps his limit or capacity; as long as he can keep within his capacity, both mentally and physically, he may do very well. He soon learns what he can do and how far he can walk before his heart muscle finds it difficult to contract. The filling up of the lumen of the coronary ves- sels may take years to accomplish, or again, spasm or a thrombus may occlude the lumen of the ves- sel and sudden death may take place at an early stage of the disease. It is a disease which is no respecter of persons. It is most frequently found among the great men- tal workers, and also among men and women who live a quiet life and who have no severe mental worry or strain. It is also found among housewives, clerks, policemen; people who cannot be accused of great intellectual weariness. There comes a time with most of these patients when the slightest exertion will produce the pain. As a rule, it is a progressive disease; all depending upon the amount of occlusion of the coronary vessels. The majority of patients who suffer from angina pectoris have not had syphilis. During the past 2 years I have treated 6 patients with this dis- ease and not one of them had syphilis. In this noil- luetic type of angina pectoris we do not find an inflammatory change in the coronary vessel wall, but a degenerative process; an atheromatous con- dition; while in the syphilitic type we have an in- flammatory change in the vessel wall — a mesaor- titis; while the same changes take place in the coronary vessels. In the majority of my cases no change in the heart condition was to be detected; as a rule the sounds were not quite so loud as in normal sub- ject: and if an organic valve condition were present it was caused by a previous rheumatic infection. Angina pectoris is a very common cause of death among physicians, and many eminent men in our profession have succumbed to this disease. John Hunter suffered from angina pectoris for 20 years, and after his death his coronary vessels were found to be calcified. Sir James MacKenzie, Charcot, Nothnagel and William Pepper all died from this disease. Granted that the cause of angina pectoris is disease of the coronary vessel walls, what pro- duces the pain and sudden death? To me, it does not appear to be a difficult problem to solve. If the lumen of the coronary artery is lessened by disease of its coats, part of the circulation to the myocardium is cut off ; the result is that when the patient is sitting, he, as a rule, feels no diffi- culty, but as soon as an extra strain is placed upon the muscle (which is already suffering from a diminished blood supply), the left ventricle dilates suddenly and the patient suffers from this severe pain in the chest, and down one or both arms, as well as from great mental distress. A keen ob- server can pick out these anginal patients as they walk along the streets. They stop suddenly and stare into a shop window and then continue their walk as soon as the agonizing pain is over. Frederick Price states that the hypotheses which have been advanced in explanation of the attack are numerous and include the following 2 which are important: (1) That angina pectoris consists in the distention of an enfeebled ventricle. (2) That it consists in a myocardial ischemia generally due to an affection of the coronary arteries (atheroma, functional contraction, thrombosis, etc.) ; this ischemia being the direct cause of the pain. I pin my faith to 2 drugs, viz., potassium iodide and to belladonna. The potassium iodide must be pushed; we must get the momentum of the drug. I give 30 gr. in a cup of water to be sipped during the daytime. I mean by this, sip a little every half hour; it can be taken in a bottle in the pocket and sipped while at work. My patients; also get 8-10 minims of tincture of belladonna. The potas- sium acts as an alterative, and the belladonna dilates the coronary arteries and their branches. I give 60 gr. of potassium iodide with 10 minims of tincture of belladonna to my chronic cases, and this foi'm of treatment is kept up for weeks and months with no remissions. Amyl nitrite is not required. The patient can- work if it is of a quiet character, such as office work. Avoid excitement and getting into a tem- per; exercise according to his capacity- — he will soon find out what his capacity is. With this form of treatment I can get results that are lasting. None of these patients have de- veloped iodism. Amyl nitrite is not required when this form of treatment is administered. Current Events TRISTATE MEDICAL CONFERENCE The seventeenth session of the Tristate Medi- cal Conference was held on Saturday, February 28, 1931, at the Pennsylvania Hotel, New York City, at 10 a. m., Dr. Joseph S. Lawrence, of Al- bany, presiding in the absence of Dr. William H. Ross, President of the New York State Medical Society, who arrived later. Those in attendance were : New York: Drs. William H. Ross, Brentwood, Long Island; Frank Overton,, New York City; and Joseph S. Lawrence, Albany. Pennsylvania: Drs. Ross V. Patterson, Phila- delphia; Walter F. Donaldson, Pittsburgh; Frank C. Hammond, Philadelphia; and Harry W. Albert- son, Scranton. New Jersey: Drs. George N. J. Sommer, Tren- ton: John F. Hagerty, J. B. Morrison, Newark; Spencer T. Snedecor, Hackensack; and Henry O. Reik, Atlantic City. Dr. Reik: As Secretary, I have nothing special to report but I would like to call your attention to the absence of one of our Pennsylvania repre- sentatives who has been most faithful in attending these conferences ever since he was chosen as President-Elect of the Pennsylvania State Medical Society. Dr. Morgan is absent because of the recent death of his wife, a death which recalls the subject of our last meeting when we discussed automobile accidents. Mrs. Morgan suffered a 498 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 fractured skull from an automobile accident which occurred, I believe, last summer. I would like to put in the minutes an expression of regret at Dr. Morgan’s absence, and an expression of sympathy- in his recent bereavement. This was unanimously approved. Dr. Lawrence asked if there was any business to be brought up before beginning the regular program. Dr. Donaldson said that he was authorized by Dr. Mayer, the President-Elect, to extend a hearty invitation to the conference to hold the next meet- ing in Pennsylvania, and in Pittsburgh, if it met with general approval. Dr. Reik : Remembering the last time we were in Pittsburgh, I am sure we should be very glad to go back there. I move that we accept Pennsyl- vania’s invitation to hold our next conference in that state, and leave it to the President and Secre- tary of the Pennsylvania Society to decide the time, place and program. This was unanimously approved. Regular Program What Are State Departments of Labor Doing to Advance Industrial Surgery? Dr. Lawrence: I have in mind to conduct this part of the program as a round table discussion. I have no set paper. I am going to introduce sub- jects and give my point of view, and would like to get yours in return. As an introduction, I shall tell you something about the organization of a Department of Labor in New York State. I pre- sume you probably have similar organizations in your states. I know that there are some differ- ences but whether they are material or not we can develop. Our department is headed by a Com- missioner, a lady who has among her qualifica- tions for this particular job the experience derived from chairmanship of a legislative committee that was appointed years ago to make a study of the sweat shops in New York City. Her committee, I think, started really as a local voluntary organ- ization and after securing state authority extended beyond New York City to other large cities in the state. It is said that without question she prob- ably knows more about factory work in this state than any other single individual because of her various personal inspections and years of exper- ience. She is assisted by an Industrial Board of 5 members appointed by the Governor. They pre- sent no qualifications aside from the fact that they are familiar with industry and problems that the Department of Labor might take up. Of course, as a State Department of Labor she has the assist- ance of the Attorney General’s Department when she needs it. She hfis also an Advisory Committee composed of 10 members, 5 of whom represent in- dustry and 5 represent federated labor, but this group has no mandatorial powers; she need only consult them at her will and may take their advice or not as she chooses. From experience, however, I think that she relies upon them to a great ex- tent and finds their advice very valuable. I have sat in several times at conferences, that she has called, where they considered not only subjects which you would expect them to be very familiar with, that is subjects relating directly to industry or labor, but medical problems as well. These 10 men were her advisers on matters that affected administration of the Workman’s Compensation Act. Then she has several volunteer committees, on codes and rules, that she consults also at her pleasure. There is a Deputy Commissioner in each of various other cities, like Rochester, Buffalo, and Syracuse, in addition to the officers in New Y’ork City. And then, she is directly head of the State Insurance Fund; and the latter is growing to be, if it is not already, the most extensive carrier of insurance in the state. As a matter of fact, I believe it was said not long ago that it carries an amount almost equal to that of all the other car- riers, and there is a bill in the legislature now that would make it incumbent upon communities and municipalities that carry insurance to take such insurance from the State Insurance Fund instead of from private carriers. That, if made law, would leave the private carriers only such in- dustries as would want to go to them. This bill also pi'ovides that the State Fund may carry pri- vate insurance if requested. So, it may be only a few years until the insurance work in New lrork State will be carried by the state and the self- insurers. Labor is back of this movement; medi- cal men are not. In New York City the State Fund operates very satisfactorily but up-state physicians tell us that they have more difficulty in getting settlements from the State Fund than from any other carrier. Of course, the Commissioner of Labor controls a number of subdivisions; among which are women in industry, industrial relations, and self-insurance. She has a division of industrial hygiene, and sev- eral, 10 or more, employment agencies throughout the state. You will see, however, that she has no voice aside from, the State Fund that relates to the compensation of injured workmen. Now, this is no small matter. In 1929 there were 199,035 injuries reimrted. In that same year there were held in the state 523,604 hearings. They dis- charged about that many cases from their calen- dar that year. Of course, some cases go on from year to year before they are finally closed, but she has averaged 5 hearings in every 2 cases. I will leave that for our discussion to bring out — why there should be so many hearings. The admin- istration of this Act and the paying of the au- thorizations allowed amount to more than $32,- 000,000 in our state. When a matter so extensive as that presents itself, in which the crucial point is the medical examination and report, it does seem to us that medical men should have a more direct relationship to administration of that part of the law. Our relationship at the present time is limited to her employees. She has physicians employed to assist with the hearings. They have in the year 1929 submitted a report of the medical division which occupies just 1% pages of this small book. As compared with our Department of Health, the Department of Labor in its medical phase seems very poorly administered. One wonders whether it is not time that we take a greater in- terest and see that we get an opportunity to help contribute something to the operating of this law. In your states, are the men who do industrial work selected in any particular way, or is it purely a matter of voluntary choice? Dr. Morrison: Do you mean the Deputy Com- missioners or the medical men? Dr. Lawrence: The medical men. Dr. Patterson: The most adequate and com- plete surgical and medical care is given to the employee. Dr. Sommer: If he so desires, he can select his own physician. Dr. Morrison: But the law does not recognize the insurance carrier. It only recognizes the em- ployee and the employer. Dr. Sommer: They sometimes employ physicians, June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 499 in our community, who are not members of the county society and if they have cases requiring hospital care from this compensation clinic they park them in a private institution. Of course, we get in our general hospitals a great many of their injury cases and whenever they can in any way get hold of them they take them away from those physicians. Dr. Lawrence: Do you have a similar system in Pennsylvania? Dr. Donaldson : Pennsylvania has an insurance plan of its own that is subsidized by the state, but most of the larger industries in Pennsylvania, such as the railroads and the steel and coal com- panies, maintain services for their own em- ployees. Dr. Lawrence: We call them self-insurers. How about the selection of medical attendants by the injured ? Dr. Donaldson: That is not left to the choice of the employee. It is the choice of the employer. Dr. Lawrence: Does your law read that way? Dr. Albertson: The law says that the employer shall provide proper medical and surgical aid for the injured. Dr. Lawrence: So our 3 laws are about the same. Dr. Morrison: In New Jersey the compensation is paid for by about 30 carrier insurance associa- tions and they have found in an experience of 10-15 years that, because of allowing physicians chosen by industries to treat their cases, losses have become so enormous that they are coming to the conclusion themselves that it will be cheaper to have the physician chosen either by the em- ployer or the employee himself than to keep on with the present system ; that under the present system they are paying for long periods of disa- bility and greater amounts for permanent disa- bility, because of treatment by incompetent physi- cians. Dr. Lawrence: You mean the employer in this group appoints the physician, or the insurance carrier ? Dr. Morrison : The insurance carrier appoints the physician. Dr. Lawrence: And they are not satisfied with that and think it would be better to have the in- jured employee select his own physician? Dr. Morrison: Yes. Dr. Lawrence: The question suggested by Dr. Sommer might well be discussed at this time. He referred to the fact that patients are placed in general hospitals and moved at times without good reason. Do the hospitals charge the insurance company a particular rate for compensation cases? Dr. Sommer: They charge the regular ward rate. The insurance carrier will only provide for regu- lar ward rates. However, they will sometimes provide special nursing services and private room for an individual patient. I think that depends upon the man who insures. If he has influence enough with the company they will provide most anything. I have had one patient, who was very badly burned, for whom they provided special nursing, private room, and took care of him for more than 2 years, paying my bill also. Dr. Lawrence: Does this same condition hold in Pennsylvania? Dr. Donaldson: They make provision now for only 30 days’ care and $100 limit. YVe have hopes of increasing both of those 50%. There is much dissatisfaction all over the state about services rendered to individuals who are necessarily in the hospital longer than 30 days. There is provision made for adjustment but adjustment is required in each individual case. That is true also in the other states. Dr. Morrison: In our state the statutory pro- vision is only $50 for medical and surgical fees. That does not include the hospitalization. And we have a gentlemen’s agreement with the carriers by which the physician will' notify the carrier that his bill is to be in excess of $50 and then the bill is submitted and if the insurance company thinks it excessive can refer it to a medical commission, which we have in each judicial district of the state. If the commission reports that the bill is fair, the company pays it without further ques- tion. Dr. Sonvmer: I have attended a lady with a frac- tured hip who has been in a private room of our hospital for months. By some special arrange- ment they take her occasionally before the Board and give her a hearing and extend her time. Or- dinarily, you would not think she should be 8 or 9 months in the hospital for a fractured hip, but they are as a general rule quite liberal. I think, too, they take into consideration many fac- tors which we ordinarily would not consider. In this case they have just extended her time and her compensation. Dr. Hagerty: Is not that provision referred to by Dr. Morrison really more than a gentlemen’s agreement ? Dr. Morrison: No, it is simply a gentlemen’s agreement. Dr. Reik : I think it is written into the Act that the physician must give notice if the charge is likely to extend beyond the $50. Dr. Lawrence: I know that we are not limited by statute in this state in regard to the amount of our fees, and our limitations come from in- spectors whom the carriers employ and they may interfere with the treatment or care of a patient at any time, it seems. They may take him from one physician to another or from one hospital to another. We get quite excited here about what we call “lifting cases”; this is done so extensively. Cases are lifted, I am told, from! the far end of Dong Island and brought to New York to be treat- ed, or from Albany to Syracuse, with no reason to exjject getting better care, so far as we can see. Another difficulty that we have with carriers is with regard to the payment of hospitals for ser- vice. They insist upon putting patients in our wards; and our wards are all operating under a deficit. In some cases the ward rates are $2 or $3 a day and our hospitals up-state during the last year — several very reputable hospitals — stated that they could not operate at that rate, that it cost $5.80 a day for their patients in the ward and when they did not get those rates it resulted in a contribution of the local charity to those in- surance carriers. So, many hospitals are refusing their wards to compensation cases and are insist- ing on a semi-private ward for such cases, where they can charge a rate that will equal at least the cost of carrying that patient in the hospital. The insurance companies, especially the State Fund, up-state object to that method but we are grad- ually getting ourselves together and insisting upon it. The administration of our Public YVelfare Law is aiding us on that score. The state has wards under that law and they are the people who heretofore were carried as charity patients in the hospital, and as charity patients of course they had a claim on the community, but now, under the Welfare Act, they become the wards of the state and there is no particular reason why a community chest should raise money to pay for expenses of a State ward when the state has made provision to have that 500 JOURNAL OF VUE MEDICAL SOCIETY OF NEW JERSEY June, 1931 case cared for. It is our hope that we shall finally get an understanding by which compensation cases will pay their way in the hospital as though they were private cases, not of course as if they were millionaires, but as private patients able to pay. Dr. Sommer-. Our local hospitals are not com- plaining of rates. With us they seem to welcome the compensation cases. We operate our insti- tutions, of course, much more cheaply than you do in New York State. Dr. Morrison : There was some objection at first, but the insurance companies are taking care of us now all over the state. Dr. Sommer : I think the carriers are dealing very fairly with us now. The medical officer in charge of the rehabilitation clinic acts as an ex- pert and decides upon the degree of disability. However, the man does not have to accept that advice; he can obtain an outside physician and have him certify to his disability and, depending upon the standing and character of the physi- cian he brings in, the commission takes consider- ation of that and he may have his time of disa- bility extended. Moreover, they settle upon a basis of each particular injury, and if there is a residual injury there may be a question of how much per- manency there will be to the injury. These cases may be re-opened within a certain time limit, for adjudication. That is at the option of the em- ployer as well as the employee or the insurance carrier. I think our law has worked very well in the main but it has met with some opposition. For instance, an insurance carrier will enter into an agreement with the medical officer to have him care for a particular patient, and that is where we have trouble, but we hope to change that and pro- vide for full-time officers who will no longer be allowed to do private practice. Dr. Lawrence-. Do you mean by the medical officer the physician in charge of the rehabilita- tion clinic, and who acts in the hearing, or who is appointed by the state to preside over the hearings? Dr. Morrison: The referees have the power to select physicians to conduct the examinations at headquarters. Dr. Lawrence : That is done in about the same way here. Dr. Morrison: Dr. Lawrence referred to the great number of hearings in each case. We have had the same condition in New Jersey, and es- pecially around the larger centers there has arisen a system of racketeering among the physicians and lawyers solely for the collection of fees — by persuading the commissioner or deputy commis- sioner to have a series of adjournments and every time they appear in court they charge from $25 to $50. We had to put a time limit on that. We now have an unpaid commission appointed by Colonel Blunt, the Com|missioner of Labor, mak- ing a study of the compensation law and its administration in the state. We have been study- ing the matter for a year and are about ready to submit our report. We have a time limit during which an application for a hearing can be made and if the applicant does not appear upon the date set for him the case is to be dismissed, un- less he subsequently makes another application. That, would bar hundreds of cases. Then the deputy commissioners are instructed to be very careful and insist upon adequate reasons for any adjournment. If the case is set for today it must be tried today and will not be set aside merely on the request of a lawyer. Dr. Lawrence: Now it seems to me — and I put it as a suggestion for discussion — that the Depart- ment of Labor and the physician who treats the case are too remote from each other, that there should be a more direct relationship. It seems to me that one of the reasons for adjudication is that the department or the carrier is taking advantage of the lack of understanding or jumper recognition of the physician who treats the patient. For in- stance, I have knowledge of many men in this state who rarely have any of their bills disputed. They treat a patient and, just as Dr. Sommer has said, I know men who have carried cases for an unusual length of time; the patient needed the at- tention, of course, and the bills were paid with no argument whatever. On the other hand, I know some men, who are just as honest and sincere as they can be, who have every bill disputed and have their office 'fees reduced by 25 to 50%. If they want more they have great difficulty getting it from the insurance company. The insurance company, after a bill is submitted, will frequently send back a statement that so much will be paid and send the check along, making their own re- ductions at the time. These physicians have no support, nobody at court to protect them, and therefore accept this reduction and the insurance companies have found the method so profitable that they continue its use. Dr. Morrison: If your State Society will secure this gentlemen’s agreement such as we have, and the appointment of physicians to examine doc- tors’ accounts, that will be done away with. It has been working with us for 7 or 8 years. Dr. Lawrence: I feel that if we had some in- termediate positions filled by physicians that such things would not need to occur. We had some dozen or more years ago a similar situation with regard to public health. The individual physi- cian who did public health work was not recog- nized and usually his work was considered wrong. Others would duplicate it, or his field was invaded without consultation, and so we developed here a very nasty feeling toward public health work. Machinery was established later which brought a direct contact between the practicing physician, the district state health officer and the commis- sioner, and communications went back and forth, instructions were carried along, so that at the present time the average practitioner does not feel any hesitancy whatever in taking care of com- municable diseases. He knows what is necessary to satisfy the State Department and the State De- partment does not have any nervous feeling either with regard to the practitioner. Communicable diseases are reported, and not always is the diag- nosis checked by the health officer; it is simply accepted. I believe if we had more complete ma- chinery between the physician and the carriers their diagnoses would be accepted, their statements believed and their bills paid as they should be. I think Dr. Morrison’s statement with regard to the Advisory Board is exactly a justification of the point I am trying to bring out. Dr. Morrison: We have had that Board in satis- factory operation for about 7 years. It was brought about through the State Medical Society. Dr. Reik: I think we should explain that the smooth working of that law in New Jersey is largely due to the Commissioner that we had and to the machinery that was then established, for, as you have learned by the narcotic and prohibi- tion laws, rules and regulations established for the enforcement of the law are more important than the law itself. Dr. Morrison: I think our agreement was made by Dr. Eagleton prior to Commissioner McBride’s appointment. June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 501 Dr. Reik: After the first Commissioner’s death, Dr. McBride was made Commissioner and he fur- ther developed the work that Colonel Bryant had started, and through his service of 7 years the rules and regulations developed in the department, plus the fact that he went through the county medical societies teaching the doctors their re- lation to the laws, have brought about much smoother working. Also, the judicial district rep- resentatives who pass upon bills have helped smooth the way between the physicians doing the work and the employers and carriers. Dr. Lawrence: How is this Advisory Board or- iginated ? Dr. Sommer: One man represents the profession, one the department and one is elected through the insurance carriers. Dr. Lawrence: Who selects the physician? Dr. Sommer: The county society. As a matter of fact these boards do not have many cases to con- sider because any man who has a dispute knows whether his bill is just or not and it is seldom that a bill is brought up before that committee. Dr. Hagerty is on .the Board of Essex County and he can tell us that it has not had a great deal of work to do. Dr. Hagerty: I was appointed when we had no rules or regulations laid down for us. I think in justice to the carriers I might say that we had as much trouble with the doctors as with the car- riers. The work was new and some doctors saw a chance to get big fees and were charging large fees for trivial work. That was one of the un- pleasant features about the work. For instance, a man would have to be put in plaster and the doctor would go in every few days to see the man and it caused considerable trouble. But after our conferences our judgment in the matter was ac- cepted and the matter was settled amicably and the work went along very well. Dr. Lawrence: How was the physician ap- pointed? Dr. Hagerty: The appointment was received from the county society to which the man be- longed. Dr. Lawrence: There is more than one county in your district? Dr. Hagerty: Yes. Dr. Lawrence: How do you determine which county he shall be appointed from? Dr. Hagerty: I do not know except that Essex is the largest county in our district and I think the others looked to us for that appointment. Dr. Lawrence: He contributes his services? Dr. Hagerty: Yes. Dr. Sommer: I know in our judicial district the committee has very little work to do. I think once the profession realizes that physicians will be checked up they will be much more careful. Dr. Lawrence: Do you have opportunities to increase the requests of certain physicians as well as to decrease them? Dr. Hagerty: Often they failed to notify the in- surance companies that a case would need longer treatment and we would take that into considera- tion. This provision that Dr. Morrison has men- tioned was written into the act, that is, the car- rier must be notified that the condition will last longer and that more money than $50 is needed. Before that was done the Advisory Board decided tvhether the bill should be paid and our recom- mendations were accepted. Dr. Morrison: There has been also another cause of complaint. The carriers’ plea was that doctors did not submit satisfactory bills. For instance, a man has a burned hand and every finger has to be dressed; the doctor sends in a bill for $3 or $4 for a dressing. The companies will cut that down to $2 right away. But if he specifies that it was an extensive burn necessitating the dress- ing of each finger separately the bill would be paid. Dr. Sommer: You do not want to render a lump sum bill to insurance carriers, for they will com- plain about that. But, if you itemize, and send even a larger bill, it will be paid; that is an inter- esting fact. Dr. Reik: The principal complaints at the pres- ent time are; first, a failure to notify the insur- ance company that the bill will amount to more than $50; and secondly, the failure or refusal to render an itemized bill. Those are the 2 main complaints. Dr. Lawrence: The next point I want to bring out. is that in our state the Department of Labor limits its interest almost entirely to disputing the amount of compensation. So far as I am in- formed, our Department of Labor is limited in its constructive work with regard to injuries and oc- cupational diseases to the issuance of a small journal, 4 pages once a month. Usually, half of that is taken up by description of a particular type of machinery in some factory, or some scheme of ventilation, and it only goes to a limited number of people in the state, usually, I believe, to physi- cians who are employed by self-insurers or work- ers in the Department of Labor. No effort is made by the Department to bring the physician to a better understanding of industrial injuries and occupational diseases, the value of which was so beautifully demonstrated in the Army. Every man went to war, I think, feeling that he would be as good a doctor as the next fellow, that he could treat a gun-shot wound, or this or that, but he was not there long before he found there was a lot he had to learn. And those men coming back have added more to the constructive study of injuries and to the advancement of the care of injured workmen in our state than was learned during all the years that the department itself has been in existence. Dr. Morrison: One of the reasons why your de- partment's chief function seems to be to limit the amount of mloney paid for compensation of in- jury is the fact that you have a State Fund. If your insurance was all carried by business con- cerns you would not have so much of that trouble. Dr. Lawrence: In any of your departments, is there any constructive interest being taken in the injured men? Dr. Morrison: Yes, the basis of the law in New Jersey is the interest of the employee. Dr. Lawrence: The thing I have in mind is this: Take the common head injury. Does the Depart- ment of Labor make any effort to get at the physi- cians who are doing industrial work and to keep them abreast of the times concerning the treat- ment of head injuries? Dr. Morrison: No. Dr. Lawrehce: Last year we made it a special point at our branch society meetings to discuss head injuries, and it was one of the most inter- esting subjects that we had at our conferences. Dr. Morrison: That is one of the duties of our state societies. They must explain that industrial surgery is a branch of general surgery, that it is almost another specialty, and the ordinary family physician is not always prepared to take care of these cases. We must recognize the men who are making this .a special line of work. Dr. Lawrence: I will agree with you in part but we did not solve our public health problem in that 302 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 way. The public health department made it a point to see that the doctors were getting an op- portunity to know the differential diagnosis of chicken-pox and small-pox, of measles and scarlet fever and other things. They instituted regular methods of instruction, giving the physicians an opportune to get that information if they wanted it. I think the Department of Labor has a similar obligation to the physicians who are willing to take care of injured workmen. Dr. Reik : Don’t you think a large percentage of the profession would resent instructions of that kind coming from a lay organization? Dr. Lawrence'. Yes. It should have a medical advistory division that would take care of the medical work. Dr. Morrison: Why doesn’t the state society recognize industrial surgery and teach its mem- bers? Dr. Lawrence : Even that would be limited in its extent. Dr. Morrison: But it at least would be accepted by the physicians without resentment. Dr. Hagerty: The profession would come to recognize that. In St. Michael’s Hospital, with which I am connected, every case of head injury is referred to the head department with consult- ing head-surgeons. When it is found that the patient has not a fractured skull he is sent back to the general surgeon but all cases of head injury are referred to the department of head-surgery until it is determined that there is no head in- jury. Dr. Lawrence: Of course, the problem is not limited any more to surgery. There are the occu- pational diseases. In New l'ork State there are many diseases and conditions as difficult to diagnose as the communicable diseases. There are the different types of poisoning, and then there are abrasions, the asthmas, and various pulmonary troubles. I may be wrong but I do think that the Department of Labor should be in a position to assist the medical societies in helping a man to get instruction up to the minute on conditions that are to be treated. We raised this question in a group here in New Y'ork City one day in regard to handling just a broken bone. It was demonstrated that appliances could be created that would be very effective in holding bones in place and some very elaborate machinery was devised. There are certain types of industrial injuries, or certain groups of injuries, broken bones, for instance, that occur more frequently than others and cer- tain physicians who see many of those cases have devised improvement in the manner of handling them. The compensation people are acquainted with that and they get the notion of what such an injury ought to be allowed in compensation. Well, a man up in the woods who has a similar injury does not have the advantage of this man’s exper- ience down here and he treats it in his own way. The result may be that it takes him twice as long, and then, maybe, it is not as satisfactory. Dr. Albertson: I know that it is not correct. I know, personally, that we have in our district many men who treat fractures and they may take longer to rehabilitate their patients than the men in the cities take. The way the army has brought out the method of treating fractures is mostly a myth. I will admit, frankly, that there are some Improvements but I happen to come from a com- munity that has both the metropolitan and an urban condition, and I happen to see patients with both classes of men, and it is often surprising to me — the result which a doctor will get in a coun- try farm house where he has few or no modern appliances but treats the fracture in the way he was taught to do years ago. I am thinking par- ticularly of fracture of the femur. I have seen many of them treated in a farm house with won- derful results, and without the use of an x-ray apparatus. I am not advocating this as the best thing to do, but I am bringing out the point that it is done with good results. Dr. Lawrence: I grant the exception. I was speaking of the principle. Dr. Albertson: The matter of time for rehabili- tating a fracture or a head injury, particularly in compensation work, is based largely on the repu- tation of the physician. If he is anxious to do good work the company will usually take the right attitude toward that man. If they find an- other man who is dragging his cases along they soon know that and adjust his bills accordingly. Dr. Lawrence: But a man who has had ex- perience is pretty likely to have advantages in the treatment of industrial injuries over the man who has but little experience, and would it not be wise to have the experience gathered by those men who have many cases transmitted in some way to the other men? Dr. Albertson: Generally speaking that is true but there is a great deal of superspecialism today. We are specializing in everything. There is ad- vance being made in medicine and surgery and particularly along the line of industrial surgery all the time. There is a chance for everybody to learn. But I am satisfied that most of those things should be thoroughly tried out and proved before they are given out to the general prac- titioner as adopted facts. I believe, arid I think the industrial surgeon will bear me out, that there are too many men who have gotten an idea that certain forms of plaster splint, for instance, are adaptable to all kinds of fractures and very many serious results will be shown in the hands of men who do not know how to use plaster. Dr. Reik : I think we have lo'oked upon the point that you make regarding education of the pro- fession as an obligation of the profession to itself, and we are covering that, in part at any rate, by arrangement of our programs at the state and county medical society meetings. In the annual state society meeting, for the past 2 years, 1 ses- sion has been devoted especially to industrial medicine. For instance, at the last meeting there were 2 sets of papers, one that started with in- juries of the eye and special organs, and the other dealing with fractures in general, skull and long bones. We invited selected men to prepare those papers, and invited in to discuss them experienced physicians and also representatives of the Labor Department and of the insurance carriers. Those discussions practically amount to a carefully pre- pared dissertation on the whole subject of in- dustrial medicine. I happen to remember it be- cause we have been publishing the proceedings in the December and January Journals. At times we have touched upon occupational diseases, and the April Journal covers the question of lead poison- ing, including 1 paper from a man who has de- voted his attention largely to medicolegal affairs and he tells us the legal aspect of occupational diseases. We have assumed that education of the profession in regard to this matter belongs to us rather than to the Labor Department, but I see no objection to having the said department aid in the matter and I think it should be glad to do so. Dr. Lawrence: Did you not have the same feel- ing at one time regarding Public Health? Dr. Reik: I think I have it yet. June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 503 Dr. Lawrence: In Pennsylvania they rely a good deal on their Secretary of the Public Health De- partment for instruction and assistance in develop- ing' public health work, do they not? Dr. Albertson: Oh, yes indeed. Dr. Lawrence: Your public health work in New Jersey is largely under a lay department, is it not? Dr. Reik: At the present time the Commissioner is a layman. Dr. Sommer: Ours is an industrial city, of course, and we have industries in which poison- ings were common at one time. Now they are comparatively rare. In the pottery industry we have practically no lead poisoning occurring. The methods of manufacture have changed so much, there is less hand labor, and more casting and machine labor. The American steel and wire mills have not for years had such a thing as lead poison- ing. Until recently a case would occasionally oc- cur. In the process of heating the wire there is a vaporization of steam and the workers would in- hale the steam and get lead poisoning.. Now, the only types of lead poisoning we see are due to carelessness of some individual who takes up painting as a side line or in the home. So far as the industries are concerned, these cases have practically disappeared. Dr. Morrison: There has been called to the. at- tention of our Commission the fact that there are at present pending in New Jersey suits for lead poisoning_ amounting to $9,000,000. All of these are in the hands of racketeering groups of physi- cians and lawyers, and the injured claiming com- pensation are negroes or Portuguese. It has be- come so extensive that the men engaged in such industries in New Jersey pay $900 a year per em- ployee in insurance to protect themselves. Dr. Sommer: I can only speak for local condi- tions. It has practically disappeared in my dis- trict. Dr. Morrison: Speaking of instructions, in ad- dition to what Dr. Reik said about the program of our state society, we have 2 groups of Post- Graduate Lectures offered to the county societies, that are given by men connected with hospitals and colleges in Pennsylvania and New York. Be- sides the elective courses in medicine we have one in minor surgery, and that concerns practically all sorts of conditions that are treated under com- pensation. Our physicians are thus informed how to manage those cases. Dr. Lawrence: How do you give that informa- tion? Dr. Morrison: We are giving the information through lectures in our Post-Graduate Courses offered by the State Society. Dr. Lawrence: We have in this state, of course, an Industrial Surgeon’s Association but the mem- bership is largely composed of men who are full- time surgeons in industry. There are quite a num- ber, probably 40 or 50, at these conferences which are held twice a year and the sort of things I have been talking about are discussed there, that is, injuries or conditions that frequently arise in industries. Methods of treatment and the newer attitudes that are being developed with regard ^to treatment and care of such cases are brought out at these conferences. We have thought it very valuable, but the average physician did not go to the conferences. Dr. Reik: I want to interrupt the meeting to in- troduce Dr. Snedecor, of Hackensack, New Jersey, and to offer him the privilege of the floor in order that he may take part in the discussions. Dr. Lawrence: We are glad to welcome you, Dr. Snedecor, and trust you will take part in our discussions. My next point is on the other side of the picture. The Department of Labor people make no con- structive contribution to the problem but they do sometimes encourage destructive criticism. Last year they smiled very favorably upon and helped to give expression to, if they did not definitely organize, the investigation of industrial clinics in this city and they unearthed what they considered many very deplorable conditions. They offered some legislation that would correct the conditions which they found, unsanitary offices, places where only a nurse was in attendance, and where physicians treated patients by merely looking at them, and many cases of neglect. I do not doubt that all of this was based on fact but they picked out cer- tain places to condemn, as almost any one can do in certain neighborhoods. It seems to me that it is only fair if we listen to their criticisms of that character we ought to expect from them some constructive aid. Our Department of Labor has contact with employees and with industry, but no satisfactory approach to medicine. I consider the next point of great value. How does the general care of those suffering from in- dustrial injuries or occupational diseases compare with the general practice of medicine at the pres- ent time? Has not a great deal more advancement been made in the general practice of medicine in the last quarter of a century than has been made in the handling of occupational conditions? Dr. Albertson: The handling of occupational diseases is comparatively young, perhaps since 1915, but I will venture to say that the advance made in handling industrial injuries in the past 15 years has been greater than in the 60 years previous. It certainly keeps abreast of the ad- vance in g'eneral medicine. Dr. Morrison: I agree with Dr. Albertson. Dr. Lawrence: A very prominent surgeon has said that the general practice of medicine is 10 years ahead of the methods of caring for indus- trial conditions, and he is an industrial surgeon. He is an up-state man and a general surgeon but does a lot of industrial work which is referred to him. Dr. Albertson has suggested that in referred work he sees only the worst cases, which may be true. I am glad to get the reaction from your 2 states and I will balance that with the opinion of the man from up-state. Dr. Albertson: It would be interesting to get the reaction from several viewpoints, say from 10 general practitioners in different localities, 10 in- dustrial surgeons, and from general, surgeons in 10 different counties. Dr. Lawrence: That would be the way we should go about it. There is another phase with regard to this. I think that our treatment or care is not entirely that which the physician himself would select in many instances but when he is treating an industrial case he does about what is suggested to him or what he has found from past experience will be acceptable to the insurance companies. For instance, when ultraviolet lamps came on the market the industrial surgeon was the man very generally who bought the lamps. Dr. Morrison: Plus the osteopaths and the cult- ists. Dr. Lawrence: Yes, but among the medical men connected with the insurance carriers it seemed to be the thought that an open injury especially was bound to heal with a limited motion unless it was given a certain number of treatments with the lamp. We made an investigation and got the car- riers to testify and there was just one carrier who 504 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 said there are probably some advantages to be de- rived from the use of the lamp. All the others said it had no advantage, and yet the lamp is still used to a great extent. Some doctors have nurses in their offices who give treatments with the lamp for $2 or $3 each and extend the treatments in- definitely. Dr. Albertson : All of these subjects are too large to take any one’s individual opinion. The thing that would be of advantage is the opinion of many men in different localities. Dr. Lawrence: Another point: I do not know what the legislation in your several states is with regard to advancement of the number of compen- satable conditions, but in New York State we are very likely this year to enact legislation that will remove this enumeration of conditions and simply let the law read that a person shall be compensated for any injury or incapacitating condition arising out of occupation. That may mean because of the apparatus or because of the work the person is doing. Now, if that is passed, there is a porton of it which says that a man who is discovered to be incapacitated from an industrial occupation which may have originated in a previous employ- ment shall have his compensation divided between the several employers. In other words, if a man is working in a woolen or porcelain factory, and has worked during the past 25 years in 5 or 6 other factories, and comes down with pneumo- coniosis, that enormous and definite disability, they will have to go back and share that com- pensation among the various employers if the pre- vious employers cannot prove that he was in splendid condition when he left them, or if the present employer cannot prove also that he did have some such condition when he came to work for him. As I have pointed out to the Depart- ment of Labor, this will mean that every work- man when he starts to work will have his card, and when he is leaving and seeking employment elsewhere his card will follow him, and different notations will be made of the findings. He may be examined by another physician G months later who will add another note. When he has reached the age of 35 or 40 no one will want to employ him. The key position for this is the physician in his medical examination. We will be the goats every time. You may not be threatened with such legis- lation but we are. Dr. Donaldson : All labor legislation seems to or- iginate in New York State. Dr. Albertson: I am interested to know what the reaction of your State Medical Society is to that. Dr. Lawrence: We are opposed to it because we know that it will encourage malingering and poor practice. Dr. Albertson: Not only that, but if that goes through it will be the beginning of state medicine. Dr. Lawrence: Certainly. This would not even exclude the office force. A man might go home and have a terrible headache. He may have been out the- night before but if he develops pneumonia it will be blamed on the poor ventilation in the room. Dr. Patterson: Does that mean that all the sclerotic conditions can be ascribed to occupational disease? Dr. Lawrence: It depends on what the examin- ing physician says. Dr. Patterson: If a man who is engaged in laborious occupations for a number of years de- velops arteriosclerosis might he be said to be suffering from occupational disease or a series of occupational effects? Dr. Lawrence: So far as the law reads, that is right. Dr. Patterson: That is a very dangerous thing. Dr. Reik: If we expect employers to compensate laborers for what happens to them while engaged, then requiring examination of laborers when they enter upon employment is inevitable. So, is it not easier for us to prepare for that than to let the Labor Department put over such a bill as Dr. Law- rence talks about now. If it comes from private interests it will surely be wrong. Dr. Albertson: May I ask to what extent your carriers in New York and New Jersey require that the employees be examined before accepting a position ? Dr. Lawrence: So far as New York is concerned there is no general demand for that at all. Dr. Reik: No, but a great many employers are doing it all the same. Dr. Albertson: So many employees in Pennsyl- vania had old hernias which had to be fixed that now some industries will not accept a man for any position until he has a physician’s statement that he has not a hernia at that time, and it must usually be some physician in whom they have sufficient confidence. Dr. Lawrence: I think that is a pretty general practice among our self-insurers. They do ex- amine their employees, and in some instances give them periodic examinations, but where the insur- ance is carried by the State Fund or by a carrier they do not examine them. Dr. Reik: Wouldn’t you want to insist upon the initial examination if you were an employer? Dr. Laivrence: Y'es, I would. We have for several years been following a suggestion made by the In- dustrial Survey Commission, appointed by the legislature, upon supporting a bill which would create a Medical Advisory Council in the Depart- ment of Labor to balance with the ones already there representing labor and industry. Last year we got it through one house and up to the final reading in the other, when the Commissioner stop- ped it. She promised me a conference, which she has not yet granted. The only objection she stated was that she had already allowed herself to be too liberal in taking public advice. I know, however, that she would not give this as a real reason. Dr. Morrison: One of the recommendations of our commission is that a referee commission of 3 physicians be appointed, to be at the call of the commissioner, the cases to be examined by this Advisory Commission and its findings accept- ed as final. That will solve a great many diffi- culties in the conduct of these cases. Dr. Lawrence: I think if we had a medical ad- visory committee composed of 5 physicians, 3 nominees from the State Medical Society, 1 from the State Homebpathic Society and 1 from the State Osteopathic Society, it would be helpful. They could with profit study and classify injuries and diseases arising from occupations. Dr. Morrison: They will not do this unless they are paid for it. Dr. Lawrence: It would be worth the money we would pay for it when we have so many men in industry liable to certain types of disease who will come up for compensation at some time or other if we pass this other measure. And the earlier we know what these things are the better. At the present time if there is a community in the state where health conditions are not good the Department of Health develops that fact. There is no longer doubt as to where you will locate with your family because of the water supply, because June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 505 that knowledge can be gotten from the state. But you can go into an industry and not know whether it is a dangerous industry or not; there is no gen- eral information of that character. One point that industrialists have made at sev- eral of our hearings lately, which is well worth thinking about, is that they are leaving New York State with their industries and going south be- cause we are legislating too much up here in a haphazard way. The industries are going south, some few into Pennsylvania, because those states have more liberal conditions than exist in New York. Dr. Donaldson: For a number of years legisla- tion in Pennsylvania has been controlled by the representatives of capital rather than by the rep- resentatives of labor. Dr. Lawrence: Our cotton mills have almost all gone south and many other industries are leaving us. If we had this statute we would be in a position to intelligently do something. I think this Medical Advisory Committee should supervise the preparation of pamphlets of in- struction regarding treatment and care of these cases. The industrial surgeons issue monthly a publication of their own, among themselves, and I think the Department of Labor, through a Medi- cal Advisory Board, should send to all physicians in the state, at regular intervals, pamphlets or a journal containing information regarding the treatment and care of industrial conditions. Then there should be private means for supply- ing medical and surgical instruction for those de- siring to engage in industrial work. We have our large industrial clinics in New York and you per- haps have them in other places. Why should not facilities be made available there, just as they are for general hospital work, for the man in the smaller community so that he may inform himself concerning the newer methods of handling certain types of illness or injury? And I believe that a Medical Advisory Board should take care of that. There should be facilities for the inspection of medical work in large centers by medical men. That would sort of meet what New Jersey has in its Advisory Board. Dr. Sommer: When Bryant introduced the re- habilitation clinics he had an advisory board at each clinic but they did not seem to function prop- erly, but once they got a medical man appointed to do the work there was nothing more to com- plain about. But, we selected the medical man originally to take charge of the work. Dr. Morrison: We have those rehabilitation clinics in different parts of the state; I think there are 4 of them, and the plan is a monument to Dr. Mc- Bride. Dr. Sommer: Any doctor who sends a patient to those clinics may designate the type of treat- ment he wants given but under the law it must be done under the Director of the Clinic. Dr. Lawrence: Could the physician take the pa- tient there and care for the treatment himself, and then take the patient back home and care for him? Dr. Sommer: No! He could go there and see it done but it is done in cooperation with the Direc- tor of the Clinic who is responsible for the work of the clinic. Dr. Reik : Perhaps it should be made clear that we have a double advisory system at the present time. After Dr. McBride went out of office a non- medical man came in as Commissioner of Labor and he has appointed an advisory board, of which Dr. Morrison is a member, that is separate and dis- tinct from the district advisory boards handling disputed claims. Your scheme of a committee of 5 medical men working in the Department of Labor to carry on the instructive work for the medical profession seems to me of doubtful value. I have always be- lieved that if you wanted a thing well done you should do, it yourself, and I think you will reach your goal much quicker if such a committee is ap- pointed within your medical society to carry on this instructive work, because there you can as- sure yourself of getting the best medical advice for dissemination to the medical profession, and you can arrange it much better than any group appointed by the Department of Labor. And, you will get it promptly, instead of waiting for legis- lation and new appointments and starting a com- mittee to work on something that it knows noth- ing about. I think you would do more effective work and reach your goal much more quickly by education of the profession through the profes- sion. Dr. Morrison: And if you do it through the De- partment of Labor you will be putting another spoke in the wheel of state medicine. Dr. Lawrence: I had thought that it would be a step in the other, direction. At present our great- est desire from the general group of men who are doing industrial work is for the free choice of physicians by the injured employee. Industry and labor, I have been told recently, are both opposed to this. We had thought labor was with us and that they appreciated the advantages to be de- rived from their own selection of physicians but apparently wre were misinformed. Now, if we had a medical advisory board we believe that we would have an approach to the commissioner and an opportunity to argue the question and possibly secure our desires. Dr. Morrison: Not unless the advisory board was composed of medical men. Dr. Lawrence: We nominate the man. That is in the Bill. With reference to this free selection of physician, I appeared at a hearing last winter and although I was not thoroughly sold to it I put up a pretty good argument. The industrial surgeons and also the industrial carriers have had a num- ber of conferences during the summer. One point brought out by the average opponent of the free choice of physicians is the fact that if a man is injured in the factory he cannot go to his home and have his family physician but he must select some one nearby, and he will probably pick up some one of the type of doctors who are posting notices in our factories right along, so it would be safer for the carrier to say who the physician shall be. If, on the other hand, a man has lead poisoning, why can’t he have his fam- ily physician? There are, too, many other conditions which might be treated better at home. Why should he be obliged to go down town and be treated by the physician selected by the carrier? That was not brought out at the hearing but I have thought it over a great deal since then. I believe that in 3 out of 5 instances where a physician is needed the family physican would be the logical one to have. Dr. Alberston: That is all true but it all goes back to the same point we spoke of some time ago. Dr. Morrison: The man who pays the doctor’s bill will always demand the right to choose his doctor. Dr. Lawrence: That point I think needs a lot of consideration. It leads up to an enormous prob- lem in this state. It is also an enormous problem of the Federal Government. The man wffio 506 June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY pays the bill is not necessarily the one who handles the money. In this state, at the present time, it is the fad to have everything done by State Aid, as though the state brought money down as manna from heaven. They do not realize that state aid means increased taxation. Dr. Albertson-. The real argument is purely a personal one. If you were ill, who would you want to take care of you? Dr. Lawrence : That is the very question I put before the hearing in the Capitol. I said: “Gentle- men, I leave it all to you. I only want to ask you if, in leaving the chamber here, you should slip and fall on a step, as one of the legislators did a few months ago, and break a leg, do you want to select your physician or do you want me to do so?” Dr. Morrison: I understand that your Public Kelations Committee has secured from the car- riers a promise to allow the employee to select his own physician. Dr. Lawrence: Yes, but those are only gentle- men’s agreements. Dr. Morrison: A gentlemen’s agreement can carry you very far if it is lived up to. Our car- riers say that they are getting worse results where the employees choose their own physicians. Dr. Lawrence: Our carriers have said the same thing. It has only been tried for a few months, so we really do not know what the result will be. Dr. Morrison: We are watching that with a great deal of interest. Dr. Albertson : I have been interested in this subject in my limited community since compen- sation became a fact. Recently I talked with the manager of the compensation fund in Scranton. The State Insurance Fund has certain districts in which it works and a man is appointed to supervise each district. I said to him: “You in- sure groups of employees and the employer selects the physician. Other groups of people have a choice in selecting their own physicians. What is your experience in the relative length of disa- bility in those 2 groups?” He said there was no difference. That was very interesting to me. Of course, that is only in a small community and whether that would be- true in the whole state I do not know. The doctors in that particular com- munity have dealt for many years with industrial conditions and when the compensation law came along we had the same problem to deal with that you had. They now treat these conditions in an improved manner and I do not think we have any trouble about the compensation. There is a sub- ject I would like to take up sometime correlating with this, and that is the matter of compensation to hospitals both by the insurance carriers of compensation cases and the compensation to hos- pitals and physicians from accident insurance. I think it is a very timely subject for this group to discuss. You have in New York, a compulsory in- surance covering automobile drivers? Dr. Lawrence: It is hardly that. It is not like the Massachusetts law. If a man has an accident and cannot pay for the damages, he may lose his license and cannot get it again unless he can give assurance that in the future he will be able to pay all the damages. Dr. Albertson : That means that the man who has any sense insures his car. There are more cars insured than ever before but the difficulty today is to collect your bill from those companies. Dr. Morrison: In New Jersey last year we passed a law providing that against any money indemnity in accidents, except compensation cases (covers all automobile accidents), the hospital bill shall be a prior lien. We tried to get it to include the physicians and nurses attending such patients but did not succeed. Dr. Lawrence: Can the hospital include the physicians’ fees? Dr. Morrison: No! We hope to get the law amended later on. The year before our law went into effect the hospitals lost $395,000 on account of such unpaid-for patients. Dr. Lawrence: One of our big hospitals is ser- iously handicapped by caring for individuals brought into the hospital with injuries, who have received compensation themselves, and some even have cashed their checks through the hospital, but leave when their time is up without paying their bills. Dr. Morrison: One of our hospitals solved that by having an attachment put on the patient’s car. Dr. Hagerty: May I express the hope that any education to be given the doctors doing industrial work will come through the profession itself and not through any alliance with labor. We had a very enlightening experience in Newark last year. You might get the impression from Dr. Morrison that our work had gone on very satisfactorily. It has, but Dr. McBride’s office was subjected to criticism last year and the press took up the cudgels of labor. Dr. McBride, in self defense, ap- pointed a committee and asked that his office be investigated. The investigation was started by a lawyer who was a very bitter fellow. There was a point, however, on which he was right, that some of the physicians were serving in a dual capacity, serving both the employee and the carrier. When Dr. McBride was convinced of that fact he promptly suppressed the practice. Dr. Morrison: The report of our commission recommends that hereafter physicians engaged by the state be not allowed to do any other practice. Dr. Hagerty: They had been doing other practice up to that time. Dr. Lawrence: At one of our clinics men were being examined and referred to another clinic for treatment, and that clinic was conducted by the doctor’s wife. The meeting adjourned for luncheon. After luncheon the discussion was continued. Dr. William H. Ross presiding. Dr. Ross: I will ask Dr. Snedecor to give us some of his views on Councilor District meetings, as I know he has given some little thought to the subject. Dr. Snedecor: The councilor districts in New Jersey are really just beginning to function, as I would conceive it, and we are rather looking to Pennsylvania and New York for aid and advice. As Councilor for one of the districts it is possibly appropriate to open the discussion on the develop- ment of such district branches and ask that you enlarge upon some suggestions I may make. We see a real need for such district conferences in the growth of our medical societies, for the very vital reason that organization is probably the bulwark of the future for the medical profession. Upon the medical oi'ganization during the next few years there will be many stresses and strains and if we do not ramify and integrate in order to meet the problems we will regret it. Looking back over the development in our own state so- ciety, I thought of the great changes that have occurred in the last 10 years. It has been a renais- sance. Looking to the future, I think there will be even greater changes because problems are June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 507 appearing that were never heard of before.. The reason that medical organization has even been developed to its present extent is due to the in- dividual practitioners feeling the need for a repre- sentative organization. When that came to pass the real work in medical societies started. That need, they say, is of greater importance today. They are willing to progress further and take their part in medical organization. It is also under- stood that the private practitioner cannot speak out in his own behalf without losing a tremen- dous amount of prestige and protection which the profession has at present, but through medical organization we may' reach out to meet the prob- lems of the future. Medical organization, therefore, deserves a great deal of under- standing and of scientific investigation in order to insure its proper development. In our state the Councilor District fits in between the state and county societies, just as it does in New York and Pennsylvania. We have a Councilor for each district but up to the present his duties have only been to look after local responsibilities, such as malpractice suits, and report at the State So- ciety’s Annual Meeting. The incentive for develop- ing our district meetings was started in Trenton last November, at the meeting of County Society Secretaries and Reporters, largely through Dr. Lathrope’s effort and his inducing Dr. Donaldson, of Pennsylvania, to describe his state’s system. It was then left to the individual districts to de- cide the type and manner of association that they would form. The First Distinct recently had a meeting in Newark at which its 4 county societies were invited to be present. Dr. Ross addressed that meeting and the discussion which followed his paper was lively enough to indicate that it was of widespread interest. There was no business trans- acted, however. The Second District, of which I am Councilor, has organized along a little different line which is perhaps worth explaining. We met at Jersey City and discussed our problems, the officers only of each society being present. We looked over the various needs that a councilor district might serve, analyzed them, and decided that scientific meetings would be of very little value, if not superfluous, because we have so many of such meetings during the year. We considered the social aspects and decided that the men would have to come from too great distance and their problems were too diverse to make the meeting a success unless we had a topic in which they were all interested. We did conclude that the ad- ministrative, economic and public health phases need a district organization where we might cor- relate our mutual suggestions, compare them, and do some constructive work, carrying back to our county society units what we had talked over, and taking to the state society some of the problems that we felt should be met there. The third phase of possibilities is included in the topics that came up for discussion at that conference. I will give you these topics so that you may understand what is in the minds of the second district men, what they have on their program for the April meeting in Hackensack to which all our 4 county society officers are invited, and also our Delegates to the State Society. (1) Legislation to obtain liens for physicians in accident cases; (2) deciding how to regulate specialism; (3) free school examinations; (4) a definite policy to continue immunization against diphtheria, in relation to doctors, school boards and boards of health; (5) county society publicity, supervision of free medical service, and certification to county health units. These were all live topics to the group and were assigned to members to be presented at the April meeting. It is hoped to get from that April meeting some con- structive ideas to carry back to our own county societies and to carry forward to the State Society Convention. We hope in so doing to interest the Delegates with a sense of responsibility of their duties because in the past our experience has been that some were not sufficiently interested in the state society meetings even to attend them. So, there are the 3 phases that we see in the councilor district meetings. It is entirely experi- mental with us at present. We are open to sug- gestions and we see the opportunity to develop the administrative, economic and public health possibilities in the county societies, to interest the delegates to the state society, to give them a definite program to go to the state society with in June, to rewrite our own constitution and to give the councilors some duties to perform. Dr. Ross: I think this is a mighty constructive talk. ' I am not so sure but that the New Jersey men, with the experience of the other 2 states represented here, may quickly advance very far. If we are not careful they will certainly outdis- tance us. There is nothing more vital today be- fore the profession than better organization for its public service. Dr. Donaldson: I feel like continuing the dis- cussion because I am very much interested in seeing what New Jersey will accomplish, having paid me the compliment of asking me to represent our society and go down to their society for a dis- cussion of this subject last year. We certainly feel a glow of satisfaction when we hear the program that Dr. Snedecor has outlined and I believe it will soon accomplish as much as we have in a great many years. I was particularly interested in the suggestion that they are going to invite the county delegates to their state society to come and sit in on their discussion and actually hear about the problems before they go to their state meeting. However, I was a bit surprised when Dr. Snedecor said that they rarely attend the House of Dele- gates to which they have been chosen. I am sure they do not have so many interesting political dis- cussions as we do in Pennsylvania or they would not be permitted to be absent. We have a great deal of difficulty on account of political influence in having the same men come year after year representing their county society, so that they become a little too cognizant of their power and strength, too well organized, and they are very likely to keep down a discussion of the very sub- jects the doctor has touched upon. Perhaps I misunderstood you when you said you would take up all of these problems at your meet- ing in April. Dr. Snedecor: They are to be presented briefly. We would not expect to solve all of them. Dr. Donaldson: I would caution you against taking up too many of them at your first meeting. I think you would do better to give careful thought to attempting to solve 2 of them rather than to give a mere smattering of consideration to a dozen of them. I certainly am pleased to see that the thing is going and that it is in such excellent hands. Dr. Reik: Dr. Donaldson might like to hear that his visit to Trenton and the inspiration he aroused by telling us what had been done in Pennsylvania has led to this development in New Jersey. I can tell him further that we have 5 councilor dis- tricts, embracing in groups the 21 county so- cieties, and all 5 have arranged for or held such meetings since Dr. Donaldson’s visit. Having left 508 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 this to each district to decide what the course of action should be, the first district, meeting- in New- ark, with Dr. Ross as guest speaker, discussed economic problems. Dr. Snedecor has spoken for the second district. Programs for the third and fourth are not yet announced although meetings are being arranged. Down in the fifth district they have arranged for an entire day’s meeting, a combination of scientific and economic programs. The afternoon is to be devoted to a discussion of economic problems, they will then meet at dinner, and in the evening there will be a joint meeting of the Atlantic City Hospital Staff and the sev- eral county society groups at the hospital where there will be clinical demonstrations. The start that Dr. Donaldson gave us has re- sulted in unanimous acceptance of the plan and an active interest in developing it. Dr. Ross: In New Y'ork State no one knows more about this subject than Dr. Overton. Per- haps he will tell us something about the situation in New York State. Dr. Overton: For several years one of my duties has been to attend each of the 8 District Branch Meetings. I was interested in one of the western states, I think Wisconsin, that in its constitution one of the duties of the councilor is to act as an investigator, as a peacemaker and as a censor. The peacemaker seems rather a remarkable thing. Mr. President, I presume that what you refer- red to was possibly an editorial which I wrote several years ago on the ideal district branch meeting. These district branch meetings have been held since the amalgamation of our 2 state societies in 1906. There is very little said in the constitution as to what the district branches should be, so each district branch can do as it pleases. All of the district branches except the second, which includes Long Island and Brooklyn, put on a scientific program. Possibly that is not entirely wise because the business of the district branches is administrative rather than scientific, but everybody goes to the district branch meet- ings. There will always be from 100 to 115 present. In the editorial referred to, I made a study one year of what I believe to be the important fea- tures of the district branch meetings and I made a composite program of these 8 meetings. In the first place there is sociability, which is stressed. Dr. Dougherty stresses the importance of socia- bility and I, too, think it is extremely important. There is the scientific end which is also very im- portant although I think that New Jersey’s second district is taking the proper attitude possibly re- garding the scientific phase. We cannot put too much in. The third phase mentioned was reports from the different districts. The councilor was to make a review of the work. In all the state societies with which I am familiar it is the duty of the councilor to visit the county societies and find out what they are doing and to make a report on that. Some of the districts do it very, very well and when it was done well it seemed to be quite a help. But, remember that each district makes its own program and the leaders, the Presi- dent and Secretary, are not always experts in the state society work and have not a wide vision, so that the program is not always carried out. Last year our President did carry it out; he made a study of what is going on in each county. If one undertakes that, particularly in New York State with its 60 counties, he will be a busy man. There is an average of 8 counties in each of our districts and to visit them all is not an easy matter. The ideal district branch meeting it would seem, judg- ing by the way the doctors take hold and show an interest in the program, has a three-fold in- terest— social, scientific and administrative — and the coordination of what each district branch is doing. The visit of the councilor to the different societies is very valuable but I must confess that the councilors do not carry this out more than 10-20% of the time. Report . op Governor Roosevelt’s Commission to Devise a Public Health Program Dr. Ross: I have no formal paper to give on the the report of Governor Roosevelt’s Commission on a State Public Health Program and I have attend- ed so many meetings this month that I am getting a little cautious for fear I may get them mixed up, so, before coming here today, I put down some notes which may help me. The science of medicine is an advancing force. There is no question about that. The relationships of medicine are steadily shifting and they will continue to do so. The changes are going on today in government, in industry, and in all social con- ditions. We have recently carried this gospel to more than 100 groups of doctors. The idea of or- ganization that we hold now is based entirely on the understanding that the outstanding problems of medicine are its public relationships, and also on the understanding that the science of medicine is perfectly secure; its phenomenal advance and the momentum it has acquired during a course of years is now so secure, its cultivation is so care- fully looked after by the schools, so carefully nourished in the laboratories of research and in the scientific and organized meetings, that the scientific part can rest for a time while we under- take to bring up to that level our relationships, and the organization of service for better avail- ability of the science of medicine to the public so that the present day scientific knowledge of the prevention of disease and the conservation of life may be brought within the reach of everyone. That is really the problem we have. The problems of health are summarized in this way. We should have effective local health departments with a qualified personnel. We must have more effective service in the control of tuberculosis and cancer and venereal diseases. I attended a meeting of the Cancer Control Committee last night, and an- other a week ago. and although I knew something about it, the work that is starting is rather mar- velous. We must have more comprehensive meas- ures to reduce death from child-birth. It is a serious matter that there are more deaths among moth- ers in this country than in other civilized coun- tries, and it is also rather appalling to find out that those who have studied it most believe that it is largely due to hurry. We need better public health nursing. In some counties in New York State we have 1 nurse to over 500 people. We have also several other minor problems. Last year, in May, the Governor of this state created unofficial commissions to study the administration of health in the state and the adequacy of the laws relating thereto. Nothing much has been done in the way of organ- ization since 1913 and even up to that time there was no real, definite organization. But, there have been added to the law of 1850, when conditions were vastly different, many very splendid pieces of legislation. This Commission appointed by the Governor is made up of 14 individuals representing the widely distributed interests in the state, including every department of the state government that has any June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY interest in medicine. There were 8 doctors on the commission. However, only 3 were actually in- terested in medicine. Still, medicine has had a very much bigger voice in this than it has ever had before. Then, there were sub-committees ap- pointed, subjects were assigned to each of the 14 members, and with the sub-committees there was a total of 86 people working on this subject all the time. A preliminary report was made to the Governor recently, a report of 50 printed pages. 1 have some copies with me so that all of you may have one. The preliminary report covers the ground that involves some form mainly of legislation. The final report will not be published until next spring. It will be a large volume and it is as comparable to the reports of the Child Health Conference in Washington and the Com- mittee on the Study of the Cost of Medical Care as a state is comparable ,to a nation. The Gover- nor has transmitted this report to the legislature with a message, and a Bill was introduced this last week into the Senate and the Assembly ask- ing for the enactment into law of the recommen- dations. I would like to refer to one page of it. I have told you that the membership of this Commission so far as possible covered the various interests of the state. It covered very specially the Depart- ment of Labor. In that department industrial hygiene has had less attention, perhaps, than any- thing else. It concerns from 2,000,000 to 4,000,000 people. Now, the outstanding feature of this re- port is that there is to be better organization, an organization on a county basis with county boards of health. I might say in passing that practically every scientific organization interested in public health in this state has endorsed this form of organization. The Commission has had regard for the econ- omic situation. It has not undertaken to impose a definite form of organization upon every county in the state but has endeavored to set up a pre- liminary basic organization and to permit each county to work out its problems as well as it can. Further than that, it has only insisted upon full- time personnel in counties having more than 50,- 000 population, and those having 30,000 it will bring under conditions of the Public Health Coun- cil. In the latter counties it does not require them to go to the expense of having full-time officers but the state will assign one of its district health officers until that county wants to take on more work. Greene County said last night it did not want to take advantage of this but wanted to have a full-time man when establishing its or- ganization. The major recommendation is very constructive. First, the county provides a health officer and then the county is left to work out its own plans. In cities of more than 50,000 they should have a full-time health officer. Even New York City does not have a full-time Commissioner of Health at present. In tuberculosis problems the death rate has been cut in half. There is a law in the state requiring a sanatorium in every county, but it is not economically sound and has never been car- ried out; 27 counties have no facilities for treat- ing tuberculous cases and this Bill carries with it provision for the establishment of 3 district sana- toriums in proper locations so that they will serve counties not having such facilities; they are to be built at the state’s expense and maintained, and the cost charged back to the counties that use them for patients. We have no general venereal disease control in this state, and a program is being developed for 509 that. At the same time, when we stop to think that New York voted a $50,000,000 bond issue by a vote of 6 to 1, and that $8,000,000 of that must be spent to accommodate persons who will become insane from syphilis in the next generation, it really does become a great problem. The division of Cancer Control built up about the Institute for the Study of Malignant Diseases, in Buffalo, which has been very largely supported by the state, admitted last year 1800 people for treatment. But that does not extend over the state. Then we have maternal, infancy and state hygiene, and the Bill has something to do with all of these things. I have spoken in 5 counties within a week, on questions arising from this report, and find a marvelous unanimity of opinion as to its construc- tive value. The only question is the relationship of the present health officers to the report, and the Bill carries the provision that the present local health officers shall become “deputy officers” so that they shall be continued, only having to come up to certain average standards. Continued contact with organized medicine in New York State this year, and with its component county societies for several years, taking part now in more than 500 of those meetings, conferences and committees in the last 6 years, furnishes a basis for a conclusion that I want to now state, that the problems of medicine are not scientific, for that part is being well taken care of as we go along. The scientific end needs a minimum of attention, but its relationships and the application of its science to public service are the big problems of the future. An opportunity to observe these problems in 8 other states this year, and hearing their discussions, shows a tremendous ris- ing tide of interest in medical relationships, and as clear an understanding that the obligations of medicine are not entirely met just by a considera- tion of the cure of disease after it has appeared. It seems plain the the public expects from the pro- fession a solution of these problems and that social organizaUons, philanthropies, foundations and the state itself, are simply aids and cooperative factors and will remain so if the medical profession offers leadership in the solution of these great problems of health and sickness service. Just now we need, as never before in the history of medicine, to ad- vance our statesmanship. Just let me say in con- clusion that changing times demand a changing organization; that idealism is needed in medicine today just as much as it ever was. Doctors do not and cannot work without it. The majority of doctors everywhere are as great idealists today as they ever were. However, I have sometimes heard, in discussions in this state, of medical commercial- ism that seemed to make ideals gasp for breath. We need in medicine, no less than in all public life, a spirit that will not set private gain above common welfare or the common good. And then, when we are tired of everything else, we might remember what Osier said, that “medicine is an art not a trade, a calling, not a business, a calling in which there is exercise for the heart as well as for the head”. Discussion Dr. Overton : May I introduce a personal note, which is possibly not entirely appropriate to what Dr. Ross has said. Dr. Ross started by saying that he had not prepared a paper and then he stated that at Poughkeepsie last night he had written out a speech. I want to tell you, gentlemen, that Dr. Ross has made more than 100 speeches since he became President last June. He has written out 510 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 every one of those speeches in his office and he has gone to every meeting prepared to speak to that particular meeting with an individual talk, and he came here with an individual talk to us. Yrou will remember that at the last meeting of this confer- ence Dr. Ross was down for a discussion but he came with a written speech. In other words, he prepares himself and that is the secret of why he is in demand all over the state to deliver speeches. The preparation takes a much longer time than it does to deliver a speech. Dr. Ross has brought out the points of recom- mendation made by the Governor’s Commission which will probably be enacted into law. I want you to notice as you read these recommendations that there is no suggestion as to what the doctors are to do. Dr. Ross says that the doctors them- selves practice good scientific medicine, that there is no scientific problem, that, in other words, these laws are not directed against the doctors. But, the laws specify what the municipalities shall do in every instance; there shall be a county health department and the establishment of county hospitals in New York State. Last year we passed the Welfare Law providing that there should be a County Welfare Commissioner, and that has solved some of the medical problems. It is not what the doctors shall do for the practice of medi- cine, it is what the public, particularly the munici- palities, shall do. Now, we who have borne the heat and burden of the medical profession for these many years know that there is often no facility to help us in our work. There are in some districts no hospitals and it is difficult to work in the homes of the poor. All this law is administrative and deals with what the public shall do. In other words, if the public would do half as much as the doctors have done we would have less difficulty. Dr. Ross spoke of the idealism of the doctors. I don’t think he meant to imply that the doctors are not already imbued with that. The most hard boiled doctors in my own county are delighted with this public welfare law and are glad to have the County Commissioner instead of the overseers of the poor, and that he shall provide medical atten- tion for those otherwise unable to get it. A man who has several children, who works and is a good honest fellow, may be suddenly taken with pneu- monia and his income cut off. Under the old sys- tem the physician would get nothing for attending that man. Under the new system, if he cannot pay for medical attention the county will pay for it under agreement with the county commissioner. Now that is the biggest advance that we have had in the economics of the practice of medicine. Dr. Ross: I want to supplement all of this by saying that every practice adopted under this law is under the state aid. The thought came to me while talking at the lit*le County of Greene meet- ing the other night that it is perfectly delightful to find that where 10 doctors are gathered to- gether you find the same degree of intelligence as you find among 100. They worked out a plan that would double their health activities in that county at the same price that they were now paying for it, or $13,000 a year. They had worked out a sche- dule that would double their activities at the same cost and the state immediately gave them a check. Greene County is next to the last county in New Y'ork that has not a hospital within its boundaries. They have gathered a fund of $35,000, the super- visors have voted to have a county hospital and are adding something to that amount, and the state has agreed to match it. So that leaves only 1 county without a hospital. This method of solving our problems by meeting our obligations is bringing a remarkable response from the whole country. In this small group, I think I can tell you, and I hope you will not think that there is the slightest degree of ego about it, my personal correspondence this year numbered 1G21 letters that I have dictated, every one of them on the problems of medicine, the obligations of service and the relationships that medicine must assume, all with the idea of solving the problems of medi- cine, putting medicine in its place of leadership. There must be a recognition that medicine and the public are partners, that the profession must fur- nish the leaders but that the people are the re- cipients. Dr. Morrison: I think New Y'ork State is to be highly congratulated this year on the personality of its President. He has done a job that probably has never been so well done in the medical circles of New Y'ork State before and he is setting a pace for those who fill the chair in the future if they at- tempt to follow in his footsteps. YVe are always grateful to Dr. Ross when he brings his talks to this conference in the spirit in which he has done it today. The conception of this Tristate Confer- ence was an attempt upon the part of the members and the leaders of the medical profession to break away from the old traditions of medicine and try to teach the profession in these 3 states the re- sponsibilities that it owes to the public. It was that, I imagine, that Dr. Snedecor referred to when he said there had been a renaissance in medicine in New Jersey. The thought occurred to us that we must realize that doctors have a larger duty than to treat those who are critically ill and sick. The public looks to us and is beginning to demand leadership and advice in the health prob- lems that are so rapidly coming to the front, and it is our constant endeavor in New Jersey to carry out the very policy that Dr. Ross has laid down, to carry to the county society the idea that we must broaden the scope of our activities and accept the new responsibilities that the conditions of the times are imposing upon us. The public is looking to us and expecting leadership. The social and labor groups, all those Foundations and Boards that are interested in child health and the welfare of the public, are looking to us for counsel and leadership. YY'e shall look forward with a great deal of pleasure to an analysis of Governor Roose- velt’s report when it comes to our hands next May for study. It will also give us many leads to fur- ther the work that we have already been doing. In New Jersey we have been particularly for- tunate in recent years in the progress of our Pub- lic Health Departments. We have a full-time health officer in Jersey City, Newark, East Orange, Paterson and Trenton and we have half-time offi- cers in many smaller communities. We have tuber- culosis hospitals, apart from the State Hospital, in several counties, Mercer, Atlantic, Essex. The cure of tuberculosis is going on at a fairly rapid rate and the incidence of tuberculosis is decreasing with enormous rapidity. We are very proud indeed of our record. I am very glad that the ideas of this Conference in the last few years are leading us to promulgate more activity with a full sense of responsibility that the profession has toward the general health of the public. Dr. Patterson: I hesitate to discuss your very excellent presentation of this very important sub- ject. I find myself so entirely in agreement with v hat you have said that what I shall say is only a repetition of that already presented, and a less well thought out presentation than that which you have made. June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 511 Looking over the whole field of medicine it does seem to me that the advance of medical knowledge is reasonably satisfactory as carried on in our re- search institutes and by research workers. Prog- ress is being made all the time, very gratifying progress, and medical education is reasonably satisfactory and has made wonderful progress in the past 25 years without question. It is true that those teaching institutions which did not come up to satisfactory standards have been elimi- nated and that those that are left are all meritor- ious, and it is a matter of particular gratification to know that. The future doctors of the nation, as determined by the young men being admitted to the medical schools of today, will be better than ever before. I suppose medical teaching falls somewhat short of utilizing all medical knowledge. It seems to me that medical practice probably falls considerably short of utilizing all that is taught in the medical schools and is therefore 2 jumps behind the best of our medical knowledge. It does seem to me that so far as the practice of medi- cine is concerned, as regards the relation of the doctor to his individual patients, conditions of practice were never more satisfactory than they are at the present time, and that is no longer a real problem. I quite agree with you that the real problem before the medical profession today is meeting the conditions of community health, and there are a large number of them, and in that en- deavor we fail to a far greater degree than we did in any of our other endeavors. Now, is it not true that industry is more alert in utilizing medi- cal knowledge for solution of its problems than the profession is in handling public health prob- lems? Is not that a source of one of our fears of what might be called the industrialization of medi- cine? If the medical profession itself were as alert and as efficient in utilizing medical knowl- edge for the solution of these problems to which you point, venereal disease control, cancer and tuberculosis control, and the care of the indigent sick, those problems would not be so great as they are now. And, of course, it is true that if we do not take the lead in directing these activities, leaders of industry, or political leaders, or others, will take it from us and our position will be rela- tively less satisfactory and the profession will lose in prestige. I feel that Dr. Ross should be commended for the most admirable work which he has done. If we had many such leaders as Dr. Ross in the medi- cal profession the solution of our problems would advance apace. My remarks have really added nothing to this discussion but I did not want the opportunity to go by without giving Dr. Ross a special word of encouragement. Dr. Ross: All of this is very helpful. I just want to tell you one interesting little thing. Recently I attended a meeting in Utica, by invitation, and I found the county society had sponsored the move- ment and there were present 120 delegates from 60 social organizations. I had the impression there of the power of public opinion. Those 60 organ- izations represented health and welfare. They rep- resented the Parent-Teacher Associations and every organization on earth I had ever heard of, even a Bureau of Home Economics of Cornell University. I was never before so impressed with the fact that health questions are becoming public matters, and constructively so. I just recall some- thing that the editor of the London Lancet said not long ago: “No longer is the medical man the sole repository of medical knowledge but he must take his place in the ranks of other scientific workers.’’ I received just that impression. The meeting formally adjourned at 3 p. m. Henry O. Reik, M.D., Secretary. THE NEW JERSEY CONFERENCE ON CHILD HEALTH AND PROTECTION Reported by Dr. Ellen C. Potter The physicians of New Jersey have a very special interest in the outcome of the New Jersey Conference on Child Health and Protection, since on their cooperation and leadership the success of the future program depends, not only in the field of health but in that of social welfare. To an un- usual degree the medical profession was called upon to formulate the program and they partici- pated in the discussions during the sessions held on April 17 and 18 at the New Jersey College for Women at New Brunswick. As the White House Conference, called by Presi- dent Hoover in November 1930, studied the present status of health and well-being of the children of the United States and its possessions, and re- ported on what is being done for them and should be done; so, the people of New Jersey called by Governor Morgan F. Larson found it wise to get together in conference to sum up the entire situation of child health and welfare in this state, to measure the state’s facilities and program with the standards set by the White House Con- ference, and to make recommendations bearing on the immediate needs and looking toward future accomplishments. The recommendations of the White House Con- ference, based on a 16 months’ study by 1200 ex- perts in problems of childhood, from all sections of the United States, can be carried out only as their importance is realized and they are brought to completion by public or private agencies in the states and local communities, and, for this reason, the citizens of New Jersey came together to study their problem. Registration The conference was conducted at the Governor’s request by the New Jersey Conference of Social Work, of which William J. Ellis is President, in co- operation with the 4 major state departments that deal with the child: the Department of Education, Department of Health, Department of Institutions and Agencies, and the Department of Labor. Altogether 1700 persons met, representing these state departments; county, municipal and private agencies which are in close contact with children ; members of public and private social welfare agencies interested in the development of whole- some family and community life; and other socially minded citizens from all parts of the state. Delegates were present from the Parent-Teachers’ Association, the State Federation of Women’s Clubs, League of Women Voters, State Nurses’ Association and the Public Health Nurse Associa- tion, State Medical Society, Freeholders’ Associa- tion, Probation Officers’ Association, State Police, fraternal, service, recreational and character- building organizations, Protestant, Catholic and Jewish societies, the American Legion, Urban League, and students from the state universities. 512 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 The Program The conference was divided into 4 general sec- tions which in turn were subdivided into smaller groups for the general discussions growing out of specific subjects presented. Dr. Ellen C. Potter was chairman of the general program. The Medical Service Section had as its chairman Dr. Allen G. Ireland, Director of Physical and Health Education of the New Jersey State De- partment of Public Instruction. During this ses- sion Dr. Edgar A. Doll, of the Vineland Training School, spoke on “Growth and Development”. Fol- lowing him there was a talk on “Prenatal and Ma- ternal Care” by Dr. S. A. Cosgrove, of the Mar- garet Hague Maternity Hospital, in Jersey City. Then there was a discussion of “Medical Care for Children”, by Dr. Julius Levy, consultant for the Bureau of Child Hygiene in the New Jersey State Department of Health. A general discussion of these topics followed their presentation. The Public Health and Administration section’s chairman was Dr. Stanley H. Nichols, who is chairman of the Public Health Committee of the Monmouth County Medical Society. Public Health Organization, Communicable Disease Control, and Milk Production and Control were the general sub- jects which were presented in their several phases by able speakers and experienced administrators. The Education and Training Section, under the chairmanship of Dr. Bruce B. Robinson, was di- vided into 8 groups for the discussion of special topics, as follows: (1) Parental Education, Mrs. William F. Little, Chairman. (2) Vocational Guidance, Herbert Meyer, Chair- man. (3) Child Labor, Mrs. Isabelle M. Summers, Chairman. (4) Recreation, Lewis R. Barrett, Chairman. (5) Special Classes, Meta Anderson, Chairman. 16) Mental Hygiene, James S. Plant, Chairman. (7) Spiritual Training, Ralph Glover, Ph.D„ Chairman. (8) Library Extension and Children’s Reading, Edith Smith, Chairman. The Handicapped Section, under the chairman- ship of Edward R. Johnstone, met in 5 groups. The first considered the “Physically Handicapped” (the blind and partially seeing, the deaf and hard of hearing, the crippled, the children with internal conditions such as tuberculosis and heart diseases), ways of preventing such physical handicaps and the vocational adjustment of the handicapped. Joseph G. Buch, Chairman of the New Jersey Crip- pled Children’s Commission, was chairman of this group. The Mentally Handicapped under the group chairman. Dr. Joseph E. Raycroft, Chairman of the Board of Managers of the Trenton State Hos- pital, were considered from the angles of the clinics, psychiatric, social service and institutional care for the mentally disturbed, the feeble-minded and the epileptic. Mrs. Thomas W. Streeter presided over the De- pendency and Neglect group which considered the prevention of dependency, the administration of relief, and other phases of child dependency. Delinquency and its problems was presented through consideration of the juvenile courts, pro- bation, detention, and improvements needed in handling the delinquent children, under the chair- manship of Dr. James S. Plant, Director of the Essex County Juvenile Clinic. Community Organization for the Handicapped. with emphasis on the value of county- wide ser- vices, was presided over by Mrs. Harriman N. Simmons. President of the Council of Social Agen- cies, of Elizabeth. In the 2 days, 103 speakers, each a specialist on some phase of child health or welfare, were heard at some of the 25 sectional and general meet- ings on April 17, and the 12 on April 18. The program mapped out for developing the child and preparing him for his living and for his life’s work, included: thorough examination of all children to discover and diagnose early any ab- normalities that need curative or remedial treat- ment: treatment to adjust any handicaps; educa- tion, both academic and vocational, to the fullest possible extent of his abilities; recreational facili- ties in a community alive to its responsibilities; protective legislation: and research into all fields of child welfare to prevent and control anything detrimental to childhood; development of district and municipal public health organization and full- time trained service; and comprehensive recre- ational programs. Resolutions were formulated by the committees after discussions; presented to a resolutions com- mittee of the conference as a whole; and consider- ed and adopted by the entire conference at the closing meeting. Summary of the Resolutions The resolutions adopted by the conference took cognizance of the ways in which our present facilities, organizations, and legislation fall short of the needs of the normal child, as well as the dependent or neglected child and the physically or mentally handicapped. They include certain standards for which the state should strive and they specifically ask for definite action on the part of governmental bodies for the health, edu- cation and protection of the children, for legisla- tion whenever it is necessary to bring the desired results, for complete surveys where only general facts or conditions make impossible a real picture of the problem. A Continuation Committee on Child Health and Protection, as a committee of the New Jersey Conference of Social Work, was constituted by the conference to carry into effect the recommenda- tions that the childhood and youth of New Jersey might receive the maximum benefits. A number of physicians are members of this Continuation Com- mittee. The specific recommendations that require re- sponse from a definite group include that the State Board of Education shall : (1) Appoint an advisory council to study ways of making specialized education available to local districts and to give adequate opportunities to the gifted child. (2) Establish classes in parent education for intelligent and inquiring parents. (3) Set up minimum standards as to the num- ber, qualifications and training of school atten- dance officers: (a) Governor be requested to ap- point a committee to study the efficiency of local health administration in small districts for the purpose of suggesting legislation, (b) Health offi- cers be full-time workers, (c) The various state and local departments engaged in the work of child care and protection be reviewed for further advancement of their activities. fd) Additional legislation be enacted for the protection of chil- dren in industry and for the migratory child, (e) Civil Service Commission keep its standards high for all social workers who deal with children, (f) A research council be formed to promote co- operation in child research. General recommendations suggest that: (a) ade- June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 513 quate public or private child caring agencies be established in the state for the protection and care of children, thus providing case work facilities to prevent delinquency and dependency and subse- quent commitment of children to the care of the state; (b) desertion and nonsupport laws be more strictly enforced; (c) money earned by prisoners be applied to the relief of their families and that employment of prisoners be increased when feas- ible; (d) the state and local systems of mental and tuberculosis clinics be further enlarged, and psyco- pathic wards in general hospitals be further de- veloped: (e) the principles of mental hygiene be taught in the colleges, medical, law, and divinity schools, police training schools and the like; (f) health education be emphasized in the secondary schools and colleges that adults may be prepared to guard child health; (g) facilities for treating contagious diseases be increased; (h) funds be made available for developing a research program into the causes, prevention, treatment and education of the physically handicapped child; (i) state co- operate with the county administration of proba- tion and a state-wide program for the extension of probation be developed. Recommendations were also made that there be set up in the Department of Education a central bureau of pupil Dersonnel guidance; that school boards and municipalities provide adequate play space and facilities for all age groups; that public libraries, municipal and county, and school libraries be adequately supported and promoted and that the use of libraries by children be en- couraged. Childrbn-’s Bill of Rights A “bill of rights” was adopted enumerating the rights to which all the children of the state are entitled whether they live in the city or in the country, in the remote sections or in the centers of population, whether they be rich or poor, physi- cally and mentally able or handicapped. The conference agreed that all children of New Jersey had: A Right to Happiness, as represented by the spiritual and moral training and sympathetic at- mosphere of a home financially secure in a com- munity affording adequate recreational facilities. A Right to Health, as represented by prenatal and postnatal care, nourishing food, sanitary liv- ing conditions in school, home and community and health education and protection. A Right to Growth, physical, mental educa- tional, personal, and recreational from an un- hampered childhood throughout youth to adult life. Results The uniting of all the forces in the state work- ing for the betterment of conditions relating to children is perhaps the most important outgrowth of the conference. Through this renewed co- operation, the child himself will be considered by the groups in the future, and programs will not emphasize one phase of his development as separ- ate from the others. The practical results will be manifest during the next few years as the recommendations of the conference are carried out through the cooperative effort of existing state and local organizations. The Continuation Committee will further the program of child health and protection and will give publicity to the needs of all children so that there may be developed the will on the part of the people of the state to provide for their needs in the unshakable faith that the childhood of the state~ is its most precious possession, an asset in whose interest every sacrifice is supremely worth while. AMERICAN COLLEGE OF PHYSICIANS (Proceedings reported by Dr. W. Blair Stewart, of Atlantic City.) The Fifteenth Annual Session of the American College of Physicians was held in Baltimore, Mary- land, March 23-27. General Headquarters, Ses- sions and Exhibits were located in The Alcazar. Dr. Maurice C. Pincoffs, Baltimore, was Chairman of Committee of Arrangements, ably assisted by Dr. Sydney R. Miller, President of the College, and an efficient corps of assistants. Clinics and demon- strations were given every afternoon in the various hospitals of Baltimore. Every subject of Internal Medicine was ably covered. The general sessions were held morning and evening and were devoted to a most instructive series of symposiums on Gastro-Intestinal Disease, Heart Disease, Public Health, Medical Practice, Medical Economics, En- docrine Disorders, Anemia, and general subjects. The latest research work on all these branches was presented in such an interesting and instruc- tive form that the whole meeting was converted into one of the best post-graduate courses on In- ternal Medicine ever staged. It will be impossible to review even the high spots in this report. All papers will be published in the coming monthly issues of Annals of Internal Medicine, the Official Journal of The American College of Physicians. Without doubt the outstanding address was the classic talk by the Dean of American Medicine, Dr. William H. Welch, who spoke on “research and historic medicine”. The various reports show a healthy growth of the College in science and research, as w^ell as an increment of a large number of America’s best internists. There are 8 Masters of the College; 2297 active Fellows and 583 Associates — a total membership of 2888. Of this number, 366 were elected at this session. The Treasurer’s report showed a net balance of $23,214 for 1930 which, added to the Endovunents and general fund, amounted to $88,338 — a very healthy financial con- dition for such a young organization. The official Annals was published witll a surplus of $561 at the close of its year, March 1931. Aside from routine business at the annual meeting, the following resolution -was enthusias- tically adopted, only 1 vote being cast in the negative. Text of Resolution “The enactment of laws by the United States Congress and many State Legislatures has de- prived the medical profession of its inherent and deputized rights to prescribe drugs and remedial measures in such quantity as it may deem neces- sary in treating the sick. New laws and regulations have been and are now being forced upon medical men to such an extent that they can no longer be the judge of their own methods or treatment, but must bow to the prescribed form of non-professional legislators and boards. State medicine is gradually undermining the ancient and traditional rights of medical practice and, if continued at its present rate, legitimate practice will soon be displaced by a commercial type of cults and advertised self-methods of treat- ment by patent and proprietary medicines. 514 JOURNAL OF THE MEDICAL SOCIETY O-F NFAV JERSEY June, 1931 Recognizing these deplorable conditions, the American College of Physicians, met in regular as- sembly, recommends: (1) That every legitimate effort be made to im- press upon the members of Congress that un- restricted medical treatment of disease by properly licensed physicians should be granted, and that they should not be penalized on account of the misuse of medical methods by a very small per- centage of so-called medical and non-medical men. Let the profession be its own judge of how it can best treat the sick, and properly penalize those who flagrantly abuse their licensed or unlicensed trust. (2) That the fellows and associates of the col- lege must become more active in medical legis- lation and join with their state societies in an effort to repeal inimicable state laws now en- forced, and influence a higher type of medical methods for the further protection of the sick and those to whom their lives are entrusted.” Dr. S. Marx White, Minneapolis, Professor of Medicine in the University of Minnesota, was elected President for the ensuing year. Dr. Francis M. Pottenger, Monrovia, California, a specialist in diseases of the chest, was made President-Elect. Dr. Aldred Scott Warthin, Ann Arbor, Michigan, First Vice-President. Dr. Charles G. Jennings, Detroit, Second Vice-President. Dr. John A. Lichty, Clifton Springs, N. Y., Third Vice-Presi- , dent. Regents and Governors were also elected. The total registration for the session was over 1800. The next meeting of the College will be held in San Francisco in 1932 — date to be decided later by the Regents. There were over 60 commercial exhibitors of A. M. A. standard type. New Jersey was represented by 85 Fellows and Associates. A post-convention session of clinics was held in Washington, D. C., on Saturday, March 28. Opportunity was also given to visit the various Government museums, libraries and public build- ings. Among those attending sessions of the Congress were the following doctors from New Jersey: John Wesley Gray, Edward C. Klein, Jr., and Charles L. Rosenberg, of Newark; Harry Bloch, Arturo R. Casilli, Horace R. Livengood and Michael Vinciguerra, of Elizabeth; John V. Smith, of Perth Amboy; William W. Davies, of Lakehurst; Clyde M. Fish, of Pleasantville; Philip Marvel, Sr., Philip Marvel, Jr., W. Blair Stewart, William w! Fox and Samuel L. Salasin, of Atlantic City; William G. Herrman, of Asbury Park; Frank C. Johnson, of New Brunswick; Richard E. Knapp, of Hackensack; Marcus. W. Newcomb, of Brown’s Mills; William S. Collier, Barney D. Lavine, Na- than Swern and Harry D. Williams, of Trenton. The list of newly elected Fellows of the Ameri- can College of Physicians includes the following New Jersey physicians: Harry Bloch, Elizabeth; Arturo Raymond Casilli, Elizabeth: William Shreve Collier, Trenton ; William Walter Davies, Lakehurst; Clyde Mulhollon Fish, Pleasantville; William Wellington Fox, Atlantic City; John Wes- ley Gray, Newark; William Gettier Herrman, Asbury Park; Frank Chambliss Johnson, New Brunswick and Plainfield; Edward Caffron Klein, Jr., Newark; Richard Edward Knapp, Hacken- sack; Barney Doibe Lavine, Trenton; Horace Rutherford Livengood, Elizabeth; Marcus Ward Newcomb, Brown’s Mills; Louis Charles Rosen- berg. Newark; Samuel Lyon Salasin, Atlantic City; John Vincent Smith, Perth Amboy; Nathan Swern, Trenton; Michael Vinciguerra, Elizabeth; Harry David Williams, Trenton. Public Relations THE CONTROL OF PROPRIETARY MEDICINE (From the London letter, Jour. A. M. A., Mar. 7, 1931.) A bill emanating from the health advisory committee of the Socialist party, to be known as the proprietary medicines bill and intended to regulate the manufacture and sale of such prep- arations, is about to be brought forward. Its provisions are drastic, and considerable opposi- tion is already announced by manufacturers and pharmacists, but the provisions should with one exception receive approval from the medical pro- fession. It is proposed to appoint a registrar to keep a book containing the names of the owners of all proprietary medicines and full par- ticulars of their ingredients. Every such medicine must be registered and allotted a number, which must figure on any vessel or packet in which it is sold. The advertising of proprietary medicines is to be rigorously censored. No statement that a physician or dentist has recommended such a preparation may be published without his qual- ifications and address. It may be remarked that this practice is forbidden by the ethical rules of the medical profession. Quotations from medi- cal journals must be accompanied by the name, date and page of the publication. It will be an offense for the vender of a proprietary prepara- tion to invite persons suffering from any ailment to correspond with him with a view to treatment. After 6 months from the passing of the act, no person will be permitted to sell any medicines or appliances purporting to cure or relieve deaf- ness, or any other of 10 ailments mentioned in the bill. The Minister of Health will be empowered to remove from the register any medicine that he considers likely to cause injury if used in accord- ance with its registered directions. One of the chief objects of the bill is the establishment of a new government department to act as an offi- cial censor of advertisements. The trade interests concerned will do everything in their power to oppose the bill, as they maintain that the compul- sory publication of formulas would have the gravest effects on well known proprietary busi- ness. A “WHITE-COLLAR” HOSPITAL THAT IS PROVING THE CASE (From Newark Evening News, Mar. 9, 1931.) There has been much talk and some planning toward hospitals for the less than well-to-do and the not-yet-poor in New York and elsewhere in this region. In Boston such a hospital has been in operation a year. The results it has attained are instructive. They justify the belief of some medical men and many others that the problem of the high cost of being sick is not beyond solv- ing. The hospital is the Baker Memorial, a unit of the Massachusetts General. For a century the latter institution has been primarily for the poor, receiving from its patients only what some of them felt they could contribute toward the cost of what the hospital gave them. In 1917 Phillips House was built and equipped to provide private rooms and the type of service required by those June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 515 who do not have to consider cost. There remain- ed unconsidered in the Massachusetts General, as in most hospitals, the great middle class whose means are limited, but whose economic status and self-esteem make them both ineligible for and unwilling to accept charity, even in time of grave illness. Baker Memorial was constructed to meet this need, $1,900,000 being provided for the purpose. The first patient was received March 3, 1930, To December 31 it served 1973 patients, whose av- erage income, or the average income of the bread- winners in their families, was $2101. The average time of their stay in the hospital was 13 days, and the average cost per patient $158.94. Of this total, hospital charges consumed $94.48, doctor’s fees $55.71. Total expenses of the institution amount- ed to $282,539.19 and total receipts were $213,- 884.08, leaving a deficit for the 10 months of $68,- 655.11. This deficit is smaller than was expected. It has been underwritten for 3 years by the Julius Rosenwald Fund to encourage t-he experiment, and is expected to decline this year to $35,000. That it may be overcome when the full capacity of 3 30 beds, of which only 150 are now in use, become available is apparently within the possi- bilities. Medical and surgical fees are limited to $150 a patient, no matter what type of service is rendered or over what period. Beds with nurs- ing attendance and ordinary medication range from $4 in a 9-bed ward to $6.50 in single rooms. The anesthetic fee is $5, the operating room charge $15, with proportionate charges for x-ray and other special services. School Health Department MINIMUM BIBLIOGRAPHY FOR SCHOOL PHYSICIANS Allen G. Ireland, M.D., Director of Physical and Health Education, State Department of Public Instruction, Trenton Andress Health Education in Rural Schools Houghton Mifflin 1925 Averill Educational Hygiene Houghton Mifflin New York 1926 $2.00 Averill The Hygiene of Instruction Houghton Mifflin 1928 2.00 Ayers, Williams, Wood Healthful Schools, How to Build, Houghton Mifflin 1918 2.25 Equip and Maintain Them Bennett School Posture and Seating Ginn and Co. 1928 ■Cornell Health and Medical Inspection of Davis 1922 School Children Dickson & Dineley Examination for Health and Cor- Lippincott 2.00 rection Fisk and Crawford How to Make the Periodic Health Macmillan 1928 4.00 Examination Keene The Physical Welfare of the Houghton Mifflin School Child New York 1929 Morrison and Chenowith Normal and Elementary Physical Lea & Febiger Diagnosis Philadelphia 1928 Newmayer Medical and Sanitary Inspection Lea & Febiger 1913 4.00 of Schools Roberts Nutrition Work with Children Univ. of Chicago Press — Chicago 1927 3.50 Wood and Rowell Health Supervision and Medical Saunders Inspection of Schools Philadelphia 1927 7.50 Wood and Rowell Health Through Prevention and World Book Co. 1925 Control of Disease Monthly Bulletin of American Association of School Physicians — Dr. William A. Howe, State Department of Education, Albany, New York. Publications of the American Child Health Association, 450 Seventh Avenue, New York City, New York. Physical Measures of Growth and Nutrition, Franzen It 1929 Present Practices in the Light of Recent Research, Whitney A., and Palmer, G. T. 1930 Public Health Aspects of Dental Decay in Children, Franzen, R 1930 School Health Progress — Sayville, L. I., Conference Report 1929 Publication of National Society for the Prevention of Blindness, 450 Seventh Avenue, New York City, N. Y. Conserving the Sight of School Children — Wood, T. D. and Committee 1928 (Bibliography supplied upon request) Publication of Joint Committee of National Education Association, and Amercian Medical Association Health Education — National Education Association — Washington, D. C. 1930 DIG JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 State Health Department NARCOTIC CONTROL D. C. Bowen, Director of Health New Jersey State Department of Health, Trenton, N. J. Those interested in statutory control of habit forming narcotic drugs and treatment of addicts are vitally concerned with the proposal of the United States Public Health Service, in April, for further state regulation of narcotics. The New Jersey Legislature in 1929 enacted Chapter 301 as its latest pronouncement governing prescription and sale of narcotics by recognized authorities subject to state control. The proposal of the United States Public Health Service made orally April 17 for state assistance in enforcement of the Harrison antinarcotic statute was not a complete surprise to officials of New Jersey. In substance, the plan of the U. S. Public Health Service is modeled similarly to the legal machinery for enforcement of the eighteenth amendment of the United States constitution, i.e. the federal enforcement act synchronizing with the several state enforcement laws on the same subject. The New Jersey antinarcotic law. Chapter 301 of the Laws of 1929, in general, specifies those who may manufacture, prescribe, sell and distribute drugs in the interest of the conservation of human life in emergencies. Records pertaining to ad- ministration of the statute in question, filed by medical practitioners, are confidential, in the archives of the State Department of Health, ex- cept for the purpose of enforcing the law, under penalty of a fine not exceeding $1000, imprison- ment of 1 year or both. The proposal of the U. S. Public Health Service for control of habit forming narcotic drugs and the treatment of addicts embraces those features which are said to be exclusively within the do- main of state enactment. These include laws controlling the sale and use of chloral hydrate, cannabis and peyote, as well as the exemption of preparations containing such drugs or their possession, the sale and possession of hypodermic syringes; the prescribing of nar- cotic drugs for habitual users thereof; the revo- cation of professional licenses to practice; the further curtailment of exempt preparations; the commitment of drug addicts to institutions for treatment; the declaring of buildings or resorts where narcotic drugs are illegally sold or used to constitute public nuisance and the instruction in public schools as to the effect of narcotic drugs Further the proposal of the United States Pub- lic Health Service was outlined as follows: “So far as the requirements of the Federal law are concerned, they take precedence over state laws and must be complied with, as a minimum, by all persons who are engaged in the sale or use of restricted- narcotic drugs. On the other hand, in those instances where State laws are more com- prehensive than the Federal law, those more com- prehensive requirements are not set aside by the Federal law, but serve to emphasize the need for additional restrictions as to the sale of habit- forming narcotic drugs.” The State Department of Health is calling atten- tion to the suggestion of the United States Public Health Service at this time in order that there may be adequate consideration of the entire subject by interested parties. Communications REPORT OF PROSECUTIONS FOR ILLEGAL PRACTICE (Submitted by Dr. James J. McGuire, Secretary of the State Board of Medical Examiners.) December 5, 1930, Walter B. Carr, of Millville, a naturopath, was found guilty of practicing medicine without a license. December 11, 1930. James W. Frazer, a licensed chiropractor, of Bayonne, pleaded guilty in the First District Court of Jersey City to a charge of practicing medicine without a license. The charge against Frazer was based upon the fact that he exceeded his license to practice chiropractic by giving drugs. December 11, 1930, Roger Henry, Jr., of Trenton, pleaded guilty in the Trenton District Court to a charge of practicing medicine without a license. December 15, 1930, Dabbi Francisco, who con- ducted the Little Spanish Homeopathic Drug Store at 153 S. Orange Avenue, Newark, was found guilty of practicing medicine without a license by the Judge of the Second District Court of Newark. January 15, 1931, Helen Quasdorf, of Clifton, who advertised electric treatments, colonic irriga- tions, etc., paid the penalty for practicing medi- cine without a license. January 21, 1931, Eugene B. Taylor, of Cran- ford, was found guilty of practicing medicine with- out a license by the Judge of the Elizabeth Dis- trict Court. January 27, 1931, Frank Vermeulen, a chiro- practor, of Paterson, was found guilty of practic- ing medicine without a license by the Judge of the Paterson District Court. February 11, 1931, Joseph C. Kindler, a physio- therapist, of Jersey City, pleaded guilty in the First District Court of Jersey City to a charge of practicing medicine without a license. February 19, 1931, Hugh F. Mitchell, of West New York, who held himself out as a medical doctor, was found guilty of practicing medicine without a license by the Judge of the First Dis- trict Court of Jersey City. March 4, 1931, Mary Kaczmarek, a licensed midwife, of Perth Amboy, was found guilty by the Judge of the Perth Amboy District Court, of practicing medicine without a license. She ex- ceeded her license by administering pituitrin to patients. March 4. 1931, Joseph Brander, of South Amboy, pleaded guilty to a charge of practicing medicine without a license in the Perth Amboy District Court. On the same day Miriam Resnick, a masseuse, of Perth Amboy, paid the penalty for practicing medicine without a license. March 11, 1931, Hildur Karlson, who conducts the Karlson Baths on the Boardwalk in Atlantic City, paid the penalty for practicing medicine without a license. June. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 517 On the same clay, Kathryn McBride, of Atlan- tic City, who was giving electric treatments, paid the penalty for practicing medicine without a license. March 11, 1931. Don D. Modica, of Atlantic City, was found guilty on a second charge of practicing medicine without a license by the Judge of the Atlantic City District Court. March 30, 1931, Evelyn AYienckiewicz, of Irving- ton, a naturopath, pleaded guilty in the Second District Court of Newark, to a charge of practic- ing medicine without a license. April 4, 1931, Theodore B. Mickley, a masseur of Perth Amboy, paid the penalty for practicing medi- cine without a license. April 9, 1931, Paolo Piccone, of Hackensack, was convicted in the Englewood District Court on a charge of practicing medicine without a license. Piccone was giving drugs to his patients. April 10, 1931, Alfonso De Mercurio, a druggist, of Bayonne, paid the penalty for practicing medi- cine without a license. April 14, 1931, William C. Roller, an unlicensed chiropractor, of Bayonne, was found guilty in the First District Court of Jersey City, of practicing medicine without a license. April 21, 1931, David Decker, of Newark, who prescribed Indian Herb Remedies for his patients and who had been found guilty of practicing medi- cine without a license by the Judge of the First District Court of Newark, was committed to jail for 30 days. April 24, 1931, Walter C. Quinn, an electro- therapist, of Plainfield, pleaded guilty to a charge of practicing medicine without a license in the Eliza- beth District Court. January 15, 1931, the Board revoked the license to practice midwifery of Maria Vidale, who had been convicted of practicing criminal abortion. April 16, 1931, the Board revoked the license to practice midwifery of Sophia Kovacs, who had been convicted of practicing criminal abortion. THE AMERICAN COLLEGE OF PHYSICIANS San Francisco, 1932 The American College of Physicians will hold its Sixteenth Annual Clinical Session at San Fran- cisco with headquarters at the Palace Hotel, April 4-8, 1932. Following the Clinical Session, a large percentage of the attendants will proceed to Dos Angeles where a program, principally of enter- tainment, will be furnished April 9, 10 and 11. Announcement of the dates is made now with a view not only of apprising physicians generally of the meeting, but also to prevent conflicting dates with other societies that are now arrang- ing their 1932 meetings. Dr. S. Marx White, of Minneapolis, is President of the American College of Physicians, and will arrange the Program of General Sessions. Dr. William J. Kerr, Professor of Medicine at the University of California Medical iSchool, San Francisco, is General Chairman of Local Arrange- ments, and will be in charge of the Program of Clinics. Dr. Francis M. Pottenger, of Monrovia, is President-Elect of the College, and will be in charge of arrangements at Los Angeles. Mr. E. R. Loveland, Executive Secretary, 133-135 S. 36th Street, Philadelphia, Pa., is in charge of general and business arrangements, and may be address- ed concerning any feature of the forthcoming ses- sion. Woman’s Auxiliary WOMAN’S AUXILIARY AMERICAN MEDICAL ASSOCIATION Ninth Annual Convention Philadelphia, June 8-12, 1931 General Chairman, Mrs. Walter Jackson Freeman A message from Mrs. George N. J. Sommer, Chairman of the Inter-County Committee. Each County Chairman is advised to get as much publicity as possible in the local newspapers about the coming Convention. A photograph of herself or of some other member who is active in the County Auxiliary will not only awaken in- terest in the Convention but will also create inter- est in the work of the Auxiliary. Mrs. Freeman, our General Chairman, hopes one of the results' of the Convention will be an increased member- ship in the County Auxiliaries. Here is one announcement that must be given circulation — All members of the Woman’s Aux- iliary to the American Medical Association desir- ing hotel reservations, and who are coming un- accompanied, kindly send request to — Mrs. Frederick S. Baldi, Chairman, Hotel Committee, Woman’s Auxiliar5r, Room 304, Chamber of Commerce Bldg., 1129 Walnut Street, Philadelphia, Pa. On Monday, June 8, at 4.15 p. m. there will be another general meeting of all the committees at the Bellevue-Stratford. Mrs. Freeman will preside. Please read the above announcements carefully, note the dates and take action on the publicity. W omen at the A. M. A. Meeting A message from Mrs. Walter Jackson Freeman The Woman’s Auxiliary to the American Medical Association has been placed in charge of all en- tertainment of women visitors, and began its labors in June 1930 by engaging the whole Roof Garden of the Bellevue-Stratford Hotel for the period of the convention. All - women’s activities will center in this hotel — registration, meetings, luncheons and supper dance, and all excursions will start from the Broad Street entrance. Invita- tions and tickets must all be procured in the Roof Garden in advance, as nothing but programs will be obtainable elsewhere. Members of the A. M. A. are invited to join all excursions, and should reg- ister for them in advance in the Roof Garden. Rooms for State Headquarters have also been re- served in the hotel, and sponsors will be appointed to look after all women registered from their own states. The list of sponsors will be printed in the program. The chairman of the Women’s Hotel Committee is Mrs. Frederick S. Baldi, 2117 Porter Street, Philadelphia, who will be glad to make any desired reservations. The convention will open with a subscription buffet luncheon in honor of all National Auxiliary Presidents from Mrs. Red to Mrs. McGlothlan, im- 5X8 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 mediately followed by 3 round tables of 35 minutes each, with 10 minute intermissions, each under ex- pert leaderships. The subjects will be: (1) Programs for County Auxiliary Meetings. (2) The Technic and Value of a Committee on Public Relations. (3) History and Archives. These informal gatherings will be a sort of pre- liminary canter, designed to bring together those interested in special phases of auxiliary work and give them opportunity to discuss the subject thoroughly during the following days. The Na- tional Board dinner and pre-convention meeting are scheduled for Monday evening. A new and, we hope, helpful feature will be a Question and Suggestion Box to which we beg all with good ideas to contribute. This seems the most practical way of finding out what our mem- bers want continued, what discarded, and what plans are indicated for the future. The regular business sessions will be held on Tuesday and Wednesday mornings. National Chairmen will be allowed 10 minutes for their re- ports, State Presidents 3 minutes. Reports to be printed may be as long as desired (in reason), but let no one reporting on the floor imagine these limits an idle jest. Nor will the hours announced on the program be found to mean “about”. Have your watches cleaned and regulated, and practice your wrist drill before leaving home. You will need it. Thursday morning, too, will be a busy one, the post-convention Board Meeting, a special meeting for state and county treasurers desiring further elucidation of the treasurers’ receipt blanks, and at 10.30 an informal round table presided over by the new president, the subject, “What Have I Gotten Out of the Convention?” At this meeting, Mrs. McGlothlan will announce her committee chairmen and outline her plans for the coming year, and the subjects in the Question Box will be discussed; a sort of stock taking, closing the year’s business, and opening the new books. Philadelphia as an historic and cultural center is the keynote of the entertainment planned for our guests. Except Monday, all afternoons and evenings will be devoted to pleasure, and a variety of excursions is offered to suit all tastes, all physi- ques, and all weathers. They include bus trips to Valley Forge and to Longwood, the beautiful es- tate of Mr. and Mrs. Pierre S. du Pont, a boat trip on the Delaware, and visits to the Fairmount and Rodin Museums and to the Historical Society of Pennsylvania. The Museum authorities are de- lighted to provide escort service for those de- sirous of more than a passing glance at their treasures, and the Historical Society will arrange a special exhibition for the week, including por- traits, prints, and engravings, documents, silver, etc., from its unsurpassed collection of Americana. There will also be a brief historic address by Dr. Charles W. Burr, of Philadelphia. Wednesday will be a field day — the big Aux- iliary Luncheon — with guests and speakers from the A. M. A. and a beautiful musical program, the gift of the Delaware Auxiliary. In the after- noon the Philadelphia County Medical Society in- vites the women to be guests on a bus trip through historic Philadelphia (a 10 minute stop at Inde- pendence Hall), Fairmount Park and Germantown to “Stenton”, where the New Jersey Auxiliary in- vites us all to tea. “Stenton”, the home of James Logan, Penn’s friend, Secretary of the Colony, still stands just as it was built in 1728, the furni- ture of the period, the garden laid out as described by contemporaries. On Wednesday evening the Pennsylvania Auxiliary invites all visiting ladies to a reception in the superb Chinese Rotunda of the University Museum, a setting probably un- surpassed in any museum anywhere. This meeting of the A. M. A. in Philadelphia is the first in 30 years, and the County Medical So- ciety, desiring to mark so auspicious an occasion, and also in appreciation of the work of the Aux- iliary, invites all members of the A. M. A. and the visiting ladies to be its guests at a supper dance in the Ball Room of the Bellevue, following the big meeting of the A. M. A. on Tuesday evening at the Academy of Music. The President’s ball at the Benjamin Franklin Hotel on Thursday evening, to which all are invited, will close the formal fes- tivities. To those still able to rise from their beds on Friday morning there are offered a tour of Wana- maker’s with luncheon in the Crystal Tea Room, or an all-day bus trip to Atlantic City, where the New Jersey Auxiliary will meet them for luncheon at the Claridge. This program includes also a visit to the new Convention Hall, an hour in a chair on the Boardwalk, and plenty of time for window shopping or a swim. And finally, every day and all day there will be a booth in the Roof Garden inscribed “As You Like It" — Anywhere, where those wishing to golf, shop, go to Garden Days, or carry out any other pet project not elsewhere provided for, may find information and assistance in making a profitable use of their opportunity. Will you not reward our efforts by the largest and most enthusiastic women's attendance in the history of the American Medical Association? Atlantic County Mrs. Maurice Chesler, Secretary The last regular meeting of the Atlantic County Medical Society Auxiliary was held Friday even- ing, May 8, at the Chalfonte Hotel, Mrs. J. T. Beckwith presiding. At a public card party given at the Claridge Hotel, Wednesday, April 29, the amount of $75 was cleared, and will be placed in the Welfare Fund. Five-o’clock tea and refreshments were served complimentarily by the Claridge manage- ment. Mrs. James FI. Mason, 3rd, was in charge of this party, assisted by an able committee. Another delightful affair was held at the Clar- idge on Wednesday, May 20, in the form of our annual spring luncheon and bridge. Floral decora- tions adorned each table and bird-nest plants were given as prizes. Violin selections were beautifully rendered by Mr. William Stokking, of the Clar- idge Orchestra. Mrs. James H. Mason, Chairman, was assisted by Mrs. J. T. Beckwith, Mrs. W. Blair Stewart, Mrs. Robert A. Bradley, Mrs. Law- rence A. Wilson, Mrs. James North, Mrs. Percy C. Joy, Mrs. D. Wlard Scanlan, Mrs. Samuel L. Sala- sin and Mrs. Maurice Chesler. Mrs. J. T. Beckwith graciously welcomed 5 new members to our Auxiliary, namely: Mrs. Henry O. Reik, Mrs. Stanley M. McGeehan, Mrs. J. C. Marshall, Mrs. Harry Subin, Mrs. B. B. Barab. Interesting accounts were given by Mrs. James North, Mrs. Percy Joy and Mrs. J. T. Beckwith, who attended the Washington trip sponsored by the Philadelphia County Medical Auxiliary. Mrs. John F. Massey spoke of the coming con- vention and arranged for her committee to assist in receiving the national delegates and their June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 519 friends upon their visit to Atlantic City on June 12. After the meeting' social hour and cards were enjoyed. Gloucester County Reported by Mrs. Henry B. Diverty The Woman’s Auxiliary to the , Gloucester County Medical Society met Thursday evening, May 21, at 9 o’clock, at the Woodbury Country Club, the same hour and place of meeting of the medical society. The President, Mrs. Elwood Downs, was in the chair, with the following members present: Mrs. David Brewer, Mrs. William Brewer, Mrs. J. Har- ris Underwood, Mrs. Oram Kline, Mrs. Henry B. Diverty and Mrs. Downs, of Woodbury; Mrs. Ralph Hollinshed, of Westville; Mrs. C. I. Ul- mer, of Gibbstown; Mrs. Wandell, of Clayton, Considering the heavy rainfall all day and evening the attendance was fine. After adjournment the ladies were invited to hear Prof. Pennock, after which all partook of a collation served by the Country Club chef. Mercer County Reported by Mrs. George N. J. Sommer Delegates to represent the Woman’s Auxiliary to the Mercer County Medical Society at the meet- ing of the Auxiliary of the Medical Society of New Jersey to be held at the Berkeley-Carteret in Asbury Park, during the first week in June, were elected at a meeting of the members on May 12, at the State Home for Girls. They are: Mrs. D. Deo Haggerty, the president; Mrs. A. Dunbar Hutchinson and Mrs. Alton S. Pell. The alternates are Mrs. James J. McGuire, Mrs. D. M. Yazujian, and Mrs. J. Otto Denelsbeck. Plans were discussed for the tea to be given at “Stenton”, the home of the late General Dogan, in Philadelphia, by the Auxiliary to the State So- ciety on Wednesday, June 10, in connection with the meeting of the American Medical Association. Preceding the meeting, which was arranged by Mrs. G. N. J. Sommer, the members made a tour of inspection of the school and classes while in session. Mrs. Kate Burr Johnson, superintendent of the home, entertained the members at tea fol- lowing the session. There were about 30 present. County Society Reports ATDANTIC COUNTY John S. Irvin, M.D., Reporter The regular monthly meeting of the Atlantic County Medical Society was held Friday night, May 8, in the Chalfonte Hotel. The President, Dr. Norman J. Quinn, called the meeting to order at 8.30 p. m. The Secretary, Dr. Joseph H. Marcus, read the minutes and since there were no correc- tions they were accepted as read. Board of Censors : The applications of Drs. Rob- ert Durham and Anthony Merendino were ap- proved. The application of Dr. Van Delein for Associate Membership has not been turned down but merely is being held over until September as he has not been practicing dentistry more than 8 months here and we are merely following a prece- dent in not accepting a man for membership un- less he has been in practice here for at least a year. Public Health and Sanitation : Dr. Stewart re- ported that the State Board has investigated a great many men and women here who are acting contrary to law. They are always trying to keep after these irregular practitioners. He said that it was the duty of the members of the society to report the names of these individuals who are practicing illegally. Two names have been handed to him recently. '‘At our last gathering, jointly with the Council- or District Meeting, we couldn’t take any action on the death of Dr. George Scott. 1 want now to say a word in regard to Dr. Scott. He was born in New York City, in 1849, and graduated in medi- cine in 1871. In professional work in New York he was quite successful. As you all know, he was a married man and had’ 2 sons. Unfortunately, one was taken ill and died, and the second was taken ill and on account of that boy’s health he came to Atlantic City in 1903; and many of you remember that in later years that son was taken ill with pneumonia and subsequently died. It was a great cross to Dr. Scott and his wife. Recently, the doctor passed away at the age of 81 years. I am glad to recall that in 1925 the Atlantic County Medical Society honored him upon the fiftieth anniversary of his graduation, and at the same time honored Dr. Marvel, who had not quite reached his fiftieth anniversary.” Inasmuch as Dr. Scott was such an honored member of our society I would like to move, Mr. President, that a page be set aside in our Minute Book in his memory. This motion was adopted. Another member of our society is very ill in the hospital — Dr. Thomas Taggart. It was also moved and carried that a letter with the society’s best wishes for an early recovery be sent to Dr. Taggart. Special Committee : Dr. Harvey reported that the committee met and decided to enter the “Know Your City Day Fair”. We have completed all our arrangements and I believe we are going to put over a very fine show. We are going to have a lot of moving pictures. The lay people will un- doubtedly ask a lot of questions and in order that someone may be there to answer questions I feel that some younger men should be there, or else I wish some of the other men would volunteer to stay there either a part of or a whole day. The President asked Drs. Timberlake and Meren- dino to stay in the booths on Monday. A letter was received from Dr. Barbash in which he acknowledged his appreciation to the society on the courtesies extended to him on his wife’s death . A letter was also received from Mrs. Scott thank- ing the society for the courtesies shown her on the death of her husband. The president announced that Drs. Mason, Johnson and Reyner comprise the Entertainment Committee for the June rrieeting, which is in the form of an outing. The president then introduced the speaker of the evening. Dr. Joseph C. Doane, Associate Profes- sor of Medicine, University of Pennsylvania Grad- uate School of Medicine, who spoke on “The Etio- logy, Diagnosis and Treatment of Diseases of the End Arteries”. (To be published later in the Journal.) 520 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 Atlantic City Hospital Staff Joseph H. Marcus, M.D., Secretary The regular monthly meeting of the Atlantic City Hospital Staff was held April 24, with the president, Dr. Milton S. Ireland, presiding. The scientific program was opened by Dr. Gerald A. Cyr, who spoke of “Barbituric Acid Derivatives and Their Toxic Manifestations”. Much has been written about the therapeusis of the barbituric group of acids, but strange to say very little work has been done, or should I say reported to date, regarding toxicity. In an effort to obtain the best information regarding this topic, I wrote to the American Medical As- sociation and am allowed to use the various clippings and articles collected relative to this matter. Even then I found it very difficult to correlate the material because all the articles dealt mainly with the toxic effects of 1 or 2 of these acids chief among which were the toxic ef- fects of barbital itself. Finally, I wrote to the Eli Lilly Company, but was again discouraged by finding no literature on the relative toxicity of the barbituric group of acids. Just a few words might be said at this time about the chemistry of this group of acids. That part of the barbituric acid residue which is re- sponsible for the production of sleep is of interest. Urea is capable of acting as a hypnotic only when combined with radicals rich in carbon, and it is most effective in the cyclic arrangement found in barbituric acid. Dox believes that to induce hyp- nosis without extreme untoward effects, the mole- cule must possess substituents on the number 5 position, which is the methylene group of the melannic acid radical. Few, if any, of the reports dealing with a deriv- ative of barbituric acid have included descrip- tions of all the associated toxic symptoms, but I have included the toxic symptoms which have been described. (1) Cutaneous Rash. Littenfield, in 1903, pointed out that one disadvantage of diethyl barbituric acid was the erythema which it might produce; similar to that of antipyrene. A case is reported, where a man took 4.25 gm. in 2 days and 8.5 gm. in 3 days, with the following manifestations: erythematous rash; tenderness in the region of the right mastoid process; discharge from the right ear; temperature 101°; pulse rate 125; de- lirium and semicoma: but recovery was prompt after the drug was stopped. In 1907, House re- ported on cutaneous eruptions after a dose of 1 gm. diethyl barbituric acid. He also pointed out that cutaneous eruption is the most constant symptom following all but the most rapidly fatal dose. Tardieu pointed out that the rash usually appeared only in subacute cases or during con- valescence from severe poisoning, and generally constitutes favorable prognosis. Blamoutier reports the case of a woman who took several doses of diethyl barbituric acid with- out any symptoms; 5 months later, she took 5 gm. the same drug and an erythema developed; 15 months later she took 20 drops of somnifene and in 10 minutes erythema and edema of the face and buccal mucosa developed. This illus- trates the danger of giving any other derivative of barbituric acid to a patient who already has shown intolerance or sensitivity to one member of the barbituric group. Coma. Symptoms of a serious overdose are coma and stupor. Many cases have been reported. Farncomb reports a case where a woman was totally unconscious for about a day; in 2 days temperature was 102° with anuria; next day tem- perature 103°, pulse rate 160-180, and consolida- tion was beginning at the bases. Fever soon rose to 104° and the lungs became totally congested. The temperature continued to rise at the rate of V2° every % hour until it reached 107° by axilla, and death occurred. This brings out a point, the so-called barbituric acid fever, which may be the result of pulmonary congestion, and only indi- rectly due to the drug. Eye. Pupillary changes may be observed from diethyl barbituric acid poisoning. Reports of cases of acute poisoning show that the lethal dose varies from 30 to 200 grains. A patient took 150 gr. and was comatosed for a few hours. There was complete muscular relaxation and abolition of all tendon and cutaneous reflexes; pupils were fixed and did not react to light or accommodatioin ; Cheyne-Stokes’ respiration de- veloped. The following day there was evidence of congestion of both the lungs, a cutaneous erup- tion developed, and the patient died. It is evi- dent from one of these reports that ocular phe- nomena are incident to poisoning from barbituric acid but these signs are not pathognomic of poi- soning from barbital and only call attention to the effects of these drugs on the reflexes. Farnell, in 1913, reported 2 cases in each of which it was evident that action of the drug did not manifest itself until the cumulative effect had set in. He pointed out that 5 gr. luminal has about the same action as 8 gr. veronal. In 1925, Weig reported a case of fatal poisoning by this drug. A woman, 67 years of age, suffering from arteriosclerosis, died 39 hours after she had tak- en 15 gr. luminal. This should call attention to the decreased tolerance of those of advanced age. Many cutaneous eruptions have been reported from large doses of luminal. Hang, in 1919, reported 2 cases of epilepsy in which 1 % gr. of luminal t.i.d. had been pre- scribed. In 4 weeks in 1 case, and 11 days in the other, from the time that this treatment was begun, the patient suffered from high fever, diar- rhea with mucous stools, and eruption resem- bling scarlet fever covering the whole body except the hands and face. The total amount taken by first patient was 12 6 gr. ; the second 50 gr. The first patient was slightly stuporous, the second had albuminuria. After suspension of the drug, the symptoms subsided in a few days. Rutonal is closely related to luminal and both have been used clinically with about the same results, and their toxic effects are about the same. Dial has produced toxic effects. Zuelehour, re- porting on the administration of 800 doses of dial to 25 patients, noted transient vertigo, but observed that a rapid tolerance to dial develops. Christofel, in 1918, pointed out that 3 gr. of dial is equivalent to 8 gr. veronal and 30 gr. chloral hydrate. Buc-hel, writing on poisoning from dial, pointed out that death is due to respiratory par- alysis and that the cardiovascular system is lit- tle affected. He felt that fewer cases of poison- ing from this drug had been reported and that the essential signs of poisoning from dial are slight dyspnea and coma. Somnifene. Zaffison reports upon a man 24 yr. of age who took 2.4 gm. of the drug and was un- conscious for 24 hr. with complete retention of urine which persisted for another 24 hr. He was treated with gastric lavage and salt solution, and recovered in 3 days without complications. He believes that this drug should not be used for June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 521 postoperative pain as it increases the percentage of postoperative thrombosis. Amytal has been used in large and small doses with results comparable to the other derivatives of barbituric acid. It has been uniformally ob- served that in overdose it lowers the blood pres- sure; particularly true in cases where there is arteriosclerosis and hypertension. Some men have called attention to the advantages and dis- advantages of amytal. The extreme quietness following operations increases the likelihood of postoperative pneumonia or massive pulmonary collapse. There can be no question that when excitement or pulmonary complications follow the use of amytal, too much of the agent has been used or the blood pressure has been lowered to a critical point. The clinical lesson which one should learn from this short review is that the speed with which a derivative of barbituric acid takes ef- fect depends on the route of administration of the drug. However, and this is the important factor, the depth of hypnosis or the anesthesia produced is not essentially based on the route of administration, but on the dose used. If a dose larger than the hypnotic one is to be used, then it is safer to follow the intravenous method; otherwise, it is safer to use divided doses. In conclusion, allow me to emphasize the fol- lowing important points; (1) One must remem- ber that all derivatives of barbituric acid are as potent to do great damage as they are to do good, if given in too large doses. Fatal results have resulted from overdose of each member of the group. (2) One must keep in mind that to adminis- ter the drugs daily for a long period of time might result in poisoning due to the cumulative effects, especially barbital, which is only slowly eliminated from the body. (3) One must also remember that a patient can easily become sensitized to the drug, and that to re-administer the drug to him at a later date might produce in him an anaphylactic reaction. (4) Finally, that no 2 patients will respond in the same manner to these drugs, each patient being a problem in himself, and that it then be- comes the duty of the physician to carefully watch his patient for the slightest evidence of intoxication. Dr. Louis .Downs spoke of “Sodium, Amytal and Its Chemical Uses, with Especial Reference to Value as a Pre- Anesthetic Agent''. Before going' into the chemistry, I would like to review the general pharmacologic features of sod. amytal and other barbituric acids. (1) Barbituric acids are primarily hypnotics; only occasionally will hypnotic doses produce analgesia or anesthesia. (2) There is a marked variation in effect, and selection of proper dosage is difficult. (3) Doses that will cause deep hypnosis may seriously embarrass the respiratory and circula- tory systems. Amytal and neonal are not recovered in the urine. Intravenous injection of as much as 22 gr. amytal failed to give traces in urine; evidently amytal is completely destroyed in the body. Opinion is divided as to the carbohydrate me- tabolism, some stating that hyperglycemia and glycosuria follow administration of amytal; while others find no effect. Animals with high blood urea showed no untoward effects from amytal and the dosage needed was less — indicating that the drug does no harm to the kidneys. Patients receiving amytal as a pre-anesthetic took fluids more freely the following day and nausea was ab- sent, or rather they had greater freedom from it. When injected intravenously the induction of sleep is rapid and quiet. Drowsiness, yawning and slurring of words come on after administra- tion of 3-9 gr. Increase in dosage causes reflex hypersensitiveness but finally produces profound narcosis. Patients are very restless and time is required before patient is calm and reposed. This narcosis lasts from 3-6 hours. Afterward they are drowsy, but are cooperative in taking fluids.. Patients who have experienced other opera- tions under ether claimed that sod. -amytal made their present operation a pleasure in contrast to the previous one. For exophthalmatic goiter and other apprehensive excitable patients, amytal has a definite place in anesthesia. Mason and his associate call attention to the individual susceptibility; dosage ranging from 3-9 gr. in their report. Old debilitated patients fall asleep with 3-5 gr. and robust patients need 7-9 gr. From their observations in 305 cases, the patient slips away into a sleep that certainly, to all appearances, resembles physiologic sleep. In only 1 instance was there any evidence of ex- citement during the induction of sleep by sod.- amytal or by the later induction of deeper anes- thesia by inhalation anesthetics. Lundy used it oralis^ in doses of 6-9 gr. in 73 0 cases and observed little if any nausea or de- lirium and there were no respiratory difficulties. By intravenous route he used it 457 times to pro- duce part or all of anesthesia. He calls atten- tion to the rapid injection of the drug and fol- lowing large doses he observed delirium, edema of lungs, pneumonia and inability to raise mucus after thyroidectomy and stated these as an ob- jection to the use of the drug as a sole anes- thetic. The uses of this drug, other than pre-anes- thetic, inclyde the control of convulsions from any cause. Dr. V. Earl Johnson reported the Surgical Ser- vices of Dr. Thomas Taggart and himself for the months of November and December 1930, and January 1931. During this tour of service, of approximately 3 months, there were admitted 19 0 patients. Of this number, 9 3 were of traumatic origin; or approximately 50%; 133 operations were per- formed. There were 17 deaths this year, or about 9%, as compared with an 8% mortality rate last year; 10 of these deaths occurred with pa- tients who had been operated upon — a post- operative death rate of approximately 7.5%, as compared to an 8 % rate, last year. The question of choice of anesthesia on our service has been given considerable care and it has been interesting to make a comparative study. A tabulation shows that we used: Nitrous oxide with ether, 14 times; nitrous oxide alone, 40; spinal anesthesia, 22; avertin — either alone or combined with nitrous oxide or local, 14; local field block or local infiltration, 15; chloroform, 2; ether-oil colonic, 1; sodium amytal preliminary, 5. Dr. Robert A. Kilduffe, Director of Pathologic Laboratories, presented his report for 1930, which comprised a total of 45,305 reports made. The volume of work can best be appreciated by esti- mating its book value, amounting to $132,930, an increase of $25,706 over 1929. In addition to’the laboratory work done for the hospital as an en- tity, work was also performed for the Municipal Hospital, Betty Bacharach Home, Board of Health, Asylum, Almshouse, and Pine Rest. 522 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 There were 19 publications issued by Dr. Kil- duffe in various journals in the United States and abroad. BERGEN COUNTY C. H. Littwin, M.D., Reporter About 35 members attended the regular month- ly meeting which was held at Bergen Pines by invitation of Dr. Morrow. The minutes of the last meeting were read and approved, as were also those of the Executive Committee. Dr. Kilts reported for the Credit Protection Committee, that he fejt the only satisfactory credit bureau would be one organized and super- vised by the physicians themselves. He will sub- mit a proposition for consideration at the next meeting. The Public Relations Committee announced through Dr. Wolowitz that the broadcasting has come to an end for this year; he also stated that the Post-Graduate Course is proving very suc- cessful; 31 men taking it. Drs. Wilson and Pallen spoke on the proposed organization of a Cancer Clinic. Dr. Levitas spoke of the difficulty in arranging a program for the June meeting, which conflicts with the A. M. A. Convention, and at his sug- gestion a straight business meeting was ordered. Dr. Neil McLeod Whittaker was elected to membership. Dr. R. M. Anderson, a former member, was reelected by transfer from the Minnesota Society. Dr. Frank L. Niles, of Hack- ensack, was elected by transfer from the Lacka- wanna County Society of Pennsylvania. The applications of Joseph Bono, of North- vale; Luke A. Mulligan, of Leonia; and Herman Feit, of Hackensack; for associate membership, were read. The death of Dr. Max Wyler, of Fort Dee, form- erly president of the society, was reported. A motion was adopted that the President appoint a friend to draw up resolutions for the society to adopt. The proposed County Laboratory was endorsed by the society. Dr. Levitas introduced Dr. Reuben Ottenberg, Associate Physician of Mt. Sinai, who spoke at Length on “Diseases of the Liver and Their Treat- ment’’. His talk opened up many new concepts of liver conditions which are now being unfolded by research workers. Many new tests of differ- ent liver functions are being developed, and these he explained. It is certain that a great deal more attention will be focused on this important organ in the future, both from the viewpoint of tests for incipient disease and for treatment. Second Councilor District Meeting (Reported by the Councilor, Dr. Snedecor) The delegates and officers of Hudson, Sussex, Passaic and Bergen County Medical Societies met for dinner at the Oriental Club, at Hackensack, April 29. This meeting, admittedly an experiment, brought together 37 representatives of these medical groups. All of these men were empowered with the re- sponsibility to carry back to their constituencies the proceedings in which they all had an oppor- tunity to take part and then to carry them for- ward to the State Convention. Dr. Harry Perlberg, Secretary of the Hudson County Society, presided. Dr. Spencer T. Snede- cor, as Councilor for the district, welcomed the group to Hackensack. A brief talk on the oppor- tunities for constructive action by this group was given by Dr. Quigley, Third Vice-President of the State Society. The first topic on the program was introduced by Dr. Coleman, of Sussex: “Shall the Physicians Seek to Amend the Hospital Lien Law to Include Doctors and Nurses?’’ This was forcefully dis- cussed by Drs. Poliak and Kuhlman. Dr. Quig- ley’s motion was passed, without a dissenting voice, as follows: Resolved that the Welfare Committee of the State Society be urged to secure, if possible, at the coming session of the legislature an amend- ment of the hospital lien law to include doctors and nurses. Dr. Waters, of Hudson, presented a careful re- sume of the attitude of other states, Canada, and Europe, on the “Problem of Licensing Specialists”. He then submitted a carefully thought out plan for proper accrediting and control of specialists and specialism by the State Medical Society. In prin- ciple, this was heartily approved and was felt to deserve consideration by the State Society. It was discussed by Drs. Kelley, Littwin, Schwarz and Levitas. It was moved that the plan be referred to the Welfare Committee of the State Society with the request that a special subcommittee be appointed to consider it and report next year. Dr. Joseph R. Morrow, of Bergen, opened a discussion on the “Supervision of Public Health Nursing”, and was followed by Drs. Knox, Mar- ris and others. “The Need for Better Public Relations Through County Medical Society Publicity” was spoken of by Dr. Spencer T. Snedecor, of Bergen. This was discussed and the following motion passed: Re- solved that the State Medical Society be asked to appoint a special committee for the promotion and supervision of county society publicity. Dr. Harry Perlberg, of Hudson, spoke on the problem of “Medical Charity”. He was closely seconded by Dr. Hasking who spoke at length on the new state poor laws, which make the medical care of the poor a direct municipal responsibility. He said he felt that most of the problems of free medical service would be worked out by municipal payments. Dr. Wilbur, of Sussex, presented for considera- tion a “Plan for Continuing Immunization Against Diphtheria”. When a certain percentage, possibly SO to 90%, of the children have been immunized in a school, it should be made a requirement for admission, and the immunization should be done by the family physician. Dr. Wayne Hall, of Passaic, discussed the sub- ject of “Preschool Examinations”, and urged the need for a campaign to encourage this work.' When the meeting adjourned it was felt that a great deal of fruitful discussion had been held on topics which are of vital interest to the general profession. More than that, many new friends were made among the delegates of other societies whom we expect to meet again at Asbury Park in June. Plan for Proper Accrediting and Control of Specialists and Specialism by the State Medical Society (I.) Formation of a State Society Committee on Credentials for accrediting members for special practice, with subsidiary county committees to re- fer approved applicants to the state committee for action. These committees might be formed as follows: State — President, ex-officio, the Chair- June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 523 man of the Welfare Committee. Chairman of Pub- licity Committee, Chairman of Board of Trustees, and member of the State Examining Board. County — 12 members, with the president ex- officio; the members to be chiefs of departments or ranking attendings in their respecitive hospi- tals, and members of the colleges or groups now nationally accrediting physicians for special prac- tice, apportioned as follows: Surgery 2, Medicine 2, Obstetrics 1, Eye and Ear 1, Nose and Throat 1, Roentgenology 1, Genito-Urinary 1, General Practice 1, Gynecology 1, Pediatrics 1. (II.) Requirements for Acceptance as Special- ists: (1) Those accepted by the respective groups of specialists gathered under the following Societies and Colleges: (a) American College of Surgeons. (b) American College of Physicians. (c) American Society of Obstetricians and Gynecologists. (d) American Boards of Otolaryngology and Ophthalmology. (e) American College of Radiology and the Radiologic Society of North America. (f) American Society of Psychiatrists. (2) Accrediting by Recognition of Experience: (a) Men in practice longer than 10 years who have been notably identified with certain branches of medicine and surgery and who are accepted in their communities by their fellow practitioners as competent in the field to which they are giving special attention. (b) Men in general practice, holding a hospital service in a special branch of medicine, which ser- vice is sufficiently active to allow of attainment of a high degree of proficiency in that branch of medicine. The duration of appointment must be not less than 5 years. (c) Properly qualified and trained men, not classified in (a) and (b). Those of ample hospital and post-graduate training in practice 5 years or more, who furnish proof of qualifications which are acceptable to the State Committee on Cre- dentials. (III.) Distribution of Information Regarding Accrediting of Members for Special Practice and those so Accredited: (1) Newspaper notices, prepared by County Committee on Credentials and certified by the State Commjttee on Credentials. (2) Radio talks; best through the State Com- mittee. (3) Through agency of the medical profession; office placards and pamphlets on the subject of “Choosing a Specialist’’. (4) Display of Certificate issued by the State Society through the State Committee on Creden- tials for Special Practice. (5) Distribution of information through a Cen- tral Information Office in each county medical district; (a) Physicians’ and Surgeons’ Telephone Exchange; (b) Secretary’s Office of the County Society. BURLINGTON COUNTY Roscius I. Downs, M.D., Reporter A regular meeting of the Burlington County Medical Society was held in the Community House, Moorestown, Friday, May 15. The Presi- dent, Dr. Joseph M. Kuder, called the meeting to order at 2.15 p. m. by asking all present to take their places at the dinner table and join in the repast. Dr. Kuder asked the guests to arise when he announced their names, as follows; from the Bucks County Medical Society, of Pennsylvania— Drs. W. M. Le Compte, J. F. Wagner, James Col- lins, Joseph Abbott, Frank Lehman and Miss Lehman; Drs. John C. Hurst, P. Brook Bland and R. P. Andrews, of Philadelphia,; Dr. Frank Wood, resident physician at the Burlington County Hos- pital. Immediately following dinner the minutes of the March meeting were read and approved. The Secretary reported that return questionnaire postcards had been sent to all members of the society, requesting an expression of opinion on the following questions: Do you prefer that meet- ings of the society be held in the Burlington County Hospital or elsewhere in various com- munities in the county? — Do you prefer that scientific papers be presented by outside men or by members of the society? — If you prefer the latter, will you present a paper if requested to do so ?- — Do you think a meal a desirable adjunct to meetings? The Secretary reported that of the 5 0 cards sent out, 34 had been returned, which tallied as follows: 13 in favor of meeting at the Burlington County Hospital; 17 in favor of meet- ings elsewhere; 22 were in favor of having men from outside the county present scientific papers; 22 thought a meal a desirable adjunct to a meet- ing. The Board of Censors having reported favor- ably on the application of George J. Wagner, of Delanco, he was elected to membership. Dr. Eugene A. Meyer, of Moorestown, who had been elected to membership at a previous meet- ing, signed the constitution of the society after having responded affirmatively to the declaration made by the President, Dr. Kuder, to comply with the constitution and by-laws of the society. Dr. Kuder announced for the Woman’s Aux- ilary that a dinner dance and card party would be held at Log Cabin Lodge, Medford Lakes, on Tuesday, May 26, at 7.30 p. m. The Burlington County Auxiliary has a very active and efficient organization and its members have expressed eagerness to cooperate with the society in any suggested work. Dr. Kuder sug- gested in matters of health education particularly, in which the physician with grace and propriety cannot extol the value of his own services, the auxiliary may render noteworthy service in ar- ranging meetings between the public at large and the medical profession. It was regularly moved and seconded that the president appoint a committee of 3 or 5 to be known as the Public Relations Committee. The secretary reported that the Fourth Coun- cillor District Meeting, held at Lakehurst on May 1, had the largest attendance of any of the district meetings in the state, there being 170 present. The combined social outing with an in- structive scientific evening, by our host — The Naval Medical Corps — was well worth while. Such meetings should make for more widespread acquaintance among the members of the profes- sion in Burlington, Camden, Monmouth, and Ocean Counties, and thus better the fellowship at the Annual Meeting of the State Society. Dr. Edward R. Hunter, Chairman of Section Gynecology and Obstetrics, announced the pro- gram, and introduced Dr. John Cooke Hirst, of Philadelphia. Dr. Hirst, after an impromptu talk on sterility, demonstrated by manikin the contraceptive tech- nic used by the Maternal Welfare Clinic at 69th 524 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 Street, Philadeljahia. He said that many patients from New Jersey were coming to the clinic and that no one was treated unless she presented a note from her physician requesting it. Dr. Hirst thought the physicians in New Jersey should take up the matter of opening a clinic in this state. Dr. P. Brook Bland, of Philadelphia, demon- strated by moving picture film the “Trichomonas'’ with discussion of the most frequent gynecologic symptom, leukorrhea, and certainly presented his subject in a most interesting and instructive man- ner. Leukorrhea is a symptomatic expression of a disease, with variable clinical characteristics, and is usually treated in an unscientific manner. Trichomonas is quite prevalent in the colored race. Usually the patient has very little distress except the bubbling, yellowish discharge. Diag- nosis of the parasite can be confirmed by the microscope. The exact pathology is not yet proved and the source of infection is not known. The parasite has never been found in the intes- tinal tract. The important point in treatment is mechanical cleansing by vigorous scrubbing of vaginal mucous membrane with tincture of green soap, a vaginal douche of Lugal’s solution and water at night, followed by an alkaline douche in the morning. Drs. Bland and Hirst were given a vote of thanks from the society. The society adjourned to meet in September, there having been 31 members and 9 guests pres- ent. CAMDEN COUNTY Robert S. Gamon, M.D., Reporter The regular meeting of the Camden County Medical Society was held in the City Dispensary Building, Tuesday, May 5, 1931, at 9 p. m., with Dr. W. J. Barrett presiding. The scientific paper of the evening was pre- sented by Dr. Frank C. Benson, of Hahnemann Hospital on “Radium in Prostatic Pathology”. The essayist gave a most instructive discourse on radium and radio-activity and then gave the re- sults of his clinical and experimental work with radium in prostatic pathology. The paper was discussed by Drs. A. H. Lippincott, D. F. Bentley, Jr., and Albert Bothe, by invitation. The Committee on Public Relations presented a report which was accepted by the society. Its recommendation included the establishment of a Public Speaker’s Bureau, sponsored and endorsed by the county society and consisting of members of the society who would be available to address public gatherings. The committee reported nega- tive findings on newspapers and radio publicity. The next meeting of the Camden County Medi- cal Society will be held in conjunction with the annual outing of the combined societies of Cam- den County. The date has not as yet been an- nounced. The meeting was well attended. ESSEX COUNTY E. LeRoy Wood, M.D., Reporter The economic problems of the physician con- tinued to hold attention of the Essex County Medical Society at its meeting held Thursday evening, May 14, at the Academy of Medicine, 91 Lincoln Park, Newark. Dr. Charles Gordon Hayd, President of ihe New York County Medical Society, spoke on “Modern Medical Problems and the Practitioner”. He pointed out that physician’s fees play a very small part in the high cost of medical care, a subject being featured in many lay journals. He said that a report would shortly be rendered by a com- mission studying the “High Cost of Medical Care” showing that the bulk of medical expense goes for medication (especially patent medicines), nursing and institutional care, and laboratory examina- tions, but a relatively small proportion to the at- tending physician. He suggested that the ex- pense of laboratory diagnostic aids be reduced by greater use of the physician’s own abilities. An accurate diagnosis can generally be reached after adequate use of the 5 senses and a good history of the illness. He said: "The fundamental object of medical practice is to provide and make avail- able adequate, effective and efficient medical ser- vice at all times for every member of the com- munity, regardless of race, color or creed. Medical service as provided today is in a large measure effective and efficient although not always ade- quate or available. The payment to physicians for medical service is not a large item in the so- called cost of medical care, as only about 50% of patients hospitalized in general hospitals pay a doctor’s fee. There is no logical reason for be- lieving that the professional item for adequate and effective medical service can be materially lessened or reduced. On the contrary, there are many reasons for believing that it will be in- creased. The doctor is a citizen and must dis- charge all of his obligations of citizenship the same as any other member of the community. The doctor is entitled to a monetary return for his labor that is fair and commensurate with his ser- vices, training and experience. The fact that the practice of medicine is a profession does not mean that the doctor shall continue to work under a system that is ethically wrong and economically unsound. The doctor must be paid for his ser- vices in order to function as a useful and con- tributing member of society. These postulates present the background and serve as an introduc- tion to considering what is the economic contri- bution of physicians to the community. Physi- cians annually contribute to the community $365,- 000,000 worth of free medical service. It is claimed by competent statisticians that physicians treat y8 of the population of the United States free of charge. Since at all times 2% of the population is incapacitated and about 4% physically impaired, it follows that from 375,000 to 500,000 persons are daily treated without charge. If only $2 per per- son were charged for treatment, the sum total monentary equivalent for contributions annually made by physicians in the form of free medical treatments would be $365,000,000. If all the medi- cal and quasi-medical foundations were consoli- dated into one organization their entire contribu- tion to society in dollars during the last 20 years is not equal to the annual donation of the physi- cians of the country. The medical profession may, therefore, justly claim that under the present medico-social system it stands without a rival in the entire field of medical charity and health philanthropy. This immense philanthropic enter- prise is created by the labors and services of 150,000 physicians working for an average re- muneration of $3000 per annum. The average doctor today is about 28 years of age before he begins practice. What has it cost in actual dollars to produce this educated and trained product? His premedical and medical edu- cation will certainly cost, with fees, maintenance and miscellaneous expenses, $16,000. His loss of June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 525 earning capacity while being professionally edu- cated may be estimated roughly for 6 years as $12,000. This young man then begins practice with an estimated indebtedness of $28,000 upon which he should pay $1400 a year as interest. I seriously doubt, although I have no figures to verify it, whether 80% of the doctors ever over- come this primary indebtedness. In other words, more than 4/5 of our profession never repay their capital investment by leaving an estate equal to $28,000 and never make up the carrying charges by annual savings of approximately $1400. To just break even the doctor must logically pay this interest and create a capital of $28,000 before he dies. That the medical service provided by doctors in the last 30 years has, cn the whole, been effec- tive is indicated by a study of the mortality rate in 1900 as compared to the mortality rate in 1925. If the medical service given to the middle class (white collar) had been ineffective or inadequate, then we should expect to find that the people suf- fered from such service. This is not apparent because the decline in modern mortality is im- pressive. Mr. Wolman has calculated that, based on the death rate obtaining at the be- ginning of the century, in 1925 there would have died 1,962,999 persons, but actual deaths were only 1,389,673 persons, a saving of 573,326 lives. With only 43% of the community gainfully em- ployed and 87 % of the community receiving less than $2000 a year, no matter how much the cost of medical service can be reduced, it cannot be brought sufficiently low to allow this large group of the community to pay for medical service with- in its income. More is spent on nonessentials than on medical care. The costs of cosmetics, cigarettes, and chewing gum are expenditures that are in no sense necessities and are distinctly in the luxury class. These luxury expenditures total over 5 % times the total cost of all nongovernmental health services. The amount spent for tobacco alone is 3 times as much as that spent for physicians, and the American people spend more for candy than they do for doctors. There are other economic disabilities that are enforced on the doctors as against the other pro- fessions. The establishment of a free clinic by a I philanthropist, without the employment of paid physicians, is a most unphilanthropic act. Such an individual is forcing other sick people who are already burdened with debts and whose incomes have stopped, to hire and pay doctors who attend the patients in the free clinic. No free clinic should be permitted to operate without reimburs- ing the attending physicians for their time. It would be a splendid move in social medical ad- justment (1) to curtail the unrestricted system of gratuitous relief, by excluding those not entitled to gratuitous medical advice; (2) to insist on pay- ment of the medical staff engaged both in clinic and out-patient work, and the payment of fees by patients in the pay ward and in the consultation departments of voluntary hospitals. If the doc- tor could be assured of, let us say, a minimal revenue from all the patients whom he takes care of, he could well afford to permit a reduction on some percentage of his work. But what is attempted, if one may judge from recent newspaper publica- tions, is to oblige the doctor to continue his free medical service and at the same time accept a reduction in his charges to patients whom he takes care of and who are occupying certain types of rooms which are essentially private hospital ac- commodations. Dr. Henry C. Barkhorn, President of the Essex County Medical Society, presided. He asked the support of the profession for the Society for Re- lief of Widows and Orphans of Medical Men, an or- ganization making an immediate payment to the members’ widows and supplying aid, on request, to any needy widow or orphan of a medical man. The following new members were elected: Drs. Gordon P. Goodfellow, Aaron H. Horland, Harry A. Lowenstein, Prank W. Senna, and Ernest Tut- schulte. An organization meeting of the county delegates to the state society followed, which lasted to a late hour. Prior to the meeting, Dr. Barkhorn entertained the delegates and alternates at dinner. Academy of Medicine of Northern New Jersey Eye, Ear, Nose and Throat Section E. LeRoy Wood, M.D.. Secretary ‘ The meeting of the Eye, Ear, Nose and Throat Section of the Academy of Medicine of Northern New Jersey held Monday evening, May 11, was planned to celebrate its organization 20 years pre- viously. The founder members and past officers were specially invited to attend. The Chairman, Dr. J. Wallace Hurff, presided. One of the original members, Dr. Charles W. Buvinger, read the minutes of the first meeting, enumerating and recalling the founders and giving a verbal sketch of each. I)r. Fred Weiner , the first secretary, recalled the early days of the society and traced its progress. Dr. Wells P. Eagleton, President-Elect of the Academy, made helpful recommendations for the conduct of the society during this coming year. He suggested that 2 of the 8 meetings, of the year be bedside clinical meetings, and that the meetings be held at different hospitals having instructive clinical material. This suggestion was favorably commented on and accepted for future consideration and action. Dr. Henry C. Barkhorn recommended that this section of the Academy engage in an organized teaching program for the benefit of its members, tie said: “We must realize that a new group of young men is growing up in our midst. A group of men who have taken post-graduate work, who are bet- ter prepared in just those things in which we are weak; a group with a ‘show me’ attitude, and we must meet our responsibilities. There are in- numerable opportunities for teaching. We are all a little weak in anatomy and to someone might well be assigned the task of summarizing each of the special fields for us. In pathology we are even weaker and still the literature is full of patho- logic findings ail'd descriptions. It might be well to have a subsection of just those who are really interested to meet once a month, either here or in successive homes, to sum- marize the preceding month’s literature and new books for criticism and discussion. I am sure I would be glad to join and do my part of the work. A cadaver could be procured and shown at a meeting to demonstrate operative procedures. The first night could be given to the more massive operations such as mastoids, simple radical and classical labyrinth, followed by Eagleton’s unlock- ing of the petrous tip, a cerebellar and subtem- poral decompression, a frontal and antrum, with some eye operations such as the Kronlein and an evisceration of the orbit. The next night, for a smaller group, could be devoted to intranasal 526 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 manipulations, lachrymal sac operations and sur- gery of the neck; and a final, third night, on pig eyes, to a still smaller group for cataract opera- tions, etc. I emphasize the smaller groups be- cause I am sure the crowd would dwindle down. The one thing that is really painful to the av- erage present day doctor, as to the lawyer, business man, and all modern Americans, is hard work, and 1 suggest these things with fear and trepidation because I feel that if in the future as in the past we are to continue to be leaders in ophthalmology, otology, rhinology and laryngology in this vicinity, our work is never finished and we must go on not only developing our own fields but enlarging them, correlating the advances in other fields to ours, making more surveys of the entire body, clarifying our information, appreciating our pathology, learn- ing to apply proper therapy and operative proced- ures, and crystallizing the facts. This group should be the clearing house for all these matters. It should sponsor courses such as those by Brunner and Spiegel. When Brunner gave his course the enlarged mailing list of this section was used for prospects. We should, how- ever, tell these teachers exactly what we want and not let them spin their work out interminably with a lot of padding. We need a didactic night on sinus thrombosis, one on the labyrinth, 1 on the cerebellum and 1 on the petrous tip, but only 1 on each of these subjects, and if properly condensed and tabulated they could easily be put across. We have been peculiarly fortunate in being the first-born of the sections of the Academy. We have carried on the traditions of the Academy with more success than most of the other sections. We have done more with and by our own men, it seems to me, than any of the other sections, and this is what the Council most desires. I know, for I have been on it for many years. We have been proudest of the accomplishments of our out- standing members and have made special efforts to give them ample opportunities for self-expres- sion and to bring to us that which they have learned. We have cemented old friendships and developed new and firm ones. This section has done much in letting us know others who have similar tastes in medicine and in fostering those friendships which are formed because of the strong personal interest of its members in the advancement of our specialty.” Dr. Erwin Reissman, the retiring President of the Academy, recommended that most of the sec- tion program be developed from local talent, from our own members. Dr. J. Wallace Hurff then installed the new Chairman, Dr. Charles W. Buvinger, and there followed a discussion of the future meetings. Dr. Elbert S. Sherman suggested the utilization of more clinical material, that better facilities be provided for the proper showing of patients, and that the cases be fully listed on the program. Dr. George J. Holmes suggested that an informal “dutch treat” dinner for all interested be held be- fore the meetings and that there be teaching courses. Dr. Dennis O'Connor suggested that the meet- ings begin earlier and on time. About 35 were present. The Academy of Medicine of Northern New Jersey Adrian Ralph Kristeller, D.D.S., Reporter On April 16, Dr. Julius Levy, Director of Child Hygiene of the State Department of Health, was the essayist of the evening at the Academy of Medicine of Northern New Jersey. He cited the reduction of infant mortality from 112 per 1000 in 1918 to 55 per 1000 in 1930, progress that was due to the advancement of child hygiene, which should not be confused with the medical care of sick children, but is mainly educational and pre- ventive in nature. A child hygiene bureau gives prenatal advice to expectant mothers by nurses, prenatal care and medical examination by physi- cians in private practice and in clinics, and proper obstetric care. The bureau further supervises in- fant care through Baby-Keep- Well Stations, where necessary. It advocates immunization of children of pre-school age against smallpox and diphtheria and advises proper diet to insure good teeth. Pre- vention of blindness at birth, proper care for ille- gitimate children and their mothers, and elimina- tion of baby farms is also the aim of child hy- giene. The bureau cooperates with other social agencies, and tries to improve sanitation and housing con- ditions. It discovers and properly cares for crip- ples and follows up cases of deformities. Two forms of death rate have not decreased in the last 10 years. One is the infant mortality rate for the first month of life, the other, maternal. Dr. Levy concluded by saying that numerous measures were still necessary to aid further de- velopment of child hygiene, namely, the more ef- fective control of respiratory disease, premature births and cerebral hemorrhage. Dr. Elmer G. Wherry said that Dr. Levy, with the late Dr. Henry L. Coit, did much of the pioneer work in child hygiene. Dr. Rathgeber, in turn, honored Dr. Wherry as pioneer also in that field. Dr. Edward T. Wharton discussed dental as- pects of child hygiene, particularly in relation to the improvement of diet for greater calcium de- posits and greater masculatory function. GLOUCESTER COUNTY Henry B. Diverty, M.D., Reporter The regular monthly meeting of the Gloucester County Medical Society was held May 21, at the Woodbury Country Club. The speaker of the even- ing was Dr. D. S. B. Pennock, of Philadelphia, whose subject was “Has Manipulation a Place in Medicine?” The following were present: Drs. I. W. Knight, C. I. Ulmer, R. K. Hollinshed, D. Campbell, H. B. Diverty, O. R. Wood, W. J. Burkett. E. E. Downs, B. A. Livengood, H. Nelson, H. M. Fooder, Church, Ristine, J. H. Underwood, F. G. Wandell, Corson, of Cumberland, and Kline, of Camden. The members of the Woman’s Auxiliary to the Gloucester County Medical Society were present at the reading of the paper by Prof. Pennock. A luncheon was served after the literary pro- gram. HUDSON COUNTY Harry J. Perlberg, M.D., Secretary The regular meeting of the Hudson County Medical Society was called to order at 9.30 p. m., the president, J. M. Cassidy, in the chair. The minutes of the previous meeting were accepted as printed in the Bulletin. The president reported the Executive Committee meeting of April 27 at the Carteret Club. Mr. Etiror), of the Druggists’ Association, spoke regarding the tradesmarking and renaming of well known U. S. P. preparations and formulas by June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 527 well known drug' houses, which are widely adver- tised to the physicians for them to prescribe under easily remembered names. The average intelli- gent citizen now reads all of his prescriptions and then re-prescribes for himself and his friends, the druggist dispensing over the counter. Mr. Feinbers, of the druggists’ committee, also spoke, giving the druggists’ angle on this mat- ter. There was considerable discussion. Dr. Alexander moved that a committee of 3 be appointed by the president to study and offer concise suggestions regarding the matter, and to confer with a similar committee to be appointed by the Druggists’ Association. Carried. Dr. Shapiro spoke regarding preschool examin- ations and said he was ready to cooperate with the society in determining the proper attitude toward them and the manner in which they should be handled. He said that the County Medical So- ciety recognized the value of preschool examin- ations but deemed it wise to refer such examina- tions to family physicians to prevent the over- burdening of school examination facilities. Dr. Maras made suggestions regarding the pro- gram for the May meeting, and also spoke ex- tensively on the matter of public relations. Dr. Waters moved that a sum, not more than $500, be appropriated to the Welfare Committee for use in advertising for the benefit of the Hud- son County Medical Society. A conference had been held with the Committee of Druggists in reference to the prescribing of various compounds by physicians. The following resolution had been presented by the Druggists’ Association : Whereas it is becoming a rapidly growing prac- tice among pharmaceutic manufacturers to com- pound various well known formulas' and introduce them to the medical profession under proprietary names, and Whereas such preparations contain ingredients of known and definite standards and which are commonly found on all drug store shelves, and Whereas the pharmacist is capable of making these compounds without any difficulty, and Whereas the introduction of these compounds under proprietary titles and in easily identified packages, design or colors, increases the tendency to self-medication, since usually these proprietary names are of such character as to be perfectly legible to the lay public, and Whereas the recommendation of these com- pounds through prescribing by the medical pro- fession is accepted by the public as an unqualified endorsement for the preparation, and Whereas the cost of these compounds are neces- sarily far in excess of normal, due to the fact that advertising, detailing and distributing costs must be absorbed, and thus necessarily bring the cost to the patient far in excess of the actual value of the preparation as compared with the cost of the same preparations when compounded by a pharmacist, Be It Therefore Resolved that the Hudson County Retail Druggists’ Association, in the in- terest of a closer cooperation with the physician, pharmacist and patient, deprecates the practice of prescribing, recommending and fostering the use of such compounds under a proprietary title. The following resolution was presented regard- ing preschool examinations: Preamble. The large number of children enter- ing the schools each year who have demonstrable physical defects, evidences the need of having all children of preschool age carefully examined, and sufficiently in advance of their entrance to school so that correctable defects may be treated and the child put in the best physical condition to get the most from his schooling with the least dam- age to his health. Dr. Haven Emerson recently, in an address before the American College of Physicians, stated that 65% of all children enter- ing school show some physical defect. The resultant loss of time and delayed educa- tional progress caused by illness due to neglect to correct physical defects amenable to treatment, is unfair to the child, and a great economic waste. Also the school days lost, to correct defects after entrance to school, which could have been treated a few months earlier with added advantage to the child, is an indefensible waste of valuable time. We believe the physician who has treated the child for the usual illnesses of early childhood is best qualified to make this complete examination and to advise treatment for defects found. We are desirous of cooperating with the school authorities, medical directors and inspectors of the schools of the county, in every reasonable way, in an endeavor to improve this situation. We feel, however, that it is not the function of school systems, through their medical inspectors, to ex- amine children who are not actually attending school, therefore, Resolved that the Hudson County Medical So- ciety recognizes the need for an increased inter- est and understanding on the part of parents, of the value of examination of children of preschool age, and wishes to cooperate with the various school authorities and established health agencies of the county in bringing to the attention of the public the necessity for these examinations. But, believing, for the reasons above set forth, that the examination of the child should be cared for by existing agencies, i.e., private physicians . and, in the case of those unable to pay, established clinics; and also convinced that it is not the legiti- mate function of the schools to engage in this medical activity, other than for proper publicity to show its need and value, therefore be it further Resolved that no members of this society, in their capacity as medical directors or inspectors of the school systems of the county, shall engage in the examination of children until they are ac- tually attendants of school, and be it further Resolved that the several Boards of Education of the county, and all members of this society, be apprised by letter, of the action of the society relative to this matter. It was regularly moved and seconded that this be adopted and the motion was carried. The Board of Censors reported favorably upon the following applicants: Nicholas M. Alter, and Lawrence V. Lindroth. Post-Graduate Committee, Dr. L. C. Lange, chairman, reported that 36 members had signed up for the course. Publicity Committee, consisting of Drs. Maras, Jaffin and Schwarz, rendered the following report: (1) To bring before the public any subject per- taining to Medical Science and the Practice of Medicine. (2) A program of education of the public with the sole purpose of enlightening the public on the results of scientific efforts in the prevention, con- trol and cure of disease. (3) A program to enlighten the public on the source of knowledge of medical science and upon the methods by which this knowledge is acquired. (4) Radio broadcasting by authorities in the various branches allied to medical science: Dr. Salmon, Chief of the Division of Health of Jersey 528 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1031 City; Dr. Brinkerhoff, Chief Medical Director of the Public Schools, (5) Lectures before the Chamber of Commerce, Service Clubs and other organizations of the laity. Lectures on medical topics by members of this society are offered to any organization or bodies of laity, other than the Civil Courts, which de- sire them, for the purpose of learning or for ex- pert medical opinion, not involved in the Civil Courts or other Bureaus of Litigation. Such lec- tures and expert opinions to be first submitted to the Executive Board, for censorship, before they are rendered to the ones seeking' same. (G) Lectures in Public Schools, Parochial Schools and High Schools on medical topics such as “Im- munization against Diphtheria, etc. We recommend to the authorities that such lectures be presented by the Medical Inspectors in their respective schools. (7) Showing of moving pictures on diphtheria, in the High Schools. (8) Distribution of pamphlets to school chil- dren, on diphtheria prevention. (9) Distribution of posters in windows of busi- ness stores and other places, of protection against diphtheria. (10) Printing and distributing to members dis- play cards “Endorsing Immunization Against Diphtheria”. Also printing and distributing record sheets, to be filed by the Local Board of Health of each community for permanent record. (11) Printing of Publicity Committee station- ery. (12) Conducting campaign of immunization against diphtheria, through the public press, news columns and paid advertising, “to make the pub- lic diphtheria minded”. (13) Meetings were held at numerous instances, by this committee, together with President Cas- sidy, to formulate a basis for future working plans in the great field open to the medical profession in this country, whereby a free practice of medi- cine may be obtained, unhampered by legislation propounded and foisted upon the profession by lay organization. (14) Communications were sent out to various societies, including the New York Academy of Medicine, the Academy of Medicine of Northern New Jersey and the American Medical Associa- tion, informing them of our intentions and re- questing their own experiences and ideas on the matter. At this time it is the extreme pleasure to report a communication from the Hon. Frank Hague, Mayor of Jersey City, through his office and medi- cal staff, on the campaign against diphtheria, with which he is heartily in accord. He also delegated Dr. Salmon, Chief of the Flealth Division, to repre- sent the interest of Jersey City in this campaign and suggested obtaining all the publicity possible for this campaign, and he will approve whatever is decided upon in the course of this program. (16) Joint meeting held of the Publicity Com- mittee and the Boards of Health of Hudson County. Discussion of health measures advocated in our State Legislature, activities of various groups at- tempting to gain control of and “harness medical profession”. Campaign against diphtheria, a health measure threatening us and forced upon us, and by execution of which we will prevent lay organizations from gaining access to the medi- cal profession and meddling with its affairs. The statistics on diphtheria having been investi- gated by Dr. Schwarz, of the Publicity Committee, who will represent same at May meeting of this society, it is shown that the percentage of positive Schick tests before immunization of the large numbers during such campaigns is so small that it does not warrant its execution at such times: and New York City, as well as other large communities of the country, has deferred Schick testing to a period 4 to 6 months after in- oculation. It was also shown that toxin-antitoxin is preferred to toxoid. (17) Attended meeting of Executive Board and discussed abuses by Medical Inspectors of Public Schools in their examination of preschool children in the Public Schools of Union City, without due compensation, thereby initiating the first step of “state medicine”. Publicity Committee was instructed by the Executive Board to conduct the campaign against diphtheria at its own discretion and authorized the Publicity Committee to call upon the members of this society for assistance in writing articles for the public pres>s, and same to be entered as “sponsored by the Hudson County Medical So- ciety”. The Schick test to be stressed at the time of inoculation and arrangements made by physicians to make such test 6 months after inoculation. Advertise the campaign in the public press. Report May meeting of the Hudson County Medical Society to the press, instead of inviting members of the press to attend that meeting. Publish the list of members of the Hudson County Medical Society in the public press. Appropriation of $500 was made to be used by the Publicity Committee in its present activities. (18) On April 29 attended the Councilor Dis- trict Meeting at Hackensack. For delegates to the State Convention, from Hudson. Passaic, Sussex and Bergen Counties. (19) Held Joint Meeting of the Boards of Health of the various commuties of Hudson County and the Publicity Committee, to make final arrangements for the campaign of immunization against diphtheria. There has been no representative nor communi- cation received in answer to (requests to join this campaign from the following communities: West New lrork, East Newark, Harrison, Secaucus and Guttenberg. The campaign is being conducted in Union City, which is partly administering to 7 communities: Weehawken. Kearny, North Bergen, Hoboken. Bayonne campaign is postponed to May 12, after election. The following letter from Mayor Hague to the Publicity Committee was read: “The campaign to immunize against diphtheria which your society is about to inaugurate in Hudson County, and par- ticularly in Jersey City, has my hearty approval and endorsement. A similar campaign carried on by our health department about 2 years ago achieved very satisfactory results, although it was the first one attempted here and it is only fair to suppose that with your carefully organized program and the experience we had in the former campaign, that your efforts will be more completely effective, and productive of more complete and informing results. June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 529 Every city department concerned will g-ladlv co- operate with your body in making the movement successful. The Health Bureau will furnish the necessary serum free to physicians, and the Board of Education will aid you in any reasonable way in the school part of the work. The city physi- cians and nurses in the public and parochial school will also do their part cheerfully. Wishing you every success in the campaign, I am, Very truly yours, Frank Hague, Mayor. The following nominations were made from the floor for members of the Nominating Committee to serve in 1932, and all were elected: Drs. Poliak, Cosgrove, Klaus, Maras, Chapman, Alexander, M. Shapiro, B. T. D. Schwarz, Binder and Jaffin. Dr. B. Maras nominated Dr. B. T. D. Schwarz and Dr. Leonard Fauqier as members of the Pub- lication Committee, and they were duly elected. Drs. Nicholas M. Alter, 85 Van Reypen Street, Jersey City, and Lawrence V. Lindroth, 4633 Hud- son Boulevard, North Bergen, were declared elect- ed to membership. The president announced that there would be a meeting of Delegates and Alternates to the State Society on Monday, May 25, at 9 p. m., at the Carteret Club. Dr. J. B. Morrison, the State Society Secretary, made a few brief remarks. He stated, among other things, that the Welfare Committee of the State Society had been extremely energetic; that no Bill inimical to the profession had passed the legislature this year. He spoke in reference to the Post-Graduate Courses and stated that he expected next year to have money appropriated so that the courses would be given all over the state for a nominal fee of $10. In reference to the bill concerning the discus- sion of specialties, he felt that this matter should be kept out of politics and within the State So- ciety, that they should be empowered to certify to the qualifications of various specialists. He advised the Publicity Committee to get in touch with the Parent-Teacher Associations and get a list of children who are going to enter schools. He asked that the report of the publicity committee submitted at this time be sent to him and a condensed report to the secretary of each county society. The president appointed the following committee to confer with druggists: Drs. Alexander, Chair- man; J. Koppel, and S. G. Scott. Dr. Joseph Schapiro moved that a committee be appointed to confer with the Medical Directors of schools of the various municipalities of Hud- son County, so that some concrete action could be formulated in accordance with the resolution adopted at this meeting. The secretary moved that he be authorized to print and distribute the new constitutions to the members of the county society; carried. Dr. Alexander moved that the recommendation of the Executive Committee appropriating $500 for the Publicity Commmittee be approved by the society. The motion was seconded and carried. The president asked that every man keep a record of the children he immunizes so that the names can be sent to the Chairman of the Pub- licity Committee, or the county society secretary. Papers of the Evening Dr. A. E Jaffin read a paper on “The Role of the Practicing Physician in Public Health Af- fairs’’. As good citizens and by virtue of pro- fessional training, we are especially qualified to give advice in public health affairs. It' is the duty of every physician to thoroughly enlighten the public regarding false cures, quacks, cults, etc. The public interest should be stimulated in good medicine as it always has been in travel, history, music or other sciencies. They should be made familiar with the methods of prevention of con- tagious diseases so that in civil life typhoid and small-pox can be eliminated as thoroughly as has been done in the army. The same, of course, now holds true of diphtheria. With regard to the periodic health examination, while it may not be wise to stress it too much, for fear of criticism directed toward the financial ad- vantage of the same to the physician, nevertheless the importance and value of such examinations should always be emphasized and the plan en- couraged by every physician. Too often the doc- tor is disinclined to make this examination just because the applicant does not happen to be ill. The early diagnosis of tuberculosis may prop- erly be considered in this connection. The physi- cian’s duty is not ended with the diagnosis of an individual case until all the other individuals ex- posed to this patient have also been properly and carefully checked. It is much to be regretted that many physicians, after making the diagnosis of tuberculosis, still send the patient off on his own to lead an undisciplined life for a longer or shorter time, permitting the patient to lose the benefit of proper methods of curing. The practice of teaching rational living rather than seeking remedies for the effects of irrational living cannot be too strongly emphasized. Every doctor would then make of himself a health officer in private as well as in public practice. He will at the same time help maintain the fundamental in- timate relationship that should exist between doc- tor and patient. A faithful adherence to these duties will, more than anything else, eliminate the gradually increasing economic problem facing the general practitioner. Altogether these efforts will constitute good medicine, good practice, and good public service. Other papers presented were: Symposium — “Tuberculosis in Children”: (1) “History, Symp- toms, Pathology” by Dr. Walter Gonzales, Ho- boken. (2) “X-ray Diagnosis and Interpretation”, by Dr. Benjamin Joseph. (3) “Tuberculin-Reac- tion; Technic and Interpretation”, by Dr. Harold Tidwell. (4) “Treatment and Prognosis”, by Dr. Edward Lupin. Short History of Diphtheria Eradication Berthold T. D. Schwarz, M. D., Member Publicity Committee Hudson County Medical Society, Jersey City Diphtheria, . the scourge of childhood, is fast dis- appearing. Near the close of the last century, there were more than 150 deaths from diphtheria per 100,000 population. In 1930 the rate has drop- ped to less than 4 per 100,000, truly a remarkable reflection on the efforts of preventive medicine. The death rate from diphtheria in the nation, in the brief space of 3 years, has been practically cut in half. The death rate has been reduced more 030 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 than 1/3 in 1930 over that of 1929. Since 1911 it has diminished more than 80%. Diphtheria is a very old disease. Writings of it can be found in the Babylonian Talmud. Aretaeus described the disease in the first century. Diph- theria swept over the civilized world, in the form of great throat pestilences in the middle ages, particularly in Spain, and continues throughout all countries to the present day. While diphtheria usually attacks those under 6 years of age, it has also caused death to men famous in world history. Diphtheria caused the death of George Washington. It is highly infective and is transmitted from one person to another. The boy King of Roumania is reported as having the disease and his mother, Princess Helene, is reported to have contracted the disease while nursing her royal son. Until the cause of diphtheria was discovered by Klebs, in 1883-, and isolated 1 year later by Loef- fler, the medical profession was very seriously handicapped in fighting this deadly disease. Ig- norance is deadly. The early attempts to control diphtheria were directed toward the isolation of those affected by the disease and disease carriers. Because of its marked prevalence in those days, it was rather heart-breaking on the part of Boards of Health in the last century to cope with this problem of diphtheria prevention. Cultures were taken of the nose and throat of suspected indi- viduals but since there were also many individuals who were not sick, yet carried the germ and in- cidentally transmitted it to others who were sus- ceptible, the efforts directed toward its control seemed to be all in vain. It was apparent that in order to successfully control the disease at that time, it would be necessary to isolate almost the entire population; an impractical solution. Fortunately, not long after, the toxin evolved by the diphtheria germ was discovered, especially by the works of Roux and Yersin. The dis- covery of the poisonous element of this disease led to further research. Von Behring found the means by which the poisonous substance could be neu- tralized. This serum was called “antitoxin”. How efficacious diphtheria antitoxin is in the treatment of diphtheria, and the immunization of those al- ready exposed to the disease, is graphically indi- cated in the remarkable decline of about 82% in the death rate. It does not take much to visualize the very great saving in lives, or the amount of anguish and financial loss, which illness or death causes. The use of antitoxin has resulted in the saving of about 10,000 lives each year! Little won- der that infant and childhood mortality has di- minished. Although many would say that the advance of diphtheria prevention has reached its highest peak with the use of antitoxin, it is characteristic of men of science to ever probe deeper for more ef- fective control of disease. The incidence of diph- theria, despite antitoxin, was still too great. Well over 15,000 children still died of this disease yearly in the United States. To alert minds it demon- strated the fact that a surer preventive must be found before this dreadful disease could be con- quered. The serum which specifically combats the poison of diphtheria is mostly obtained from horses, which are inoculated with the diphtheria toxin. When toxin is administered in sublethal amounts it evokes a reaction on the part of the horse to neutralize it. So provident is nature in elaborat- ing a defense that its neutralization efforts result in a considerable excess of antitoxin which may be separated from the horse serum and purified for use in treating diphtheria. It was found that when mixtures of diphtheria toxin with antitoxin were administered, the horse did not become as sick, and still produced a very fine antitoxin. Dr. Theobald Smith suggested that this method of mild reaction, using diphtheria toxin-antitoxin in horses, be used in immunizing human beings against diphtheria. Dr. Schick, in 1913, found that by injecting a very minute amount of the toxin-antitoxin into a superficial layer of the skin it could be deter- mined whether or not the person tested was im- mune or susceptible to diphtheria. It was sub- sequently found that individuals of different ages had a varying susceptibility to diphtheria. Dr. Park and his associates in testing thousands of individuals with the Schick Test determined that the susceptibility at different ages ranged as fol- lows: Agf. Susceptibility LTnder 3 months 15% 3 months to 6 months 30% 6 months to 1 year 50% 1 year to 2 years 00% 2 years to 3 years 60% 3 years to 5 years 60% 5 years to 10 years 30% 10 years to 20' years 20% Over 20 years .. 15% It is easily seen that the largest incidence of the disease and death occurs between the ages of 3 and 5 years, the preschool age. Diphtheria can be successfully controlled only by the administration of toxin-antitoxin or toxoid because individuals transmit the infection to others frequently without realizing that they are subjects of diphtheria. It may manifest itself merely as a slight nasal catarrh, mild tonsillitis, or running ear, or it may be transmitted by diph- theria bacillus carriers. Long after recovery from diphtheria the germs may linger in the throat. As a rule, a person is considered free from diph- theria if he shows 4 successive negative throat cultures. Most cases are not infectious after a period of about 5 weeks. In some, however, the infection exists for several months. The diphtheria toxin cripples the heart and damages the nervous sys- tem. Antitoxin neutralizes the toxin and prevents damage. Besides being curative, when used, it gives a temporary immunity of about 6 weeks’ duration. This immunity conferred by antitoxin is called passive. When toxin-antitoxin is given it creates an active .immunity; that is, the individual elaborates his own antitoxin. So far as is known, the duration of this active immunity is lifetime. Diphtheria immunization by toxin-antitoxin be- gan to be employed on a large scale after 1920. In 1920 over 15,000 school children died of diphtheria! In 1930, thanks to the effects of toxin-antitoxin administration, the number of children in the United States who died is well below 5000. Since this is the occasion of inauguration of a “diphtheria eradication campaign”, conducted by the Hudson County Medical Society, we can scan with interest the United States Public Health Service reports for the year 1929, the last avail- able year, which shows the incidence of diphtheria June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 531 in the various communities of Hudson County, to be as follows: Jersey City, 537 cases; Bayonne, 168; Harrison, 18: Hoboken, 57; Kearny, 10; Union City, 51; West New York, 43. Data for the other communities is not available at this time, but it is certain that the reported incidence of diphtheria in Hudson County for the year 1929 indicated well over 1000 cases. The entire state of New Jersey reported 5361 cases. The death rate of diphtheria in Hudson County was approxi- mately 10% of the cases reported. The presence of diphtheria in any community is an insult to the intelligence of that community. While there are numerous cities that have amply demonstrated the efficacy of diphtheria cam- paigns in the past, it may suffice to know the findings of an investigation conducted by the Metropolitan Life Insurance Company, which found that during the years 1926 to 1929, where campaigns were instituted against diphtheria in 53 cities, the diphtheria mortality diminished 33%. In 31 cities where no campaigns were made, there was a 9% increase in diphtheria. A classic ex- ample of what diphtheria immunization can do is illustrated in the town of Auburn, N. Y. In the year 1922, toxin-antitoxin was administered to 58% of the school children and in that year no case of authentic diphtheria developed in that group. Among the 42% that were not immunized, there were 80 cases of diphtheria reported and 13 deaths occurred. In 1923, 73% of the school children were immunized, and no authentic cases of diphtheria were reported, while among the 27% not im- munized there were 15 cases of diphtheria reported and 1 death. In 1924, 85% of the school popula- tion was immunized and among these children, no ■case of diphtheria occurred; among the 15% not yet immunized, there occurred 3 cases among the ■school children and 3 cases in the preschool age. In the year 1925 no case of diphtheria was re- ported. In the years prior to immunization there was an average of 104 cases of diphtheria and 14 deaths occurring therefrom, reported yearly. This is also the story of San Joaquin, California, and Grand Rapids, Michigan, and other cities. For every day of the year 1930 there were 22 people who died from diphtheria. Surely with means at disposal of the medical profession, and with the aid of an aroused, in- telligent public, diphtheria can be vanquished. Clinical Society of North Hudson Hospital J. Africano, M.D., Reporter The regular monthly meeting of the Clinical So- ciety was held Tuesday, May 12, with Dr. B. Koop- erman acting as Chairman, and 55 members and guests present. Dr. Tannert read the hospital report for April: 224 admissions, 227 discharges; 20 deaths, of which 7 were medical, 6 surgical and 4 new-born. Dr. W. Braunstein briefly discussed the 7 au- topsies (35% of the deaths) performed during the month. Case Reports Dr. E. Bailyn. “Empyema and Generalized Tuber- culosis in Infant of 7 Months.” J. P., white in- fant, 7 months old, admitted on February 20, with history of chronic productive cough, dyspnea, cyanosis and generalized eczematous rash over face and body. No evidence of tuberculosis in family. The infant was a full-term baby, normal delivery and bottle-fed, developing normally until 4 months old, when a cough started and gradually became productive and spasmodic in character; so severe at times as to cause cyanosis. There was no history of convulsions or vomiting and no fever was observed. In that same period a scaly rash 1 appear- ed about the head and face; also a mass in the upper right femoral region. Examination of chest revealed decreased expansion of the left side, which was flat on percussion, with markedly diminished voice and breath sounds. Abdomen negative. In the right femoral region a large gland, the size of a walnut, could be felt. Diagnosis of left-sided empyema was verified by a roentgenogram. Thor- acotomy was done and about 4 oz. purulent material was evacuated, which on culture proved to be full of pneumococci. There followed a very stormy, postoperative course. In spite of good drainage, there were remissions and exacerbations and prac- tically no improvement in the spasmodic cough, which now became very brassy and could be heard all over the ward. The temperature be- came septic in type and the child expired on March 12'. Autopsy findings: (1) A cluster of very much enlarged nodes, partially overlapping and sur- rounding the pericardium, trachea and bronchi, which on section presented areas of caseation. (2) The pleural cavity contained a moderate amount of fibrinopurulent exudate, and lungs were diffusely infiltrated with small whitish nodules. (3) Ab- domen contained no excess of fluid. Liver was of normal size, but greatly congested, and spleen had a few scattered, minute, whitish spots sug- gestive of tuberculosis. The important points in this case are (1) its comparative rareness in children under 1 yr. old; (2) the complication of empyema following the original pneumonia which activated the latent t.b. focus in the glands; (3) the characteristic chronic cough which sounded very much like a whooping- cough of 3 months’ duration, and corfld be ex- plained as a stridor caused by pressure of the en- larged tracheobronchial glands; (4) the extremely poor prognosis in generalized tuberculosis in young infants. Dr. Stein. “Meningococcus Meningitis Treated by Cisternal Puncture.” M. S„ white, male infant, aged 5 V2 months, admitted on April 16, with history of vomiting, fever and anorexia for 2 days. Anterior fontanelle bulging; eyes staring; pupils equal and reacting normally; neck showed marked rigidity; knee-jerks exaggerated; Babinski positive; Ker- nig’s sign present; temp. 103°; pulse 156, respira- tions 28. Spinal tap yielded about 7 c.c. turbid fluid under slight pressure. Cell count 21,300. Smear and culture positive for meningococci. Blood count: R. B. C., 3,284,000; Hb., 65%; W. B. C„ 8100: polys, 42%. On April 17, spinal tap yielded only 1 c.c. turbid fluid, but cisternal puncture brought 25 c.c. turbid fluid under high pressure. During the following 3 weeks cisternal puncture was performed about 20 times; on 7 occasions, antimeningococcic serum was given by the cisternal route. After the first week there was definite improvement, but then the child had projectile vomiting, became stupor- ous, finally comatose, and died on May 12. The spinal canal was blocked practically through- out the entire course of the disease; at times dur- ing the later stages of the disease there was also blocking of the cistern. There was no very mark- JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1031 532 ed benefit that could be attributed to the serum. Apparently, there was much more relief obtained by drainage through cisternal puncture. The pathology in this case was probably exten- sive, involving the base of the brain. Judging from the block in the spinal canal and the xantho- chromic nature of the cerebrospinal fluid, there was hemorrhage and an extensive plastic exudate involving the base of the brain and spinal canal. Probably there was no block in the ventricles, be- cause the bulging fontanelle would always become soft after cisternal drainage. The pathologic state of the subarachnoid space at the base of the brain prevented absorption of the cerebrospinal fluid and caused increased intracranial pressure, as was evident by the bulging tense fontanelle which had to be relieved by frequent cisternal puncture. Dr. Luippold. “Hypertrophic Cirrhosis of the Liver.” The following 2 cases occurring in our wards in rapid sequence will serve to illustrate how difficult it is at times to make diagnosis of liver disease. A R., male, aged 67. was admitted March 3, complaining of weakness, fatigue, short- ness of breath and nervousness. Previous history: typhoid at 27; “rheumatism” 10 yr. ago; drank beer moderately for many years, occasionally a little whiskey. About 1 month ago had, according to his description, a definite attack of grippe. Since then, he had felt weak, with a decided dyspnea upon exertion; so much that it was diffi- cult to climb even a flight of stairs. He also noticed a marked nervousness, and at times a marked tremor all over the body. Excessive sweating upon the slightest mental or physical strain was another feature. Physical examination: Well developed and well nourished, with sallow complexion, and depressed, anxious facies; coarse tremors of both hands; sclera slightly icteric; tongue coated, also with coarse tremor; teeth in poor condition; heart sounds weak but of regular rhythm, with sys- tolic murmus at apex. The liver margin was palp- able below level of umbilicus and could be made out extending away over and under left costal margin, with a smooth surface throughout, only slight tenderness upon deep palpation, and no pulsations perceptible. The spleen appeared mod- erately enlarged. No evidence of ascites, nor edema of extremities; abdomen moderately tym- panitic. Blood count showed a mild secondary anemia. Wassermann and blood chemistry negative. Icteric indices from 34-50. Stool on gross ap- pearance fairly normal, but biochemically strongly positive for blood. Van den Bergh test gave im- mediate direct reaction. Urinalyses negative. About March 19 the presence of fluid in the ab- domen became evident, and an icteric tint to the skin and conjunctiva more apparent. Patient more somnolent. Paracentesis abdominalis was per- formed March 29, when only a few ounces of fluid were obtainable, but oh April 4, 52 oz. were re- moved. After this he seemed a bit better for a day or two, but then gradually lapsed into an irrational, stuporous, involuntary state and finally into coma; coincident with this he developed a hypostatic pneumonia and died April 12. While at first liver congestion secondary to a heart lesion was suspected, it soon became ap- parent, especially after the ascites developed, that the condition was more probably a portal cir- rhosis, but a diagnosis of malignancy could never be entirely ruled out. Autopsy revealed an enormously enlarged liver occupying the greater part of the abdominal cavity; weight estimated at 10 lb. There were very strong bands of surrounding adhesions. The organ was brownish-green in color and uniformly granular, with smooth surface, firm consistency and cutting with resistance. Section showed a diffuse fibrosis with bands of connective tissue running through and about the bile-ducts, and polygonal cells dis- torted and degenerated, i.e., as in a typical portal cirrhosis. The lungs showed a congestive and terminal pneumonia; the aorta an atheroma; spleen was moderately enlarged from congestion and fibrosis; and the kidneys showed parenchy- matous degeneration. C. L., male, aged 75, entered the hospital April 10, complaining of chills, fever and a jaundice for the past 2 or 3 weeks, with dizziness, anorexia, vomiting and constipation. Typhoid at 25; mod- erate beer drinker throughout his entire adult life. Apparently in continuous good health until 3 weeks ago when, while at work as a watchman, he was suddenly seized with chills and fever. The fever continued but at times seemed more pro- nounced, and the chills also recurred at irregular intervals. During the first 2 days had marked at- tacks of vomiting. Jaundice was first noticeable 2 weeks ago and this gradually increased. Skin and sclera markedly jaundiced. Drowsiness was very pronounced, but he could be aroused with little difficulty and gave evidence of an average intellect and memory. Teeth very bad and tongue heavily coated. Heart sounds regular; brady- cardia; poor quality. Liver very much enlarged and extended to 4 finger breadths below the costal margin. Blood count: Hb., 69%; R. B. C., 3,550,- 000: W. B. C., 19,000: polys., 78%; lymphs, 22%; coagulation 1-3% min. Urine showed small amount of indican, much bile and urobilogen in dilutions to 1:200; feces chalky and negative for blood. The somnolence became steadily deeper and the jaundice more intense. The fever which had fluctuated from 100-103° from the third to the ninth day, gradually subsided to normal as the patient slid into practically a coma the last 3 days before he died on April 26. Comments: The acute onset of symptoms made the diagnosis of an acute hepatic infection prob- able. The larger liver was believed to be a latent cirrhosis, which, suddenly activated by this com- plicating, acute infection, disturbed the hepatic compensation and rapid degenerative changes set in even before marked ascites or hemorrhages could have occurred. The jaundice was believed to have been of toxic origin and also obstructive, by occluded, swollen biliary ducts. On the other hand, the advanced age of the patient, the enlarged liver that had even the suggestion of masses in its contour (to some of us), and the jaundice, re- membering that it has been repeatedly demon- strated that the jaundice of rrtalignant disease may be ushered in by an accompanying acute gastro- intestinal upset, all made the diagnosis of malig- nancy likely. Autopsy disclosed a very large liver weighing about 10 lb. Color was dark greenish-brown; sur- face, smooth; cut surface, granular with exudation of greenish material; bile-ducts, markedly dilated: gall-bladder distended and filled with a watery fluid (hydrops). Microscopic section of liver showed a fibrosis about the bile-ducts, with edema and dense collections of polys, thus featuring an acute, suppurative cholangeitis with congestion, and an early biliary cirrhosis, probably secondary. Spleen was slightly enlarged and congested: the kidneys were polycystic with amyloid degenera- tion ; and the pancreas showed fibrosis and conges- tion. Dr. 8. Braunstein. “Perinephritic Abscess.” A woman, aged 48, admitted April 5. with complaint of pain in the left hypochondrium and weakness. June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 533 Typhoid at age of 2; hemorrhoidectomy at 16; all teeth were extracted at age of 29. Has always been constipated and troubled with gas. Had a cough about 4 weeks ago lasting 10 days; no ex- pectoration. Has lost 29 lb. No urinary symptoms. Onset dates back to January, when she had chills and fever; she believed grippe. Following this, she developed an otitis media which ruptured and discharged for several days. A few weeks later she had a nonproductive cough lasting 10 days, so severe that it left her with a terrific pain in the left abdomen; pain not controllable with opiates. On April 1 the patient was seen at home; she showed evidence of marked weight loss but ex- amination was negative except for the abdomen, which was soft; no rigidity, but there was marked tenderness in the left upper and lower quadrants and a large mass could be felt, hard and extending from the xiphoid process to the left anterior iliac spine. Urine showed a trace of sugar and no albumin. Medical consultation was held 2 days later and it was decided that the mass was a large spleen due to infection, splenomegally or throm- bosis in the splenic vein. In the hospital, blood showed: Hb., 68%; R. B. C., 4,100,000; W. B. C., 12,000; polys., 80%; lymphs., 20%. Urine: 0.5% sugar, acetone and dia- cetic acid. Temperature ranging from 100-103°. The patient then felt better, temperature dropped, and the mass became smaller; but 11 days after admis- sion the temperature rose again and she complain- ed pf severe pain in the region of the left kidney. Examination showed a large fluctuating mass in region of the left kidney. Dr. Klaus examined her on the next day and felt sure that we were dealing with a perinephritic abscess. She was operated upon that same afternoon and a large quantity of foul smelling pus was evacuated through an incision over the left kidney region. Following operation, the temperature dropped; she was free from pain and the mass in the left abdomen began to disappear. She was discharged May 2, and with a diabetic diet and liver extract is making a rapid recovery. Dr. Klaus believed this to have been a primary perinephritic abscess, in contradistinction to one secondary to renal infection ; he cautioned against depending upon the urinary findings to assist in making the diagnosis; tenderness is the best sign of deep-seated infection, as shown by the follow- ing case which is similar to the one presented: a boy who suffered with a “cold”, and extreme tenderness in one of the loins — no abscess could be palpated, as it was walled-off — there were no signs in the urine, yet on operation a profuse amount of pus had formed around the kidney, and the patient was cured. Dr. Lange suggested use of x-rays to diagnose spleen from kidney, after injection of the rectum with air; also, the feel of the spleen is softer and more pliable than the kidney. Dr. Luippold called attention to the low white and low poly counts; with such a large amount of pus under pressure a higher count would have been expected. Dr. D’Acierno suggested cystoscopy, and the P. S. P. test as an aid in arriving at diagnosis. Dr. Pearlstein summarized the sequence of events as: ear abscess; hematogenous infection; renal (cortex) infection, which healed and broke into the capsule; then generalized infection, which accounted for the splenitis; finally, infection of the perinephritic space. Dr. Hekimian described the relations of a peri- nephritic abscess: there are 2 layers of fascia en- veloping the kidney, one adherent to the organ and the other paranephritic, between which there is a large amount of fat having its own inde- pendent renal vessel; thus is explainable how a carbuncle, or an otitis, tonsillitis, etc., will lead to a perinephritic abscess without involvement of the kidney itself; also via the lymphatics, this abscess may be consequent to adnexal disease, or to chronic recurrent appendix. In diagnosing by means of x-rays one should look for deviation of the border of the psoas muscle of the affected side. Dr. Bender. “Acute Osteomeylitis of Femur in Infant.” R. R., aged 7 months, white, born in this hospital, instrumental delivery. Patient was ad- mitted March 23 with diagnosis of osteomyelitis of the left femur. Breast fed for 2 months, then bottle fed. Bronchitis at 2 months. Pertussis at 4, which was cured within a month under vaccine therapy. Present illness began March 4, with fever, vomit- ing, constipation, cough and sweats. Signs of consolidation over the right lower lobe, with dul- ness, bronchial breathing and fine crepitant rales. Next day the signs on the right side increased, and the pneumonic process spread to the left lower- lobe. The following day the process had involved the greater part of both lungs. Temperature at on- set 103°, ranged between 104-105° until March 8, when it dropped within a period of 3 hr. to sub- normal, and the infant collapsed. Rallied under adrenalin and camphor stimulation. After 2 days of normal temperature, it rose to 101° and examination showed rales over the entire chest. The ears showed bilateral myringitis, which on puncture discharged profusely. March 18 it was noticed that the baby assumed a peculiar attitude; left leg drawn up and slightly abducted. On motion the child would cry pitifully. Radio- gram of the hip confirmed the suspicion of os- teomyelitis and showed destruction of the upper part of the femur shaft. Chest picture at the same time showed fibrosis and effusion in the lower right chest and extensive pneumonia of the left lung. Under regional anesthesia, an incision about 3 in. long was made over the left trochanter; hip joint exposed, opened and a large amount of thick pus was aspirated; no loose or roughened bone. Owing to the poor condition of the patient, no other pro- cedure was taken and the wound was packed with 3 gauze drains and a rubber tube inserted. After the operation the temperature began to rise rap- idly and reached 107.6° at 7 p. m„ when the pa- tient died. Exploratory puncture before the op- eration failed to obtain any pus from the pleural cavity. Culture of the pus from the femur re- vealed the pneumococcus. Dr. Klaus. “Jejunal Ulcer Following Pylorectomy for Duodenal Ulcer.” G. D., male, aged 29, admit- ted April 1 with a postoperative jejunal ulcer. One year previously, he had been operated upon for a large penetrating ulcer of the first portion of the duodenum of 5 years’ duration. A pylorectomy was done, which included both the ulcer and acid- bearing area of the stom'ach ; the resection was completed by a posterior Polya anastomosis; ap- pendix also removed. The patient made an un- eventful and rapid recovery and 2 weeks after operation was discharged as cured. Upon dis- charge he was entirely free of symptoms, but was advised to remain on a special selected diet. He was readmitted 6 months later with history of having been perfectly well for months, when he began to have cramp-like pains in the upper abdomen, and particularly in the vicinity of the old operative scar. At no time was there any 534 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 vomiting. The pains began shortly after eating and continued for 1-2 hr. Gastric analysis showed total acidity of 85; free HC1 40; combined 56; no blood. X-ray examination showed nothing con- clusive. A diagnosis of postoperative marginal ulcer was made, and after 5 days of rest and diet he requested to be discharged, feeling greatly im- proved and practically free from abdominal pain. He was back to the hospital in 5 months with history that he had remained free of pain for 3 weeks after his last discharge but that the pains returned much more severe, and have become practically constant. Food has no relation to the pain, nor does it relieve it; never any vomiting. A diagnosis of marginal ulcer was made by the Medical Service. The usual ulcer treatment was thoroughly tried for 2 % weeks with no improve- ment, and an exploratory laparotomy was done. A large indurated ulcer 1x1% in. was found in the jejunum on the spur between the 2 loops of jejunum as they joined the anastomosis with the stomach, the ulcer being situated directly opposite the stoma. It seems fair to assume that the ulcer formed at this point by the direct flow of gastric contents pouring out into the jejunum. There was much induration in the mesentery immediately beneath the ulcer. The old anastomosis was taken down, and the ulcer, together with about 5 in. of jejunum and a portion of the stomach, were re- sected. A new anastomosis was then constructed by suturing the stomach to the distal loop of jejunum by end-to-end suture and then suturing the proximal, or short loop of the jejunum end-to- side anastomosis to the jejunum below the new stoma, this procedure constituting a Y-shaped method on the Roux principle. He was discharged again, free of any gastric symptoms, about 2 % weeks after operation. This case was presented because the complica- tion of postoperative jejunal ulcer is frequently seen following any operation for the cure of gas- tric or duodenal ulcer. It is most commonly seen following the simple gastro-enterostomy. Pylorec- tomy, with excision of the acid-bearing area of the stomach, has been in recent years especially advocated to prevent just such a complication. Many surgeons claim that jejunal ulcers will not occur after this procedure, but that such is not the case has been proved by numerous other such cases in the literature. I)r. Klaus. “Benign Pancreatic Tumor Compli- cated by Subacute Pancreatitis.” G. S., female, aged 26, married, admitted to the Surgical Service April 3, with a sudden, severe abdominal pain of 24 hr. duration. The pain was intense and local- ized to the epigastrium and right upper quadrant; of a continuous character with radiation to the back, as in gall-bladder disease. Vomiting had been continuous since the onset and bowels had moved effectually only with enemas. During the past 3 years patient had at least 5 similar attacks, but of less severity. She was operated upon 2 V> years previously for what appeared at that time a gall- bladder disease, but she was told that a tumor was found under the liver and that the gall-bladder was not removed. She does not know what the surgeon did at the time, but following the operation she remained fairly well for several months. We were unable to get any information from the hos- pital where that operation had been done. Temp., on admission, 101°; pulse, 88; W. B. C., 17,800; polys., 94%. Abdomen showed an old scar in the right upper quadrant, slight distention, consider- able tenderness and rigidity over the entire epi- gastrium and right upper quadrant. No masses could be felt. The urine showed a slight amount of albumin and 0.2% sugar, which is of much significance in light of the operative findings later. From the history and physical findings a diag- nosis of acute cholecystitis was made, and partial intestinal obstruction was seriously considered, as well as a perforated duodenal ulcer, yet there was sufficient evidence to rule both these out. Acute pancreatitis was not considered. A considerable amount of slightly blood-stained fluid was found throughout the abdominal cavity; entire upper abdomen was a mass of extensive ad- hesions to the old scar and the loops of intestines; gall-bladder was completely obscured by the ad- herent bowel; stomach likewise adherent to sur- rounding viscera. After separating all these ad- hesions, the gall-bladder was found slightly thickened but otherwise normal; it contained no stones; fat necrosis of the omentum in the upper abdomen was noted. After separation of the ex- tensive adhesions, it was found that at the pre- vious operation an anterior gastro-enterostomy had been done. After further investigation, a large, hard, nodular mass, the size of an orange, was found in the region of the head of the pancreas. It is fair to assume from the history that this tumor was found at the first operation 2% yrs. ago, but why the gastro-enterostomy was done is hard to explain unless it was thought that the tumor was causing an obstruction to the stomach, cr possibly might do so later. The long duration of the pathology certainly excluded any malignancy and it seems reasonable to assume that one is dealing here with a benign tumor of the pancreas that has not grown rapidly, or more likely a chronic pancreatitis with a superimposed acute attack of pancreatitis as definitely shown by the blood-stained abdominal fluid, fat necrosis, and the symptoms of severe abdominal pain, vomiting, temperature and leukocytosis. Her past attacks of abdominal pain were no doubt due to attacks of pancreatitis. The urine before operation showed sugar and this continued for 1 week following operation and then cleared up without any special treatment, which shows we were dealing with a pancreatic disturbance and that should have been considered more carefully before operation in localizing the lesion to the pancreas. A cholecystostomy was done for the puropse of draining not only the biliary ducts and liver but likewise the infectious process of the pancreas. The patient has made an uneventful convalescence and has been discharged free of any symptoms and in excellent condition after 4 weeks of drain- age. The case is presented as a most unusual one of subacute pancreatitis in the presence of a large mass in the pancreas which is either a benign tumor or a chronic pancreatitis, in which the dif- ferentiation at the time of operation could not be made, but which most likely, from the history and long duration, is a chronic infection of the pan- creas. MERCER COUNTY A. Dunbar Hutchinson, M.D., Reporter The Mercer County Medical Society met in the Lecture Room of the Nurses’ Home, St. Francis Hospital, May 13, with Dr. Swern presiding. We had the inestimable privilege through the efforts of our Treasurer, Dr. North, of hearing an address by Dr. Chevalier Jackson, the premier on bronchoscopy and esophagoscopy. A capacity audience listened to Dr. Jackson while he described June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 535 in a most interesting manner “Bronchoscopic Ob- servation on Diagnosis and Treatment in Suppura- tive Diseases of the Lung”. Dr. Jackson illustrated with lantern slides, chalk, and moving pictures the many conditions arising within the pleural cavity as the result of obstructed breathing, and a rising vote of appreciation was tendered the distinguished speaker. Drs. Elmer J. Elias, J. L. Wikoff, A. J. Lattiere, of Trenton, and J. C. Hiden,. of Princeton, were elected Active Members; and Dr. Gerold H. Miller, Cranbury, as an Associate Member. The applica- tion of Dr. A. James Fessler was read and took the usual course. The President appointed Drs. Reddan, Douress and Yaeger as a committee to draw resolutions on the death of Dr. Walter Madden. Committee appointed to consider the death of Drs. (gray thorn, Seibert and Stratton submitted resolutions which were read and adopted. (See Obituary Section.) A communication from the Trenton College Club, with reference to the request of Dr. Joseph Colt Bloodgood, of Johns Hopkins Medical School, for opinions of certain statements to be presented to the Board of Trustees of the American Society for the Control of Cancer, was read and referred to the Public Relations Committee. A communication from Dr. James A. Fisher, relative to the Golf Tournament, was read and due notice taken thereof. Dr. Sica, Chairman of the Committee on Con- tract Practice, made a verbal report, with detailed account of the various opinions, statistics and schedules of fees received by the Committee as the result of a questionnaire. The motion carried that the next meeting of the society will be held at the Hopewell Valley Golf Club, in the afternoon of June 18. MIDDLESEX COUNTY Medical Section of Rutgers Club John H. Rowland, M.D., Secretary The medical group of New Brunswick was en- tertained by Dr. F. C. Johnson, Chairman of the Medical Section of the Rutgers Club, at a beef- steak dinner at his home on the Easton Avenue Turnpike, on Wednesday, May 13, at 7 p. m. About 30 physicians were able to attend. It was expected to hold the dinner at Dr. Johnson’s mountain lodge at Dock Watch Hollow, but be- cause of inclement weather a change was neces- sary. Before dinner. Dr. Johnson very appropriately and with very sympathetic and touching attitude, spoke of the recent deaths of Dr. Gruessner and Dr. Schureman, speaking of their wonderful at- tributes and the great loss to the profession. After 3-4 hours of complete relaxation, and with a satisfied gastro-intestinal feeling, the members adjourned to their homes, having spent a very pleasant and enjoyable evening. MONMOUTH COUNTY W. Von Oehsen, Reporter The regular meeting of the Monmouth County Medical Society was held Wednesday evening, April 29, at the Berkeley-Carteret Hotel, Asbury Park, Dr. William K. Campbell presiding. Minutes of the previous meeting were read and accepted. Dr. J. Bennett Morrison. State Society Secre- tary, addressed the meeting on some phases of state medicine, acquainting the society with the workings of certain arrangements which approach state medicine in various sections of the world. Dr. Henry O. Reik, Executive Secretary and Editor of the Journal of the Medical Society of New Jersey, spoke on the progress the Journal had made during the past year. Dr. Harvey S. Brown brought to the attention of the society a letter which he had received from the Board of Governors of the Monmouth County Welfare Home. There was first a discrepancy in the length of Dr. Brown’s service, and second, the fee basis was against the minimum fee schedule of the county society. It was moved by Dr. Stan- ley Nichols, seconded and carried, that the Presi- dent appoint a committee to meet with the Board of Governors to arrange a satisfactory solution to this problem. Dr. Campbell appointed Drs. Harvey Brown, Fairbanks, Kazmann and Nichols. Dr. James Ackerman reported for the Com- mittee on Radio Broadcasting. It was brought up that heretofore the names of the doctors have not been used in the weekly broadcast and it was decided that hereafter the name of the speaker would be given, together with his subject and the fact that he whs speaking under the auspices of the Monmouth County Medical Society. Dr. Ackerman reported that the subjects and speakers to date were as follows: James E. Ackerman Joseph Ackerman Albright F. J. Altsehul R. Appleton Joseph Bryan Byron Blaisdell J. C. Clayton W. Campbell Henry Dorr S. Edelson W. H. Fairbanks D. F. Featherston James A. Fisher T. E. Fenton W. Golsing W. G. Flerrman O. R. Holters Heatley S. Hausman W. F. Jamison L. L. Leonard Robert MacKenzie Stanley Nichols Charles D. Prout H. G. Thomas Daniel Traverso J. Villipiano W. Von Oehsen Robert Watkins Frank Wilbur George Wilbur G. V. Warner Helen Upham History of Medicine Influenza Psychology of Childhood Life Expectancy Head Colds Diabetes Exercise State Board of New Jersey Diet The Modern Heart Progress of Medicine Aviation Medicine Regarding Mental Develop- ment of Children Tuberculosis First Aid and Fractures Care of the Nose and Throat Tetanus Obesity (Treatment of) Cancer Cancer Communicable Diseases of Children Schick Test — Dick Test Vitamins Skin Tumors Ethical Medicine as it Re- lates to Public Service Some Interesting Gyneco- logic Data Prevention of Disease in Babies and Children Prophylactics in Children Obesity Something I Ate Emergencies First Month of Life Contagious Diseases Over-Heating of Houses Medical Thoughts The Alleged High Cost of Medical Care Women in Medicine 536 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 Dr. James Ackerman brought to the attention of the society the illness of Dr. J. C. Clayton. It was voted to send a letter of encouragement and flowers to Dr. Clayton. Dr. D. M. P. Magee also mentioned the illness of Dr. Garrison and the Secretary was instructed to write to Dr. Gar- rison. Dr. George Van Voris Warner reported on the revision of the County Constitution and By-Laws and read the first draft. The President was to appoint a committee to review this draft and re- port at the next meeting. Dr. W. G. Herrman suggested the formation of an Executive Committee to handle all routine business so that the meetings of the society would be confined to scientific discussions and such busi- ness as the Executive Committee thought should be brought before the body as a whole. The paper of the evening was given by Dr. W. G. Herrman who spoke on “The X-ray and Ra- dium Treatment of Uterine Hemorrhage”. The paper was discussed by Drs. Slocum, Pons, Acker- man and Featherston. A buffet lunch was served. MORRIS COUNTY Marcus A. Curry, M.D., Reporter A special meeting of the Morris County Medical Society was held at the State Hospital at Grey- stone Park, the evening of Wednesday, April 29. President Sutphen presided over a very gratifying attendance of approximately 80, including visitors, among whom were Second Vice-President Flagerty of the State Society, and a group of Hudson County physicians, including Drs. Arlitz, Cobham, Larkey, Maver and Stuart. The president introduced the speaker of the evening, Dr. J. M. Wainwright, of Scranton, Pa., Chairman of the Pennsylvania State Commission, on Cancer, who provided a most interesting talk on “Interesting Conditions of the Mammary Glands and Nursing Habits of Native Women and Lower Animals”, which was illustrated by lantern slides with pertinent comments and observations. Dr. Wainwright prefaced his very interesting presentation by stating that it had not much to do directly with medicine of any kind but stiil the more we know of subjects allied to medicine the better off we will be. He spoke of books having been written on “From Fish to Man” and “From Ape to Man” and hoped some day something would be written about the mammary gland; that he had gotten up some interesting facts that he would present more or less disconnectedly. His illustrations and explanations of the dif- ferent locations in various animals of the mam- mary glands, and the evolution which seems to have brought about a. reduction of the number of “restaurants” were very interesting and some- times amusing; the female elephant seeming to be the only animal that has the udder and nipples between the forelegs; which he explained was a provision of nature so that the mother could supervise and manage any unruly young with her very useful appendage, the trunk, which could not be used so efficiently if the “restaurant” patronized by the young was situated in the ex- treme rear. He also illustrated and explained what to the uninitiated were novel locations of the nipples on what might be termed aquatic animals, these being on the side, and some up near the back, so that the young could ride along on the back of the mother through the water and suffer no in- convenience with the approach of hunger, and so that the mother could gad about from place to place through the water without having to dock and lie down to enable the young to feed from beneath, as would be the case with most animals; also of interest were the mammary functions of some ani- mals that had no nipples but simply by muscular contraction exuded the milk to the hair from which the young licked it and so fed themseives. Also interesting were the idiosyncrasies of the young of the pouch animals, where the young go to the pouch immediately after coming into being and hang on to their particular gland continuously until the time arrives for them to let go and main- tain themselves otherwise; it seeming that if they should let go they are unable to recover the gland and they would perish; of further interest was the situation of the nipples on animals that slither along on their bellies, they being depressed so that they will not damage or wear in the process of travel, such as the seal, etc. While many of us are familiar with the bat it is unlikely that we are quite so familiar with the mammary features of this little bird-animal and the fact that bats carry their young with them on their flights, the young holding fast to the nipple with their claws; then when the mother hangs herself upside down on a beam for sleep the young bats reverse themselves and take hold of 2 unfunctioning nipples on the other end and thus maintain their hold on the mother bat and on life itself. Dr. Wainwright’s program provided a novel and interesting evening and he was given a fine round of applause, and upon the suggestion being made he promised to return sometime in the future and give a talk on the subject of cancer, his capabili- ties in this respect causing everyone to look for- ward with anticipated pleasure to that meeting. Mention was made of the candidacy of one of our members, Dr. Julia C. Mutchler, of Dover, for the nomination of Assemblywoman from Morris County and the sentiment was that it would be in the interests and for the welfare not only of the county society but of the physicians of New Jer- sey if her nomination and election be effected, which is altogether within the realm of definite probability. After the formal meeting Superintendent Curry of the State Hospital invited the members and guests to partake of refreshments, which they did with much enjoyment, in the employees’ cafeteria. Special May Meeting A special meeting of the Morris County Society was held the evening of Thursday, May 21, at the State Hospital at Greystone Park, with Presi- dent Sutphen presiding and about 45 members and guests present. Preliminary to the main purpose of the meeting, the President called attention to the annual meet- ing of the State Society at Asbury Park, June 3-5; that the golf tournament would be June 3 and for golfers to communicate with Dr. J. A. Fisher, Jersey Central Building, Asbury Park: and stat- ing that we all should be pleased that Doctor Julia Mutchler, one of our members, won the nomination for Morris County Assemblywoman; also announc- ing that 2 applicants for membership, Drs. Ferris and Falvello, had been approved by the investi- gating committee and would be voted on at the next regular meeting. The feature of the evening was a presentation by Dr. Joseph Jordan Eller, dermatologist, of New York: his subject being “The Diagnosis and Treat- ment of the Common Skin Diseases, with a Dis- cussion of Precancerous Lesions”. The 3 main types of skin diseases discussed were dermatoses caused June, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 537 by various drugs, poisons and toxins; dermatitis caused by local or internal infections, and derma- tosis caused by fungi. Dr. Bart M. James, of Newark, lead the discus- sion which was also entered into by Drs. Costello, Christian, Collins, Young, F. Grendon Reed, Gibb, AJlaben, and the questions asked were fully an- swered by the speaker of the evening. After adjournment refreshments were enjoyed in the cafeteria. OCEAN COITIVTY Eugene G. Rerbener, M.D., Reporter The regular meeting of the Ocean County Medi- cal Society was held at the Ocean House, Toms River, May 20, at 6 p. m. Those answering the roll call were: Drs. Woodhouse, Towbin, Ober, Gold- stein, V. M. Disbrow, Sawyer, Brouwer, Harold B. Disbrow, Swan, Denniston, and Herbener. The President, Dr. Adolph Towbin, called the meeting to order and extended a greeting of wel- come to our new member, Dr. ,Ober. The report of the Committee on Membership was received and Dr. W. E. Dodd, of Beach Haven, was unanimosly elected. Drs. Lieutenant Bruce Bradley, and Lieutenant Commander William W. Davies, of Lakehurst Naval Air Station, were elected unanimously to honorary membership in the society. Drs. Towbin, Thompson and Swan agreed to represent our county in the Golf Tournament of the New Jersey State Medical Society to be held Wednsday, June 3, at the Asbury Park Golf and Country Club. A general discussion of matters of minor im- portance followed, after which the meeting ad- journed. PASSAIC COUNTY W. W. Flail, M.D., Reporter The regular meeting of the Passaic County Medical Society was held at the Health Center, Paterson, May 8, at 9 p. m. Dr. Carlisle presided. The minutes of the April meeting were approved as read. The following applications for membership were received and referred to the Board of Censors: Drs. Morris PI. Saffron, 200 Jefferson Street, Pas- saic; Jeremiah PI. O’Brian, 204 Madison Street, Passaic; J. Thompson Stevens, 55 Park Street, Montclair. The paper of the evening was presented by Dr. A. A. Berg, Attending Surgeon, Mt. Sinai Hospi- tal, New York City. His subject was: “Surgical Treatment of Diseases of the Colon”. The lecture was illustrated by numerous lantern slides. Dr. Berg’s talk was closely followed. The meeting adjourned at 11 p. m. UNION COUNTY Summit Medical Society W. J. Lamson, M.D., Secretary April Meeting The regular meeting of the Summit Medical So- ciety was held at Wallace Pines on Wednesday, April 29, at 8.30 p. m., with the President, Dr. Smalley, in the chair, and Dr. Meeker entertaining. Present, 19 members and 3 guests. A paper was read by Dr. Meeker, entitled “An Outline Study of Endoerines”. Dr. Meeker gave a comprehensive summary of our present knowledge on the subject of internal glandular secretions, symptoms caused by hyper and hypo-secretion, and the therapeutic use of hor- mones. Much remains to be worked out, however, before they can receive thfe value they must ulti- mately have in the treatment of various conditions in which they are indicated. The paper was freely discussed by Drs. Dengler, Morris, Byington, Prout, Bowles, Jamison, Hal- lock, Moister and Johnston. Dr. Byington called attention to the fact that 2 hormones, thyroxin and adrenalin, ai’e already produced synthetically. Dr. Morris likes to combine several hormones, and said it was necessary to continue their use over a long period of time to obtain desired re- sults. Dr. Prout, on the other hand, does not approve of pluriglandular therapy, but insists that indi- cations for use should be carefully studied and then the appropriate hormorie should be given, in order to test their true value. Dr. Moister pointed out the fact that, with the- single exception of thyroid substance, the glan- dular hormones should be given hypodermically rather than orally. May Meeting The annual meeting of the Summit Medical So- ciety was held at Wallace Pines, on Tuesday, May 26, at 8.30 p. m., with the President, Dr. Smalley, in the chair, and Dr. Hallock entertain- ing. Present; 24 members and 5 guests. The election of officers for the year 1931-1932 resulted as follows: President, Dr. Wellington. Campbell, of Short Hills; Vice-President, Dr. Joseph E. Pollard, of Chatham; Secretary, Dr. William J. Lamson, of Summit. The newly elected President, Dr. Campbell, then took the chair. The Secretary read an in- vitation extended to the society to attend the Graduation Exercises of the Training School for Nurses, at Overlook Hospital, on June 5. The Secretary was requested to write and thank Mr. Thomas J. Watson, of Short Hills, and his foreman, Mr. William MoCue, for entertain- ing the members of the society at his farm at Oldwick, N. J., on May 21, and for the oppor- tunity of inspecting his model dairy. A paper was read by Dr. Hallock, on “Factors Affecting the Length of Pregnancy”. There is no single standard of estimating this period — each man having a method of his own — but all are based on the date of last menstrua- tion, date of quickening and height of fundus. The duration is apt to be less in young than in older women. On account of the uncertainty of some of the data on which the computation is made, it is wise to wait until within 3 weeks of the expected date before inducing labor. Dr. Hallock described various methods for in- ducing labor — castor oil and quinin, pituitrin, bags, bougies, accoucbment force and rupture of membranes, and cited reports and statistics to show the desirability of the latter method. WARREN COUNTY Charles B. Smith, M.D., Secretary The spring meeting of the Warren County Medi- cal Society was held at the Elks’ Home, Phillips- burg, April 23, being called to order by the Presi- dent, Dr. Bossard, at 11 a. m. Members, present: L. H. Bloom, G. H. Bloom, H. 538 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY June, 1931 B, Bossard, G. W. Cummins, Paul Drake, L. 'W. Hackett, F. J. LaRiew, C. H. Lyon, C. B. Smith, T. F. Spillanc and A. C. Zuck. Visitors present: Dr. George N. J. Sommer, Trenton, State Society President; Dr. F. G. Scammell, Trenton, Councilor; Dr. Frederick Roberts, of Easton, and Dr. Baldauff, recently located in Belvidere. The minutes of the last meeting were read and approved. It was regularly moved and seconded that Dr. Baldauff’s application for membership be accepted and referred to Censors. The death of Dr. L. C. Osmun, of Hackettstown, which occurred on March 30, 1931, was reported. The President appointed Dr. C. B. Smith, of Washington, as Secretary pro-tem. The President also appointed Drs. A. C. Zuck and C. B. Smith to draw proper resolutions on the death of Dr. Osmun, who had served as Secretary of the Society for the past 7 years. It was unanimously agreed that the cost of the room in Farrell Arms Plaza, Washington, N. J., where Post-Graduate lectures are being held, be paid by the society. It was reported that the lec- tures were most interesting and practical and very much appreciated by the members attending. Dr. T. F. Spillane, of Phillipsburg, was elected to fill the unexpired term of Dr. Osmun as Delegate to the State Society. Dr. Osmun was elected on October 15, 1929, for a term of 3 years. Dr. Frederick Roberts, chief of the Medical Staff of the Easton Hospital, read a very interesting paper on “Bronchial Asthma”, and he was compli- mented by all the members who took part in the discussion, also by Drs. Sommer and Scammell for jn-esenting such an interesting and practical paper on such a troublesome subject. After a very good dinner, served at the Elks’ Club, Dr. Sommer gave a talk on what the Society had done during the past year for its members, and Dr. Scammell told us how he got his start in surgery, his first operation being successfully per- formed on Dr. Reese’s back porch. Obituaries LINDLEY', Charles L., formerly of Lakewood, died at 'Los Angeles on March 26, 1931, in his seventy-seventh year. Dr. Lindley was well known in Lakewood where he took an active part in the professional, social and sporting life of the resort. Ill health, 10 years ago, compelled him to take up his residence in California where, despite his advancing years, he enjoyed a retired life. Dr. Lindley was born in Durban, Natal, South Africa, November 3, 1854. He was the son of Rev. Daniel Lindley, a missionary to the Dark Continent, and Lucy (Allen) Lindley, a descendant of Ethan Allen, of Ticonderoga fame. He received his early education in a German school in Her- mann sburg, South Africa, and later studied in Vienna. He was graduated in 1897 from the Col- lege of Physicians and Surgeons, Columbia Uni- versity, with high honors. SCHUREMAN, James Percy, of New Bruns- wick, died in the Middlesex Hospital, May 6, 1931, after an operation for appendicitis. He was 51 years of age and had practiced in New Brunswick since 1905. Dr. Schureman was a graduate of Princeton and the University of Michigan. He was a Captain in the Medical Reserve Corps, a member of the Middlesex County Medical Society, the New Jer- sey and American Medical Associations and a Fel- low of the American College of Surgeons. He was on the attending staffs of the Parker Memorial and St. Peter’s Hospital. Resolutions oil tlio Death of Dr. Charles J. Cray- thorne, Adopted by the Mercer County Medical Society Resolved. That there be entered on the official minutes of this society, an expression of the great loss it has sustained in the death of Dr. Charles J. Craythorne. In the successful labors of a long life he has constantly added to the respect and dignity of our profession. Thoroughness and con- scientiousness were characteristics of all his work. These qualities, added to ability and clear judg- ment, secured for him, in all his professional and personal relations, the confidence and friendship of those who have been associated with him. Resolved, That we tender our sincere sympathy to his family and, that the Secretary be requested to send them a copy of these resolutions. N. B. Oliphant, Chairman Frank G. Scammell D. B. Ackley Resolutions on tlic Death of Dr. Raymond S. Seibert. Adopted by the Mercer County Medical Society Whereas Almighty God has seen fit to remove from our midst, Raymond S. Seibert, M.D., a. valu- able member of the medical profession. Be It Resolved, that in his death this society has lost a faithful and untiring member of the profession; a man who served his country in both peace and war; who spent unselfishly many hours of service for his fellow-men and in so doing im- paired his health to such an extent that for the past 3 years he had been unable to follow his life’s work. His memory will be cherished by his fellow practitioners who have adopted this reso- lution, and ordered that a cojiy be sent to his family. Respectfully submitted, J. FI. McCullough. Sr. A. W. Atkinson W. E. D’Arcy Resolutions on the Death of Dr. William N. Strat- ton, Adopted by the Mercer County Medical Society Whereas the members of the Mercer County Component Medical Society have suffered a great loss in the untimely death of Dr. William N. Strat- ton, one of the valued members of their society; and whereas because of his kindness of heart and sincere devotion to the lofty ideals of his pro- fession, the members of this society sincerely re- gret his passing; and. whereas we desire to extend the sincere sympathy of the society to his family in the loss of a kind and loving husband and father; Be It Resolved, that as a mark of the esteem in which our late colleague was held by this society, this resolution be spread upon the minutes and a copy of the same be presented to his family. M. M. Kent Harry Berger F. B. Zandt 539 journal of The Medical Society of New Jersey Under the Direction of the Committee on Publication Vol. XXVIII., No. 7 ORANGE, N. J., JULY, 1931 Subscription, $3.00 per Year Single Copies, 30 Cents PRESIDENTIAL ADDRESS* George N. J. Sommer, M.D., F.A.C.S., Trenton, New Jersey Even if custom did not require it, I am sure that I should want at this moment to ex- press to you my appreciation of the honor conferred upon me in the call to service as President of this ancient and honorable guild of physicians and surgeons. I have never cared especially for antiques merely because of their antiquity, but I confess to strong ad- miration of institutions that have continued to live for a long period of time and which have maintained consistently and persistently an ac- tive and praiseworthy existence. To have been deemed worthy to fill the presidential chair of the oldest and one of the most dis- tinguished medical societies in this country, will ever be to me a happy recollection and I wish now to thank you, my colleagues and my friends, for this signal expression of your faith and trust. I was content to walk in the ranks of this noble company, but when you chose me to serve temporarily as captain, I determined to work in that position as I would in any other, to the best of my ability, realizing fully that no other honor, however great, can ever mean so much to me as does this one that I now gratefully acknowledge. As your leader for the past year, the time has come to render an account of my observa- tions. At the time when our society inaugu- rated the plan of having an annual presidential * (Delivered at the 165th Annual Meeting of the Medical Society of New Jersey, at Asbury Park, June 5, 1931.) address, it was customary to present a dis- course upon some scientific subject related to the practice of medicine. Since then, how- ever. many things have changed and nearly every aspect of the presidency appears differ- ent today from the picture 20 years ago. I could, and felt very much inclined to, speak to you of some one of the many interesting surgical questions of the day, but the science of medicine has gotten so far in advance of its practice that it seems better to discuss problems that are more in need just now of serious consideration. So, following the lead of some of my immediate predecessors in this office, I shall devote this time to a short re- view of my official conduct and present for your further consideration some of the more pressing questions now demanding the atten- tion of organized medicine. Accepting the task as both a duty and a privilege, I have during the year visited all but one of the 21 county societies while in session, participating when I could in the dis- cussions of scientific papers and conferring with them on matters that affected their re- lationship to the state and national societies. In addition, I managed to attend 3 of the 5 Councilor District meetings, 3 Tristate Con- ferences, the Annual Conference of Secre- taries and Reporters of our own component so- cieties, and accompanied Morrison and Reik to the Annual Conference of Secretaries and Editors of State Societies held in Chicago under the auspices of the American Medical Association. The presidency of the American Medical Association has become a full-time job. with burdens that weigh heavily in the balance against the honor of holding that 540 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 office. From practical experience I can tell you that presidency of the state society is no longer a sinecure, but is rapidly becoming a full-time job. My deep personal interest in the economic as well as the scientific prob- lems of the day, and my affection for mem- bers of the medical profession, have, however, made the work pleasurable. Those of you who have not had so full an opportunity to meet with confreres of coun- ties other than your own, or from other parts of the nation, may find it difficult to under- stand why economic problems have suddenly come to occupy such a prominent position, but, as was pointed out by the Executive Secretary in the last of his travel articles, those who now occupy official positions are finding themselves in the midst of turbulent conditions and faced bv controversies, by prophecies and by threats, that compel thought and sometimes decisive action. I am not greatly alarmed by the threats of legislative action looking to the control of or to inter- ference with the practice of medicine, but some of the problems being discussed in lay magazines and some of those appearing in the columns of national and state medical jour- nals. are of sufficiently serious import to re- quire contemplation and possibly preparation for organized action. After the recent pro- posed settlement by Great Britain of an age- long dispute with India, it was said of the English Ambassador: “It is an achievement of Lord Irwin to have robbed India of griev- ances. In that he has shown great statesman- ship.” It may be the part of wisdom to settle some of our controversies by depriving the public of its grievances, real or imaginary. At the county society meetings, all over the state, the economic problem most fre- quently encountered has been one always in some manner related to enforcement of the Workman’s Compensation Law. The very frequency of the question’s appearing would seem to indicate that there is much dissatis- faction resulting from the manner in which insurance companies deal with physicians in paying for medical service. Some of the trouble appears traceable to physicians not understanding or not complying with the law, but many instances are reported where action of the insuring agent, or the employer, seems to have been arbitrary and unreasonable, and not infrequently physicians have been disre- spectful to the rights of one another. An ad- visory commission, appointed by the Commis- sioner of Labor, has, after a year of investi- gation, just made a series of recommendations designed to improve conditions for those who handle compensation cases, said report hav- ing been published in the May Journal. W hether or not those recommendations, sup- posing that all will be adopted, will remove all causes of dispute remains to be seen ; un- doubtedly, the situation may thus be improved, but as similar laws are being passed and put into efifect in other states, differing in some respect from ours, and as there are many as- pects to some of the disputes, involving ques- tions of ethics as well as of economics, it may not be amiss to provide a special committee to study the whole problem and to make recom- mendations in the event that it is considered desirable to have the law amended. At the same time we should keep in mind the fact that New Jersey is now favored by having a better Workman’s Compensation Law than other states ; a state of affairs for which the profession owes thanks to Dr. McBride and previous welfare committees. A close second to this problem is that which concerns the growth of industrial medicine and contract practice. Here, too, we seem to be in need of an investigating committee to ascertain facts upon which action may be based,. New Jersey, especially in its north- ern half, is becoming highly industrialized and with the growth of factories, both in number and in size, there is developing a form of medical practice often referred to under the general term of “industrial medicine”. It has been pointed out that the medical profession has for years past encouraged factory owners and department store managers, for instance, to employ physicians to take care of their employees, especially to render treatment in the event of accidents and emergency illness, and the employers have learned that it pays better to keep the employees healthy than to allow them to become sick from any avoid- able disease. Having promoted the idea, can we now declare that physicians engaged in July, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 541 such work are practicing unethically ? In some fields of industry this type of practice is car- ried on under special contract, and thereby comes under consideration in relation to our opposition to contract practice in general. Such contracts were not dreamed of at the time when our rules were made, and it seems necessary now to modify the language of those rules or to issue an interpretation of them for guidance of those who, by written or verbal contract, engage in such medical prac- tice. It is useless to denounce physicians for doing things that are beneficial to the public, and which are in themselves both right and proper, merely because the letter of the code is against them ; it is the spirit of the code about which we should be most concerned, and everybody involved must wish for clari- fication of this situation. The Mercer County Medical Society, having this matter under consideration at a meeting in February 1930, decided that contracts negotiated by any of its members should be in accord with the principle of “covenants openly arrived at”, and adopted the following resolutions, which seem reasonable and satisfactory : (a) This society believes that contract practice, except such as this society shall sanction as rep- utable under existing' compensation laws, is at variance with the Code of Medical Ethics and de- rogatory to the dignity of the profession. Therefore, the name of any member receiving or renewing such contract shall, ispo facto, be dropped from the roll. (b) Any member having or considering a con- tract under existing compensation laws shall pre- sent a certified copy of the contract to the secre- tary of the society. Such contract shall be presented to the society at a regular meeting, and be referred to the Board of Censors, who shall consider such contract and report to the society at the following meeting. Any member failing to present such contract to the secretary will be dropped from the roll, after due action by the society. (c) Any physician engaged in contract prac- tice, making application to the society for mem- bership, shall present with his application a cer- tified copy of his contract. While dealing with the general subject of contract practice, I may be allowed to report an action taken by the Mercer County Medical Society with relation to physicians’ holding full time institutional positions engaging in private outside practice. Inasmuch as the whole mat- ter is embraced in a single communication from Commissioner Ellis, of the Department of Institutions and Agencies, I will simply read that letter : "Dear Dr. Sommer: The State Board of Control has taken the fol- lowing action in reference to the consideration of the work of physicians’ giving full time to the state institutions: At a meeting under date of May 27, a resolution was passed as follows : ‘WHEREAS, the Mercer County Component Medical Society has brought to the attention of this Board by resolution its intention to eliminate from that society physicians employed on full time in state institutions who receive maintenance and engage in outside practice, and WHEREAS, the State Board of Control has con- sidered carefully the questions involved, BE IT RESOLVED that we here record our de- cision that physicians who are employees of state institutions shall not make use of equipment or facilities for the treatment of persons not regu- larly committed to such institutions and that the use of dwellings or other state property for private practice is contrary to the policy of the State Board of Control.' At the meeting of the State Board of Control on Tuesday, June 24, the following resolution was passed : "Dr. Dowd reported that the State Board Com- mittee, together with representation of the medi- cal membership of the local institution Boards, had conferred with a committee of the Mercer County Medical Society, and that it was the rec- ommendation of the State Board Committee that positions of physicians residing in the institutions should be clearly set forth as full-time positions, and that all extra-mural work outside the insti- tution should be limited to consultation work in their special fields. The State Board concurred in the recommenda- tions made by Dr. Dowd for the committee and commended the committee for its work in this connection.’ I have transmitted to the Presidents of the Boards of Managers of the several institutions copies of the above resolutions. The State Board understands that the above policies were made after conference with the medical members of the local Boards of Mana- gers. It is the understanding of the State Board that the policy as outlined met with the full, cordial cooperation of the various state institutions and the professional medical staff of each of the in- stitutions. It is, of course, the idea of the State Board that the local Boards of Managers will work out the administrative details of applying the policies as outlined in these resolutions. We all understand the desirability of making it possible for the professional medical staff of the institutions to maintain professional contacts of the consultation type with other men in the pro- fession. I will be very glad to have you bring this ac- tion of the State Board to the attention of the State Medical Society and the officers of the Mer- cer County Component Medical Society.” I wish to express appreciation of the cour- teous cooperation received in this matter from Commissioner Ellis, Dr. Dowd and Dr. Ray- croft. At the several Councilor District meetings, 542 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 as well as at some of the county society gath- erings. considerable attention has been de- voted to economic problems. At the first dis- trict meeting, held in Newark, the single topic was “state medicine”. At the second district meeting, the number of topics was greater but the principal one concerned recog- nition and classification of specialists, and resolutions were adopted to be passed on to this society. At the fifth district meeting, in Atlantic City, Dr. John Hartwell, of New York, discussed this same question and de- scribed the plan being put into operation at the New York Academy of Medicine to im- prove conditions in that city. One cannot read the numerous magazine and newspaper articles and the now consider- able number of books criticizing the medical profession for laxity in providing safeguards for the public against unqualified specialists, without recognizing the fact that some of the complaints are justified and that even the ex- aggerated statements used by some lay writ- ers have a certain foundation in fact. It would seem to be our duty to give thought to these matters and to make an attempt, at least, to meet the wishes of the public with respect to exerting some control over those members of the profession who hold themselves out to be surgeons or specialists, and to provide the people with some means of recognizing those physicians whom we consider qualified to practice as specialists. There is nothing un- reasonable about such a proposition and we may better cooperate in the movement than be compelled to submit later to more regula- tory laws. Nor can one read the legislative records of the past few years without realizing that so- called “state medicine” may be our fate if we persist in ignoring problems that require our help for proper solution. At the most recent Tristate Conference, one of the speak- ers called our attention to recent national legislation extending medical care and hos- pital privileges to war veterans and their families, and asked if we realized that by changing a very few words in now existing laws state medicine in its full sense could be established on a national basis. Our Journal Editor has given us a sum- mary of the national health insurance laws now operative in other countries, and has pointed out the gradual encroachment upon our own territory. During the earlier months of this year the states of Massachusetts and New York both had such laws to fight in their legislative chambers. We are. apparently, in no immediate danger but does not that fact suggest that this is an opportune time to con- sider these things in order that action may he taken to prevent the introduction of such acts — by removing the existing incentive— -or to prepare for that fight which will otherwise inevitably come. At the meeting of Secre- taries and Reporters o*’ Count) Societies, in Trenton last November, a resolution was adopted requesting this society to appoint a commission to study the state medicine prob- lem ; and at the Second Councilor District meeting, as I have already stated, resolutions bearing upon the control of specialism were adopted for passage along to us. I commend these resolutions to your careful considera- tion. There is nothing to be gained by shut- ting our eyes against obvious facts; much may be gained by cooperating with other institu- tions and organizations and by an honest ef- fort to correct any evils that may be found in our own practice— thus to deprive critics of any basis for proposing new legal enactments. In the matter of legislation, we have suc- cessfully passed through another year. Our greatest concern was aroused when the Gen- eral Assembly had under consideration the so- called Abell Bills. In an effort to improve governmental business, the investigating com- mission presented a group of new laws, most of which were good, but the mistake was made of going to extremes in one matter and of framing an act without full knowledge of its probable effect. In that matter we were glad to cooperate with other organizations con- cerned— especially the dental and pharma- ceutic associations- — and our joint efforts re- sulted in prevention of an apparent calamity. A closer alliance with such other organiza- tions should be cultivated and I hope will now be maintained steadily. Among many propositions that have come to hand during the year is one requesting our cooperation with the State Hospital Associa July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 543 tion in asking the Governor to appoint a special health commission to study and make recommendations for modernizing the health activities of New Jersey. We were informed at the Tristate Conference in February that a similar commission, appointed by Governor Roosevelt, of New York, had about com- pleted a report, after making a survey of con- ditions in that state. Since that time most of Governor Roosevelt’s program has been en- acted into law and we might well profit by New York's experience. At our last annual meeting, Mr. Bowen, Director of the State Department of Health of New Jersey, de- scribed conditions in this state and asked our support in bringing about improvements. Nothing was done about it at that time, and I think it would be wise to take some action now ; perhaps through the channels named, co- operation with the State Health Department and the State Hospital Association. The Tri state Conference also had under consideration a paper written by one of our own representatives on the question of In- creasing Fatalities Caused by Automobiles, and a plan calling for physical examination of all applicants for a chauffeur’s license was unanimously adopted. Wre hope you will adopt the recommendations, which were pub- lished in the February Journal, and take such steps as may be necessary to induce the Com- missioner of Motor Vehicles to put some such plan into effective operation. Incidentally, let me say that the importance of these Tristate Conferences can scarcely be overestimated. The State Medical Society officers of New York, Pennsylvania and New Jersey are meet- ing 3 times a year to consider important ques- tions that concern the physicians of these states, and it has been both illuminating and pleasing to take part in their deliberations. Our hearty support has been given to the movement from its inception and I recom- mend that it be continued. Observing closely the immense amount of work being conducted from our Executive Secretary’s office, I have been tremendously impressed by the necessity for a permanent home for this society, with proper equipment and facilities for housing records, for pre- serving a working library, for conducting the Journal, for directing our public educational program, for all the functions of the organ- ization including provision for committee meeting rooms and possibly a hall large enough to accommodate the society in its annual convention. This question has been considered by some of my predecessors and it has been my pleasure to aid in develop- ing some plans which we hope may prove effective in the course of time. When visiting the county societies, it has been my pleasure in many instances to attend meetings of the Woman’s Auxiliary to those local bodies, and I know something of the work and plans of the state auxiliary and the national organization attached to the Ameri- can Medical Association. This entire move- ment has developed within a very few years and can scarcely lie said to be yet well estab- lished. Its success is going to depend in the main upon the support given by our own so- cieties. In states and in counties where the physicians encourage the auxiliary, there will surely develop a strong organization with po- tential possibilities for helping the medical so- cieties. In states or counties, where such en- couragement is withheld, progress will neces- sarily be slow. Where any degree of active opposition exists, even on the part of a small minority of the medical society members, the auxiliary cannot live. I am very earnest in seek- ing support for the Woman’s Auxiliary, be- lieving fully that we can trust our wives to look after our interests as carefully as we would ourselves. Several years ago a committee was appointed to serve the auxiliary in an advisory capacity but it seems desirable now to have such a committee given the duty of outlining a policy or course of action for the auxiliai'y, to cooperate constantly with the auxiliary in developing its work, and to supervise its ac- tivities. Our women are interested in our professional as in our home affairs, and I be- lieve there is a slogan expressing that interest, in the phrase — “The home, the profession, and the public health.” Where county aux- iliaries are properly established one notices a 544 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 greater sociability and better understanding among the families of physicians, and there has also resulted an increase of attendance at those county society meetings. Effective or- ganizations, fully functioning, can also help us in legislative matters, particularly in op- posing acts that threaten the welfare of our profession, for the women are quick to realize that whatever strikes at the income of the physician necessarily affects the home and family life of the physician. When Governor Larson, responding to the appeal of President Hoover, called a State Conference on Child Health and Welfare. I directed our Executive Secretary, Dr. Reik, to represent this society in the organization plans, and you have heard from him and from those of our members who participated in the several conference sections what results were obtain- ed. I hope that everything possible will be done to further the aims and objects of those national and state conferences and that the children of New Jersey may benefit from our help in vitalizing the child health program. Although it was not directly related to that program, I might mention here that the Gen- eral Assembly of New Jersey passed a law, at its last session, providing for a permanent commission to care for the crippled children of this state, and, as one member of that body must be selected from the State Medical So- ciety, I have asked the Trustees to name 3 members from which list the Governor may select one for appointment. During the month of May I attended the Eighth Annual Conference of Midwives, sponsored by the Bureau of Child Hygiene, of the State Department of Health, directed by Dr. Julius Levy, and Dr. Reik attended the Conference of Nurses of the Child Hy- giene Bureau, and both of us were impressed by the good work performed by that Bureau. It was pleasing to learn that there are now no unregistered midwives in this state ; that these practicing midwives are keen for post- graduate courses of instruction and strive to win approval of their study and accomplish- ments; and that the spirit of cooperation be- tween these inspectors and the midwives is perfect. I trust you will keep in mind the fact that the midwife is an essential factor in the obstetric field and that it is our duty to aid in her education and to promote fur- ther development of the plans so well started. Some of the hospitals might offer the use of their facilities as have the 2 institutions that now provide courses in midwifery. One of my first official acts consisted in taking the liberty of inviting the 3 vice- presidents to sit ex-officio in all Welfare Committee meetings. I believe the plan has worked satisfactorily and that it should be- come a fixed feature. It affords an oppor- tunity for the vice-presidents to become ac- quainted with the problems confronting the organization and to learn about the details of organization work, so that when they reach the presidential chair they will be fully in- formed as to their duties and obligations. The Welfare Committee is a very im- portant factor in our organization, and I wish to thank that Committee, and particularly its Chairman, Dr. Lippincott, for the excel- lent service rendered this past year. So, too, would I thank the Field Secretary, Mrs. Tanevhill, for the effective manner in which she has carried to the public our campaign of public education in preventive medicine. In closing this review of my service, I wish to acknowledge my indebtedness to all those who have assisted in making my admin- istration a success. Particularly do I offer thanks to the Secretary, Morrison, and the Executive Secretary, Reik, for their guidance and cooperation. Presidents come and go; the tenure of office is short, and usually the president enters into office ignorant of his duties and responsibilities. Secretaries, if they be good ones, are retained in office and become the embodiment of all the knowledge, history of the past, and methods of procedure so important to the smooth running of an or- ganization. We are fortunate in having 2 such reliable, loyal and efficient secretaries, with whom it has been a pleasure to work. July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 545 THE GENERAL PRACTITIONER AND OBSTETRICS* Samuel A. Cosgrove, M.D., Jersey City, N. J. It is furthest from my desire, as one who perhaps pretends to specialization in obstetrics, to “talk down” to the general practitioner, for 2 reasons : First, the specialist obstetrician must or- iginally be, and must remain, a general prac- titioner. He is treating human beings who are subject to the varied ailments which all hu- man beings of their sex and age group are. In many cases, the fact of their pregnancy is hardly more than incidental ; in many others it is of importance chiefly by reason of its effect on some other clinical condition present. So that there commonly come under the care of the obstetrician, cases of biliary tract disease, gastric conditions, diabetes, appendicitis, colitis and hemorrhoids ; of endocarditis, myo- carditis and vascular disease ; of pyelitis, nephritis and uremia; of pneumonia, pulmon- ary tuberculosis, scarlet fever, erysipelas, meningitis, malaria and septicemia; of chorea, hyperthyroidism, neuroses and psychoses. He encounters dangerous hemorrhage and shock more often than the traumatic surgeon and has to be as thoroughly at home in pelvic pathology and intraperitoneal manipulation as the gynecologist. So that it is as one to an- other that he talks to general practitioners. On the other hand, in his devotion of time to the larger obstetric material which it is his privilege to serve, he largely loses his finesse in handling all these other varied ills of mankind, and must perforce avail himself constantly of the help of internists and sur- geons. So that my admiration is large for the man who, handling his obstetric cases •competently, just as competently handles without aid his cases of diabetes, pneumonia, syphilis, fractures, appendicitis and heart dis- ease. Secondly, obstetrics belongs largely to the *(Read at the Osier Society meeting, Jersey City, February 17, 1931.) general practitioner. Statistics are not com- piled specifically for the purposes of this talk, therefore it is hard to arrive at close calcu- lations of just how largely this is true. Guesses sufficiently close can be arrived at, however. In 1930 there were in the state 68,325 living births. The proportion of midwife deliveries throughout New Jersey is 14.8%; so, 58,211 births were attended by physicians. Probably about 18% of these occurred in institutions. If we assume, an assumption not of course valid, but convenient at this time, that all of the institutional births were attended by specialists, and that none of those outside of institutions were, we find that 47,829 births, or 70% of them all, were cared for by general practitioners in the homes of patients, which is no mean score for the general practitioner. This may logically prompt the question as to how well the general practitioner is doing his obstetric job. No absolute answer can be made to this, nor are invidious statements necessary, nor intended. In general, a man’s obstetric practice is on a par with his other work. A careless medical man will do care- less midwifery; one who lacks a conscientious attitude toward his other patients will show a similar lack toward his pregnant ones ; one who takes a careful history on, and com- petently examines and watches, his stomach cases, will warrant the confidence of his ex- pectant women ; one who cares enough for his work to train himself to deft, gentle manipu- lation of gall-bladder and stomach is apt to have proper regard for the soft parts of the parturient, and to handle the fetus gently and skilfully. I am inclined to feel that the graduate of the last few years has had oppor- tunities for undergraduate and hospital train- ing that my own student years did not afford. Therefore, other factors of capacity and per- sonality being the same, the young practi- tioner of today should be a better one, and his obstetrics should be better, than was the case a generation since. And I am sure, from my own observation, that these things are true. Not so often does one hear, as formerly, of doctors engaging confinement cases with no expectation of seeing the patient again before labor starts. Doctors, young and old, are watch- JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 DIG ing their pregnant women more closeiy and intelligently than they used to and the change is of tremendously beneficial importance to womankind. For in obstetrics as in other fields of medicine, prophylaxis is the true key- note of enlightened practice. The salvage of maternal and infant lives dependent on alert watchfulness in the prenatal period is directly proved. In New York State, in 1930, while the uncontrolled neonatal mortality was 42:1000, that in the group of mothers known to have been under good prenatal supervision was 28:1000. This would mean a saving of 957 babies in 1 year, in New Jersey, if such supervision could be extended to all pregnant women. The statistics from all centers where prenatal care has been established indicate an equally salutary improvement in the incidence of life-threatening conditions in mothers, notably in relation to severe toxic conditions. In the actual conduct of labor the prac- titioner encounters his greatest test, for it in- volves diagnostic acumen and judgment, me- chanical dexterity sometimes of high order, and the maintenance of surgical cleanliness under difficult conditions. A local practitioner of gracious memory who served very many women in child birth, is reported to have said that there were 2 classes of labor cases : Those which needed no doctor, and those which needed 2. While somewhat inaccurate, as such aphoristic statements generally are, it indicates at least 2 important truths. The majority of labors will terminate spontane- ously and will need no doctor to meddle with the normal processes of Nature’s own me- chanics; 100 years ago Ramsbotham, of Lon- don, reported 19,439 deliveries in 8 years, with the following “difficulties and irregularities’’: Adherent and retained placentas 135 Forceps extractions 35 Craniotomies 25 Vectis cases 1 Difficulties due to transverse presentation, etc., presumably relieved by version 68 A total of 264 or an incidence of operative delivery of only 1.35%. This demonstrates the fact that in nearly all cases women can actually extrude a conception product, even at term, without arti- ficial assistance, if they have to. Unfor- tunately, Ramshotham’s table does not give the average duration of labor, maternal mor- tality. fetal mortality, nor the cost to mothers in terms of invalidism of such extreme con- servatism, though he does confess to 5 rup- tures of the uterus and 1 of the broad liga- ment. Certainly it is to be feared that today such over-conservatism would not be popular with the ladies. As perhaps fairly typical of present prac- tice, on my own service at Jersey City Hos- pital in 1930, in 1784 del iveries there were : Adherent and retained placentas 12 Forceps extractions 241 Craniotomies o Versions 35 Cesarean sections 25 — 1.1% Hysterectomy . . 1 Total incidence of operative delivery 314 or 17% Of this series, the maternal mor- tality was 0.67%, the neonatal 3.3% The incidence of forceps delivery in this series is artificially high, due to extensive ex- perimentation during this period with spinal anesthesia and “elective” use of forceps. A normal incidence of forceps operations would reduce the total operative incidence to about 9%. 1 bus we see that even in the face of easier recourse to operative delivery of present day practice, 90% or more of cases will deliver spontaneously, requiring of the medical at- tendant wise watchfulness and estimation of the situation, the maintenance of cleanliness, the moral support of the patient and her friends, her protection from excessive soft tissue damage, the repair of that which does occur, the exhibition of pain palliative agents, and appropriate care of the new-born. This sounds like, and is, a great deal, and would seem to give the lie to the statement quoted that such a case does not need a doctor. But a well-trained nurse-midwife might do all or nearly all of it competently. And the doctor errs most frequently in not being con- tent to do only these things. The most fre- quent valid criticism of him is, that goaded by his own limitation of time and the impor- tunities of the suffering woman, he is too ready to resort prematurely to operative de- livery in cases quite capable of spontaneous termination if reasonable patience be ex- July, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 547 ercised. The most frequent error observed in consulting practice is the "employment of for- ceps before there is full engagement of the head or full dilatation of the cervix. In reference to the last statement I would particularly stress certain definitions'. Full en- gagement of the head signifies such a degree of moulding that the maximum plane of the head must coincide with, and occupy, the least plane of the upper strait of the pelvis. Until this takes place the head cannot be extracted with forceps without undue trauma. If ad- ditional time for spontaneous moulding fails to attain this object, cesarean section must be considered as an alternative, unless contra- indication exists to the latter procedure. Yet in many cases, before the greatest diameter of the head is actually engaged, the elongated peak thereof will be well down in the pelvis, and give to the person of limited experience a false estimate of the progress of accommo- dation to the inlet. The complete dilatation of the cervix is in itself a good gauge of the complete moulding and partial descent of the head. It must he not only dilated, but retracted, so that no por- tion of it can be felt around the head except perhaps a small segment anteriorly. Only in the presence of such conditions should the forceps be used without the grav- est consideration. For to do so endangers the integrity of the cervix and the contiguous soft parts, and constitutes a grave jeopardy to the baby. Yet, frequently one receives in the hos- pital or sees in consultation cases in which these inhibitions to the use of forceps have been disregarded with pitiable results. Morphin or one of its equivalents is the great conservator of the natural expulsive forces which will frequently convert a dif- ficult, dangerous, so-called “high forceps” ex- traction into a relatively safe and much sim- pler operation. This brings us to the second part of the aphorism quoted above, to the effect that a case needing operative relief “needs 2 doc- tors”. Is this true? Yes, emphatically. There are vaudeville performers who win applause, and. one hopes, a livelihood, from their abil- ity to play a whole orchestra of instruments at once, all by themselves. But for a man conducting any manipulation upon which 2 lives depend, to attempt alone to perform the duties of anesthetist, assistant, instrument nurse and operating surgeon, is fool-hardy in the highest degree. No young practitioner is too poor to pay the extra expense for help, himself, if necessary ; no old practitioner is so extra good that he can always get away with- out it successfully. I know, because I have been all the things named ; young — poor — foolhardy — and am getting old. Ideally, of course, all such cases should be institutionalized. In saying this I know the re- luctance of certain types of people to leave their homes under even urgent circumstances. This can usually be overcome by sufficiently strong representation of the situation, how- ever, especially if backed up by a threat to otherwise resign the case. It may be urged that closed staff arrangements in the several hospitals preclude universal reference of com- plicated cases to institutions, yet there have always been available for financially compe- tent patients, accommodations in institutions with “open” or “courtesy” privileges extended broadly to the profession. In cases financially incompetent the desire to retain the case at the sacrifice of the patient’s interest may be more selfish than conscientious. The conservation of the physician’s time and nervous energy in having his patient un- der competent nursing observation, the as- sistance of interns, and the facilitation of his own work by adequate equipment, will pay him for insistence on institutional care apart from considerations of his patient’s welfare. Finally, I think the practitioner should re- member that obstetricians are available for consultation. Recently a physician said to me — “I always feel stultified in calling an ob- stetric consultant.” I said: “Why? You would not hesitate to call an internist in a case of pneumonia for which it is probable you would lie doing all that he could suggest your doing. Certainly you would promptly call a surgeon should you diagnose acute appendicitis or mastoiditis. In neither case would you feel ‘stultified’ nor would your patients impute in- capacity to you. To feel differently about an JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 548 obstetric case presenting unusual difficulty, is either to deny equal importance to a matter involving 2 lives or to deny to all your col- leagues experience and dexterity possibly su- perior to your own.” Obstetrics should be conceived by the gen- eral practitioner, not as a necessary nuisance, but as an important, dignified branch of medi- cine belonging peculiarly to him, worthy of his most painstaking, conscientious service, in which he should avail himself when neces- sary of the cooperation of experts to the end that mothers and babies may receive the full- est benefits that modern surgical science is capable of affording them. CONSIDERATION OF THE CAUSES OF DIARRHEA* E. W. Rodman, M.D., Beverly, N. J. When the term “diarrhea” is used one im- plies a lessened consistency and usually an in- creased frequency of the stools. The lessened consistency need not be extremely marked, be- cause we may consider it as diarrhea where there are but a few soft stools in which mucus, pus or blood is noted. Diarrhea includes not only the forms due to disease of the gas- tro-intestinal tract but also those due to con- ditions arising outside of the tract, such as are observed in toxic states and in disturb- ances of the nervous system of a functional nature. Loose movements are usually caused by stimulation of the bowel due to increased peristalsis which may be found in both the large and small intestine. Irritating sub- stances may cause the fluid contents to be carried rapidly into the colon, preventing ab- sorption in the small intestine, or causing an outpouring of water from the blood into the bowel with increased production of fluid or mucus. Again, the increase in peristaltic movement may be due to lesions in the bowel itself, such as inflammatory changes, ulcer- ations, growths or obstructions. ‘(Read at the Burlington County Medical So- ciety meeting of January 14, 1931.) In studying the causes of diarrhea it is im- portant to determine the intestinal site of the disturbances and note whether or not the per- istalsis of the small bowel is increased with that of the large. When diarrhea originates in the small intestine the stools show an acid re- action, food particles poorly digested, mucus intimately mixed with the feces, and unre- duced bile pigment. When it originates in the large intestine the stools show usually an alka- line reaction, food particles well digested, free mucus and reduced bile pigment. Like most other medical subjects, the diar- rheas may be divided into acute and chronic forms. Most of the acute forms will fall into 1 of 4 large groups : (1) Diarrhea due to improper food. In- discretions in diet with a resultant gastro- enteritis are often followed by diarrhea. The food may be coarse, improperly prepared, not thoroughly masticated, taken in too large quantities, or too hot or too cold. A violent diarrhea usually accompanies food poisoning from tainted meat, sausage, milk, fish, spoiled vegetables and food infected with various microorganisms. (2) Diarrhea from intoxication other than foods. This condition may be caused by poi- sons or medicine. Drugs such as mercury and arsenical preparations, and drastic purges such as jalap, senna and podophyllin are examples. Poisons such as phosphorus, mineral acids, alkalies and bichloride of mercury may cause acute diarrhea when taken internally. (3) Diarrhea in acute infectious diseases. In acute infectious diseases, like measles, in- fluenza and pneumonia, diarrhea is often secondary to the associated gastro-enteritis. The specific infections in which diarrhea is preeminent are typhoid, cholera and dysen- tery. (4) Diarrhea from nervous influences. This type of diarrhea is a result of either excessive stimulation of the nerves controlling peris- talsis or from the pouring out of serous ma- terial into the bowel, produced by nervous in- fluences. 1 he stools in acute diarrhea are frequent and watery, contain mucus and undigested food, and there is generalized abdominal pain. July, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 549 lack of appetite, weakness and malaise. When there is an associated gastro-enteritis the nausea and vomiting may overshadow the in- testinal condition. In severe cases, fever and albuminuria are present and an alarming state of weakness may ensue. Nervous diarrhea usually has a sudden onset and terminates rapidly. This condition often appears in in- dividuals in normal health when overworked or under a strain, as for instance in students preparing for examinations. There may be a few or many watery, thin stools a day with a small amount of mucus and undigested food particles. It is extremely difficult to arrange a satis- factory classification of the varieties of chronic diarrhea. The causes are many, and today with the finer methods of diagnosis the group is an extremely large and diversified one. Moreover, no matter what classification is made, some of the groups will be very similar and will overlap, and this increases the diffi- culty in differentiation. The following is the classification of Friedenwald and Morrison, based so far as possible on etiology of the con- dition. Diarrhea due to achylia gastrica. While about 30% of the patients affected with achylia gastrica present diarrhea, it may also occur as a result of the diminution of gastric secretion in chronic gastritis. It is believed that owing to the lack of digestion in the stomach, caused by the lack of HC1 and the lessened pepsin secretion, undigested food is thrown quickly into the bowel and acts as a mechanical irritant. It also often happens that because of impairment of activity of the pancreatic secretion, due to the absence of HC1, fermentation occurs in the intestine and produces diarrhea. In the early stages diarrhea is intermittent with periods of well being extending over days or weeks; it soon becomes more frequent, until it is almost constant. Often, most of the stools occur before noon, are yellow in appearance, foul smelling, and contain undigested food, mucus, and sometimes blood. A fractional gastric analysis reveals an absence of free HC1. Diarrhea due to disturbances of pancreatic function. In diseases of the pancreas there are often large irregular stools with alternat- ing constipation and diarrhea. Deficiency or absence of pancreatic ferments may be deter- mined by use of a duodenal tube, and a con- stant absence of one of them is, according to Einhorn, indicative of chronic pancreatitis. Here we have marked diarrhea, emaciation, colicky pains, and often sugar in the urine. Diarrhea is often intense in carcinoma of the pancreas, with occasional fatty stools. After a time jaundice appears, the liver enlarges and becomes nodular, the urine contains sugar, and cachexia is evident. This affection is so fre- quent that whenever a persistent diarrhea is observed in a person over 40 years of age,, which cannot be accounted for by the usual causes, carcinoma of the pancreas should be borne in mind. Pancreatic cysts give rise to> diarrhea not only on account of the disease present in the pancreas, but also due to the pressure on the abdominal organs as well. Diarrhea in disturbed liver function. In a small percentage of cases of disturbances in hepatic function, diarrhea appears, but consti- pation is the rule. Cases described as bilious- ness or “torpid liver", the Lyon method of nonsurgical drainage of the biliary tract has shown to be due to infection in atonic gall- bladders. These patients are sallow in ap- pearance, weak, affected with indigestion, and are frequently the subjects of sick head- aches and migraine attacks. Constipation is usual, but a certain few have identical symptoms with the exception that the consti- pation is replaced by diarrhea. In Weil’s dis- ease, together with the chills, fever, headaches, muscular pain, jaundice and gastro-intestinal disturbances, diarrhea is usually present. It is not uncommon in active and passive con- gestion of the liver and also in atrophic and hypertrophic cirrhosis. Diarrhea due to chronic intestinal catarrh. Chronic enterocolitis often results from an untreated or unhealed acute catarrh ; it is often caused by an abuse of laxatives and errors in diet. There is usually a persistent diarrhea extending over several years with frequent acute attacks associated with pain and tender- ness over the colon. The stools are thin, wat- ery, offensive, contain considerable mucus and vary from 3 or 4 to 8 or 10 a day. In intes- 550 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 tinal fermentative dyspepsia, carbohydrates are digested imperfectly, and the undigested matter undergoes fermentation, becoming acid, producing gas and giving to the stools a putty, foamy appearance with very sour odor. In addition to the diarrhea, abdominal pain, gurgling and distention are often noted. This condition may be primary disease or secondary to catarrhal affections of the intes- tines or to achylia gastrica. Ulcerative colitis, sigmoiditis and proctitis. Of the ulcerations of the large bowel leading to diarrhea the most frequent are entamebic, bacillary, tuberculous, syphilitic and carcino- matous. Entamebic dysentery. This is a frequent form of dysentery, and the entameba should be looked for in all cases of chronic diarrhea. In doubtful cases the organisms are best ob- served in scrapings obtained from ulcerations, through the proctoscope. In this disease there are 10 to 20 stools a day containing mucus, pus and blood. When the stools are passed the patient is affected with colicky abdominal pains, often associated with tenesmus, and in addition there are fever, emaciation and ex- haustion. Bacillary dysentery. The symptoms are similar to those in the entamebic form with the exception that the bacilli are found in the stools and will agglutinate with the blood serum. Tuberculous ulcerations. Tuberculous ul- cerations are very common complications of chronic pulmonary tuberculosis, and the diar- rhea is most pronounced when the lesions are in the lower bowel. Pain is a frequent symp- tom, occurs in the lower abdomen, and is most severe before the passage of a stool or after taking food. Mucus is mixed with the stools and there is also usually a small quantity of blood. The finding of tubercle bacilli in the stools is of little diagnostic significance. In some cases the tuberculosis is localized about the ileocecal region, and a mass is frequently felt resembling a malignant growth. In these cases, in addition to the paroxysmal pain, diarrhea alternates with constipation. Syphilitic ulcerations. Luetic ulcerations of the small bowel are very rare, the most com- mon being in the rectum. The picture is very characteristic; the ulcer is elevated, with in- durated edges and a smooth base, and there is some stenosis of the bowel which gradually increases. A positive Wassermann reaction makes the diagnosis more certain. There is usually diarrhea, but the stools may be semi- solid ; considerable amounts of mucus and sometimes shreds of tissue are found. The appearance of large amounts of blood is rather rare. Carcinomatous ulceration. This may occur in any part of the colon. Symptoms of in- complete obstruction appear early and are manifested by attacks of colic associated with constipation ; soon, blood or bloody stools ap- pear from the ulceration. When the neoplasm is in the rectum there is usually a constant desire for bowel evacuation, accompanied by a discharge of gas with mucoid material. As the condition advances, ulceration appears and there is a marked diarrhea of small waterv stools containing blood and mucus. Mucous colitis. There are 3 theories con- cerning the etiology of this disease; first, that it is entirely a nervous affection and that the mucus is purely a nervous hypersecretion ; sec- ond, that it is due to a catarrh of the bowel ; and third, that the disease is due to both a nervous irritation and a catarrhal condition. The signs noted are frequent attacks of col- icky pain in the abdomen, expulsion of mucus in the form of a membrane, and often diarrhea. The liquid movements always con- tain much mucus in the form of shreds, bands, or even complete casts of the bowel. Simple colonic infections. Among infections of the bowel that may give rise to persistent diarrhea (not including the amebic and bacil- lary forms) are various microorganisms, in- cluding tapeworm, hookworm, whipworms, flukewornis, strongyloides, and various flagel- late parasites. Diagnosis can usually be made by careful examination of the stools. The diar- rhea usually appears suddenly and without any apparent cause ; stools are evacuated with much gas, but without pain, and are alkaline, soft, contain mucus and blood, and have an ammoniacal odor. Intestinal obstruction and stasis. When the obstruction is incomplete, constipation alter- nating with diarrhea is found. Together with July, 11)31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 551 the diarrhea there is abdominal distention, colic and difficulty, and often inability, in expelling gas. As the bowel becomes almost completely blocked, dilatation is observed in the area above the obstruction and the diarrhea is increased inasmuch as onlv liquid stools pass the ob- structed area. There are 3 well marked varie- ties of intestinal stasis that may give rise to persistent diarrhea. In the first the stasis is due to a dilated cecum, often in connection with a dilated colon. Because of the retention, fermentation is produced which is followed by diarrhea. In the second variety, on account of prolonged retention, the fecal masses are so channeled that the stools pass through in diarrhea form ; periods of diarrhea accom- panied by abdominal pain and distention are not uncommon. When the irritation extends over a long period of time, catarrhal condi- tions of the bowel are very common, and as a result of mjurv to the mucosa ulcerations may occur which further increase the tendency to diarrhea. In the third form of stasis, the diarrhea is due to a spastic condition of the bowel, giving rise to a frequent passage of small round fecal masses. The lower bowel is constantly filled with these masses, and irri- tability is produced with frequent desire for defecation with passage of watery stools con- taining mucus. Chronic appendicitis. It is sufficient to men- tion in passing that rarely diarrhea occurs when a chronically inflamed appendix is plastered against the bowel. Diverticulitis involving the sigmoid and rectum; polyposis of the colon. Diverticulitis is associated in its early stages with consti- pation, abdominal discomfort and a general distention from gas ; after a time, however, the constipation is often alternated with diar- rhea and pain becomes localized in the region of the sigmoid, producing symptoms like those of appendicitis but on the left side. I he lower bowel is filled with fecal masses which give frequent desire for defecation. Multiple polyps of the colon often give rise to severe diarrhea and hemorrhages. The movements are watery and consist largely of mucus and blood. Lesions of the brain and spinal cord. Diar- rhea is frequently noted in cerebral hemor- rhage, brain tumors, tabes, and transverse myelitis, the severity of the diarrhea varying with severity of the central involvement. Die slightest pressure exerted by the patient is often followed by the passage of liquid stools ; a cough or a sneeze may bring about a similar result and in some instances the movements may pass when he urinates or walks; in oth- ers he may be unaware of the bowel discharge, the stools passing unconsciously in liquid form. Disturbances of the , glands of internal secretion. The diarrhea in hyperthyroidism and in disease of the suprarenals has been ex- plained by the fact that due to a disturbance- in the internal secretions of the glands s. hyperperistalsis is produced. As has been noted above, diseases of the pancreas produce diar- rhea, the large fatty stools aiding in diagnosis, Diarrhea due to cardiorenal disease. In myocardial insufficiency, diarrhea is a fairly common symptom, due to the general passive congestion of the abdominal organs. That of nephritic origin is probably due to excretion into the bowel of irritating toxins, because the severity of the diarrhea usually varies with the exacerbations of the nephritic disease. In patients suffering with chronic nephritis over a long period of time, uremic ulcers have been observed in both the small and large intestine. Diarrhea associated with disturbed metab- olism. Pellagra, sprue and gout are the dis- eases in this group often accompanied by diar- rhea. In pellagra it is usually very severe and is accompanied by pain. The stools are either serous or bloody and often contain undigested food elements. In the late stages of severe cases an uncontrollable diarrhea occurs, which is a great factor in the final prostration. The diarrhea in sprue is very characteristic. At first it is accompanied by pain and tenesmus, the stools being liquid and dark; later the movements occur usually in the early part of the day and the pain and tenesmus disappear. The stool is copious, frothy and fermented, light in color and acid in reaction. Ulcerations of the colon may also play a part in the 652 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 causation. Gout is rarely complicated by diar- rhea, but when it is, other gastro-intestinal symptoms may be present, such as foul breath, furred tongue, flatulence and abdominal pain. Cholecystectomy. In a small percentage of cases there is a persistent diarrhea, the exact nature of which is unknown, but it is thought to be due to disturbed pancreatic secretion, since it has been found that the duodenal con- tents are deficient in ferments in these cases. Gastro-enter ostomy. Diarrhea may appear almost immediately after operation and is thought to be caused by the rapid discharge of undigested food into the bowel, setting up a mechanical irritation. Pyloroplasty. The cause of the diarrhea in these cases is similar to that in gastro-enteros- tomy but is never as severe. Appendectomy. Removal of a chronic ap- pendix is occasionally followed by a profuse diarrhea, due most likely to some injury to the adjacent bowel occasioned by the operation. Resection of the bowel. Often severe diar- rhea follows this operation, and is sometimes very alarming. It is not difficult to explain if the severe nerve injury inflicted upon the intestines by the operation is borne in mind. Nervous influences. These forms of diar- rhea have their onset often after severe ex- citement, worry or shock. The trouble is caused by hypermotility of the bowel, the stimuli being either psychic or reflex or a combination of both. The psychic variety is produced by worry or shock, while the reflex form occurs as a result of stimulus like sud- den chilling of the body. The onset is sud- den, with gurgling sensations in the abdo- men, while the patient is in good health. Be- tween the attacks there is no discomfort and all varieties of food can be eaten without causing recurrence. An examination of the stools shows no abnormal constituents, and there is very little fermentation. On account of the increased motility, undigested food par- ticles may be found. TREATMENT OF BRIGHT’S DISEASE* Rolfe Floyd, M.D., New York City. It is my purpose to define some of the prob- lems that arise in the treatment of Bright’s disease and to indicate how and to what ex- tent they may be solved. The conditions with which I shall deal are convulsions, uremia, dropsy and hypertension. Convulsions. The convulsions of Bright's disease have been called uremic for 3 gener- ations and believed to be due to poisoning of the brain by excess of nitrogen waste. In the last 2 decades this conception has been stead- ily losing ground for the following reasons: (1) The closely similar convulsions of child-birth are now known not to be uremic. (2) Many chronic nephritics die of uremia without having had convulsions. (3) Convul- sions are frequent in acute Bright’s disease when there is little or no uremia. Volhard believes, and many are in partial or complete accord with him, that most con- vulsions in Bright’s disease are due to inter- ference with the hloocl flow to the brain. This interference is thought to be brought about in 2 ways: (1) by spasm of the cerebral ar- terioles often superadded to a preexistent gen- eral hypertension; (2) by edema inside the skull compressing the brain and its vessels. Volhard states, and my experience coincides, that patients with general anasarca are less lia- ble to intracranial edema than those that have slight puffiness of the face and little dropsy elsewhere. When there is edema inside the skull lum- bar puncture often works excellently. A boy on my service with acute Bright’s disease had many convulsions within a few hours, increas- ing in violence and threatening life. He had another while lumbar puncture was being done but no more after that. When lumbar puncture fails, venesection should be at once resorted to? In cases that seem to be due to spasm of the cerebral arterioles a prompt re- *(Read at the Passaic County Medical Society meeting of February 12, 1931.) July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 553 duction of blood pressure is the indication and venesection the method of choice. Chloral and a quiet room are important after either puncture or blood letting. The great majority of convulsions can be successfully handled in this way, but I do not wish to convey the impression that we yet know just how they are caused or that retain- ed poison is not a factor in some of them. Uremia. This condition has been supposed to mean certain nervous and bodily symptoms due to poisoning by abnormal amounts of nitrogenous waste accumulated in the body through failure of the kidney to excrete them fast enough, but this primary conception has had to be modified in 2 ways : First, all the nervous symptoms are not due to nitrogenous waste, but quite a proportion result from a reduced blood supply to the brain. Hence, symptoms due to nitrogenous waste have been called “true” uremia, while those due to other causes have been called “false’ uremia. It is only of the “true” uremias that I wish now to speak. Secondly, none of the known nitrogenous waste substances causes uremia when artificially introduced, so the toxic sub- stance is yet unknown, but it occurs in quite definite proportion to those that are known. Hence, uremic symptoms hardly occur until the NPN, which is normally about 25 mg. to every 100 c.c. of blood, passes 100 mg. This figure is not absolute but is a convenient one to remember. On the other hand, uremic death hardly ever occurs below 250 mg. and may not occur till 500 and over is reached. So, while estimation of NPN is an invaluable guide, it is not an actual measure of the toxic substance itself. It is as impossible to treat a uremic intelligently without blood chemistry determination as it is to treat a cardiac irregu- larity without an electrocardiogram. There are 2 main ways in which NPN in- creases in the blood which depend on 2 sep- arate functions of the kidney in dealing with nitrogen waste. The separation of these func- tions is not sufficiently explained in most books on the subject yet an adequate under- standing of the treatment of true uremia de- pends on proper understanding of these 2 functions and of how they interact. In the first place, the kidney extracts urea from the blood, and in the second place it puts the urea into the urine. As it cannot store urea in any considerable amount within its cells, the amount of urea that it can extract from the blood becomes quickly dependent on the amount it can put into the urine. Very few normal kidneys can put more than 40 gm. of urea into a liter of urine (or 4%) and the ordinary urine output is between 1 and 2 liters a day. On ordinary diet and activity a human being furnishes some 20 gm. of urea for excretion per day, so the maximum is about 3 or 4 times the normal demand, not an enormous reserve as bodily functions go. Many people in middle life even without any manifest kidney disease cannot put over 20 to 25 gm. in a liter and it is an important fact that this power to concentrate urea in urine may weaken very rapidly under strain. By strain I mean the demand for constant maximum concentration over a period of days. On the other hand, it may recuperate as rap- idly when the strain ceases. .It is evident that the way out of such a difficulty is to increase the urine volume, and this is exactly what happens in chronic ne- phritis when large volumes of low gravity urine are passed, the low gravity necessitating the large volume. Any condition that leads to continued low urine volume may easily lead to a rapid rise of NPN. Prolonged vomiting, so that little fluid is taken and some lost, is a classical cause. I recall a vomiting gastric ulcer patient with apparently normal kidneys whose NPN was found to be 150 mg. and dropped to normal in a week with administra- tion of fluid by other channels. After surgical operations postanesthetic nausea results in small intake, and a totally unsuspected uremia creeps in. About the seventh day the patients look badly and by this time it may be too late to save them. A gall-stone patient whose blood chemistry and urine were normal before operation was lost in just this way. The way to avoid these accidents is to un- derstand the genesis of this kind of uremia, to keep close watch of the NPN when urine volumes are low, and to begin forcing fluids before dangerous figures are reached. The ways to get the fluid in are various. The 554 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY •Tilly, 1931 stomach is the best route. When nausea blocks this, the duodenal tube may occasion- ally be used. Four ounces of tap water every 3 hours per rectum is well tolerated by some patients, the Murphy drip by others. If the rectum proves intolerant, the subcutaneous tissue may take up a lot, but is liable to get sore from repeated clysis. In children, the peritoneum has been much used. Venous in- fusion is a standard method. However much you put in, by any or all these channels, you must realize that you do no good unless it comes out as urine. These large amounts of fluid may act viciously in 2 ways : first, they may strain the heart, and secondly, they may simply add to edema without increasing the urine; \y2 liter of water caused edema of the lungs in one patient, but, fortunately, an immediate venesection saved him. Let me urge you not to be faint-hearted in the pres- ence of extreme uremias of this type. There are 2 cases in my records of patients whose NPN reached 400 and yet was reduced to normal. As much as 8 liters of fluid in 24 hours have been given without doing harm. Stimulating other channels of elimination is a method doomed to failure in this condition because no other organ can replace the kidney in this most fundamental function of getting rid of nitrogenous waste. The diminution of urine through purging and sweating is apt to do more harm by reducing urine volume than can be compensated for by the amount of nitrogen that is gotten rid of in the diarrhea and the sweat. Moreover, both these proce- dures when carried to emergency extremes ex- haust the patient. Blood letting is of little avail because it cannot be repeated. With an NPJNT of 300 mg. per 100 c.c., for instance, 500 c.c. of blood only contains 1.5 gm. of NPN; while 500 c.c. of urine contains 5-10 gm., even if the con- centrating power is weak. The only way then to save these patients is by increasing urine volume, and the one best diuretic for this pur- pose is water in large amounts. The second type of uremia which occurs in chronic nephritis need not detain us long be- cause there is so little to do for it. It re- sults from the failing power of the kidney to extract urea from the blood. The stimulus that makes the kidney take urea from the blood is the presence of urea in the blood. As the kidney becomes less responsive this stimulus has to be increased in order to drive the kidney to excrete the daily accumulation. In this way, the NPN slowly rises, often very slowly. There is an old painter working at the hospital whose NPN has remained be- tween 75 and 100 for the past 5 years, with- out causing any uremic symptoms. In his case this stimulus is enough to drive his kid- ney to do its work from day to day. This, how- ever, is a dangerous situation, for as the kid- ney loses power the NPN must keep on ris- ing to make it do its daily work, and finally reaches the point where the NPN accumula- tion in the blood and body becomes toxic and dooms the chronic nephritic to die from the adaptation which had helped him to live. The condition is a hopeless one because we know of no other stimulus that will drive a worn- out kidney to excrete enough nitrogen. We stop the ingestion of nitrogenous food but accomplish little because nitrogenous waste is formed from the body tissue, as well as from nitrogenous food, and if we give less than about 50 gm. protein, enough of the body protein to make up the balance will be used as food and we only make a bad matter worse. Reduction of protein in the food, a sufficient urine volume, occasional blood letting and glucose infusions, all delay the tragedy a little, but if the uremia is high and of the second type a fatal termination is still in- evitable. It is by no means easy to be sure of the genesis of the uremia in every case and so we always try forcing fluids if the heart will stand it. but in a late chronic nephritis with a failing hypertensive heart, extensive changes in the eye grounds, an NPN of 200, and de- veloping uremic symptoms, the outlook is grave in spite of any treatment. Morphin should be freely used to relieve the pathetic suffering of these patients. Dropsy. The normal consistency of the var- ious tissues depends largely on the presence in them of a certain amount of water. When the tissues are dehydrated they become shrunken and firm; when they contain too much water they become swollen and soft. July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 555 When this increase in water becomes so °reat that an incision causes the fluid to come out in drops, the condition is called dropsy. When dropsy occurs in the walls of a serous cavity the fluid collects in the cavity, sometimes in large amounts. When it oc- curs in a mucous membrane the fluid exudes from the mucous surface, as into the lung, the nose or the bowel; when it occurs inside the skull, it is often produced with sufficient force to increase intracranial pressure and re- strict the blood supply to the brain. General dropsy occurs most frequently with cardiac and renal disease but its genesis is very complex. Fluid reaches the tissues only through the capillary walls, while it is drained from the tissues both through capil- lary walls and the lymph channels. In other words, we believe that food and oxygen are carried from the blood stream to the tissues as an aqueous solution which passes out through the capillary wall, and that carbon di- oxide and waste products, similarly dissolved in water, pass from the tissues to the blood stream through the capillary walls, except for such as are exhausted through the lymph. In other words, there are 2 streams, opposite in direction, constantly flowing through the cap- illary walls. We do not know whether these streams occur alternately in the same capillary or if some capillaries subserve the purpose of outflow while others subserve that of intake. We do know, however, that normal tissue moisture results from a balance between the volume of outflow from the blood, and the in- flow to the blood plus the lymph flow, and that dropsy is the result of a predominance of out- flow over exhaust. The factors which control this exchange of fluid between the tissues and the vessels are very imperfectly understood. I wish to men- tion some of them. Salt exchange is the chief adjuster of osmotic pressures in the body fluids ; so, when salt accumulates in a tissue water regularly follows it so as to prevent a rise of osmotic pressure to a mischievous level in the tissue concerned. Widal and his fol- lowers believed that dropsy was caused by the deposit of an abnormal amount of salt in the tissues and the resulting accumulation of enough water to adjust the osmotic pressure. They showed patients who could be made dropsical or normal by simply varying the salt in the diet, and I have seen such. They showed that extra salt caused sudden rises in body weight and vice versa. There can be no question that salt is an important factor in dropsy, but it is by no means the only one. The colloids exist in the body as jellies ; that is, they are combined with a certain amount of water. And the jellies which they form may be thicker or thinner ; that is to say, under influences which apparently do not change the chemical structure of the colloids, the amount of water which they can bind varies considerably. Moreover, the colloids do not pass through animal membranes nearly so readily as the crystalloids. So the blood protein tends to stay in the blood stream while the salt may easily escape. Similarly, the tissue colloids stay outside the blood stream. The enthusiasts hold that blood-tissue water ex- change depends on the amount and the water- binding power of the colloids inside and out- side the capillary wall, and that normally the blood-water is kept inside the vessels by the water-holding power of the blood 'colloids. They regard the dropsies that occur when the blood proteins are reduced as due to this fact. While this whole subject is difficult, there is a strong leaning on the part of many able in- vestigators to regard the relation between col- loids and water as another important fact in water distribution within the body. Krogh has shown that the capillary bore is controlled by a hitherto unknown set of con- tractile cells applied to the outside of the capil- lary walls and under the control of a separate set of vasomotor nerves. It is further known that when the capillaries are dilated the out- flow through their walls becomes greater than the inflow ; in other words, wide capillaries tend to “leak”, and this leakage ceases when they again contract. So capillary dilatation is another factor in the production of dropsy. Hydrostatic pressure rising above normal inside the capillaries favors an excess of out- flow through the walls. Perhaps it does so by causing dilation. At any rate its effect is seen every day in the marked influence of gravity on the site of edema. When capillary circulation slows below the 556 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 normal limit ( stasis ) “leakage” is favored. Perhaps it is because the capillary walls suffer reduction of their oxygen supply. The least understood and probably the most important factor in controlling the water ex- change is the life activity of the endothelial cells which form the walls of the capillaries. How they govern the 2 opposite currents is as unknown as how the brain cells produce thought. This factor, though unknown, must never be forgotten in considering a dropsy. When we are faced with a dropsy it is well to bear in mind just what we wish to ac- complish. First, we must induce a flow of tissue fluid into the vessels greater than the outflow from them. Then we must induce some excretory organ to pick up this extra water from the blood and eliminate it from the body. Unless both these things happen the dropsy will remain. The kidney may be stimulated but the tissue fluid fail to move; on the other hand, the kidney may fail to pick up the extra water from the running blood. It is not surprising, in view of the com- plexity of the problem, that the most effective treatment of dropsy is primitive and empiric rather than rational. We can mitigate the influence of gravity by putting the patient to bed; wre can foster the speed of the circulation by cardiac drugs; we can limit the supply of dropsy, forming sub- stances by reducing the intake of salt and ■water ; we can try to increase the blood col- loid by infusions in gelatin or a protein-rich diet ; we can remove some of the accumulated fluid by puncture; but when it comes to di- rectly influencing the flow of the dropsical fluid back into the vessels, that is a harder matter. Here, as in uremia, the one important chan- nel of escape, besides the puncture needle, is the kidney. We see dehydration from dysen- tery, but I have never seen a dropsy cured by inducing a diarrhea. Free bowels help a little but not much. Similarly, I have yet to see a massive dropsy sweated out. A French writer says that the edematous patient “urinates into his tissues” ; and the problem is to make him urinate into his blad- der. With this purpose in view, we give drugs which have been found by experience to in- crease the flow of urine. Of these, the most used are the purine group, caffein, theocin, and especially diuretin. As we all know, they often start a urine flow but fail to maintain it. The stronger ones may irritate the kid- ney. Like all diuretics, they work better in cardiac dropsies than in those associated with renal disease. Many of the inorganic salts have a diuretic effect, and of these the acetate and citrate of potash are most used. They do not irritate, but frequently fail. Urea is recommended as non-irritant, but it has to be given in such large doses that the stomach often rebels; 20 to 100 gm. per day is a good deal to stomach, and what experience I have had with it has not been very encouraging. Of all diuretics there is one that stands out, and that is mercury. It may be given by mouth, as calomel, and I used to have success with Guy’s pill — calomel, squill and digitalis, 1 gr. each. The new preparations, novarsurol and salyrgan for intramuscular use, are cer- tainly remarkable in their effects ; they surely influence water exchange and stimulate the kidney at the same time, but must not be used in severe or acute renal inflammation because they irritate in stimulating. They may cause stomatitis or colitis, though I understand that salyrgan very rarely produces toxic effects. One word about puncturing dropsical legs, as all writers stress the danger of fatal infec- tion from this procedure. When an intern, I hastened a death that way and consequently for many years have watched cardionephritics die with massive dropsies, feeling content to let them do so without trying leg puncture. Two years ago, persuaded bv something I had read, I tried making a cut about j/2 in. long in the skin on the outer side of each ankle. The patient had a huge anasarca and had to sit in a chair to breathe. Diuretics had failed utterly. The incisions were made under strict asepsis and dressings were changed with as much ease as if the wound were into the peri- toneum or into a joint. He drained 1 to 3 liters a day through these wounds, and after the legs began to shrink a copious urine flow began spontaneously and the dropsy completely disappeared. Subsequent attempts have caused no infection, so I have become a convert. If you try it, remember the risk, and carry out July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 557 the strictest asepsis till the wounds are com- pletely healed. Hypertension. The immediate genesis of hypertension is easier to understand than that of dropsy, but its treatment, in general, is less successful. Hydrostatic pressure of the blood within the arterial tree depends on 3 varying factors : the volume that is in the tree, volume that is being pumped in, and volume that is escaping. The arterial tree is a reser- voir with elastic walls and the fuller the res- ervoir the greater the pressure exerted on the contained blood. This reservoir has one in- flow from the heart and many outflows through the arterioles. The blood com- ing in tends to distend its walls and so raise the hydrostatic pressure of its fluid contents. The blood that escapes allows the walls to shrink and so lowers 'the hydrostatic pressure of contained fluid.’ The relation of inflow to outflow then determines the pressure. Re- duction of inflow regularly lowers pressure ; we see this every day in failure of the heart. Reduction of outflow causes increase of pres- sure. Normally, blood supply of the various or- gans is constantly increased or decreased, ac- cording to their changing needs, by dilatation and constriction of the arterioles through which blood must reach them. Yet this con- stant shifting is accomplished, except in con- ditions of unusual activity, without any sig- nificant departure from normal blood pres- sure. If, however, the average tonus of all the arterioles rises the total capacity of their myriad opening's becomes less and outflow from the tree as a whole is reduced. This re- sults in a rise of blood pressure, and is the predominant cause of blood pressure as we meet it clinically. The cause of this increase of average tonus is not well known. One of the theories about it is that it is a beneficial adaptation for in- suring the necessary blood supply to vital organs when their vessels have become nar- row through sclerosis, and therefore no at- tempt to reduce it should be made. The kid- ney requires more blood in proportion to its size than almost any other organ in the body. When we look, after death, at a kidney whose arteries are so sclerosed that their bore is re- duced to perhaps normal size, and con- sider the possibility if their dilatation is pre- cluded, it is not hard to believe that the blood flow to all the rest of the body must have been restricted through arteriole contraction in or- der to insure the kidney its proper share of blood. In many other cases we find no such basis at autopsy for explaining the purpose of the increased pressure which had existed dur- ing life. That hypertension shortens life, chiefly through heart failure and apoplexy, there is no question; it also limits the func- tional power of the patient while he lives. The higher the pressure the more trouble it makes. When it falls, as the result of rest or any other indirect cause, the patient is regularly benefited. When it is reduced by direct treatment, even over short intervals, the pa- tients are benefited. Perhaps when we get more potent remedies to lower it we shall find cases with sclerosed kidney arteries in which we may do harm by trying to reduce it too much. In the present state of our knowledge, however, I think we are justified in always trying to reduce it to as near normal as we can. A good deal of sanity is required in hand- ling hypertension cases. The condition is of bad prognosis, and yet patients carry it for years without apparent damage. I recall 2 patients, 1 still under observation, who have had pressures well over 225 for 10 years with- out any symptoms, without retinal changes and without any pronounced enlargement of the heart as seen by x-rays. So, it is bad practice to talk too much of its dangers. Then again it is always difficult to fail gracefully. After telling the patient that he is fortunate to have consulted us in time, and trying one plan after another with no success, it is a little awkward to say that his pressure had better not be reduced, as it is a beneficial pro- vision of nature in his case. I quite under- stand the psychology of physicians who feel that this is one of the times when it is best for the patient not to know the full truth. If we look dispassionately over the list of methods for reducing blood pressure, this fact stands out; there are many effective methods of reducing it, but not one method that can be thoroughly relied on to keep it down. The 558 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July. 1931 one certain way to reduce it in a crisis is vene- section. This reduces the volume of blood in the arterial tree and if enough blood is let the pressure is bound to fall. The blood volume is so quickly restored, however, that the pres- sure often rises to its former level within 24 hours and the procedure cannot be often re- peated. Some clinicians bleed plethoric hypertension patients every month or so and report benefit, but this use of the method can hardly prove generally helpful. Rest, sweat- ing, sedatives, arterial dilators, all help tem- porarily, but when ordinary activities are re- sumed the pressure is apt to come back. When we turn to examine the question of more prolonged effects we find that potas- sium iodide, the reliance of the former gener- ation. has failed to prove its effectiveness and is no longer thought to hold the blood pressure at a lower level than it would lie if the potassium iodide were not taken. Chloral and aconite work in some cases, but for a time only. Good reports of liver extract and watermelon seed have been recently published, but these reme- dies are still in the experimental stage. A mode of life which permanently removes the strain and effort is quite effective for con- siderable periods, but it is impossible to per- manently reduce the strain of life enough in most of our patients to significantly reduce the blood pressure. There is only one method that has worked for me and that is the salt- free diet. Salt privation is recommended more or less generally in dropsy, but regarded as useless in hypertension by most competent ob- servers. My experience with it in hyperten- sion has been so convincing that I wish to discuss it with you at some length, not only in relation to hypertension hut also in regard to dropsy and inflammation of the kidnev. The salt-free diet was suggested by Widal and Javal, about 1900. as a result of their work on salt and dropsy. After trying it, the French also believed that salt irritated an in- flamed kidney and that it caused increase of blood pressure, so they recommended salt privation in these conditions also. Salt is a threshold body ; that is, it is only taken from the blood by the kidney and put into the urine when its percentage in the blood rises above a certain figure, known as the threshold point. This threshold point is about 0.55% or about 5.5 gm. in a liter. There is reason to believe that this threshold may move up and down. If salt is excluded from the diet and large quantities of water are drunk and voided, a urine without any salt is produced, while the salt in the blood remains at the threshold point. So. a salt-free diet simply removes the excess of salt ; it does not deprive the bodv and blood of salt. Another point to remem- ber is that salt is neither formed nor destroyed in the body to any considerable extent, so that the output approximately equals the in- take and we are not faced with the difficulty met with in uremia, where taking protein out of the diet cannot prevent the accumulation of nitrogen waste in the body. Dropsy cases react very differently to the salt ration. There are cases of massive dropsy that will completely disappear within a few days on salt privation and will reappear as promptly when salt is again given. These dropsies, in ordinary language, are due to salt and can be cured by taking salt away. Un- fortunately, they are the rare exceptions. A great many dropsies can be made definitely worse by excess of salt in the diet and can be made a little better by salt privation. Some severe dropsies are not at all reduced by salt privation. We do not try to make them worse by giving it, but there is evidence that salt may increase the dropsy in such cases. It is, therefore, proper to reduce the salt intake to a minimum in every dropsy. Salt is the basis of all good seasoning and the salt-free diet is so insipid to some patients that it interferes with their taking enough to eat. When salt privation is doing no appar- ent good and tasteless food is causing a loss of nutrition, enough salt should be given to make the food palatable. In hypertension, many good observers have tried salt privation and report that it yields no results ; among them Munk, Lichtwitz in Germany, Christian in Boston, and many competent men in this city. Others have had success with it. It is difficult to understand these completely opposed views. As I am an advocate and in the minority, let me state my experiences and leave judgment to you. There are many cases on my office records July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 559 of patients in middle life who have come with pressures between 200 and 240, who have been put on a salt-free diet without any medi- cation and without any modification of their modes of life, and who have returned to the office in a week or two with pressures of 140 to 160. This fall in pressure has been main- tained for many of them as long as they have consented to follow the strict diet. I have similar records of hospital cases, but their rest in bed and other treatment might easily have produced the result, and the follow-up has been much less accurate. There is 1 case of a school teacher who had a blood pressure of 220 for 3 years, who was then put on a salt-free diet and whose pressure has remain- ed around 160 for 10 years. On occasions she breaks over the diet restrictions and the pressure rises, only to fall again when .the strict diet is resumed. There are other records of patients whose pressure has been only slightly reduced, and there are many records of cases in which the salt-free diet has not reduced the pressure at all. It is my im- pression that in nearly J4 the cases of hypertension, as they occur in office practice, a notable reduction can be attained by this plan. In the advanced nephritics in the hos- pital wards it yields much less. There is perhaps a reason why some clini- cians have found it futile, and that is the salt has not been sufficiently restricted. Salt priva- tion will 'usually not affect blood pressure until the diet contains less than 2 gm. per day, and in some cases not until the salt intake falls be- low 1 gm. In hospital work, diet errors often creep in. As the salt output approximates the intake an excellent and easy check is to de- termine the amount of salt in the 24 hr. urine. Even in private practice it is surpris- ing how often salt outputs above 2 gm. are found in patients who intend to cooperate in every way. I believe that many clinicians who doubt the efficiency of the salt-free diet have not instituted such checks. Perhaps another reason for its disrepute is because many clini- cians have tried it first on advanced ward patients, and, obtaining no results, have hesi- tated to force its discomfort on their private patients. The French writers believe that salt is a kidney irritant and so avoid an excess of it in acute renal inflammation. Many authors fol- low this restriction, probably because edema also is apt to occur in such cases. My belief in the salt-free diet was deeply rooted by the following case : A man, 30 years old, was admitted to the hospital June 5, 1923. He had scarlet in childhood. Had a bad sore throat during the previous January. On February 13, 1923, he went to bed with a little dropsy, right hydrothorax, and obstinate nausea and vomiting, which latter persisted till his admission. His urine contained some albumin. On February 18 he had 6 convulsions and was delirious. On April 24 he had 7 convulsions, and following these his sight failed till he was totally blind by May 5. On May 1 his NFN was 37 mg. The family money was exhausted and he was sent to the hospital to die. On examination, he was emaciated, very sick and totally blind. The eye-grounds showed a mass of hemorrhages and patches and the disc outlines were completely lost. Blood pressure was 200/140. The heart was large, with a diffuse apex beat, accentuated second aortic, and an apical systolic murmur. The urine contained a heavy trace of albumin and some casts. There was no edema. He was not anemic. NPN was 51 mg. He was put on a salt-free diet and 2 tests of his 24 hr. urine showed 1.9 gm. and 1.3 gm. respectively. No other treatment, except nursing, was tried. In a week he began to improve. By June 18 he was out of bed. On July 21 he was discharged. He could then read the headlines, all his other symptoms were gone, the eye-grounds looked remarkably better, his NPN was 39 mg., he had gained about 20 lb. weight and his blood pressure was 148/95. I kept track of him until the end of 1926, when he left the city for business reasons. He went to work Jan. 1, 1924. During the following 3 years he worked hard and was well. His eye-grounds healed so completely that the surprised eye specialist, who had seen him in the hospital, pronounced them practically normal. His sight was normal and blood pressure remained near 140/90. Urine continued to show a trace of albumin and a few casts. NPN was 40 JOURNAL OF THF. MEDICAL SOCIETY OF NEW JERSEY July, 1931 5(>0 mg. at his last visit. Weight rose to 158 lb. He remained on a salt-poor diet. I am sure if any one reports a similar case treated only with watermelon seed or liver extract it will cause quite a stir. So you must not blame me if I remain an advocate of the salt- free diet in certain cases of hypertension and nephritis. In conclusion, I ask you, then, to dis- tinguish between 2 kinds of uremia and to treat that which results from failing concen- tration with large amounts of water, to try lumbar puncture and venesection in con- vulsions, to always think of the capillaries in cases of dropsy, and to give the salt-free diet a fair trial in hypertension. CIRCULATORY DISTURBANCES IN THE EXTREMITIES OF DIABETICS; THEIR RECOGNITION* David W. Kramer, M.D., Associate in Medicine, Jefferson Medical College, Chief of Diabetic Clinic, Jewish Hospital, Philadelphia, Pa. Diabetes mellitus has been given in the past 10 years considerable thought and attention by the medical profession. This has stimu- lated scientific research and has resulted in one of the best and most valuable gifts to mankind — insulin — the pancreatic extract de- veloped by Banting and his co-workers. With the advent of insulin, we became privileged to witness the solution of some of the most difficult problems presented by diabetes: (a) diabetic coma, always before a potent factor in the diabetic mortality rate; (b) juvenile diabetes, dooming its sufferer to a brief 2-3 year life span (a group now proudly, and justly so, spoken of by Joslin as his “10 years’ club”) ; (cj surgery in diabetes. To all dia- betics insulin has brought the boon of a lengthened life span, we know, but what medi- cal pitfalls may be waiting in these prolonged years for the patient still remains to be in- vestigated. If the continuous course of the diabetic condition persists, what complications ♦(Presented at the Monmouth County Medical Society meeting, January 28, 1931.) may be expected and how may they perhaps be averted by our vigilance? The cardiovascular system claims first place in any investigation of this kind. The im- portance of giving priority to this system is obvious ; first, the notorious influence worked by diabetes in producing changes in the walls of the arteries ; second, the prevalence of cor- onary disease in diabetics ; and third, the in- crease in complications of the extremities at- tributable to impaired circulation, the most important of such complications being gan- grene. Gangrene has long challenged medical science, not only because it is said to be re- sponsible for more deaths than any single factor, but also because it has the baffling faculty of developing while the patient is un- der medical observation and treatment. It seems logical, then, to direct our investigation so as to determine whether or not this com- plication is preventable. To accomplish this we must first have some understanding of the development and pathology of atheromatosis and arteriosclerosis and their relationship to diabetes mellitus. The next step should be the ability to recognize early these pathologic changes in the circulation so as to be prepared to check further progress and prevent the sub- sequent effects which invariably follow. Onr problems, therefore, are: (1) how do athero- matosis and arteriosclerosis develop and what influence does diabetes have upon these con- ditions; (2) what are the signs and symp- toms of impaired circulation in the extremi- ties. The first problem is to determine what in- fluences are at work in the development of atheromatosis and arteriosclerosis, and num- erous contributions have appeared in the litera- ture upon this subject. Time and space do not permit going into a detailed discussion of these pathologic changes. Among the various explanations offered, Aschoff's “imbibition” theory has received most favorable comment, The increase of lipoids, particularly choles- terol, in the blood predisposes to changes in the intimal ground substance. As the process develops, the intima itself becomes involved. Subsequently, atheromatous plaques make their appearance. Later, chemical changes of July, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 561 the cholesterol esters with calcium salts may take place, resulting in the calcific deposits seen in arteriosclerosis. Added to these in- fluences, the hyperglycemia and acidosis in diabetes must also be considered. Warren mentions the “possible influence of a high sugar concentration in producing swelling of the intimal ground substance through changes in osmotic pressure”. Joslin comments upon the role played by hyperglycemia and also acidosis in the production of atheromatosis. Is it surprising that the diabetic individual is prone to develop sclerotic changes in the ar- teries? The frequency of atherosclerosis in diabetes is now an accepted fact. It may be demonstrated even in the young diabetic, par- ticularly after a period of 5 years ; this phase of the subject has been recently discussed by Shepardson. The next problem is early recognition of vessels that have undergone pathologic changes. When this is accomplished, then de- tection of potential gangrene is possible. In- formation can be gathered in 2 ways; (a) by a careful history, particularly for symptoms which may lead us to suspect impairment of circulation, and a thorough physical examina- tion of the extremities; fb) confirmatory tests which may throw some light upon the condi- tion of the arteries and capillaries. Pathologic changes in the arteries naturally affect the normal distribution of blood to the extremities, resulting in trophic disturbances and also a lowered resistance of tissues against infection. Manifestations of disturbance in circulation will depend upon such factors as the type of vascular pathology, such as athero- matosis, arteriosclerosis, thrombo-angiitis ob- literans or embolic; the extent and duration of the impaired circulation and the degree of suc- cess in establishing a collateral circulation. Regardless of the type of pathologic change in the vessels, the method of approach in studying these cases is practically the same. The history should yield information as to whether or not the patient complains of claudication, cramps in the calves of the legs, coldness in the feet, numbness and pains. A history of trophic ulcers or focal gangrene may be significant. Examination of the extremities is exceed- ingly important, and in a vast majority of cases this method alone may permit diagnosis of a definitely impaired circulation. The fol- lowing signs should be observed : pallor when the feet are in the reclining position, and par- ticularly so if it exists when the feet are in the dependent posture ; rubor and cyanosis, when the feet are dependent should likewise be observed ; diminution or absence of the dorsalis pedis pulsation ; sclerosis of the dor- salis pedis artery ; coldness of the parts and a variety of lesions which will be discussed subsequently. These lesions were described in detail in a previous publication as “early or warning signs of impending grangrene”. Briefly, they include rose spots, scars, pig- mented areas, blebs, ulcerations and small areas of focal gangrene. The rose spots are small, pink, or erythematous, areas usually seen on the legs and sometimes on the feet ; they are not numerous, and are not unlike the rose spot seen in typhoid fever. They are pre- sumably due to some pathologic changes in the minute vessels and seem to indicate recent ac- tivity. They may last for weeks. Ultimately, they change to pigmented areas and in time are replaced by small scars. Scars are fre- quently seen on the legs in these cases of im- paired circulation. The large oval or elliptic scars are often attributed to injuries or bruises. This may be so but it is question- able whether all of these scars may be so ex- plained. Not infrequently patients are unable to say exactly when or how they were bruised and there may be scars over the soft parts which do not bruise so easily. They may be the expression of insidious atrophic changes of the tissues supplied by small vessels which are slowly but progressively undergoing oc- clusion. There are smaller scars which merit some consideration ; they have a punched-out appearance and look like the pock marks of smallpox ; they are not numerous and are usually seen over the legs and sometimes on the dorsum of the foot ; they may be later developments of the rose spots mentioned above. Bullas may be found on the toes or on the feet. On one occasion they were observed on the fingers. They vary in size from 1 to 3 cm., usually develop over night and may 562 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 have been preceded bv a burning sensation. As a rule, the)' are painless, not surrounded by an inflammatory area, and have a tendency to become purple in color and be followed by local gangrene. These blebs are most likely due to a recent and more or less rapid occlu- sion of the smaller vessels. They are not com- monly found but when they do exist, are highly significant and may be looked upon as forerunners of gangrene. This fact has been observed in practically every case where the bul las were seen. Other lesions, such as ulcerations, infec- tions on a small scale, trophic disturbances and focal gangrene need not be discussed ; they should be recognized without difficulty even in hasty examinations. Various laboratory methods have been sug- gested for studying the condition of the ar- teries and capillaries. It is true that a care- ful observer may be able to recognize patho- logic changes in the vessels by a thorough ex- amination. This may apply to well developed conditions. However, in patients who do not present sufficient symptoms and signs, the laboratory may help greatly in confirming or detecting evidences of impaired circulation. Among the tests may be mentioned : ( 1 ) calorimetric studies, including skin tempera- ture readings and heat loss in the extremities ; (2) the oscillometer; (3) skin reactions to histamin; (4) Roentgen rays; (5) intrader- mal wheal test; (6) intraarterial injection of opaque solutions followed immediately by roentgenography; (7) capillary microscopy. It is not my intention to discuss the technic of these measures in this presentation. Studies of the extremities and an attempt to evaluate the different methods are being carried out and will be published in the near future, but I will briefly mention some of the benefits which may be expected from the more prac- tical tests such as the oscillometer, the his- tamin test, skin temperature and Roentgen rays. The oscillometer, modified by Pachon, is an instrument based on the principles of the sphygmomanometer. Readings of the thigh, leg and foot will give us some idea as to the condition of the larger vessels. Zero readings of the thigh and legs are significant and in- dicate that there is a dimunition of the circu- lation. and particularly point to the larger vessels. Zero readings need not indicate that gangrene exists. Skin reactions to histamin have been studied bv Lewis, and its clinical application, particularlv in diabetes, has been discussed by Starr. Bv studying the wheal formation and local erythematous reaction of the skin fol- lowing the inoculation of histamin acid phos- phate, one may gather facts concerning the condition of the capillaries and the smaller vessels in the extremities. Of the calorimetric studies, the skin or sur- face temperature test is the most feasible. Some interesting contributions by Brown, Allen and Mahorner, and by Scott, indicate that this method of study is reliable. It not only informs us as to the condition of the vasomotor system in the region studied but may also throw some light upon the condition of the larger arteries. Roentgen rays are helpful by revealing cal- cific changes in the larger arteries. This in- formation, unfortunately, is limited and may give a false impression of the exact state of affairs. Despite sclerotic changes in the main arterial branches, it is quite possible that a sufficient collateral circulation has been estab- lished; thereby maintaining a fairly satisfac- tory state of nutrition of the parts. The methods of study described above may all have their limitations. One need not rely solely on any single test. When employed with the idea of confirming suspicions of im- paired circulation, after a thorough and com- plete examination, they undoubtedly will prove their usefulness. If used routinely, in some cases they will point out deficiency in blood supply where the impaired circulation might have been overlooked. The discussion thus far has been more or less limited to the understanding and recog- nition of impaired circulation. A word now concerning other disturbances of the extremi- ties in diabetes, among which may be men- tioned phlebitis, infection and gangrene. Phlebitis has received little consideration. Thrombophlebitis does occur but it is doubtful whether the incidence is any higher than in nondiabetics. July, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Infection is included in the discussion of circulatory disturbances for 2 reasons : first, because of the well known fact that im- paired circulation lowers resistance of the tis- sues supplied by the damaged vessels ; and second, because infection often precedes the development of gangrene. Another fact worth mentioning is that infection may be deep seat- ed and easily overlooked. This applies particu- larly to the feet. It is not uncommon to find a deep cellulitis in the foot either independent of or associated with osteomyelitis of one of the metatarsals. This type of infection almost in- variably is followed by a local gangrenous process, or gangrene of one or more toes may appear. Gangrene is easily recognized by examin- ation of the extremities. Various forms of gangrene may be observed, such as the ar- teriosclerotic type, thrombo-angiitis obliterans, obliterative endarteritis, embolic and the so- called “diabetic gangrene”. Since the topic ■of this presentation concerns itself chiefly with the understanding and recognition of circulatory disturbances of the extremities, a discussion of the different types of gangrene is intentionally avoided. Detailed descriptions and differential diagnoses may be found in any text-book on gangrene or diseases of the circulatory system. Gangrene usually appears late in the course of diabetes. It is the end-result of changes in the walls of the arteries. Individuals past middle age and who have had diabetes for 5 years or more are liable to develop this com- plication. Infection, either local or deep seated, may produce gangrene in any stage of the disease. Since gangrene is a later develop- ment of vascular changes, is it not possible to prevent it? This can only be accomplished by the early detection of vascular changes and impaired circulation by the various methods of study described above. After recognition of the underlying pathology, measures should be taken to correct the diet, having in mind not only the hyperglycemia but the lipoids and the cholesterol content as well. It is exceed- ingly important to control the diabetic condi- tion. Other preventive measures may be directed toward improvement of the condition of the vessels by systematic foot exercises and 563 diathermy. Incidentally, these patients should be warned that they are potential cases of gangrene, that the utmost care should be given to the feet, that trauma and infections are to be guarded against, and that only the fullest cooperation may ward off the most dreaded of all complications, gangrene. COMMON DISEASES OF THE ORAL MUCOSA* Bart M. James, M.D., Newark and Montclair, N. J. A routine examination of the oral cavity for abnormalities should be made as a part of every physical examination in any branch of medicine. This applies particularly to the specialty of dermatology and syphilology. Our predecessors in medicine recognized - the value of close observation of the tongue and gained many helpful ideas from that part of their examination. Diseases of the skin are often preceded by or associated with definite clinical evidence of the same pathologic entity within the oral and nasal mucosa. This relationship can be ex- plained by the fact that the skin and the mucous membrane of the nose and the mouth is derived from a common embryologic source — the ectoderm. Also some diseases affecting the general constitution very frequently have their prodromal symptoms within the oral cavity. This is evidenced by the Koplik spots of measles, the pharyngeal congestion of scar- let fever, and the ulcerations of agranulocytic angina. The appearance of a few discrete miliary tubercles may lie the first clinical evidence of tuberculosis and a persistent but mild stomatitis associated with burning of the tongue may antedate the blood picture of per- nicious anemia. Certain oral lesions may oc- cur as part of the menstrual cycle and preg- nancy. Vicarious bleeding from the gums with submucous hemorrhages, aphthous stoma- titis, herpes, salivation and toothache, may ap- pear coincident with the menstrual period. *(Read before the Middlesex Dental Society, New Brunswick, N. J., November 1930.) 564 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 Gingivitis and alterations in the teeth are seen at times in pregnancy. Urticaria, angio- neurotic edema and purpura may involve the mucous membrane of the nose and mouth. The usually fatal disease, pemphigus, may be- gin in the mouth in the form of bullas which quickly change to erosions and ulcerations ; diagnosis would be influenced by age of the patient, subsequent skin eruption and the gradual deterioration in health. The diagnosis of certain diseases of the skin is often facilitated or proved by examin- ation of the mouth for similar lesions; modi- fied in the mouth in appearance and structure because of the moisture and resulting macera- tion. Irritation from the teeth and from food alter the appearance of lesions, and very fre- quently secondary infection occurs. The sur- face of papules may be covered with a mem- brane, and vesicles and bullas are usually seen as simple erosions. However, there are cer- tain oral conditions the appearance of which may be sufficient to make a diagnosis; for in- stance, certain benign and some of the malig- nant tumors. Grouping and distribution of lesions in the mouth are less distinctive than on the skin and a complete examination of the entire skin may be necessarv in order to find an eruption associated with the lesions in the mouth. The oral lesions of lichen planus are often mistaken for leukoplakia but if the characteristic flat-topped, shiny, violaceous papules are present on the skin, for example, of the fore-arms and glans penis, the diag- nosis is complete. The mucous patches of secondary syphilis may be confused with aphthous stomatitis, erythema multiforme and other local affections but they can be differ- entiated by an examination of the entire skin. Oral lesions produced by the ingestion of drugs are usually difficult to diagnose unless concomitant skin lesions are present or a his- tory is obtained of taking the suspected drugs. There are some drugs which have a pre- dilection for the oral cavity as a site of erup- tion, such as the antisyphilitics (mercury, bis- muth, arsphenamin), the barbital group (in- cluding veronal and luminal), the antipyretics (antipyrin, acetanilid, phenacetin and pvram- idon), the salicylates and the phenolphthalein compounds. Poor dental hygiene, complicated by bacterial infection, plays a predominating part in the production of a stomatitis. Mercury. Stomatitis due to mercury begins usually with edema and intense lividity of the gums in conjunction wiith excessive flow of saliva and pain on closing the jaws. This may continue until the tongue, tonsils, soft palate and pharynx are affected, with formation of a necrotic membrane. Toleration to mercury can be increased by rigid dental hygiene. Arsphenamin. Stomatitis caused by arsphen- amin may be due to an idiosyncrasy rather than an overdosage. It may or may not occur in conjunction with a dermatitis. The lips, tongue and buccal mucosa are dry, hot and red. in contradistinction to stomatitis due to mercury. There is usually a decreased flow of saliva. Bismuth. Thirty to 40% of patients had stomatitis from bismuth in the first year of its use. It is not as prevalent as formerly, because of decreased dosage and longer inter- vals between treatments. It is usually charac- terized by bluish or bluish black pigmentary deposits along the free border of the gingiva and which spread until the entire gun is in- volved; and stomatitis similar to that caused by mercury occurs if the drug is continued. 1 he pigmentation remains for months and will reappear rapidly if the drug is again used. Antipyrin group. This includes antipyrin, acetanilid, phenacetin, pyramidon and oth- ers. These drugs are very prone to cause an eruption of the buccal membranes and the genitalia. The eruption may vary from a simple congestion of the pharynx and edema of the lips to the formation of vesicles and bullas followed by erosions and deep ulcera- tions. In patients addicted to the use of acetanilid a pronounced cyanosis of the lips and the buccal mucosa is caused by the pro- duction of methemoglobin. Barbital group. The lesions in the oral cav- ity vary from a mild redness and edema to the formation of vesicles and bullas with con- sequent ulcerations and erosions. Lesions pro- duced by this group cannot be distinguished clinically from those produced by the antipy- rin and phenolphthalein groups. Salicylates. May cause a vesicular or bul- July, 19 31 565 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY lous eruption of the oral mucosa and the lips, and at the same time erosive lesions of the glans penis may occur. Shelmire mentions the occurrence of extensive ulcerations of the tongue and soft palate following intravenous injection of sodium salicylate for the tieat- ment of rheumatism. In another case re- ported by him vesiculation and erosion of the lower lip occurred following intravenous use of salicylates. Phenol 'phthalein. Eruptions of the mouth, lips and the genitalia are frequently observed following ingestion of phenolphthalein as a laxative ; usually seen on the lips in the form of vesicles with varying amounts of edema of the parts. Ruptured vesicles in the form of erosions and ulcerations may be present on the tongue and other parts of the oral cavity. At the same time there may be an erythema- tous, urticarial or bullous eruption of the skin which results in various sized violaceous, pig- mentary plaques, d his pigmentation may last for some time and will show acute exacerba- tions following the second ingestion of the drug. However, some cases may show a period, the so-called refractive period, dur- ing which the idiosyncrasy to the drug has diminished or entirely disappeared. Ulceromembranous stomatitis. Vincent’s an- gina has been more prevalent since the World War. Foerster predicted that Vincent’s dis- ease would be an important factor in the dif- ferential diagnosis of lesions of the mouth after return of the troops. McKenstry called attention to an increase in number of these cases in England and Canada among former troops and civilians, and history of trench mouth while in the army can be obtained from some of the patients. Vincents disease must be differentiated from stomatitis due to mer- cury. diphtheria, and mucous patches of syph- ilis. It may occur on the tonsil, as a super- ficial or deep ulceration partially covered with a dirty gray membrane, with some enlargement of neighboring lymph-glands ; on the ramus of the lower jaw posterior to the last molar tooth, as a localized abscess; as a general mouth infection involving the entire mucosa, pharynx and tongue ; or it may be confined to the gums where it often has its primary source and may be confused with pyorrhea alveolaris. Vincent’s disease may also pio- duce an ulceration of the vulva, a conjunc- tivitis, or an ulcerating balanitis, lhomas and Klapproth recently reported a case of Vin- cent’s infection of the ear following the bite of a human, and they had previously reported 2 cases following bites of humans with infection on the fingers. In all cases the characteristic odor, membrane formation, and sloughing was present. The spirillum of Vincent and the fusiform bacillus can be demonstrated by smears or by dark-field preparations. Arsenic, in the form of Fowler’s solution in glvcerite of tannin, applied locally, has- been used with benefit in some cases. Arsphen- arnin and neo-arsphenamin locally and intra- venously has been the treatment of choice foi many years. Applications of 2% chromic acid and paste of sodium perborate have been used with success. Bismuth intramuscularly may be of benefit. Aphthous stomatitis. Aphthous stomatitis is an acute inflammatory affection occurring mostly in children. It may be part of a gas- trointestinal upset or due to faulty dental hygiene. Small vesicles with an inflammatory areola appear on the gums, the inner sur- face of the lower lip or the buccal mucosa, which soon become shallow ulcers covered with superficial gray exudate, and they are sensitive and painful. Applications of 10 °/o silver nitrate, with a mouth wash of potassium chlorate or boric acid, are usually sufficient to heal the ulcers. Existing gastrointestinal dis- turbances usually require treatment. Superficial and deep yeast infections. Yeast organisms are found normally in scrapings from the mouth and are therefore of little sig- nificance unless obtained after the areas in- volved have been cleansed, dried and painted with tincture of iodin, and bits of the mem- brane removed for microscopic examination and culture. The most common superficial yeast infections are thrush, macroglossia and mac- rochilia mycotica caused by the monilia or- ganisms. Thrush or white mouth is usually seen in nursing infants and consists clinically of a superficial stomatitis and gingivitis ; usually 566 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 confined to the oral cavity, particularly the cheeks, hard palate and margins of the tongue, but may spread to the skin of the child and the nipples of the nursing mother. It is caused by the oidium albicans which is carried to the infant’s mouth through the medium of the mother’s breasts or of feeding utensils. There are usually not any clinical changes in the sur- rounding mucous membrane. Diagnosis is readily made by appearance of the lesions and microscopic examination of a bit of the membrane which has been macerated in 20% sodium hydroxide. The infection readily yields to swabbing of the lesions with boric acid solution, followed by application of 1% gentian violet or 2% ferric chloride solution. Perleche is seen at the oral commissures in the form of whitish opaque patenes which have a mother-of-pearl tinge. Small trans- verse fissures appear later, showing a redden- ed base when the lip is stretched. It is con- tagious and is frequently seen in epidemic form. In adults, the upper lip droops at the angles of the mouth in such way as to form an intertriginous area, an exaggeration of the normal fold. Finnerud has recently re- ported a series of 100 cases of perleche which he found to be mycotic in origin. Perleche simulates the split or hypertrophic, syphilitic papule seen in the same location, or it may be confused with the late ulcerating lesions of syphilis. It :s best treated by application of 10% silver nitrate solution. Macroglossia mycotica. Castellani and oth- ers have reported cases in which the tongue was greatly enlarged, occasionally painful, and presenting various sized, elevated, white plaques which resembled a beginning leuko- plakia. Various types of the yeast organism were isolated from these cases. The infection may invade other parts of the oral cavity, as in the cases reported by Shelmire; 2 cases in which the buccal mucosa, entire gums, palate and the Vermillion borders of the lips, were covered with hypertrophic whitish growth, and he compared the appearance to a diffuse map- like leukoplakia. Cultures from the membrane revealed a pure monilia, and his cases proved extremely recalcitrant to various therapeutic measures. Cauterization healed the involved areas temporarily. Iodides by mouth and Lugol’s solution intravenously were of tem- porary benefit. Actinomycosis usually begins through the medium of a carious tooth or an abrasion of the gum. Pea to egg sized nodules appear first on the cheeks or tongue ; later break down, and yellow granules or ray fungus can usually be easily demonstrated from the discharge. Blastomycosis is a distinct raritv. Shelmire. in 1928, reported a case of blastomycosis in the oral cavity. The lesion was confined to the lower gum and consisted of a sharply de- fined verrucous mass which filled the lower labial vestibule. Several sinuses exuding pus extended down into the tumor. The histo- logic diagnosis was a granuloma of unknown origin. Blastomyces were demonstrated by smear and culture. Extensive ulceration of the lower jaw followed, with multiple sinuses opening on the cheek, chin and neck. Death occurred within a few months. Sporotrichosis may involve the mucous membrane of the mouth and form abscesses with severe ulceration. It must be differen- tiated from syphilis and tuberculosis. 7 itmors. Almost every benign tumor of the human body may have its counterpart within the oral cavity, such as tumors of the vascular system, fibromas, lipomas, neuromas, muscle tumors and dermoids. Tumors derived from the dental system, such as adamantinomas, epulides, odontomas and various cysts may be found solely in the oral cavity. Angioma is a rather frequent tumor of the oral cavity and is usually situated on the lips, buccal mucosa and tongue. Angiomas con- sist of the embryonic type of tissue in con- tradistinction to the fixed or adult type seen in nevus flammeus, which explains their marked response to radium. They usually re- main stationary in size, while lymphangiomas, which may be differentiated bv the various sized vesicles filled with lymph, usually have a tendency to continual extension and enlarge- ment. A capillary nevus, or nevus flammeus, of the face may extend into the mouth, in- vading the inner surface of the cheeks, gums and palate. Venous nevi occur usually on the anterior portion of the tongue; their color is July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 567 bluish and the size of the tumor can be tem- porarily reduced by pressure. Simple telangi- ectasis may occur anywhere in the mouth. Simple varices may be seen under the anterior portion of the tongue ; and the blood blister of the lip in the aged. Angiomas yield to various therapeutic meas- ures, such as radium, coagulation, carbon dioxide snow or excision. The method of choice depends on location and size of the tumor. Papilloma. This benign tumor is frequently seen on the dorsum of the tongue, the gums and lips. It may vary in size from that of a match head to that of a pea; is elevated, and usually has a verrucous surface. Distinction must be made from a malignancy. It can be snared off with a cutting current and a microscopic examination made. Mucous retention cysts. Cysts of this type are seen frequently on the lower lip and may be the result of trauma. They vary in size from that of a pin-head to that of a hazel nut; are pale, translucent and contain a clear viscid substance. Recurrence after excision is usual. Desiccation is the best means of permanently curing the condition. Carcinoma is often engrafted on a long standing process such as gumma, leukoplakia or fissures. Jagged teeth, irritation from ex- cessive cigar or pipe smoking and chewing, or senile and seborrheic keratoses of the lips may be the offenders ; more common in males ; may begin anywhere in the mouth but the lower lip. tongue and buccal mucosa are the areas most frequently attacked. On the lips and within the oral cavity the squamous or prickle cell carcinoma is the type invariably found. Basal cell epithelioma of the lip is usually an extension from the adjacent cutaneous surface and is seldom encountered. Early recognition of a malignancy of the oral cavity is of paramount importance since metastasis occurs early because of the abun- dant blood and lymph supply. Carcinoma may commence as a papillomatous eleva- tion which later infiltrates the surrounding mucosa and ulcerates, or it may develop from a fissure, and palpation will reveal an infiltra- tion in the surrounding mucosa. In its in- cipiency the diagnosis may be difficult. Eatly biopsy, which is best accomplished by the cut- ting- current, should be done and the section o examined microscopically. A positive Was- sermann should be kept in mind. Tuber- culosis and actinomycosis must be ruled out. Superficial, localized carcinoma of the lip responds favorably to radiotherapy. The les- ion may be destroyed by electrothermic meth- ods followed by use of radium plaques not only to the destroyed areas but the surround- ing tissue. If the lesion shows an area of infiltration, gold radon seeds should be plant- ed deeplv, in conjunction with the surface ap- plication. Carcinoma arising from a leuko- plakia of the lip is best treated by a wide re- moval of the involved area with the cutting- current, followed by the use of radium. Tongue lesions may be treated by excision with the high frequency knife followed by radon implantations or by interstitial irradia- tion with gold radon seeds implanted perman- ently in the tumor area and also across the base of the tongue in order to block the drain- ing lymphatics. Prophylactic exposures of filtered Roentgen rays should always be given to the lymphatics draining the lips and the oral cavity. IAchen planus occurs in the oral cavity in approximately 50% of cases associated with the typical skin lesions. Lichen planus also appears on the vaginal or urethral mucosa and the glans penis and if there are lesions in the above locations in association with the oral lesions a diagnosis of syphilis might be sug- gested. Therefore, an understanding of the clinical appearance of the oral lesions is of importance to rule out leukoplakia and syph- ilis, which are the conditions most often con- fused with lichen planus. The most frequent site of the eruption is the posterior surface of the buccal mucosa, usually along the line of the closed teeth. A few gray, miliary papules only may be present but the typical and the usual eruption seen consists of an irregularly outlined network of fine white lines. The older the process, the more do the papules coalesce and form circulate plaques which resemble mucosa to which silver ni- trate has been applied. The lesions seen on 668 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 the dorsum of the tongue are usually in the form of oval plaques or stripe-like plaques. On the margins, solitary papules may be pres- ent. The oral lesions of lichen planus do not degenerate, erode or ulcerate, nor are they followed by malignant changes. Lichen planus simulates the mucous patches of syphilis and leukoplakia and, to complicate the diagnosis further, it responds to anti- luetic remedies. Fordyce said: “Leukokera- tosis in patients who are not smokers, and with a negative luetic history, should suggest the probability of lichen planus and further evidence of that affection sought for.” Leukoplakia is the most common of the oral keratoses and is often part of an old luetic process. However, there are some cases based on excessive smoking, irritation front rough and carious teeth, alcohol and highly spiced foods. The condition is seen more frequently in males. The most frequent lo- cations are the lips, anterior portion of the tongue and the anterior portion of the buccal mucosa just within the oral commissures in the form of a triangle. Its recognition is import- ant owing to its tendency to degenerate into a squamous celled carcinoma. The proportion of leukoplakias which result in carcinoma has been variously estimated from .20 to 50%. It is not always possible to say from observation whether or not a leukoplakia is based on a syphilitic condition, unless there is an associat- ed glossitis and smooth atrophy. The mucosa primarily assumes a blanched grayish or whitish tint with effacement of the papillas and furrows. The areas involved may grad- ually merge, forming a thick white plaque which is densely adherent and cannot be re- moved by scraping. These plaques may be fissured or more rarely present a verrucous appearance. There are no subjective symp- toms, as a rule, except a feeling of dryness and roughness, unless fissures are present to cause pain. Squamous celled carcinoma may arise from a leukoplakia. Treatment of leukoplakia consists of rigid and constant oral hygiene and the removal of irritating foods. The use of tobacco and al- cohol is interdicted. If syphilis is the cause, the patient should secure injections of mer- cury, bismuth and iodides. Caution should be employed with the use of arsphenamin be- cause arsenic causes epithelial proliferation and may be the provocative factor in the be- ginning of a carcinoma. In cases which do not respond to the above measures, and where the process is extending, the entire area should be destroyed by electrocoagulation. Tuberculosis of the oral cavity or lips is usually secondary to tuberculosis of the vis- cera or lupus of the skin. It is most com- monly seen on the free border of the lips, the tip and border of the tongue, and the soft palate. Small, yellowish nodules appear, ranging in size from a pin-head to a lentil. Superficial or deep ulcers may result, sensitive to pressure and painful on talking or eating. The ulcers are round or linear in outline, their border is abrupt and often undermined, and the floor is covered with a loose yellowish crust. The surrounding area is not indurated nor inflamed but tubercles may be seen which have not reached the stage of ulceration. On the dorsum of the tongue a linear or fissured ulcer is the most characteristic form of lesion. The process is usually prolonged for weeks or months, with some attempt at and signs of healing. Syphilis and epithelioma must be differentiated by means of the microscope and other laboratory examinations. Radium ther- apy or destruction of the lesions by electro- coagulation will usually cure the condition provided there are no active foci in the lungs or elsewhere. Lupus erythematosus attacks the mucous membrane in about 25 % of cases showing cutaneous involvement. The lips, buccal mucosa and soft palate are the areas most frequently invaded. In the early stages, the involved mucosa is intensively red, inflamed and edematous, and differentiation from other acute inflammatory processes cannot be made unless cutaneous manifestations of the dis- ease are present. Later, the center of the lesions becomes depressed, eroded and the sur- face is covered with adherent yellowish mem- brane. The inflammation gradually subsides and is replaced by scarring and atrophy. In addition to erosion, the lips may be covered with adherent dry scales. The oral lesions of July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 569 lupus erythematosus do not respond to in- travenous gold therapy as readily as do the cutaneous lesions. The beta rays of radium, the actual cautery, and desiccation can be used with good results. Syphilis may attack the oral mucous mem- brane without any other visible evidence of the disease. Chancre of the lip should be sus- pected in any indurated lesion which has sub- maxillary or submental glandular enlarge- ment. Chancre of the tonsil is difficult to diagnose and differentiate from Vincent’s dis- ease unless other concomitant symptoms are present. Mucous patches which are analogous to the macular and papular skin eruption changed by moisture and maceration vary in form from a distinct redness to definite erosions and ulcerations. They are seen most frequently on the tongue, gums and soft pal- ate. The ulcerations are usually covered with a thin diphtheroid membrane and may be con- fused with the conditions enumerated pre- viously. General examination of the skin will dif- ferentiate a great many of these conditions; in conjunction with appropriate laboratory ex- aminations. Darkfield examination should be done but caution must be exercised in order to not confuse the Spirocheta pallida with Spirocheta microdentium and refringens. However, an interstitial glossitis, with a leukoplakia and a smooth atrophy of the tongue, is diagnostic of syphilis. The sharply defined, punched out ulcerations of the hard and soft palate, which produce perforations of these parts, can be clinically ascribed to syph- ilis, although some of these are due to tuber- culosis and to Vincent’s infection. The presence of infiltrated ulcerations and fissures in the lips and around the oral com- missures of emaciated infants is symptom- atic of congenital syphilis. These fissures frequently result in linear scars or rhag- ades which are seen in older children, and are usually associated with other signs of syph- ilis such as a saddle nose, keratitis, perfora- tion of the hard and the soft palate, glos- sitis and changes in the teeth. The alterations in the teeth are caused by nutritional disturb- ances from intra-uterine infection of the fetus, not to a direct action of the spirochetes on the tooth. Lingua geographica. Erythema migrans, or the so-called wandering rash of the tongue, is of interest because of its clinical appearance and unknown etiology. It appears on any portion of the tongue as sharply defined, oval, red areas with a yellowish gray, slightly ele- vated border, which spreads peripherally forming red patches. The appearance and location change from day to day. It does not cause anv symptoms and most patients are unaware of its presence. X-ray therapy has been of benefit in some cases. Moellers glossitis may be confused with lingua geographica. It occurs mostly in middle-aged women of neurotic tempera- ment. The tip, edges and dorsum of the tongue are the parts most commonly af- fected but at times the inside of the lips, cheeks, hard and soft palate is involved. The patient complains of severe pain made worse by eating. Examination discloses sharply de- fined patches, intensely red in color, in which the filiform papillas are thinned or absent and the surface epithelium denuded. The condition is recalcitrant to treatment. Re- moval of infected teeth and treatment of in- fected gums should be done routinely. Scrotal tongue. Lingua plicata is usually a congenital and often a familial anomaly. The mucous membrane of the tongue is plicated and resembles the scrotum in appearance. The condition is permanent and does not cause any subjective symptoms. Detritus may accumu- late in the deeper fissures and result in irri- tation, consequently the tongue should be kept clean with an alkaline mouth wash. Herpes of the lips is seen frequently, while herpes of the oral cavity is rare ; that of the lips is prone to recur. The characteristic grouped cluster of clear vesicles on an ery- thematous base follow varying degrees of pain and burning. The vesicles soon rupture and the eroded areas may be confused with mucous patches. Herpes is seen frequently in asso- ciation with certain general infections, such as malaria, cerebrospinal meningitis and pneu- monia. Some cases may be caused by infec- tion within the oral cavity, such as infected 570 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 teeth, tonsils and sinuses. The contents of herpetic vesicles have been inoculated on the scarified cornea of the rabbit, following which an encephalitis developed similar to encephali- tis lethargica. X-ray therapy has been of benefit in the cases which recur in the same location. Arsenic has been used with some success. Other cases have been benefited by vaccination with smallpox virus. Eczema may attack the lips primarily or secondarily from the skin. Varying degrees of redness, scaling, crusting and Assuring may be present. The circumoral eczema seen in children is caused by the habit of moistening the lips and adjacent skin with the tongue, in conjunction with exposure to cold and wind. Tooth pastes, cosmetics and mouth washes may cause an orbicular eczema in a susceptible individual. The cause should be ascertained, if possible, and a protective salve such as Las- sar’s paste used. Fissures may be touched witih 10 c/o silver nitrate. In obstinate cases fractional weekly doses of x-rays are indi- cated. Among other, but far less common condi- tions of the buccal mucosa, should be listed leprosy, mycosis fungoides, the lymphogranu- lomas, Kaposi’s sarcoma, foot-and-mouth dis- ease, pellagra, rhinoscleroma and lead poison- ing. DIABETES MELLITUS AND THROMBO- ANGIITIS OBLITERANS IN THE SAME PATIENT Harold S. Davidson, M.D., F.A.C.P.. Atlantic City, N. J. The association of diabetes mellitus and thrombo-angiitis obliterans has been noted be- fore in the literature. (Adams S.F.. Med. Clin., N. A., Vol. 14, No. 3.) The associa- tion of these 2 definite pathologic entities has a very serious significance for any patient be- cause of the difficulties encountered in at- tempting to heal a pedal lesion. In this patient, a spot of gangrene did develop on the foot and only after prolonged and persistent ef- fort was it not only kept from spreading but made to heal. The lesion appeared on the sole of the right foot. Determinations of the pulse of the feet and legs showed that the lesion was on the best foot. The circulation was decidedly worse in the left leg and, in all probability, had this gangrenous spot de- veloped on the left leg it would never have been arrested. I believe the prognosis is now- good because of the progress made so far, and certainly every precaution will now be observed to allow no further trauma to occur to either extremity. This patient, J. P>., white, aged 65, was ad- mitted to the Atlantic City Hospital on De- cember 28, 1930. His father died at 93 years of age from senility, and his mother at the age of 49 years from heart trouble. He had 2 brothers, both of whom were diabetics ; 1 is dead and the other living. The patient had measles and diphtheria in childhood and rheumatism 44 years ago. He stated that he was well until 15 years ago, when he developed a diverticulitis for which he was rushed to a New York Hospital for an emergency laparotomy, and as a consequence developed peritonitis, fecal fistula and second- ary operations covering many weeks. It was at the time of his entrance into this hospital that his diabetes was discovered. When he was ready to get out of bed. following this, he developed phlebitis in his left leg, which kept him hospitalized for many more weeks. The phlebitis finally cleared up. However, for a long time before this he had what w?as called “fallen arches” with tiredness in his feet and legs after walking short distances. Arch sup- ports and other appliances were made without relief. After recovery from his operation and phlebitis, he found that after walking about 1 city block he would have cramp-like pains in the calves of his legs, so bad that he would have to stop and rest. He now can only walk- half a block before he must stop. Ever since, he has had intermittent claudication. All his adult life he has been a heavy smoker. At the time of his operation he smoked about 15 cigars a day. At that time he consulted Dr. Leo Berger, of New York, who advised cutting down his smoking, graduated July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 571 exercises, etc. Since then he limits himself to 3 cigars a day. He had been on a moderately strict diet, with some lapses, having very infrequent blood sugar determinations made. He never was given insulin. Examines his own urine. A week before being seen by me he attempted to shave callus from the sole of his right foot, and later a dark spot appeared which was painful to touch. This, in the course of a week, developed into a spot of superficial gangrene. On admission patient was a thin but well nourished male. General examination, aside from an incisional hernia and spot of gan- grene 2 cm. in diameter on sole of right foot, was negative. Both feet were cold and pur- plish-blue when patient was erect. During his stay in the hospital his tem- perature ranged from 97' to 98.3° F. ; pulse 60 to 100 and respirations 16 to 22. Blood count was normal ; no increase in leukocytes. Repeated urinalyses at first showed less than 0.5 mgm. sugar, trace of albumin and few hyalin casts, and later all specimens were free of albumin, sugar and casts. On admission his blood sugar was 168 mgm. per 100 c.c. of blood, and on a diet of 60 gm. carbohydrates, 100 gm. protein and 130 gm. fat, his blood sugar varied between 117.5 mgm. and 90 mgm. per 100 c.c. of blood. Blood urea was 35 mgm. per 100 c.c. of blood. Radiogram showed heart and aorta on the whole slightly enlarged. The aorta showed no calci- fication. Transverse diameter of chest 26 cm.; heart 13.5 cm.; and aorta 2.75 cm. The patient was treated by rest in bed with a cradle over foot holding a blue incandescent lamp to keep feet warm and dry. He was given daily diathermy. Attention to bowels and general hygiene was observed. At first the gangrenous spot tended to spread and there was a light serosanguineous oozing. After 2 weeks the spot became entirely dry and very slowly separated and scaled off. As determined by the oscillometer, the cir- culation in both legs was very poor ; less ex- cursion of the indicator on the left than right. Only above the middle-third of the thighs wrere the pulsations nearly normal. Had the trauma and resulting gangrene occurred to the left instead of the right foot, the patient would, in all probability, have lost the limb. REVIEW OF RECENT LITERATURE ON THROMBO- ANGIITIS OBLITERANS WITH REPORT OF AN AD- VANCED CASE* Max Gross, M.D. Long Branch, N. J. This is a review of the recent literature to call your attention to this important topic so that an early diagnosis can be made possible, thereby giving us a means of instituting non- operative measures and avoiding the disas- trous results which follow when recognized too late; as will be illustrated by the case to be presented. This is a disease which has been taken out of the confused material of arterial diseases by Buerger. It is a characteristic inflamma- tory lesion of the deeper arteries and veins of the extremities, with extensive thrombosis fol- lowed by organization and canalization, thus matting the arteries, veins and nerves into dense connective tissue cords. The arteries and veins of the lower extremities are the most frequently affected and their nerves are included in this inflammatory process, with accompanying migratory phlebitis in about 25% of the cases. Etiology: Confusion still exists as to actual cause of the disease. Various theories have been advanced, without definite conclusion. (1) Race. The Hebrew seems to be the most affected, especially among Russians, Galacians and Roumanians. It used to be a disease considered typical of the Jewish race but from recent reports many Gentiles have been found to be afflicted. Cases have also been reported in the Orient. Buerger reports, in his book, that out of a series of 500 cases, 10 were Gentiles. However, from more re- cent reports by Allen, Brown, and others, the * (Read before the Monthly Conference of the Monmouth Memorial Hospital November 12, 1930.) 572 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 19 31 total number of Gentiles recorded is around 100. (2) Sex. This disease has a peculiar affin- ity for the males. Females are rarely affected. Of the same 500 patients seen by Buerger, only 3 were females. If, as it seems to Silbert, who will be mentioned later, tobacco is a causative factor, the recent fad of women smoking should add to the number of that sex afflicted. (3) Age. The ages range from 20 to 40 years. (4) Infection. Buerger thoroughly believes that the underlying arteritis is caused by an infectious agent which may be a specific or- ganism, although he is unable yet to prove this bacteriologically. In a recent paper he further tries to prove that the disease is caused by an infectious agent ; a series of ex- periments carried out on normal and affected individuals and on experimental animals. He made a coagulum of an infected vessel and in- jected it into and around veins which were ligated proximally and distally, and in a period of 10 days removed the veins and made mi- croscopic slides of them. The pathologic picture of the removed veins which had the perivascular coat injected was almost iden- tical with the migratory phlebitis which is so frequently present in this disease. (5) Tobacco poisoning. Silbert is convinced that the etiologic background for this disease is intoxication from tobacco smoking, and that everyone who gives up smoking shows a marked improvement. He claims further that there is an hereditary factor that makes these victims susceptible to some intoxicant from the tobacco. This factor he believes is in- fluenced by the endocrine system. Many au- thorities agree and others disagree with Sil- bert as to tobacco being of sucb great import- ance in this disease, but one cannot cast aside the impression derived from case reports of the patients becoming improved as a result of refraining from smoking. (6) Other theories have been advanced, none of which has any background and will not be discussed here. The diet of the He- brew has been considered of importance in the etiology. Symptomatology: Most of the symptoms are due to the thrombotic healing rather than the inflammatory lesions. (1) We have phlebitis migrans accom- panying the superficial veins in 25% of cases which may affect the lower or upper extremi- ties; the deep veins are affected in 40% of the cases. An attack of such a nature with- out obvious cause should make one suspicious and lead to a thorough investigation of the blood vessels. However, if such a condition exists in the arms, careful search should be made of the lower extremities as regards the deep vessels. (2) Pain. This consists, first, of pain of an acute inflammatory nature, which is a vague ache, deep seated and independent of accompanying paroxysms and tenderness in the calves ; second, pain of the intermittent claudication type which is manifested by cramp-like or lancinating pain in the muscles of the calves or a diffuse ache throughout the leg coming on with exertion and ceasing with rest ; third, pain accompanying or preceding trophic lesions, which is most frightful. A small fissure, bleb, or ulcer may be the site of the most agonizing type of pain and usually is the precursor of gangrene. (3) Ischemia is a pallor or blanching ob- tained by raising the limb. Persistence of pallor when the extremity is in the horizontal or dependent position is suggestive of an early gangrene in that region. (4) Erythromelia is a hyperemia and is almost always present. It is a purplish dis- coloration of varying intensity, which begins in the toe and gradually extends upward. There are 2 types: first, the induced type, brought on only by elevation of the limb ; second, the chronic type, which is present while the extremity is kept in any position be- tween horizontal and the dependent, at room temperature. (5) Obliteration of the pulse. This is com- monly seen in the dorsalis pedis artery, next the posterior tibial, the popliteal, more rarely the femoral, radial or ulnar, and occasionally the digital or interossei. Superficial oblitera- tion of the vessel is easily felt but one must bear in mind that the deep vessels which are July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 573 obliterated are not so easily accessible to pal- pation. One must remember also that Buer- ger’s disease can be present even though the arteries have not been obliterated. In 5% of the cases seen at the Mayo Clinic the pulsa- tions of the dorsalis pedis and tibial arteries were seen and occlusion involved mostly the interossei and digital arteries. Constam. of the Mayo Clinic, reports that in 24 out of 94 cases involvement of the vessels was seen in the upper extremities. In most of the cases, however, the lower extremities are afifected and then the upper. Allen has reported cases in which he found the radial and ulnar arteries only slightly diminished in their beats but found the interossei and digital vessels of the hand definitely afifected. (6) Trophic changes as seen only late in the disease ; due to the fact that the disease affects young people who are able to develop good collateral circulation. However, due to slight trauma, fissure, pustule or bleb, we may have an increase in pain and the development of gangrene. (7) Interesting is the fact that people suf- f erring with thrombo-angiitis obliterans show some coronary changes, some of them being of the same pathologic process that goes on in the extremities. The most important vessel involved is the left coronary. It is, rather surprising that very few autopsies have been performed in Buerger's disease. This is prob- ably due to the fact that a pathologic diag- nosis was made from the amputated leg, and the rather generally accepted idea that only vessels of the extremities were affected. In his book, Buerger reports 4 autopsies, 3 of which showed coronary changes, the patho- logic picture being similar to that of the ex- tremities. The cases reported by Perla and 1 by Lemann with autopsy findings showed similar coronary changes. It would be an interesting point to obtain electrocardiograms of every person afflicted with thrombo-angiitis obliterans to note the relation of coronary changes in this disease. Having this in mind, many more cases of cor- onary disease would show changes similar or identical pathologically to the vessels in the extremities. (8) The usual laboratory examinations in this disease show nothing characteristic. Re- moval of a vein showing migratory phlebitis may make possible an early diagnosis. Many authorities claim that there is an increase in the number of red blood cells, platelets and hemoglobin in this disease. Still others be- lieve that there is a hyperglycemia. Differential diagnosis. About 90% of the cases can be divided according to Brown’s classification into vasomotor and organic groups, by the presence or absence of the pul- sations of the arteries that are usually palp- able. However, 30% of the cases of throm- bo-angiitis obliterans show vasomotor dis- turbances, and one must remember that gan- grene may develop in this disease even when pulsations of the vessels are felt, because in these vessels the obliteration takes place dis- tally to the area of palpation. In other cases there is much difficulty encountered, and con- fusion exists as to differentiation of vaso- motor thrombosis and organic changes in the vessels. This may be particularly true in cases where upper extremities are involved. A satisfactory classification has not yet been given for diseases of the blood vessels. Buer- ger has attempted to divide them into 2 types : first, those of vasomotor disturbances which include Raynaud’s disease, erythromelalgia ; and second, organic, such as arteriosclerotic changes in the vessels, thrombo-angiitis ob- literans, etc. Peri-arteritis nodosa must also be included in the second group. Early in the disease the occurrence of indefinite pains leads one to the diagnosis of rheumatism, neuritis, gout or flat feet. The following are the most important diseases which may be confused in the beginning with thrombo- angiitis obliterans : ( 1 ) Erythromelalgia. Arterial circulation here is bounding and stronger during the at- tack, redness is paroxysmal — disappears on deep pressure and returns quickly. No ische- mia is present and pain is brought on by pres- sure but there is no intermittent claudication. Trophic lesions are very rare, gangrene is of the Raynaud’s type, and the vessels pulsate. Females as well as males, and all races are equally affected, and this is a symmetric lesion. 574 ' JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 (2) Raynaud’s disease. About 70% of these cases are in women; the upper extremities being mostly involved. The lesion is sym- metric, with attacks of local syncope, asphyxia and rubor. The veins are not pulseless, and redness does not disappear on raising the limb. Intermittent claudication and phlebitis are ab- sent. The x-rays show atrophy of the terminal phalanges. (3) Arteriosclerosis. This occurs usually in older people, blanching and rubor are not so regularly present, arteriosclerotic gangrene is of the moist type, and its occurrence in the upper extremities is rare. X-rays may show calcified arteries and they are distinctive here. However, one must remember that arterio- sclerosis may be superimposed upon a Buer- ger's disease. Treatment. The impression that the dis- ease finally ends in amputation is combated by Silbert, who holds the optimistic view that the disease can lie checked by proper and newer therapeutic measures, whereas the earlier treatment resulted usually in that 85% of the cases came to amputation. Spontaneous improvement has occurred but as the patient is further watched he is bound to have a re- lapse which within a few months may lead to gangrene. Silbert has studied 258 cases that were un- treated and found that 77% of 155 cases re- quired, within 5 years, amputation of one ex- tremity. In another series of 200 cases treat- ed under a single method he claims that in a period of 1-5J4 years only 10% of the cases came to amputation, and of these some were far advanced when they first appeared for treatment. He goes on to say confidently that if cases are recognized early, amputation will become a rarity. Prognosis under treatment depends greatly upon the circulatory de- ficiency, and palpation cannot determine that, so he resorts to the Paclion oscillometer and can thus early detect cases. With this method we have 2 distinct major groups: first, those having an oscillometric reading of or more at the ankle of the affected extremity, with an excellent prognosis ; second, those having a reading of zero or less than */-> in advanced cases, and if gangrene is present amputation is inevitable. Of course, prognosis depends upon the collateral circulation being sufficient to maintain nutrition. Various methods have been advanced as to treatment, the most important of which will be taken up : ( 1 ) The use of hypertonic salt solution, which consists of a 5% salt solution in dis- tilled water. The modus operandi is claimed by Silbert to be a mechanical one in that it increases the blood volume, by repeated in- jections, of the collateral circulation; this re- sults in a dilatation of the existing vascular channels and the opening up of new capillary channels. No specific effect of the salt is expected and salt is used because it is least toxic. His first dose is 150 c.c. and subse- quent doses 300 c.c. At least 7-10 minutes are allowed for each injection, and they are given 3 times a week and reduced as improve- ment takes place. The only effects at the time of injection are a sense of warmth and thirst, accompanied by flushing of the face or engorgement of the veins. It takes at least 48 hours to excrete 15 gm. of salt and that is why only 3 injections are given a week. A febrile reaction indicates a foreign protein in the salt ; usually the resultant of bacterial growth. Repeated injections have caused a certain, amount of destruction of red cells, but the patients have an increase in the blood elements and Silbert thinks it is of no conse- quence. Cardiac or renal impairment in a patient over 60 years of age is a contrain- dication to its use. Silbert has given some- where around 13,000 injections without any fatality. He claims that improvement may be seen within a few weeks and the first sign is an increase in the warmth of the affected part of the extremity with subsequent de- crease of pain. Most gratifying, are results obtained in early cases. We thus have an increase in temperature, growth of nails, later healing of the ulcer. In addition to these in- jections, rest in bed, hot foot baths, baking, diathermy and exercises recommended by Buerger are given. (2) Typhoid vaccine. Injections are given as advocated by Allen and Smith. This raises the temperature from 1 to 2° and is believed July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 575 by some to be just as beneficial as some of the surgical procedures recommended. (3) Insulin injections have been advocated. No final statement can be made as to its value, as not enough cases have been reported to show its benefit, and the theory is very defin- ite. Perhaps the question of a hyperglycemia may have some foundation. Insulin injections of from 10-15 units are given 2 to 3 times a day and may be of value in helping pain. However, it should be preceded by a glass of orange juice to combat any hypoglycemic re- actions that may arise. (4) Peri-arterial sympathectomy, as ad- vocated by Leriche and others, has been tried with some success. Considering the anatomy of the sympathetic system, and especially that supplying the blood vessels, it will be plainly seen that this form of operation is a waste of time. The operation as advocated by Hunter and Royle is that ramisection has been of value but not enough cases have been report- ed to have any final say about it. Ganglionec- tomy has also been performed, some claiming success, others refuting it. A similar method has been tried by exposure of ganglion to Roentgen rays with temporary relief only. However, all these operations are temporary in effect and just as good results can be ob- tained by nonoperative means. (5) Surgical treatment. Of course, con- servatism is uppermost in these cases and operations should be deferred as long as pos- sible to allow nature to form a collateral cir- culation. Silbert believes that nature should be given a chance to allow circulation to form and often nature performs a spontaneous amputation of the gangrenous toe. A major operation should be done only in the face of rapidly spreading gangrene even though in the presence of infection and ascending lymphangitis. Silbert treats his cases with simple drainage and wet dressings, with some good results. Trauma and infection must be guarded against. Unfortunately, some pa- tients come too late, but even here he believes that a trial of salt solution should be made. Silbert advocates ' amputation below the knee because an artificial leg functions much bet- ter with a natural knee-joint; however, ac- cording to Harvey and Oughterson, if there is evidence of a possible arteriosclerosis superimposed on this disease it is better to amputate above the knee. Case History. M. R.. white, male, Hebrew, American, 31 years of age, married, with no occupation for the past 5 years, entered the hospital October 17, 1930, complaining of severe backache and severe pain in the right wrist. For the past 3 weeks, he had experienced sharp, stabbing pains in the lower back, which radiated to the front and into the groin on the left side, lasting 6 or 7 hours and nof easily relieved by opiates. No nausea or vomit- ing accompanied the pains. The latter are intermittent, occur almost every day, are of the same nature and almost always double him up. At the time of these attacks he has had difficulty in starting his stream when voiding but with no polyuria, frequency or hematuria. He claims to have passed a stone from the bladder 7 years ago and one 4 years ago when he had similar attacks but they were not as severe as now. For the past 7 years he has had a dull aching pain in his back, which was constantly present but was not severe enough to alarm him. Also complains of sharp, stabbing, cramp-like pain across his right wrist- joint shooting along the ulnar side so that at times he does not feel the presence of his fingers at all. These attacks occur al- most every other day, at times twice a day, and he is rarely free from them for more than a week. They come on with such sever- ity that they drive him to the “verge of sui- cide”. At times he has “pins and needles” sensation in the tips of his fingers and during such attacks the right hand becomes very pale, taking a long time to return to its normal color, and being colder than its fellow. This has occurred intermittently for the past 8 months. About 12 vears ago, while a member of the 27th Aerial Pursuit Group, A.E.F., in France, both feet became numb and cold. Later he had “pins and needles” sensation, and the army medical man told him he had frost- bitten feet and a touch of rheumatism. From that time on he suffered with pain in both 5 76 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 legs but more so with the right, and the least exposure to cold caused him great suffering. He had these attacks for 8 years, being seen by various medical men who diagnosed it “rheumatism”, “flat feet”, “neuritis”, etc., without any help to his condition. Four years ago the pain became unbearable in his right leg and he was unable to stand on that foot. He was recommended to Dr. Buerger with a diag- nosis of “thrombo-angiitis obliterans”. He was hospitalized, given intravenous saline, Buer- ger’s exercises, etc., without satisfactory bet- terment. An amputation just above the knee was performed by Dr. Buerger. Five weeks later the patient fell and hurt his stump, resulting in a tumor formation which later discharged a seropurulent material and showed no signs of healing. He was sent to the Brooklyn Naval Hospital where a second amputation was performed 3 in. above the first and good healing resulted. The patient went around on crutches for a period of 3 years. In the meantime, his left leg began to bother him and he experienced the same symptoms as in the right leg. He was unable to walk a block without getting cramp-like pains in his left leg. One year later he went to the Brooklyn Naval Hospital where he received intravenous typhoid vaccine. He developed a severe reaction from the treat- ment, necessitating the use of adrenalin. At the same time he experienced a tingling sen- sation of the right hand. The toes on his left foot felt like “ice” and at other times “hot”. He developed an abrasion on the left big toe, and one on the second toe which in- creased the pain. He was sent to the Marine Hospital at Key West, Fla., where he had a partial amputation of the anterior-third of the left foot. He again experienced very sharp pain in his leg so that an amputation of his left leg between the hip and thigh was performed at the St. Francis Hospital, De- cember 14, 1929, where he made a good re- covery. Past history: Had measles and whooping cough. Habits : Nothing unusual except that he smoked about 40 cigarettes per dav and since the onset of new pains he smokes even more. There is nothing unusual in the family his- tory. His occupation was that of a painter since boyhood. However, since loss of both extremities he does not do anything. Previous hospitalization : Entered Mon- mouth Memorial Hospital February 27, 1927, complaining of pain in the right leg. A diag- nosis of “plumbism” was made and also Buer- ger’s disease was suspected. Entered again August 15, 1927, complaining of intermittent sharp pains in both feet. Diagnosis was “acnte foot strain”. He was in again on November 22, 1927, complaining of the same pain. Definite rubor changes were seen in the right leg and foot as compared to the left. Diagnosis— -Buerger’s disease. On July 9, 1930, he entered the hospital with both 'legs amputated and complaining of sharp stabbing pain in the left groin with a lump in scrotum. Diagnosis — • thrombosis of left spermatic veins, probably of same nature as that of the legs. He returned 3 days later with acute pain as on July 9, which has radiated to the left lower quadrant, with spasm and tender- ness of the left rectus muscle. In the last 3 admissions he complained of severe pain in the right hand and wrist. Progress : The patient was in the hospital fully 3 weeks. The pain in the left kidney area disappeared within a week. However, the intermittent claudication of the right hand became progressively worse. The at- tacks were agonizing, driving him to threats of suicide. Almost a grain of morphia would not hold him. Everything in the line of pal- liative means failed to help. Insulin was tried without avail. Persuaded to refrain from smoking. When the patient was discharged, one of our physicians called 3 or 4 times a week, and patient was no better; is now in Florida, thinking that the climate would be of benefit to him. Summary: We are dealing here with a disease which is almost in the last stages of thrombo-angiitis obliterans. Here is a pa- tient who had the disease almost 9 years be- fore it was recognized and when it was diag- nosed it was too late for nonoperative treat- July, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 577 ment. This proves the great difficulty of recognizing the condition in its early stages unless we bear in mind possibility of the dis- ease in people who complain of pain in the legs or hands. It also teaches us not to make a diagnosis of “flat feet" or “foot strain” un- less we have ruled out Buerger's disease. When presenting the patient at the confer- ence, he complained of severe pain in the left cubital fossa. On examination he showed a definite migratory phlebitis of the median cubital vein extending for about 4 in. with palpable nodosities along the newly inflamed vein. At the same time he had intermittent claudication of the left hand. It would be interesting if one could de- termine the cause of his pain in the left lower back, which was so typical in the history of renal colic or stone. Are we dealing here with some thrombotic process in the left renal vein? Was it a migratory phlebitis of that vein? Radiographs of the kidneys were nega- tive. In view of these negative findings one would be inclined to think that this is a part of the general disease which has attacked so many other vessels. Another interesting thing is his intermit- tent pain in the precordium. Here again one would be led to the idea that the coronary vessels are a part of the same thrombotic pic- ture seen elsewhere, in view of the extensive involvement in the other parts of the body. Neither an electrocardiogram nor physical findings of coronary involvement are positive. Only microscopically can it be proved to be thrombo-angiitis obliterans. Nevertheless, cor- onary involvement is to be thought of in peo- ple suffering with Buerger’s disease. THE BELL BUOY Ralph S. Cone, M.D. Rising and falling With the swell. The bell buoy tolls A funeral knell, Ringing ceaselessly, O’er the shoal ; Peace to the unknown Sailor’s soul ! Rumbling upon Thy lonely shores Like the wind In the chimney roars ; Sad one, watching By the sea, What could the cruel Waves tell to thee ! But merrily, Mockingly, they rave And the bell buoy tolls O’er the wanderer’s grave Doth absence make Thy love grow fonder? Wild heart, be still. He waits thee yonder ! 578 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 Economics FAMILY DOCTOR’S INCOME IN RELA- TION TO PREVENTIVE MEDICINE (Editorial from the Wisconsin Medical Journal, March 1930, part of which was taken from the American Journal of Public Health, January 1930.) From time to time the question is raised as to what effect the extensive program of pre- ventive medicine that is developing in many parts of the country will have on the income of the practicing physicians. The falling death and morbidity rates in all parts of the country compel recognition of the fact that this question has other than academic signifi- cance. Thinking persons realize that the prac- tice of medicine is no more a static condition than any other human relationship. In the evolution of social adjustments, the means and mechanism of furnishing necessary hu- man service must be modified to meet chang- ing conditions. The shrewd horse trader long ago sold his livery stable and bought a gar- age. The physicians of the kerosene era ob- tained a large part of their income from the treatment of diphtheria and infantile diarrhea. While preventive medicine has reduced the physician’s income from both these sources almost to the vanishing point, the physician of the gasoline age has more practice of a far better kind. Mathematic demonstration of this state- ment may be presented with available figures. The last year for which figures on diphtheria rates of the various states of this country are obtainable is 1927. In that year there were 82 cases of diphtheria reported in the state of Michigan for each 100,000 population. A comparison of incomes to the physicians be- tween fees received for treatment of cases and those paid for immunization of babies re- veals that even where the disease has the above unusual prevalence, preventive medi- cine is as productive financially as curative medicine. The income from treating 82 cases at $50 each would be $4100. Among each 100,000 population in the state of Michigan in 1927, there were 2200 babies born. If each of these babies had been immunized at only $3 each, the income from this practice in 100,- 000 population would have been $6600. It is also to be noted that these data predicate only the immunization of the new-born, or an equivalent number of persons in the commun- ity. There are of course 4 times as many preschool children as babies, and 10 times as many school children. The opportunity for increasing practice by carrying on immuniza- tion among the preschool and school popula- tion in the physician’s clientele offers an al- most unlimited field. I had occasion to visit the dentist the other day. Because I had postponed the visit too long, some of the necessary repair hurt a good bit more than as though it had been done earlier ; and, the bill was larger. When I was dismissed, the doctor asked: “Would you like to be placed on the 4 months’ list?” He then explained that people forget about inspections and the dentist until the night that toothache awakens them, and said that the “4 months’ list” meant that at the end of each fourth month his assistant would call for an appointment, — and call repeatedly until I did come in. I, like 75 other patients of that particular dentist, was pleased with the sug- gestion. If that pleases the patient of the family dentist, why should it not please the patient of the family physician? I venture to sug- gest that it would. ARE WE UNDERPAID? (An article by Dr. H. M. Tolleson in Medical Economics, February 1931.) There is much ado about the doctor’s fee, methods of collecting, and like problems. Here is a thought not so much discussed in the meetings of our medical societies and in the editorial columns of our journals : There is one way in which a doctor, a real physician, is paid that isn’t entere'd on his ledger. There is one form of compensation that doesn’t come under the income tax re- port. Have you; Brother Physician, ever experi- enced the feeling of satisfaction and gratifica- tion that comes like warm sunshine permeat- ing the drab, sordid grind of the day’s wyork from the sight of a helpless infant gradually growing stronger under your care? Has you heart been touched and your eyes moistened as a mother looks up at you with a glowing face as she holds a baby who is re- covering from the brutal attack of disease, recovering as a result of your timely inter- vention ? Do you recall that night when you sat be- side the patient as he passed his crisis and the anxious little wife and bewildered little children looked up to you and put all their trust and faith in you ? And then, when you could safely say, “He is out of danger, Mrs. Brown” — do you recall that look, that “Thank God — and the Doctor!”? Did you collect a fee 1 Whether you did or not. Doctor, were you underpaid? July, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 579 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J. Entered at the post office at Orange, N. J., as seccnd-class matter PUBLICATION COMMITTEE HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J. EDITOR: HENRY O. REIK, M.D., F.A.C.S., Vermont Apartments, Atlantic City, N. J. Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing ta receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact. NOTE. — The transaction of business will be expedited, and prompt attention secured if: All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to The Editor, Dr. Henry O. Reik, Vermont Apartments, Atlantic City, N. J. All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements, or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication Committee, (address above), Newark, N. J. ASBURY PARK CONVENTION The 165th Annual Meeting of our vener- able State Society, held at Asbury Park, June 2-5, was no less interesting than the many similar previously held conventions of this organization. Good weather conditions pre- vailed throughout the week, and proximity to the larger centers of population embraced in the counties of Essex, Hudson, Mercer, Mid- dlesex, Morris, Passaic, and Union, favored an increase of attendance. The total regis- tration did not, however, reach the high fig- ures established in Atlantic City — only 890 in all as compared to 1065, and 310 members exclusive of delegates and officers as against 459 — lint the percentage of elected delegates present 180%) was unusually large. Only 2 Fellows and 3 Trustees were absent. There were, however, 2 attendance drawbacks to the success of the meeting : many of the regis- trants from the northern portion 'of the state drove by automobile from and back to their homes the same day, merely “looking in” upon the convention ; and, several of the southern counties were very poorly repre- sented (3 without representation at the meet- ing of the Nominating Committee) because of the inaccessibility of Asbury Park by rail- road. The figures at hand do not enable us to cal- culate the effect upon attendance resulting from abolition of the Permanent Delegates, but we are inclined to think it was less than had been feared. Two years ago, we editor- ially expressed the belief that “the old de- pendables” would continue their interest in the organization, and a superficial view of the recent meeting tended to confirm that opinion. A sense of gloom hovered over the Trus- tees’ meeting Tuesday night and the opening session of the House of Delegates on Wed- nesday, because of the death of Dr. Hunter, a former President and until Tuesday morn- ing, Secretary of the Board of Trustees. Dr. Hunter had packed his bag, including his of- ficial papers completed up to the minute, and retired to bed with the intention of making an early morning start to drive from Westville to Asbury, and ere normal sleep could come he was stricken by coronary thrombosis and lived but a few minutes thereafter. In his passing, the Society lost one of its safest, sanest and most efficient organization work- ers, as well as one of its most illustrious mem- bers. At this meeting, President Sommer closed a year of marked activity in the presidential office, and presided over one of the busiest sessions the House of Delegates has ever held. The amount of work inaugurated during the past year, considered by the Delegates, and advanced to his successor, is indicated by the large number of special committees provided for to carry on the projects approved and resolutions adopted. The scientific program for the general ses- sions was not up to standard and its presen- tation suffered further from the lack of an audience Friday afternoon. The exodus of those who had been chiefly interested in the business and political conferences of Wednes- day and Thursday, and the fact that so many 580 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 members merely dropped in for part of one day, and made choice of that day which af- forded the greatest amount of entertainment, serve to explain the fiasco of the last after- noon session. All of the sections were well attended, and a movement was launched to establish next year a Radiologic Section. The Woman’s Auxiliary apparently had a very satisfactory meeting and is progressing as well as could be expected. We hope to publish the “Official Transac- tions” this year along with the August Jour- nal. ENTERING UPON A NEW FISCAL YEAR At the close of the Asbury Park meeting, Dr. John F. Hagerty, of Newark, ascended to the presidency of the state society and opened a new year of the organization’s work. No more worthy person could have been selected from the society’s membership for this honor. In the city of Newark, where he is best known. Dr. Hagerty is universally loved and respected, as a surgeon of great ability, a physician of professional distinction, and a man of the highest probity. He is tak- ing leadership in the society at a critical moment in its life, a time when questions of the most serious import are demanding con- sideration and, if possible, solution, but all who know him feel that he will prove himself an active, wise and courageous leader. As will be seen later, in reading the convention transactions, he is instructed or authorized to appoint an unusually large number of com- mittees to study a variety of problems. Every member, as appointed o: called upon for ser- vice, should give him all possible assistance in his efforts to conduct the affairs of this so- ciety satisfactorily. The election of other officers resulted in promoting Dr. Lancelot Ely, of Somerville, from Chairmanship of the Committee on Scientific Work to the position of Third Vice- President. Dr. Ely has represented his county faithfully and well in the work of the Welfare Committee for a number of years, besides having filled all the offices of the Somerset County Society. STATE SOCIETY TRANSACTIONS It has been customary to publish the com- plete transactions of the Annual Meeting as a Supplement to either the August or Septem- ber Journal, depending upon receipt of the reporter’s transcript. This year olir meeting was held a week earlier than usual, and the reports are being received with sufficient promptness to justify the expectation that the proceedings can be published early in August. In consequence of that hope, it seems unneces- sary to present this month any elaborate sum- mary of the happenings at Asbury Park, but our readers who were deprived of the privi- lege of attending the convention will doubt- less want to have some news of the event. At the opening session of the House of Delegates, on Wednesday morning, President Sommer called attention to an unfortunate feature of the Constitution and By-Laws, which provides for delivery of the Presiden- tial Address at a fixed time that is not reached until after the Delegates have completed their work upon the Society’s business affairs. As lie pointed out, at the conclusion of his term the President should have some recommenda- tions to offer and advice to give as the result of experience. Dr. Sommer met that situation by at once presenting an abstract of his pre- pared address, but some provision should be made by law makers of the society to correct the complication. Perhaps the most marked feature of the convention was the amount of new business introduced and the number of problems of- fered for solution. The incoming President was authorized to appoint special committees to investigate and study such questions as state medicine, classification and control of special- ism. the Workman’s Compensation Law, amendment of the Hospital Lien Law, pro- vision in the Medical Practice Act for a griev- ance committee, urging the Motor Vehicle Commissioner to require more complete physical examinations of those seeking license to drive automobiles, revision of the state health laws, cooperation with the Board of Education regarding health measures applic- able to school and pre-school children, and others that escape our thought at the moment. July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 581 Medical Ethics MEDICAL SOCIETIES John Hammond Bradshaw, M.D., F.A.C.S., Orange, N. J. “In order that the dignity and honor of the medical profession may be upheld, its standards exalted, its sphere of usefulness extended, and the advancement of medical science promoted, a physician should as- sociate himself with medical societies and contribute his time, energy and means in order that these societies may represent the ideals of the profession.’’ — Principles of Medical Ethics, A.M.A. We find it the case inside and outside the profession that some men like clubs and some detest them : And while a medical society in many ways is a club, it is also in many ways very different. Generally speaking, a “club- able” man is glad to join a medical society. But there is no special obligation for a man to be an Alpha Delta Phi or an Elk, a Rotarian, or even to join his Country Club in the sense that he should join his local medical society, his county medical society (and the American Medical Association), and, if he is a special- ist, some regular organization that represents his special work. In social clubs, the advantages are mostly social, whereas the medical society is, rightly speaking, almost altruistic as well as social, highly educational, and its chief object is the advancement of medical science. No doctor in his own interest can neglect his medical so- ciety. If he does so, his own is the chief and only loss. Look at the names of the great leaders of the medical profession and you will be amazed to find so few of them who are not also lead- ers in medical societies. These societies are the clearing houses in their different localities for medical thought. They stand in the medi- cal world as the Stock Exchange does in fi- nance, for here you get increase in your stock of medical knowledge, and in our medical ex- changes the losses are few and the profits are great. Dr. Osier wrote of this subject, membership in the medical society, with his unusual un- derstanding : “But, after all, the killing vice of the young doctor is intellectual laziness. He may have worked hard at college but the years of probation have been his ruin. Without specific subjects upon which to work, he gets the newspaper or the novel habit and fritters his energies upon use- less literature. There is no greater test of a man’s strength than to make him mark time in the ‘stand and wait’ years. Habits of systematic reading are rare, and are becoming more rare, and 5 or 10 years hence, as his practice begins to grow, may find the young doctor know- ing less than he did when he started and without fixed educational purpose in life. Now here is where the medical society may step in and prove his salvation.” (Italics mine.) But even medical societies can have their diseases ; which may even cause gangrene and death. A certain amount of well directed pol- itics is absolutely essential to the preservation and advancement of any society. But if this is misdirected and actuated by selfish motives, medical politics can cause dry rot. Esthetics CULTURE (This article, taken from the front cover page of the American Medical Association Bulletin of May 1931, was abstracted from The Dip- lomats by Thomas G. Orr, M.D.) “Any professional man is hardly doing his full duty to himself and to the profession he represents unless he gives some time to edu- cation and cultural improvement. I am con- vinced that by so doing in medicine one will make a better physician. Even a doctor is partly judged by his general information of affairs, and, therefore, cannot afford to neg- lect all the better things in general education. Eben Holden was right when he said : ‘Got t’ judge the owner as well as the hoss. If there’s anything the matter with his conscience it’ll come out in the hoss somewhere.’ A doctor cannot afford to be substandard in things edu- cational or the evidence will crop out some- where and his shortcomings be made evident. Education keeps us out of a rut, it demands respect, and, of equal importance, it is a last- ing pleasure. Education and culture go hand 582 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 in hand. Culture is quite difficult to define, and I am confident that many times it exists in outward show and mannerisms only. A mother may teach her son to tip his hat to women and to stand in the presence of her guests, but he will not be cultured if he lies to her about his escapades or steals from his neighbors. Most men of science are led to be- lieve that many of the qualities that go to make up an educated and cultured gentleman are inborn and cannot be the result of envi- ronment only. Such a heritage does not mean family or social position. ‘The creature we call a gentleman lies deep in the hearts of thousands that are born without chance to master the outward graces of the type.’ (Owen Wister.) If the qualities that lead to education and culture are born in a man, he is fit to become a doctor.” Concerning the last mentioned aspect of the question, the degree of culture desirable in a prospective physician, the Journal of the Michigan State Medical Society, of Tune 1931. contained an interesting editorial from which we quote as follows : “Culture is an elusive entity; it is of a class of words such as light, life, death, difficult to define, yet its manifestations are clear to ev- eryone. Nor in our opinion can culture be acquired by memorizing Elbert Hubbard's scrap book nor by 15 minutes a day with El- iot’s 5 ft. book-shelf, as interesting as these may be. We can see how such a course might make of a man or woman an intolerable bore. Externally we associate culture with neat- ness of attire, with carefulness combined with ease in speaking, with a voice that is not un- pleasant. We can hardly conceive of a cul- tured man who is not educated, but there are many educated persons who are anything but cultured. The cultured life may be built upon a book foundation. The cultured person is critical in his outlook on life. In other words, he does his own thinking and accepts truth only on evidence ; yet. he is tolerant where tolerance can be considered a virtue, which it is not always. He should aim at accuracy, avoid cock-sureness of statement, and never hesitate to acknowledge his limitations. Yet all this is not a definition. We are inclined to place the term culture in the same category as personality, a word we were never able to define to our satisfaction.” In Lighter Vein Home Treatment “Good morning, Mrs. Kelly,” said the doctor, “did you take your husband’s temperature, as I told you?” “Yes, doctor, I borrowed a barometer and placed it on his chest; it said ‘very dry,’ so I bought him a pint o’ beer an’ he’s gone back to work.” — Bos- ton Transcript. Those Luscious Accents Wife — “John, is it true that money talks?” Husband — "That’s what they say, my dear.” Well. I wish you’d leave a little here to talk to me during the day. I get so lonely. — Bennington Banner. Desperate Moment Mother — “Johnny, if you eat more cake, you’ll burst.” Johnny — “Well, pass the cake and get outa the way.” — Boston Young Men’s News. Explained at Last “Well, you’ve got one of them ear things for your deafness at last. That's what I’ve been tell- ing you to do for 5 years.” “Oh ! That's what you've been telling me for 5 years, is it?” — Punch. Friend of the Stork The doctor of a country village had 2 children who were acknowledged by the inhabitants as be- ing the prettiest little girls in the district. While the 2 children were out walking one day, they happened to pass quite near 2 small boys; one lived in the village and the other was a visitor. “I say”, said the latter to his friend, “who are those little girls?” “They are the doctor's children,” replied the vil- lage boy. ‘ He always keeps the best for himself.” — Montreal Star. Doctor — I suppose, Mrs. Johnson, that you have given the medicine according to directions. Mrs. .Johnson — Well, doctah, I done mah bes’. You said give Sam one o' dese heah pills 3 times a day ontil gone, but I done run out o' pills yistaday an' he hain't gone yet. Joshaway Crabapple says: “Wooden legs are not inherited; wooden heads often are.” Consulting the Oracle Gentleman (at police station) — “Could I see the man who was arrested for robbing our house last night?” Desk Sergeant — “This is very irregular. Why do you want to see him?” Gentleman — “I don't mind telling you. I only want to ask him how he got in the house with- out awakening my wife.” — Harvard Lampoon. There's No Perfect Crime Betty — “How did mama find out you didn’t really take a bath?” Billy — “I forgot to wet the soap.” — Boston Trans- cript. July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 583 Lighthouse Observations COMBINATION" ANESTHESIA Much has been written recently about anes- thesia and anesthetics — general, spinal or intra- venous— and a variety of drugs usable by one or other of these methods. The reasons for such consideration are well stated by Willard Bartlett (Jour. Missouri Med. Assoc., 28:43, January 1931): “No one now alive remembers the period when it was current practice to tie or hold a patient down during a harrowing surgical procedure. Having this picture in mind, the surgeon of an earlier day must have been more than satisfied when the introduction of ether and chloroform forever freed the sufferer from the torture that had been his while on the table. Are we now, nearly 100 years later, keeping step with progress in other fields unless we make every effort to overcome the anxiety, insomnia, restlessness, nausea, sweating, pain and thirst which custom- arily precede or follow surgical operations? If we eliminate these, we can accomplish 4 desirable ends by diminishing the likelihood of (a) respira- tory complications, (b) vomiting, (c) distention and (d) bladder paralysis. Up to May 1 of this year we had studied the effects of veronal and luminal upon 1218 patients, having in mind widening the scope of surgical anesthesia. This- paper gives the result of our ex- perience with 190 individuals who, in the accom- plishment of our anesthesia plan, took relatively large amounts of luminal, the drug being admin- istered in a single dose to 134 of them, and in broken doses to the remaining 56. Our patients are carried for about 36 hours in what may be called a dream-state, being actually unconscious during the operation only. They are more or less responsive at all times, seem wholly rational, answer questions, but manifest no in- terest in their surroundings then and later retain only the haziest, if any, recollection of this entire period and its happenings. Our prolonged semi- anesthesia renders it unnecessary in goiter cases to operate outside the operating room, or, indeed, to start gas in a patient’s bed no matter how toxic she may be; she is indifferent to the change from bed to operating table, hence no psychic damage is done. Every satisfactory anesthesia is a compromise between advantages gained and risks taken. One does not claim that a drug so potent as luminal, for example, is utterly harmless; it cannot pos- sibly be harmless. Still, it has seemed in our hands to have greatly reduced the need for much of the more dangerous anesthetic substances and at the same time to have possessed advantages not inherent in them. It is easy to exceed the proper dose of any sedative drug, thus risking the pathologic rather than the wanted physiologic ef- fect. With this axiom in mind we endeavor to induce a mild anesthetic state of from 24-36 hours’ duration by superimposing upon one another the influences of luminal, nitrous oxide (sometimes ethylene), one dose of morphin if great postoper- ative pain be present, and several doses of pyram- idon. In some instances, of course, spinal, regional, or other form of local anesthesia is sub- stituted for the gases, but the patient is never al- lowed to remain completely awake. We believe it more humane to carry out major surgical opera- tions under general anesthesia if feasible, but it must be remembered that an occasional goiter pa- tient will seem on the verge of drowning in mucus soon after gas is started. Just here the luminal preparation has its particular value. Gas is dis- pensed with, procain is injected, the operation pro- ceeds with the patient rather oblivious to her sur- roundings and later unable to state just what anes- thetic method was employed. No doubt many other similar emergencies arise touching every part of the body. Atropin tends to rouse the sleepy luminal patient if employed before an in- halation anesthesia, hence its use is not to be re- commended if it can be avoided. However, we are frequently forced to employ it when an exces- sive amount of mucus is secreted early in a thy- roidectomy. Should there be actual need of pro- ducing artificial sleep at any period of the hos- pital stay outside the vital 36 anesthesia hours, so-called, we resort to chloral hydrate and par- aldehyde by mouth or rectum. Our standard dose for strong patients in middle life is 15 gr. of powder in hot milk, taken all at once by mouth 3 hours before the operation, pro- vided the blood pressure is not low. A very small or greatly depleted woman takes less, and a very large, active man needs more, as does one having a toxic goiter. A deep surgical inhalation anesthesia sometimes seems more difficult to secure after luminal prep- aration for the reason that a patient so treated cannot inhale as deeply as would otherwise be possible. This may possibly be a blessing in dis- guise, so far as danger from the inhalant is con- cerned. The writers present a plan of anesthesia which has been maturing during 10 years’ study on selected patients; its conspicuous value in general surgery has quite naturally suggested employment in several other fields where a more or less com- plete anesthesia is essential or at least desirable. Hence the plan is amplified at this time in the hope that it will meet the needs of most men who comprise a general medical assemblage. A perusal of German and French literature dis- closes indications that barbituric acid compounds neither slow up uterine contractions nor- poison the fetus, hence one is inclined to believe that this anesthesia plan might be of use especially to the physician who has neither a hospital nor an anesthetist. From the obstetricians we gather that a multipara might average about 6 hours and a primipara about 12 hours in labor; hence we are advising that 3 gr. of luminal be given every hour to the former from the onset of pain until 5 doses have been taken. The primipara might bet- ter take 1% gr. every hour until 10 doses have been used. For the actual delivery, a very little gas or ether may be needed as is the case in major surgery. Dr. Tonelli tells me that a tonsillectomy pa- tient under the influence of luminal is much more manageable during the operation and preceding nerve block than is one who has not taken the drug. Further, it very greatly lessens the misery of the first postoperative day although he uses only one-half of our dose. Our wide experience ,in general surgery has demonstrated that it may be used in rather large doses without abolishing cough, gag, or swallowing reflexes, a matter of superlative importance since retention of these I’eflexes constitutes the patient’s best defense against lung abscess resulting from, inspiration of infective material during or after a mouth opera- tion. Dr. Caulk feels that a field for this plan of semi- anesthesia exists in operative cystoscopic work, there being many such patients whom one desires to make oblivious to their condition and surround- ings for 24 hours following the procedure. A 15 gr. dose of luminal goes far toward en- abling one to make satisfactorily the type of 584 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 bimanual pelvic examination for which a general anesthesia has been considered essential. In some instances the woman retains no recollection of what has transpired. The saving of expense and the avoidance of risk are quite obvious. This plan cannot, of course, be used in the treatment of ambulatory patients. Among the many highly disagreeable surgical procedures is the induction of a spinal anesthesia. We always prepare such a patient with luminal, and then, provided the blood pressure has not dropped too low, introduce the needle while she lies on the side or on the face, depending on the operation to be done. Not all patients react alike to the after-effect of luminal, hence postoperative treatment deserves special consideration. The great majority of pa- tients need no sedative after leaving the tab'e; a very small second group which has been under- dosed before operation is given luminal (1H gr.) with pyramidon (5 gr.) every 4 hours as long as restlessness or complaining continues, while mem- bers of a still smaller third group become mildly maniacal and require morphin (% gr.), after which they act as do patients in the large group first mentioned. The actual results obtained in the treatment of 134 patients who received a single dose of luminal are tabulated as follows — Effect upon reaching op- erating room: slight, 13: medium, 87: profound, 34. The effect of the anesthesia lasted 26 hours in the average individual.” Intravenous Sodium Amytal Reporting an experience of 200 surgical cases in which complete or partial hypnosis was pro- duced by intravenous administration of sodium iso-amylethyl barbiturate, Floyd L. Grandstaff (Am. Jour. Surg., 10:300, November 1930) says: “In preliminary observations published by the manufacturer, it was recommended that sodium amytal in doses of 20 to 25 mg. per kilogram of body weight be used for prolonged surgical anes- thesia. In order to use sodium amytal as the basal agent in anesthesia, this dosage was regard- ed by us as the maximum. This was computed as 1 gr. per 10 lb. of body weight. We estimated that temperature, thyroid dysfunction, age, develop- ment, cachexia, dehydration, preoperative medica- tion, type of operation, duration of operative pro- cedure, etc., would alter the amount of sodium amytal necessary to produce satisfactory narcosis, and allowances were made for such factors. Patients with hypertension and arteriosclerosis were observed to react more quickly to sodium amytal, and required less than patients having nor- mal blood pressure. Obese patients required less per kilogram than did lean or muscular patients weighing approximately the same. An increase in metabolic rate required an increase in the amount of sodium amytal, and this was manifested in adolescents who required more per kilogram of body weight. A decrease of 3 to 5 gr. of sodium amytal was possible by increasing the preoperative morphin from 1/6 gr. to *4 gr. Alcoholics, and patients who had been receiving barbituric acid derivatives for sleeplessness over long periods, required the maxi- mum dosage. The average dose required for la- parotomy was 11 to 13 gr. The relatively small dose of 10 mg. per kilogram of body weight, or 1 gr. per 20 lb. of body weight, was used in combination with local anesthesia for cystoscopy and nose and throat operations. In these instances, the patients did not lose con- sciousness, and they were susceptible to requests, so that pyelograms were obtainable if desired, or the patients were able to cough and raise mucus or blood as the case might be. The patients would often complain bitterly and appear rational, yet none of them had any memory of painful exper- iences. Sodium amytal as dispensed, when mixed formed a 10% solution. No solution was allowed to stand for longer than 15 minutes before use, and a solu- tion was discarded if not clear and cloudless. A 10% solution was injected intravenously not more rapidly than 1 c.c. per minute. In cases in which profound hypnosis was desired, the rate of in- jection was decreased to 0.5 c.c. per minute as soon as the patient became unconscious. A record of systolic blood pressure, pulse and respirations was made during each minute of injection and at 5 minute intervals throughout operation. It was found that a decrease in rate of injection would often control what appeared as a too rapid de- crease in blood pressure. This was especially true in cases of hypertension and arteriosclerosis. Hyp- nosis was produced in the average patient in 3-5 minutes. The supplementary anesthesia consisted of inhalation of nitrous oxide gas and oxygen. Sodium amytal, as used in this series of cases, did not produce anesthesia, but produced hypnosis, and a supjilementary anesthetic was required. The administration of sodium amytal produced a lower- ing of blood pressure in all cases, and the decrease was more marked in cases of hypertension and arteriosclerosis. The immediate or remote effect of the blood pressure change was not determined. Relaxation of the throat and tongue produced a temporary cyanosis unless closely watched and an airway or Connell tube inserted. The shallow res- piration and long period of quiet after operation was credited with a tendency to pulmonary con- gestion. Of the first 100 cases, 25% required catheterization, but once the nursing staff became accustomed to awakening sodium amytal patients and encouraging them to void, the percentage was no higher than after other general anesthetics. Urine specimens of all patients were found to con- tain acetone during the first 24 hours. Two pa- tients manifested a bright red rash which dis- appeared within 36 hours. Postoperative complaints of nausea and vomit- ing were absent in 95% of the cases. There ap- peared to be less paresis of the intestinal tract with consequent less pain from postoperative gas pains. The quantity of inhalation anesthetic was re- duced. Amnesia without hypnosis was obtainable and with local anesthesia was especially adaptable to minor operations with special reference to cys- toscopy. Use of sodium amytal as the basal agent in combination with inhalation of gas and oxygen, with or without a preoperative dose of morphin, produced satisfactory obtundation for all major surgical operations, and was considered to have many advantages not obtainable from other anes- thetic drugs.” Concerning intravenous use of sodium amytal, Francis M. Findlay, reporting experiences at the Cambridge (Mass.) Hospital (New England Jour. Med., 203:1029, Nov. 20, 1930), says: ‘‘Intravenous anesthesia has been used abroad for the past 10 years. It was first introduced in France, later in Germany, and for the past 2 years has been employed in some of the larger clinics in this country. Its use has been some- what limited, as it has been regarded by many as a rather dangerous drug. Our experience at the Cambridge Hospital embraces a small but varied July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 585 series of cases in which the results were uni- formly satisfactory, and I deem the drug of suffi- cient merit to warrant reporting at this time. We are not advocating discard of any of the generally accepted anesthetic agents which have been used so successfully over long periods of time; we are simply offering our experience with an anesthesia which we feel holds a definite place and has made a distinct contribution to our anesthetic equipment. The toxic effects of ether,, particularly in debilitated patients, or in poor risks, are too well known to discuss at this point. Local anesthesia, well administered, has come to have a definite place in the surgical field. Abroad, the majority of surgical operations are done under local anesthesia. In this country there is an in- creasing tendency toward the use of local anes- thesia, but many surgeons and patients object to the mental strain to which the patient is subject- ed because he is conscious. In spite of this fact, local anesthesia has m,ade rapid strides and in many clinics is employed by choice. With sodium amytal supplemented by local anesthetics we feel that we have an ideal anesthesia for carefully chosen cases, particularly the aged and poor sur- gical risks. The only preliminary medication we have used has been morphin sulphate, 1/6 or % gr., an hour and a half, and repeated half an hour, be- fore administration of the sodium amytal. We have not wished to complicate the picture by the administration of other drugs. In patients hav- ing morphin, the anesthesia was pronounced and of longer duration than in those without morphin. Lundy, in the Mayo Clinic, advocates 10-15 gr. of chloretone by mouth, 2-3 hr. before operation, fol- lowed by a single dose of morphin, % -1 /6 gr., and atropin, 1/150 gr. The average duration of the anesthesia is from 40 minutes to 1 hour. The pa- tient, at the end of this time, usually begins to move and may make a few incoherent remarks, but for the next 12-24 hr. generally sleeps quite soundly. There has been no postoperative nausea or vomiting in any of our patients. With sodium amytal alone, without preliminary medication, we have been able to obtain satisfac- tory anesthesia for simple operations, such as re- duction of fractures, curettage, rectal operations, and simple operations on the neck, head or extremi- ties. In combination with morphin, we have ob- tained satisfactory anesthesia for a radical breast amputation, appendectomy and hernia. In combina- tion with spinal anesthesia, any abdominal opera- tion that does not require over 40 minutes can be readily done. Relaxation is complete, and the pa- tient is entirely unconscious. From our experience, we feel that the combination of spinal anesthesia- subarachnoid block — as Labat terms it — with amy- tal offers the ideal anesthesia in the poor risk. The spinal anesthesia insures complete relaxation of all muscles, while the amytal renders the patient un- conscious and assures from 12 to 24 hr. postopera- tive comfort. Mason and Baker feel that the chief virtue of the drug is that it frees the patient from mental strain and worry. We concur in this find- ing but feel that the lessened shock, especially in the aged and feeble, is the greatest contribution. In 1 or 2 operations in which there was some de- lay, it was necessary to administer novocain in- filtration to close the abdominal wall, or supple- ment the sodium amytal by gas or ether. In 2 cases we were able to perform radical operations upon patients with hypertension and chronic ne- phritis without any discomfort or injury. The pa- tients require less postoperative morphin, as the sedative effects of the anesthesia often last until well into the next day following operation. Two of our patients required secondary operations. Both requested sodium amytal. We have had no deaths attributed to the use of this drug. There were 2 deaths in this series of 30 cases, 1 in a cardiac aged 74, who died of cardiac failure 4 days after drain- age of the gall-bladder; the second in a 92 year old woman with general peritonitis, who develop- ed a volvulus of the small intestine 10 days after operation. It does not seem fair to attribute either one of these deaths to the anesthetic. We have not noted the bladder complications or pulmonary edema which Mason reports. Certainly our pa- tients have suffered less shock than those having inhalation anesthesia. We have used the drug twice to quiet excitable nonoperative patients. We have used it once for a wildly excited alcoholic, with excellent results. It is ideal for operations about the head or neck, and wherever the cautery or diathermy is used the explosion hazard is re- moved.” Current Events TRISTATE MEDICAL CONFERENCE The eighteenth session of the Tristate Medical Conference was held Saturday, May 23, 1931, at 10.30 a. m., at the University Club, Philadelphia. Those present were: New York — William H. Ross, Brentwood; and Joseph S. Lawrence, Albany. Pennsylvania — Ross V. Patterson, Philadelphia; William H. Mayer, Pittsburgh; Walter F. Donald- son, Pittsburgh; Frank C. Hammond, Philadel- phia; Harry W. Albertson, Scranton; Arthur C. Morgan, Philadelphia; William T. Sharpless, West Chester. New Jersey — George N. J. Sommer, Trenton; J. B. Morrison, Newark; Ephi'aim R. Mulford, Burlington ; Henry O. Reik, Atlantic City. Dr. Lawrence expressed Dr. Sadlier’s regrets at being unable to attend the Conference. A tele- gram containing Dr. Vander Veer’s regrets also was read by Dr. Reik. PROGRAM Our Responsibility for Public Education Regard- ing' Comparative Costs of Sickness Ross V. Patterson, M.D., Philadelphia, Pa. Our program is encompassed by 2 topics, but they are related and I think perhaps it will fa- cilitate the discussion if both presentations be first made and the discussion follow. With your permission we will proceed along that line. In making my own presentation, I may say that I have had in mind for some time the relation of certain facts and studies that have been made within the past few years with regard to the cost of medical care, the cost of medical education, the obligation of the profession to provide certain medical service to the indigent and to those in moderate circumstances. There has been a good deal of medical discussion, a good deal of lay com- ment, and I think there has been a good deal of misunderstanding with regard to the purport of certain facts which have been ascertained in va- rious studies and of certain opinions that have been expressed by leaders in our profession. There is thought to be a need for public education. My 586 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 own feeling is that there is a greater need for edu- cation of the profession itself and that public un- derstanding will be the better when medical un- derstanding of certain facts becomes clearer than it is now. Dealing with round figures, the national income is about $100,000,000,000 a year and we have to understand that fact in order to interpret the na- tional cost of any activity or of any industry.. About $3,000,000,000 is the cost of medical care; which is, of course, approximately 3% of the na- tional income. That $3,000,000,000 is apportioned to various bodies and activities concerned in medi- cal care and, roughly, about !4 of that goes to doctors; which is, of course, $750,000,000 per year for the 120,000 practitioners in active practice — a little over $6000 per year each. And yet studies have shown that only about Vz of those physicians make so much as $3000 per year. So, it is ap- parent that the average doctor is not being over- paid. The hospitals receive about % of this $3,000,000,- 000 expenditure for medical care; that is another $750,000,000; or perhaps a little more than that. There are some 8000 hospitals in this country and they have about 1,000,000 beds. I do not know what they cost but the investment of hospitals would certainly have to be $4000 per bed as a low figure for construction cost ; which would mean $4,000,000,000 invested in hospitals, and it takes something less than $1,000,000,000 a year to run them and some 500,000 people to carry on their activities. From the total expenditure for medical care about $750,000,000 goes to the druggists, not only for prescriptions but for all the patent medicines and self medication of the people of this country. Then the remaining $750,000,000 goes to dentists, nurses and quacks. Flow there is, in round fig- ures, our expenditure of $3,000,000,000 for medical care; V\ to the doctor for division among 120,000 doctors; Vi to the druggists; !4 to the hospitals; and % to the dentists, nurses and quacks. Even these figures seem very large but their importance is only to be estimated by comparing them with other national expenditures. We learn, for in- stance, that the salaries of railroad employees in this country amount to $3,000,000,000 a year. That is as much as is paid for all the expense of medi- cal care, regular and irregular. The bootlegging bill of this country is not less than $3,000,000,000 a year. The tobacco bill of this country : you know in 1930 there were 120,000,000,000 cigarettes sold in this country. That is 1000 for each man, wo- man and child, and the cost of tobacco in this country was about $2,000,000,000. Jewelry and furs to the amount of $750,000,000, or the equal of what is paid to the doctor. Perhaps we could consider jewelry and furs as luxuries, yet we hear very little complaint about the high cost of jewelry and furs. There are $4,000,000,000 a year spent for automobiles; that is more than the entire cost of medical care. It takes $1,000,000,000 worth of gasoline to run them each year, and that is more than all the doctors get put together. The wo- men of this country spend for cosmetics and in beauty parlors as much as $750,000,000 a year — as much as the entire country pays to all the doc- tors. Now do not understand me as criticising this expenditure. If it were twice as much I would still approve of it. I believe it is a woman's duty to be even more beautiful than nature has made her, and if it costs many times that amount it would be a proper expenditure. But, I merely mention it in comparison to the cost of medical care. When I make these comparisons it is seen that the cost of medical care is not out of pro- portion to other national expenditures. It is un- fortunate that the public has somehow or other, chiefly through what has been said by the medi- cal profession itself, come to believe that it is paying an excessive amount for the fees of the 120,000 doctors, for the hospitals which contain 1,000,000 beds and to which nearly 10,000,000 peo- ple i>ass each year, and that it is paying too much for all of these things. Now, as a matter of fact, it is not. Calling attention to these facts does not mean that we should not continue to do what we can to lessen the cost of medical care, and particularly for those who find the bur- den heavy, but there is no good reason why the doctor should disparage the value of his own ser- vices or the institutions in which he works. Now, what about the doctor himself? Well, we hear a good deal these days about the excess of applicants for medical schools, that there are a large number of men seeking to get into the medi- cal schools, and a large number are turned away. Some who believe this to be the fact interpret it as the endeavor of the medical profession to imi- tate the methods of trade unions by limiting those who may enter the practice of medicine. What are the facts? Every first-grade medical school in this country has a large number of ap- plicants for admission; a number far in excess of the number of places in the classes. If we take a half dozen leading schools of this country they will show 2000 or 3000 applications for every 150 places; that is 20 men for each place, and it seems to indicate a tremendous number of applicants b - ing rejected. Facts are that about 8000 men make about 30,000 applications, and that 6000 of those men are accepted and 2000 are rejected; % of those who apply and complete their applications find admission to some medical school — not neces- sarily the school of choice. Of those 6000 men, about 4500 are graduated; that is, Vi of the num- ber are eliminated after admission to the medical course. It is interesting, in endeavoring to ascertain whether or not the doctor is over-paid, to inquire into the cost of his training. Those men who are admitted to the medical schools are for the most part college graduates. Some of them have had but 3 years of college work, and a few of them are admitted in some of the schools upon 2 years of college work following the completion of a high school course. If one estimates the cost of the medical course itself, eliminating the expense of the college preparatory course, he will find that each student must spend a minimum in tuition and in expenses of living, for books and instru- ments, during the session of 8 months for 4 years, not less than $5000. That does not include his traveling expenses to or from the school. It does not include those who are more liberal but it represents about the minimum; $1200 a year is about the least that any medical student can get along with these days; $400 of that is tuition, and the other $800 is only $100 a month for his board and room and books. If one would add to that ex- pense the value of his lost time, or what his earn- ing capacity might be. one would say that a medi- cal education would cost from $10,000 to $20,000, eliminating the expenses of his college preparatory work. He graduates at about the average age of 26, then takes 1 year or 2 in a hospital, and it is 2 or 3 years more before he is self-supporting. At 30 years of age he is just about prepared to sup- port himself and to begin to be active in the prac- tice of medicine. Now. it is an interesting fact that if you would take the amount that his educa- July. 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 587 tion lias cost and add to it the loss in earning power, and put those sums together at the time of his graduation and invest the fund at ordinary 6 Co compound interest, at 50 years of age he would have a sufficient ,sum to maintain him for the rest of his life. And yet, how many physicians at fifty could retire? Is the doctor over-paid? He most certainly is not, with an average income of §6000 a year and fully half of them earning only §3000. There is one other thing that has been in my mind for some time. I have noted on many occa- sions a tendency on the part of the m'embers of the medical profession, and often of its leaders, to speak rather disparagingly of the work of the medical profession, and of its accomplishments and its attainments. Modesty is, of course, a vir- tue but undue modesty may be a fault. How many of us have heard physicians in public addresses speak amusingly of the failures of the medical profession, call attention to opinions which were held 50 years ago that today seem ludicrous, which, of course, is an easy way to get a laugh. When I served on the Commission of the Healing Arts, there were many, many times when the chiropractors, osteopaths and other quacks con- victed the medical profession of the grossest blunders, of the most deplorable lack of knowl- edge, from words taken out of the mouths of our •own leaders. I believe that it is an important thing for our medical societies to have in mind the education of our own members, to enhance some- what the self-esteem of the rank and file of the practitioners of medicine. It is amazing how lit- tle is known by members of our organization about the history of medicine, its great accom- plishments, its great names. There is too little said about these things. I believe it would be a good thing if every county medical society de- voted one evening of each year to a program which set forth biographic sketches of great medi- cal men or dealt with great achievements in medi- cine. These facts are too little known by the profession, and they are almost totally unknown to the public. For instance, the most recent bul- letin issued by our Health Department, of Phila- delphia, calls attention to the fact that in 1906 there were in the city of Philadelphia almost, not quite, 10,000 cases of typhoid fever, and that last year — 24 years later — there were just about 100 cases. I began the practice of medicine in Phila- delphia in 1906, and when I saw this statement my mind went back to the time when, as a young practitioner, a considerable portion* of my practice was made up of cases of typhoid fever. From a pecuniary standpoint they were particularly prof- itable cases, for typhoid fever is a disease of long duration, of many sequels, and has prolonged con- valescence; need for medical care continues over a period of many weeks. From a pecuniary stand- point the loss to the medical profession, incurred by a reduction of typhoid fever cases from 10,000 a year to 100 per year, if worked out in figures, would be stupendously high. And yet, how was this brought about? By the profession itself; the only profession in the world that seeks to reduce the material upon which it depends for an exist- ence. The public should be made aware of this fact. First of all our own members should be made aware of these and similar facts, and should show pride in them and be prepared to defend the profession against assaults by the ignorant, the malicious and those who attempt to discredit our importance and the value of our work. It would be well, I think, to call attention to the uninter- rupted existence of medicine — the oldest profes- sion in the world, older than Christianity — going back to Hippocrates, 400 years before Christ. At- tention should be called to the great accomplish- ments in surgery, in bacteriology, in preventive medicine, and all such things. Get it into the con- sciousness of all of our own members first, and then the public may learn from them something of our work. A Romance of Paternalism Walter F. Donaldson, M.D., Pittsburgh, Pa. Tom Jones and Paul Smith, each aged 21 years, graduated together from a Pennsylvania college in June 1918, and immediately enlisted for service in the World War. They remained in separate training camps in the United States, and were honorably discharged in improved health in De- cember of the same year. Jones entered a broker’s office, and 10 years la- ter, at the age of 32, was prosperous and in good health, except for an epididymitis, which devel- oped in 1930 after an ardent but ill-fated affair with a woman of easy virtue. Smith entered medical college in 1919, and after the necessary 5 years of preparation and 2 additional but volun- tary years of hospital training, began practice in his home town, and in 1930 was chosen to be the genito-urinary surgeon on the staff of the local general hospital. Broker Jones consulted Dr. Smith, his former comrade in arms, regarding his infection, and Dr. Smith advised an operation, to be performed at the home town hospital, and plans were made ac- cordingly. But an enthusiastic former comrade, with a political slant toward special benefits, hear- ing that Jones was hospital-bound, reminded him that a vote-seeking' group of congressmen had re- cently successfully piloted through Federal legis- lation providing free hospitalization and treat- ment for all former soldiers, regardless of their ability to pay or the relation of their disability to their war service. So, prosperous Jones, with his impairment received in an affaire cl’arnour 11 years after his discharge from the army, was transported, at government expense, to and from a distant government hospital, while Dr. Smith chalked up another fee lost, and the local hospital another empty hospital bed, to the absolutely un- fair paternalistic competition of Uncle Sam. Who provided the cash to pay for Broker Jones’ free transportation, free hospitalization, and free treatment? His former comrade Dr. Smith, his neighbors who maintain the hometown hospital, and others who pay a Federal income tax. Ap- proximately 15,000 of the approximately 30,000 World War soldiers at present in recently built, but frequently unnecessary, government hospitals are being treated for ailments in no way related to their army experience, and without considera- tion of their financial ability to pay the charges of hospitals and physicians adjacent to their places of residence. Was Jones, during his convalescence at the hos- pital, much in contact with other patients — the much honored and worthy beneficiaries of a grate- ful government? No! Those today in government hospitals surviving wounds and sickness or disease actually related to war or camp service number but 15,000, and they are often segregated from the other 15,000 at present in , government hospitals, who, like Jones, are receiving free treatment for ailments in no way related to their army exper- ience and without consideration of their ability to 588 JOURNAI, OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 pay for treatment nearer home. So, in company with other country club members, who are conva- lescent from tonsil or appendix operations, or from an attack of gout or “nineteenth hole” neuritis, Jones whiles a way a prolonged period of conva- lescence criticising the wise President of the United States, who successfully obstructed the passage of legislation designed to extend the same econom- ically unsound free hospital benefits to all the members of the families of former soldiers. Of course, Jones and the others wondered when an ungrateful government would include free cloth- ing and free shoes, or begin to transport its in- dolent heroes to free hospitals built in Hawaii or Porto Rico, rather than to those only 2000 miles away from home. After a stay in the hospital 3 weeks longer than necessary, or possibly had Jones been paying for it, (it is difficult to find enough patients to fill the beds in many of the government hospitals) Jones returned to his home town, where for a long time he “groused” about the quality of the free service he received from a bureau-controlled gov- ernment hospital. In the meantime, Dr. Smith having aroused the interest of his fellow Federal income-taxpayers on the board of directors of the local hospital, as well as in the county medical society, is, or should be, endeavoring to convince his congressman and the senators from his state that the Federal govern- ment must respect certain fundamental principles of “states’ rights”, and abandon its policj’ of pro- viding free medical and hospital care, and finan- cial relief, for war veterans, except for impair- ments which can be reasonably related to war ser- vice, or the veteran who is unable to pay for treat- ment. Dr. Smith contends that since physicians represent the first group of citizens whose eco- nomic welfare is seriously threatened by this form of paternalism, and since they compose one of the few remaining individualistic professions, it is the duty of physicians to become politically conscious and to take the lead in fighting for recognition of “states’ rights” and for discontinuance of Federal interference. Those of us who retain knowledge of the mean- ing and relation of such Victorian words or terms as “pork barrel”, and “rivers and harbors”, to con- gressional raids on the Federal treasury, will no doubt agree that the large sums of Federal money spent in a congressional district to “improve” the harbor facilities of an erstwhile lack-a-daisical creek or river, or to erect a post-office building extravagantly large and ornate for the actual ser- vice requirements, pale into insignificance polit- ically when compared with the patronage possi- bilities following upon success in landing a $2,000,- 000 veterans’ hospital for the “old home district”. The initial investment may appear a paltry sum, but the annual budget and the political strength and patronage garnered in the influence of several hundred hospital employees in a congressional dis- trict may assure the fortunate congressman many terms in office. Therefore, the Veterans’ Hospital Racket is here to stay. Surely, those who pay taxes to the United States Government will not supinely continue to approve free medical, surgical, and hospital treatment ol the disabilities of -1,500, 000 veterans which origin- ate as ordinary incidents of every-day life 12 or more years after the World War ended. Congress- men and Senators who support such legislation must be rebuked at the polls, and the great ma- jority of the veterans retaining their patriotic principles must repudiate the noisy minority who continue their raids on the public treasury. An editorial writer in a recent issue of the “Outlook" ascribes the victory in the passage of the Johnson Bill to the "grasping element in the American Region'’, and to “cheap politicians in Congress who will oblige any vigorous minority in order to be reelected”. The same writer describes the bill as: “A grab, a gouge — nothing more. Under the guise of providing for some meritorious border-line cases of disability, it opens the door for general pensions for everybody (4,500,000) who wore khaki during the World War.” “When the country adopted the War Insurance Act in 1917, it was assured that the scandals of the G. A. R. pension grab would never be repeated. When it granted the bonus, it was reassured again. The Legion itself went on record as opposed to general pensions. Y'et, where are we now? Now we have a brand new method of granting money based on present-day accidents in civil life, and having nothing to do with the war.” With full knowledge of such facts, Calvin Cool- idge said: “All countries on earth, in all history all put together, have not done as much for those who have fought in their behalf as our country alone has done since 1880.” It becomes hard for physicians to remember the earlier resolve to support every possible form of assistance to veterans, the victims of disease and injury resulting from war service, when we look on with righteous indignation while prosperous veterans are treated, without cost, at government hospitals, for civil life impairments such as en- larged tonsils, while vacant beds remain plentiful in home-town hospitals that are supported by the same citizens whose tax money also pays for the erection and maintenance of the already too nu- merous veterans’ hospitals. Apparently nothing can daunt the determination of the American Legion and other veterans’ or- ganizations in their relentless march toward big- ger and better government aid for ex-soldiers. Fol- lowing the recently enacted Federal legislation making available the cash bonus will come the al- ready announced legislative program for immediate cash payment of all bonus certificates at their ma- tured value. Who shall take the lead in devel- oping resistance to this veterans’ pressure, in shaming veterans out of such demands? If our younger men are taught that service to their country means that our Government thereafter must reward them irrespective of their needs, then we are indeed undermining the very founda- tions of good citizenship. Veterans must develop and manifest a? peace-time patriotism before the burden of pensions becomes intolerable. Our Civil War pensions, instituted in 1879. amounted in the year 1919 to $125,000,000 or 4 times as much as they were 50 years earlier. If, as was recently proposed by National Commander O’Neil, of the Legion, the next Congress grants equality of pensions for veterans of all wars, then in a short time the Federal government will be paying out annually to its more than 4,000,000 vet- erans more money than we spent v’hile actually engaged in the World War. A Billion Dollars a Y’ear ! Dr. Smith, while agreeing that our Federal gov- ernment should show’ every possible reasonable consideration to our war veterans, also emphasizes the fact that a larger proportion of physicians entered government service in 1917 and 1918 than from any other professional group. When the proposed 47 or more veterans’ hospitals, each sus- taining more salaried employees than patients, have been completed and occupied, then will “state medicine” have been thoroughly established July, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 589 throughout the United States, never to be dis- placed because of the political patronage involved. And when veterans or their relatives no longer abound, then will the free hospital service be ex- tended to other citizens; and by 1960 the private medical practitioner and the neighborhood hos- pital may largely have passed out of the picture. Think it over, readers or hearers of this basical- ly true story. Discuss it with your tax-paying neighbors, and with your congressmen. Any gov- ernmental policy which decreases the present-day attractiveness of medical practice to the intellec- tual type of mind, and causes men of ability to forsake it, is certainly against sound public policy. Xone can successfully deny, it is believed, that the Federal government, by the policy herein com- plained of, is in unfair competition with private physicians and the supporters of local hospitals who in turn are taxed to finance this paternal- istic, bureaucratic form of medical and surgical hospital and dispensary practice. Discussion Dr. William H. Ross: Both of these papers are so true and unquestioned that I can do nothing more than endorse them. It seems to me just at this moment that I have never heard any clearer presentation of 2 problems, the need of education of our own men, and the need of doing something about the increasing paternalism. Just how to do it is a. little more difficult to state clearly. The suggestion that we should educate our own men through our county societies is undoubtedly ex- cellent. The remedy, medically, is to endeavor to estab- lish leadership by our own people. I think that we are too modest in many respects. If we do not assume leadership it will be done for us. Some increase in state medicine is rather inevit- able and we can only minimize it by our own lead- ership. Some solution of the problem must be found and I do not know, after considerable study, more intense study than I have given to anything else, whether health insurance is not the solution. They have some forms of insurance in Europe that have not destroyed the medical profession. The average income of the physician in Denmark is as much as it is in this country. There, they hold their own because they are well organized; every doc- tor must belong to the Medical Association of Den- mark; their graduates are all of one school; 80% of the population is insured. It is voluntary in- surance, the government does not dictate the pol- icy, and they have gotten along very well in meet- ing their social conditions. I believe that we must awaken to this one thing — that we must take leadership — and that does not mean that we shall change things very rapidly, but the influence of things that we do today will be of 2 kinds; one is the obvious thing that we can do, and the other the intangible influence which will be producing results even when we think it is not acting at all. Dr. William T. Sharpless: With regard to Dr. Donaldson's paper. I accept it in full. I think it is a very good and timely presentation of the case and it ought to claim our interest and our action politically, as he suggests. With regard to Dr. Patterson’s paper, I cannot get all those figures in my mind. 1 hope that will be published and that we will be allowed to have an opportunity to digest it and work it out for our- selves. I noted in a recent Bulletin of the American Medical Association a proposition to standardize specialists. Specialists get large fees: general practitioners do not, though they are largely the feeders of the specialists. If the value of services by general practitioners was more fully recognized, I think it would make matters more satisfactory all around. Recently, for instance, I had a patient with cataracts. She was operated upon by a Phila- delphia specialist. She is a person of moderate means, but she received a bill of $1800 for the operation. She has only 10% vision in the eye operated upon, and he now wishes to operate on the other eye. That is the kind of medical charge that seems to me unfair. I would like to see all the specialists standard- ized, for many people are posing as specialists who are not qualified but who advertise themselves, in one way or another, as specialists and charge large fees which they do not earn. Dr. Joseph S. Laivrence: I wish that Dr. Pat- terson had taken a few minutes more to suggest at least one solution for part of the problem which he has so ably described to us. I am convinced that the one thing above all others that the medi- cal profession is lacking in today is self-confidence. The average doctor trembles at criticism by the public health nurse regarding his methods of diag- nosis or treatment, and yet she doesn’t mean to be unkind but is simply expressing what she has been thoroughly saturated with ; i. e., that medicine is advancing so rapidly today that the m,an who is out of college for some time is obsolete. If I may draw upon my imagination to characterize medicine today, I would say that we are in the machine age, the time when a man’s material equipment counts for more than his mental equip- ment. Unless laboratory procedures, some very ex- tensive and complicated, are called upon to assist in diagnosis; unless a man’s office is equipped with very impressive and expensive machinery; he is by many people considered not qualified to practice medicine. A portion of this feeling is due to the efforts of those public spirited people to bring to the people the best that there is in medicine, as they understand it, and not having been medically trained they do not understand medicine as physi- cians do. They rather look upon health as some- thing that can be rationed out as food and cloth- ing were in the army. I think that is one reason why the Legion succeeds as it does with Congress. It makes the people believe that medical care is something the soldiers had in the army; given to them as part of the equipment which the govern- ment issued to its soldiers in order to make them as nearly perfect as possible; and now that they are ordinary citizens, should not be denied them. We are living in a time when many people believe that medicine, or medical care, is something that should be bestowed upon the public, rather than that the people should know that there is avail- able at any time this scientific knowledge. People are not taught to seek their doctors for informa- tion but are told that medical advice or service can be secured at such and such a place and that they should seek it there. I think it is a reason- ing of this kind that is fostering health insurance. In my opinion, the public is certain to be disap- pointed later. Dr. Arthur O. Morgan: It is seldom that one hears a presentation in such clear-cut manner as the 2 speeches we have had today. I happen to be a member of the Committee on the Cost of Medical Care, whose Chairman is Dr. Ray Lyman Wilbur, and last week we had a 2 day session that was at- tended by 50 of its 54 members; absentees were either sick or out of the country — which indicates the intense interest that is being taken all over the country in this very vital subject. Truths are taught by contrasts. Dr Patterson 590 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 has shown us, by contrast, the part that we of the medical profession play in the economic life of this nation. Our studies in the committee will give you amplified information from many angles. Dr. Patterson has likewise told us of the difficul- ties now attendant upon teaching medical stu- dents. If I may make the charge, I would say that many medical teaching institutions are be- coming too specialized. They are concerning themselves too much with the ultra-research men. The Johns Hopkins University, Duke University, and the University of Rochester, are ultra-spe- cialist institutions. I am pleased to state, and, thank God, that the Medical College of Albany is training general practitioners. There is your con- trast. There has been too much of the fetish in recent years, in respect to training specialists, the fault for which lies largely in the faculties of the various medical schools of this country, which consciously or unconsciously create and set the pace for the young men and women as they go out into medicine. Dr. Patterson pleads for education of the doctors. I plead for education and enlight- enment of the medical faculties. Dr. Wilbur has pointed to the threat of state medicine but he al- ways has emphasized that the family doctor is the key-note to the situation. In our work at Wash- ington we have the very valuable aid of many economists who are helping us to solve this prob- lem of the cost of medical care and. to resolve it into an economic picture which can be presented to lay people. The doctors cannot put the eco- nomic aspect of medicine before the lay people; economists can, and that will be one of the major accomplishments of this committee. There are many magazines today eager to ac- cept the specious statements, the “sounding brass and tinkling cymbal’’ of men and women who write for money, who can catch the eyes and ears of the public, and that is why we are having- so much criticism of the medical profession ; because editors of such magazines accept that tinpan stuff as presented to them, and which they think pleases the reading public. Dr. Donaldson is to be commended in highest manner for his clear-cut presentation of a truth. I am a member of the American Legion. I have never been affiliated with the Veterans’ Bureau, and have never been bound by any medical group, so that all the time I have been a free lance, and sometimes I have had the temerity to say things which brought forth criticism from others who would like to have said the same thing if they had dared. The American Legion seems to have gone wild in respect to wanting something for nothing, and especially on this matter of present day pension grants. Personally, from examining boys who were in the war and who have been re- ferred to me, I am firmly of the belief that many of these boys have lost their American backbone and have become sycophants because they think, as Dr. Donaldson said this morning, that a pa- ternalistic government will take care of them. They want also to have their families cared for. If the tide is not turned, there is no telling what will take place in time to come, simply because the “loud noise” and not the “best element” is in the saddle. A word as to Workmen’s Compensation and State Medicine, for the first is here and the second is in the offing. Workmen’s Compensation has accomplished great good for the working man, but when the Act was put over in Pennsylvania, the medical profession was not awake to its op- portunities and privileges and the result is that under that law the physician has not received his right as measured by dollars and cents. Dr. Ephraim. R. Mulford: I unfortunately got into contact with a bus and automobile accident coming down the road and missed hearing Dr. Patterson’s paper and got only a part of Dr. Don- aldson’s splendid essay. It seems to me that education is the power that must turn the tide which now seems to be sweep- ing over the country and leading the public to be- lieve it can get something for nothing. Being a general practitioner in a small town, it does not seem to me that we will ever be able to do with- out the family physician. f I)r. Wiiliam II. Mayer'. It is difficult to dis- agree with either of the essayists, and I certainly pay high tribute to the excellence of their pre- sentations. The man on the firing line determines the efficiency of the army. So it is with the gen- eral practitioner in his ability to apply his art of medicine. Certainly the strongest link in the chain of medical practice is the man who first sees the patient and who has an intimate contact with him and his environment. I was struck by what Dr. Donaldson said about political patronage and the necessity to fill the government hospitals and to extend the number of people in them. This is so clearly the problem which we see with social work in the large cities, where to get everything at any cost is part of their work and they do it at the expense of the morale of citizenship. I feel that we have a big- ger and greater duty to humanity than simply the question of preventing illness and curing sickness. The citizenship of this country is one of the prin- cipal factors of its constitution and when we al- low our people, either through governmental agen- cies or through the mass influence of the Ameri- can Legion, to fail in recognition of responsibility for preservation of their own health, then we are helping to vitiate citizenship. We are allowing certain agencies in this country, with a paternal- istic spirit, to remove the backbone from our citi- zenship. From a sociologic standpoint, this is an important public matter. There is a group of phy- sicians who feel that they have no responsibility for public medical service; thinking it demeans them, destroys their self-esteem, and blows up much that has been constructed in a free country. If we allow the people to feel that they do not have to pay for medical care, the same as they have to pay for insurance on their household goods, then we have done an irreparable harm to the constitution and to the morale of our citizen- ship. Dr. Patterson said that % of all the money ex- pended for medical care goes to nurses and drug- gists. There is a big problem before us in regard to this. The use of prescriptions for certain kinds of drugs approved by the American Medical Asso- ciation is something which appeals to the general mass and to the individual who indulges in self- medication at the drug store. In regard to allonal, for instance, these tablets cost the patient 10 cents a piece. For every tablet made the man who has a patent on allonal receives 1 cent. The cost of manufacture is probably about 1/32 of a cent. The use of such tablets by more than 100,000,000 peo- ple amounts to an enormous sum. I have been told that the man who makes allonal tablets was once a poor chemist, but that he has become a rich man. While I haven’t any objection to a man becoming wealthy because he has chanced upon something of this kind and has shown some gen- ius, yet I think the American Medical Association should, when approving such drugs, retain some July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 591 control over a reasonable sale price. That may seem like going a little too far socialisticaliy, but it is not. If these people are going to use their dis- coveries to exploit sickness, they should not re- ceive our support. I have only cited this one in- stance but there are a dozen others. A few years ago we were prescribing aspirin. It was a good way to administer salicylates without upsetting the stomach. Today, aspirin tablets are mixed with bathtub gin to increase intoxication, and even Amos and Andy are talking about it. All that adding materially to the sum of what people pay for sickness. One other thing in regard to nursing costs. The nurses do not get more than they are worth but the individual often pays more than he can af- ford. Here is a point that should be considered, and I am sure the Committee on the Cost of Medi- cal Care will feel that it is diplomatic to put some reference to that subject in its report. Dr. Harry W. Albertson : When I received the program from Dr. Reik I wondered what could come out of it that would be interesting to 3 states, but I want to say now that I think this is one of the best programs I have listened to ini at- tendance at these Tristate Conferences. I must also say to the Chairman that he was extremely modest in his assertion that $7-50,000,000 were spent annually in cosmetics, because it was re- cently brought out by a convention of beauty specialists in Chicago that $3,500,000,000 were thus spent; which is greater than all the costs of medi- cal care. I was impressed last night, on picking up my lo- cal newspaper, with the inefficiency of the busi- ness side of medical practice. A man in my neigh- borhood, reputed to be wealthy, died recently, and I noticed in the statement of settlement of his estate that his doctor was paid $4000, covering a long period of illness, and his attorney’s fee for work during 5 or 6 weeks in settling the estate was $6500. That is just an example of how quick- ly men with business ability get money, while doc- tors who spend a long time and much patience get little in comparison. I want to disagree with Dr. Lawrence, while I have much respect for his opinion and his knowl- edge of the medical profession generally, regard- ing the statement that we are in a machine age. I had this forcibly brought to my mind a few days ago. I had occasion to call upon 2 doctors, both good fellows. The office of one was composed of a suite of 4 rooms, 3 of which were filled with machinery, and his waiting room held 3 patients. The other man had but 2 rooms, meagerly furn- ished, but there were so many patients in his waiting room that there was not room to sit down. That man is a very careful practitioner, a man who makes a study of every case and goes into the intricate problems, and whose work is most satisfactory. Unquestionably we need to have the medical profession look to its business ability, and I believe with Dr. Patterson that in educating our younger professional men to realize that typhoid fever and diphtheria were such large factors in the general practitioner’s income 25 years ago, he will understand that medicine has done something and stands for something accomplished. Also we should get it across to the people who are thinking dis- paragingly of the medical profession. I admire Dr. Donaldson for the stand that he has taken on this matter of paternalism. It re- quires a good deal of nerve to bring forth a prop- osition which affects 4,000.000 men. 4,000,000 voters in this country. I sincerely wish that we were able to get that matter out of politics, that we were able to educate a great majority of those men to the fact that there is something more to patriotism than that which they get for the ser- vice they rendered. Dr. Georye N. J. Sommer: I was very much in- terested in Dr. Patterson’s discussion of the cost of medical education. 1 recall that it cost my father about $400 a year to educate me in medi- cine, and it is costing me $2500 a year to educate one son at the present time; so I can readily ap- preciate the difference between the costs of 40 years ago and now. There are so many side is- sues that enter into the education of a young man today which did not exist then, and it is these Side issues of a social nature that really cost money. I believe that we are largely responsible for some of our difficulties. Our lack of success, in the main, is due to lack of business education, for the principles of success in medicine are the same as in any business. You have to sell yourself as a business has to sell itself, and the men in our profession who have made good have been fel- lows who w~ere not only skilfull and capable but who also were able to sell themselves to the com- munities in which they practiced. I feel that my own success has been largely due to the fact that I could sell myself to my patients and make them feel that they are getting from me a square deal. If I have accomplished anything in the practice of medicine it is because I have held true to medi- cine and not permitted myself to be diverted by other things. I started out to be a physician and hope to remain one as long as I live. I have not been a politician nor tried to mix much with pol- iticians, but this fact remains — that if I want something for my friends, from politicians, my reputation as a physician and citizen in my com- munity enables me to get it. Dr. J. B. Morrison': I think the papers we lis- tened to this morning give us some very basic ideas to carry back to our county and state so- cieties. The conclusions that will be drawn from the report of the Committee on the Cost of Medi- cal Care must be promulgated through our pro- fession to the people in such way as will make them realize that of the total cost of medical care the portion paid to physicians is probably less than it should be. I make it a practice, whenever opportunity offers, to speak of this subject to my patients. In such a conversation last week with a man and his wife I gave the figures which Dr. Patterson presented today and showed the small returns to physicians relative to the amount of labor performed and the value of lives protected in the community. The wife said that those fig- ures are excellent and cannot be disputed when you speak of the people as a mass, and of the ser- vice of the medical profession as a mass, but when you come to an individual it is different. She said her sister had a child operated on for mastoiditis. The father earned $2500 a year and the bills from the hospital and surgeon were $750. I reminded her that her doctor’s bill was only $150 and that the hospital and nurses received $600. Then I said: “M'y dear woman, you and your husband have no right under our present economic system, nor your sister and her husband, to spend on the care of that child $750 for a mastoid operation.” She had no moral right to put that child in a pri- vate room and require 2 private nurses unless the doctor demanded it. The fault is not with the medical profession nor with the hospitals but it is that the people of the United States have forgotten what economy means, and they must give the best to their children and indulge in luxuries that only 592 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 a person with an income of $25,000, instead of $2500, could have. If the child had been treated in the ward, the result would have been the same, and if a private nurse had been necessary she would have been supplied. The child could have been brought back to health for half of the money spent, and neither the medical profession nor the hospital should be criticised for what was con- sidered an enormous bill. We must drive this teaching- home to patients whenever possible. It is easy enough to make them understand that the fees are not exorbitant except in certain lines of work. The matter of carrying this to the public be- longs, I suppose, to the profession, and it will never be done in a satisfactory way until it is tak- en from the hands of the individual physician and done as a business policy by the state societies. 1 believe that if every state society in the Union were to follow in the footsteps of New Jersey, and spend $10,000 to $15,000 a year to carry this edu- cation to the public, spend from their own funds for this educational campaign, it would be money well spent and the results would be found as suc- cessful as we have found them in New Jersey. This is legitimate advertising; and the business man realizes that returns from his business are in direct proportion to his advertising. I heartily agree with what Dr. Donaldson has said in his paper. I happened to be in Washing- ton during the debate on payments to soldiers on their Bonus Bill allowance and I sat in the Sen- ate on the evening when the vote was taken. I heard 2 Senators, members of the Legion, criti- cise that Bill very severely, expressing the opin- ion that there was a large group of veterans who did not want legislation of that kind, nor be- lieve these favors should be given them by the Government. But, the argument was lost and the vote was overwhelmingly in favor of the bonus, because the politicians were able to make political capital of it. Whether or not 150,000 physicians in the United States can organize and stop this thing is questionable. Perhaps, given 10 years time, with an organized effort and the matter put into the hands of committees to work judiciously, we might be able to influence public opinion but I do not think we can do it as fast as it is being created in the opposite direction. I have been rather severe- ly criticised in New Jersey because of my stand in the discussion of state medicine. I have taken the bull by the horns, and brought the matter to the attention of many of the county societies. I believe the time has come when we must realize that state medicine is more than a possibility. For a while we were buoyed up by an idea that it was un-American, that the living wage was so high that state medicine could never gain a foothold in America, but in the provinces of Canada where the people are of English. Scotch. Scandinavian stock, where the immigration has been markedly restricted, where they probably have not 1/10 as many people from the Slavic races of Europe as we have in America, where the earning capacity of the average citizen is about as much and where the independent spirit is just as great, state medi- cine is making enormous strides and it is antici- pated by some leading physicians that in less than 5 years it will affect every province. Canada is my native home and as we travel through Canada the only difference from the United States is the fact that we live under a different flag. Now, if they are solving their economic problems in that way it will be brought to the attention of the peo- ple of the United States very soon and my plea is that in every state society a committee shall make a study of this matter and be able to present to the Government at the proper time a plan to avert or guide state medicine, and prevent its being crammed down our throats. A comparison with Austria and Germany shows that the organized efforts of the French physicians wrested from their Government plans that were 50 times more favor- able than those in Austria and Germany. Will state medicine get here? We do not know, but if it is in the offing it will do us no harm to make this comprehensive study of the matter and be prepared to meet it when it comes. It will in all probability only apply to those earning under $2500 or $3000 a year. Others will want to retain their independence and have their family physi- cians just as they refuse now to accept charity in hospitals because they want to pay their way. So, you need not fear that state medicine will ever at- tain here the volume or proportion it has in East- ern countries. There are several methods of ap- plying it. If the Government starts it, there will likely be a tax on our income. If it is done along the lines of compensation, labor will pay part, the Government part and the individual a part. But, with a people as independent as ours, there is no reason why it should not be carried by voluntary insurance just as we do with life insurance. The average outlay in a family is from $60 to $80 for the year’s service and it can be readily seen that by the payment of $S0 or $100 a family can be protected and funds established to meet an emer- gency. Even those families in America who run on a budget make no allowance for the medical or surgical care that may be imposed upon them, and when an emergency comes they must go to a loan association and borrow money, at 12 to 36%. I feel that in all our states a careful and com- plete study should be made and plans organized whereby we can offer the Government a solution that will be favorable to the people and the doc- tors. Dr. Henry O. Reik : I want to begin by thank- ing you. Dr. Patterson, for the suggestion that the county societies should be urged to devote at least 1 meeting a year to the subject of medical history or biographies of medical workers. We shall re- commend that back home and see if we cannot put it into effect next year. We have had- some papers on the history of medicine published in the Journal and are at the present time much inter- ested in studying for publication the history of medicine in New Jersey. I was interested in Dr. Sharpless’ comment, call- ing your attention to a resolution that will be in- troduced in the House of Delegates of the Ameri- can Medical Association regarding the control of specialists and specialism. Of course, you are all familiar with the Presidential Address of Dr. John Hartwell, before the Academy of Medicine in New York, and the effort the Academy is now making to classify its members. Dr. Hartwell addressed one of our Councilor District meetings recently on that subject, reported the progress of the work in New York and expressed the hope that it would be tak- en up elsewhere. Our Second District had that topic up for discussion and I learned from a report of the Secretary of that gathering that they pass- ed a series of resolutions to be submitted at the meeting in June, recommending that the State So- ciety put into effect a plan like Dr. Hartwell pro- posed in New Y’ork. The resolution that is to be introduced at Philadelphia by one of the repre- sentatives from Michigan will, I presume, come before the House of Delegates for action and I wanted to ask whether or not the Pennsylvania and New York delegates have taken any action July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 593 upon that resolution, and if you know whether it is contemplated to approve and support it or whether there is going' to be opposition to it ? The question may come up at Asbury Park, as to whether our delegates shall be instructed. If we could ascertain today the position of New York and Pennsylvania regarding that matter, perhaps the 3 state societies can act in unison. Several speakers have referred to the public educational work. Of course, that is a topic in which I am vitally concerned. W e have all read with interest, sometimes with provocation, some- times with disgust, the articles that have been appearing in the newspapers and magazines. I believe I have only seen two answers published through the magazines, one by Dr. Johnson some- time ago and the one by Winford Smith in last week’s Saturday Evening Post. I want to ask the question, to what extent you think we should go in trying to get publication of answers to those criticising articles. Is it a wise proposition to secure, and seek publication of, answers to such articles through the same magazines? For in- stance, if we could get an answer published in the Saturday Evening Post to some of its preceding articles, either along the same line or going fur- ther than Dr. Smith did, because in his article he only answered a few points and not those for which we have been most criticised. I once tried to get an answer published in the Forum but the editor answered my letter saying that he could not allow the magazine to pursue a controversial ques- tion. That, mind you, after he had published one side of the controversy. Is it, possibly, a better policy to ignore such things? In the matter of public and professional edu- cation, I am much more puzzled as to how to pro- ceed with the medical profession than with the public. It is much more difficult to get the subject be- fore them properly and have it read. Dr. Ross has had an experience this winter, and I can see it in his remarks, about the question of state medi- cine. During the past 4 months one of my own articles has ben published in sections, intended to give an account of the progress of national health insurance laws in Great Britain and France, as observed in my travels, and then such information as I could collect from literature regarding other countries. I have been a bit afraid of one result, that as soon as a medical man reads an article of that sort, and you have presented the facts to him, he jumjps at the conclusion that you are supporting the idea of state medicine. I very carefully stated each time, and wrote accompany- ing editorials on the subject, that I was not ad- vocating state medicine but merely trying to lay the facts before them so that they could prepare for action, either to forestall it or to meet the situation when it does arise, but I hear that some readers have accused me of advocating state medi- cine. That sort of misconstruing things makes educational work extremely difficult. Dr. Walter F. Donaldson (Closing) : I may men- tion in passing that this is Dr. Mayer’s first ap- pearance at one of these conferences and he may understand now why former state society presi- dents continue to attend these meetings years af- ter they have ceased to serve as active officers. They are welcome, of course, to continue as a part of the organization, but I think their constant at- tendance is due to the protean character of the discussions; we are not limited in our discussions to the specific subject announced. As an evidence of how close we may be to state medicine, I want to mention briefly a point re- cently brought out in Pittsburgh by a public health officer. He mentioned the fact that it would be only necessary to introduce 2 or 3 words into the Workman’s Compensation Act to bring about state medicine; they would only have to make that law applicable to illnesses as well as to in- juries. If the editors who are here today will adopt the suggestion that has been brought out in Dr. Pat- terson’s presentation, and put in parallel column form the contrasts of what the people of this country are spending on tobacco, cosmetics, and movies with what they are actually spending on doctors, hospitals, nurses and dentists, it might make very instructive reading and would be dig- nified enough propaganda to be hung in the average doctor’s reception room. I see no rea- son why a few facts of that kind, arranged in parallel columns, appropriately framed, should not decorate a doctor’s reception room. I would start the pace and hang one in my reception room if I had it, so I challenge you editors to get to work on this. The problem involved, in extension of the de- sire to get something for nothing, is one that we must consider not only as physicians but as citi- zens. Senator Reed, of Pennsylvania, recently ex- posed a situation in Washington in which he pointed out that some 6 or 8 men, dentists, physi- cians and attorneys, who were drawing maximum pensions from the Veteran’s Bureau, about $250 a month, because they were supposed to be completely disabled and theoretically, at least, unable to sup- port themselves, were also drawing salaries from that same bureau ranging from $5000 to $8000 a year for services rendered. There we have it in high places. How in the world can we blame the ditch digger or the man who cuts lawns for ask- ing if he may be pensioned $10 or $20 a month merely because he patriotically served his country, when we have men of type mentioned accepting more. We are still an individualistic group and I be- lieve we must when necessary put a little bit of sting into our criticism and discuss pensions with our neighbors. When you see a prosperous neigh- bor go off to a Government hospital to receive service, make him realize that your taxes are con- tributing to his up-keep while the neighborhood doctor and hospital are suffering because of his action. It is only a question of time before we shall have this tremendous financial burden con- fronting us. Dr. Foss V. Patterson (Closing): If I may have an opportunity to bring the discussion to a close I would add briefly to what I have already said and perhaps emphasize the main point that I en- deavored to bring out. In the first place, let me say that the figures which I offered on the cost of medical care were exclusive of governmental and state agencies with which Dr. Donaldson’s paper concerns itself. Let me say again that the $3,- 000,000,000 expended by this country for private medical care constitutes 3% of our national in- come, and that it covers the entire cost of the ser- vices of physicians, hospitals and drugs prescribed by physicia.ns, and prescribed by patients or sold over the counter, and of dentists, nurses and quacks. Now, if my arithmetic serves me correct- ly, 120,000,000 people spending $3,000,000,000 is $25 each per annum, and $4 of that goes to the doc- tor:. that is $6.25 per annum from each individual in this country goes to the physician. Figuring it another way, if the physicians re- ceive $750,000,000 and there are 120,000 of them, that is $6250 average to each physician; and it checks one with the other. JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 594 There is still another way: If there are 120,000 practicing physicians in this country treating 120,- 000,000 people, that is 1000 persons for each phy- sician. and if they pay $6.25, that is $6250 for each physician or $6.25 each. Now, when we reduce these figures to an analysis of that sort it becomes apparent that the physician is not being over-paid, and that the cost of medical care in this country is not disproportionate to other expenditures. That does not mean at all that there are not inequalities, but, speaking in terms of the average, the situation is not fundamentally wrong. If it is fundamentally wrong, it is because the physician receives less rather than more than he should get. The average income of dentists is greater than that of doctors. Now, is not the solution of the burden of medical care, as pointed out by Dr. Morrison, first of all, education of the profession itself as to the dimen- sions of the problem, and then to pass that on to their families and have families budget medical care just as they budget their other expenses of rent and coal and food and amusements and clothes, and if on the average each family sets aside $6.25 for each member it covers the average cost of the doctor’s fees, and if $25 is set aside for each mem- ber it covers the cost of all medical care. If we come to the panel system of state medicine, we can easily figure what the return of the doctor should be provided his income is not increased. It amounts to $6.25 for each physician per indi- vidual per year, or $25 for each member per an- num to cover the entire cost of medical care. Dr. Sharpless asks how we are to get at this. It seems to me there are various ways of getting this conception of the relation between medical institutions and the physician to those for whom they care. Certainly it should start in the medical schools. Perhaps you would be interested if I told you what I have personally endeavored to do in this matter. Some 7 or 8 years ago a student medical society was organized in the institution with which I am connected. It has 28 members made up of senior students. There are 7 meetings a year. 1 each month except the last month of the session. At each meeting 4 students present pa- pers. That means that in 7 meetings all 28 mem- bers of the society present papers. Those papers deal with the history of medicine, with the epochs in medicine, with great medical figures, so that each student prepares 1 paper and hears 27 other papers of 20 minutes length. At the end of the year I believe that those 28 men have had a be- ginning in education as to what medicine is, what its history is, and what it stands for. They have had the inspiration of hearing of the great ac- complishments in medicine, and we follow some- what a chronologic order. We may start with Hippocrates, then we come down to notable fig- ures like Tenner and Harvey and men who have made great discoveries or great contributions. I think it is proper that such study should begin in the medical schools, and should be extended to include the entire student body. My own oppor- tunities at the moment seem to be limited to this particular group. You know some of the medical schools are establishing Chairs in Medical His- tory. and I feel that the value of that would be to inculcate into the graduates a proper apprecia- tion of medicine. The second great opportunity is in the hospitals. Of the 120,000 physicians in this country, 90,000 are connected with hospitals. Why is it not proper for hospital staffs to concern themselves with this side of medicine? Dr. Sommer liaised a point in regard to the art of medicine. Under our system of medical edu- cation today the hospitals become a part of the medical educational system. The function of the medical schools is to train men in fundamentals. The function of the hospital and its staff is to train them in the art of medicine. If they lack in the art of medicine it is chiefly because of a defect in hospital training. If the members of the hospital staff could be brought to an appreciation of their responsibilities it would tend to elevate our ethical standards in medicine, and why should they not concern themselves with the ethics, with ihe history of medicine, first applying it to them- selves and meeting once a year with the interns, perhaps having the interns themselves prepare papers? It can be done and it is easy enough to do. My experience with these senior students has been surprising. Some of their programs would be admirable programs to present at county medi- cal societies. They would be instructive and the members would be interested. I am glad that Dr. Reik thinks well of the suggestion. The younger men would be interested and the older men would profit. Then the committees on publicity for the state journals might be avenues for brief articles dealing with some historic man or event. They should be short articles which could be read in about 3 minutes, for longer ones would be passed over. I am always interested in what Dr. Ross says. I think his views are very sound. Conditions have changed generally and the medical profession must change and adjust itself to changing conditions. The day of the gold headed cane and the periwig, the short trousers and the silver buckles has gone and they have become a matter of historic rec- ord. The top hat and frock coat are things that have passed. It is no longer a time for the medi- cal profession to continue in a position of aloof- ness but it must be active and take part in what is going on. It must make its influence felt in a practical way. I do not believe much in medical lobbies in our state capitols, but I do believe tre- mendously in county activities through proper committees, discussing problems of medicine with their representatives, and, after all, the Legisla- ture is simply made up of units coming from various communities. The doctors are and should be influential. Merely to sit down and talk with them is often quite enough provided they are well informed, although very often we know they are not. How many of the rank and file of the pro- fession are able to talk intelligently and submit convincing facts to the legislators? Not very many, I am sure. If we are to start out to edu- cate the public we must educate ourselves and our own members and it must be carried on through their offices and in their communities. We need leadership, we need study of these problems, and we need to understand what our relation to these very important changing industrial and economic problems is. We would benefit some by studving trade organizations and their methods, not to adopt them exactly but to modify them to our own pur- poses, applying our own ethics and our own ideals. Of course, one great trouble with the medical pro- fession is that it is always looking for its defects: that is our training: we are hypercritical. We talk about our mistakes more than about our accom- plishments. We find fault with ourselves and it is not strange that the laity finds fault with us and echoes what we say, often adding to it. Our opponents among the quacks distort these things frightfully and we suffer the consequence. We are not given to following leadership. Medicine is the most individualistic of all professions. We do not have enough pride in it. Why, the fact of the July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 595 matter is that today the medical graduate is the best educated product of our civilization, and in this country our standards of training are uni- formly higher than those of any other country in the world. Here and there are nations that com- pare but do not equal the standards enforced in this country. And, further, the medical profes- sion is the best educated profession in this coun- try today, compared with law, architecture, en- gineering or the clergy. The doctor comes up to a higher standard than any of the others. Here and there are those who equal them but the stand- ards of medical education are higher than those of any other profession. A few of the law schools may equal the medical schools as to their stand- ards but as a group they fall far short of it. Dr. Sharpless is somewhat confused by my fig- ures and I do not wonder. They are not mine but have been gathered here and there and I have remembered them because of my interest in this question of the cost of medical care. They have been published. Dr. Morgan's Committee will bring out in systematic and finished form the facts I have presented. I merely presented them in an endeavor to give you a more or less con- crete idea of the subject. There is one thing that it seems to me is funda- mental, that medical men are entitled to decide the extent and the character of their gratuitous con- tribution to public welfare, but if we are not care- ful some one else will decide it for us. If we do not study these problems and maintain our leadership in the matter, some one else will be directing us. Dr. Mayer referred to the influence of the nurses. I am afraid I am quoting figures until I am becoming tedious but this is a fact and the figures show it : here in Pennsylvania we have about 30,000 graduate nurses about half of whom register annually. If we go back to 1890, there were 318 nurses graduated from all the training schools in this country. In 1929 there were 13,000 and in 1950 there will probably be 65,000 at the present rate of increase. I would express gratification and appreciation of your interest and your discussion and reception of the papers presented. Dr. Relic extended an invitation to the confer- ence to hold the next autumnal meeting in Atlan- tic City, which invitation was duly accepted. Adjournment at 2.30 p. m. Communications CIIIU) GUIDANCE (Abstract of a pamphlet from William Doody, M.D., of Jersey City, Director Traveling Clinic, Catholic Charities of New York.) The widespread establishment of child guidance clinics has been due to an increasing appreciation of what may be accomplished through applying the principles of mental hygiene to the study and treatment of children who present problems of behavior and personality. Its effectiveness de- pends largely on an understanding of its functions and proper adjustment of relationship between the clinic and the various institutions with which it cooperates. Therefore, what is a child guidance clinic? A child guidance clinic is an agency for study of the child as a whole, in all its reactions, particularly toward its environment. A clinic con- sists of a psychiatrist, a psychologist and a psy- chiatric social worker, each trained in his or her own field. The chief object of the Traveling Clinic is to aid the Sisters in adjustment of the particu- lar children placed under, their care; which means understanding the child and his reactions. To carry on successful work there must be co- operation on every side. The institution and the clinic must work together to evolve a plan suit- able for the children in their present environment. Important in this type of work is an analysis of the history of the child — not only the history of his difficulty, but the history of his family through as many generations as possible, because family history may have a great influence on problems of the individual. A knowledge as to mental disease and chronic physical diseases in the family is im- portant because a child may be handicapped from the start because of a poor physical or mental make-up. Observations by his or her superiors should be noted; e. g., the attitude in the class- room, on the recreation field, in competitive games, in the company of older people, toward playmates and those in authority. Other important factors such as shyness, timidity, stubbornness, temper tantrums, drowsiness in school, insomnia, cruelty toward younger children and how victory or de- feat is accepted, should be considered. Special attention should be paid to the so-called “shut-in” boy or the one who holds himself aloof from the group; the boy who is not fond of out- door sports or male companions, who may be an apt and model pupil but needs watching because he .is apt subsequently to develop a mental condi- tion. A careful physical examination is import- ant, in which deafness and poor vision may be de- tected, as such defects may manifest themselves in abnormalities of conduct. Staff conferences are valuable because they give an opportunity to all concerned to discuss the problem and to offer a means of interpreting and correcting it. Sisters, teachers and group mothers should feel free to ex- press their opinions regarding the conduct and personality of the children, as the psychiatrist is only an adviser and it is not his aim to disrupt the institutional plan of child care and training. It is important to note that spokesmen for such well known organizations as the Judge Baker Foundation, in Boston, and the .Institute of Child Guidance in New York specifically state that in- vestigation, research and teaching are their major functions. When the situation is studied more closely, it is quite evident that much of the treat- ment in all institutions is left to the teacher and the group mother, who have been enlightened by the accurate and painstaking investigation of the group. Bach child must be studied as an individual and his particular abilities and disabilities must be un- derstood, and he should be educated accordingly. Many children acquire knowledge easily and repre- sent the so-called superior child who should be recognized as such and be given every opportunity to profit by training in keeping with his mental- ity. It has been shown that if we place such chil- dren in an ordinary class where there is insuffi- cient competition, they become lazy and without ambition because their intelligence is not being given sufficient outlet. Such children do better in a class of superior children. On the other hand, the normal slow child should be placed in a slow progress class so that he is not the victim of un- fair competition with the bright group. The bor- 596 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 derline and definitely defective children do not re- quire special pedagogic methods but rather a real- ization that they have subnormal intelligences and cannot hope to go very far in the regular grades. Furthermore, it must be realized that their eventual adjustment in life must be through the teaching of special work in the nature of man- ual training, because they will have to earn their living through manual work. The placement of these children in vocational classes causes many behavior problems to disappear because they find that, at last, they are given tasks which they can accomplish, and with that comes a satisfaction and happiness which they have never had previously. The placement of these children vocationally after they leave the institution becomes much easier when they have received vocational training be- fore discharge, and will, we firmly believe, result in the elimination of social maladjustments in the community. We have found through psychologic examina- tions that normal children are frequently regarded as retarded because of the presence of special dis- abilities; e. g., reading, spelling and arithmetic, and with correction of these defects through spe- cial coaching, they are able to assume their proper places in the school. We have found many be- havior problems which have depended solely on the presence of these disabilities. In conclusion, I would say that the clinic aims simply to establish a better understanding of the individual child, who, because of his conduct, does not seem to be normal, and that the cooperation of all concerned with his training leads to a better understanding of him and the installation of rem- edial measures. The maxim should be cooperation and team work on the part of all concerned. ADDITIONAL DISTRICT HEAI/TO OFFICERS (A letter from D. C. Bowen, Director of Health, New Jersey State Health Department, Trenton.) On and after July 1, 1931, funds will be available to permit this department to employ four ad- ditional District Health Officers. Appointments will be made from a list of can- didates declared eligible by the State Civil Service Commission. That Commission has recently fixed the date of examination of candidates as Thursday, July 30, 1931. The following information regard- ing these positions has been published by the Civil Service Commission. “District Health Officer — - Salary, $3000-$4200 per annum. Open to male citizens, resident of the state for 12 months immediately preceding the announced date for this test. Vacancy — State Board of Health.” DORCAS PRIZE TO NEW JERSEY GIRL A release from the Gorgas Memorial Institute, dated June 26, announced that Miss Margaret E. Beal, a recent graduate from Hammonton High School, of Hammonton, New Jersey, had won the Charles R. Walgreen Prize of $100 for writing the third-best essay submitted by high school students in the Third Annual Gorgas Memorial Essay Contest. The subject of this year’s contest was — “Keep- ing Fit: the Gorgas Program of Personal Health.” Miss Beal said: “Although a man is apparently in good health he should have an annual health ex- amination and a bi-annual dental examination. Why? For the very same reason that a man’s au- tomobile is brought to a garage every 6 months or so. There isn’t an automobile existing that doesn't run more smoothly and longer for being looked over, and every human being is just the same.” DEFENSE AGAINST MALPRACTICE SUITS (An item contributed by Dr. Christopher C. Beling, Chairman of the State Society’s Special Committee on Medical Defense.) At the recent Annual Meeting of the Medical Society of New Jersey, held at Asbury Park, the Committee on Medical Defense and Indemnity In- surance included in its report a recommendation that 1 column of each issue of the Journal be re- served for publication of matter pertaining to mal- practice claims, and to the means of avoiding, or protecting one’s self against, such suits. It was the belief of the committee that members of the society could thus best be kept informed concern- ing the nature of claims commonly filed, and, through discussion of actual cases, best advised how to prevent similar complications. In such journal space we could report cases, re- late facts, and discuss pertinent questions, for the following purposes: (1) Keeping before members the common or uncommon errors that occur. (2) The method to pursue to avoid compromis- ing statements. (3) How to treat the unreasonable allegations of patients. (4) What is expected of the doctor in such cases. (5) What cooperation members may expect from the Society. Case reports may serve many purposes and the Committee urges each member to study these re- ports so that the number of claims may be dim- inished, and each doctor may be on guard to avoid, so far as possible, similar mistakes. A short syn- opsis of the cases will be made, no names or cities will be mentioned, and only the essential facts will be given. More than 120 cases have been filed in the last 2 years. In 1 case judgment was for a sum of money nearly double the limit of his coverage. Naturally, the doctor had to pay the balance; which amounted to about $10,000. Adequate protection best preserves your interest, and by being prepared beforehand you are twice protected. The best interests of the individual doctor and of the Society can be preserved only through the cooperation of all, and it is to that end we dedicate this column of information. Case 1. This concerned an abdominal operation' that was supposedly successful in every way. At the end of the second week the patient returned to her home apparently recovered. About 1 month later the patient called at the doctor’s office again complaining of pains in the abdomen. It was de- cided to operate again. They found that in the previous operation a sponge and an iron ring had been left in the abdomen. The patient suffered shock which caused her death within 30 days. July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 597 What system of checking do you require? Do you personally supervise every article used and is each accounted for at the end of the operation? There is practically no defense in such cases, and the doctor should be extra watchful. School Health Department SUGGESTED LIST OF ACTIVITIES FOR SCHOOL PHYSICIANS Allen G. Ireland, M.D., Director of Physical and Health Education, State Department of Public Instruction, Trenton, N. J. From observation and reports, the following ac- tivities are apparently typical of the school physi- cian's program in New Jersey: (1) The conduct of an annual health examina- tion of all pupils, as required by state law. (2) Conduct of a health examination of all pu- pils referred to the physician as being in need of further diagnosis. (3) Special medical examination of all mem- bers of athletic team squads. (4) Conduct of periodic inspections of school . buildings, together with a report of the findings to the respective principal and the school admin- istrator. (5) Recommendation of standards for the sani- tation of school buildings, including the work of janitors and helpers in so far as that work re- lates to pupil health. (6) Recommendation of standards for meas- ures governing the control and prevention of com- municable disease, including specific instructions to teachers, principals, nurses, and janitors. (7) Instruction of teachers by means of meet- ings and conferences on all matters pertaining to child health concerning which the teacher should be familiar. (S) Supervision of the work of the school nurse except those phases for which the school ad- ministrative officer is directly responsible. (9) Instruction of parents on matters pertain- ing to pupil health by means of meetings, personal conferences, letters, leaflets and bulletins. The public press may also be used. (10) Special examinations of pupils attending all special classes, and supervision of the health activities involved in the conduct of such classes. (11) Cooperating with the physical education department in designing health programs for in- dividual cases. (12) .A health examination of teachers, janitors and all cafeteria workers. (13) Supervision of water, milk, and food sup- plies. (14) Conferring with the superintendent of schools and building principal on all school health problems that may arise. (15) Assisting in the development of mental hygiene in the schools and providing teachers with the necessary information for putting mental hy- giene into practice in the classrooms. (lfi) In some places the school physician is subject to call in emergency cases. There is some doubt as to the justification of this activity ex- cept in emergencies of a serious nature. He should not be called for treatment of minor in- juries. ’ (17) The school physician should state spe- cifically what treatments the school nurse may be permitted to give. State Health Department DISTRICT HEALTH OFFICERS D. C, Bowen, Director New Jersey State Department of Health, Trenton. N. J. These are busy days in the State Department of Health which is about to witness the consumtna- tion of a program to strengthen its organization by the appointment of additional district health officers. For more than a decade, the department, with an undermanned staff, has attempted to carry out the important work of looking after the health of a rapidly growing state. Concentrating its efforts to induce the respon- sible authorities to provide for additional district health officers, the department about July 1 will witness the fulfillment of its campaign. Governor Larson twice included in his budget recommen- dations provision for the additional health officers. The Legislature this year voted $12,000 for at least 4 new district health officers. At present there are but 2. For years, in emergencies, the bureau of local health administration has dispatched its trained but limited personnel to municipalities broadcasting distress signals when communicable diseases got beyond local control. Health officials through their various organizations were on record endorsing the department’s program to so district the state that the personnel operating from the bureau of local health administration at the State House would be so thoroughly organized that un- usual prevalence of disease could be arrested be- fore assuming epidemic proportions. Authority has been given for arrangement of examinations for civil service for the district health officers to be named. At present Monmouth County constitutes one health district. The coun- ties of Gloucester, Salem, Cumberland and Cam- den, exclusive of Camden City, constitute the other health district. Operation of the 2 districts was cited to the law-makers as a reason for ex- tending the system to the remaining 16 counties of the state. Tentatively the department’s program contem- plated the grouping of the remainder of the state as follows: Cape May, Atlantic, and parts of Ocean and Burlington counties; Hunterdon, Somerset, Mid- dlesex and Union; Warren, Sussex and “Morris; and, Bergen and Passaic. Hudson and Essex, be- ing practically all urban and having already many well organized city health departments, might not need assistance. Mercer and the northern part of Burlington County could be cared for from the central office of the department at the State House. JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 598 Woman’s Auxiliary PANORAMIC VIEW OF THE WOMAN’S AUX- ILIARY TO THE AMERICAN MEDICAL ASSOCIATION IN 4 ARTICLES No. 3 — Southern District Mrs. C. W. Garrison The Southern District of the Woman’s Auxil- iary to the American Medical Association may not have moved so rapidly as regards the num- ber of auxiliaries organized as other sections but the quality of those existing' have proved them to be of the greatest value in promoting the aims of the national body. Alabama reported 3 counties organized last year, and is particularly interested in a health pro- gram giving especial attention to children with a tuberculous condition. The group visited in Birm- ingham was alive and interested, and had the co- operation of its medical society. Arkansas reported 13 counties organized, all giving attention to a health program and trying to raise an adequate loan fund for medical stu- dents only. Some of the counties contributed ob- stetric kits for use in the rural districts. Many of the auxiliary members in Arkansas are devot- ing much time and energy to the Parent-Teacher work and are aiding in the various civic and wel- fare organizations. All will be gratified when the state is organized 100%. Florida, large areas of which are sparsely set- tled, has 10 auxiliaries. Some of these are com- posed of a combination of 2 or more counties. Proof of the quality of these groups was seen when a large medical organization and its auxil- iary were entertained in Miami, in 1929. Mrs. .T. Ralston Wells, the little woman who now heads the State Auxiliary, furnishes further proof of its aliveness and interest. Florida with its marvelous fruits, flowers, vegetables and wonderful sunshine has just as wonderful and marvelous women in the Medical Society Auxiliary. Georgia, which has given to the national auxil- iary one of its most efficient presidents, Mrs. Allen H. Bunce, has more counties than any other state of its size and has 21 of these organized. They have the full approval and cooperation of the State Medical Association and. having attended that state convention in 1929, the writer will vouch for the fact that no national meeting is more replete with interest and enthusiasm, nor have we found anywhere a greater desire to foster the aims and purposes of the national body. No group of wo- men can possibly have greater courtesy, interest and encouragement shown them and their work than is given to the Georgia auxiliary by the medi- cal men. Mrs. Harrold will bring from her state a goodly report. Louisiana reports only 2 parishes organized. Taking into consideration the fact that one of these auxiliaries has a greater enrollment than have some whole states, makes us feel that Louis- iana will not be far behind in the number of par- ishes when her final accounting comes in. She is not lacking in interest in any direction because the president of the State Auxiliary, Mrs. Harrold, is of the type who says “We will”. Mississippi reported 4 auxiliaries last year, and again we are able to speak with assurance of our expectations from that state. The president of the state auxiliary attended the meeting in Detroit and returned to her state with additional enthusiasm and determination to gather into the fold more county organizations. This dream will come true. Mrs. Polk was the first to respond to our first circular letter. She has the approval and encour- agement of the medical men of her state to go forward. We may expect to hear of more interest, as well as more auxiliaries, in North Carolina. Mrs. W. B. Murphy is the President of this great state auxil- iary, and though we have before us no report for last year we do know of its interest in the past and believe we may hear the number 5 at least doubled in the next report. South Carolina shows 13 counties organized, and Mr,s. Mauldin was prompt to reply with assurances that better things are ahead for next year. Mrs. L. M. Sackett now leads the one auxiliary report from Oklahoma, and we feel certain that others will be added before June. On invitation from its President we had the pleasure of meeting with the Davidson County Auxiliary in Tennessee early in October, and found a splendid group of women earnestly desiring to serve in the most useful way. AVe found as a member of this auxiliary the State President, Mrs. Milton S. Lewis. While only 4 auxiliaries are re- ported from Tennessee, they are the counties in which the largest cities are located. The dis- tances are great between, but with the known in- terest and enthusiasm of the 2 counties visited, Davidson and Shelby, we are assured that Tennes- see will bring to the next national meeting a re- port filled with accomplishments which tend to fulfill the aims and purposes of the auxiliary. While we were not fortunate enough to meet with the Texas auxiliary, we did have a little visit with the energetic and charming president, Mrs. O. M. Marchman. Texas, the mother state of the Medical Society Auxiliary as it is now recognized, has 35 county auxiliaries, and with a live, inter- ested organization chairman, such as Mrs. J. T. Moore is proving herself to be, others will be add- ed before the next meeting in May. Texas aux- iliaries have earnestly promoted a health program, always working shoulder to shoulder with the fine progressive men of the medical association who, in turn, endorse the auxiliary movement and are unstinted in encouragement to further develop- ment of the organization. County Society Reports ATLANTIC COUNTY Atlantic City Hospital Staff Joseph H. Marcus. M.D., Secretary The stated monthly meeting of the General Staff of the Atlantic City Hospital was held May 15, with Dr. Milton S. Ireland, President, in the chair. The medical service of Drs. D. Ward Scanlan and Harold S. Davidson was reported by Dr. Davidson, owing to the absence of Dr. Scanlan. The service embodied the months of November and December 1930 and January 1931. Following a classified por- trayal of the 191 patients admitted and a discus- sion of the mortalities, Dr. Davidson continued: July, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 599 Of especial interest were the pneumonias, of which there were 14 cases, lobar and bronchial, not including- tuberculous pneumonias, with 3 deaths, a mortality rate of 21%. This year we treated our pneumonias with daily, or, in some cases, twice daily, intravenous injections of con- centrated glucose solution, to the exclusion of all other medicaments, and we believe our results justify continuation of that plan. Until the last few days of the service it was thought we would get through without any pneumonia deaths, but all of a sudden we had the 3 fatalities. This fact alone shows how impractical it is to draw conclu- sions from a series of cases as to the value of any special plan of treatment. It may be that this year the pneumonias during the early months of the winter were especially avirulent. At any rate, we believe the plan should be tried further in or- der to get some basis for comparison with other plans of treatment on a larger series of cases. MERCER COUNTY A. Dunbar Hutchinson, M.D., Reporter The Mercer County Society held an “Outing” on June 18, just a reg'ular out-of-doors picnic in the grove at the Hopewell Valley Golf Club. The Com- mittee of Arrangements, Drs. Pierson, Seely, North and Hutchinson, definitely determined that any attempt made at scientific discussion on this oc- cassion would only result in failure because so many members had availed themselves of the pleasure and instruction to be gained through at- tendance upon both the State Medical Society Con- vention, and the A. M. A. meetings recently held. Golf and quoits occupied most of the afternoon; the interval being enjoyed around the buffet lunch counter tastefully prepared. Many very useful prizes were awarded to winners in the several con- tests which were hotly waged in and about the rough and hubs. MIDDLESEX COUNTY Samuel G. Berkow, M.D., Reporter The June meeting of this society was held at the Middlesex General Hospital, New Brunswick, on June 26, at 9 p. m.-, with Dr. William H. McCor- mick presiding. Members present were: Drs. Nafey, McKiernan, Rowland, Johnson, Brown, Feher, Klein, McCor- mick and Berkow. Minutes of the previous meeting were read and accepted. Dr. McKiernan reported for the committee -on amending the constitution of the society. Through the assistance of Dr. Brown he had obtained a copy of the Constitution of 1884, which is still in effect. By-Laws of 1816 have been lost. To pro- vide against such loss in the future, the society voted, on motion by Dr. Nafey, seconded by Dr. Rowland, to make the Voorhis Library, of Rut- gers University, repository of the important docu- ments of this society. Dr. McKiernan read the constitution and the committee’s recommendations. Further changes were suggested by various members and, on vote, were incorporated in the committee report. The revised constitution will be submitted at the September meeting. Medical Section of Rutger’s Club John H. Rowland, M.D., Secretary The annual , outing of the Medical Section of the Rutger’s Club was held at 6 p. m., Wednesday, June 24, at the Ross Fenton Farms, Asbury Park, with 24 members and 2 guests present. After various forms of enjoyment in the after- noon, including the boardwalk promenading, bath- ing', golf and other recreations, the members en- joyed an excellent dinner. They also enjoyed the famous entertainer, Luke Burnett, who acted as head-waiter, and who was successful in aggravat- ing 7 or 8 members taken by surprise because un- aware of this unusual form of entertainment. Afterward, Mr. Burnett was introduced in his real personality and told many humorous stories, to the great satisfaction and pleasure of all those pres- ent. Besides this form of entertainment, the Ross Fenton Farms presented music and vocal selec- tions. At a late hour the members' adjourned to their homes, feeling that this was one of the best an- nual outings they had experienced. MONMOUTH COUNTY W. Von Oehsen, M.D., Reporter The May meeting of the Monmouth County Medical Society was held at the Garfield-Grant Hotel, Wednesday evening, May 27, with Dr. W. K. Campbell in the chair. Minutes and communi- cations were read and accepted. Dr. R. W. Baeseman was elected to membership. The applications of Drs. Davies, Neiderhoffer and Jordan were read and referred to the Board of Censors. Dr. R. A. MacKenzie, chairman of a committee which met with the committees from the State Medical Society and the New Jersey State Homeo- pathic Society to inspect the Dr. E. C. Hazard Hospital and School of Midwifery, reported as follows : “At the conclusion of the inspection and follow- ing a meeting in which a thorough discussion was held, it was unanimously voted to sustain the ac- tion of the State Board of Medical Examiners in denying approval of Dr. Hazard’s School of Mid- wifery, such action having been recorded following inspection of the Hospital and School in April 1930. No students of midwifery are at present enrolled at the Hazard Hospital, those taking the course having discontinued their studies in 1929 following the action of the State Board in refusing admis- sion to examination of >3 graduates of this school. Dr. Hazard had been formally notified, following inspection and consideration of his Institution in 1925, that his school of midwifery could not be approved and the action of the State Board in refusing admission to the above mentioned candi- dates in 1929 has been sustained by the corjrts. In the meeting of May 14, 1931, of the joint com- mittee including your representatives, the ques- tions brought up for discussion were: (1) The need of midwives in New Jersey; (2) the character of equipment and availability of material for ob- stetric practice and practical teaching at the Dr. E. C. Hazard Hospital; (3) adequacy and accuracy of the teaching curriculum proposed for the school of midwifery at this institution. It was decided 600 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 without dissenting vote: (1) That need for aug- menting the ranks of midwives in this state and locality is not great; (2) that the equipment and facilities at the Dr. E. C. Hazard Hospital are not worthy of highest approval; and (3) that in- sufficient evidence was demonstrated as to the quality and sufficiency of theoretic and practical teaching along standardized and modern lines to select this institution for the training and gradu- ation of midwives.” Dr. Stanley Nichols recommended that the re- vised Constitution and By-Laws be adopted by the County Society. His motion was seconded and carried. Dr. J. Wiener, of Asbury Park, gave the paper of the evening on ‘‘heart failure” which was well received. June Meeting The June meeting of the Monmouth County Medical Society was held at the Log Cabin Inn, Pleasure Bay, Wednesday evening, June 24. No business was transacted except the election to membership of Drs. Sydney Neiderhoffer, L. E. Davies and J. B. Gordon. The members had the pleasure of hearing talks by Dr. John P. Hagerty, President of the State Medical Society; Dr. W. H. Herman, of Asbury Park, and Judge Ward Kremer, of Asbury Park. A steak dinner and dancing were enjoyed by the members and their waves. MORRIS COUNTY Marcus A. Curry, M.D., Reporter The quarterly meeting of the Morris County Medical Society was held the evening of June 18, in the recreation hall of the employees’ cafeteria building at the New Jersey State Hospital, Grey- stone Park. President Sutphen presided over a gathering of members and guests numbering about 40 ; among the guests being President Hagerty of the State Society. Routine matters were dispatched, including reading of the minutes of the March meeting and 2 subsequent special meetings, and the proceedings of the executive committee. Among items of the latter record was the resignation of Dr. Emory as Treasurer, which was accepted with regret. The applications of Drs. Falvello and Perris, having been reported upon favorably, were voted upon and they were unanimously elected to mem- bership. The application of Dr. Attilo Galasso, of Morris Plains, was duly referred to the credentials committee. A communication was read by the secretary from Dr. Julia Mutchler thanking members for their support at the recent primary, at which she was nominated for Assemblywoman, and bespeak- ing a continuance of support through the Novem- ber election. The Nominating Committee submitted the fol- lowing recommendation of officers for next year, to be voted upon at the annual meeting in Sep- tember: President, Fletcher I. Krauss; Vice-Presi- dent, Frank N. Pinckney; Treasurer, George J. Young; Secretary, Albert J. Ward; Reporter, Mar- cus A. Curry; Historian, Henry W. Kice. For councilor members of the Executive Committee, Drs. Sutphen, Frost and McElroy. For members of the House of Delegates of the State Society for 3 years, Drs. T'eskey and Teller; alternates, Drs. Gilbertson and Truax. For member to rep- resent the society on the Nominating Committee of the State Society, Dr. Costello. President Hagerty gave a very interesting talk on matters of fundamental interest to medical men, during which he touched upon the subject of con- trol of specialization and expressed his views, and the steps that have been taken to give full con- sideration to the proper handling of this matter that is now inviting much thought, and stressing the protection that should be given to those al- ready holding the rights they have earned and which have been bestowed upon them. Dr. Costello, being called upon by President Sutphen, gave a lucid account of the state medical society meeting at Asbury Park, and discussed very clearly many points of present and future interest. After dwelling upon the value and im- portance of the Journal and of the work of the Executive and Field Secretaries, Dr. Costello pre- sented a resolution which tvas unanimously adopt- ed, as follows: “Mindful of the high standard attained by our State Journal and appreciating the excel- lence of the work done by our Publication Committee and our Executive and Field Sec- retaries, we respectfully request that no meas- ures be instituted by the Board of Trustees which will diminish the resources or limit the activities of those departments.” Dr. Lath rope gave a very interesting talk along the lines of specialization and introduced a resolu- tion which was unanimously adopted: ‘‘That the Morris County Medical Society is opposed to any legislative regulation in the realm of specialization.” The scientific chapter of the evening was pre- sented by fellow members, Dr. Krauss presenting 5 case reports with x-ray plate illustrations, of ‘‘gastric crises in infants and children”, and Dr. Costello 2 very “interesting fracture cases”, one chiefly to show use of the Goldthwait apparatus in a fracture of the vertebra, the other an “unusual case of enlarged spleen with abscesses, and ab- scesses of the liver”. After adjournment refreshments were enjoyed in the cafeteria underneath the recreation hall. SOMERSET COUNTY Robert Scully, M.D., Acting Reporter Members of the Somerset Hills Clinical Society, composed of physicians attached to the new Vet- erans’ Hospital at Millington, held a joint meeting with the Somerset County Medical Society at the hospital on Thursday, June 11. The visiting physi- cians were accompanied by many of the members of the Woman’s Auxiliary to the County Medical Society, and a most interesting program was en- joyed. All of the visitors were first conducted through the various departments of the hospital. The ladies were then entertained at cards and with music in the beautiful new Recreation Hall which has been erected on the reservation. Music was rendered by an orchestra composed of a group of patients, assisted by Miss Betty Booth, of Basking Ridge, who sang many delightful songs, and also July, 3 931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY by Mr. "Boz” Cook, of the Triangle Club of Prince- ton University, and Mr. Earl Gardner. Meanwhile, the physicians were given an oppor- tunity to see medical cases of interest in another department of the hospital. Dr. Tester W. Day presented a series of dementia paralytica cases; Dr. A. C. Delacroix a series of manic cases; and Dr. D. M- Gardner a most unusual series of neuro- logic cases. At 5 p. m. a buffet s/upper was served in the Recreation Hall, which had been banked with palms and flowers for the occasion. The hos- tesses were Mrs. T. F. Neil, Mrs. D. M. Gardner, Mrs. R. L. Eltinge, Miss Helen Powell and Miss Mary A. Neill. Assisting were Miss Elizabeth Brown and Miss Lingenfelder. Tea was poured by Miss Moxley, Miss Borzner, Miss Berkshire, Miss Hudson, Miss Brown and Miss Lingenfelder. Much of the success of the function was due to the efforts of Miss Mary A. Neill, hospital dietician, and the whole-hearted cooperation of the workers of her department. Obituaries IN MEMORIAM JAMES HUNTER, JR., M.D. SINCE I MUST DIE (By Scammon Lockwood) If death must be my lot, my knee I bend That I die quickly and alone I die; On no fond breast my parting soul rely, But sink as traveler at journey's end And all alone to Erebus descend, Without one tear, without one parting sigh; So much for me, but ah, for you, my friend, 1 ask it that the fates may thus defend Your heart from scourging pain of vigil long; Slow day and night and week and month and year ; Ordeal too much for soul or body strong: Thus I would spare all those who are most dear, Thus would I join grim Charon’s eager throng, Quickly to go sans sorrow and sans fear. 6 01 On Monday, June 1, .1.931, Dr. James Hunter, of Westville, New Jersey, died after a sudden at- tack of coronary thrombosis, at the age of 65 years. Dr. Blunter was born in Philadelphia, January 14, I860, the son of James Hunter, Sr., and Martha M. Church. He was educated in the Philadelphia public schools and later graduated from the Phila- delphia College of Pharmacy. He entered the Uni- versity of Pennsylvania Medical School in 1885, graduating in 1888 as the youngest member of the class. He began his practice in Westville on Decem- ber 5, 1891, later devoting most of his energies to the treatment of eye troubles. Pie was a surgeon on the staffs of the Wills and Jefferson Hospital eye clinics from 1904 to 1920, retiring on the death of his chief, Dr. William Sweet. As a result of his work in those clinics he established a wide reputation as an eye specialist. Dr. Hunter was a past-president of both the New Jersey State Mtedical Society and the Glou- cester County Medical Society, and at the time of his death was Secretary of the Board of Trustees and also a member of the Welfare Committee of the State Medical Society. During the World Wjar he served as Chairman of the Medical Advisory Board for Gloucester County and was one of the founders of the Physicians’ Association of Woodbury and vicinity. He was a member of the American Medical Association and the Medical Club of Philadelphia. In politics Dr. Hunter was a Republican and served 3 terms as coroner of Gloucester County. He is survived by his widow, Elizabeth; a daughter, Avis, the wife of Carl F. Rumpf, of Germantown; and a son, James Hunter, 3rd, a jun- ior in the Woodbury High School. Resolutions of the Gloucester County Medical Society on the Death of Dr. James Hunter, Jr. RESOLVED, that the Gloucester County Medi- cal Society records with the utmost sorrow and regret the sudden death of our esteemed fellow member, Dr. James Hunter, Jr., of Westville, New Jersey, on Monday, June 1,- 1931, at the age of 65 years. Dr. Hunter had suffered from a se- vere cardiac attack 3 months ago, and had ap- parently recovered, when suddenly stricken with a fatal heart attack. Dr. Hunter was a past-president of the Glouces- ter County Medical Society, and also of the New Jersey State Medical Society, and was Secretary of the Board of Trustees of this latter body at the time of his death. He also served the State Medi- cal Society as a member of many important com- mittees and had for many years been one of the most influential members of that body. During the World War, Dr. Hunter served as chairman of the Medical Advisory Board for Gloucester County. He was one of the founders of the Physicians’ As- sociation of Woodbury and at the time of his death was an active member of the Medical Club of Philadelphia. 602 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY July, 1931 On January 14, 1X66, Dr. Hunter was born in the city of Philadelphia. He was educated in the Philadelphia public schools and the Philadelphia College of Pharmacy. In 1888 he was graduated from the University of Pennsylvania Medical Col- lege and attained high distinction in his class. Prom 1904 to 1920 Dr. Hunter was a surgeon on the staffs of the Wills Eye Hospital and the Eye Clinic of the Jefferson Hospital, of Philadelphia, where he established an enviable reputation. Our colleague began the general practice of medicine in Westville, on December 5, 1891, but later specialized in diseases of the eye. By his skilfull and faithful service to a large clientele throughout Southern New Jersey, and par- ticularly to the community in which he resided, he endeared himself to all with whom he came in contact, for Dr. Hunter emulated in his daily life and in contact with his patients the lov- able characteristics of the Great Physician. He has left a place in the affectionate regard of those to whom he administered, which will be extremely difficult to fill. By his constant and active interest in the Glou- cester County Medical Society, he had been a power for good; his association with his fel- low members had always been kind and consider- ate. The ethics of the profession always main- tained a high place in his regard and he was always a source of inspiration to those of the profession with whom he came into contact. BE IT FURTHER RESOLVED, that we, the members of the Gloucester County Medical So- ciety, have lost a distinguished, a faithful and a beloved member; that the state, the county and the community which he served so long and faith- fully, has lost a beloved and eminent physician; and we hereby express our sorrow and profound sympathy to his family in its bereavement. BE IT FURTHER RESOLVED, that a copy of these Resolutions be sent to his loyal and devoted wife, Mrs. Hunter, and that they be spread at large upon the Minutes of this Society. Dated June 4, 1931. Henry B. Diverty, William Brewer, J. Harris Underwood, Committee. Resolutions on (lie Death of Dr. James Hunter, Jr. Adopted by the Board of Trustees of the Medical Society of New Jersey The Trustees of the Medical Society of New Jersey record with deep sorrow and a feeling of ir- reparable loss the passing of our beloved mem- ber, Dr. James Hunter, Jr., at his home in West- ville, Gloucester County, at the midnight hour of June 1, 1931. Stricken with an attack of angina pectoris a few months ago, from the effects of which he had apparently recovered, he was actively engaged in preparing to attend our recent meeting at Asbury Park, and his unfinished report as Secretary of this Board, on which he was working when the call came to join Sproul, English, Johnson, Chand- ler and Dickinson in the Gi'eat Beyond, was fofind on his desk. For years his chief professional delight had been association with these past leaders and with the present members of this Board. Because of his integrity, his sterling character and his charm- ing personality, a deep bond of friendship had grown up between him and his associates on this Board. Dr. Hunter was President of our Society in 1922, a member of the Board of Trustees for 15 years and its Secretary since 1925. He loved our So- ciety as he loved his profession, and scattered through our “Transactions” in the past are the records of his devotion. It was during his term as President that the recent renaissance in the Medi- cal Society of New Jersey developed, and to him, in no small degree, was due credit for much of what has been accomplished. Members of this Board, of the Fellows, the State Board of Medical Examiners, the Judicial Council, Chairmen of Standing Committees, and a host of physicians from all over the state, attended the funeral services to pay their last respects to one who had been a friend to them all. On behalf of our Society, we express the univer- sal feeling of grief and loss at the untimely pass- ing of our friend and counselor. RESOLVED, That this tribute be spread upon our minutes and a copy sent to the bereaved family. John B. Morrison Harry R. North John F. Hagerty. BLAIR, James A., a practicing physician in Newark for 30 years, died at his recently acquired home in Binghamton, N. Y., May 29, 1931. Dr. Blair was born in Scotland and came to this country as an infant with his parents. He had lived in Newark nearly all his life and practiced many years at his home at 404 Avon Avenue. Some time ago he retired from active practice and moved to Binghamton with his wife. He was a lifelong member of St. Luke,’s Metho- dist Episcopal Church, a member of the Essex County Medical Society, the New Jersey State Medical Society and the American Medical Asso- ciation. VOORHEES, Nathaniel Whitaker, formerly of Elizabeth, died at his home in High Bridge, June 3, 1931. Born December 4, 1859, the son of the late Na- thaniel Whitaker and Naomi Leigh Voorhees, he was a graduate of Rutgers University and the University of Pennsylvania, from which he re- ceived his medical degree. After graduation, he was resident physician at Blockley Hospital, Phila- delphia, and later practiced medicine in Danville, Pa., before coming to Elizabeth. In that city. Dr. Voorhees held an eminent position in his profes- sion. He was a member of the medical staff of the General Hospital. A descendant of old American stock, he was of distinguished appearance. He was widely read on many subjects, and well informed on problems of economics and domestic and in- ternational politics. About 18 years ago Dr. Voorhees retired from active practice and with his brother, the late Fos- ter M. \ oorhees, former Governor of New Jersey, went to live on his country estate “Hill Acres", at High Bridge. He resided there until his death. 603 Journal of The Medical Society of New J ersey Published on die First Day of Every Month Vol. XXVIII., No. 8 ORANGE, N. J., AUGUST, 1931 Subscription. $3.00 per Year Single Copies. 30 Cents THE CULT OF ASKLEPIOS Walter B. Stewart, M.D., Atlantic City, N. J. In the early days of Greece, when the gods of Olympus still roamed the earth, and his- tory was recorded by word of mouth rather than on stone or parchment, there lived one by the name of Asklepios, in later Roman times called Aesculapius. Little is known of his life as a man among men. In the time of Homer, about the tenth century B. C., he had been dead for 200 years but had not yet been raised to the level of a god, being known merely as a famous chieftain of Thessaly who was well versed in the art of healing and went abroad doing good and performing miracles. Homer, in the Iliad, spoke of his sons, Machaon and Podalirius. who not only were military surgeons at the siege of Troy but also commanded a fleet of vessels. Other authors mentioned his daughters, Hygieia and Panaceia, who later became assistants in the temple rites and curators of the sacred snakes. Asklepios received his medical knowledge, as did also Achilles, Jason, and other worthies of the day, from the centaur Cheiron, son of Saturn, who in turn had been tutored by Apollo, the Homeric god of medicine and the ' father of Asklepios. Apollo could cause plagues and epidemics by his arrows, and could heal the wounds and diseases of the gods with the root of the peony. On this ac- count, his name was closely associated with that of Paean, the physician of the gods, in the form of Paean Apollo, and to him chorals or paeans were sung. But it was his son Asklepios who was the real healer of men. That he was considered worthy of deification as god of medicine, was fitting testimonial to his outstanding ability in the healing art and to the high esteem in which he was held by his contemporaries. We have received a fascinating account of the birth of Asklepios from the poet Pindar. Apollo once wooed and won a fair maid, Coronis, by name, but she, unsatisfied with the delights of one such love, and despite the fact that she was with child by Apollo, encouraged another suitor, a shepherd lad of Thessaly. The snowy raven, favorite bird of Apollo, es- pied this scandal and reported it to his mas- ter. Such was Apollo’s jealous rage that he turned the snowy raven coal black, seized his bow, and shot a deadly arrow through the heart of Coronis, his love. But when he saw her on the funeral pyre, before the flames had yet reached her dead body, he relented, and from her womb snatched the living babe, Asklepios. Thus was performed the first Cesarean section, long before the time of Cesar. One day the infant Asklepios was found on a hillside by a herdsman, sucking peacefully at the teats of one of his goats and guarded by a dog. Ever after the goat and the dog were considered as animals sacred to Asklepios. Another legend told of the discovery of the secret of restoring the dead to life. One day, while walking in a garden, Asklepios saw a snake mourning over the dead body of an- other snake. Soon the living one began to crawl about the garden and examine various plants. It broke off a branch of one herb, 604 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 1931 chewed the leaves, and forced the quid into the mouth of the dead animal. Immediately life returned and the recovered snake crawled away to its nest. Asklepios, marveling at what he had seen, took careful note of the herb used. Asklepios performed so many miracles, and restored so many of the dead and the dying to life, that Jupiter, fearful lest he thus de- prive Hades of all its shades and produce a race of immortal men on earth, hurled upon him a lethal thunderbolt. His father, Apollo, took revenge by killing the Cyclops who had forged the bolt. The cult of Asklepios originated in ex- treme simplicity. A number of devotees of the new god of healing, enthusiastic patients who had been cured, and their friends, gath- ered about a mineral spring on the side of a beautiful mountain near the little town of Tricca in Thessaly. There they erected a simple temple to Asklepios, containing his statue and a few sacred serpents ; they hung up their crutches on the walls, just as con- valescents have always done at famous shrines ; and they appointed one of their num- ber to officiate as priest in the worship of the god. The priest was preeminent ; the phy- sician had hardly yet appeared in the temple. The fame of the god and of the shrine, to which invalids began to flock, spread so rap- idly throughout Greece that many other tem- ples were established, the most famous of which were those at Epidaurus, Cos, Cnidos, and Pergamos. These temples, or asklepieia, became popular sanatoriums managed by trained priests, the asklepiads, and not unlike many health resorts of modern times. They were located in elevated spots, preferably on the side of some mountain, by a medicinal spring, amidst inspiring natural beauty. The grounds were laid out with woods, lawns, and fragrant gardens. Cypress, oak, and olive trees afforded ample shade. The spring was essen- tial for purification of the patient and treat- ment of many of his ailments. About the temple there were erected beautiful and elab- orate buildings, often among the noblest and most imposing examples of Grecian architec- ture. Ornate in detail, they were adorned with the most admirable works of the paint- ers and sculptors of a country so famous, even then, for cultivation of the fine arts. The ground plan would resemble in many respects that of a modern college campus. Even the stadium, the gymnasium, and the theatre were there as parts of the course in occupational therapy. Upon the walls of the temple were hung the votive tablets, recording the name of the patient, his disease, and the manner in which he had been cured. Many of these tablets have been discovered at Epi- daurus. Hotels were built for the accom- modation of the hosts of visitors. Between 200 and 300 asklepieia are known to have existed in various parts of Greece. Such was the popularity of the temple cult at these health resorts that it spread rapidly to the ur- ban centers. It was introduced into Athens by Sophocles, in 420 B. C., and into Rome in an effort to check a raging plague, in 293 B. C. As the cult grew in influence and complex- ity, some of the priests assumed more purely medical functions, although the majority per- formed only devotional and sacrificial duties. A few extramural physicians, bringing with them a knowledge of rational, scientific medi- cine, were added to the temple staff. It was assuming more the nature of a great hospital center. The temple doctors, the asklepiads, in the century before Hippocrates, were sharp- ly differentiated from other Greek physicians by a rigid organization which found expres- sion in definite rules and formalities. They were free to practice their calling, at their own discretion, outside the sacred precincts or even in foreign countries. At first they inherited position by primogeniture, but later were chosen by lot at annual sessions con- trolled by the state and its politics. Urey jealously preserved the prerogatives of caste and exercised their privilege with all that im- pressive ostentation practiced universally by the priesthoods of all mystic cults. The as- klepiads offered not treatment, but cures ; and the unfortunate incurable was ushered from the temple as an outcast from divine mercy. Hence, inasmuch as the cure depended not upon the sagacity and experience of the heal- August, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 605 er. but upon the righteousness and purity of soul of the patient, the asklepian priest was infallible. The patient, on admission, was put through a routine course of treatment. His imagina- tion having been tuned to the proper pitch by the inspiring scenery, by the presence of the god in effigy or in symbol, and by narra- tion of his famous cures, the patient sacri- ficed to the god a cock or a ram, and offered up appropriate prayers. He was further puri- fied by a bath from the mineral spring, and by massage, inunctions, and other physico-thera- peutic measures. He received instructions in dieting or fasting. Then he was inducted in- to the special rite of incubation or temple- sleep, which consisted of lying down to sleep in the sanctuary for 1 or 2 nights, of dream- ing, and of having the dream interpreted by the priest who would then prescribe the ap- propriate remedy. If the patient was not a good hand at dreaming, there were profes- sional mediums who would dream to order for a small fee. If the patient happened to be awake during the night, the priest in the guise of the god presented himself before the patient to administer medical advice. If the treatment was successful and he was cured, the patient presented a thank offering to the god, usually a model of the diseased part in wax, silver, or gold ; and he hung up his vo- tive tablet on the walls of the temple. Thus the priest was the center of faith of the pa- tient, effecting his cures by advice and guid- ance, and depending for his success upon the credulity of those who sought his aid. Sev- eral examples of these miracles which have been preserved for us may be mentioned here : (1) A skeptic, all of whose fingers save one were paralyzed, came to the shrine, and during his period of incubation dreamed of playing at dice, during which the god straight- ened his fingers. (2) Cleo had been with child for 5 years. After 1 night in the dormitory a son was born, who in the morn washed himself with the sacred waters and betook himself from the shrine. (3) Pandarus came seeking to have re- moved some letters branded upon his fore- head. He dreamed that xA.sklepios bound a fillet about his head and bade him take it off and dedicate it to the god. Lo ! In the morn- ing, the letters were no longer on his troubled forehead but had been transferred to the fil- let. (4) Thyson. the blind boy, had his sight restored through the licking of his eyes by a dog of the temple. (5) A man with an ulcer of the toe was cured by the forked tongue of the sacred ser- pent while he lay asleep. (6) Apellas underwent 9 days of treat- ment for indigestion. The first item of ad- vice was not to get angry, following which there were directions as to diet, exercise, bath- ing, the making of sacrifices, and the neces- sity of paying the honorarium. In the event of his failure to make an adequate monetary compensation, the disease and suffering of the patient could be restored to him. Irrespective of the reality of the cures ef- fected at these places, one would hardly con- sider the methods as contributions to medical therapeutics. The routine of treatment is so strongly bound up with divine intervention that it is difficult to distinguish any of the ancient art of medicine in it. It belongs rather to the realm of comparative theology. The popularity of the cult was due in part to the wisdom and sympathy of the priests, but mostly to their close association with so powerful a deity as Apollo. Parallel with the development and expan- sion of the cult, scientific rational medicine was gathering experience and formulating its rules. Many of its principles originated in Egypt, Chaldea, and Persia, and were carried through maritime channels to the lay practi- tioners of pre-Hippocratic Greece. Hippoc- rates was indebted to Egypt for much of his knowledge. His accurate clinical pictures closely resemble those in the last section of the Ebers papyrus on the subject of tumors; and his famous oath corresponds in sentiment and expression to some of the ethical precepts of the ancient Egyptian physicians. However, later Egyptian medicine was entirely in the hands of the priests, while Greek medicine, even in the Trojan War, long before the time €06 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 1931 •of Hippocrates, was largely free from priest- ly domination. Hippocrates, living between 460 and 376 B. C., developed his great sys- tem of rational medicine at a time when tem- ple medicine was exercising its greatest in- fluence. Greek medicine by no means orig- inated with Hippocrates ; in reality, he repre- sents to us the embodiment of a period in which he forms only the most striking figure. After he had received what knowledge he could obtain from the temple of Cos, of which he was a graduate, he did not disdain to travel among the secular group of physicians and learn their art. It is most significant that he, during the period in which the asklepiads were most numerous and influential, was practicing and teaching methods in which the religious and mystic element was almost neg- ligible. In his writings he did not mention the temple at Cos, although his home was at its very doors and his education was received within. Rational medicine and temple medicine were not necessarily competitive, but perhaps the asklepaids served as a supplement in at- tending to those sufferings of humanity which transcended in their obscurity the wisdom of rational medicine. The great importance of the lay practitioner can be realized in the fact that many Greek cities maintained state phy- sicians, and that both Homer and Xenophon told of men of great surgical skill. Even in the sixth century B. C. Athens boasted of her public health officers. Democedes, a public physician of Athens, had an annual salary of $2000. Although the temples at first repre- sented depositories of empiric knowledge, they later became hot-beds of jugglery and deception. No element of charlatanism en- tered into the cures of Hippocrates. When rational means failed, he left the cure to deity and the “vis medicatrix naturae’’, which force he recognized as the great physician. Our word “physician” is derived from the Greek word “phycis”, meaning nature. The legit- imate province of his art as a physician he felt was merely in the aiding of this innate healing power of nature. In the fifth century, when the art of think- ing was being developed to such a high point among the Greeks, philosophy came to the aid of medicine and rescued it from the clutches of religion. The ancient Greek physicians believed that all disease was of di- vine origin. They knew about disease only what could be perceived with their unaided senses; all else was conjecture and hypothesis. However, this new philosophic attitude en- deavored to reduce all thought of phenomena to a uniformity of idea which led only to guess work and to neglect of fact. Pythagoras, Empedocles, and other philosophers, taught that the macrocosm, or the world as a whole, was composed of fire, air, earth, and water; and that the microcosm, or individual unit, was of blood, mucus, yellow bile, and black bile. Health was said to consist in a harmony or due admixture of these humors ; disease, in a disharmony or imperfect admixture. For 2000 years this humoral pathology dominated the profession. Even in the Hippocratic writings the nature of disease was still under this influence of the philosophers. But, on the whole, the Hippocratic school freed medicine of religious and philosophic dogmas and as- sumptions, and stressed accurate observation and knowledge from accumulated experience. Pythagoras, Empedocles, Democritus, Soc- rates, and other philosophers of that day, were also distinguished physicians. Few of their medical writings have been preserved, al- though we know that Democritus wrote a treatise entitled : “On Those Who Are Attack- ed with Cough After Illness”. Plato expressed some interesting views on the limitations of temple medicine. He wrote that Asklepios did not instruct his descendants in vali- tudinarian arts, because he knew that in well ordered states individuals with occupations had no time to be ill. If a carpenter felt sick, he asked the doctor for a rough and ready cure — an emetic, a purge, a cautery, or the knife — these were his remedies. Should anyone prescribe for him a course of dietetics and tell him to swathe and swaddle his head, and all that sort of thing, he could see no good in a life spent in nursing his disease to the neglect of his customary employment. Therefore, bidding goodbye to this sort of physician, he resumed his ordinary habits and either got well and lived and carried on his business, or, August, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 6 07 if his constitution failed, he died and had no more trouble. An Athenian father of the fourth century worried about the poor health and the sus- picious cough of his adolescent boy, had re- course to 3 procedures : he could ask the ad- vice of Hippocrates or some brother prac- titioner, he could resort to the asklepieion in Epidaurus, or he could send him to the pal- estra of Taureas for a systematic course in gymnastics. The cult of Asklepios is essentially a re- ligious sect and unmitigably pagan. It is built upon the foundation of a mythologic hero or deity, a legendary figure from among those earth spirits who were ancient even to Hom- eric audiences. Such an earth spirit was the serpent, dwelling in mother earth and hence symbolic of her. Appearing to be wisei , stronger, subtler, and longer lived than man, it inspired fear and awe, thus awakening re- ligious impulses. It became a sacred and mys- tic animal, endowed wdth magic poweis le- lating to dreams, prophecies, and healing. So, naturally, it was an almost constant associate of Asklepios and his cult, and became a sym- bol of medicine and the medical profession. The serpent was often worshipped as the god himself. It was carried to Rome in 293 B. C, swam ashore, and indicated by the point of its landing on an island in the Tiber the site on which should be erected the temple to Asklep- ios. ' The care of these large, yellow, non- poisonous, trained serpents was an important function of the priest and his assistants. It was believed that the cleansing of one’s ear by the tongue of a serpent brought about supernatural understanding in the patient. Many ulcers and sores were healed by licking of the forked tongue. The belief in the medi- cinal qualities of snakes has carried down to the present day. Do we not find bottles of rattlesnake oil for the cure of all ailments in our best drug stores? You have all seen the statue of Asklepios standing at the head of the staircase in the library of the College of Physicians in Phila- delphia. He is represented as a vmle man with bared chest, and refined, thoughtful coun- tenance, garbed in a flowing cloak, and hold- ing a club-like staff around which coils a o single serpent. This staff doubtless had an Egyptian origin, being derived from the sac- red uas staff. Hermes or Mercury also car- ried a staff around which 2 serpents were coil- ed and surmounted by wings, the so-called caduceus. Hermes was worshipped by the early Greeks as a god of healing, the averter of disease, and as a phallic deity. But the chief functions of Hermes were as messenger of the gods, and as the god of merchants, com- mercial travelers, and thieves. Hence it would seem hardly appropriate that the medical corps of the United States army, and many medical publishers, have adopted the caduceus of Hermes as the official symbol of medicine rather than the single-serpent staff of Asklep- ios. The caduceus was originally the em- blem of the sun god, Horus, which, mythology says, Hermes received from Apollo in ex- change for the lyre. In Assyria it appeared first at about 3500 B. C. on a libation vase; and in predynastic Egypt, in a slightly differ- ent form, on monuments. It was used as a medical emblem first in the sixteenth century by a publisher of medical books as a title-page device. The sacrificial offering made most fre- quently to the great god Asklepios was the cock. In Plato’s description of the death of Socrates we recall his dying words: “Crito, we owe a cock to Asklepios”. The meaning of this solemnly smiling farewell would seem to be that to Asklepios, a god who always pre- scribes potions and whose power is manifest in their effects, was due that most welcome and sovereign remedy which cured all the pains and ended all the woes of Socrates, the cup of hemlock. For this great boon of awakening into real life Socrates owed Asklepios a thank offering. This offering of a cock was plainly intended for him as the awakener of the dead to life everlasting. 608 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 1931 FACTORS IN THE EARLY DIAGNOSIS AND TREATMENT OF FRAC- TURED SKULLS H. Wesley Jack, M.D., Camden, N. J. In presenting this paper on skull fracture, it is not the aim or intention of the writer to bring forth or advocate any new or original measure or information dealing therewith, nor has any attempt been made to discuss the causes of types of skull fractures. It is more to call to your attention and impress upon your minds the application of some of the sound principles of surgery that are beneficial in conditions associated with the symptoms resulting from severe trauma to the head as is so often the case in skull fractures or cranio- cerebral injuries. As a result of the tremen- dous growth of automobile traffic, and the accidents occurring therefrom, it has become increasingly necessary for the general surgeon to know more about fractures of the skull. About 1/5 of the accident cases actually ad- mitted to the hospital, and many of the cases admitted to the accident wards, must be con- sidered and examined for a possible cranio- cerebral injury. iMore knowledge and ut- most care must be had in the diagnosis of these cases, because most of them become medicolegal cases months later, and the course one pursues in their treatment is always open to criticism. Just what is the duty of the general sur- geon? In the past 10 years, the tendency in treatment of cranial trauma has been toward conservative measures rather than immediate surgical intervention. The high operative mor- tality that resulted from rushing all serious head injuries to the hospital and performing subtemporal decompression has produced a re- action in favor of a more careful consideration of the need for surgery in those cases. The pen- dulum has swung in the opposite direction and the general trend of feeling is — do not open the skull, except as a last resort — while formerly it was the first procedure; but on *(Read at the Camden County Medical Society meeting Jan. 6, 1931.) the whole, results in mortality have not been so promising bv the operative method. In the hands of some, a very low mortality, and in others, the rate of death high. What has spelled this difference? Has it been the oper- ator alone, or is it the class of cases? On the other hand, in a number of cases in which the operation was not performed there was a fatal termination within the first 24 or 48 hours. Such cases naturally give rise to the question whether or not surgical intervention might have changed the course of events. Hitherto, concussion and continued stupor, with or without localizing signs pointing to the area of the brain injured, was considered by most surgeons as sufficient reason for im- mediate decompression. As a rule, no at- tempt was made to estimate the degree or nature of the injury, or to formulate any rule upon which to decide for or against opera- tion. It was considered that in cases of de- pressed fracture and hemorrhage exploration should be made, if the general physical con- dition of the patient justified the procedure. Numerous classifications of brain injuries have been given in medical literature but most of them are only of value from a theoretic standpoint. To the man doing traumatic surgerv there are only 2 types of brain injury, those that should be operated on and those that should not, or: (1) Those patients who die no matter what is done, and those recovering spontaneously without treatment. (2) Inter- mediate group that usually die if untreated or that may be saved by timely and intelligent in- tervention. Our early efforts should be di- rected to placing patients in one of these classes, but this cannot always be done. The injury to the cranial bones is the least im- portant feature. The prognosis depends in great measure on the damage that has been inflicted upon the underlying nervous struc- tures. Cushing, in 1908, was the first to call at- tention to the fact that the injury to the brain and its membranes, rather than the fracture of the skull, was the thing to be treated in cranial injuries. It now seems obvious enough to us that the primary hemorrhage and compression, and the secondary swelling and edema, of the brain and its membranes consequent upon August, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 609 such injuries cannot be successfully accom- modated in the closed box which we call the skull. In addition to this purely mechanical condition which must be corrected. Weed also has shown that the fluid balance in the cere- brospinal system is destroyed by the presence of blood, which renders absorption impossible. Our task, then, is three-fold: to restore the cerebrospinal balance ; to make room for the reactionary swelling and edema ; and to care, for the immediate and remote effects of hemorrhage. Brain injuries that require operation fall into 3 classes, and are: (1) Middle meningeal hemorrhage. (2) Simple or compound frac- ture with bone pressure or bone fragments in the brain. (3) Cases in which there is a rapid increase in intracranial pressure. Injury accompanied by middle meningeal hemorrhage should be operated upon imme- diately after shock reaction. A subdural or ex- tradural hemorrhage usually offers no diffi- culty in diagnosis or localization ; due to early paralysis and pupillary reaction. There is a monoplegia or paraplegia on the side opposite the hemorrhage, and in some cases there is dilation and fixation of the pupil on the side of the hemorrhage. Retinal examination is of little diagnostic value at this stage. A subtem- poral decompression over the area of the middle branch of the middle meningeal is the best method of approaching the site of hemorrhage. Enlargement of the opening can be easily accomplished to the right or left as is necessary. Simple or compound fractures with bone pressure or bone fragments should be oper- ated on immediately. Bone pressure should be entirely removed and a careful search made for fragments penetrating the brain. Fre- quently, fragments are overlooked and will later cause trouble. From the point of view of intracranial tension, head injuries may be divided into 2 classes. Immediate operation is required in patients exhibiting symptoms, to determine, with fair exactness, the area of the brain involved. By “immediate operation” is meant any time after the injury that the pa- tient has rallied sufficiently to make opera- tion justifiable. Intracranial tension alone, without localizing signs, does not require im- mediate operative opening of the skull, for we have to contend with pressure caused in large part by the edema, and we fear overwhelming medullary pressure and collapse of the vaso- motor, circulatory and respiratory centers. Unconsciousness, of itself, has no fatal ten- dencies ; neither have paralysis, Hutchinson’s pupil, or an exaggerated reflex. The indica- tions for treatment should be kept clearly be- fore you. If you assume that pressure is not due to massive hemorrhage, to which refer- ence already has been made, the pressure of a traumatized brain can be relieved best by 50% glucose solution given intravenously and by repeated lumbar punctures. Glucose is a hypertonic solution that withdraws fluid from the tissues into the circulation, where often it is needed to conserve the blood volume. Usually 50 c.c. twice a day will suffice, but do not hesitate to double the dose during the first 24 hours if the medullary picture is threaten- ing; watch your tracing of pulse rate and pulse pressure, and when these lines cross as the former decreases and the latter increases, the situation is critical. As a subsidiary measure for the relief of pressure, withdraw cerebrospinal fluid from the lumbar spine, if need be twice in the 24 hours, but not without certain precautionary measures. Do not ruth- lessly drain off every drop of fluid, but with the aid of your manometer stop before the pressure reaches normal. This condition may be handled as effectively by other means, namely, lumbar puncture, hypertonic solution by rectum or veins, and ventricular tap. Sub- temporal decompression for the relief of pressure is reserved as a last resort and is rarely performed in the first 8 hours after injury; only when a spinal reading of 30 or above is reached will reduction in the amount of cerebrospinal fluid lower the intracranial pressure. Some surgeons prefer merely decompression and opening of the dura to reestablish cere- brospinal fluid balance, while others advocate drainage by rubber tissue for the period of 48 hours or more. For patients with middle men- ingeal syndrome or extradural hemorrhage, decompression would seem to be the only measure offering any prospect of cure. The nonoperative cases or brain injuries CIO JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 1931 that should not be operated on, fall into 2 classes: (1) Extensive injury with lacerations and separations. (2) Injury in which there is no primary increase in intracranial pressure, but where pressure usually develops later; due to fluid accumulation and edema. Included in this class are the simple, nondepressing fractures and so-called cases of concussion. Injuries in which there are extensive lacer- ations and cellular separations reach a rapid stage of exhaustion and medullary paralysis. 1 hese massive types of brain injury are fatal and no treatment is of benefit ; patients pass rapidly into coma and soon die. The following items are always worthy of consideration : ( 1 ) Visit and examine the patient at the earliest possible moment and carefully note findings. (2) The element of shock must be con- sidered and combatted before operative pro- cedure of any kind is instituted. (3) Careful examination, both physical and neuralgic, should be made and repeat- ed from time to time. Roentgenograms of the skull should be taken in every case of sus- pected fracture. In many instances, especially in cases of basal fracture, the line will not be shown. On the other hand, when a linear fracture of the vault or base is shown, this fact should not be taken as a deciding factor for operation. Whenever possible, fracture of the skull should be demonstrated, just as fractures of the long bones are demonstrated, but pulse, temperature, respiration and blood pressure records should be made frequently. A good custom has been to have the pulse rate taken every half hour and the blood pressure at intervals of from to 2 hr., in severe cases. From a neurologic standpoint: ex- amine the pupils to see if they are equal or unequal, react to light and accommodation ; note whether the ocular muscles are normal ; is there nystagmus or inequality of the facial muscles ; deviation of the tongue ; ability to whistle or purse the lips; bleeding from the external auditory canal or postnasal space ; grip of both hands; reflexes of the arms; epigastric reflexes ; cremasteric reflexes in men ; patellar and plantar reflexes ; and Ba- binski ? It is only by watching closelv the varia- tion in these phenomena that one can judge the opportune time for operation. (4) Ophthalmoscopic examination is re- quired and often may be advantageously re- peated. It is not believed that the eve- ground picture in itself is a reliable earlv guide to the degree of change in intracranial pressure; this is especially true in the first few hours after injury. There have been cases terminating fatally, in which the eye- grounds have shown little more than over- filling of the vessels and hyperemia of the retina. Even with the patient dying shortly after the injury, the disk margins have re- mained essentially clear-cut, and the optic cup has been well seen. After 48 hours, when the brain has had time to adjust itself to the con- ditions of increased pressure, the eye-ground picture becomes more significant. (5) The mental state of the patient is re- garded as a fair index of his condition. This applies principally to those cases in which the patient is suffering from edema of the brain. On occasion, decompression has been resorted to when the patient was exceedingly irritable and disoriented, provided lumbar punctures and dehydration had failed to give relief. Un- less something can he done fairly early to re- establish normal processes for these patients, it has been found that they not infrequently develop post-traumatic neuroses. The recent work of Dr. Frazier, of draining off all the cerebrospinal fluid and injecting oxygen in its place, followed by x-ray examination, has brought to light many hitherto unknown brain lesions resulting from what were considered slight head injuries, and has explained many of the so-called cases of neurasthenia. Care- ful examination should be made by the oto- rhinologist for bleeding from the external auditory canal, bleeding into the pharynx by way of the eustachian tube, and perforation of the tympanic membrane or hemorrhage within the middle ear. Nasal or postnasal bleeding suggests fracture at the base of the skull. (6) Examination of the spinal fluid, while not routine, is made in all cases where there is a possibility of more than simple concussion. \\ e believe that the spinal fluid pressure read- ings are of more value than the ophthalmo- August, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 611 scopic finding during the first few hours. Dr. Frazier, of the University of Pennsylvania, has suggested a rule : whenever the pulse pressure exceeds the pulse rate per minute, lumbar punc- ture should be performed. Pressure readings should be taken at each puncture. Many cases in which bloody spinal fluid is revealed, es- pecially when it is under increased pressure, present signs and symptoms of a meningitis which disappears after the blood has been ab- sorbed or drawn ofif by repeated punctures. While we have had no untoward results from lumbar puncture, we always watch the pulse and general condition of the patient while the fluid is being removed, and invariably stop if the pulse shows any variation either up or down. (7) Subtemporal decompression, when performed for relief of pressure, is usually drained, for we cannot conceive of getting sufficient mechanical relief from decompres- sion alone to accommodate an edematous brain. The drainage which usually follows during the first 48 hr. is of great volume, as judged by the amount of fluid absorbed by the dressing. We believe it is the drainage which is largely responsible for relief. Dr. Frazier states that there can be secreted as much as 1000 to 1500 c.c. of cerebrospinal fluid in 24 hr., and the relief from decompression alone would not be sufficient in many cases. (8) It is considered proper to operate in all cases of suspected local hemorrhage, for we believe that mechanical removal of the clot is safer than absorption. Dr. Charles Bagiev, Jr., of the Johns Flopkins University, Balti- more. after experimental work performed on 18 adult dogs and 26 puppies from 5 different litters, and also after studying a number of children and adults, has summarized his re- port as follows : Autogenous blood or blood from an animal mixed with the cerebrospinal fluid in young and adult dogs produces neuro- logic disturbances varying from slight differ- ence in behavior to severe convulsive seizures. Though some of the animals were severely af- fected bv small quantities of blood mixed with cerebrospinal fluid, others have survived more than a year and are apparently normal. Following the introduction of blood into the cerebrospinal fluid, there begins a reaction of the parts of the meninges which have come in contact with the blood. The meningeal re- action tends to subside and may disappear as the blood disappears from the fluid. After several weeks, the cellular elements are less numerous in the meninges, but a large amount of fibrous tissue is present. Later in the course of the meningeal reaction, changes in the structure of the cortex are also observed. Moderate dilatation of the ventricle not in- frequently occurs following the introduction of blood into the cerebrospinal fluid of the young. The condition may occur in adults, but with less frequency. For example, in 1 case in which a subdural hemorrhage was al- lowed to absorb, the patient returned 6 months later with Jacksonian epilepsy. At subsequent operation, the cortex zvas yellowish in color, and many adhesions were present at the site of the old hemorrhage. (9) It is now the practice of most men to open the dura in the majority of cases in which an extradural clot is encountered. In a case that it was my privilege to watch, there was found an extradhral, a subdural and a subcortical clot in the same general location. After successful removal of the extradural clot, it was most discouraging to find that later the patient’s condition was unimproved ; it was, in fact, even worse, and upon reopening the wound and laying back the dura, we discovered a subdural clot which had not been disclosed at the first procedure. Opening of the dura may add slightly to the risk of infection, but a wide opening is not necessary in order to in- vestigate the subdural space, and it may be easily closed. (10) Local anesthesia is frequently em- ployed. If the patient is in deep stupor or coma, the operation may be performed with- out difficulty. In cases presenting irritability and restlessness, a combined local and general anesthesia is employed, a minimum of ether being used. Large, depressed fractures have been elevated under local anesthesia when the patient was conscious throughout the proce- dure. There is little pain, except when ten- sion is brought to bear by leverage on the fragments. (11) Hypertonic saline (15 to 25%) has been employed intravenously in a number of 612 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 19 31 cases to reduce intracranial pressure. Most men have not been favorably impressed with the results and have come to rely chiefly on dehydration by the administration of mag- nesium sulphate, either by mouth or rectum, as advised by Dr. Frazier. From 1 to lj4 oz. (28.35 to 42.52 gm.) of magnesium sulphate are given twice a day when it is possible, or 1 to 3 oz. (28.35 to 85.05 gm.) of crystals dissolved in 6 oz. (170.1 gm.) of water are given as retention enemas every 3 or 4 hr., ac- cording to degree of increased intracranial pressure. The intravenous use of glucose is considered by many to be even better than magnesium sulphate, to dehydrate the brain, its action more lasting; 20 c.c. of 5% solution being used. This recalls the teaching of sur- geons of years past, who prescribed for all skull fractures a daily dose of castor oil. It appears that more prompt relief is obtained from re- peated lumbar puncture than from other methods. A good routine treatment of cranial injuries is as follows : On admission, the pulse, respiration, tem- perature and blood pressure are obtained. If the blood pressure registers below 60 mm. Hg. in systole, or if the temperature is markedly subnormal, a state of shock exists. The head is lowered, external heat applied and 0.5 c.c. pituitrin given by hypodermic. If external lacerations are noted, they are cleansed and explored by incision, often in the accident ward. Flere, many times, a fracture is shown to exist and several hours of preliminary ex- amination is saved. The wound is packed if there is bleeding, flooded with some antiseptic, and then covered with sterile gauze. A solu- tion of 2 to 4 oz. of magnesium sulphate crys- tals dissolved in 6 oz. of water is allowed to flow into the rectum. The head-down position aids in retention of this solution. Lumbar puncture is performed, with careful man- ometer readings of the pressure. Dr. Dandy advises against lumbar puncture, feeling that it so lowers intracranial pressure that if extradural or subdural hemorrhage ex- ists the lumbar puncture, relieving the pres- sure, allows the hemorrhage to increase. This is especially true of hemorrhage in the pos- terior cranial fossa. This same applies to solutions to dehydrate the brain, and the fact that blood may be found in the spinal fluid is not of great consequence, according to Dr. Dandy. lie advises the following procedure: (1) Leaving the patient strictly alone, until you know that nature is unable to cope with the situation. (2) Study and observe the pa- tient more carefully. The exact state of in- tracranial pressure can be determined by : (1 ) State of consciousness. (2) Pulse, respira- tions, temperature, restlessness, involuntary micturition or defecation. Fie feels that a certain percentage, perhaps 20%, will be lost, with the utmost available efforts, because the injuries are so severe. About 70% will re- cover if left alone, and 10% of patients that would be lost if left alone can be saved by well timed and well directed operative treatment. We are now in a position to determine what the next step will be. If the neurologic signs point definitely to one hemisphere, that region is exposed. This applies only to signs point- ing to cortical involvement. Paralysis or definite weakness of one or both extremities on the same side, convulsions, Jacksonian in type, motor or sensory aphasia, are the kind of localizing symptoms required to indicate ne- cessity for operation. If the neurologic signs are vague or indefinite, decompression is not done, unle’ss there is a rapid increase of intra- cranial pressure and spinal manometer read- ing of 30 or beyond. Most patients with cranial trauma are given the rectal injections of magnesium sulphate. As a rule, they are insufficient to prevent manifestations of a rise in intracranial pres- sure from appearing. If, however, the pulse and respiration rate continue to be depressed’ or become retarded, and the pulse pressure continues to rise until it equals the pulse rate, then other steps are necessary to reduce the rising tension within the cranium. Thus, these cases should be subject to very active and careful study from the earliest possible moment. Each case is individual ; no 2 seen alike. Only general rules can be used to govern these and only by the combined or collective opinions of a team of trained co- workers can the greatest number be brought to a successful conclusion. If each patient, August. 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 613 as soon as possible following the injury, could be examined carefully and repeatedly by a corps of trained specialists (surgeon, neuro- logist. ophthalmologist, otorhinologist, roent- genologist and laboratory pathologist) the percentage of correct diagnoses would be much greater, the course of procedure would be more definite and certain, and the percent- age of recoveries would be much greater. Summary (1) Intracranial injuries constitute a class of accidents whose frequency is increasing in civil life and whose mortality will probably always be in the neighborhood of 50%. (2) Attention should be directed to the damage of cranial contents rather than to damage of the bony parts, and it should be remembered that while the immediate re- covery of the patient is a serious considera- tion. the remote consequences of the injury are equally important. (3) Intracranial hemorrhage should be drained either by repeated lumbar punctures or. if that fails, intraventricular puncture, or by operative means. (4) The subtemporal decompression de- vised by Cushing is a valuable measure in these conditions ; it should never be done dur- ing the period of shock, and it is wise to sup- plement it by lumbar puncture or by the use of dehydrating agents. In mild cases, lumbar puncture alone may be adequate, but expectant treatment is seldom justified. 15) A fracture with rapid increase of in- tracranial pressure demands either dehydra- tion or operation, next in importance to those accompanied by hemorrhage. Cerebral edema is best treated by dehydration, with epsom salt and glucose, repeated lumbar punctures and subtemporal or suboccipital decompres- sion as the occasion may demand. (6) Skull fractures are not in themselves fatal. It is. the accompanying complications that render these conditions so disastrous. (7) Head injuries, if severe, have a more favorable prognosis if a linear fracture of the vault is present to assist in preventing forma- tion of cerebral edema. We should have more thorough and repeated examinations by a corps of trained specialists. We should not hurry patients to operation ; except those with active bleeding such as from meningeal in- volvement. All skull fractures do not require operation. A simple linear fracture with a moderate increase in intracranial pressure does not necessarily indicate operation. (8) Hematoma of the scalp overlapping fractures should be evacuated to prevent in- fection. (9) The spinal mercurial manometer is a valuable aid to determine the degree of intra- cranial pressure. In conclusion, we desire to state that we do not advocate spinal puncture as a cure-all, nor do we want to infer that we prefer the con- servative method of tapping the spinal canal instead of the operative method of opening the skull, but it is firmly believed that its more extensive use, in selected cases, will prevent the more serious complication of cerebral edema, which, if unrelieved, either results in death or permanent brain damage, with subse- quent residual symptoms, such as headaches, mental dulness, change in disposition and character, and a train of symptoms ascribed to neurosis. OCCUPATIONAL DERMATITIS* John E. Kiley, M.D., Newark, N. J. Injuries of the skin undoubtedly taxed the skill of the primitive medical man but the first authentic descriptions of industrial skin dis- eases were recorded by Italian physicians early in the sixteenth century. The chimney sweep’s cancer, grocer’s itch, washerwomen’s dermatitis, and the dermatoses peculiar to metal and salt workers, were described. The scope of occupational diseases has steadily grown with the development of industries and new chemical processes, to gain recognition by dermatologic clinics and organizations in- terested in industrial hygiene. Careful and methodic observations of indus- trial dermatoses were worked out by the *(Read before the Industrial Disease Institute, at the Academy of Medicine Building, Newark, March 3, 1931.) 614 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 19 31 Germans. Ulmann, Oppenheim, and Rille have made noteworthy contributions in the classification and description of these affec- tions. In this country, White of Boston, made extensive pioneer investigations of ivy poisoning, of the venenata group. The Ger- man, French, English and American investiga- tors have written much on all phases of occu- pational affections of the skin. Our state has been ably represented by Dr. Wallhauser, who was appointed by the Governor to the com- mission which defined the occupational dis- eases made compensable in New Jersey. Varying estimates of their incidence have been made by clinicians and public health work- ers ; the consensus of opinion grants that a high percentage of cases requiring industrial compensation is limited to trauma and inflam- mation of the skin. Conservative estimates, not including domestic workers, attribute more than 5% of admissions to the dermato- logic clinics to occupational origin. New in- dustries have a high incidence and suitable preventive measures become necessary. The manufacturers of lubricating compounds, lin- seed oils, insect powders, and anilin com- pounds had as high as 30% of employees in- volved before preventive measures were de- veloped. Trade specialization creates many problems, and the sensitized worker finds difficulty in adapting himself to another trade. Improved working conditions, suitable cloth- ing, and personal hygiene have been valuable preventive measures. Workmen’s compensa- tion legislation and industrial insurance firms have encouraged first aid measures to increase the efficiency of workers. The industrial sur- geon treats most occupational skin affections, and only those presenting special problems of diagnosis, prognosis, and therapy are re- ferred to the dermatologist, which places the latter in the role of medical expert and referee. I erminology for these conditions has un- dergone evolution from the early descriptions such as baker s itch and trade eczema. Occu- pational afiections with the qualifying terms determining industrial origin, allergic condi- tion, duration and distribution have found some usage in the descriptions of the in- flammatory types. The Germans described 3 classes : the toxicodermias, circumscribed occupational dermatitis, and occupational eczema. The toxicodermias are erythematous, edematous, or exudative inflammations of sud- den onset and considerable intensity, follow- ing minor irritations, with a tendency to pro- gress even after removal of the cause. There is idiosyncracy to a particular irritant and its occurrence is comparatively infrequent. The second group, circumscribed occupational der- matitis, usually develops in a skin that gives a normal reaction after prolonged or intensive exposure to a pronounced irritant, although it may be due to temporary hypersensitiveness or increase in strength and activity of the irritant. Occupational eczema is similar in onset to the second group and develops in a sensitized skin, spreads peripherally, and progresses even after removal of the irritant. This type suggests skin sensitization and is the more common of the 3 groups. After careful study there has been a general recognition that many irritants produce similar skin reactions, and that a single irritant may produce a multiformity of lesions. There are many clinicians in this country who advocate the term dermatitis in- dustrial is, qualified to determine the type of lesion and particular occupation, in order to give better classification of industrial affec- tions of the skin. Knowledge of physiology and biochemistry is essential to the interpretation of skin dis- eases. The skin is the largest organ of the body, usually calls attention to irritation bv itching, is highly resistant to chemical and physical agents, affords excellent insulation, and plays an important part in heat regulation. The skin is our chief protection against many diseases and is an important source of anti- bodies to combat infections which have gained entrance to the body. It is sensitive to dis- turbances of metabolism and alteration of normal body function, and investigation of skin sensitization and allergy threatens to give us a new specialty in medical practice. Inflammatory reactions occur when the threshold of tolerance is overcome by the in- tensity or prolonged application of irritants. Normal tolerance and adaptability protect the majority from industrial affections. Lowered threshold tolerance implies hypersensitivity and may be either local, inherent, or overcome August, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 615 by adaptation. Disturbances of circulation, visceral, nervous, and trophic changes, alter the local reactions. Jaddasohn recognizes a general susceptibility which renders the skin sensitive to all forms of irritation, and a special susceptibility which confines the sensi- tivity to a single irritant. Predisposing physi- ologic factors in local tissue reactions are more noticeable in youthful, senile, blond, and fe- male skin. Pathologic factors in sensitivitv are : excessively dry or abnormally moist skin ; previous injury; debility from disease; and repeated exposure to irritants. Dyes, soaps, acids, alkalies., and most inorganic compounds bring about inflammation and swelling by first removing or diluting the natural oils in the upper layer of the skin, then attacking the lin- ing cells of the follicles and pores. General predisposing factors are food allergies, ana- phylaxis, local infection, constitutional dis- orders, and unhygienic environment. Ichthy- osis, hvperidrosis, seborrhea, and various cu- taneous inflammations are predisposing con- ditions. The exciting causes are physical, chemical, occupational, and infectious agents. Under physical causes are : mechanical traction, pres- sure, friction, and thermal action which in- clude the effects of heat and cold ; also actinic and photo-electric changes produced by radium, Roentgen, violet, and sun rays. The chemical causes are : acids, alkalies, oil and coal tar products ; also many plant and wood extracts. Many organic, and most inorganic, compounds produce some irritating effect upon susceptible individuals. Occupational exciting causes have been carefully investi- gated among those employed as mulespinners in the knitting industry, and workers in shale oils, pitch, paraffin, tar, asphalt, arsenic, ani- lin oils and dyes, because of latent keratoses and cancers. The infectious agents are : parasitic, my- cotic, and bacterial organisms. The more common parasites are those of pediculosis, scabies, and grain itch. The bacterial and protozoan organisms are usually secondary in- vaders, where some mechanical or chemical agent has broken down the normal integument. Furunculosis is common among workers in oils, greases, paraffin, and especially cutting oils which become mixed with abrasive and in- fectious material. Erysipeloid is common in those engaged as commercial fishermen ; also those who handle meat and cheese products. Anthrax is encountered in those who handle imported hides, furs, and bristles. Blastomy- cosis and actinomycosis are confined mostly to farmers. Mycotic finger-nail infections and dermatitis are recognized diseases in fruit pickers and canners. Syphilis constitutes a menace to dentists, physicians, and railway employees. Pathology. The pathologic changes in the skin are not specific, and great variation in effect of the same irritant in different indi- viduals is recognized. The reaction may be slowly cumulative, as recognized in x-ray irri- tation, and tar keratoses and cancers. Irri- tants in the form of dust or vapor produce more rapid effects than liquids and solids. Alteration in strength and composition of material often precipitates an attack. The dermatoses are generally localized to the area of exposure, usually the hands, face, and neck. In toxic inflammations, the extensor surfaces of the extremities, face, neck, genitalia, and areas of opposing skin become involved. Oc- cupational affections exhibit the primary and secondary lesions characteristic of nonoccu- pational diseases, and differentiation is often difficult. The toxic reactions from mercury, phenol, arsenic, turpentine, and satinwood are often scarlitiniform. Etherial and balsamic oils, such as copaiba, produce measles-like lesions. Retifonn and pellagra-like eruptions have been noted in those who handle dinitro- benzenes and explosive compounds. Acute, diffuse erythema and purpuric lesions may re- sult from the absorption of quinin, chromium salts, benzene, and have been observed in cais- son disease. Most occupations leave their trademarks on the skin. Diagnosis. In attempting a diagnosis, the localization, character of the skin, and asso- ciated history must be carefully considered. The eczematoid and venenata groups give the most difficulty ; the predisposing factor must be sought. In cases of dermatitis involving the hands and face, lie on the alert constantly for industrial causes. The interpretation re- quires careful search for local patches of 616 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 19 31 seborrhea irritated by excessive perspiration and faulty hygiene. If latent seborrheic der- matitis becomes aggravated by chemicals or irritants peculiar to the occupation, compen- sation should be allowed for the limited period of exacerbation. According to legal interpre- tation, compensation is not dependent on an implied assumption of perfect health, and does not exclude the weak, physically unfortunate, or those with latent or unknown tendencies to disease. Mycotic conditions of the hands and feet, and syphilitic lesions superimposed on traumatized areas produce perplexing prob- lems of economic importance. A thorough knowledge of differential diagnosis is import- ant ; the responsibility placed on the physician necessitates the most careful study of all facts pertaining to the condition, and exhibition of sound common sense in arriving at conclu- sions. The physician should not attempt a medicolegal analysis, nor should he indulge in hypothetic speculations. Malingering is of special importance, and self-inflicted lesions must be suspected in cases of prolonged dura- tion ; most of these have their origin in bona fide dermatoses, and healing is prolonged to gain an increase of compensation. Prevention and treatment. A patient suffer- ing from an industrial skin affection, or one suspected of being such, should be carefully investigated and reported. Dermatoses are en- countered in all trades. The clinical data must be carefully checked, for many occupational dermatoses are accepted as ordinary skin dis- eases, since they do not present unusual mani- festations. Some are of short duration, others simulate dermatoses of long standing, and many appear as burns, boils, or other common skin lesions. Some immediate name is given to the condition, and the possibility of an occupational affection is overlooked in the rush of the clinic, or a sketchy, imcomplete record is made, especially when the patient cannot speak English. There should be more exact analysis of the trade and hygienic en- vironment. It is not enough to know that a man is a printer, tanner, or rubber worker; one must find the irritating agents which he handles and their effects on the skin. Study of the processes of vulcanizing, printing, dy- ing, plating, and other trades have been of in- estimable value in the proper management of preventive measures. Tradesmen in the printing and rubber industries have been care- fully investigated, and precautionary meas- ures have greatly reduced the number of cases of chromium, anilin, and hexamethylenamin irritation. Careful hygiene in cleansing the skin, and care of work clothes have been effective in those handling stains, dyes, and oil products. Allergic tests select those who have been sensi- tized to a particular drug, chemical, or food product ; oftentimes the individual is sensi- tized to a group of protein compounds. In a recent series of cases of occupational derma- titis, allergic tests in IS gave the etiologic ma- terial, and the 3 others showed exacerbation of symptoms on application of the specific irritant. All cleared up when the specific sub- stance was avoided. Preventive measures should be directed by experts familiar with factory technic, working conditions, material, and medical administration. Routine medical inspection should detect those subject to ex- cessive perspiration, seborrhea and active cu- taneous diseases, and direct them to suitable work with advice to use bland protective measures, and to avoid the use of turpentine, gasoline, and alkaline soaps as cleansing agents. The first treatment is important and as- sumes correct diagnosis of the lesions. The strong ointments and antiseptics often used as first aid measures are important factors in intensification, extension, and prolongation of the affection. For acute and nonmalignant processes, fomentations are in order, followed later by bland dusting powders or boric acid ointment. Erythema and Assuring may be treated with calamine in limewater and olive oil. Cleanliness and bed rest are important, and in handling the sequels look for factitial irritation. Should shagreen skin or licheni- fication be noted, x-ray treatment will be valuable. An old employee recovering from a dermatitis should be placed at other work sufficiently long to permit the disappearance of heightened susceptibility to irritation. The last vestiges of active dermatitis should be cured before discharge. August, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 617 A few suggestions for those encountering irritants are : (1) Emollients before and after work. (2) Complete removal of the irritant en- countered at work by harmless methods sev- eral times per shift. (3) Inspection of hands and arms by ex- perienced observer to enforce: (a) Early treatment of cuts and burns, (b) Scrupulous cleanliness of the finger-nails, hands, arms, and overalls, (c) Removal from irritants, and prompt treatment of early lesions. Summary More accurate classification and recognition of occupational affections of the skin is desirable. Industrial clinics will do much for the iden- tification, suitable management, and preven- tion of these affections. The subject of industrial diseases is being given increased attention, and the dermatolo- gist, because of his training, takes an import- ant part in the development of this field of medicine. PREVENTION OF MEASLES IN PRIVATE PRACTICE* George Heller, M.D., Englewood, N. J. It has been proved that measles may be 'either prevented or modified by the use of serum or whole-blood from a convalescent person, and to a less certain extent by the in- jection of serum or whole-blood from a per- son who has at any time had the disease. The specific prophylaxis is yet unproved. Most reports concerning measles prevention have issued from institutions in which facilities ex- isted for study that do not exist in private practice. It is for this reason that I wish to ■demonstrate that the prophylaxis (that is, the prevention or modification) of the disease may be expeditiously carried out on the out- side, with no especial difficulty in the use of *(Read before the Bergen County Medical So- ciety, Dec. 9, 1930.) equipment, with no great expense to the physi- cian or to the patient, and with a minimal amount of danger. It may be argued by some that the disease is of no consequence, and may be disregarded ; that the disease is bound to be contracted at some time during life, and may as well be contracted during the pre-school years as at any time. To this argument I can oppose a few telling statistics : ( 1 ) Measles in this country is responsible for a little less than 1% of all mortality. (2) Of measles mortality 90% occurs under the age of 10 (that is to be expected, because the greater number of cases occur during those years), but 70% of all measles deaths occur under the age of 3, although measles morbidity is higher above the age of 3 that under that age. (3) There is a mortality under the age of 2, affecting in many epidemics over 10% of cases. I doubt that it is generally appreciated that measles in children under 5 years accounts for more than 5 times as many deaths as scarlet fever; almost % as many as diphtheria; and 2/3 as many as pertussis; the 2 latter diseases being notoriously severe in the very young. It is also accepted, though I have no figures to support the premise, that measles is dan- gerous in children with tuberculosis (active or incipient) and in those children who have fre- quent attacks of bronchitis. The method of prevention that I have em- ployed uniformly in these cases, is simply the injection of blood from an adult, who has had measles, into the muscle of the exposed child. In the majority of cases I have used the par- ent, and have therefore contented myself with assurance regarding recent acute infection and syphilis ; I have not taken routine Wasser- mann tests. Compatability of blood is not essential. I have noted no immediate febrile response to the injection. The necessary equipment can be carried in a small bag : A 20 c.c. Luer syringe and a 20 gauge venapuncture needle, sterile in a sterile towel ; 1 bottle of iodin ; 1 bottle of alcohol ; a single swab ; package of sterile gauze squares ; tourniquet ; and adhesive. The donor sits or lies adjacent to a chair 618 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 1931 where another individual holds the child prone on her lap, right hand on the nape of the child’s neck, and left arm about the bend of the child’s knees. The donor’s cubital space produces a turgor of the overlying skin in small children, but they sit down and run about with no apparent discomfort in less than 5 minutes. and the child’ s buttock are swabbed with In 2 cases I have seen a swelling with all iodin. Then, about 2 5 c.c. of blood are with- the signs of acute inflammation, together with drawn and quickly injected deeply into the elevation of temperature, occurring on the child's buttock The needle is then with- tenth day, but in each case the swelling and TABLE No. 1 No. Name Age Exposure Temperature Rash Illness Complication Remarks l. D.B. 3 House -t- + + 0 0 0 2. R.Z. 10 mo. House 0 0 0 0 0 3. A.S. House 0? + -+- 0 0 4. M.O. l House 0 0 0 0 0 (2) 5. B.S. 2 House 0 0 0 0 0 6. J.V. L House 0 0 0 0 0 7. C.P. L House 0 0 0 0 0 8. R.H. 2 House 0 + 0 0 0 9. J.F. House 0 0 0 0 0 (2) 10. D.E. 1 House 102 + + + + 0 0 others q-uite ill 11. J.F. House 0 0 0 0 0 12. H.E. 1 House 0 0 0 0 contact contracted measles Number of cases. 12; prevented, 7 (58%); modified, 5 (42%). TABLE No. 2 No. Name Age Exposure Temp. Rash Illness Complication Remarks 1. A.W. 5 Play 0 0 0 0 0 2. M.W. 5 House 103 V2 T + + + + + + ■ 0 0 3. M.B. 7? House 0 0 0 0 Unprotected sibling also well 4. E.L. 6 Play 0 0 0 0 r, M.R. 4% House 102 ++ + -)- 0 0 6. A.R. 6 House 102 ++ _1_ _L 0 0 7. M.R. 10 House 103 y2 +-K+ + + + 0 0 8. F.R. 6 House 104 + +Jr+ + + + 0 Local reaction. 9. S.R. 11 House 0 0 0 Measles from 2nd ex- posure TABLE No. 3 No. Name Age Exposure Temp. Rash Illness Compl ication Remarks 1. J.P. 10 mo. ? maid 0 0 0 0 0 4- + 2. M.G. 19 mo. Visited 0 0 0 0 0 T Visited 0 0 0 0 0 3. N.W. iy2 + + Visited 0 0 0 0 Local reaction 4. D.S. 3 -4— (Kissed) 5. D.H. 3 Visited 0 0 0 0 0 + 6. C.D. 7 mo. Visited 0 0 0 0 0 drawn and the buttock massaged. The whole operation consumes less than 1 minute. There is no necessity for a change of needles, nor for citration of the blood. The operation is not essentially painful ; older children who have in no way been restrained have winced, but have not cried, and described the injection as hurting comparatively little. The injection all symptoms subsided completely in 24 hours. I have chosen to accept this phenomenon as an unusual serum reaction rather than the result of the introduction of microorganisms. Before presenting the tabulation of results, it is only fair to explain that the epidemic, during the course of which this study was made, was of secondary magnitude, having August, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 619 about 2/5 the incidence of that in 1926, and the severity of the cases was minimal. There was no death reported in Englewood or Tena- fly, and I and others to whom I have spoken observed very few complications, none serious. The total number of children injected was 27 and I have arbitrarily tabulated them in 3 divisions: (1) Very young children with maximum exposure. (2) Older children. (3) Very young children, exposure doubtful. I have attempted to make these tables suffi- ciently complete to preclude the necessity for detailed explanation of their content. I have not noted the day of exposure because in every case the rash had appeared in the indi- vidual to whom they were exposed and in no case did I inject after the fifth day of ex- posure (accepting the invasion period arbi- trarily as 3 days.) On the whole, I am better satisfied with a case of modified measles than with absolute prevention. I do, however, feel that post- ponement of the disease to a later time, when the infant's fraility has been superseded by the robustness of the older child, is a worth- while accomplishment. I do not feel that the results described in table number 2 have any positive meaning re- garding the value of the procedure in older children, but I feel that table number 1, even with its relatively small number of cases, shows a very great preventive value of the injection. Table number 3 has very little scientific worth because of the problematic exchange of virus, but the failure to contract the disease after known exposure sufficient to prompt several of the parents to request in- oculation. is rather unusual unless one accepts the fact that the blood helped them to escape infection. In passing, it should be pointed out that the parents in every instance were glad to co- operate with us, after the rationale of the procedure had been explained, and several anticipated the suggestion by themselves re- questing the inoculation. Conclusion (1) Measles prophylaxis is a sufficiently simple and safe procedure to be carried out in the home. (2) The use of whole-blood from an adult who has at any time had the disease is effec- tive in very young children, no failure either to modify or to prevent the disease having been noted in this series of cases. (3) I feel that the use of whole-blood or serum from an adult is indicated in cases of known exposure if the child is under 4 years of age, or, if older, it has any constitu- tional weakness, such as bronchitis or tuber- culosis, provided the procedure can be car- ried out sufficiently early in the period of in- cubation. THROMBOSIS AND EMBOLISM* Frederic W. Bancroft, M.D., New York City Thrombosis and embolism have become relatively more important in the surgical world as the improvement in technic has di- minished many other types of complication. The sudden exodus of a patient 5 to 15 days after operation, often occurring as prepara- tion is being made to leave the hospital, is a surgical calamity of inestimable moment. Strangely enough little has been done to dis- cover the cause and thereby diminish the in- cidence of thrombosis and embolism. Various clinics have made statistical reports, and we know the incidence is higher in certain ab- dominal operations than elsewhere. It is generally accepted that trauma, infec- tion, slowing of the blood stream and in- creased dehydration of the blood are factors in producing thrombosis ; nevertheless, some patients develop thrombosis with a minimum number of the above factors, while others with a maximum number remain unscathed. For this reason we decided to study, at the Fifth Avenue Hospital, the blood clotting factors of all patients admitted to the surgical service. Studies of the prothrombin, fibrinogen and antithrombin content, with the resultant de- termination of the clotting index, will be given in a later part of this article. We believe, *(Read at the Bergen County Medical Society Meeting March 10, 1931.) 620 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 1931 from this study, that we may prognosticate in the case of the patient who is apt to develop thrombosis, and we believe that certain thera- peutic agents may be administered that will decrease the incidence. Physiochemical studies reveal that blood plasma, so long as its constituents are not dissociated by extraneous forces, is a single complex in equilibrium, rather than a mix- ture of substances. The initial views of Har- vey (1633) and of Woodbridge (1886) have come again into their own — “blood plasma is protoplasm and clotting is the last act of liv- ing blood”. When blood is shed the plasma dissociates into substances which yield a clot. During the latent period of dissociation antithrombin is precipitated and prothrombin is activated by calcium ions. The resulting thrombin gels soluble fibrinogen into insoluble fibrin. Factors Producing Clotting in the Blood Stream Having reviewed the accepted mechanism of normal clotting, we must now consider what happens in normal conditions, and why, in diseases and trauma, we find spontaneous clotting in the blood stream. The 3 factors most commonly recognized as producing spon- taneous blood clotting are: (1) changes in character of the blood; (2) changes in the rate of blood flow; and (3) changes in the vessel walls. It has long been recognized that a clot can be started by throwing out to the periphery the blood platelets when the circulation is slowed down. As these blood platelets clump along some portion of the vessel walls there takes place a coagulation, forming a red clot around the nucleus of platelets. The great question which comes up is whether this for- mation of clot can take place with only a slowing of the circulation or trauma, or whether there must be first a change in the blood-clotting elements of the blood. Some writers feel that mild damage to the liver stimulates fibrinogen formation. Others think it is an interaction of the liver and the ad- renals. One of the most interesting pieces of work in this field was done by C. A. Mills and is concerned with the effect of diet on clotting and basal metabolism. He showed that a carbohydrate and fat diet will raise the basal metabolism but will not increase clotting, while a protein diet not only raises basal metabolism but definitely increases the blood- clotting elements, and attributes this to some unknown factor connected possibly with the amino-acids derived from protein meta- bolism. In order not to go too far afield, and to limit the subject so as it may be discussed in the time allowed, this paper will be limited to postoperative thrombosis and thrombophle- bitis, and to embolism which occurs therefrom. An embolus, as you know, is a blood-clot or other body carried by the blood-current and obstructing circulation at point of lodgment. Obviously, it would be out of place to discuss tumor, air and foreign body embolism. The problem of fat embolism, which may be a considerable factor in postoperative compli- cations as well as in fractures, is too large and complex a subject to attempt to discuss at this time. Adami describes the difference between postmortem clotting and thrombosis as fol- lows: Postmortem dotting. (1) There is no injury to the vein wall; the clot may be easily picked out; it is moist. (2) There is no or- ganization or lamination of the clotting, i.e., the blood is coagulated en masse. It may have 2 layers, a pale outer and a dark inner mass. Thrombosis. (1) The thrombus is attached to the vein wall, with microscopic evidence of injury to the intima. (2) It is dry and friable. (3) There is a definite arrangement of the contained cells. There are several types of thrombi : (a) A blood platelet thrombus, white in gross appearance, and showing, on micro- scopic examination, a great mass of platelets, (b) Hyaline thrombus, due to conglutination of erythrocytes ; on microscopic examination numerous shadows of erythrocytes may be seen, (c) Fibrin thrombus is usually small and microscopic examination shows pure fibrin in laminated arrangement, (d) White thrombus is quite common and microscopic examination shows infiltration with leukocytes, (e) Red thrombus, which somewhat grossly resembles a postpartum clot but on micro- scopic examination shows fibrin and red blood August, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 621 cells in a laminated arrangement, and it has more white blood cells and platelets than a postmortem clot. Thrombophlebitis is more commonly asso- ciated with direct injury to the vein wall and is primarily an infection of the vein with a secondary thrombosis. On microscopic ex- amination the entire vein may be infiltrated with leukocytes and in extreme cases there may be periphlebitis which may become sup- purative. Clinically, one observes 3 main types of thrombophlebitis: (1) An acute, fulminating phlebitis, associated with chills, high temper- ature, redness and tenderness along the course of the vein, with swelling of the limb. The thrombus may break down and numerous sup- purative emboli be distributed throughout the body. In such cases there is evidence of a bacteriemia and there may be septic foci in almost any organ. (2) Acute thrombophlebitis associated with a moderate elevation of tem- perature, swelling of the limb, and pain. Fever may persist for 5 to 15 days. As these cases are usually observed early and precautions taken, embolism is not frequent. A clot in the vessel wall may become organized and the lumen entirely occluded. Return circulation of the leg is usually accomplished by either compensatory dilation of the superficial veins or a canalization of the thrombus and subse- quent reestablishment of blood supply through the affected vein. The present day furore of obliterating varicose veins makes it impera- tive to examine every patient coming for in- jection treatment to rule out the possibility of a previous thrombophlebitis. If the com- pensatorily dilated superficial veins are oc- cluded the leg will again become swollen and remain so until a second collateral circulation can be established. Let me cite an incident : A boy of 19 was operated on, by another sur- geon, for a loose internal semilunar cartilage of the knee. His postoperative course was uneventful, and he left the hospital at the end of 2 weeks. At the end of 6 months he came to me complaining of varicose veins in this extremity. On reviewing his chart I found that he had run a slightly higher postoperative temperature than normal. In one of the nurse’s notes was the statement that he complained of pain in his leg. The postoperative surgical notes made no statement about swelling or pain. There was evidence, when I saw him, of enlarged anastomotic veins extending from below Poupart’s ligament upward on to the abdomen. I advised the patient not to have ■any operation for the enlarged veins. He was dissatisfied and went to another hospital where his veins were operated upon. I saw him 2 months after his discharge from that hospital, with leg swollen, cold and white, and he was suffering considerable pain. We must assume that this patient had a silent thrombo- phlebitis following his first operation. The later appearance of varicosities on his legs was a compensatory act of nature to return the blood through the superficial veins, as the deep ones were occluded. At his second operation the compensatory veins were re- moved and, as a result, he had a cold, swollen, edematous leg. (3) Silent thrombosis. It is probable that there is very little thrombophlebitis associated with silent thrombosis. It is this type, run- ning a relatively normal postoperative tem- perature, having a sudden massive embolus occluding large vessels, with resulting death, that is the most distressing to the surgeon, to the family and the public at large. It is with particular reference to this type that we have attempted, at the Fifth Avenue Hospital, to study the blood-clotting factors involved. It would seem advisable at this time to enter into a philosophic discussion of the causes of postoperative thrombosis and thrombo- phlebitis. Analytic reports from surgical clinics tend to show that these conditions are more prevalent following -operations upon the lower abdomen and in fat people, and rarely do they occur following operations on the brain and skull. One may ask why this should fie, for many veins must be traumatized in skull operations. I venture to suggest the following factors concerned in their etiology: (1) Where the surgical approach has been through the abdominal wall there is constant motion in the field of repair during the first 48 hours ; in operations on the skull, with the rigid skull cap, the field is kept at rest. With every breath taken, and with the usual post- operative nausea and vomiting, there is a con- 622 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 19 31 stant thrust and pull on the operative field, which might easily dislodge an embolus or cause an extension of a small thrombus down- ward into a larger vein. (2) Approach for an abdominal operation is through an area of subcutaneous fat, while in skull operations there is a relatively small amount of fat. With the insertion of sutures, often under too great tension, and with the application of a tight abdominal dressing, necrosis of the trauma- tized fat may result. Experimentally, we have found in dogs that if fat is taken from the subcutaneous tissues or the omentum and ground up with a small amount of saline in a mortar, the resultant fluid contains approxi- mately 2-4% fat. When this emulsion is in- jected intravenously a marked rise in the blood-clotting index is produced. (3) Since Welch’s classical discussion of thrombosis and embolism, in Allbutt’s System of Medi- cine, almost all pathologists and surgeons have accounted slowing of the blood stream as one of the primary factors in production of thrombosis. It has been shown that throm- bosis rarely occurs in arteries because the cir- culation of the blood is too rapid. Experi- ments have been performed, inserting forma- lin-prepared arterial segments in arterial de- fects, without subsequent thrombus forma- tion. Pathologic specimens of aneurysms have shown that thrombosis occurs in the portion where there are eddies ; but where a dissect- ing aneurysm has allowed a rapid flow of blood, thrombosis 'has not occurred. Following abdominal operations it has been an almost universal practice to apply tight surgical dressings. The distension which usually fol- lows in 24 hours causes a marked increase in intraabdominal pressure. If we consider that the return flow of blood in the vena cava is largely due to heart suction and respiratory movements, this increased abdominal pressure and splinting of the diaphragm must cause considerable stasis in the veins of the lower extremities. Moreover, with the almost uni- versal use of the Gatch bed in the Fowler position we have the double factors of gravity and constriction in the region of Poupart’s ligament, increased by flexion of the thighs and by the lower border of the tight dress- ings. (4) Infection or the presence of bac- teria or their by-products iu the blood stream is generally advanced as another contributing factor. These complications may occur where, to all apparent gross observation, the opera- tive wound is healed per printum. We know that bacteria enter the blood stream through the intestinal walls. With postoperative dis- tension and slowing down of peristalsis, the bacterial flora of the intestinal canal must multiply to a marked degree. Moreover, it would seem probable that, with the thinning out of the intestinal wall due to distension, more bacteria might enter the blood stream. (5) Dehydration, with resultant increased viscosity of the blood, is another factor men- tioned in etiology of thrombosis. It is hard to estimate in the first 48 hours postoperative the increase of fluid output over intake. With preoperative purgation, increased sweating due to postoperative elevation of temperature, vomiting and urination, the fluid output is tremendously increased ; at the same time the intake of fluids is markedly diminished. If a patient is vomiting, the oral method of intake is almost impossible. Blood-clotting factors. In the beginning of our study we were impressed with the fact that some patients with a minimum number of the known predisposing causes had throm- bosis occur, while others with a maximum number escaped. For instance, a woman aged 38 years, after resting her arm on a desk for 4 hours while collecting tickets at a moving picture theater, developed phlebitis of the basilic vein of the arm. As a contrast, we could cite numerous cases of war injury where there was infection, vascular injury and slow- ing of the blood stream without resultant thrombosis. This striking contrast convinced us there might be something in the blood-clot- ting factors inherent in an individual that would be an unknown agent in the production of thrombosis. We decided, therefore, to study the clotting factors of each patient ad- mitted to the stafif service of the Fifth A. venue Hospital. At the beginning we analyzed the antithrombin index, the prothrombin index, fibrinogen, platelet count and the rate of plate- let dissociation. As the platelet count is greatly influenced by chronic infection, we have recently discarded the platelet count and August. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 623 dissociation rate. As prothrombin and fibrin- ogen hasten coagulation and antithrombin re- tards coagulation, a blood-clotting index has been formed of which prothrombin and fibrinogen are the numerators and antithrom- bin the denominator. The detailed descrip- tion of the tests has been published in an article bv Bancroft, Stanley-Brown and Kugelmass, in the Annals of Surgery for August 1929. It would seem inadvisable to take up these details at the present time. As the normal prothrombin is 0.1, fibrinogen 0.5 and antithrombin 0.1. the index then becomes 0.5 ± 0.2. Blood examinations have been made post- operatively and, at first, 3 and 5 days later. Lately, the postoperative examinations have been changed to 5 and 9 days. The blood of 965 patients has been examined. Not all of these, however, had preoperative determina- tions, as some of the patients were refer- red from the medical clinics and, also, some examinations hai^e been made elsewhere on patients suffering from fully developed phle- bitis. We have considered any patient with a blood-clotting index of over 0.9 as having a clotting tendency. In all, we have studied 25 patients who have had clearly demonstrable thrombosis, thrombophlebitis or embolism, and with 2 exceptions . these have had high clotting indices. About 20% of all the pa- tients examined have had high clotting in- dices but have not developed an obvious thrombosis. Nevertheless, almost without ex- ception these patients have run a rather high postoperative temperature. For instance, a hernia patient occasionally would run a tem- perature ranging from 99° to 100 J for 12 to 14 days without obvious wound infection or evidence of external phlebitis. Hysterectomies or gangrenous gall-bladders tend to have high indices, and we have felt that they probably had a concealed thrombosis or thrombophle- bitis and came into the potentially thrombosis class, but we have not considered them, in our analysis, as such. Technic of tests. By venapuncture 9 c.c. of blood is taken and put into 1 c.c. of 1% sodium oxalate. The specimen is centrifuged and the plasma removed. Tests are then made on the plasma for prothrombin, fibrinogen and antithrombin. About 40 minutes is required to do a complete test if the platelet count is made and platelet disintegration time noted, but four tests can be done in 1% hours. We have been able to prove experimentally on animals and humans that there is only a slight postoperative rise in the blood-clotting factors in uncomplicated surgical procedures; but if a gangrenous process with thrombosis associated therewith is produced, the clotting factors rise. We have had 3 patients with high clotting- factors, either before operation or shortly af- terward, who have developed either throm- bosis or embolism. Allow me to cite 2 illus- trative cases : Case 1. A patient admitted for gall-bladder disease. She had high clotting factors on ad- mission. Because she had not seemed to us to be a satisfactory risk, operation was not considered and the patient left the hospital. She later returned, on the medical side, with symptoms suggesting pellagra and was placed on a high protein diet. A month later she was admitted to the hospital with a bilateral femoral phlebitis. Case 2. A patient was operated upon for cholelithiasis and benign polyps of the stom- ach. The operation of cholecystectomy and gastrotomv for removal of 2 benign polyps in the pyloric end of the stomach was performed. On her fifth postoperative day, when tempera- ture was practically normal and convalescence apparently satisfactory, she had a high clot- ting index. On the night of the sixth day she got out of bed, fell and struck her right arm. The following morning there was definite evidence of an embolus in the right brachial artery. An embolectomy was per- formed and the blood flow apparently re- established, but the patient died from shock, the following evening. The chemical nature of the clotting com- ponents has been established, as lipins for the platelets originating in the bone-marrow, and globulins for the prothrohibin and fibrinogen synthesized in liver. Lipins and globulins are the source of the blood-clotting substances, initially arising from the daily dietary. This nutritional basis for the composition of blood in clotting substances led me to a dietary treat- 624 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 10 31 ment for certain hemorrhagic diseases. In our animal experiments it had been shown that an acid diet with high nucleoprotein con- tent will increase the clotting factors of the blood, while a basic diet omitting as far as possible proteins and fats will diminish the clotting factors. We have also been able to demonstrate this clinically on human patients. We feel that this experimental work on the blood clotting factors is still in a very in- definite state. The tests for prothrombin, anti- thrombin and fibrinogen are complex and are not practicable for routine examinations in a general hospital. It is our hope that we may be able to simplify this procedure for adapta- tion as a routine test even by a relatively un- skilled technician. Trfa.tmf.nt If we base our treatment upon our theoretic concepts of the etiology of thrombosis and thrombophlebitis, the following suggestions can be offered for consideration : ( 1 ) In abdominal cases every effort should be made to reduce the postoperative nausea and vomiting in order to keep the field of operation quiet. In peritonitis, and in high upper abdominal cases, the Levin tube insert- ed through the nostril immediately after the patient has regained consciousness greatly re- duces vomiting. (2) The approach for an abdominal oper- ation is usually through a layer of sub- cutaneous fat. Experimentally, we have found that emulsified fat increases markedly the blood clotting factors. Care should therefore be taken to avoid traumatizing the fat by over- zealous pulling of the retractors. Tension sutures should be loosely tied, because the secondary edema following operative trauma rapidly increases tension. Irrigation of the fat with ether before closure would seem ad- visable in order to dissolve out the free fat particles. (3) Pool, in 1913, published an article on "Systematic Exercises in Postoperative Treat- ment”, in which he illustrated the type of ex- ercises to be used, and recommended that treatment be started on the third postopera- tive day. The motion of the arms and legs would in no way interfere with healing of the wound, and would tend to improve circulation. In our opinion, tight abdominal dressings should be eliminated. G. W. and Kingsley Roberts, of the Fifth Avenue Hospital staff, for years have not used any abdominal dress- ings and have concealed their wounds with court plaster strips. Their incidence of evis- ceration or infection has not been greater than when tight dressings are used. It is our cus- tom to apply sufficient gauze to cover the in- cision and to hold it in place with merely enough adhesive plaster to prevent its mov- ing. No attempt is made to apply pressure, and no abdominal binders are used. During the 3 years this procedure has been followed there has been only 1 case of wound eviscera- tion, which was due, I believe, to other causes. The patients are infinitely more comfortable and their upper abdominal distension is cer- tainly less. It has been our custom on the first day postoperative to inspect all dressings, and any that feel the least bit tight are loosen- ed so that the patient is made comfortable. Even with dressings applied loosely at the time of operation one is often surprised to see an expansion of at least an inch after cutting the adhesive the first day postoper- ative. We believe that distension is lessened if food is given early. Theoretically, it is logi- cal to assume that if no food is present in the intestinal tract there is no stimulus for peris- talsis, and fermentation will take place. If a bolus of food enters the intestine there is stimulus for peristalsis, which will carry with it gas as well as solid material. In uncompli- cated cases, after spinal, ethylene or gas an- esthesia, the patient is routinely given tea and toast the afternoon following the morning operation. (4) Fortunately, in most clinics, the giving of active catharsis the night before operation is now omitted from preoperative preparation. Active catharsis, which tends to dehydrate a patient and make the night before operation uncomfortable with cramps, is unnecessary. A mild catharsis given 2 nights before opera- tion. and an enema the evening and morning before are sufficient to allow almost any oper- ative procedure in the abdomen. The routine August. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 625 administration of fluids, either by intravenous or subcutaneous methods, will aid toward diminishing postoperative dehydration. Some authors have suggested that intravenous ad- ministration of glucose might be one cause of increased incidence of thrombosis. Experi- mentally we have been unable to find any in- creased clotting factors after glucose admin- istration. (5) From our studies of the clinical cases and of the blood clotting factors, we have come to believe there are 2 types of throm- bosis of the lower extremities : (a) The more or less silent type, with slight elevation of temperature, but associated with swelling of the leg and definite venous obstruction, (b) The septic type, associated with high fever, frequently bacteriemia, and infection as the predominant characteristic. Arbitrarily, we have attempted to treat each type as a separate entity ; with thrombosis as the predominant factor, treatment has been by sodium thiosul- phate. Although a nonprotein diet is successful in reducing a high clotting index, it cannot be depended upon in postoperative cases, for it is in this group that a quick reaction is often needed to prevent an accident. We therefore began to look for some drug which, given in- travenously, would rapidly reduce the index, especially in the group in which the prothrom- bin was high and the antithrombin low. Sodium citrate was naturally considered, as it is such a well-known agent for keeping blood fluid. Our results were good, but large amounts were required and unless great care was used in buffering the solutions bad re- actions were frequent. At the suggestion of Dr. Lieb, we tried sodium thiosulphate. They had used this in large doses on animals when they wanted to prevent clotting in extracor- poreal tests on the circulation. We found that it was necessary to give only 10 c.c. of 10% solution, and repeat the dose in 24 hours, to obtain the desired effect. Larger amounts can be given safely but are not needed. We have used it now on 15 cases, 6 of which had some form of phlebitis or thrombosis, and 9 re- ceived prophylactic doses because the index was found high following operation. In all but 1 of these cases the index dropped; the main effect being to lower the prothrombin and raise the antithrombin. In the case which did not respond, the prothrombin was normal and only the fibrinogen high. The chemical action is not known, but it is probably due to the sulphate combining with the ionizable cal- cium and preventing its action with the pro- thrombin. This, however, is purely theoretic. The following case illustrates the way it acts on a postoperative phlebitis : Mary Boylan, suffering from fracture of the femur, develop- ed a pulmonary infarction ; following this a phlebitis of her right leg ; then a second pul- monary infarction and a recurrence of phle- bitis in her leg. With the onset of a third attack of phlebitis, this time in the left leg, we were called in to see her. At that time her index was 1.1; prothrombin 1.38; fibrinogen 1.04, and antithrombin 1. We started her on small doses of sodium thiosulphate. After daily doses for 4 days her temperature, which had been running around 101° and 102°, was down to 99° and 100°, the pain had left the leg, and her index was 0.84 ; prothrombin 0.93; fibrinogen 0.94; antithrombin 1. As this had been an extreme case we continued the sodium thiosulphate every other day for the next 2 weeks. The index stayed normal and the patient had no further return of symp- toms. In all cases where the solution was used as a prophylactic measure the index dropped. In all these cases where the prothrombin was 1.38 it was brought down to 1. The fibrino- gen was not lowered consistently. In cases with thrombophlebitis the pre- dominant factor, following the report of Shellenberger, in a paper read before the Southern Surgical Association in 1924, we have used the intravenous injection of gentian violet 0.5% solution. The gentian violet crys- tals are dissolved in sterile, freshly-distilled water, the solution filtered and injected. The maximum dose is 5 mgm. per kilo of body weight. It has been our custom to inject 50 626 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 19 31 c.c. and repeat the dose alternate days for 2 or 3 doses, and we have been impressed by the satisfactory results obtained. Chills have occurred in 1 or 2 cases, but of small moment. Relief from pain has usually occurred follow- ing the first injection and we have noted in 2 cases a decrease in the circumference of the leg of 1 to 2 inches in 3 to 4 days. One pa- tient. who had a severe infection 20 days postoperative, had an evening temperature of 103' for 4 days before the injection. She was given 46 c.c. of 0.5% solution. At that time her thigb measured 24 and her calf 1 1 in. That night her temperature went to only 100.8 and from there on returned steadily to normal. The second dose of 50 c.c. was given 5 days later. In 4 days after the first injection the thigh had decreased 2Tj in. and the calf 1 in., and they were of normal consist- ency and color. Two months after the operation there was no evident swelling of the leg. We feel that in the septic type of thrombophlebitis gentian violet is a therapeutic agent of con- siderable value. During the 3 years we have used the above mentioned prophylactic meas- ures we have not had a sudden death from embolism. Walters, of the Majo Clinic, has advised the routine postoperative use of thy- roid extract to prevent thrombosis and em- bolism. His results in the series published are very encouraging: We have not had suffi- cient experience with this method to form any opinion of its value. Conclusions (1) The application of surgical principles, such as the avoidance of trauma, the obliter- ation of dead spaces, and the prevention of postoperative anemia cf wounds, should re- duce the incidence of infection. (2) Experimental work on the blood-clot- ting factors associated with thrombosis and thrombophlebitis suggests that there may be inherent in an individual a predisposing ten- dency in addition to the generally accepted factors of infection, slowing of the blood stream, trauma and dehydration. This work is in its infancy and is suggested as a possible prophylactic solution of a surgical calamity. STATISTICAL STUDY OF DIPHTHE- RIA IN NEWARK, WITH SPECIAL REFERENCE TO CASES OC- CURRING AFTER SCHICK TEST OR TOXIN-ANTI- TOXIN IMMUNIZATION Joseph William Gardam, M.D., Director, Communicable Disease Division of Health Department Newark, N. J. Many of my medical friends have asked from time to time why diphtheria cases in- creased during 1929 and spring of 1930, and why diphtheria occurred following Schick- test and toxin-antitoxin immunization. Be- cause these questions have arisen so repeatedly and the interest in the subject seemed so gen- eral, I felt that I should endeavor to answer the question to some degree. If you saw the survey of epidemic diseases published in the American Medical Associa- tion Journal, June 1930, you no doubt realize that Newark holds the unenviable position of lowest in the list of cities rating 100,000 or more in population for the year 1929. this rat- ing being based on disease incidence. Like ev- erything else, there’s a reason ; Newark’s figure is a true one and that is more than can be said for many of the other cities listed. For some years back the advertising campaign of the Health Department has stressed the culture idea. As a result, most doctors culture every throat showing any congestion, patch or ton- sillar exudate, no matter how slight. It is surprising the number of cases that have been found in this way. Furthermore, when a case of diphtheria is reported, the Health Department Inspector cultures all other members of the family, all contacts in the quarantined home, and even to neighboring apartments when such procedure seems justifiable from the history of ex- posures obtained from quarantined family. All contacts in the individual’s class at school are also cultured by the school authorities. This results usually in 50 or more cultures for each case and, as a result, many secondary cases have been found. This increase in cul- tural activity has resulted in a great increase August, 19 31 in our known cases and even though an in- dividual shows no clinical signs but has had 1 positive culture, it is carried as a case on our records, whereas in other communities these are not so classed. Secondly, the intensive Schick work (by this I mean testing, immunizing and re-testing) that has been done, has increased the danger of infection for those who are not so protect- ed, because it has broken the chain of direct contact that ordinarily would give some pro- tection and at the same time has increased markedly the number of “carrier cases”. Each of these carriers, whether temporary or per- 627 manent, has been placed on our books as a case. The immunization procedure has given the individual sufficient antitoxin to prevent his being ill but not enough to prevent carry- ing live bacilli. Thirdly, the entire Atlantic seaboard has passed through an epidemic of no mean pro- portions with its direct center situated in New- ark, New York and Philadelphia. Fourthly, more adequate and zealous at- tention upon the part of school physicians and nurses has brought to light another lot of cases that would usually have been passed by. (See Chart No. 1.) JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 1930 Population 474,000 Total 1915 Population 375,000 Year Jan. Feb. Mar. CHART 1 DIPHTHERIA April May June July Aug. Sept. Oct. Nov. Dec. 46 5 7 8 3 6 1 3 1 1 1 6 4 1210 1915 146 138 160 90 83 51 58 51 71 90 112 160 57 7 2 4 6 8 4 6 1 4 3 3 9 923 1916 124 85 70 96 99 71 61 47 29 57 102 76 50 2 5 5 2 7 5 4 1 2 3 7 7 870 1917 79 81 84 70 77 73 44 35 59 103 108 57 82 8 7 7 11 5 4 1 5 11 7 6 10 974 1918 81 112 95 103 63 60 65 49 91 87 77 91 50 5 7 11 7 2 2 2 4 2 0 5 3 1565 1919 154 154 149 161 149 122 96 64 72 121 182 141 62 7 11 5 7 5 1 4 2 1 5 4 10 1022 1920 129 94 95 60 70 72 47 34 44 92 146 139 44 6 5 7 5 3 5 2 2 2 1 3 3 1059 1921 173 128 126 75 102 76 43 24 47 67 78 120 73 13 8 11 7 8 5 1 4 3 2 7 4 771 1922 129 94 73 52 75 36 34 32 43 51 72 80 34 10 3 3 4 2 0 3 0 1 2 4 2 634 1923 89 69 50 40 64 43 24 30 17 57 63 88 39 2 4 6 9 3 1 0 3 0 4 2 5 575 1924 69 64 71 55 50 30 27 33 20 47 42 58 42 6 4 5 4 1 5 2 3 3 3 4 2 509 1925 45 33 53 54 47 39 43 28 27 47 35 58 21 0 1 4 1 4 2 2 1 0 3 1 2 409 1926 45 31 49 24 51 32 23 12 22 32 41 47 62 3 2 7 1 5 0 4 4 4 9 14 9 696 1927 44 47 30 38 34 47 50 30 40 92 121 123 94 7 8 9 10 7 18 6 4 3 1 7 15 1362 1928 107 95 111 94 110 197 83 52 70 113 149 181 92 10 10 9 7 11 5 10 7 5 4 6 8 1717 1929 182 128 184 176 193 132 102 88 78 128 183 143 48 12 8 6 5 6 2 0 3 3 0 0 3 871 1930 116 94 122 147 93 64 39 28 47 40 40 41 Top line figures show deaths. Lower line figures, number of cases 628 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 10 31 Fifthly, the population of Newark has in- creased a great deal since 1915 and the type of population has deteriorated markedly. The increase in poorly educated, law-defying, su- perstitious classes is a problem in the control of all communicable diseases. (See Chart No. 2.) Sixthly, cases reported as clinical diphtheria by a physician are carried on our records as actual diphtheria, regardless of the fact that positive cultures are not obtained. In other words, it is not necessary to have both clinical and bacteriologic diphtheria for cases to be definitely classed as such by our Department. CHART 2 DIPHTHERIA MONTHS WARDS 1920 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 JANUARY 29 3 9 3 7 6 7 13 12 20 12 10 17 14 13 7 182 FEBRUARY 13 7 10 2 10 6 7 10 4 12 11 6 5 11 4 10 128 MARCH 20 3 13 13 17 8 8 4 11 30 6 9 17 16 3 6 184 APRIL 27 2 7 6 12 4 7 7 6 42 10 9 10 11 11 5 176 MAY 22 8 1 12 15 1 10 11 46 7 13 6 20 10 11 193 JUNE 10 3 8 10 17 1 8 5 27 9 7 7 12 5 3 132 TOTAL 121 18 55 25 68 56 31 52 49 177 55 54 62 84 46 42 995 JULY 5 9 2 3 9 4 8 2 12 8 12 3 10 8 7 102 AUGUST 13 2 9 2 4 5 7 5 3 14 3 6 1 5 4 5 88 SEPTEMBER 7 1 5 2 4 15 1 3 6 7 2 7 3 13 2 78 OCTOBER 17 4 3 7 8 6 1 8 4 12 5 37 8 6 1 1 128 NOVEMBER 22 2 9 2 3 7 2 14 12 28 3 32 11 1 4 14 8 183 DECEMBER 9 9 3 1 3 2 5 7 19 10 47 4 15 2 7 143 TOTAL 1 04 27 99 43 91 101 48 95 83 269 86 195 92 147 77 70 1717 CHART 3 DIPHTHERIA BY AGE SEX COLOR MONTHLY FOR YEAR 1929 Under Under 5 10 15 20 25 35 45 55 65 Totals M F W BLK. 1 1 2 3 4 5 9 14 19 24 34 44 54 64 74 Jan. 69 113 174 8 6 12 20 20 25 83 51 15 3 11 13 5 1 182 Feb. 66 62 118 10 4 14 17 11 18 64 21 12 5 4 12 6 2 1 1 128 Mar. 100 84 168 16 3 12 15 27 21 78 62 15 3 7 15 3 1 184 April 86 90 158 18 2 19 18 20 20 79 65 14 2 6 9 1 176 May 95 98 170 23 5 10 24 22 17 78 81 20 4 2 5 3 193 June 63 69 101 31 4 6 11 14 15 50 57 16 2 1 3 2 1 132 July 49 52 88 14 2 8 7 7 7 31 49 8 5 2 2 4 1 102 Aug. 42 46 73 15 2 5 5 7 11 30 41 5 5 2 2 1 2 88 Sept. 41 37 66 12 2 3 5 3 12 25 33 6 2 1 6 4 i 78 Oct. 62 66 110 18 1 6 20 10 11 48 60 9 5 2 3 i 128 Nov. 91 92 161 22 5 7 21 16 10 59 70 27 9 6 7 4 i 183 Dec. 69 74 134 9 4 5 2 17 19 47 49 19 12 4 10 2 143 813 904 1521 196 40 107 165 174 186 672 639 166 57 46 86 38 8 3 2 1717 August, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 629 Our incidence record and Newark's position in the American Medical Association chart could be materially improved by requiring all cases to have both clinical and bacteriologic signs positive before we classified cases as diphtheria. The question of age and its relation to diph- theria occurrence has been admirably shown in the accompanying age chart, and this in turn has been verified by our Schick work. Diph- theria, as you know, occurs most frequently under 5 years of age, and that age group runs 90% Schick-positive. From 5 to 10 years is our second greatest period of diphtheria oc- currence and runs about 50 to 60% Schick- 74.5 % received antitoxin within 24 hours af- ter the physician’s first visit. As to the Schick test and toxin-antitoxin status in our cases, of the total of 1717 occur- ring in 1929, we had 67 patients who gave a history of having been schicked or immunized some time prior to occurrence of the dis- ease, and of these, 34 were sent to the Isola- tion Hospital at Soho at various dates, where from data at hand we find the following: One diagnosis changed to acute pharyngitis with rheumatic endocarditis; 2 negative cases as to clinical signs ; 1 with patches on right tonsil, described as noncontagious ; 5 as car- riers (positive cultures only — no clinical CHART 4 1928 DIPHTHERIA MORTALITY 95 Deaths: 77 white and 18 colored. No doctor in attendance 11: hospital cases 52. How long was pa- Same Day 1 Day 2 Days 3 Days 4 Days 5 Days Uliknown tient ill before 7 33 24 13 7 4 7 doctor was called? 7.3 34.7 25.2 13. G 7.3 4.2 7.3 When after doc- Same Day Next Day Third Day Fourth Day Fifth Day Unknown tor’s 1st visit was 48 23 13 3 3 5 antitoxin given? 50.4 24.1 13. G 3.1 3.1 5.2 W'hen did patient Within 48 Hrs. Three Four Five Six Seven Eight Nine Ten Above Ten die after antitoxin 24 Hr. Iabe Ruth. Even the radio is doing its bit to protect the American colon, along with your Adam’s apple. Now, instead of saying that you are acid, your kindly, non-medical, volunteer ad- viser would probably say that you are toxic. And then the tragedy begins — if you believe him and start self-treatment. “He who treats himself has a fool for a patient and a knave for a doctor.” Though that is a questionable dictum, it is a fact that pitfalls beset one on all sides when he at- tempts self-treatment. The 2 greatest errors the layman makes in self-diagnosis and self- treatment are apparent ; the diagnosis may be wrong, and the treatment may he wrong. A simple, yet serious indictment. Many who consider themselves so may really not be constipated. When it exists, con- stipation is inefficiency of a vital system. Its treatment is just as important as the treatment of diabetes, stomach ulcer, arthritis, or other departure from health. It warrants the same scientific study and treatment as the generally accepted medical problems. Its causes are legion, and its treatment often far at variance from popularly accepted ideas. Just as it would he laughable to be told that all people between 40 and 50 years of age should wear a size 6 B. shoe, so it is folly to think any one treatment applicable to all types of consti- pation. Nature has been generous to us in having endowed our bodies with many safety fac- tors to protect us from our own indiscretions and from accidents beyond our control. We have in the human system much duplication of function. If we, of necessity, lose a kid- ney or an eye, or have a lung out of com- mission, we can still live quite comfortably, because a fellow organ will take on the added responsibility. But. we have only one intestinal system. Show it the same consideration you show your automobile. Do not try to adjust the carbureter unless you are a mechanic, and then you had better have assistance of another mechanic. The cathartic habit is dangerous. Do not acquire it as the result of bad judg- ment or advice. August, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 661 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Office of Publication: 14 SOUTH DAY STREET, ORANGE, N. J. Entered at the post office at Orange, N. J., as second-class matter PUBLICATION COMMITTEE HENRY C. BARKHORN, M.D., Chairman, 45 Johnson Avenue, Newark, N. J. EDITOR: HENRY O. REIK, M.D., P.A.C.S., Vermont Apartments, Atlantic City, N. J. Each member of the State Society is entitled to receive a copy of the Journal every month. Any member failing to receive the paper will confer a favor by notifying the Chairman of the Publication Committee of the fact. NOTE.— The transaction of business will be expedited, and prompt attention secured if: All papers, news items, reports for publication and any matters of medical or scientific interest, are sent direct to The Editor, Dr. Henry O. Reik, Vermont Apartments, Atlantic City, N. J. All communications relating to reprints, subscriptions, extra copies of the Journal, books for review, advertisements, or any matter pertaining to the business management of the Journal are sent direct to The Chairman of the Publication Committee, (address above), Newark, N. J. NECESSITY FOR VACATIONS With the arrival of midsummer, no one re- quires much urging to lay down the imple- ments of his trade and take a vacation from routine labors, for a rising thermometer slows up other activities and the appeal of the “great outdoors” is hard to resist. Even those who have congenial occupations, who work amid pleasant surroundings, and who really love their work and dislike putting it aside, should, however, if opportunity affords, take advantage of any chance to secure a change and develop the benefits of recreation. The word recreation is defined as “refreshment of body or mind”, and grows out of the verb ■ — re-create — meaning “to impart new vigor” or to “refresh after labor”, and that implies a necessity for replenishment of our natural forces after an expenditure of energies. One of our contemporaries, the Editor of the Pennsylvania Medical Journal, some time ago, in an editorial entitled “physiologic tides”, drew an interesting picture of the ebb and flow of living power, which picture is deserv- ing of reproduction here : “The comparison of an undulatory swing in the higher things in life to the tidal move- ments of the ocean has often been made in prose and poetry, but the highest development in all things, whether mental or physical, is attained through such change and variation; the sleeping hours are as necessary as the wak- ing hours, rest as exercise, constructive as de- structive metabolism. It would be well if this truth were more generally and thoroughly ap- preciated. • What is it that is causing the nervous breakdowns among our business men, society women, and students? Does not every one in this modern rushing life feel that there is more put upon him than he can possibly do ; more work and play and engagements and cares? Yet, the trouble in most cases is not that people are over-worked but that they work against physiologic law. The business man feels that there can be no pause in work if he is to win success, and it is the con- tinuity of strain that is killing him; the scholar who studies night and day loses originality and insight and finds himself becoming a book-worm and a pedant. It is the old story of ‘All work and no play makes Jack a dull boy’, which might well be reversed to fit the suffering from nervous exhaustion of plea- sure-seekers whose lives are blighted by ennui and discontent. The best work of our lives is not done with the feverish, over-whelmed, and burdened mind which comes from con- tinuous, unvarying strain, whether physical or mental, whether from business or pleasure. We all need the ebb-tides of reaction, relaxa- tion, and quiet thought in order that there may follow the flood-tides of health and strength for the real decisive efforts of life.” THE OFFICIAL TRANSACTIONS This year we are publishing the complete Official Transactions, of the 165th Annual Meeting of the Medical Society of New Jer- sey, as a Supplement to the August Journal, a month earlier than usual, and we strongly recommend to all members a careful reading 662 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 19 31 of the reports submitted by officers and com- mittees showing the accomplishments of the organization and, especially, the progress made during the past year. We believe you will be gratified by the detailed accounts of work performed and the promises of further advancement to come from plans outlined for the next fiscal year. Members who could not attend the Asbury Park meeting will find in- teresting reading in the full record of pro- ceedings and will thus become conversant with all that transpired during the convention, as well as with the reports presented and action taken with regard to plans for the future. Those who did attend the convention will also probably benefit hv reading the transactions, through the fact that it is difficult to follow closely and understandingly the public presen- tation of a report; whereas, the subject matter is easily understood and absorbed when read in the quiet atmosphere of the office or home. In the July Journal we mentioned the un- usually large number of special committees for which provision was made at Asbury Park, and referred to that fact as indicating increas- ing interest in some of the problems, par- ticularly economic problems, now confronting the prbfession. President Hagerty has prompt- ly appointed most of those newly provided for committees, and has requested all ap- pointees to respond at once — expressing will- ingness to serve — or else to decline and make way for the appointment of others who can and will work. On the last page of the advertising section of this Journal we present a revised list of the officers and standing committees for this fiscal year. Some of the special committees will be mentioned editorially so that other mem- bers desiring to submit information or sugges- tions bearing upon special problems under consideration will know with Whom to com- municate. STUDY OF STATE MEDICINE Among important special committees, pro- vided for at the recent convention, is one in- structed to study the question of so-called state medicine. This topic was presented in one form or another by the President, the Secretary, the Executive Secretary, and other officers and members in the course of deliver- ing committee reports or in discussion. At the present moment, no other single topic is re- ceiving so nearly universal consideration bv members of the medical profession. We have stated before that in the brief course of 5 months, May to October, in 1930, this office collected from one source alone — other state society journals — 28 articles, dealing especially with the possible or probable advent, into the United States, of state medicine as it appears in “national health insurance laws” of other countries. We can now say that an additional group of 35 articles has been abstracted from the same source during the past 9 months. These 63 papers do not by a long way repre- sent the total output of literary contributions to the subject; though they do fairly well rep- resent the arguments’ for and against this “socialistic" — or, as some writers describe it, “evolutionary” — proposition. We have learned, without surprise, that the Secretary, Dr. Morrison, and the Editor, have been accused of favoring adoption of state medicine. No charge could he much further removed from the truth. Both of us knew in advance of our speaking or writing upon the subject that some listeners or readers would probably misunderstand or misinterpret our motives, but an honest man cannot side-step duty merely to escape criticism or false ac- cusations. We explained on various occasions that we felt impelled to direct the attention of members to this matter, offering what factual information was to us available, in order that the physicians of this state, at least, might become familiar with the subject and pro- tect themselves against such legislation as has elsewhere worked to the detriment of the pro- fession and of the people. “In knowledge there is strength!” If that axiomatic statement he true, let us gather in all possible knowledge concerning this matter, for we will need the strength. The special committee appointed to invest- gate and study the question consists of Drs. Francis FI. Todd, Chairman; Efenry C. Bark- horn, W. Blair Stewart, John H. Rowland and Barclay S. Fuhrmann. August, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 66 3 Medical Ethics THE LAW IS AN ASS (From The Kalends, Williams and Wilkins Company. ) There is no originality attached to the above caption for, as is generally well known, it first was used upon a memorable occasion by the beadle, Mr. Bumble, in Oliver Twist. But even the despicable Mr. Bumble did but give voice to a thought often found lurking in the minds of thinking men throughout all the ages of which there are tangible records. Let us go back to the territory presumably immediately adjacent to the Garden of Eden. Did not Cain seek to dodge the issue when he countered the leading question by naively inquiring : Am I my brother’s keeper? According to Scripture, Cain knew jolly well what had happened to Abel. The example of Cain is not cited as an ex- tenuation of regarding the law as an ass, but simply as an illustration of how an issue may be avoided by asking pettifogging questions seemingly relevant but misleading. Even to- day, thousands of years since the time of Cain, most people are more concerned about the merits or demerits of Cain’s question than they are as to the point originally at issue, viz., did or did not Cain slay Abel, and if he did so was he justified in doing it? Perhaps he was. Who knows? But certainly there aiJe numbers of people today who invoke the aid of the law in an outrageous manner to enable them to answer in the affirmative Cain’s dodg- ing question of Am I my brother’s keeper? Especially is this true in so far as their “brother’s” morals are concerned. And the law aids such self-appointed custodians of morality. Why? The only intelligent answer deducible is that the law is an ass. Is it not true that for more than a century our national government wisely steered clear of legal interference with personal habits? Such matters were sanely left to the jurisdic- tion of states and municipalities. A, bout 20 years ago, however, due to the agitation of paid doers-of-good, the national government jumped into the puddle with both feet. With what result is well known to students of gov- ernment and politics, medical men, and scien- tifically trained sociologists. The mere opin- ions of paid doers-of-good can have no weight when placed in the balance with the results of scientific research. The Harrison Act upon narcotics, the Mann Act upon prostitution, and the Volstead Act prove conclusively that our national law is an ass. Scripture tells us that by their fruit ye shall know them. The fruits of the ungodly trinity above mentioned are : Before the pas- sage of the Harrison Act there were 100,000 drug addicts in the United States, today there are more than 2.000,000; the Mann Act was to. “cure” a relatively minor and local evil, to- day sexual license is rampant throughout all strata of society; the Volstead Act was to so function that all jails would be emptied, crime diminished, and all homes made happy, today President Hoover authorizes the expenditure of $6,500,000 for national penal institutions, because those of all states and municipalities are filled to overflowing, he also has appoint- ed a committee of outstanding citizens to in- vestigate and report upon the magnitude of our national crime record, and if the output of our legal divorce mills is a criterion upon happy homes, then Mr. Volstead did but add oil to the flames. All these pernicious results of the assininity of our national law are as naught when con- trasted with the damage done to clear and straight thinking, for the essential self-dis- cipline of body and soul has been replaced by the silly doctrine that a majority in the ballot box is the arbiter of right and wrong, and — law. It is easy to figure out why it so often: happens that the law is an ass. Esthetics TIMES SQUARE HAS A SUMMER VISITOR (From New York Times, July 3, 1931.) Glimpsed, in Times Square, a butterfly. Not a metaphoric butterfly, but a real one, all brown and beautiful, and very gay and lively, in spite of his long trip from somewhere. Perhaps from Central Park, or across the river. If he had been just a figure of speech a moth would, of course, have been more appro- priate— to the night lights, at any rate. But this visitor was an actual creature, and he came in broad daylight. What attracted him? Maybe the cool morning breeze wafted him on his whimsical way. Maybe he smelled a rotten banana, on which even the best nur- tured butterflies dote. He flitted past the sign in a restaurant win- dow advertising half a cold lobster with cold slaw and potato salad for 60 cents, without so much as batting a wing. Overhead a gar- ish sign advertised the Return of Dr. Fit Manchu. but he was absorbed in deeper mys- teries. He did not stop to read even “The Green Pastures” ad, although it might have allured him. Instead, he perched, this early morning voyager, a little weary but content, on the roof of a Coney Island bus. 664 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 19 31 Collateral Reading THE IMMORTAL LYDIA The above title of a recently published book naturally attracted our attention, because of interest in the general subjects of patent medicines and effective advertising to the gul- lible public. Once upon a time we clerked in a country drug store, and, though it was many years ago, we still remember the buying demand for Lydia Pinkham’s Compound. We have not had time to make a personal review of this biography — The Life and Times of Lydia Pinkham, by Robert C. Washburn — but inasmuch as the Saturday Review of Literature, of May 30. 1031, has published a very interesting summation of the book’s con- tents, we are taking the liberty of passing that along for the entertainment and edifica- tion of our readers : “Reach for a vegetable instead of a sweet.” This prophetic phrase appeared in the ad- vertising of Lydia E. Pinkham’s Vegetable Compound in 1891. It was a part of the skil- ful publicity campaign which, in the course of 50 years, converted a harmless nostrum, prepared by a farmer’s wife over a kitchen stove, into the greatest of all patent medicines. Lydia Pinkham, dead since 1883, still smiles benevolently upon the world, offers her pri- vate advice to thousands of feeble-minded fe- males, and sells several million dollars worth of her preparation every year. The engaging story of this gigantic hoax is told by Mr. Washburn with an abundance, even a superabundance, of detail. Lydia Estes Pinkham was not only a real person but a personable person. Born in Lynn, Mass., on February 9, 1819, she was brought up as a Quaker and became in her youth a militant abolitionist and feminist. After she gave up school-teaching to marry Isaac Pinkham, her life was devoted for the next few years to child-bearing, while her husband tried eveiw- thing from business to farming. Eventually, he plunged heavily into real estate and was broken in the financial crash of 1873. It was then that Mrs. Pinkham came to the rescue with her Vegetable Compound, an elixir of herbs and alcohol, prepared according to a formula originally received by her husband in cancellation of a bad debt. Hitherto she had occasionally cooked up the mixture for her familv and friends in time of illness. It was now to prove equally useful in time of pov- erty. One of her children suggesting that they put the Compound on the market, all of the family rallied to the support of the idea. The next 5 years were spent by the mother in brewing and stewing, by the 3 sons in peddling bottles and circulars from Boston to New York. The extracts from their correspon- dence given by Mr. Washburn are delightful. The Compound was advertised to cure “wo- men’s weakness”, but young Dan Pinkham reported that, while men eagerly read the cir- culars, women tore them up if the}- saw any- one looking. He suggested, thoughtfully, that it would be well to mention a few men’s diseases. His mother was nothing loth, being certain that her Compound would cure any- thing and everything. She continued to ap- peal mainly to women, however, and grad- ually came to regard herself as the savior of her sex. Recognition of this role was achieved in 1880 with the publication of her picture. The confidence created by so matronly and respectable a countenance was overwhelming. The sales of the Compound went bounding up, and the flood of personal letters began. Mrs. Pinkham answered these herself at first ; then she trained her daughter and daughter-in-law to help her; finally women clerks were employed whom, however, she taught with equal care. She was most in- sistent that feminine delicacy should always lie respected. The word “leg” must never be mentioned. Her modesty preferred to write, for example, that a patient had “a purple place nearly as large as her hand . . . about 8 inches above her knee on the inside of her right limb”. The Compound made the family fortunes but it did so too late to benefit greatly the original producers. Two of Mrs. Pinkham’s sons had literally worked themselves to death in its behalf. Dan dying at 33 and Will at 28. Mrs. Pinkham herself lived for only 3 years after her success. Her heirs made a genuine effort to acknowledge her decease and, tact- fully, to substitute her daughter as a second savior of the sex. But the world of women would have none of this. They insisted upon having their own Lydia. So the firm revived the old lady and mounted upon her posthu- mous wings to greater glory. Every attack upon the Compound merely increased its sales. Edward Bok's denunciation in the Ladies' Home Journal sent them soaring. Though the Food and Drug Act has shorn the plum- age from the advertising until today the Com- pound is recommended, with unquestionable truth, merely “as a vegetable tonic in condi- tions for which this preparation is adapted", nevertheless the immortal physiognomy of Lydia Pinkham still goes marching on. Mr. Washburn rightly emphasizes the sig- nificance of his heroine as one of the found- ers of modern personal advertising and as a contributor to the present reign of feminism. But he is too over-awed by the magnificence August, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 665 of her achievement to do full justice to the essential comedy of her story. He wastes much space in apologia — which is much as if one should apologize for Falstaff or Bottom the weaver. There is a good deal of padding in the book. Thus a whole chapter — and a very uniiluminating one — is devoted to Mrs. Eddy, simply on the grounds that she. too, dis- believed in doctors, was a self-advertiser and a feminist, and lived in the same town with Mrs. Pinkham. The endeavor to trail a whole period from Lydia’s skirts is unsuccessful. To take her quite so seriously is to wrong the dear woman. In Lighter Vein Cross Marks the Spot A man touring Europe sent back a picture post- card bearing 'the message : “Dear Son: On the other side you will see a picture of the .rock from which the Spartans used to throw their defective children. Wish you were here. — Your Dad.’’ — Wall Street Journal. Change of Diet It was the duty of Janet, the maid, to tie up Jeff, the house dog, every night before she re- tired. One night she failed in her duty, and next morning found Jeff loose. He had played havoc with the contents of the larder. When the mistress heard the news, she inquired : “Has he eaten much, Janet?” “Every blessed thing”, replied the maid, “ex- cept the clog biscuits!” — Tit-Bits. Voice of the Tempter Small Boy: “I don’t think the gentleman next door knows much about music.” Mother: “Why?” “Well, he told me this morning to cut my drum open and see what was inside it.” — Birmingham Gazette. Whiskers on It 'Comic Artist: “This joke ought to be good, I’ve had it in my head for 10 years.” Heartless Editor: “Sort of aged in the wood, as it were.” — Hummel. Oh, My! Parent (anxiously) : Nurse, is it a him or a her? Nurse: It's a them. — Boston Transcript. Selfish Man Bluebeard: You have the freedom of the entire house excepting this closet. This, you must never enter. His Eighth Wife: Do you mean to keep an entire closet for yourself when I haven’t room to hang half my things. Lighthouse Observations ACUTE HEMORRHAGE FROM CORPUS LUTEUM AND GRAAFIAN FOLLICLE In 1917, Novak reported that a search of medi- cal literature disclosed only 40 recorded instances of copious hemorrhage into the abdomen caused by ruptured Graafian follicle or corpus luteum. During the 13 years since that announcement, 37 additional cases have been discovered, including the case related by V. Earl Johnson, who reports the most recent search of literature (Am. Jour. Surg., 9:538, September 1930), bringing the pres- ent total up to 77. In describing his own case, Johnson discusses the etiology of this unusual condition and some of the difficulties in making a differential diagnosis. After explaining the physiology of ovulation, he says: “It is easy to imagine injury or a solution of continuity of these fragile vessels brought on by a sudden hyperemia of the pelvic organs, as by sexual excitement, or by a sudden increase in the intravascular pressure due to sexual excitement or increased intraabdominal pressure. After in- jury to these vessels a hematoma forms in the corpus luteum cavity and if hemorrhage persists long enough the pressure in that cavity will be- come so great as to burst the wall at its weakest point. It has been proved that a large proportion (60 to 80%) of all ovaries removed at operation show hematoma formation in some part of their structure, showing the vulnerability of the smaller ovarian vessels. This bursting of the walls of the corpus luteum might eventuate in a copious hemorrhage or in a trivial one. This seems to me the theory most likely. Whether there is a pathologic condition of the ovarian (or more strictly, thecal) vessels, as shown by Schumann to be present in his case, remains unsettled. Ref- erence to the pathologic study in my case is in- cluded in this paper. The pathologic changes in the vessels in Schumann’s case is a very interest- ing observation, but whether there was any re- lation between such pathology and the hemor- rhage is debatable. The question of cause and effect is not thereby demonstrated, for there is no reason why the hemorrhage could not have been a coincident condition. I do not believe that changes in the vessels alone would satisfactorily explain the occurrence of hemorrhage. Returning to the normal physiology of the ripening Graafian follicle, we note that hemor- rhage occurs into the cavity after the ovum has been expelled. This hemorrhage occurs from the thecal vessels. The additional physiologic hemor- rhage from laceration through the stigma is no doubt negligible because the point of rupture has become so thinned out by pressure of the develop- ing follicle. A pressure ischemia of an oblitera- tive nature would seem most logical in the pro- duction of the stigma. Presuming that in the ovary a Graafian follicle is almost, but not en- tirely, ripe when a sudden hyperemia of the pelvic organs occurs and causes an increased intravas- cular pressure in the ovarian blood vessels, pre- mature separation of the ovum within the follicle might occur. This premature separation would produce hemorrhage into the follicle and if this hemorrhage was continued sufficiently long a bursting of the follicle at its weakest point would naturally occur. Intraperitoneal hemorrhage would then take place from the thecal vessels and from the laceration in the ovary. This hemor- 666 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 1931 rhage might be copious or trivial. I believe that in all the cases presenting serious hemorrhage such a process occurs in Graafian follicles that are not quite ready to rupture. In other words, a prema- ture separation of the ovum, with hemorrhage, and premature rupture of the follicle, are the mechanisms producing the condition under dis- cussion. It is very significant that in the 25 case reports, used as a basis of study for this paper, increased intraabdominal pressure was specifically mention- ed in 9 cases. Eight of those patients stated that intraabdominal pressure was increased either by vomiting or by straining at stools. In view of the frequent diagnosis of appendicitis in these cases, and realizing that the majority of appendicitis cases vomit one or more times, I am satisfied that the incidence of increased intraabdominal jjressure would be greatly increased if definite records of this point had been made in all cases. It is in- teresting, however, that it was definitely stated in approximately one-third of the cases studied. What is the possibility of making a correct diagnosis before operation? This study has found 77 cases reported with a diagnostic error of exactly 100%: no case having been diagnosed correctly previous to operation. The greater number of mistakes have been made in diagnosing the condition as acute appen- dicitis, because of the pain in the right lower quadrant, vomiting, fever and leukocytosis. It therefore appears that the physical examination must be the all important factor. The chief differ- ences in favor of hemorrhage from the ovary would be: (1) Pallor of skin and mucous mem- branes: (2) more shock: (3) fainting or sinking spells; (4) less amount of rigidity of rectus which, in fact, may be absent; (5) area of exquisite ten- derness is rather definite in appendicitis, while with ovarian hemorrhage the tenderness is rather diffuse over the lower quadrants. Differentiation from ruptured ectopic pregnancy is more difficult. They both have in common: (1) Cramp-like pains over one or the other lower quadrant; (2) fainting or sinking spells; (3) evi- dence of internal bleeding- (4) fever and pulse elevation; (5) leukocytosis. Ruptured ectopic pregnancy usually gives a his- tory of one or more abnormal menstrual periods, there is usually some vaginal bleeding, softening of the uterus just proximal to the internal os may be present, and the breasts may show the changes of early pregnancy. If there is bleeding, not menstrual in type, from the uterus, the case is probably not one of ovarian hemorrhage. This vaginal bleeding was present in only 1 of the 25 cases studied. However, it is much easier to make the diag- nosis on paper than it is in practice and, without practical experience to keep this possibility in mind, past records suggest that the condition will be confused with the 2 commoner ones, appen- dicitis and ectopic pregnancy. The diagnosis should not be missed by those who have previously en- countered the condition." Mental Hygiene and the Child (During the past year our Field Secretary has been using mental hygiene as the principal theme in her public educational work, lecturing to large groups of school teachers and pupils especially, and the following editorial from the Pennsylvania Medical Journal of March, 1931, seems appropriate for repetition here) : ‘‘Possibly no other contribution to the study of the child’s conduct and behavior has aroused the interest of the general practitioner as has men- tal hygiene. It is true pediatricians have always considered the mental, nervous, and physical re- actions of children, but, in the field of general medicine, the psychologic aspect of the child, like consideration of the psychologic aspect of the adult, somehow or other in the passing years re- ceived minor consideration. In arousing this interest, the true mental hy- giene workers have tried in every way possible not to infringe on the territory of the pediatri- cian; per contra, they have always been conscious of the pediatrician’s cooperation and his contribu- tion to the knowledge of the child. Their efforts, therefore, have been more along the lines of re- minding the general practitioner, the parents, the teacher, the nurse, the social worker and society, that childhood is the golden period for proper guidance of the growing child: that it is here the child should be given the best opportunity for de- velopment of his psychologic processes which will enable him to meet, life’s situations, and encour- agement in developing proper adaptation and men- tal attitudes. To this end. mental hygiene sponsored the men- tal clinics in the field either as independent units or part of our governmental agencies and the mental hospitals. Child guidance clinics were also sponsored for the further research, study, and guidance of certain types of children, all of which was for the purpose of making available places of examination of children of all ages who are not able to effect adaptation to the new world in which they find themselves. Time has proved that mental hygiene made no error in focusing on the child as one of its first steps in the broad program of the promotion of mental health and the prevention of mental dis- ease. The case records of these clinics reflect in numbers and types of children examined, that such agencies are meeting a very definite need. The physician in general practice will make no mis- take in availing himself of the facilities of these clinics in many of his cases of problem children when consultation is desired.” Current Events THE 82nd ANNUAL/ CONVENTION OF THE AMERICAN MEDICAL ASSOCIATIOtN Following close upon our own State Society’s 16 5th Annual Meeting, and convening at a place so convenient for most of our members, the Phifa- delphia session of the American Medical Asso- ciation attracted a large attendance from New Jersey. Our registration figures (565) being sur- passed by only 2 states- — Pennsylvania (2806) and New York (936). As the total number of regis- trants was 7006, New Jersey supplied 8% there- of. New Orleans was chosen as the place for meet- ing next year. Dr. E. H. Cary, of Dallas, Texas, was unani- mously chosen as President-Elect. From the general proceedings we have selected the following items as being of special interest to New Jersey physicians. Dr. E. Starr Judd, President-Elect to succeed President William Gerry Morgan, addressing the House of Delegates, said, in part: An association is as strong as its man power. August, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 667 Few associations that I know of have as many capable and industrious officers and departmental heads as has the American Medical Association. This condition must be maintained. If, for any reason, a new man is needed to fill in and super- vise a new bureau or to replace some one, the best person available must be obtained. In the selection of men for bureaus and committees there will constantly be competition with large organ- izations and foundations and the various medical centers. These foundations have much money to spend for personnel, and for this reason, if the Association is to continue to have the best, as it must have, it must expect not only to pay well but also to see that each and every one of the permanent men on these bureaus and committees is well cared for in every way. A strong financial foundation is necessary for the success of any or- ganization and in order that our position may be maintained we must make every effort to increase our resources and to establish funds for stability and future development. Much has been said about a new building for the headquarters of the Association, and all are looking forward to the time when this plan can be carried out. I know that the trustees have given careful thought to plans for a new building, and any help that might be offered, I am sure, would be welcome. I understand that a building fund has already been started, but it does not seem to me that it would be good business to postpone the building of the contemplated structure until we have money enough to pay for it. It seems to me that it would be a fine thing if the medical profession itself could finance the structure. First of all, a new building would be a great source of pride and satisfaction, as well as most stimu- lating. A new building would give an opportunity for more and better space, for the development of our already large and active library. It takes many years to build up a library, and anything that facilitates this must be considered. A room containing portraits of leaders in American medicine as well as those of leaders of medicine in other countries, and historical data concerning those who have accomplished much in medicine, will be most stimulating and appro- priate in this buildng. The new building should contain a small audi- torium and several committee rooms of good size, some of which could be used as permanent quar- ters of the different councils. Bureau of Health and Public Instruction The Bureau of Health and Public Instruction has ever-increasing duties and associations. The American Medical Association must be the leader in preventive medicine and public instruction and in public health activities. Public health and pre- ventive medicine are the most discussed subjects in medicine today, and influence and leadership in this work must be retained. Those who attended the meetings of the White House Conference must have been impressed with the fact that so few physicians were present. While the profession welcomes cooperation from the outside organizations, nevertheless it is of interest to society and of importance to medicine for us to retain our position in these affairs. A great deal of very commendable work has been done on public health, preventive medicine, public instruction, child welfare and all other phases of this subject by this bureau and also by certain state organizations. This is especially evident in Illinois, New York and several other states. I make a plea that we not only continue our efforts but that we enlarge them and main- tain our position. Bureau of Medical Economics The Bureau of Medical Economics is just being organized and ultimately will have all available in- formation regarding the cost of medical care. So much misinformation regarding economics is being broadcast that it is certainly our obligation and responsibility to set this aright. This means a great deal of study and work, and is a task for those who have had much experience in these activities. There are few actual practitioners of medicine on the 5-year committee on the costs of medical care. The statistical work of the com- mittee has been tremendous, and a great deal of information will be available. It seems to me that a bureau made up of men from the Asso- ciation would be better able to put the proper in- terpretation on the findings of this committee than would those in government and public health work alone. This bureau must have the best man power that can be obtained. Resolutions on Appointment of a Commission on Qualifications for Specialists Dr. Carl F. Moll, Michigan, presented the fol- lowing resolutions which were referred to the Reference Committee on Medical Education: Whereas, The advancement of medical science through the results of research and practical experience has stimulated many physicians to confine their professional ac- tivities to limited and special fields of medi- cal practice, and Whereas, There has thus been created class of specialists in medicine, and Whereas, There appears to be a growing tendency on the part of physicians who are not properly qualified to hold themselves out as specialists; therefore be it Resolved, That the Speaker of the House of Delegates shall appoint, by and with the advice of the President and the Board of Trustees, a Commission on Qualifications for Specialists, composed of 9 members; that said commission shall undertake to define the qualifications that should be required of the individual physician who desires to limit his practice to any special field and to be known as a specialist, and that in arriving at such definition the Commission on Qualifications for Specialists should give 'consideration to questions of education, training and clinical experience; and be it further Resolved, That this commission shall give consideration to the present status of special- ization in medicine, and shall define the var- ious specialties which in the opinion of the commission may be considered as necessary for the best interests of the public and of scientific medicine; and be it further Resolved, That the Council on Medical Elu- cation and Hospitals be directed to render its assistance to the Commission on Qualifica- tions for Specialists, and that the Board of Trustees be requested to provide necessary clerical assistance; and be it further Resolved, That this commission shall report to the House of Delegates concerning the ad- visability of the possible enactment of legis- lation whereby state boards of medical ex- 668 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 1031 aminers or other bodies charged with the ad- ministration of practice acts may be em- powered to issue special licenses to physicians who wish to qualify and practice as special- ists; and be it further Resolved, That the report of this com- mission and its recommendations shall be sub- mitted to the House of Delegates, through its secretary, at the next annual session. The Reference Committee on Medical Educa- tion considered the above resolutions and pre- sented the following report, which was unani- mously adopted: In regard to the resolutions introduced by Dr. Carl F. Moll, Michigan, seeking definition of the qualifications of those physicians who hold them- selves out as specialists, and consideration of the present status of specialization in medicine, your reference committee is in entire sympathy with the spirit of these resolutions, and after careful study of them, and after thoughtful consideration of reports presented to the committee by repre- sentative otolaryngologists, ophthalmologists, der- matologists and abdominal surgeons who appear- ed before the committee, your committee recom- mends that the Council on Medical Education and Hospitals be requested to investigate the entire subject and to make recommendations looking to the establishment of proper qualifications of physicians who shall engage in special practice, and that the report of the Council and its recom- mendations be submitted to the House of Dele- gates as soon as practicable. Resolutions on the Policy of Rendering Medical and Hospital Benefits to Veterans with Non- Service Connected Disabilities Dr. H. H. Shoulders, Tennessee, presented the following resolutions, which were referred to the Reference Committee on Legislation and Public Relations, and later adopted: Whereas, The federal government has in- augurated the policy of rendering medical and hospital benefits to veterans of the World War with non-service connected disabilities; and Whereas, This policy was inaugurated over the opposition of the American Medical Asso- ciation; and Whereas, The policy now in force, if car- ried to its logical conclusion, involves the construction, the staffing, and the main- tenance of a sufficient number of hospitals to accommodate the hospital needs of all the veterans of the World War; and Whereas, Such a policy places the federal government in unnecessary and unjust com- petition with the civilian hospitals and the medical profession of the United States; and Whereas, The present policy is of unequal benefit to veterans by reason of the fact that many disabled veterans cannot (for one reason or another) avail themselves of the benefit; therefore be it Resolved. That the House of Delegates of the American Medical Association petition the Congress of the United States and the American Legion to abandon the policy of rendering hospital and medical benefits to veterans of the World War with non-service connected disability, and substitute therefor a plan of disability insurance benefits with the following provisions: First, the creation of a Bureau of Disability Insurance in the Veterans' Bureaus as now constituted. Second, the issuance of a disability insur- ance policy to each veteran with a disability benefit clause, as follows: (a) The payment of a weekly cash benefit during a period of total disability, and (b) The payment of liberal hospital benefit sufficient to cover the hospital expenses of a veteran during a period of hospitalization for any disability. Such benefits to be paid to a veteran on satisfactory proof of total disability, and (c) Such other provisions as are necessary for the proper administration of the act. Be it further Resolved, That the proper officers of this association be instructed to approach the offi- cers of the American Legion with the view to securing the adoption of the policy above set out as a part of the legislative program of the American Legion, and be it further Resolved. That each state medical asso- ciation be requested to form a committee whose duty it will be to approach the state and local Legion posts throughout the coun- try with a view to securing the adoption of this program by them. Resolutions on Filling Out of Claim Proofs of Health and Accident Insurance Companies Dr. J. D. Brook, Michigan, presented the fol- lowing resolutions, which were referred to the Reference Committee on Miscellaneous Business, and later to the Bureau of Medical Economics for study and report at next annual meeting. Whereas, The Michigan State Medical So- ciety. through its Committee on Civic and In- dustrial Relations, has made a comprehensive i study of the question of filling out claim proofs of health and accident insurance companies; that this study has extended over a period of 3 years and has involved an extensive analysis of the subject, including a conference with repre- sentatives of several outstanding insurance companies; and that, as a result of Such study and conference, the Michigan State Medical Society has adopted suitable resolutions pro- viding for the charging of a fee to the in- surance companies of not less than $2 for filling out each preliminary and final claim proof, and Whereas, The Michigan State Medical So- ciety, by its action in adopting such resolu- tions, has created the interest and favor of other state medical societies in the question, which equally affects every other state medi- cal society; and that the Michigan State Medical Society has met with considerable opposition from the insurance companies, for the reason that they object strenuously to the plan, and point out that Michigan represents only a small section of the nation and should not undertake a project affecting the policy of all the insurance companies of the United States, and Whereas, The rights and privileges of the individual physicians of the entire United States are involved and are being encroached on by the health and accident insurance com- panies, which are continuing to insist that the services of the physician in filling out claim proofs are part of the physician’s professional obligation to his patient: that the insurance August, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 669 companies are unwilling to concede that the information given to them is for their own statistical use in properly adjusting claims; and that they are unwilling to pay the physi- cian his fees; therefore be it Resolved, That the House of Delegates of the American Medical Association concur with and approve the action of the Michigan State Medical Society in adopting resolutions providing for the charging of a fee of not less than $2 for each preliminary and final claim proof; and that the House of Delegates of the American Medical Association authorize its Speaker to appoint a committee to whom this problem shall be referred; and be it further Resolved, That this committee be instructed to study the facts and factors involved and to formulate a national policy that will result in remunerating physicians and surgeons for their service to insurance companies, when rendering these reports that contain expert opinions and professional advice; and be it further Resolved, That the committee of the Asso- ciation shall make a full report and recom- mendation at the next annual meeting of the House of Delegates of the American Medical Association. Committee on Reports of Officers The following notes are abstracted from this committee’s report; Your committee feels that the time has arrived when the medical profession should direct all independent or extragovernmental or lay health groups. We congratulate the association on the manner in which its offices have been conducted during the past year by its able and efficient manager and Secretary, Dr. Olin West. We approve of the expressed desire of the Board of Trustees to acquire the land necessary for erection of a new, larger and more adaptable building to meet the growing demands of the Association. In view of the present economic conditions and the urgent needs of the Associa- tion, we believe that now is the opportune time to construct the new home. We are gratified at the position attained by The Journal as the leader of medical publications, as well as the high standard of the special jour- nals in their respective fields. We appreciate the work being accomplished by Hygeia, especially in schools, and we feel that the Woman’s Auxiliary is largely responsible for the rapidly increased circulation of Hygeia. We approve of that part of the report of the Trustees advocating the education of the public on all matters pertaining to health and disease through radio talks, properly supervised, lay mag- azine articles and public lectures. We especially commend the Bureau of Legal Medicine and Legislation in reference to national legislation in connection with the Jones bill (off- spring of the Sheppard-Towner Maternity and In- fancy Act), the narcotic legislation, the World War Veterans’ legislation, the many bills intro- duced intended to create federal subsidies, and the government control of individual activities in the several states. We note with pride the increasing importance of the annual Scientific Exhibit, and we recom- mend that it be continued and expanded to the highest possible degree. We anticipate substantial contributions from the newly created Bureau of Medical Economics. The possible benefits to the profession from con- structive activities in this bureau should prove invaluable. In reference to the care of the World War Veterans, your committee suggests that the House of Delegates go on record as being opposed un- alterably to giving free medical and surgical care to those suffering from injury or disease of non- service origin. Further Report of Reference Committee on Re- ports of Board of Trustees and Secretary Dr. C. .T. Whalen, Chairman, presented the fol- lowing report: At the morning session, that portion of the re- port of the committee having to do with the Secretary’s report, which read as follows, was re- ferred back to the committee for further con- sideration: We especially condemn the examination of pre-school children en masse in clinics, health units and similar agencies. Such examina- tions cannot be but perfunctory, superficial and unsatisfactory to p'hysicians and child alike. The committee submits the following amend- ment: We , commend education of the public as to the necessity for medical supervision of the pre-school child by the family physician, and we insist that medical examination of each child should be thorough and individual. Dr. Whalen moved the adoption of the amend- ment. The motion was seconded by Dr. John O. Polak, Section on Obstetrics, Gynecology and Ab- dominal Surgery, and carried. Executive Session Two sets of resolutions under consideration were somewhat modified, and are presented here as finally acted upon: (1) The committee has ascertained that the intent of this resolution is to urge on the mem- bership of the American Medical Association the importance of initiating in county and state so- cieties and in the House of Delegates of this As- sociation resolutions on questions of medical eco- nomics and social relations, rather than in special societies of limited membership with a view to presenting to the public opinion of organized medicine as a unit and to prevent the presenta- tion of a divided opinion before legislators and the public in general. In order to express this more fully and more definitely, the committee has rephrased the reso- lution and now offers it for your consideration in the following form: Whereas, The American Medical Associa- tion, through its county and state organiza- tions and through its House of Delegates, affords to each of its members representation whereby he may express his views, and, if approved, receive the support of organized medicine; and Whereas, The American Medical Associa- tion is the largest body of physicians in the United States, representing every specialty, democratically organized, and including more than 100,000 physicians; and 670 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 10 31 Whereas, From time to time, members of the American Medical Association, holding membership in various medical societies, or- ganized for scientific advancement, have initi- ated in such bodies resolutions defining medi- cal policies and opinions on questions of medical economics and social relations; and Whereas, Resolutions on such subjects adopted by such organizations are given wide publicity as representing the views of the American medical profession, notwithstand- ing the fact that such bodies are of limited membership and specialistic interest; there- fore be it Resolved, That the House of Delegates of the American Medical Association urge all members of the Association to initiate such resolutions in their county or state societies or in the House of Delegates of the Ameri- can Medical Association, and that an effort be made, through the periodicals of the Asso- ciation, to inform the membership, and also all organs of public expression, that the American Medical Association is the one body, in organized medicine, entitled to speak for the vast majority of the physicians of this county. The above resolution was adopted. (2) Resolutions referred to the committee were presented by Dr. Roland Hammond, Rhode Island. These resolutions read as follows: Whereas, The Congress has undertaken to fix the doses of wine and whisky and brandy by legislative fiat, thus taking over the func- tions of pharmacologist and physician; and Whereas, The Volstead Act compels physi- cians to betray the confidence of their pa- tients by keeping a record of their diseases and ailments for inspection by federal prohi- bition agents, thus violating the traditions of the medical profession, medical ethics and the laws of a number of states; and Whereas, Relief from these conditions has been sought in the courts and has been denied by the United States Supreme Court; and Whereas, The Wickersham Commission has unanimously made the recommendations: “Removal of the causes of irritation and resentment on the part of the medical pro- fession by: (a) doing away with the statu- tory fixing of the amount which may be pre- scribed and the number of prescriptions; (b) abolition of the requirement of specifying the ailment for which liquor is prescribed on a blank to go into the public files; (c) leaving as much as possible to regulations rather than fixing details by statute.’’ Now, therefore, be it Resolved, That the Rhode Island Medical Society hereby urges each of its members to demand of his senators and congressmen the repeal of those portions of the Volstead Act which substitute the fiat of Congress for the seasoned opinion of the medical profession, which rob the sick of their right to be heal- ed of their diseases and ailments according to the recommendations of eminent medical authorities, and which deprive the physician of his right to the free exercise of his judg- ment in the practice of his profession; and be it further Resolved , That the delegate of the Rhode Island Medical Society to the American Medi- cal Association be, and hereby is, instructed to present this resolution to the House of Delegates of the American Medical Associa- tion at its next meeting for similar action. Dr. Taylor read the following endorsement of the Pteference Committee on the Reports of Board of Trustees and Secretary, presented at the Wash- ington session in 1927: Your committee would therefore recom- mend that with the cooperation of the special committee headed by Dr. Mayer, of Pennsyl- vania, and the excellent executive of the Bureau of Legal Medicine and Legislation, Dr. Woodward, the Board of Trustees be di- rected to prepare a bill to be presented to Congress correcting the unfortunate pro- visions of the Volstead Act limiting the amount of alcohol used, and providing such regulations as will permit doctors to pre- scribe whatever amounts of alcoholic liquors may be needed for their respective patients, and subject to such reasonable restrictions as may be thought wise and best after a con- ference with the head of the prohibition de- partment. Dr. Taylor moved the adoption of the above. The motion was seconded by Dr. A. J. Bedell, New York, and carried. Communication from President of the Woman’s Auxiliary The Secretary read the following communica- tion from Mrs. J. Newton Hunsberger, President of the Woman's Auxiliary: To the Members of the House of Delegates: It has been my privilege for the past year to serve the Auxiliary to the American Medical As- sociation as President. During that time we have endeavored to bring to a greater stage of perfec- tion our organization rather than to enlarge our membership, which, however, has ably taken care of its own progress as we have now 13,000 paid members in 3 7 states (organized). We have installed a new system of recording our membership which will enable states as well as counties to keep a systematic and correct file. A tabulation of the 37 replies received to the 37 questionnaires sent out shows two thirds of the states have, now, advisory committees in their respective medical societies. Fourteen states have definite study outlines prepared for their use by the state medical society or their boards of pub- lic health. Most auxiliaries contribute to and read their state medical journals. All have par- ticipated in local, social programs and at state medical conventions, and so have increased socia- bility in the profession. One new study has been prepared and dis- tributed by the Program Committee and is being extensively used not only by our own members but also by the parent-teachers associations and the woman’s clubs. The subject is “Communic- able Disease Control” arranged in 4 parts: In- troduction, Small-pox, Diphtheria, Typhoid Fever. To date 3500 copies have been dis- tributed. Our Public Relations Committee has made con- tacts which enable us to work through. The Chairman of Hygeia divided the states into 5 districts with a supervising chairman over each. Letters were mailed to all state presidents seek- ing their cooperation. Replies received from 32 August, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 671 states resulted in securing- the names and ad- dresses and terms of office of about 35 0 county- presidents and Hygeia chairmen. A survey of the reports shows that a majority of the aux- iliaries are extolling the merits of Hygeia for its educational value but it is very difficult to com- pete with other good magazines at the present price. Cur women take much interest in working for scholarship and medical benevolence funds. They rendered great assistance during the drought disaster, individually and through the Red Cross. They have participated in May Day Child Health programs, Christmas celebrations and summer outings for children in hospitals. They have housecleaned medical libraries to the satisfaction of critical doctors. Some legislative work has been done in states but only under the direction of the advisory com- mittees. A large number of our auxiliaries take special delight in collecting historical material incident to medicine and the doctor of the past. Turn about is fair play but we do greatly ap- preciate the courtesy of the American Medical Association through Dr. Olin West in printing the minutes and reports of our Detroit session and also for the use of 2 pages in the Bulletin for the broadcasting of auxiliary news to our members, a much needed medium. The one re- gret is that all husbands are not Fellows, so fre- quently the Bulletin does not And its way to our members. What is the solution of this problem? We have visited 12 different states during the year and we feel the contact personally was not only enjoyable to us but beneficial to our mem- bers. Two thousand pieces of mail have been sent from this office and many more by the chairmen of the committees. We have put forth special energy through our able convention committee to make the Phila- delphia meeting an outstanding success for all who attend. If our efforts during the past year are accept- able to you we are well repaid. Public Relations MORE PERSONS IN MENTAL THAN IN GENERAL HOSPITALS As an indication of the important position occu- pied by mental and nervous diseases in relation to the nation’s health, W. L. Treadway, assistant sur- geon general of the Public Health Service, de- clared in an address before the Southern Medical Association at Louisville, Ky., recently, that ap- proximately 324 persons in each 100,000 of the general population are confined to hospitals for mental and nervous diseases as compared with 192 in general hospitals, says The Modern Hos- pital. “Dr. Treadway pointed out that 45.7% of all hospital beds in the United States are devoted to the care of mental and nervous diseases, and 95.4% of these are occupied”, the writer continues. “Last year 128,964 new patients were admitted to these hospitals and 25,445 were readmitted. Ap- proximately 40% of all persons applying for medi- cal advice at public clinics or dispensaries are suffering from some mild form of mental illness. “For the first time in history a wider interest is now being shown in disorders of the mind by the public”, he said. “Failures and unconventional behavior and conduct are being interpreted not in terms of institutional provisions but in terms of personality factors having behind them mental implications. There is a growing conviction that institutional provision alone is an unwise and uneconomic method of handling this group of the population. Instead, it is being more and more generally recog- nized that community sources of these personali- ties must be uprooted, that mental patients must have an early and adequate treatment, that under- lying causes of mental diseases and adverse social behavior must be discovered by study and investi- gation. “The possible solution of this situation is evolv- ing through the development of psychiatry as a special branch of medicine”, he said. “This special branch of medicine, because of its knowledge of individual needs and requirements, is equipped to offer assistance and guidance to those groups of the population who cannot comply with the liberal standards of conduct maintained by society.” NEW JERSEY PHARMACEUTICAL ASSOCIATION At the Annual Convention, held in Atlantic City, June 16-19, 1931, the following resolutions were unanimously adopted, and a copy was supplied to the Executive Secretary of the Medical Society of New Jersey, who was officially representing the Medical Society at that Convention, for publi- cation in the Journal: Resolution No. 1 Whereas it is becoming a rapidly growing prac- tice among pharmaceutical manufacturers to com- pound various well-known formulas and introduce them to the medical profession under proprietary names ; and Whereas such preparations contain ingredients of known and definite standards and which are usually found in all prescription departments of the drug stores; and Whereas the pharmacist is capable of compound- ing these preparations without any difficulty, and Whereas the introduction of these preparations under proprietary names, and in easily identified packages, designs or colors, increases the ten- dency to self-medication, since usually these pro- prietary names are of such character qs to be perfectly legible to the lay public, and Whereas the recommendations of these prepara- tions through prescribing, by the medical profes- sion, is accepted by the public as an unqualified endorsement for the preparation, Be It Resolved: That the New Jersey Pharma- ceutical Association, in the interests of a closer cooperation among the physician, pharmacist and patient, deprecates the practice of prescribing, recommending and fostering the use of such preparations under proprietary names. Resolution No. 2 Whereas the quality and standard of all U. S. P. & N. F. preparations must conform with the requirements of the United States Pharmacopoeia and National Formulary, and G 72 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 1931 Whereas the letters U. S. P. & N. F. have been symbolic of the professional pursuit of the phar- macist; and Whereas the sale of such preparations under the name of the pharmacist has served as one of the remaining links whereby the public has be- come acquainted with the professional and ethical side of the business of the pharmacist; and Whereas the market for U. S. P. & N. F. preparations has been made primarily through ef- forts of the pharmacist; and Whereas it is becoming the practice of certain pharmaceutical manufacturers who derive their business from the pharmacist, to advertise U. S. P. & N. F. preparations under the manufacturers’ brand, and- Whereas such advertising is designed to create in the mind of the public the impression that such preparations are in the same category as patent or proprietary medicines; and Whereas such advertising also tends to create in the mind of the public that unless such prepara- tion bears the manufacturers’ label it may be an inferior product; and Whereas such practice compels the pharmacist to carry an unwarranted duplication of stock; and Whereas all of such practices are inimical to the profession of pharmacy : Be It Resolved : That the New Jersey Pharma- ceutical Association is opposed to the advertising to the public of U. S. P. & N. F. preparations under the manufacturers’ brand or label. STAGING A HEAI/TH DRIVE AMONG PRE- SCHOOL CHILDREN (From the Bulletin of the State Department of Health we have selected an item which is not only of general interest but which records a bit of his- tory that may serve well as an example for other towns and counties of this state. If every local committee that was left in charge of the Anti- diphtheria Campaign will adopt, adjust to its own needs, and follow this procedure actively. New Jersey can be rid of diphtheria in short order. — Ed.) Woftien of Woodbury, Gloucester County, re- cently conducted a campaign to induce parents to have the smaller children of the city protected against diphtheria. Diphtheria prevention clinics have been held in the city since 1923 and were patronized by some 1400 youngsters. About 70 children below school age also attended these clinics, but no systematic effort was made to get young children immunized until the 4 groups of the local Parent-Teacher As- sociation undertook the task a few months ago. The Visiting Nurse Association joined in this drive and together they worked out what the department terms an admirable type of campaign. First, approval of the local physicians was ob- tained for the proposed plan. The Board of Health also approved and gave a statement for publica- tion in a local paper. Various organizations were reached through speakers or messages and their endorsements published. Two doctors besides the school medical inspector wrote short articles for the paper. Publicity also included motion pictures and suitable literature. Finally the city was divided into districts by the Parent-Teacher Association leaders, and canvas- sers were assigned to make house-to-house visits. Parents were urged to take pre-school children either to family physicians or to the clinic for treatment. This canvass resulted in a list of well over 200 names of children to be immunized. The committee notified each doctor of those whom he might ex- pect to be brought to him. At the first pre-school clinic held, 102 children received their initial dose of toxoid, which is being used in place of toxin- antitoxin for this group. THE ST PERTRA1 N EI) NURSE (From the Indiana Journal, June 1931.) We have been asked why The Journal is op- posed to advanced education and training for nurses. We thought that question had been answered in comments made heretofore, but we are very glad to say a few words more on the subject. In the first place, while there is need of the expertly trained nurse, yet she actually is required in less than 5% of the cases that re- quire nursing. The balance of the cases -will do very well with a less highly specialized type of service. Second, the expert nurse demands and should have compensation in keeping with the time and expenditure put upon her education and training, and the quality of services that she is rendering. The average sick person is unable to pay for this service, and especially when, as a result of the short hours which these highly specialized nurses will work, it becomes necessary to have 2 nurses. Third, for a very large per- centage of the number of cases that actually re- quire the services of a nurse it is quite sufficient to have a nurse who knows how to give the gen- eral care needed, who can follow orders, and who can observe and report symptoms accurately. Such nurses may be created without requiring a high school diploma or records of college attendance, or 3 or 4 years of supertechnical instruction such as is given in some nursing schools that supposedly are turning out merely general nurses. Many of these supertrained nurses have neither had nor have they sought the requisite amount of prac- tical bedside training. Fourth, there is a crying need for thousands of old-fashioned nurses who know enough about caring for the sick to be ex- ceedingly useful and abundantly efficient and help- ful to both physician and the sick without pos- sessing so much of the supertraining that now is demanded of every female who is licensed to nurse or holds herself out as being a trained nurse, and who is willing and glad to work for compensation that is in keeping with the ability of 75% of the sick people to pay. We have no objections of any kind whatsoever to any high standards established as a requisite and a requirement for the highly trained nurse who expects to do technical or specialized work, but we do object to compelling all those who attempt nursing to comply with such standards. Our plea is for a very satisfactory and useful nurse, duly accredited, who can be made very satisfactory to the majority of sick persons, without this supertraining and without costing the patient so much as the supertrained nurse expects and should have as compensation. We also make a plea for more nurses who are willing to take cases as they come, just as the ordinary physician does, instead of politely but emphatically refusing to nurse only certain kinds of cases, to nurse only in a hospital, or perhaps August, 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 673 refusing to nurse at all unless the eases and con- ditions relating thereto meet with exacting re- quirements. Lastly, we are in favor of hourly nursing in the home and group nursing in the hospital by graduate nurses when needed, thus making it possible for more people in moderate financial circumstances to afford the graduate nurse. School Health Department PUPIL SUPERVISION Allen G. Ireland, M.D., Director of Physical and Health Education, State Department of Public Instruction, Trenton, N. J. Home Visiting Nurses are frequently required to visit the homes of pupils absent from school for unknown cause. The value lies in the first-hand informa- tion obtained and in the opportunity of imparting instructions to the mother. However, attendance work should not be allowed to interfere with other duties of the nurse. By having attendance officers report to the nurse daily, it is possible to keep a check on all absences. The period allowed to elapse before following-up an absence should rarely exceed 2 days. Keeping Schools Open Detection of new cases and contacts is facili- tated by keeping schools open in time of epidemic. With proper precautions, the amount of exposure at school can be kept at a minimum:; less, it is thought, than occurs among children when schools are closed. With pupils at school, it is possible to hold in- spections once a day, or more often if desired. It is possible to train and instruct pupils at such times in how to protect themselves, and in what to tell their parents. It is also possible to keep an accurate check on progress of the epidemic and the measures in operation for checking it. Cooperation in Disease Control Effective disease control depends to no little extent upon the cooperation among physicians, health officials, and the school personnel. The purpose and the program of the school should be made known to the practitioners of a community. It is especially important to have the rules for exclusion and readmission understood. Rigid en- forcement can only be effected when local physi- cians uphold the school in its efforts to prevent spread of the disease. A system of interdepartmental reports is essen- tial. The exchange should be daily, the school officials reporting exclusions and suspects, and the health officials reporting cases in the community. Similarly, school nurses and community nurses should establish a working basis for exchange of information and, in particular, a procedure for co- operating when an epidemic is threatened. Emergencies at School It is well to be prepared for emergencies and epidemics. A program of procedure should be carefully planned, put into definite form, printed, and circularized. Every person in the school sys- tem should know his part letter perfect. The latest telephone directory should be avail- able. In cases where both parents work away from home during the day, it may be of value to know where and how one or both may be reached. The addresses and telephone numbers of several physicians residing nearest to the school, including the school physician, should be typed on a card and placed near the telephone and in sight. The telephone numbers of the nearest taxicab station,, of the nearest hospital, and of the nearest garage where an ambulance or other conveyance may be engaged, should also be placed in a conspicuous, and permanent place known to all. State Health Department SPOTTED FEVER D. C. Bowen, Director of Health New Jersey State Department of Health Trenton, N. J. A case of spotted fever has been diagnosed in New Jersey and confirmed by the State Depart- ment of Health and the United States Public Health Service. The disease is new for New Jersey and attention of physicians is called to its dis- covery so that practitioners may be on the look- out for other instances. The case recently discovered was in a farmer, 32 years old, residing in the vicinity of Port Mott, Salem County. The infection is transmitted by the bite of a blood-sucking tick, and a definite his- tory was obtained that this farmer had been bitten by a tick. The investigators learned that the victim had not been more than a few miles away from the immediate vicinity of his home, and the authorities were satisfied that the infection oc- curred locally. In the onset of this disease the symptoms re- semble those of epidemic cerebrospinal meningitis. A few days after onset an eruption appears, most apparent upon the wrists, hands, lower legs, feet and back of the victim. The disease has not been declared reportable to the state authorities in New Jersey, but services of the State Department of Health were sought and an investigation made. The state authorities called in a representative of the United States Public Health Service, and the diagnosis of the disease as spotted fever was con- firmed. The patient was first taken ill May 23 and was moved to a hospital 3 days later. The eruption was first noticed May 27. The case was a relatively mild one although 2 weeks after onset of the ill- ness the patient’s hearing was still affected and he was subject to dizziness. According to the United States Public Health Service, the commonest symptoms at the height of the disease are, in order of frequency, as fol- lows; Prostration; headache, usually frontal; con- stipation; nausea and vomiting (more frequent in the Rocky Mountain spotted fever type) ; low backache and leg pains; unproductive cough. In the Rocky Mountain spotted fever type, pain in the back of the neck, and abdominal pains were not uncommon. Sweating was not uncommon. Rare symptoms were epistaxis and dysuria. JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 1931 6 74 Communications To the Editor: The enclosed manuscript is sent you in order that you may know something of what the dental profession is doing in a field in which we believe all branches of the medical profession are interest- ed. The Committee on the Study of Dental Prac- tice agreed that in the proposed investigation of medical insurance to attempt the separation of the dental from the medical phases would be impossible. The interests of the professions concerned are not and cannot be disassociated. Therefore, it is fundamental for the dental profession to realize that whatever happens to the medical profession is, for the dental profession, in the nature of a prediction. ARE WE FACING SOCIAL CONTROL OF MEDICAL PRACTICE ? (Signed by the Committee on Study of Dental Practice, H. E. Phillips, D.D.S., Chairman.) Call it “Sickness” or "Health Insui-ance” the “Panel System” or “State Medicine”, no legislation has so greatly affected so many people as that for the social control of the treatment of disease. No section has been so deeply affected as the dif- ferent branches of the profession dealing with the treatment of disease. This applies almost equally to physicians, dentists, nurses, and to nearly all the institutions concerned with human ills. These various divisions of the medical profession must suffer or profit together from the workings of such legislation. It is impossible to separate their fates, even in discussion, and certainly not in programs of action. To emphasize this solidarity the words medical profession are used to include all those so affected. Since Bismark compelled enactment of the first compulsory social insurance laws in 1883, similar laws have been enacted in practically every Euro- pean nation, in Japan and several South Ameri- can countries, and are under favorable considera- tion in nearly all other countries, including Can- ada, Australia and South Africa. The International Labor Conference, which in- cludes every nation belonging to the League of Nations, at its meeting in 1927, adopted an agree- ment binding all members to introduce compulsory sickness insurance as soon as possible. While much is made of the distinction between compul- sory and voluntary systems, there are few of the latter without some compulsory features. The dif- ference in degree is so slight that it is hard to draw the line between them, especially as the voluntary systems are constantly adding compul- sory features. In the United States, workmen’s compensation laws have already given us a system of compul- sory accident insurance in all but 4 states, while a constantly increasing number of states are ex- tending these laws to cover “occupational dis- eases”. Many features of compulsory insurance treatment have also been included in recent vet- eran's legislation. All of these measures affect the practice of dentistry. All forms of insurance tend to expand, to cover new classes, to give more generous compensation, and to extend any service once offered. In Ger- many this tendency has reached a point where but 5% of the medical profession is engaged in private practice. This percentage is higher in other countries having sickness insurance, but in few does it reach 50%ir This matter falls within the jurisdiction of state, legislatures. There are 48 states and it will be a miracle if some of them do not soon make the experiment, especially in time of industrial de- pression, which always produces social legislation. Such a change would deeply affect the income, professional standards, methods of work, freedom of practice, all relations with patients and nearly every other feature of the lives of all the physicians and dentists, whether they came di- rectly under the operation of the law or not. There is hot dispute as to the nature of these effects. Opponents declare that such legislation degrades the entire healing profession; encourages mal- ingering; reduces incomes; leads to superficial, stereotyped treatment after hasty diagnosis; in- 1 troduces lay control of professional matters; and generally demoralizes all relations with the patient, j Advocates urge that it brings increased income, \ especially to the beginning practitioner; that it brings medical care within the reach of large masses hitherto excluded makes early diagnosis universally possible; and leads to general better- ment of health conditions. Part of this disagreement is due to the multi- tude of insurance systems. These differ, not only I as to countries, but every system changes con- i stantly and produces different results at different times. In planning a program in relation to such legislation it is of paramount importance to know whether a certain good or evil result is inherent in the insurance system, or is peculiar to certain times and places. It is also important to know whether the good results can be obtained by other means and, especially, whether — if insurance be pressed upon this country — it is possible for an , organized medical profession to secure such pro- visions as will avoid its evils. It is to obtain the information that will help I the entire medical profession to meet this possible threat, in such a way as to utilize any action that may result to the best interests of the public and the profession, that the Committee on the Study of Dental Practice of the American Dental Asso- ciation is conducting a study of all phases of sick- j ness insurance in Europe and America. As fast as the results of that study are available they will be placed before the members of the American Dental Association, and will be available at any time in the future when such legislative pro- posals are under consideration. (To be continued.) FORTY-NINTH ANNUAL REPORT OF THE SOCIETY FOR THE RELIEF OF THE WIDOWS AND ORPHANS OF MEDI- CAL MEN OF NEW JERSEY The Society is in a very healthy condition. We have maintained our membership and have been able to assist a number of widows and orphans who were in need of some financial aid. The Permanent Fund now amounts to $47,100.53, and the income from this sum was $2,382.46. The proceeds of the Permanent Fund, as you know, may be used to give financial aid to the widows and orphans of former members. As in previous years, we have found it difficult to ascertain the names of those who may be in need of our help. August, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY CM so again we ask our members to communicate with the President or Secretary regarding any widow or orphan who is in need. At the present time we have 498 members; 35 new members were elected and 5 have resigned. We are sorry to report that we were obliged to drop 17 members because of non-payment of dues. Tour Board of Trustees always endeavors to induce members not to allow themselves to be dropped, because we feel we need them and they need us: not, perhaps, for any financial reward they may receive, but for a far better reason, the privilege of helping others. During the year we lost by death our faithful Secretary, Dr. Charles D. Bennett. He was one of our earliest members, and served for many years as secretary. No one loved the society more, or gave more of his time and thought to its work and welfare. His courtesy, efficiency, and willingness to serve in all capacities, will long be remembered. We regret to report the loss by death of 13 other members during the year: Drs. W. C. Lieb- man, W. S. Washington, G. K. Dickinson, C. A. Limeburner, E. W. Hedges, H. W. Nolte, Jean Wolfs, Daniel McCormick, B. Van D. Hedges, R. Kuehne, J. H. Moore, Paul Fitzgerald and F. C. Demarest. Dr. Edward J. Ill, on June 12, 1930, delivered an address before the Woman’s Auxiliary to the Medical Society of New Jersey, in which he said: “I am thankful to be able to present some facts which should of necessity interest you. If it is not for your personal benefit, you should be aware how many doctors leave their families in a desti- tute condition and how our society has been able to relieve much real distress. The Society for the Relief of Widows and Or- phans of Medical Men of New Jersey has been in existence for 40 years. It has 500 members. At the annual meeting on May 14, 1930, the Treasurer reported a Permanent Fund of $44,930. The in- come from the fund amounted to $2316.63. This income may be distributed to such widows and or- phans as in the opinion of the trustees is thought wise. The trustees wish to help such as are in need. It is not considered a charity by the trus- tees but a right to which such widows and orphans are entitled. I am asking you now to present to me the names of such widows and orphans of members, who are in need, so that the trustees may take such action as they think wise to give some relief. It has been most difficult to get the names of such as are in need. A false modesty, or let us call it pride, may be at the bottom. Let us remember that the needy have a right to request aid. A few months ago, Dr. Ill mailed a copy of his address to the wife of each medical man in New Jersey. Through this appeal 25 new members were obtained and we have great hopes of receiving more. Dr. Ill took his valuable time to do this, and also bore the entire expense. Later, when the Board of Trustees met and tried to reimburse him for the expense, his answer in a quiet, gentle way was — “No, it was a labor of love”. That is per- haps the best motto for our society: A labor of love. Respectfully submitted by W. D. Miningham, M.D., Secretary. ANOTHER QUESTION OF ETHICS (A letter received from Dr. Elias J. Marsh, of Paterson, Treasurer of the Medical Society of New Jersey.) Editor of the Journal: In common, doubtless, with many other of our members, I have received a circular letter from a firm of stock-brokers in Philadelphia, offering' to sell me shares in various manufacturing pharmaceutical houses, on the ground that “as a member of the medical profes- sion, you are, no doubt, interested in corporations whose products are extensively used in the prac- tice of medicine”. Of course, stock-brokers can- not be expected to be interested in professional ethics, but I should like to know how our Judicial Council, or the editor of your department of Ethics, regards this suggestion. It seems to me intoler- able that a physician should have an interest in prescribing a certain article, or drug, when his judgment tells him that another is better for his patient in any given case. No one preparation is the best for all cases, and no one house produces the best preparation of every kind. It is hard enough to control our prejudices or habits in favor of certain articles; we should not increase the difficulty by adding a personal interest. Signed — E. J. Marsh. The Editor's Answer The Editor replied to the above letter by saying that he, too, had received the stock-broker’s offer, and was considering how best to present his own opinion to members of the society; and, saying further, that the letter (reproduced above) would be used in this manner. So, the Editor gladly avails himself of this opportunity to endorse Dr. Marsh’s interpretation of our professional ethics, and to add that he would consider acceptance of the stock-broker’s proposition — a gross violation of ethics. We hope none of our members will “fall for” such a business temptation. AN INTERESTING ITEM OF HISTORY (Letter received from Dr. Albert S. Tenney, of East Orange.) To the Editor: One of my patients in West Orange, while exploring the attic of her mother’s home, discovered an old copy of the Saturday Evening Post, dated February 13, 1830 — a little more than 101 years ago. Perhaps you are aware that this famous periodical was at that time in its 101st year. Curiously, it had not up to that time changed its size or number of pages, of which there were only 4, from Benjamin Franklin’s or- iginal copy issued in 1729. On the second page of the found copy is a statement of deaths in “The City and Liberties of Philadelphia” during the year 1829. “Consumption” and “Cholera” headed the list of diseases, with 638 and 257 deaths respectively. There were only 5 deaths from “apoplexy”; but 34 from “drunken- ness” and 94 from “Mania-a-potu” (which for our younger readers may be translated into delirium tremens); 280 died of “debility”: 31 of “mortifica- tion and gangrene”; and 29 were “found dead”. It also lists 67 deaths from “hives”, which seems pe- culiar, and gave other diagnoses which sound strange to our ears. 676 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 19 31 Woman’s Auxiliary PANORAMIC VIEW OF THE WOMAN’S AUX- ILIARY TO THE A. M. A. IN FOUR ARTICLES No. 4. Western District Mrs. James F. Percy As my division in the organization work covers the states of the far West, branching to the middle states only to include Nebraska, this panorama will begin there. We have been enjoined for so many years to “Go West", that it has now become a favorite direction of travel. Nebraska is always up and doing, and a survey of activities of 1931 shows an extensive distribu- tion of the National Auxiliary Study Envelope on “Communicable Disease Control”; much welfare work, especially providing professional visiting nurses for public schools in various counties and definite organization of county relief work at a great saving to the County Commissioners. Here, indeed, is a far-reaching benefit for the commun- ity-at-large in a practical, economic way. Bene- fits are held to procure funds for completing files of scientific books and magazines and research work of the pathologic laboratory connected with the Sharp Building Library, at Lincoln. The Aux- iliaries’ scientific educational programs contain many important names, which, together with social and philanthropic activities, keep everyone inter- ested, useful and happy. One new county auxiliary has been reported as a last gift to this administra- tion. Colorado has kept up the interest aroused dur- ing the national presidency of Mrs. F. P. Gengen- bach, of Denver, particularly with spreading ideas of good and better health through the use of litera- ture in the less populated districts. Included with this, “study envelopes” have been used, and a greater field developed for approved health pro- grams in other organizations. Growth in numbers has not been sought so much as growth in achievements. Wyoming must be passed as having been silent to all requests for even a hint as to its status. Geographically, Wyoming and Utah are difficult of organization, but within the few years that lie immediately ahead they are certain to be caught in the vibration already swinging its way through- out the land and we feel sure they cannot long be resistant to its call. Utah has already given ex- pression, through her women visiting other states, that she is ready to take action to further a prop- erly organized auxiliary. New Mexico, with but 1 county, Bernalillo, or- ganized, and far from all centers of activity, has been an inspiration in her efforts to follow the National precepts. Unless one has traveled the great spaces of the deserts of the southwest, no conception of distances can be formed. This single county has taken up child welfare work, shle of tuberculosis seals, enjoyed programs from its medical men, County Health Nurses and the State Director of Public Health, and carried the social activities of the State Medical Society Con- vention. It is few in numbers, but verily the leaven quickeneth the whole loaf. Arizona has trebled its units from 1 to 3, but has found organization work difficult because of dis- tances. Social features have prevailed, unless some definite need loomed in the offing, such as the Basic Science Bill, for the passage of which the State Auxiliary made great effort. In a state so filled with cults, the passing of that Bill by the Senate was a real achievement, even though it was finally held up in Committee. However, nothing daunted, the members are now aroused to the possibilities and usefulness of an auxiliary, and experienced women are stepping forward, willing to serve and assist in making an active, worth-while organization. California has been concerned, aside from or- ganization, with establishing itself upon a per- manent foundation through a proper Constitution and has been able to do- this with the full sup- port of the California Medical Association, which is printing these Constitutions as a gift to the State Auxiliary. At the recent State Meeting, held in San Fran- cisco, April 27-30, 165 women registered, with 55 delegates and 115 women seated at the annual luncheon. The Auxiliary now feels safely estab- lished. The keynote of each county report was educa- tion, but the social side, welfare work. Red Cross, changing the position of a State Senator, creating sentiment for a Tuberculosis Sanatorium, local philanthropies, all had their places with the scien- tific programs. A chart — "The Technic of Follow- ing a Bill Through the Legislature’’ — provided a most unique, striking and valuable object lesson as to what we are all up against in our legisla- tures. A resolution was introduced, adopted, and di- rected to the National Committee on the “High Cost of Medical Care”, asking for a change in the name under which that Committee functions, to one more in accord with the facts it is study- ing, namely: “The High Cost of Illness or Sick- ness”. The original name implies some fault of the medical profession: while the proposed name is inclusive of all the various factors involved in the problem. A copy has been sent to the Na- tional Auxiliary asking endorsement of said reso- lution at the Philadelphia Convention. The Cali- fornia Medical Association is presenting a similar resolution to the House of Delegates, A. M. A., whose membership now closely approaches 900. The interest shown and the friendliness in the social life at this Convention demonstrated a new order which we hope has come to stay. Oregon has chiefly concentrated upon organiza- tion work and revival of general interest this year, through providing the units with a list of suggested “study topics” to encourage a similarity of subjects. Portland has monthly meetings with speakers who use the material contained in the “study envelopes” and is extending her educational and philanthropic interests as well. Temporary or- ganization in one county is hoped to soon become permanent, thereby increasing the number and justifying the work of the state officers. Washington is showing great interest to be- come organized and after considerable correspon- dence, it has been deemed best to have the pri- mary action come through the State Medical Meet- ing which takes place soon after the Philadelphia Convention. We feel it is safe to prophesy that Washington will be on the list of organized states for our successor. Idaho is listed as an organized state, but as all letters have remained unanswered the panorama must end here. August, 19 31 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 677 To those who were fortunate enough to attend the National Meeting' at Philadelphia, no further stimulus will be needed. Each state will be eager to carry out the aims and the ideals of the parent organization. We learn from those who have achieved, and in Pennsylvania the accomplishments of the Aux- iliary, together with the cojnplete plan for the National Convention, will give a wide understand- ing of a still greater organization and insure a generally more important recognition in the days to come. County Society Reports ATLANTIC COUNTY: Atlantic City Hospital Staff Joseph H. Marcus, M.D., P.A.C.P., Secretary The regular monthly meeting of the General Staff, Atlantic City Hospital, was held in the Audi- torium June 26. The scientific program was presented by Dr. John S. Irvin, Director of the Dispensary, who detailed the activities 1 of the dispensary for 1930. Total number of dispensary visits, 35,040. Dr. A. M. Rechtman, Associate in Orthopedic Surgery, presented some clinical cases. Dr. E. Harrison Hickman read a paper on “The Problem of Tuberculosis Among Children’’, as follows: Within the past decade, the conception of tuber- culosis, particularly with regard to children, has undergone a great change and out of it has evolv- ed the belief that tuberculosis is primarily a dis- ease of childhood. Two distinct types of tuber- culosis infection are now described — the primary or childhood type, and the reinfective or adult type. Primary infection is more common in the child and reinfection in the adult, but either type may occur in either period of life. Of course, the knowledge that tuberculosis generally origi- nates in childhood has induced special efforts at early diagnosis and treatment to avoid the infec- tions that occur in later life. Diagnosis of tuber- culosis in children, by consideration of the history, symptoms and physical signs, is no longer thought possible, but by means of newer procedures much may be accomplished. The tuberculin test and x-rays are indispensable in this work, but even these are not conclusive in themselves. The ul- timate diagnosis rests upon correlation of all the evidence, hence the adoption of a routine diag- nostic procedure. Our procedure, modeled upon that employed by the Massachusetts Department of Public Health, and which represents what is now generally recog- nized as being the most effective and most eco- nomic, provides for tuberculin test of all children. One physician can test 200 to 300 children per day, and 48 hours later the reactors are listed. Each reactor is sent to a roentgenologist, and those who show definite findings must undergo a thorough physical examination. A full statement is given to the parents or guardians, with recommenda- tions, and the child is provided with appropriate treatment. This “case finding procedure’’ has much to recommend it, and the plan, according to Chad- wick, works out approximately as follows: for each 100 children, including high school pupils, given a tuberculin test, 30 will be positive re- actors; of these 30, when x-rayed, 5 will show ab- normal shadows on the film which will make a physical examination advisable. Careful physical examination is then required for only 5 out of each 100 children. A word about tuberculin testing, which is the basis of our diagnostic weeding-out process. Many tuberculin tests have been devised and advocated, but only 5 have had any prolonged usage. Koch’s original test depends upon the subcutaneous in- jection of “Old Tuberculin” in dilutions of in- creasing strength ; now used only upon rare oc- casions because the resultant focal and general reactions are sometimes severe. The Moro test is performed by rubbing an ointment, containing 50% Old Tuberculin, into the skin of the chest or abdomen, and a positive reaction is indicated by a papular area of redness which appears in about 24 hours; a high percentage of positive reactors is claimed by some and it is used extensively in Europe and to some extent in this country. The Calmette test consists in placing a drop of 1% Old Tuberculin directly on the conjunctive, and a positive reaction is indicated by development of conjunctivitis; although great reliability is claim- ed for this test, its use is hampered by the danger of permanent injury to the eye. One of the earli- est, and still the most popular, of the tuberculin tests is that devised by Von Pirquet, which has the advantages of great simplicity and a fair degree of accuracy; it is performed by abrading the skin of the fore-arm and applying 1 drop of concen- trated Old Tuberculin, and a papular area of red- ness appearing in 12-96 hours constitutes a positive reaction. The test which is now supplanting all others is that suggested by Mantoux and Mendel and which carries the name of the former. This method possesses several advantages. It is simple; can be performed in a standard manner; the dose can be accurately measured; result is easy to inter- pret; it gives a slightly higher number of re- actors than the Pirquet method; it is a rough in- dex of the degree of activity; and is not harmful to the patient. The Mantoux test, which we use exclusively, is the intradermal injection of Old Tuberculin in measured dilutions; dosage in our clinic is 0.01 mgm., 0.1 mgm., and 1 mgm. Old Tuberculin in 0.1 c.c. of sterile normal salt - solution. Reactions appear from 12-72 hours later, the greatest num- ber occurring at about 48 hr., at which time tests are read. If the individual does not react to the weakest dose, he is tested successively with the more concentrated solutions. In this way, re- actors are often discovered after being negative at the first reading. An important point to be noted in reading a tuberculin reaction is that the lesion consists of 2 parts, a central area of edema and a surrounding zone of erythema. The redness should be entirely disregarded, as it is believed to be a non-specific phenomenon. In this respect the tuberculin test must be differentiated from the Schick and Dick tests, in which the area of discoloration is of primary significance. In the Mantoux test, the area of edema alone indicates sensitization to the toxin of the tubercle bacilli. What is the significance of the tuberculin re- 678 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY August, 19 31 action? It has been pointed out repeatedly that it does not always denote active disease, especially in older individuals, nor do any of the men who now employ it make such a claim. Failure to realize that a positive test does not constitute a diagnosis of activity is responsible for many clini- cal errors. A positive result does, however, indi- cate tuberculous infection, latent, active or heal- ing, and the younger the patient, the greater is the probability of activity. Intensity of the reaction is of some importance. In general, the more active lesions are attended by more severe response than quiescent lesions. However, it must be admitted that this seeming relationship is not universally accepted, for many observers have reported quiescent cases with severe skin reactions, and vice versa. Prognosis and type of treatment depend upon the extent of the disease and the child's individual response to the disease. Based upon this, we divide our positive cases into 3 groups. In general, children who react to the tuberculin test but show no roentgenograpbic evidence, those with circumscribed calcified parenchymal nodules, and those with healed tracheobronchial nodes, need no special attention except periodic examinations at intervals of 6 weeks to 1 year. In this group the prognosis is excellent. The individuals are regarded as healthy, and no restriction is placed upon them. A second group contains those children who are in danger of tuberculosis that will undermine health and who should receive the preventorium form of treatment. They show first, latent lesions of the childhood type; second, tuberculous tracheo- bronchial nodes when contact with open tuber- culosis is still present, when the tuberculin reac- tion is intense or when the lesions are very large; third, latent adult tuberculosis; fourth, arrested pulmonary tuberculosis; and fifth, lesions of the first group -where impaired health, perhaps not due to tuberculosis, is present. Since February, 3 patients from this group have been sent to the preventorium at Farmingdale, and several others have been referred for admission. The third group contains those children who should receive sanatorium treatment, those who show' both x-ray and physical signs, who show progressive lesions on repeated x-ray examinations, or who have massive uncalcified tracheobronchial lymph-node involvement. Three children of this group, with moderate activity, have been sent to Glen Gardner and 1 advanced case to Pine Rest. If children of the preventorium and sanatorium groups receive proper care, they are usually able to successfully combat the disease. However, they sometimes succumb to an excessive infection due to the breaking down of supposedly walled-off tracheobronchial nodes. The presence of such nodes should always be regarded as a potential source of danger until the period of early adult life is established. I believe that tuberculosis will eventually be treated as a public health problem. Bike diphtheria and small-pox, it should be added to the list of diseases that can be attacked with advantage in the schools, and every child, whether or not sus- pected of harboring the disease, should be ex- amined for tuberculosis by some method similar to the one described. Discussion followed by Drs. Fish, Salasin, Mar- vel, Rosenblatt. Andrews and Marcus. CUMBERLAND COUNTY K. S. Corson, M.D., Reporter Dr. Reba Lloyd, President of the Society, opened the hospitable doors of her suburban Sanatorium, Ivy Manor, to receive as guests the members of the County Medical Society together with several visitors from Salem and Gloucester Counties. An interesting report was given of the progress of plans for the inter-county Tuberculosis Hospi- tal. The selection of a central and suitable site seems to be the main point to be settled. Dr. Robert Sturr discussed the new diagnostic features of gall-bladder and gastro-intestinal tract disease. Discovery and use of newer dyes has made possible the demonstration of every form of gall- stones, and the need of surgical exploration, for determination of the character of most diseases of this part of the body has practically been elimi- nated. Dr. Graham brought out the accurate use of dyes by the intravenous method, as they are not then diluted by the gastric juices. Nonfilling gall-bladder is pathologic. Stone in the com- mon duct is less easy of detection. Gall-blad- der function test is important, and adhesions and surrounding fat change its features. Cardiospasm of the pylorus may be differentiated from ulcer by use of belladonna. Ulcers of the duodenum are never malignant. Those of the stomach are usually of the small penetrating type. Intestinal obstruction is indicated by the step-ladder appear- ance. Dr. John H. Kolmer, wh o endears himself to every audience by his personality and masterly delivery of his subject, spoke on “Infection of the Blood Stream’’. UNION COUNTY Russell A. Shirrefs, M.D.. Reporter A regular meeting of the Union County Medical Society was held on the afternoon of July 8. at Bonnie Burn Sanatorium. Scotch Plains, with President Vinciguerra in the chair. It was a pleasure to have with us as distinguished guests, Drs. John Hagerty, President; .T. B. Morrison, Secretary, and C. C. Beling, Councilor, of the State Medical Society; each of whom spoke and interest- ingly outlined the work of his respective depart- ment. On account of the heat, routine business was reduced to a minimum. Dr. John E. Runnells, Superintendent of Bonnie Burn, addressed us on the subject of “Tuberculosis”, with especial refer- ence to compression of the lung in suitable cases. His talk was illustrated by many x-ray pictures. At the close of the meeting a “shore” dinner was served in a nearby grove. Obituaries KOCH, Louis A., life-long resident of Newark, and since 1902 a Newark physician specializing in dermatology, died July 7, 1931. at the home of his brothers, William and Paul Koch, 44 Johnson Ave- nue. He was 53 years old. Dr. Koch had been ill many months. He was on the staff of the Newark City Hospital and head of the Dermatology Department of the Newark Dis- pensary. Dr. Koch was graduated from the medical school of the University of Maryland. Besides being a member of the Newark Lodge of Elks, he belong- ed to many medical societies. 670 Journal of The Medical Society of New J ersey Under the Direction of the Committee on Publicatio® Vol. XXVIII., No. 9 ORANGE, N. J., SEPTEMBER, 1931 Year PLASTIC SURGERY; INDICATIONS AND RELATIONSHIP TO OTHER SPECIALTIES Jacques W. Maliniak, M.D., New York City Plastic surgery receives equal recognition with the other special services in every mod- ern hospital because of the numerous condi- tions requiring plastic repair and in the in- terest of advancement of this relatively new specialty. Only within comparatively recent times have medical colleges and general hos- pitals established services for plastic surgery, and there is a lack of uniformity in its status in the general hospitals ; some having organ- ized it as an independent service, and others having combined it with the departments of oral surgery or of rhinolarvngology. The ne- cessity of this special service is not as yet realized by all medical boards, so there is need for further enlightenment. Preventive Measures in Injuries oe Soft Tissues The United States Bureau of Statistics re- ported more than 1,000,000 injuries and 52,- COO deaths due to automobile accidents alone in the year 1929. A toll of approximately 10,000,000 accidents of all kinds in this coun- try during the past year is reported by the Metropolitan Life Insurance Company; and, at the present rate, 100.000 automobile casual- ties are estimated for 1931. Most of the in- juries incurred in such accidents require medi- cal and surgical attention. Thorough emer- gency repair of soft tissue injuries would be of much avail in the prevention of conspicuous deformities, in the preservation of function, and in the reduction of economic waste. Hematoma, infection and inaccurate adjust- ment of tissues tend to result in a prolonged healing process, with undue scar formation and disturbance of function. The healing process of a properly treated wound requires only a few weeks, but may be protracted to months or years in the event of inadequate first aid treatment, and thus cause unnecessary suffering and economic loss. The vast number of highway and industrial accidents in this country demands the estab- lishment of ^appropriate treatment facilities in general hospitals. Emergency surgery, re- quired in extensive lacerations of soft tissues, particularly those about the face and neck, should not be left to the judgment of an in- tern, as is so often the case in general hospi- tals, but should be supervised by a competent plastic surgeon. If the accident occurred sev- eral hours before the injured person was brought to the hospital, and under unfavor- able aseptic conditions, immediate disinfection of the wound by moist warm dressings and liberal use of Dakin’s solution, is the safe procedure, postponing surgical repair for 24- 48 hr., when a culture from the wound may prove negative. Far more satisfactory end- results are obtained by the later repair of soft tissues in a properly equipped operating room, without haste and undue tension, than bv im- mediate repair in the emergency room. 6S0 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 1931 Surgery of Soft Tissue Defects Burns and motor accidents cause the largest group ot' disfigurements, the end-results of which may affect function of the involved part, as well as the vocational and social status of the individual. Proper management of burns requires the most painstaking and elaborate reconstructive procedures in order to secure satisfactory cosmetic and functional results. Exposed nerves, tendons and joints must be adequately protected by adjoining area as nearly as possible. A pedicled skin flap may not be available, but even when it is, conspicuous scarring may result. Repair of a skin defect by repeated, partial excisions is the method of choice, and should be applied whenever possible. Successful reconstruction of large defects, following cancer surgery, especially in the maxillofacial area, encourages a more thorough eradication of the disease and pro- motes the chances of cure. A. Figure 1. (A) Nullipara, aged 22, with con- spicuous pendulous breasts; patient suffered from pain around the shoulders and chest. Marked ky- phosis and faulty posture; marked mental depres- sion. pedicled flaps or by free full-thickness grafts. When the involved part does not interfere with an important function, a thick Thiersch graft will furnish a satisfactory covering. Full-thickness grafts often “take" on the fore- head but usually will not on the cheek or neck, because complete immobilization of the region is difficult. Thin skin grafts have a pronounced tendency to contract and, conse- quently, should not be used in treating wounds around the facial cavities and neck. In burns and other extensive wounds of the face, re- pair is to be done by use of a skin graft which in texture and color matches the surrounding B. (B) Same patient 3 weeks after operation which consisted in subcutaneous transposition of gland with nipple, resection of fat tissue and mastopexy to the pectoral fascia. The principal scars placed in the submammary fold and around the nipple 1 are barely noticeable a few months after operation. Indications for Plastic Repair of Pendulous Breasts Until recently, reconstructive surgery of pendulous, hypertrophic and atrophic breasts has been largely neglected, particularly in this country. A review of the literature of the past 2 decades reveals a great interest in the subject by leading European surgeons. Surgi- cal procedures for relief of this condition have been described by recognized authorities, and the best method for correction of hypertrophic and atrophic prolapsed breasts is the subcu- Sept., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 681 taneous transposition of the gland with masto- pexy. (Fig. 1.) Indications for Plastic Repair Around Facial Cavities Nose. For successful performance of rhino- plasties. training in general surgery as well as in rhinology, and a sense of proportion and harmony, are essential. As the rhinol- ogist does not always possess these qualifica- tions, and, moreover, as aseptic facilities are often lacking in a nose and throat operating A. Figure 2. (A) Female, aged 20, with conspicuous depressed type of congenital nasal deformity and double epic-anthus, causing a Chinese facial ex- pression. Patient suffered from a marked mental depression. room, association of plastic surgery with the rhinolaryngologic service in a general hospi- tal is not a satisfactory provision. The need for partial and total nasal reconstruction can he fully appreciated only by those who deal with patients requiring such repair. In addition to corrective partial and total rhinoplasties, reconstructive surgery is indi- cated in atrophic rhinitis, in narrowing of the nasal cavities bv transplantation of cartilage into the septum and floor of the nose, in atresias, and in other nasal impairments. Cor- rection of congenital or acquired nasal de- formities, performed with proper skill and under strict asepsis, should be uniformly fol- lowed by satisfactory functional and cosmetic end-results. (Fig. 2.) Ear. Indications for otoplasties and for closure of large defects following mastoidec- tomies are of less frequent occurrence than for other forms of facial repair. While partial plastic repair of the ear is accomplished with comparative ease, from the standpoint of encl- B. (B) Correction of deformity by a thick rib car- tilage transplant which corrected the nasal de- pression as well as the epicanthus. results there is need for improvement in total reconstruction. Orbit. Surgery of congenital and acquired deformities around the orbit is of vital im- portance as its purpose usually is not only to correct the disfigurement but, especially, to re- establish the disturbed function. The majority of ophthalmologists do not perform plastic operations in the orbital region, but some of them show great skill in such corrective sur- gery and have contributed much to its de- velopment. The most frequent indications for G82 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 1931 plastic repair in this region grow out of cicat- ricial contractions around the eyelid and eye- socket due to accidental injuries. The shifting of skin flaps from the adjoin- ing area, and the use of free skin grafts, en- counter far greater difficulties in the orbital region than elsewhere, because of the varieties of skin-covering required and the functional significance of the eyelids. To obtain satisfac- tory anatomic and physiologic restoration in this area, a thick skin graft must be used for the forehead, hair-bearing skin for the eye- brow, and a graft of fine texture for the eye- lids. A. Figure 4. (A) Right unilateral incomplete cleft lip with flattening’ of the nostril. Cleft Lip and Cleft Palate From the func- tional and cosmetic points of view, too fre- quently the end-results in operations perform- ed for cleft lip and cleft palate leave much to be desired, despite the surgical progress made during the past 2 decades. The technic available for repair of a cleft lip deformity is today of such precision that further failures should not occur. In the more complicated types, the operation should be done in succes- sive stages. The factors necessary for success- ful end-results are : proper outlining of flaps provided with adequate blood supply ; suffi- cient undermining of the surrounding skin and mucous membrane ; avoidance of tension ; and the use of fine suture material. (Fig. 4.) The operation for cleft lip should be done from 4 to 5 weeks after birth, and the palate i should be closed at the age of 12 to 18 months, To assure good functional results, the chil- dren should receive early and competent speech training. Skin Malformation. A nevus hemangioma, lymphangioma, fibroid, hairy mole, or an area of pigmented skin may be eradicated by re- peated excisions, without leaving a trace of the surgical intervention except a linear scar. If shifting of an adjoining skin area cannot be accomplished, free or pedicled skin grafts can be used. If indicated, plastic surgery may be supplemented by the application of x-rays B. (B) Condition 0 months after cleft lip repair, done at the age of 6 weeks. or radium. Although in these skin affections radiation alone sometimes results in partial improvement, this therapeutic measure is fre- quently misused. Prolonged irradiation is al- ways followed by scarred skin, which con- trasts conspicuously with the surrounding area. Moreover, the prolonged treatment of skin blemishes by radiation exclusively is a great economic waste, causes the patient much mental distress and rarely completely eradi- cates the deformity. Summary (1) Plastic surgery has become an indis- pensable surgical unit in the general hospital. (2) Inclusion of plastic surgery in other Sept., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 633 departments of general hospitals is inadvis- able. (3) The many problems involved in the Figure 6. (A) Partial loss of nose resulting from galvanoc-auterization of rhinophyma. plastic surgery and should be undertaken only by a qualified specialist. (4) The successful reconstruction of highly hypertrophic and atrophic prolapsed breasts is assured by the method of sub- cutaneous transposition of the gland. (5) The end-results in rhinoplasties are uniformly successful if the surgical procedure is carried out aseptically and with proper skill. (6) Intricacies involved in the plastic re- pair of the orbital region are due to the dif- ferent types of skin grafts required in a rela- tively limited area and to the functional im- portance of the eyelids. (7) Cleft lip and cleft palate, if repaired at an early age, should be followed by satis- factory end-results in the majority of cases. (8) variety of skin affections can be B. (B) Delayed tubed temporal flap, the distal end of which is sutured into the nasal defect and sutured to the flap : the lining of the nose was provided by the nasal skin from above the defect, rotated downwards. *Maliniak, J. W. : Rhinophyma — - Its Treatment and Complications. Archives of Otolaryngology. Feb. 1931, Vol. 13, pp. 270-274. prevention and correction of deformities from successfully treated, and with the avoidance soft tissue wounds caused by bums and motor of great economic loss, by plastic procedures accidents require a thorough knowledge of followed, when necessary, by radiation. 684 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 1931 SOME DIFFICULTIES OF THE ASTHMA PROBLEM* George H. Lathrope, M.D., Newark, N. J. Much is known about hay-fever. Com- paratively little is known about asthma. Of its etiology, its pathogenesis, the mechanism of its crises — some brief, others severe and prolonged into weeks and months, even lethal — of its therapy, little of a conclusive sort is known. And yet, 10 years ago, with the therapeutic solution of hay-fever in the hands of the profession, hope ran high that solution of the asthma problem also was at hand. To- day it seems as distant as ever. Hay-fever and asthma are so commonly conjoined in the professional mind, that the mention of one usually evokes the idea of the other: wherefore, it may be well to mention briefly some of their similarities and contrast- ing features. Hay-fever is an allergic manifestation. Supposedly so is asthma — sometimes. Season- al incidence is the striking characteristic of hay-fever; as an attribute of asthma it is only occasional. Hay-fever is marked by tur- gescence and watery discharge from the mucous membrane of the upper respiratory tract, with eosinophiles present in the dis- charge and in the blood stream. It is sup- posed that asthma presents a similar picture in the bronchial mucosa. Hay-fever par- oxysms may be temporarily relieved by adren- alin. Some asthmatic crises are similarly affected. Hav-fever is caused largely by sen- sitivity to pollens. Certain cases of asthma have the same apparent background. Treat- ment by pollen solutions improves a great number of cases of hay- fever. It helps a few cases of asthma. On the other hand, a considerable number of asthmatics have their first attack as the result of a respiratory infection ; and no mat- ter what the origin of asthma, there is prac- *(Read before the Morris County Medical So- ciety, March 12, 1931, as part of a symposium on asthma.) tically always, after the lapse of time, an in- fective element present, which apparently may come to overshadow all else. Some asth- matics display a pollen sensitization without ever having had hay-fever. Some have hay- fever first and then develop asthma. Others, asthmatic from the beginning, display no skin reactions whatever suggestive of an allergic condition. Practically all, sooner or later, show evidence of bronchial tract infection, and it is this fact which makes therapy by bacterial vaccines of distinct though limited value. Clinical Description. T*he usual clinical his- tory and course of the cases which yield more or less satisfactorily to treatment may be de- scribed as follows: In the history there may be shown a familial allergic tendency — asth- ma. hay-fever, eczema, etc. The patient has had asthma for a varying time from a few months to 20 years. It may have been pre- ceded by hay-fever, and the first asthmatic attack may have come in the hay- fever season while symptoms were at their height. On the other hand, no family history of allergy may be obtained, and the patient has never had hay-fever. The first asthmatic attack de- veloped during a severe cold, and every suc- ceeding attack has apparently been the result of what began as a so-called .“cold”. The paroxysms in one case may be brief and easily controlled by adrenalin, their noc- turnal recurrences continuing only a week or two. In another the paroxysms are febrile, and may be prolonged into a distressing pic- ture of constant dyspnea day and night, re- lieved only when the patient’s vital force seems so depleted as no longer to be able to endure the strain. Utter exhaustion brings a brief respite of 2 or 3 hours sleep, from which the patient wakes at first refreshed, only to be- gin another paroxysm which goes on to renew- ed exhaustion. The picture is one of a true status asthmaticus which may last weeks or even months, entailing an amount of suffering which seems unendurable. Such severe status conditions come once or twice a year with only comparative comfort in the intermissions; for these patients are definite chronic fatigue in- Sept., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 685 valids and incapable at their best of the ef- fort of healthy individuals. The cases with brief paroxysms, and in general of the mild type, are apt to obtain prompt relief of the paroxysm with 1 or 2 hypodermics of adrenalin. The discovery of a pollen or other sensitization and the admin- istration of appropriate treatment may prove very efficacious. In other cases where an in- fective element was evident from the start, or where it has crept in after several years of successive attacks, the culture of sputum, of sinus washings, or of tonsils, yields a growth from which a vaccine may be developed whose efficacy in improving the patient’s condition is more or less gratifying. The discouraging feature of most of these cases is that the attacks, despite temporary relief by treatment, keep recurring, and the patient and physician must be always on the alert for the first evidence of trouble as the signal for renewing treatment. Curing the crises or attacks has not cured the disease; and, as has been suggested above, the patient all too often is still, between attacks, an in- dividual much below the normal standards of health. It seems evident then that direct attack upon the asthmatic crisis is only a partial measure ; and this leads to an inquiry into the pathology of asthma, and to a consideration of some of the questions which arise out of any effort to solve the asthma problem. Pathology. Death from uncomplicated asth- ma is comparatively infrequent. Rackemann, in his monograph just published, has collected only 12 reported autopsies — 3 of them among his own series. These reports reveal 2 types of lesion. The one shows an hypertrophy of the smooth muscle of the smaller bronchi ; the other, hypertrophy of the mucous membrane and mucous glands. Both types are apt to be found in the same subject, but one or the other may be distinctly dominant. Emphysema is an almost constant finding in every case, and eosinophiles are scattered through the mucous membrane. The cases with muscular hypertrophy as the main lesion are supposedly those whose crises were due to bronchospasm and were most susceptible to the influence of adrenalin, and they represent essentially the type of asthma due to some outside agent ; while those with an hypertrophied mucous membrane are the ones less amenable to adren- alin, and belong more often to the group as- sociated with bacterial infection. While this statement is in the main true of the 2 types where they can be readily distinguished, it must be understood that admixture of the types is common and a dividing line may be hard to define. Study of our own cases, based on roent- genograms and physical findings, indicates that chronic bronchitis, pleurisy, particularly at the bases, and bronchiectasis should be in- cluded in the pathology of asthma. Bron- chiectasis is not uncommon, and is of import- ance because it may easily constitute a focus of infection of no inconsiderable proportions. This local condition of hypertrophy of the bronchial musculature and mucosa is ap- parently the important factor in the asthmatic crises. Just what is back of it is another matter. Hypertrophy is perhaps merely the local response to repeated attacks, just as em- physema is another pathologic feature which develops from constant renewal of attacks in the course of time. In those cases chiefly marked by broncho- spasm and without much chronic thickening of the bronchial mucosa, adrenalin may give prompt and marked relief. This apparently is to be regarded as evidence that sympathetic depression or vagus irritability is the cause of the bronchospasm, for adrenalin is known to be a powerful sympathetic accelerator. It is possible that whatever disturbs the vagus- sympathetic balance may be a potential factor for production of the asthmatic attacks, and causes for such disturbance are probably num- erous. Hypersensitiveness to antigens, pollen or bacteria is only one factor, albeit the one best known, and, to date, most important in this connection. Irregular clinical types. Properly speaking, asthma is a symptom, not the disease entity in itself. We should not confine ourselves to treating asthma; we should treat the patient who suffers from asthma; just as we treat the patient who suffers from indigestion, and JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 1931 686 search for ulcer, cholecystitis, cardiac incom- petence. or other cause. The cases with hvper- sensitiveness to antigens have been outlined. But other and confusing elements, apparently outside the range of what is known as allergy, creep into view. This leads to a considera- tion of what may be called irregular types of asthma; i.e. those cases which show some ele- ment or elements beside allergic or bacterial activity; and such are all too frequent. In a given case, let us say a timothy sensi- tization is discovered and appropriate treat- ment does much to ameliorate the attacks. However, they persist, and then a bacterial vaccine is employed which for a time works wonders. Nevertheless, there is an annoying residue and tendency to paroxysms which will not down until a weakened heart muscle is recognized and braced up with digitalis, or an hypertension has been relieved by prolong- ed rest in bed and simple diet. Then only, and thereafter only at the price of constant care of the circulatory apparatus, does the asthmatic phase really recede into the back- ground, though it never completely disappears. Another case yields unsatisfactorily to the usual methods of treatment, until a laparot- omy becomes necessary for fibroid, ovarian cyst, or some gastro-intestinal lesion, when the asthmatic condition is promptly relieved. Certain methods of treatment must be noted as revealing further vagaries of the problem. The mechanism of 2 of these is essentially similar, viz.: (1) Relief by diet which is really a starvation process; and (2) relief by the exhibition of nitrohydrochloric acid as re- ported by Beckman, in the Jour. A. M. A., for November 22, 1930. The asthmatic patient supposedly develops an alkalosis, and starva- tion on the one hand, or the addition of some acid body to the food intake on the other, brings about a diminished alkaline reserve with a concomitant relief of the asthmatic condition. Treatment of asthmatic attacks with acetyl- salicvlate and with whisky has met with more or less success in times past, and their utility is impossible of explanation on the basis of anything we know at present about allergy or infection. A more striking method of therapy is re- ported by Knott, Oriel and Witts, in Guy’s Hospital Reports for October. 1930. Thev give the report for the Asthma Clinic for the years 1928-30, which embraces a study of 205 cases. Curiously enough, from our stand- point at least, little or no effort was made in this series to employ antigens, pollen, bac- terial or other, nor is that side of the problem much stressed. Their sole treatment was an ounce of glu- cose in water, with lemon or orange juice, given on an empty stomach twice daily. Their figures are : Under 9 yr. of age 22 of 26, cured or improved 10-19 yr. of age 23 of 31, cured or improved 20-29 yr. of age 9 of 18, cured or improved 30-49 yr. of age 6 of 22, cured or improved The added infective element with increasing age is held to be the factor lowering the in- cidence of relief. They attribute this relief to the fact that the liver plays a large part in antigen-antibody reactions, and that it func- tions best when supplied with glucose. Thus are added still other factors making for con- fusion in the present current ideas of the pathogenesis of this condition. Environmental and climatic conditions have an important role. One patient finds relief at sea, another in the mountains, another in the plateau coun- try of the Southwest, or in the dry sea-level air of lower Egypt. These are not necessarily pure pollen or bacterial cases. Some factor in climate other than the absence of pollen or dust which has an influence on the human or- ganism is probably in play. Perhaps the ultra- violet sun rays have a part in these cures. Perhaps some stimulating effect on the thyroid or other endocrine glands is a potent influence. Many asthmatics, as indeed many patients with chronic infection, are distinctly hypothyroid. Others are too evidently susceptible to emotion- al influences, and relief from business worry, from the strain and irritations of ill adjusted domestic environment, is a curative measure which should not be neglected wherever pos- sible to accomplish it. Emotion, together with physical and mental overstrain, are recognized factors in upsetting the nervous mechanism, exhausting the endocrines, and disturbing the vagus-svmpathetic balance. And finally, it must be noted that a long Sept., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 6S7 recognized peculiarity of asthma is its quies- cence during pneumonia or other severe in- fections, as well as its tendency to he minim- ized, if not altogether absent, during preg- nancy. What is this common dominator which places pregnancy and pneumonia side by side as incompatibles of asthma? No satisfactory answer to this question has as yet been given ; though Beckman endeavors to explain both phenomena by his alkalosis theory. Every case of asthma needs careful and prolonged study. It can rarely be solved in one sitting. Complete understanding of the individual case is an ideal rarely attained, and observation for months, and through a varied assortment of conditions, is usually needed for any understanding whatever. It is perhaps not too much outside the bounds of probability to summarize the situa- tion as to this subject as follows: The allergic mechanism in its essence is to be regarded as a normal part of the physiology of every individual. It is not unlikely that it is an important part of the protective me- chanism. In certain individuals there is a constitutional or hereditary disposition to over-react in this respect, so that we come to recognize and speak of an allergic type. I his abnormal sensitiveness to stimuli which may produce allergic reactions is probably the fun- damental factor in asthma; but, as has been pointed out, such stimuli are numerous, and so far as our present knowledge goes, appar- ently quite dissimilar. We have nitrogenous bodies on the one hand, such as pollen, dust, animal emanations, and bacterial products, which seem to be direct in their action ; and on the other such vague conditions as climatol- ogic influence, emotional states, endocrine disturbances, maladjustment of the acid base balance, and factors causing disorientation of the vagus-sympathetic mechanism. I he pic- ture is still inchoate, and has great need for synthesis and coordination. If this has seemed a discouraging or pessi- mistic presentation, it is a warning against over-confidence and too optimistic prognosis, both of which weaken investigative curiosity. The mind must be kept open and ready for suggestions no matter how bizarre they may seem at first sight. Ignorance of the subject is so great that there should be no astonish- ment or disbelief when one investigator re- ports cases cured by nitrohydrochloric acid, or another reports cure or improvement fol- lowing laparotomy. We accept with little question the vagaries of the beneficial effect from change of climate, yet who can say what may be the mechanism of the improvement thus brought about? The present methods of attack are largely based on the removal of focal infections, the use of bacterial vaccines, of pollen or other antigens, and change of climate and environ- ment. But these methods are all too inade- quate; and the reasons for that inadequacy, like the Holy Grail, are still to seek. THE DUST FACTOR AND THE BAC- TERIAL FACTOR IN ASTHMA* Royce Paddock, M.D., Newark, N. J. The importance of dividing asthma into 2 main groups lies in the different kind of treatment to he attempted. It is our view that a majority of cases of asthma give evi- dence of bacterial infection of the respiratory system. This is usually in addition to allergic hypersensitiveness to outside dust factors, such as pollens, powders, house dust, and ani- mal epidermal substances. We are familiar enough with the cases which are described in the literature, cases of asthma found to be clinically hypersensitive to horse dander, cat hair, feathers, or orris root used in face powder. The outside factor is removed, and the patient’s symptom disappears. In every- day experience cases of this kind are not com- mon. We find the cause difficult to discover, and the symptom apt to continue. It is plain that the practical application of the methods of finding and removing the outside causes is in these every-day cases difficult and ted- ious. The patient does not recognize any outside factor as causing his symptom, or if * (Read before the Morris County Medical So- ciety, March 12, 1931, as part of a symposium on asthma.) C8S JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 1931 lie does, and the skin test is positive, removal of the supposedly offending substance does not produce the desired result. The obstacles, as we see them, are mainly 2 : the difficulty caused by the multitude of causes, and that caused by the presence of infection. They are to be attacked by different methods. Multiple outside factors. The allergic dia- thesis, or whatever constitutional predisposi- tion we assume for the clinical forms of al- lergy. such as asthma, does lead to the de- velopment of hypersensitiveness to more than 1 outside cause in many cases. We should re- member that probably about 500 different sub- stances, mainly from the animal and vege- table kingdoms, can be listed as outside causes of the various clinical forms of allergy. The allergic individual is exposed to many possible exciting causes, and chance would seem in favor of development of the allergic response to several. Although the common causes of hypersensitiveness are relatively few com- pared with the total, there are supposedly many still undiscovered, as each year’s ad- dition to the list would show. We may group them practically under such convenient heads as household dust substances, industrial dust substances, outdoor dust substances (such as pollen), meaning by dust any small particle of material that will float in the air. Inorganic dust is of secondary importance, as it does not, so far as we know, produce an allergic response, though it may aggravate it. On account of this multiplicity of exciting causes complicating the problem of diagnosis, the attempt to find the specific exciting cause or causes suffers by comparison with anv method which would be applicable to all cases. Status of drug therapy. Of such means we first have the ability to cut short the asth- matic response by drug action. With all the various possible outside factors which may be the exciting cause, the asthmatic attack varies little in its essential features, though the time, and place, and other circumstances which bring it on vary a great deal. The attack usually responds to the proper drug, in this case adrenalin, or epinephrin, with a prompt and satisfactory relief of the symptom, in spite of the various causative factors which are at work. This relief is practically always temporary, and continued use of the drug often leads to an undesired diminution in the response which further limits the result of its use. But this drug is a reliable aid. Another drug with much the same effect, used widely in at least 1 patent medicine, and usually without a doctor’s advice, is cocain, in weak solution. Carried in a spray by many patients, it cuts short the attack and enables them to do work which would otherwise be impossible. Use of patient's own household dust in diagnosis and treatment. Although these aids are in wide use, the first aim of those who are trying to control and prevent asthmatic at- tacks is of course to find the specific outside factor or exciting cause, if this is possible. This at present is our best chance of effecting permanent relief, and should be considered first. If the skin tests and history are both negative in regard to specific cases (and it is not usually practicable to try more than 20 or 30 at a sitting, or less in the case of a child), it is advisable to test the patient with his own household dust. The dust is obtained, prefer- ably from a vacuum cleaner used in the pa- tient’s own room and the parts of the house frequented by him. Sweeping is inferior because of coarse dust collected. The finer portion of the sample is taken. According to the method of Cooke and Coca, after this col- lection and separation, the finer dust is ex- tracted, after removal of grease by means of ether. The extracting fluid is prepared ac- cording to Coca’s formula, by adding a small amount of sodium bicarbonate to 0.5% saline, the extraction being continued for 48 hours under toluene. The extract is then drawn through a filter of the Berkfeld type and cul- tured to test for the absence of aerobic and anaerobic bacteria. Heat sterilization cannot be used on account of the destruction by heat of the substances extracted. About 0.05 c.c., or less, if a strong extract is in use, is in- jected into the skin of the patient’s arm, form- ing a small wheal. If the reaction is positive, as judged by the growth in size, or definite irregularity of the wheal, with redness of the surrounding skin, there are 2 plans of action Sept., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 689 to be pursued : First, is the removal of as much dust as possible from the household by means of frequent vacuum cleaning, the avoidance of large areas of carpet, upholstery, and hangings and the use of waxed wood or linoleum doors wherever possible. The prob- lem of the contents of the patient’s mattress and pillow must be attacked in a similar man- ner, or they must be changed to other sub- stances such as Kapok, cotton floss, or silk floss, depending on the substances to which the patient is sensitive. Much can be done along these lines, but it is usually best, when possible, to attempt reducing the patient’s hypersensitiveness, if this is present, by in- jections of the extract. The dosage must de- pend entirely on the degree of hypersensitive- ness of the patient. Since some patients are very sensitive, it is sometimes necessary to dilute the dust extract before attempting treat- ment. In general, doses which cause anything more than a slight local reaction should be avoided, the amount being gradually increased and the treatment continued over a long period of time, months at least. It is unde- sirable to use a dose which produces an al- lergic reaction such as a marked aggravation of the symptom, or local or general hives. Some of the best results seen are in patients who have taken the dust extract in gradually in- creasing doses for a year or more. Usually not more than 0.7 or 0.8 c.c. is given in 1 in- jection because of the larger local reactions caused by the larger amounts injected. This outline of procedure is described as a general measure of diagnosis where we sus- pect hypersensitiveness to an outside factor, which may be in the house. If we are able to obtain a definitely positive skin test to some specific substance, such as horse dander or cat hair, the procedure is simpler, and it is just in these cases that the dramatic results may occur. We find, however, that all cases which give a definite skin reaction to one specific outside factor, such as horse dander, do not lose their symptom after treatment with the extract of this substance. Some of them con- tinue with the same symptoms and the same periodicitv as before treatment. These are cases which should, of course, be investigated as to other causes, as completely as possible. The test to the dust of the patient’s house is a distinct help. Characteristics of hy persensitiveness lo out- side factors. In looking over some of the cases of asthma which we have seen, we are first struck by the comparative rarity of the dramatic kind of case that we would like to have ; the case where finding and removing an outside cause is followed by disappearance of the symptom. This type of case may be called the true or uncomplicated allergic type, where the outside factor is the exciting cause. We feel that it is characterized by a positive family history; relatively early onset; definite relation between the symptom and some out- side factor, resulting in a realization on the part of the patient of certain circumstances of time or place which are associated with his attacks; the presence of some other form of clinical allergy such as hay-fever, or eczema during early life, or possibly hives ; the dem- onstration of positive skin tests to an out- side factor, and the presence usually of a high degree of eosinophilia in blood or sputum or both. Beside these 6 primary factors we may note for this rare type of case the usual aggrava- tion of symptoms by the summer season and the absence of definite evidences of infection. When we see a case with all or even most of these features, we feel that we have one of the true uncomplicated allergic types, in which an outside factor or factors are probably the true and only exciting cause. If the skin tests happen to be negative in such a case, we are likely to think that we have failed to test with the right substance. In such a case we will continue tests and treatment until we have either located the cause or have tried all the possibilities within our grasp. Characteristics of hypersensitiveness to the bacterial factor. It is more common that the case in question shows some of the features above described, but also some of those about to be listed : relatively late onset ; or an onset with immediately preceding infection ; no definite relation observable in the history be- tween symptoms and an outside dust factor ; no positive skin tests ; the presence of poly- 690 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 1931 morphonuclear neutrophiles, together with the eosinophile cells in the spirals and perles of the washed sputum. This type frequently is worse in winter and shows evidence of in- fection of the respiratory tract on physical and roentgen ray examination. In addition, the sputum more often shows a nearly pure culture of one organism, which is not. how- ever. usually constant. If the case in question shows practically all these features, we consider the bacterial factor as probably the important element, at least the effective exciting cause. It is of course difficult to exclude an underlying al- lergic factor. It is more usual, however, to find a mixture of both types. Whether the injury caused by the outside factors, such as the various specific exciting causes, renders the mucous membranes more susceptible to infection than the normal, or whether a com- mon predisposing factor leads to both types of injury, bacterial and nonbacterial, the im- portance to us of this frequent mixed tvpe of case is obvious. We must attempt to con- trol or at least counteract the effect of the bacteria within as well as the external dust. Evidence of bacterial infection in asthma. To counteract such infection, we first need an understanding of what it is and how it works. From such information as can be ob- tained from histories, bronchial infection is connected with the onset in many cases. We may neglect the very frequent finding of “subject to colds” as vague and misleading, on account of the marked resemblance be- tween the symptoms of hay-fever and the first days of the common cold — a resemblance which possibly may he worked both ways by speculating on the role of allergy in the cold — but we cannot pass over the impressive number of histories which assert that the first symptom followed influenza, grippe, bron- chitis. or whooping-cough, as well as the many cases which report a preceding pneumonia not necessarily directly connected with the onset. On physical examination many cases of more than a few years’ standing do show evi- dence of focal infection of teeth, sinuses or tonsils, as well as the chest changes known as chronic pulmonary emphysema. From x-ray evidence a great majority show bronchitis, and especially of the basal type often suggest- ing mild bronchiectasis, and a good many show signs of pleurisy more often at the liases. The sputum commonly corroborates the other findings by showing in a majority of our cases of asthma more or less admix- ture of polymorphonuclear cells with the eosinophiles which make up the spirals and perles of Laennec supposedly formed in the finer bronchioles. Likewise, sputum culture, though less striking evidence, frequently yields a nearly pure culture of one organism, such as a streptococcus of the green type, or one of the mildly hemolytic type, a pneu- mococcus, influenza bacillus, hemolytic staph- ylococcus, or a bacillus of the Friedlan- der group. When a culture taken in the way to be described shows a predominance of Micrococcus catarrhalis, with a few green streptococci or diphtheroid bacilli, the picture does not necessarily suggest an active bac- terial cause at work in the bronchial tree. Naturally, cases in which the same organism is repeatedly found, and constantly, are not common, but they are found, and we feel very definite about them, especially when ap- parently the same organism is isolated over a period of years. \\ hatever is the relation of the bacterial to the allergic factor, in most cases of asthma it is necessary to consider both. Whereas the factor of allergy to outside causes certainly shows spontaneous improvement in many cases, such as the children who outgrow their idiosyncrasies to food, the bacterial factor tends to progress and produce more injury. We may assume that whatever direct harm the outside factors do to the hypersensitive mucous membranes, it is far less than that done by bacterial agents. Although their work in these cases is usually slow, they apparently no less certainly on that account may cause crippling of the chest over a period of years, and the final result may he permanent damage and disability, due to the condition of the chest which we call emphysema and chronic bronchitis. It is. therefore, important to reckon with the bacterial factor, and the fol- lowing measures are available. Measures directed against bacterial in- Sept.. 1031 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 691 fection in asthma. First, general hygiene, sunlight and the avoidance of fatigue and chilling, in order to prevent advance of the chronic infection. Second, adequate nutrition, including the use of glucose in thin subjects and during acute symptoms, where so much muscle work is done. Third, the removal of focal infection, according to a definite pro- gram based on the physical condition of the patient. That is to say, that no general rule can be applied to all cases regarding the elimi- nation of focal infection. Experience must guide. Fourth, the use of vaccines. Concerning vaccines, we feel that it is best to use autogenous vaccines made from the patient’s sputum after examination of several samples. Where expectoration is only peri- odic, the patient must be given a sterile bottle, the specimen to be returned to the laboratory as soon as possible following the period of ex- pectoration. Where there is a recurrence of subacute or acute infection, the sample should be taken just after the period of aggravation of symptoms, if possible. Obtaining the organism and the prelimin- ary skin test. It is important to direct the patient to avoid excess of saliva, and to bring the specimen to the laboratory, or send it in, within 1-2 hours after its production. The organisms are best grown by spreading the smaller spirals or perles of Laennec, washed tree from surrounding mucus, on the surface of blood plates. The vaccine is made when possible from the first growth, where pre- dominance of a single type of organism or a similar mixture of organisms has been found reasonably constant. It is best to make the vaccine relatively dilute, about 200 million per c.c. in order that the first dose may be very small. The first dose (0.05 c.c.) is injected into the skin in order to observe whether the patient’s skin will show any un- usual susceptibility to the organism or or- ganisms in the vaccine. This is usually evi- denced by redness or a lump at the site of injection within 1 or 2 days thereafter. In case of a positive test, start with small doses and raise the dose cautiously. Some, though not many, asthma patients do give local, gen- eral. and focal reactions to their autogenous vaccines, especially where focal infection ex- ists. Symptoms of the reaction are similar to a mild “grippe” or a temporary increase in asthmatic symptoms, usually followed by in- creased cough and expectoration and more or less improvement in symptoms for a time. As with dust injections, the aim is to give enough at a dose to cause a mild local reaction in the arm, and to continue this mild local re- action with each dose. If no local reaction is shown, then, we increase the dose gradually, about 0.1 c.c. each time, with an interval as short as twice weekly at first until the pa- tient has shown a mild local reaction, or the dose stands at about 1 c.c. We at times can- not give as much as 1 c.c. of an autogenous vaccine without marked local, or some gen- eral, reaction. As the dose increases the in- terval is lengthened, the ideal being to afford a short interval between duration of the suc- cessive local reactions. When the vaccine is made from an almost pure culture of pneu- mococcus or green streptococcus, or Fried- lander bacillus, we persist with treatment, for it is in those cases that we have seen the best results. If the vaccine used causes no local reaction on arriving at high dosage, and there is no focal reaction or improvement in symp- tom following the doses, further cultures of the sputum should be made. Different organ- isms may be discovered, particularly if taken following or during more acute symptoms. If stock vaccines are found to give local re- actions in or under the skin in small or mod- erate dosage, corresponding roughly to the autogenous or within 10% of the amount, this vaccine may be used without or with auto- genous vaccine (in separate arms). In conclusion, treatment of the average asthma case is not a simple matter, on account of the multitude of causes and presence of in- fection. Both factors must be looked for, and an attempt at control of both is usually necessary. Injections should usually be con- tinued with short intervals between the per- iods of treatment. Occasionally the removal of a single outside factor or focus of infection is sufficient. Improvement from the con- tinuous measures is slow, and marked by set- backs. While good results require time and 692 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 1031 continuous control, the results sometimes ob- tainable make somewhat tedious methods worth while. The methods used are called treatment, but are equally an attempt at pre- vention. ASTHMA FROM THE STANDPONT OF THE RHINOLOGIST* Lyndon A. Peer, M.D., Newark, N. J. The rhinologist in contact with asthma cases is impressed by the great frequency of infection in the upper respiratory tract. In our experience 2/3 of asthmatics have had some form of infection in the sinuses, tonsils, teeth, or bronchial tubes. Opinions differ as to the importance of these infections in caus- ing asthma. Since Voltoline, in 1880, report- ed a cure of asthma following the removal of a nasal polyp, the literature on this subject has contained many articles by many authors, some of whom are enthusiastic about the re- sults of local treatment while others believe that in spite of procedures both simple and radical the disease progresses without change. Thus, we have 2 schools : one holding that the removal of infective foci gives no relief aside from promoting the general health of the patient ; the other believing that many cases of asthma with foci of infection are cured when such foci are removed. We believe that importance of the infective element varies with each individual patient. In some asthmatics removal of infected ton- sils or teeth will be followed by improvement in general health, but the asthma remains the same. Another patient, following an ethmoid operation, may be greatly improved or, less frequently, cured of asthmatic attacks. Mechanism of infective foci in causing asthma. There are 2 theories; (1) Reflex theory; (2) absorption of bacterial protein. Keflex theory. Various authors, particularly Sluder, have considered that bronchial spasm *(Read before the Morris County Medical So- ciety, March 12, 1931, as part of a symposium on asthma.) was merely a reflex effect of some local stimu- lus in the upper air passages transmitted through the nasal ganglia to the sympathetic trunk in the neck or the vagus nerve. Phillips and Scott, in a recent admirable review of sur- gical procedures used for relief of asthma, declare that there is a predominance of opin- ion in favor of the vagus being the main bronchiomotor nerve ; but there is also ample evidence that there are some bronchio-con- strictor fibers in the sympathetic. Experi- mentally, stimulation of the sympathetic or of the vagus will produce an asthmatic attack — presumably due to constriction of the bron- chial musculature. Absorption of bacterial protein. Protein from the dead bodies of the bacteria or their toxins ma}' act in the same way as any foreign protein in causing asthmatic attacks. An in- fection may serve as the incitant to an asth- matic attack in an “allergic individual”. It is possible that patients who are not “allergic” do not develop asthma from infections. This explains how an allergic individual develop- ing a sinus infection begins for the first time in his life to have asthma. When the infec- tion is removed or becomes quiescent, the asthma improves or disappears until a re- crudescence occurs to again set off asthma at- tacks. Hence, a fundamental conception is that the individual is allergic to begin with but requires some stimulus to initiate an at- tack. This stimulus may be pollen, food, bac- terial protein, or a nerve impulse from an in- fection in the mucous membrane of the upper respiratory tract. Diagnosis. The history is very important in roughly grouping the infective and non- infective cases. An all-the-year asthma which does not respond to changes in diet, nor give positive skin tests to the various foreign pro- teins, is apt to have a bacteria factor, also, asthma which persists for 5 years has an added infective element which may become permanent. Bronchoscopy should be considered for diag- nostic use in every case of asthma which does not show protein sensitization or some obvious infection in the sinuses. Dr. Jackson very aptly has said “all is not asthma that wheezes”. Many cases diagnosed as asthma have been Sept., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY found to be due to benign or malignant neo- plasms. stenosis of bronchial tubes, or foreign bodies. When these are effectually treated the supposed asthma disappears. Particularly in a child, an enlarged thymus or the presence of a foreign body must be ruled out. Exami- nation of the nose may reveal a typical poly- poid ethmoiditis with or without pus, or simply a somewhat boggy mucous membrane with hypertrophy of the turbinates. Transil- lumination of the sinuses is helpful, but the roentgenography is our best preliminary means of diagnosis. When an infected antrum is diagnosed, it should be punctured, filled with sterile saline, and the saline withdrawn for microscopic cell count and culture. In this way we obtain from the sinus a specimen uncontaminated by nasal secretions. The antrum is then washed out and filled with lipiodol, and a second radiograph taken to demonstrate the condi- tion of the antral mucous membrane. Usually we find eosinophiles and neutrophiles in the infected material withdrawn from the sinus, and we diagnose an antrum as infected when polynuclear leukocytes and bacteria are found. In an allergic patient structural changes in the mucous membrane, as shown by lipiodol radio- graph, could be due to repeated edema into the tissue structure ; polys and bacteria in any considerable number, however, indicate infec- tion. There is a so-called hidden antrum infection in which the bacteria reside in the subepi- thelial layer of the mucous membrane, not producing surface change, but causing struc- tural changes in the tissue. A single washing from such an antrum may not grow any bac- teria or show any polys, but still the infection may be a causative factor in the asthma. Where there is disease of the frontal sinuses a history of intermittent, dull, frontal head- ache, particularly on bending forward or on blowing the nose, is usual. There is often tenderness on pressure at the inner frontal angle. The headaches sometimes begin after using the eyes and are mistakenly diagnosed as eye-strain. Pain behind the eyes, at the top of the head, or in occipital region, is sug- gestive of sphenoid disease. The sphenoid sinuses may be filled with sterile saline and 693 the saline withdrawn for examination through a canula inserted in the osteum. Lipiodol can then be injected and a radiograph taken to determine the condition of the mucous mem- brane. Ethmoid disease usually shows up well in an x-ray picture. The presence of polyps is always strongly suggestive of ethmoid in- volvement. Generally speaking, pus seen in the anterior portion of the nose is coming from the frontals, anterior ethmoids, or an- trum. When found postnasally it comes from the posterior ethmoids or the sphenoid. Very frequently in chronic infections no discharge will be seen in the nose or pharynx, nor will any be found in the sinuses themselves, and this dry state of sinus infection is called hyperplastic sinusitis, and includes the hidden antrum already described. The bacteria exist in the subepithelial layers of the mucous mem- brane causing a thickening of this structure but not in any surface exudation. The wash- ings from such an antrum or sphenoid are often entirely clear and yield no growth when cultured. Absorption of bacterial protein or toxin from the organisms beneath the epi- thelium, however, may be a factor in causing asthma. Hence, one cannot conclude that a sinus is uninfected merely because a surface exudation does not exist. The presence of bacteria in the mucous membrane of hyper- plastic cases has been beautifully demon- strated by Kistner. Both the exudative and hyperplastic stages must be regarded as simply differing phases of infection. Infected tonsils are diagnosed by inspection and palpation ; infected teeth and mastoids by physical and x-ray examinations. Pathology of nose and sinuses in asthma. In early stages, the mucous membrane of the nose and sinuses is swollen and the subepi- thelial tissues show edema and infiltration with eosinophiles. In the chronic cases the epithelial layer becomes thicker than normal, loses its cilia, and assumes the characteristics of stratified epithelium. The glands atrophy from pressure, and may be seen as cysts where their ducts have become occluded. There is considerable edema and connective tissue proliferation with infiltration of round cells and eosinophiles. Polyps form from sag- C94 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 1931 ging of the edematous mucous membrane. \\ here infection is present, polys and bac- teria are added to this picture. 7 reatment. In our experience removal of infected tonsils and teeth often improves the general condition of the individual, but it does not affect the asthma. Disease of the sinus, however, when cured, may lead to improve- ment. or. in rarer cases, to an actual clinical cure of the asthma. The best policy is always to proceed slowly, and simple shrinkage to promote drainage of the infected sinus is first used. If polyps or an obstructive middle turbinate hinder this drainage, they are re- moved. An infected antrum or sphenoid is irrigated repeatedly until the washings are clear and the cultures negative. Bacterial vac- cine is made from the sinus culture, and ad- ministered in conjunction with the local treat- ment. Infected tonsils or teeth are removed when they appear to he factors in causing a run-down condition. Asthma of long stand- ing may not yield readily to such treatment because of infection in the bronchial mucous membrane. Such cases should, in addition, be treated by bronchoscopic methods which re- move the irritating secretion, clean out the in- fected contents of bronchiectatic cavities, and provide locally for the infected mucous mem- brane. Most asthma patients of the infective type will be improved to some degree by the above treatment, and a few, particularly early cases, will be cured, while a small number will remain without improvement. Where conservative treatment has been without avail, we advocate removal of the in- fected mucous membrane of the sinuses. Eth- moids and antrums usually yield the best re- sults following radical operation ; sphenoids and f rentals the poorest. Local treatment, with removal of infected tonsils or teeth, will often make the patient a better operative risk for the radical sinus operations where these are found necessary. A combination of con- servative and radical measures will give a larger total number of improved cases and cures than either of these methods alone. In conclusion, the fact must be emphasized that asthma cannot often be improved and is far less frequently cured by any one panacea. The rhinologist who examines a patient, dis- covers an infected sinus, and exclaims that he will cure the asthma by operating on the sinus is unduly optimistic, to say the least. The combined efforts of the internist, allergist, and rhinologist, will effect improvement in a large number of asthma patients ; but no improve- ment in a small proportion of the total. CHILD HYGIENE Julius Levy, M.D., Newark, N. J. Child hygiene should not he confused with child welfare or the medical care of sick chil- dren. Perhaps the most fitting definition is “that phase of hygiene which has for its pur- pose to make growth more perfect, decay less rapid, life more vigorous, and death more re- mote". We have come to include in it many ac- tivities, but it will be found that only those phases which can he influenced by education are considered the immediate concern of child hygiene as we have interpreted it. It is felt that all the time and energy and money appro- priated for these purposes should be devoted purely for prevention. The functions and activities of a well-or- ganized child hygiene bureau should include: ( 1 ) Those phases of public health which deal with the reduction of maternal mor- tality. We would include prenatal advice to mothers by nurses, prenatal care by physicians in private practice and through prenatal clinics, medical examinations by physicians, irrespective of the attendant at labor, careful investigation of puerperal deaths, particularlv those attended by mid wives, and supervision of mid wives. (2) Those functions which deal with the reduction of infant mortality. We would re- peat the importance of prenatal care of moth- ers and proper obstetric care at time of de- livery, the instruction of midwives in infant hygiene, instruction of mothers in infant care with special emphasis on maternal nursing, competent supervision of young infants through private supervision or Baby-Keep- Sept.. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 695 Well Stations, and instruction to mothers in the homes by visits of competent public health nurses. (3) The proper care of children of pre- school age. This is to be obtained by periodic examination, by instruction to mothers in the importance of prompt and early medical at- tendance for all illnesses and noticeable de- fects, by a proper follow-up to see that de- formities and defects discovered are corrected before children come to school, and by the immunization of children against small-pox 'and diphtheria about the age of 1 year. We would point out here that nurses who suc- cessfully acquire the mental hygiene outlook can render great service in helping mothers to adjust themselves and their children. Further- more, since the importance of .the relationship of Vitamin D to the structure of the teeth has been pointed out, and since it has been found that carious teeth are probably the result of defective structure, it becomes clear that the most effective dental prophylaxis will be found in effective child hygiene. Dental clinics for prophylactic purposes should be more largely restricted to the detection of fissures and proper care. (4) Continuation of supervision of chil- dren of school age. For public health super- vision it is important, in addition to competent medical examinations, to have nurses visit the homes to instruct mothers in the importance of continuing the proper care, feeding, and management of school children, as well as young infants; and to impress upon them the importance of having defects and deformities promptly corrected. In this period it becomes particularly important to reduce contagious diseases and to instruct mothers in the im- portance of giving proper care and rest to children with so-called minor contagious dis- eases. If the plan of continuous child hy- giene supervision is followed, as was suggest- ed, it becomes necessary only to continue health habits which have already been estab- lished. (5) Prevention of blindness. It has long been known that a considerable percentage of blindness is a result of ophthalmia neonatorum especially that of gonorrheal origin. The use of 1% silver nitrate solution in the eyes of new-born babies is practically a positive pre- ventive. This is being done in almost all cases delivered by midwives. The child hy- giene nurses are especially valuable in this phase of public health work, since by early visits they are able to note inflamed eyes, to arrange for prompt and accurate diagnosis, and prompt and thorough follow-up and treat- ment. (6) Illegitimate infants. Infants of un- married mothers present a special problem. There are reported about 1200 each year in the state of New Jersey. It is reasonable to believe that many are unreported. Proper plans of cooperation among hospitals where these mothers are delivered, social agencies, and public health departments, have done much to reduce the mortality among illegitimate in- fants and to obtain proper care for their mothers. In Newark, the Convalescent Home for Nursing Mothers has been particularly helpful. (7) P> oar ding homes. The licensing of per- sons boarding infants has practically eliminat- ed “baby farms" from the state of New Jer- sey. It has made available safe homes for those who need to be boarded out and has, furthermore, reduced considerably the num- ber of children who are unnecessarily boarded out. This system has also reduced the num- ber of children boarded in New Jersey from outside the state. (8) Cooperation with other agencies, bureaus, and departments. The child hygiene nurse, through her intimate knowledge of thousands of families in which there are young infants, has been very effective in per- fecting birth registration ; assisting in the con- trol of contagious diseases ; improving sanita- tion and housing conditions ; reporting and following up venereal diseases and tuber- culosis ; bringing to the attention of social agencies many family welfare problems which bear heavily upon children ; and in discover- ing and reporting cripples and obtaining proper care for them. What is the status of infant mortality in New Jersey? The infant mortality rate in 1918 was 112. In 1930, it was 55. Whereas in 1918 there were many counties with infant mortality rates above 100 and only a few 69G JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 1931 with infant mortality rates below 80, by 1925 there were no counties with infant mortality rates above 100 and only 15 with infant mor- tality rates above 80. In 1929, all the counties presented infant mortality rates below 80 and 6 presented infant mortality rates below 60. One way of gauging what has been accom- plished in New Jersey is to note the number of child hygiene nurses under state super- vision alone. There are today some 135 nurses in some 500 communities; this aside from nurses under the child hygiene bureaus in the larger cities. The infant mortality rate in Newark has shown an even greater decline. This rate in 1930 was 52.1, the lowest that has ever been reported for the city and one of the lowest in the country. It is interesting to observe that the lowest infant mortality rate has occurred in the year of the greatest economic distress. This is merely a repetition of a previous ob- servation of the fact that the lowest infant mortality rate in Paris occurred in the Siege of 1870; and one of the lowest infant mor- tality rates of the cotton manufacturing cities of England occurred during the Civil War, when women were unable to obtain employ- ment on account of the inability to obtain raw cotton from the United States. At the same time, we would point out that there has been practically no reduction in the mortality of the first month of life. The deaths in the first month now represent of all the deaths which occur in the first year ; that is, as many babies die in the first month as die in the suc- ceeding 1 1 months. When we analyze the deaths in the first month we are impressed by the fact that practically of them occur dur- ing the first day, which shows clearly the re- lationship between early mortality and pre- natal and obstetric care. Our studies of maternal mortality have brought out many important and interesting facts. 1 here has been practically no reduc- tion in maternal mortality in the past 10 years. Secondly, about 1/3 of the deaths of mothers is associated with the first 6 months of pregnancy. In this sense they should not be looked upon as obstetric deaths but merely, deaths associated with the state of pregnancy. 1 here has been a reduction in maternal mor- tality associated with the last 3 months of pregnancy. It is, however, a matter of grave concern that the maternal mortality of this nation is higher than that of a great many foreign countries and that, even if we sub- tract the mortality associated with the first 6 months of pregnancy, our mortality is still higher than that of the Netherlands, Norway, Sweden, and Italy. While there has been this reduction in in- fant mortality, it is worth while to point out that this reduction has not been uniform. In the city of Newark, the mortality rate varies considerably in various wards, some presenting rates as high as those which were reported for that city 15 years ago. This is particularly true in the wards which present a large color- ed population. When we examine the causes for this reduction in infant mortality, con- siderable information is obtained by observing the mortality by seasons. Whereas in 1914-15 there was a high peak of mortality in the months of July and August, today there is a valley in the mortality graph for those months. In short, the safest period of the year for an infant under 1 year of age in Newark is in the month of July. You will be prepared, then, for the observation that the greatest reduction has occurred in the diarrheal diseases. If we were to compare the specific death rate for infants in 1929-30 with that of 1920-21, we would find that the rate is only about 1/3 of what it was 10 years ago. I here has been a reduction in the deaths under 1 year from whooping-cough and measles and, likewise, meningitis. We believe that this is a concomitant result of the general improvement in the care, management, early diagnosis, and treatment of infants. Now, as we have reviewed the saving of life which has come from practically the elim- ination of diarrheal diseases of infancy and from the concomitant result observed in whooping-cough and measles, we are the more impressed by the fact that in the past 10 years there has been practically no reduction in the deaths in the first year of life associated with early infancy and with bronchitis and pneu- monia. It is clear that further progress in the reduction of infant mortality will have to come from the development of methods which Sept., 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 697 will prevent maternal mortality, premature birth, cerebral hemorrhage, and then the more effective control of respiratory diseases. REFRACTION AND HEALTH* Pierce Shope, M.D., Camden, N. J. Dr. George E. de Schweinitz, in an address before the Medical and Chirurgical Faculty of Maryland, April 26, 1900, said: “It is un- questionably true that fully 75% of ocular disorders depend on anomalies of the refrac- tion, accommodation, or muscle balance of the eyes. Correction of such faults is followed by the greatest good to the eye and to the general organism in which the strain has been interpreted by symptoms not necessarily sug- gestive of their origin. When one comes to think about them, these symptoms stretch out into an extraordinary train, but we have ceased to wonder, and as a matter of course investigate, or cause to be investigated, the eyes whenever searching for the etiology of headache of all kinds, migraine, vertigo, nau- sea, pseudo and habit chorea, neurasthenia, and other disease-phenomena of similar mani- festation. We have learned that many so- called gastric troubles — tachycardia, flatulent and other types of dyspepsia, indigestions, night terrors, especially as they occur in chil- dren— may have a like origin, and we have found out that pains strangely and persistent- ly situated in the nape of the neck, between and under the shoulder blades, at the end of the spine and deep in the mastoid, may owe their origin to the same cause. These facts are widely — I was about to say almost uni- versally— known, although, curiously enough, many of the most important of them find no place in the most-used text-books on general medicine.” That eye-strain may produce symptoms ap- parently unrelated to the eyes but seemingly arising from disease or dysfunction of some *(An address given before the Camden County Medical Society, April 7, 1931, as part of a sym- posium upon ophthalmology.) distant organ, has been known for more than 50 years. Silas Weir Mitchell, in 1874, wrote a paper on the relation of nervous disorders to eye-strain and presented a series of cases in which such disorders were corrected by the wearing of glasses. In 1876, another paper appeared from the same pen, upon the rela- tion of headaches to eve-strain. These 2 mas- terpieces did more to awaken the ophthalmol- ogist to the remote symptoms produced by refractive errors, and to the need for accurate refraction, than perhaps any others. George M. Gould, 30 years ago, wrote voluminously on this subject. He was con- sidered an extremist because of the large number of diseases and symptoms he attribut- ed to eye-strain. Today, ophthalmologists know that while some of his statements have been shown to be exaggerations, a consider- able portion of his assertions were true, and for the relief of those symptoms Gould em- phasized the fact that only an accurate re- fraction examination is of any value. Today we see a large percentage of patients referred for relief of remote symptoms. To discuss all of them would require more time than we have allotted to us. A few will suffice. Headaches, especially frontal; although temporal, occipital, and parietal headaches are common ; hemicrania ; headaches associated with nausea and vomiting ; carsickness ; pan- orama headaches, the headache acquired at the movies, a ball game, or in crowds any- where ; vertigo ; headtilting and the compen- satory scoliosis that often accompanies it ; tachycardia ; anorexia ; indigestion ; flatu- lence ; hyperacidity ; constipation ; pains most anywhere ; neuralgia ; paresthesias ; tics ; neu- rasthenia ; nervousness ; insomnia ; sleepiness ; and a host of other complaints are frequently associated with eye-strain. Besides these reflex symptoms, the com- mon local symptoms are burning and itching of the eyes; heavy lids; blepharitis; conjunc- tival hyperemia ; blurred vision ; poor near or distant vision; photophobia; and spots before the eyes. Of course, all these symptoms so commonly associated with refractive errors may occur with disorders of other organs. Sinusitis, nasal obstruction, gastric and hepatic disorders, C98 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept.. 1931 constipation, and prostatic disease, commonly give rise to hyperemia of the conjunctiva, pain in the eyes, vertigo, nausea and vomiting. Chronic otitis media is a common source of headache, vertigo, nausea and vomiting. Pel- vic conditions, diseases of the brain and cen- tral nervous system, in fact almost any chronic disorder may produce symptoms suggestive of eye-strain. Hence, in refraction, the eye physician is first faced by the problem of determining if the symptoms complained of are due to an ocular defect. Second, he determines if the symptoms arise from disease of the eyes rather than from a refractive error. Third, if no ocular disease exists, the refractive er- ror is estimated and accurately corrected. Last, maladjustments of the ocular muscles are investigated and cared for. Refraction can be defined as the determina- tion of errors of the focus of the eye. But it is desirable at this time to deal with refrac- tion in a broader sense. In the beginning a careful history should be taken. The vision of each eye for near and far is noted. The bal- ance of the extra-ocular muscles, with the eyes at functional rest, is determined. Prism-duc- tion tests are made to determine the strength of various muscle groups. Each eye is then studied externally. That is followed by an ophthalmoscopic examination. In other words, no case is assumed to be a “refraction case” until all other ocular possibilities are ruled out. The search for ocular pathology is the first aim of the examination. Very frequently, some abnormality is found, which abnormality may be purely ocular or may be a manifesta- tion of some general disease or of disease in some remote part of the body. Here again, the eye physician is of much service to the patient and the family doctor. Frequently, evidences of diabetes, nephritis, tabes dorsalis, brain tumor, syphilis, tuberculosis, nasal ac- cessory sinus disease, focal infection, and many other conditions, are found in the eye before general signs and symptoms are mani- fest. I he eye is a part of the body. It cannot be divorced therefrom without loss of function. It must be so considered. Only a physician can be competent to recognize all the possi- bilities that this relationship implies. Only he is sufficiently interested to feret out pos- sible disease. Only he is permitted to treat disease when found. The essential thing, then, is neither the prescribing nor the fitting of glasses but proper diagnosis of the condition present. After the diagnosis of refractive error is made, the ophthalmologist proceeds to the refraction proper. In persons under presbyopic age it is cus- tomary to use “drops” of some kind. The purpose of these “drops" is to quiet accommo- dation. It is hardly necessary to explain the value of cycloplegics to physicians. I might, however, recall to your minds that the process of accommodation is one not well controlled by the will. Accommodation is constantly changing. To estimate refraction of an eye with accommodation present is to attempt to measure a constantly altering quantity. It is just as ridiculous as weighing a person who is jumping up and down upon a scale. A correction of refractive error, to he of any great value, must be exact. An approxi- mation of this error is not enough, if the symp- toms are to be relieved. Such correction should be the same as the error, to within l/§ of a diopter. Retinoscopy, an objective method of de- termining the refraction, can be done with great precision when cycloplegics are used. I hen the subjective method need be used only as a check upon the observations of the physi- cian. As with all methods used by science, the objective method is more reliable and more exact than the subjective. Of course, ret- inoscopy can be done without cycloplegia. but no accurate estimation of refraction can thus be made. A band of 1 to 3 diopters is found at every point in which the shadow test may be “with" one time and “against” the next time. Dynamic retinoscopy, as this is called in contradistinction to static retinoscopy as done under cycloplegia, is a snare and a delusion. It will not even diagnose between hyperopia and myopia unless the error is high. I hen. there is another reason for using drops’ ; and that is for dilatation of the pupil so that a thorough examination of the interior of the eye can be made. No one can ascertain with any exactitude the condition of Sept.. 1931 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 699 the periphery of the lens through a small pupil, and that is where senile cataract usually begins. Nor can the vitreous be well inspect- ed for opacities. The macula frequently is difficult to see through a small pupil, and there, again, pathology is frequently found. The periphery of the retina cannot be ob- served through a 2.5 mm. pupil, and anterior chorioiditis is no rarity. Certainly, no one can say he has examined an eye until he has studied it ophthalmoscopically through a di- lated pupil. Hence, in patients long past the age where accommodation is active, pupils are dilated unless signs suggestive of glaucoma are present. In older patients, however, no cycloplegic, such as atropin, scopolamin or homatropin is used ; instead, cocain, euco- tropin, ephedrin or some other weak mydriatic is instilled. Following the fundus examina- tion in these older people, a retinoscopy may be made through the dilated pupil. Personally, I do this routinely. When all examinations are completed that require a dilated pupil, a miotic, such as pilocarpin or eserin, may be in- stilled, which in a short time overcomes the pupillary dilatation. Another important thing that should be mentioned about the use of cycloplegia is that the eye is put at rest for a period of time depending upon the drug used. This permits the retina, chorioid and ciliary body to re- cover from the irritation and congestion inci- dent to eye-strain. As for danger from the use of cycloplegics, one can but point to statistics from large eye clinics, where, thousands of cases are refracted yearly and where untoward effects of any kind are of exceeding rarity. At the Wills Eye Hospital, a report was given about 1 vear ago of all cases refracted within 3 years preceding the report, and in 30,000 refraction cases no complication of any consequence was noted. After the drops have worn off, another ex- amination is made; the postcycloplegic exam- ination. In hypermetropic patients the amount of plus sphere that they will accept is de- termined. Myopic patients are given the exact correction found under cycloplegia unless such correction is very high, when a reduction may be made. The most important part of the postcycloplegic examination, however, is determination of the muscle balance while wearing the new correction. The latent ten- dencies to deviation of the eyes from the parallel, the heterophoria, should never be neglected. The tendency for one eye to be- higher than the other, hyperphoria, if of suffi- cient amount, should be corrected with at prism ground into the glasses. Tendency for the eyes to turn out, exophoria, is treated by exercises and reduction of convex sphere. Frequently, exophoria and convergence in- sufficiency are the result of ethmoid disease, and treatment of the latter condition is re- quired before any relief can be obtained for the ocular muscle disturbance. The tendency of the eyes to turn in, esophoria, is treated with the stereoscope and giving full convex spheres. Heterophoria is the frequent cause of eye-strain and no ocular examination is complete without investigation of the ocular muscles. Numerous patients are seen suffei*- ing with dizziness, nervousness, nausea, indi- gestion and headache, who are wearing a proper refraction correction but whose mus- cular imbalance has been neglected. These patients can be relieved only by treatment of the heterophoria. To summarize : The purpose of refraction is much broader than the term implies and is best epitomized in the phrase, “ocular examination”. The pur- pose of refraction in this broader sense is to discover the causes of the symptoms ; first, whether they are ocular at all, ocular in part, or ocular entirely; second, whether the symp- toms arise from some disease of the eyes; third, to make an exact determination of the refractive error; fourth, the muscular bal- ance and abnormal muscular tendencies are determined and treated. 700 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 1931 SQUINT IN CHILDHOOD AND ITS EFFECT IN LATER LIFE Willard G. Mengel, M.D.. - Camden, N. J. The detection of squint in children at the earliest age, and the etiologic factors involved, together with measures taken in correction of squint and the effect in later life, is briefly the scope of this paper. The importance of the ex- competent hands, so as to receive the greatest benefit during important years of develop- ment, when the visual elements, fusion facul- ties, and ocular muscle movement coordina- tions are being established. A frequent expression heard from moth- ers is : “I thought the child would outgrow the condition.” Sometimes, on advice of anx- ious relatives and friends, nothing is done, waiting the time for the child to outgrow the defect. The eyes may appear straight to them, but there may be a latent defect giving Fig. 1. Convergent Strabismus E. P. Aged 4 years Right eye convergent. Refractive error— Compound Hyperopic Astigmatism. Fig. 2. Convergent Strabismus E. P. Same as figure 1 Showing correction of convergent right eye with glasses. Using glasses one year. animation of children’s eyes, especially during the pre-school age, should lie emphasized. Many conditions of children's eyes go un- recognized until later years, when correction of the defect becomes more difficult and the result unsatisfactory. There is no reason for conditions like congenital cataract, the various forms of keratitis, phlyctenular conjunctivitis, blepharitis, and squint, to be present for years, even until the twenties and thirties, and then having to be corrected by a spectacular opera- tion for restoring vision to a person blind from birth. These conditions should be diag- nosed between 1 and 5 years of age, if in rise to severe symptoms of eye-strain. The result of delay being poor vision in one eye. Squint, or strabismus, is a condition in which the visual lines of the two eyes do not intersect at the point of fixation, and is mani- fested by a deviation in, out, up or down, of the eye. With the advance of our knowledge in regard to this subject, it has become known that scarcely one case of squint is like another, for it is not simply a faulty position of one eye, but rather the external symptom of one or another of various disturbances. Sept., 1 U 3 j JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY 701 Fig. 3. Convergent Strabismus (Esotropia.) W. P. Aged 4 years Right eye convergent. Refractive error — Compound Hyperopic Astigmatism. Fig. 4. Convergent Strabismus (Esotropia) W. P. Same as figure 3 Aged 5 years, right eye convergent. Fro. 5. Convergent Strabismus (Esotropia) W. P. Same as figure 4 Showing improvement with glasses; glasses 3 months; Compound Hyperopic Astigmatism. 702 JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY Sept., 19.31 In the majority of cases, if one eye fixes an object with the fovea, the other will do so too, giving rise to binocular fixation. In fact, the whole extremely complicated mechanism of muscles and nerves with which the eyes are supplied, is designed primarily to accom- plish this single end; i.e. to so move the eyes that they shall both he directed accurately to the object we wish to see, and that each shall receive the image precisely upon the fovea. The movements of both eyes are hence al- Fig. 6. Divergent Strabismus (Exotropia) I. M. Aged 6 years Right eye turns outward; refractive error — Com- pound Myopic Astigmatism tR), Hyperopic Astigmatism (L.) most invariably coordinated so as to secure binocular fixation under all conditions. When both eyes fix the same object, they are said to be straight. This is regarded as the ideal or natural condition. In other instances both eyes will look straight at the same object when both are uncovered, but either eye, as soon as it is covered, will deviate— turning out, in, np or down. 1 his is looked on as an “insufficiency” (heterophoria), which may give rise to squint, and is indicative of eye- strain with refractive error. There is a ten- dency to squint, becoming manifest only on covering one eye. In the third class of cases, only one eye is straight (fixes the object) at a given time, the other deviating even when both eyes are uncovered. This condition is squint, strabismus or heterotropia. Briefly, there are 3 types of squint: first, convergent squint, when the eye turns in to- ward the nose — the most common variety ; second, divergent squint, when the eye turns Fig. 7. Divergent Strabismus I. M. Aged 6 years Same as figure G, right eye turns outward, show- ing correction with glasses; using glasses 6 months. outward away from the nose; and third, ver- tical squint, when the eye turns either up or down. Convergent squint, or “cross-eye”, develops between 1 and 5 years of age in the greater percentage of cases. First, the eye turns in toward the nose only at certain times; at other times the eyes are straight. This is the forerunner of a constant convergent squint. In