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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
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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.
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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
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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-
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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
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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
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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
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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
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JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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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
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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
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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.
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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
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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-
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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
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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.
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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-
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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
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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
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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.
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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
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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.
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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
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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.)
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( 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
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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-
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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
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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