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Journal of the^Iowa State Medical Society
PUBLISHED UNDER THE AUTHORITY OF THE HOUSE OF DELEGATES.
INDEX
VOL. IV.— JULY, 1914, TO DECEMBER, 1914.
EDITOR:
D. S. Fairchild, M. D., Clinton.
ASSISTANT EDITORS:
C. A. Boice, M. D., Washington J. W. Osborn, M. D., Des Moines.
TRUSTEES :
G. N. Ryan, M. D., Des Moines
D. H. Bowen, M. D., Waukon
J. N. Warren, M. D.., Sioux City.
COMMITTEE ON PUBLICATION.
J. W. Osborn, M. D., Des Moines W. L. Bierring, M. D., Des Moines M. J. Kenefick, M. D., Algona.
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INDEX-, VOL. IV.
Address of Chairman, section eye, ear, nose and throat, J. V. Littig, M. D.,
Davenport ..109
Adhesive complications in right abdomen, Max Emmert, M. D.,
Atlantic 294
Adolescence, relation to primary and secondary disease, Frank M. Fuller,
M. D., Keokuk 369
Anaphylaxis, relation to general medicine, A. M. Does, M. D., Du- buque 359
AUTHORS.
Beibesheimer, Dr. G. A., Reinbeck . .
Bevan, Dr. A. D., Chicago
Brockman, Dr. D. C., Ottumwa
Campbell, Dr. C. L., Atlantic
Churchill, Dr. C. H., Ft. Dodge ....
Cobb, Dr. E., Marshalltown
Crawford, Dr. G. E., Cedar Rapids .
DeJong, Dr. C., Ft. Dodge
Denney, Dr. B. F., Britt .
Dougherty, Dr. J. P., Sioux City ....
Emmert, Dr. Max, Atlantic
Fairchild, Dr. D. S., Clinton
Fay, Dr. O. J., Des Moines
Fitzpatrick, Dr. M. J., Mason City . .
Fuller, Dr. F. M., Keokuk
Gratiot, Dr. H. B., Dubuque
Habenicht, Dr. H. A., Des Moines . .
Hanske, Dr. E. A., Bellevue
Harkness, Dr. G. F., Davenport .... Harned, Dr. C. W., Des Moines . . . Harrison, Dr. J. W., Guthrie Center Henninger, Dr. L. L., Council Bluffs
Howard, Dr. C. P., Iowa City
James, Dr. C. S., Centerville
Jastram, Dr. A. H., Remsen
Kessel, Dr. George, Cresco
Kime, Dr. J. W., Ft. Dodge
Littig, Dr. J. V., Davenport
Littig, Dr. L. W., Davenport
Loes, Dr. A. M., Dubuque
Levy, Dr. Robert, Denver
Luckey, Dr. J. E., Vinton
MacCarty, Dr. Wm. C., Rochester . .
Martin, Dr. L. M., Ft. Dodge
McGrath, Dr. W. J., Elkader
McManus, Dr. T. U., Waterloo ....
Patrick, Dr. H. T., Chicago
Pearson, Dr. W. W., Des Moines . . .
Peck, Dr. Jno. H., Des Moines
Robinson, Dr. R. E., Waverly
Scarborough, Dr. H. V., Oakdale . . .
Schrup, Dr. J. H., Dubuque
Sherman, Dr. A. W., Burlington
Steindler, Dr. A., Des Moines
Sumner, Dr. G. H., Des Moines
Stowe, Dr. H. M., Chicago
Studebaker, Dr. J. F., Ft. Dodge . . . .
Swale, Dr. C. M., Mason City
Wahrer, Dr. Carl W., Ft. Madison . . Williams, Dr. E. M., Sioux City . . .
158
187
280
284
151
220
37
125
451
.241
294
170, 248, 314, 455, 460, 467
. . . : . .276
445
3 69
427
32
384
117
22
271
378
12
.303
287
441
128
109
.46
359
418
413
1
237
228
114
.347
433
207
163
194
.139
375
143
472
132
146
232
382
. .297
Board of Health, Iowa, a brief history of its formation, D. S. Fair-
child, M. D., Clinton 467
Board of Health, Iowa, history since formation, Guilford H. Sumner,
M. D., Des Moines 472
Blood Pressure, how to take it and what it signifies, G. E. Crawford, M.
D., Cedar Rapids 37
BOOK REVIEWS.
Ambidexterity . ,401
Anesthesia, local 405, 486
Blood pressure 262, 333
Blood Pressure primer 102
Bones and joints, diseases 261
Chemical laboratory, A. M. A 182
y () y
Clinical History culture 102
Clinical medicine, a treatise 402
Clinics of J. B. Murphy 101, 404, 485
Eye, anatomy 184
Gynecology, medical 182
Hematology . 183
Hospital, Episcopal, Philadelphia 184
Hygiene, practical 487
Infants, summer care 404
International Clinics 489
Legislation, medical, 6 6 years 488
Manual of Biological Therapeutics 489
Mayo Clinic papers 400, 491
Medical diagnosis, a textbook 403
Nervous and Mental Diseases, serology 490
Nose and Throat, a text book 490
Nose, Throat and Ear, treatise 334
Nose and Throat, manual 333
N. Y. Hospitals report 100, 183, 332, 404, 488
Obstetrics, Manual of 491
P. & S. college, Philadelphia 183
Practical Medicine Series 102, 184, 333, 334
Practitioner’s Visiting List 491
Progressive Medicine 330
Radium 102
Sanitary Commission, Rockefeller 102
Sex Talks to Boys 490
Skin diseases 101, 334
State Board questions 404
Surgery, modern 261
Surgery, guiding principles .262
Therapeutics, practical 335
Yellow fever, U. S. Gov. reort 4 03
Brain localization, E. M. Williams, M. D., Sioux City 297
Breast, benign tumors of, Oliver J. Fay, M. D., Des Moines 276
Breast, malignant tumors of, D. C. Brockman, M. D., Ottumwa 280
Carbon Monoxide poisoning, reporting two cases, M. J. Fitzpatrick,
M. D., Mason City 445
Cesarean section, C. M. Swale, M. D., Mason City 232
Constitution and bylaws, 1914 92
DEATH NOTICES.
Brown, Dr. Marcus 338
Bryant, Dr. Jos. D 103
Darling, Dr. E 33 8
Davis, Dr. S. 0 33 8
Enfield, Dr. Chas 104
Fleming, Dr. J. C 338
Hawk, Dr. W. W 338
Heidel, Dr. G. A 33 8
Irvin, Dr. Byron 338
Jenkins, Dr. Geo. F. 336
Kinney, Dr. F. J 33 8
Langan, Dr. D v 338
Lee, Dr. James A. 49 5
Matthey, Dr. Carl 338
Mierley, Dr. W. M 33 8
Powers, Dr. Jos. L 49 5
Plunkett, Dr. I. Z 33 8
Preston, Dr. Chas 263
Roberts, Dr. Jason 495
Sawyers, Dr. J. L. 33 8
Tate, Dr. F. M 338
VanDuzer, Dr. F. H 338
Welch, Dr. F. E , 338
Drake University Medical Department, D. S. Fairchild, M. D., Clinton. 46 0 Drum membrane, indications for paracentesis, R. E. Robinson, M. D., Waverly 163
EDITORIAL.
Advertising reminders
Alumni clinics
A. M. A., 1914 meeting
Attorneys, local in defense suits
Beauty hint
Boosters and builders
Carnegie Foundation report
Carrel, Dr. Alexis
Chiropractors must comply with Practice Act
168, 169, 170, 247, 248
59
166
245
178
58
54
399
484
Coliege site donated 485
Consent, damages for visiting without patient’s 484
Consultants, referee 244
Curriculum making, principles 166
Economic league of physicians 399
Education statistics 257
Epileptic hospital, Iowa 165
Eyes, sore from face powder 255
Fellowships, teaching, in Univ. of Minn 454
Flexner, Dr. Simon 181
Florida Journal 398
Ford Hospital in Detroit 398
Friedmann treatment. Gov. report 481
Gunshot wounds, malpractice in treatment 482
Guthrie, Dr. J. R., testimonial . ..259
Health, value of in industry and war 396
Hospitals, responsibility. 392
I. and I. Sosiety, special meeting 392
Industrial accident work 56
Iowa Medical Journal, purchase 54
Lead poisoning in industry 454
Lead poisoning in smelters 483
Liability of surgeon 58
Medical defense in other states 57
Obstetrics, American Journal 167
Occupational diseases 256
Organization notes 185, 412
Oyster and typhoid fever 179
Physicians in Germany 257
Physicians, no danger of scarcity 39 7
Quack’s horoscope 483
Reclus, Professor 253
Responsibility in malpractice 253
Rules of defense committee 59
Sit straight, to make people ..485
Smith, Dr. Theobald 181
Students, university, in Germany 180
Teachers, whole-time 180
Toronto Hospital 59
Trachoma, spread of 178
Travel study club .39 9
Typhoid in army 254, 255
Typhoid vaccination 253
Verdict against Drs. Carr and Brandon 387
Workingmen’s compensation act 243, 453
Workingmen’s compensation act in New York 388
X-ray pictures, proof of 181
Elephantiasis, a case report, C. L. Campbell, M. D., Atlantic 2 84
Examinations, thorough, are they worth while? J. F. Studebaker, M. D., Ft. Dodge 146
Femur, non-operative treatment of fractures, A. W. Sherman, M. D., Bur- lington 375
Gastric Ulcer, some things about, E. A. Hanske, M. D., Bellevue .... 384 Gastro-enterostomy, unfavorable results, C. DeJong, M. D., Ft. Dodge .125
Goitre, a brief consideration, George Kessell, M. D., Cresco 441
Headaches, some ordinary, Address in Medicine, Hugh T. Patrick, M. D.,
Chicago 347
Hearing, conservation, T. U. McManus, M. D., Waterloo 114
Hip; in children and adolescents, traumatism, Arthur Steindler, M. D.,
Des Moines 143
Hydrotherapy, H. A. Habenicht, M. D., Des Moines 32
House of Delegates, transactions, 1914 .61
Hysterotomy, a method of terminating pregnancy, Carl W. Wahrer, M. D.,
Ft. Madison 382
Infant feeding, G. A. Biebesheimer, M. D., Reinbeck 158
Intracranial pathology and fundus changes, G. F. Harkness, M. D., Dav- enport ' 117
Iowa State Medical Society, transactions, 1914 88
Labyrinth, suppuration of, Reporting six cases, Edwin Cobb, M. D., Mar- shalltown 220
Laryngeal Tuberculosis, significance of during pulmonary ruDerculo- sis, based on a study of 650 cases. Address in Laryngology, Rob- ert Levy, M. D., Denver. 418
Lupus and other parasitic skin diseases, a specific treatment, J. W. Kime,
M. D., Ft. Dodge 128
Maxillae, caries and necrosis, C. W. Harned, M. D., Des Moines 22
Medical ethics, practice of the principles, J .H. Schrup, M. D., Du- buque 139
Nasal surgery, the conservative idea, L. L. Henninger, M. D., Council
Bluffs 378
New and non official remedies 106, 399
Parathyroid glands, a study of, C. H. Churchill, M. D., Ft. Dodge . . .151
Pellagra, A. H. Jastram, M. D., Remsen 287
Pellagra, case in Sioux City, J. P. Dougherty, M. D., Sioux City . . . .241
Pioneer Practice, D. S. Fairchild, M. D., Clinton
170, 248, 313, 455, 460, 467, 472
Precancerous conditions, W. C. MacCarty, M. D., Rochester, Minn 1
Propaganda for reform 107, 263, 496
Public Health, the physician’s relation to. Report of a diphtheria
epidemic, Address in Medicine, J. E. Luckey, M. D., Vinton . . . .413
Puerperal sepsis, treatment, H. M. Stowe, M. D., Chicago 132
Sarcoma, medical aspects, C. P. Howard, M. D., Iowa City 12
Sinus Infections, W. W. Pearson, M. D., Des Moines ; 433
SOCIETY NOTES.
Alienists and Neurologists 405
American Medical Association 106
American Roentgen Ray . . 26 8
Appanoose County 105, 184, 268, 408, 410, 493
Audubon County 409, 409
Benton County 411, 411
Black Hawk County 411
Botna Valley 342, 409
Cass County 410
Clayton County 493
Dallas — Guthrie Counties 342, 411
Decatur County 492
Des Moines Pathological Society 493
Des Moines Valley 105
Dubuque County 411
Fremont County 106
Greene County 106, 408
Hancock-Winnebago Counties * 493
Iowa Clinical Surgical 409
Iowa County 495
Iowa Union 408
Jefferson County 409
Jackson County 411
Keokuk County 410
Lyon and Osceola 409
Marshall County 411
Marshall, Franklin and Hardin Counties 342
Missouri Valley 105, 269, 340
Monona County 494
Page, Fremont, Montgomery, Taylor and Decatur Counties 342
Polk County 106, 339, 409, 493
Powesheik County 410
Ringgold County 407, 408, 494
Sac and Colhoun Counties 49 4
Scott County 495
Second District 408
Sioux Valley 266
Southeastern Iowa 268, 491
S. U. I., Alumni clinics 405
Wapello County 265
'Washington County 184
Wayne County 495
Webster County 342
Stomach, foreign bodies in, B. F. Denney, M. D., Britt 451
Surgery, address, Borderland cases and team work, Arthur Dean Bevan,
M. D., Chicago 187
Surgery, address in, J. W. Harrison, M. D., Guthrie Center 271
Things, simple but important often badly done, L. W. Littig, M. D.. Dav- enport 46
Tonsils and Adenoids in their relation to general systemic infections,
H. B. Gratiot, M. D., Dubuque • 427
Tonsils and adenoids, enlarged, indications for and objections to their
removal, Loran M. Martin, M. D., Ft. Dodge 237
Tonsils and adenoids, W. J. McGrath, M. D., Elkader 228
Tuberculosis, recognition early by the general practitioner, J. H. Peck,
M. D., Des Moines 207
Tuberculosis, something of the present situation and needs in Iowa, H. V.
Scarborough, M. D., Oakdale 194
Uterus, cancer of, C. S. James, Centerville 3 03
THE JOURNAL OF THE IOWA STATE MEDICAL SOCIETY
Entered at the Post Office Washington, Iowa, as Second Class Matter
EDITOR
D. S. FAIRCHILD, M. D Clinton
ASSISTANT EDITOR AND ADVERTISING MANAGER
C. A. BOICE, M. D Washington
ASSISTANT EDITOR AND SECRETARY J. W. OSBORN, M. D Des Moines
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Subscription, $2.00 per year in advance. |
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Yol. 4 |
Clinton, Iowa, July 15, 1914 |
No. 1 |
PRECANCEROUS CONDITIONS*
WM. CARPENTER MacCARTY, M. D., Rochester, Minn.
The term precancerous has become so indelibly impressed upon our minds in our search for perfect therapeutic results in cancer, that it seems necessary to study its real meaning and significance in the light of facts which have been recently determined relative to the histogenesis or development of cancer.
It is a term which has not been completely defined nor accepted by many pathologists to have a definite histological basis other than the one, which the clinician has given to it considering chronic in- flammatory conditions in general precancerous.
In this usage the prefix “pre” has had wide limits in regard to time ; it has not been given a definition which means the immediate precancerous stage of cancer.
It is the writer’s opinion from a certain knowledge of literature and some experience with clinicians that the term is more or less in- definite and needs some explanation, indeed, an explanation which will not only place the term upon a histological basis but will also in dicat e certain therapeutic measures which will be of value to physi- cians, surgeons and pathologists.
Since the question of cancer is a very large subject and not only includes many organs but embraces new-growth of both epithelial and connective tissue origin, it may be more clearly presented if we consider the question in regard to one organ and confine our obser- vations to cancer which has its origin in epithelial cells
More correctly speaking in this consideration the term precar- cinomatous would be more appropriate. The term should also be
*Read before the Rock Island, Davenport and Moline Medical Society, April 9, 1914,
2
JOURNAL OF IOWA STATE MEDICAL SOCIETY
confined in this discussion to a condition which immediately pre- ceeds cancer.
If one examines a large series of breasts which have been re- moved for chronic mastitis and for carcinoma, four definite histolog- ical facts will be seen.
I. Acini are found which consist of two rows of cells, an outer row and an inner row. (Fig. 1.).
Fig. 1. 399 09. Mammary acinus showing two rows of cells, the dark cells of the inner row are the differentiated or secretory cells. The pale cells of the outer row are the cells of the stratum germinativum. Primary epithelial hyperplasia.
2. Acini are found in which the inner row has disappeared and there is a proliferation of the cells of the outer row. (Fig. 2.).
Fig. 2. 28376. Mammary acinus containing hyper- plastic cells of the outer row (stratum germina- tivum). The cells of the inner row are absent. Secondary epithelial hyperplasia or pre-carcino- matous hyperplasia.
PRECANCEROUS CONDITIONS— MacCARTY
3
3. Acini are found in which the inner row of cells have dis- appeared, the cells of the outer row are hyperplastic and the line of demarcation between the acini and the stroma is confused and often partially destroyed.
The cells of the outer row are seen in the stroma. (Fig. 3.).
Pig. 3. 36116. Secondary or pre-carcinomatous epithelial hyperplasia in the mammary gland.
4. The cells within the acini are often morphologically indis- tinguishable from the epithelial cells in the stroma. (Fig. 2, 9 & 10).
Primary, Secondary and Tertiary Epithelial Hyperplasia. PRIMARY, SECONDARY and TERTIARY EPITHELIAL HYPERPLASIA.
a
Primary epithelial hyperplasia (not carcinoma).
b
Secondary epithelial hyperplasia (carcinoma?).
Tertiary or migratory hyperplasia (carcinoma).
4 JOURNAL OF IOWA STATE MEDICAL SOCIETY
The first two of these conditions have been termed respectively, primary and secondary hyperplasia. The last two have been called tertiary or migratory epithelial hyperplasia. The first condition
Pig 4. 2 0 79 7. Secondary or pre-carcinomatous epithelial hyperplasia in the mammary gland.
Pig. 5. 36116. Mammary acini containing epithe- lial cells which are indistinguishable morpholog- ically from extraacinar cells of carcinoma.
(diagram a) is not carcinoma, the second (b) may or may not be car- cinoma and the third (c) and fourth (Figs. 9 & 10) conditions are certainly carcinoma.
It seems to the writer that the most immediate precancerous or precarcinomatous condition is these pictures is the secondary epithe- lial hyperplasia, (Figs. 2, 3, 4, 5, 8, 9, 10). The condition is a definite histological picture and is one through which carcinoma passes be- fore it can positively be said to be carcinoma.
Fig. 7 and 8. 36116. Secondary epithelial hyper- plasia showing the indefiniteness of the line of demarcation between the stroma and the acinus
They apply to any local or diffuse non-encapsulated or encap- sulated tumor of the mammary with the exception of such rare con- ditions as sarcoma, endothelioma, myxoma, chondroma, dermoid,
PRECANCEROUS CONDITIONS— MacCARTY
The three histological conditions or apparent stages of epithelial hyperplasia which represent a benign condition (primary hyper- plasia) and a malignant condition (tertiary or migratory hyper-
Fig. 6. 35256. Secondary epithelial hyperplasia showing the indefiniteness of the line of de- marcation between the stroma and the acinus.
adenoma, simple fibro-adenoma and adeno-fibroma or fibro-adenoma and simple chronic mastitis with or without the presence of cysts, plasia) serve as a basis for definite practical rules for the treatment of mammary epithelial neoplasmata.
6
JOURNAL OP IOWA STATE MEDICAL SOCIETY
teratoma, syphilis and tuberculosis and may even apply to these if the behavior of epithelial structures is to be considered as bearing upon the nature of the tumor.
They apply to the more common conditions such as simple In general, they apply to all tumors of the breast whose benig-
Fig. 9 and 10. 31983. Tertiary or Migratory Ep- ithelial hyperplasia (Carcinoma) in a mammary
gland.
nancy or malignancy is dependent upon the biological activities of epithelial elements.
This large group comprises the vast majority of pathologic con clitions in the breast with which the practitioner and surgeon come in contact and may be treated according to definite rules.
1. The conditions which are associated with classical clinical, signs of carcinoma should be treated radically.
2. The doubtful cases in women near or over 35 years of age
PRECANCEROUS CONDITIONS— MacCARTY 7
Pig. 11. 15835. Prostatic acinus show-
ing two rows of cells, the cells of the inner row are the differentiated or secretory cells. The cells of the outer row are the cells of the stratum germ- inativum. Primary epithelial hyper- plasia.
Pig. 12. 158 3 5. Prostatic acinus. Sec-
ondary epithelial hyperplasia.
Fig. 13. 15835. Prostatic acinus. Se- FiS- 14- 15835. Prostatic carcinoma
condary epithelial hyperplasia show- (Tertiary or migratory epithelial
ing cells which are indistinguishable hyperplasia),
morphologically from carcinoma
cells.
should have the entire mammary gland removed for immediate ex- amination. If primary or secondary hyperplasia be present nothing more should be done ; if tertiary hyperplasia be present, a radical operation should be performed.
3. In doubtful patients near or under 35 years of age, a wide sector of the mammary gland including the pathological condition should he removed for examination. If secondary hyperplasia be
8
JOURNAL OF IOWA STATE MEDICAL SOCIETY
Fig. 15 and 16. 53 63 0. Epithelium in the border of the mucosa of a simple gastric ulcer.
Fig. 17. 53630. Epithelial hyperplasia Eig. 18. 35572. Tertiary epithelial
in the border of a simple gastric ulcer. hyperplasia in the gastric mucosa. Secondary epithelial hyperplasia?
present, the rest of the mammary gland should be removed and if ter- tiary hyperplasia be present, the radical operation should be ac- complished.
It may be seen that in the case of one organ the precancerous or precarcinomatous condition may be defined as a definite histolog ical picture which allows, in fact, demands definite therapeutic pre- cedures.
Since the precarcinomatous condition is a definite histological entity, and has clinical applicability in the breast, it behooves us to determine if similar histological entities exist in other organs.
PRECANCEROUS CONDITIONS— MacCARTY
9
Pig. 19 and 20. A72606 and A 77538. Secondary- epithelial hyperplasia in the stratum germ- inativum of the skin of a lip.
In the prostate gland there are three definite histologic pictures (Fig. 11, 12, 13, 14) which are identical with those which have been found in the breast. However, the anatomical character of this organ does not permit any advice from a therapeutic standpoint, al- though the presence of secondary hyperplasia should stimulate a guarded prognosis.
The natural pathologic grouping of gastric ulcerations allows somewhat the same consideration which has been advised for the mammary gland.
In the stomach one finds certain facts relating to chronic ulcer- ations and carcinoma which may be studied in the light of these find- ings.
10
JOURNAL OF IOWA STATE MEDICAL SOCIETY
Chronic gastric ulcers occur which have all the characteristics of simple chronic gastric ulcer plus the presence in the mucosa of an epithelial hyperplasia the cells of which are indistinguishable mor- phologically from the cells of early carcinoma. Similar ulcers occur plus the presence of invasion of the stroma by cells which are in- distinguishable from the intra-glandular hyperplastic cells. This latter group is certainly carcinoma.
One also finds chronic gastric ulcers in which the borders and bases are definitely involved by carcinoma.
If operative precedure is to be carried out in the treatment of these cases it may be done according to definite rules. If excised chronic gastric ulcers show a mucosa which contains differentiated
Fig. 21. A96196. Secondary epithelial hyper-
plasia in the stratum germinativum of a hair follicle.
cells (Fig. 15) without the presence of partially differentiated cells (Fig. 16) one should not, with our present knowledge demand re- section. If, however, there is an extensive hyperplasia of partially differentiated cells (Figs. 17 and 18) resection might be indicated when technically possible, if such a resection does not carry with it a greater risk to the patient than does simple wide excision. The clinical significance of what might be called the precancerous epithe- lial hyperplasia in chronic gastric ulcers may be, therefore, readily seen.
The fact that such a precancerous epithelial hyperplasia does occasionally exist in the mucosa of simple chronic gastric ulcers seems to indicate also at least one clinical consideration, namely, that it is impossible to determine by known clinical methods, by gross pathology or by low power microscopy when an ulcer is or is not in the condition of what might be termed secondary hyperplasia or precancerous epithelial hyperplasia.
PRSCANCEROUS CONDITIONS— MacC ARTY
11
There is one other organ, which has been studied by the writer in the light of histological proof of the histogenesis of carcinoma.
The skin, when in a condition of chronic inflammation, not in- frequently shows cytological pictures (Figs. 19, 20) which bear cer- tain resemblance to those which have been found in the breast.
This organ consists of two apparent types of cells, the differen- tiated or squamous cells and the socalled partially differentiated or basal cells. The latter cells have for their function the renewal of differentiated cells, when the latter have been destroyed and there- fore show evidence of hyperplasia in the presence of chronic destruc- tive processes.
They are not only hyperplastic but present marked irregular- ities in size and shape which are the same characteristics which are possessed by the intra-acinar hyperplastic cells of the outer row in the breast and which is called secondary or precarcinomatous epithe- lial hyperplasia.
As in the breast and stomach these cells are morphologically indistinguishable from the cells which have invaded the stroma in early epithelioma. This fact has a two-fold clinical significance. Since, we do not know that such a condition is or is not malignant one does not dare to do a radical operation. Since, we do know that it does bear a cytological if not a biological resemblance to epithel- ioma the clinician cannot deal with the condition justly, unless a wide excision is performed.
It seems to the writer that these observations allow the follow- ing definite conclusions.
1. There is a cytological basis for the term pre-carcinoma or pre-epithelioma and by further study this basis may apply more broadly to the term precancer.
2. The clinician may divide his therapeutic precedures into three types namely, simple excision, -wide excision and radical oper- ation with the removal of large amounts of tissue and lymphatic glands and that these may be based upon definite histological pic- tures of a condition which may be called precancerous hyperplasia.
3. The term precancerous may be limited to a cytological con- dition which immediately preceeds cancer and should not be util- ized to indicate simply a chronic inflammation.
4. Even the cytological precancerous condition has not been definitely proven to always become cancer.
References.
1. MacCarty. Carcinoma of the Breast. Transactions of the Southern Surgical & Gynecological Association, 1910.
MacCarty. Histogenesis of Carcinoma of the Breast. Surgery, Gynecol- ogy & Obstetrics. October 1913.
MacCarty. Clinical Suggestions based upon Primary, Secondary and Ter- tiary Epithelial Hyoerplasia in the Breast. Surgery, Gynecology & Obstetrics. March 1914.
2. MacCarty. Pathology and Clinical Significance of Gastric Ulcer. Sur-
gery, Gynecology and Obstetrics. May 1910.
MacCarty & Broders. Chronic Gastric Ulcer and its Relation to Gastric Carcinoma. Archives of Internal Medicine, February 1914. Vol. XIII.
12
THE MEDICAL ASPECTS OF SARCOMA*
C. P. HOWARD, A. B. M. D., Iowa City.
Since July 1st, 1910, there have been admitted to the medical service of the University Hospital, twelve cases of sarcoma among a total of 1391 cases. This shows that in a hospital medical clinic at least, sarcoma is a disease to be reckoned with, though of course when compared with carcinoma and especially with tuberculosis, less frequent. During this same period there were 47 cases of carcinoma, and 119 eases of tuberculosis, two of the main chronic capital con- ditions.
First let us refresh our memories as to what we mean by the term sarcoma. To quote Adami,1 “First and foremost a sarcoma is a richly cellular tumor of the connective-tissue type, the cells being of the vegetative, imperfectly differentiated order, or “embryonic” and the component cells develop and present characteristically in- terstitial substance.”
“The more embryonic the type of cell the greater the presump- tive evidence of malignancy”. Further “that as between two tu- mors of the same origin the more vegetative the type of cell and the greater the departure from the adult- cell standard, the greater the malignancy”.
Sarcomata “are not encapsulated but exhibit a peripheral growth and invasion of the surrounding tissues. This invasion is along the tissue spaces and leads to progressive destruction of the preexisting tissue with general absorption of all that tissue save a supporting frame-work around the vessels and capillaries”.
One feature is the abundant vascularity of the growths and con- sequently hemoorrhages into the tumors are very apt to occur. Fur- ther “the sarcoma cells are liable to become free in the blood stream and metastases along the blood stream are characteristic of these growths.” “Such metastases, it must be remembered are not con- fined to the blood vascular system ; they may occur along the lym- phatics, so that malignant enlargement of superficial and other lymph glands is not absolutely diagnostic of cancer”. The latter is especially true of small, round-celled sarcomata of the lympho- sarcomatons type. Adami, however, believes that “all sarcomatous growths of the abdomen may form such metastases”. In our series only two cases showed any enlargement of the superficial glands.
Nevertheless, extension by the blood vessels is the commonest procedure, hence the frequency of metastases in the lungs.
The varieties of pure sarcoma are as yon will remember: (1) small round-celled, (2) round-celled, (3) large round-celled, (4) oat- shape celled, (5) small spindle-celled, (6) large spindle-celled, (7)
*Read before the Clinton County Medical Society, March 6 1914.
SARCOMA— HOWARD
13
giant-celled, and lastely (8) mixedgcelled. The first mentioned is the most malignant of all.
In addition to these are the intermediate sarcomata “in which the undifferentiation has not proceeded so far so that some of the constituent cells attain a considerable degree of differentiation and tend to reproduce the tissue characteristics, whereas others are of the actively vegetative type. These are mixed celled sarcomas in another sense”. In this way we recognize fibro-sarcoma, osteo-sar- coma, chondrosarcoma, etc. Time will not permit us to analyze the features of each variety in detail.
Yet I cannot overlook the osteo-sarcoma as it is a term fre- quently used in the body of this paper. This group shows usually mixed sarcoma elements — large and stumpy spindle cells, polygonal cells, giant cells. In general the greater the development of osseous matter the less the malignancy of the tumor. The most malignant are those which show least bone and most cells of the small type. Osteosarcoma, as pointed out by Buerger,2 is not a proper term for all tumors arising in bone and should be applied only to that par- ticular form in which the inherent potentiality to produce osseous ground substance or matrix is manifested.
Sarcoma, like its first cousin carcinoma, has its medical and its surgical features. ISy this I mean the predominating or presenting symptoms will determine the patient whether to consult an inter- nist or a surgeon. The surgical are chiefly local — i. e. tumor, swell- ing, deformity, etc., and will be discussed by another speaker. The medical presenting symptoms are for the most part due to pressure of the primary growth upon the spinal cord or nerve trunks, or to extension of the process into the soft parts. The results of pressure of the tumor upon blood vessels occur less frequently but are well seen in the mediastinal sarcomata. Hence we can group for pur- poses of convenience, the main symptoms under three heads, (1) nervous, (2) visceral, (3) vascular.
The susceptible age is variable and the old teaching that sar- coma is a disease of youth and carcinoma of old age, is only to be accepted with reservation.
Too much must not be expected from the x-rays in diagnosis as in certain of the softer sarcomata, little or no shadow may be cast. In the majority of bone sarcomata some experience in the reading of skiagrams must be attained before they can be correctly interpreted.
I. Nervous Symptoms.
1. Pain is, needless to say, the most frequent as well as the earliest indication of a morbid growth, though its intensity varies from an almost inappreciable ache to the most exquisite, excruciat- ing agony. This depends upon the number and nature of the nerve tissues involved, as well as upon the possibilties of expansion of the tumor. Thus a pelvic or thoracic osteosarcoma may reach enormous dimensions without marked pain, if it merely grows into the pelvis
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JOURNAL OF IOWA STATE MEDICAL SOCIETY
or thorax without eroding the bony structures. On the other hand a sarcoma of a long bone not having the same room for growth, is as- sociated with pain almost throughout the entire clinical course, or at least until it has broken through the periosteum.
2. Paralysis: owing to the liability to primary involvement of the vertebra] columns, cord symptoms are by no means uncommon, as witnessed by our four cases. Depending upon the site of the growth and consequently upon the level of the cord at which press- ure is exerted, the picture will vary.
If the upper cervical vertebrae be involved there will develop a pressure myelitis, which may be associated with a group of symp- toms known as the Brown-Sequard syndrome.8 That is owing to the fact that one side of the cord is more involved than the other there will be hyperesthesia and eventually spastic paralysis on one side while anesthesia chiefly to pain and temperature is most marked on the other side.
Case 1. Osteosarcoma of Cervical Vertebrae: Compression Mye-
litis: Brown-Sequard Syndrome: Operation for relief of pressure. Death. Autopsy. Large round-celled sarcoma.
C. S. Age 19. Clinical No. 82. Referred by Dr. McNeal of Lost Nation. Farmer. Admitted Oct. 2 7, 1910, complaining of pain, stiffness of legs and neck. For 2 0 years he had a lipoma on right forearm. In May 19 09 another appeared in the sacral region. It grew rapidly and be- came bluish in color. It was removed, therefore, in Sept., 1909, and was reported by the surgeon to be an epithelioma. In Feb. 1910 he first noticed stiffness of neck, which gradually increased. In June 1910 he received injections over back of neck, since which patient had noticed in- duration of that region. Stiffness rapidly increased and the pain, which was slight, increased so as to interfere with sleep. On Oct. 2 0th, 1910 he noticed weakness of left arm and leg. He lost 351bs. from May to October. Examination revealed flexion of the neck upon the chest with restriction of movement. Over the posterior aspect of the neck from the occiput to the 7th cervical, the skin was dark brown and boggy, with definite tenderness particularly on the left side. No cutaneous or gland- ular tumors apart from the lipoma above mentioned. There was a well defined paresis of the left arm and leg and slight of right arm. The bi- ceps' reflex was absent on both sides, while the knee kick was more active on the left than the right side. No. Babinski. Pallesthesia was reduced to 25 per cent of normal on the left and 50 per cent on the right. Touch 50 per cent on the left and 9 0 per cent on the right. Pupils, eye- grounds, etc., negative. An x-ray pla*te showed a distinct shadow in the region of the 1st and 2nd cervical vertebrae. On Nov. 2nd the patient was given 3 mgms. of T. O. , which was followed by a marked general reaction with temperature of 104.2-5 degrees, headache, etc. Finally there also appeared to be an increase of the signs. This was followed by an improvement, in the pain, but not of the Brown-Sequard syndrome. On Nov. 7th an exploratory incision was made to drain what was thought to he a cold abscess from tuberculous caries of the heck. Nothing defin- ite could be found, apparently from want of a more extensive dissection. The sensory symptoms, as well as the motor, progressed rapidly in the next few days, both being most marked on the left side, but the sensory disturbance was present also on the right. Eventually there was com- plete left-sided paralysis, almost complete of the right upper but slight
SARCOMA— HOWARD
15
retention of power in the right lower. As the patient was evidently suf- fering from an increasing pressure over the cervical enlargement, a sec- ond operation was undertaken, and more extensive disection made, when a friable, hemorrnagic tumor of the bodies of the 1st, 2nd, and 3d cer- vical vertebrae was discovered. The patient stopped brething and death ensued while under the anesthetic. An autopsy was obtained which re- vealed in addition to the friable, boggy material above metnioned, an extradural mass, about the size of an egg, of pale yellow'-white color, of soft and friable consistency. The spinous processes of the 1st and 2nd cervical vertebrae had been destroyed. The posterior portion of the atlas had entirely disappeared. The posterior of the axis on the right side was present but eroded by the tumor process. On opening the dura it was found that the tumor had extended through on the left side and was dis- tinctly pressing on the spinal cord. Microscopically the tumor was found to be a large round-celled sarcoma. There was slight degeneration of the descending tracts below the points of compression.
Again the growth may exert equal pressure on the two anter- ior halves of the cord and a picture of compression myelitis will result. Thus in addition to the nerve root pains, motor cord symp- toms will result. If the cervical cord be involved there may be spasm of the cervical muscles, the head will he fixed, and motion will either be prohibited or associated with great pain.4
Case II. Osteosarcoma of Cervical Vertebrae; Compression Myelitis; Paraplega with Spastic Paralysis. Death. No Autopsy.
B. K. Age 43. Clinical No. 1007. Housewife. Referred by Dr. Schultz, of Garner. Admitted July 8, 1913, on account of numbness and weakness of extremities. In Feb. 1911 she first noticed stiffness of neck which gradually became more and more painful, particularly when she received a jar. In Aug. 1911, the pain first radiated into the shoulder. It was not until April 1913, that she noticed numbness and -weakness of the right hand. About June 1913, similar symptoms developed in the middle, and ring fingers of the left hand, and two weeks later in the right leg. On examination there was distinct rigidity of the neck with the chin held pointed to the left. There was definite spasm of the neck muscles and prominence of the lower cervical and upper dorsal vertebrae. No local tenderness, but jarring the head caused pain in the neck radiating to the shoulder. Glands no where palpable. All the tendon reflexes were increased and there was slight patella and ankle clonus on the right, with bilateral Babinski, though more marked on the right. Sensation to touch, pain, and temperature and pallesthesia intact throughout.
There was no reaction to subcutaneous tuberculin. Very slight anemia. A negative Washerman n, in both blood and spinal fluid. The spinal fluid was also negative as to cell count and protein content. The skiagram showed a distinct osteoporosis in the bodies of the III and IV cervical vertebrae due to the tumor invasion, with tilting of the trans- verse processes. After discharge she developed first incontinence of the bladder and rectum and then a spastic paralysis of the right arm and leg, then of the left leg and arm. She died January 15th, 1914. No autopsy.
In the thoracic region the spinal deformity will be more marked and pressure symptoms are still more common. This type is most frequently seen as a result of Pott’s disease and wras not illustrated in our sarcoma series. On the other hand we have seen several cases recently in which resulting compression myelitis was due to metast-
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JOURNAL OF IOWA STATE MEDICAL SOCIETY
ases from carcinoma of the breast and one from the prostate. The paraplegia slowly develops — first weakness and paresthesia, girdle sensation intercostal neuralgia and then a rapid loss of muscular power with spasticity and increased reflexes. Sensation is lost more slowly.
In the lower dorsal or lumbar regions the symptoms are practi- cally the same but the sphincters are involved and the reflexes are not exaggerated.
Case III. Osteosarcoma of Lumbar and Sacral Vertebrae: Compress- ion myelitis: Paraplegia with flaccid paralysis. Death. No autopsy.
T. F. Age 56. Clinical No. 9 8 5. Housewife. Referred by Dr. S. S. Westley of Manly: Admitted June 15th, 1913, on account of pain in the sacrum, inability to walk, and numbness in lower extremities. Four years before she had noticed numbness and tingling in both legs but par- ticularly the left. There was also pain in the sacral region, radiating around to the front of the abdomen. For nine months she had difficulty in walking alone. There was also retention of urine and marked consti- pation with loss of twenty pounds in weight. Examination revealed a uniform elevation in the sacral region, more marked to the right of the mid-line. The surface was regular and not tender. There was complete paraplegia without spacticity, slight atrophy of the muscles, loss of K.K. and Achilles’ reflex on both sides. No Babinski. There was an area of anesthesia to touch, pain, and temperature over the buttock and slight impairment of touch over the inner side of the left thigh arid leg. There was no anemia. The spinal fluid showed no increase in the cells but a marked increase in the protein content. The Wassermann was negative. After discharge from the hospital, the paralysis increased particularly on the left. Obstinate constipation also developed before her death on Dec- ember 15th, 1913. No autopsy obtained.
If the tumor be situated still lower, the branches of the cauda equina may be involved when again neither spasticity, increased re- flexes etc., will be present but merely anesthesia of varying degrees and extent. The symptoms are of gradual onset and often affect the motor, sensory, or sphincter functions separately. Further it is of the peripheral tyx>e i. e. follows nerve distribution and not the cord segment.
The sphincter symptoms are slight impairment of bladder con- trol and constipation, if the lesion is unilateral: or complete loss of both vesical and anal reflexes as well as loss of the powers of erection if the lesion be bilateral.
Case IV. Osteosarcoma of Sacral Vertebrae Compression of Cauda Equina; still under observation.
J. S. Clinical No. 578. Age 23. Carpenter; Referred by Dr. C. S. Kraus, Cedar Rapids: Admitted May 14, 1912, on account of pain in lower back and difficulty with walking. In Jan. 1912, he first noticed sharp pain in the lower dorsal region which rapidly increased in intensity. He next noticed incontinence of urine and he was referred in April 1912 with a clinical diagnosis of spinal syphilis. Apart from the evidence of this disease in the skin and in the blood, there was noted a mass over the lower sacral region which could be felt per rectum. It was firm and evi- dently attached to the sacrum, was irregular and somewhat indurated.
SARCOMA — HOWARD
17
In addition, an area of anesthesia to touch and pain was present over the lower sacrum, coccyx and inner side of the right thigh. Reflexes were normal. There was slight secondary anemia, with a normal leukocyte count but with the presence of marrow cells, (myelocytes and myelob- lasts) in the differential count. At the present time, the pa- tient is still under observation and the tumor occupies the entire pelvis and has almost obliterated the lumen of the
rectum, which it has pushed down before it. It can be felt
above the symphysis, extending to either iliac fossa. The prominence over the sacrum has about quadrupled in size since he first came under observation. Apart from loss of wreight and discomfort induced by the obstipation, the patient remains in fair health. The skiagram revealed at first a dense shadow in the bodies of the lower sacral vertebrae. A recent one shows a diffuse shadow filling the entire pelvis.
II. Visceral Symptoms.
Under this we would include the joint cases as well as the pleu- ral, pulmonary, mediastinal and intestinal. In these while pain may be a more or less prominent feature it is not the striking one but
only incidental to the disability of function of a joint or in asso-
ciation with cough, dyspnea, constipation, etc.
When sarcomata develop in the ends of the long bones, joint symptoms naturally are prominent. Pain, swelling, and disability of the joint cause the patient to consult his physician for rheuma- tism— that “coat of many colors”, under which too many practi- tioners are only too willing to take shelter.
Case V. Sarcoma of Fascia of Flexor TJlnaris; simulating arthritis of wrist- joint: Amputation of arm: Recovery: Round-celled sarcoma.
F. G-. Age 60. Clinical No. 59 9. Schoolmistress. Referred by Dr. Van Epps. Admitted June 7th, 1912, on account of a slight lump on the right wrist. Two years previously she had suffered occasional pain on the inner side of the right wrist but not until six months before had she noticed a small nodule at this site.. This gradually increased in size and the pain became more intense. Examination revealed an almond-sized mass on the ulner side of the right wrist. This mass was moderately tender but freely moveable. Examination was otherwise negative. After a negative tuberculin test she was transferred to the surgical side and the right hand was amputated at the middle of the forearm. The histo- logical report was round-celled sarcoma. One year later there was no evidence of recurrence.
A sarcoma of the structures forming the hip joint may give rise to a classical picture of tuberculosis of the hip. The following case was shown by me to my clinic as an undoubted case of advanced tuberculous morbus coxae with abscess formation, which had sup- posedly burrowed forward into Scarpa’s triangle.
Case VI. Osteosarcoma of femur, simulating Tuberculous Morbus Coxae: Exploratory incision: Still alive.
L. S. Age 15i Clinical No.* 9 53. School girl. Referred by Dr. Bowen of Andrew. Admitted May 19, 1913, on account of lameness and pain in the left knee joint. In Feb. 1913, she fell on the ice and injured her left hip which caused her to limp for a couple of days. This cleared up until six weeks before admission, when she again noticed lameness of the left leg and fullness in the left groin. Four weeks later, pain devel-
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JOURNAL OF IOWA STATE MEDICAL SOCIETY
oped in the left knee, sharp and knife-like at first, subsequently dull and more or less constant. She had lost nine pounds in the past three weeks. Examination revealed a slender, delicate looking girl, of somewhat phth- isical facies. The left leg was held flexed at the hip joint. When extend- ed, there was marked arching of the lumbar spine. There was marked spasm of the muscles around the hip joint and tilting of the pelvis. There was atrophy of the muscles of the thigh, but no apparent shortening of the leg. Vaginal examination revealed a mass in the region of the ace- tabulum and there was marked fullness in Scarpa’s triangle just beneath Poupart’s ligament.
A skiagram revealed a normal neck with the head of the former in the joint-cavity but there was a bulging of the acetabulum into the pelvis and a shadow' thought to be the distended capsule. The von Pirquet test was slightly positive. Under general anesthesia an incision was made over the front of the joint where a large hematoma and broken down friable tissue evidently of a sarcomatous nature were found. No histological ex- amination was made.
Another ease with the growth in the lower end of the femur caused us much trouble for several days to exclude traumatic, gon- orrheal, or tuberculous arthritis. It was not until our attention was called to the skiagram by Dr. Jepson that the true diagnosis dawn- ed upon us.
Case VII. Periosteal Sarcoma of Condyle of Femur, simulating trau- matic synovitis: Amputation of leg: Recovery. Giant celled sarcoma.
J. K. Age 2 3. Clinical No. 580. Farmer. Referred by Dr. Carlson of Thornton: Admitted May 16, 1912, an account of pain and swelling
of the left knee which had been present since July 1911. It had been red, swollen and tender. Three days before he received a kick by a young colt which caused him to suddenly jump on his left leg, since which the pain has been more marked. Examination revealed the left leg held firmly flexed at the knee. The knee joint itself was enlarged particularly above and on the inner border of the patella where there was distinct fluctu- ation. The urethral smears were negative for gonococci. The tuberculin test was tried repeatedly with as much as 10 mgms. of T. O. without local or systemic response. A skiagram revealed a diffuse shadow with considerable osteoporosis of the inner condyle of the femur. The case was transferred and the leg amputated above the knee. The histological diagnosis was giant-celled periosteal sarcoma.
So far we have been discussing sarcomata of the vertebrae and the ends of the long bones. The ribs, however, may be affected and give rise to a very puzzling group of symptoms as is well illustrated by case VIII. While Dr. Jepson at once suggested the probable origin from a rib, we were very loathe to give up the possibility that the neoplasm was primary in lung or pleura. Our reasons for this can best be understood by considering the case report.
Case VIII. Periosteal Sarcoma of Rib: Extension to Left Lung:
Death: Autopsy: Giant-celled periosteal sarcoma.
I. W, Age 24 Clinical No. 833. Housewife. Referred by Dr. Ayres, Sabula: Admitted Feb. 6th, 1913, on account of a tumor of the left
breast and shortness of breath. In August 1912 cough and a pleuritic pain in the left side developed. At the same time she noticed a small nodule on the rib just external to the left breast which gradually grew
SARCOMA— HOWARD
19
larger until the entire left breast was hard and indurated. Shortness of breath developed on Feb. 5th, and the home physician lanced the tumor and evacuated some redish material. Examination revealed a large firm mass occupying the outer and upper quadrant of the left breast extend- ing backwards to the posterior axillary fold. It was firm and adherent and not tender. There was absence of movement of the left chest, flat- ness to percussion and absence of breath sounds, as well as marked dis- location of the heart to the right. Aspiration of the left chest revealed a few ccs. of bloody fluid. A skiagram showed no definite abnormality apart from dislocation of heart, and the diffuse shadow in the left tho- rax. The patient gradually failed and died April 9, 1913. Autopsy re- vealed a primary periosteal sarcoma of the 4th rib which had extended outward between the rib above and the rib below to form the large ex- ternal mass. The left lung was completely replaced by a necrotic tumor tissue so that it could be scooped out with the hand. There was one
small nodule in the mesial surface of the right lung. Microscopically
there were areas of loosely packed round cells with mitotic figures and in the primary growth was a network of fine bony trabeculae showing mature bone and bone in the process of formation.
Lund5 points out that a primary sarcoma of the rib is more apt to develop on the sixth, seventh, or eighth. It spreads over the rib on either side and usually involve the rib above and below. The tumor does not ordinarily attack the skin or muscles. At first the tumor expands outside the chest and extends by direct growth along the intercostal spaces towards the sternal and vertebral ends of the ribs. Eventually it grows inward between the intercostal spaces. The adjacent pleura is first thickened and finally in- vaded. The visceral pleura is rarely involved because the tumor does not become adherent and extend over the lung. In rare cases however, adhesion of the visceral pleura and invasion of the lung do take place. This was certainly what occurred in our case. Invasion of the pericardium is also rare but extensions to the dia- phragm are more common.
Sarcoma of the periosteum (gums) or the medulla of the maxillary bones is by no means rare. It may be of the spindle-celled, round-celled or giant-celled variety: the latter is the more frequent. They occur oftenest in the fifth de- cade, “and arise oftener from the posterior surface of the gum in connection usually with the teeth of the upper jaw.” The myeloid variety is soft and often ulcerates. In addition to the sarcomatous epulides, the growth may originate in the antrum6, the walls of which it expands in its growth and thence project into the nose, mouth, pharynx or even into the cranial cavity.
Case IX. Sarcoma of Superior Maxilla: Metastases to Cervical
Lymph Glands: Tissue removed for diagnosis revealed spindle-celled
sarcoma. Death. No autopsy.
J. L. Age 53. Clinical No. 930. Stone mason. Referred by Dr. E. H. Knittles, Waterloo. Admitted May 6, 1913, on account of swelling on jaw and neck. In Oct. 1912 first noticed looseness of a molar tooth in right upper jaw and by degrees all the others became loose and were
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JOURNAL OF IOWA STATE MEDICAL SOCIETY
extracted. In March 1913 he first discovered enlargement of glands be- hind and below the right ear. The latter gradually increased and extend- ed to the other glands of the neck. Examination revealed on the right side a mass anterior to the angle and another posterior to angle of jaw. These were large and firmly attached, with smooth surface and not evi- dently tender. On the left was a smaller single mass of the same charac- teristics. Along the alveolar process of the right upper maxilla was a roughened, irregular, granulating area, very friable and bleeding easily on slight touch. Some of the glands eventually became infected and were drained. An x-ray plate showed clear sinuses. A portion removed for diagnosis was reported to be a spindle-celled sarcoma. The patient was discharge, unimproved. Patient died Aug. 15, 1913. No autopsy.
Sarcoma of the intestinal tract is by no means common as com- pared with carcinoma. It is usually of the round-celled type, but may be spindle-celled, alveolar and melanotic. Yet that such can occur is illustrated by the following.
Case X. Sarcoma of Ascending Colon: Metastases to Omentum.
Exploratory laporotomy: histological diagnosis of sarcoma.
F. W. Age 47. Clinical No. 8. Painter. Referred by Dr. C. P. Smith, Mason City. Admitted July 19, 1910, on account of a tumor in the right abdomen. He first had pain in the right abdomen in April 1910. Then indigestion. He had constipation for years. The tumor was notice- able in June 1910. There was forty pounds loss in weight. Examination revealed a large mass in the right middle quadrant, the note over which became tympanitic upon inflation of the colon with air. The mass was freely moveable but not definitely affected by respiration. A small nodule could be felt immediately above the main mass. A diagnosis of retro- peritoneal tumor, possibly of hypernephroma, was made. A laparotomy performed July 2 6, revealed a large tumor of the ascending colon. A nodule in the omentum, the size of a wallnut was removed for micro- scopical examination. The histological report was sarcoma, the type of which was not mentioned. Patient left hospital August 10th unimproved and has since been lost sight of by his physician.
III. Vascular Symptoms.
Engorgement of the superficial veins is the commonest of the pressure effects of sarcomata and nowhere is better seen than in mediastinal cases. Edema may also supervene as was present in our only case which illustrates this group of symptoms.
Case XI. Mediastinal Tumor: Sarcoma? PJatient lost sight of.
F. L. Retired farmer. Age 58. Clinical No. 1070. Referred by Dr. Scarborough. Admitted Aug. 31, 1913, on account of pain in the left arm and shoulder. In April 1912, he first noticed pain in the chest and arms. There was some cough. In July 1913 he had an attack of so-called pneumonia, which laid him up in bed one week, though the fever never ranged above 100°. During August he began to suffer from dyspnoea, pain in the left shoulder and arm and puffiness of the backs of hands and elbows. He had lost only nine pounds since winter. He was admitted to Oakdale on Aug. 2 7, 1913, and tuberculosis being excluded, thence transferred to the University Hospital. Examination revealed a tall, slender man with husky voice and some cyanosis of face, neck and entire chest to the costal border. No inequality of pupils. In both of the an- terior triangles of the neck, but particularly in the right, there were
21
SARCOMA— HOWARD
smooth, enlarged glands. Over the chest there were numerous distended veins. The expansion was poor with slight lagging on the left. The size and position of the heart as well as the sounds, were normal. The radial pulses equal, and synchronous. The backs of both hands were puffy and the veins prominent throughout both arms. There was also edema of the forearms. A distinct polycythemia; (Hb. 85%; R. B. C. 6,560,000, and a leukocytosis, W. B. C. 16,000, in which P. N. = 81%; Ly=14%; Tr.= 1%; E.—2%; Mz.=2%:) were present. A skiagram revealed a dense shadow at the level of the second, third, and fourth ribs, from evident mediastinal tumor. The exact nature of this was never proven but aneu- rysm could be excluded from the absence of expansile pulsation etc.
Christian7 states that of all tumors of the mediastinum, sar- coma is of the most frequent occurrence. They originate in the loose connective tissue of the meclaistinum, in the peribronchial, and mediastinal lymph nodes and in the thymus. They are either spindle- celled or lympho-sarcomatous in type ; most commonly the latter.
The most common and most troublesome symptom is dyspnoea. Pain is frequent in the late stages. Cough is generally present, in part the result of vagus irritation and in part the result of bronchi- tis due to pressure upon the bronchi. Dysphagia, hoarseness and even aphonia may occur. There may be a visible prominence of the upper anterior throax.
In addition to the dilated veins and localized subcutaneous edema, the other physical signs are cyanosis, dullness over a vary- ing area, deviation of the trachea from the mid-line, a tracheal tug, laryngeal paralysis, dilation of the pupil and radiographically a dense shadow in the mediastinal region.
Occasionally as we have said a sarcoma becomes generalized in a similar manner to carcinoma. The following case well illustrates such a generalization. It was no doubt largely by the blood stream.
Case XII. Multiple Sarcomata of Skin, Lungs, Mediastinal Glands, Spleen, Liver, Kidneys, Pancreas and Sacrolumbar Vertebrae: Death. Autopsy: Large round-celled sarcoma.
F. S. Age 31. Clinical No. 150. Farmer. Referred by Dr. Cooling, Wilton. Admitted Jan. 28, 1911, on account of pain in left hip and thigh. Three years before he had a growth removed from above the left eye which recurred twice after removal. On Dec. 1st, 1910, he began to have pain in the left hip-joint, which gradually increased and required morphia. About Jan. 14, began to suffer from a soreness in left half of scalp. Examination revealed a number of subcutaneous tumors scatt- ered over the trunk varying in size from 4 to 16 mm. These were freely moveable and not tender. There was on deep pressure in the left in- guinal region, a definite tumor, but the movement of the hip joint was free in all directions. Rectal examination revealed tenderness on deep pressure on the left, but no palpable mass. Skiagrams of the pelvis, hips, and lumbar spine showed no abnormalities. One of the subcutaneous tumors was removed for histological examination. It was reported to be a large round-celled, sarcoma, primary, in all probability, in the skin. The patient gradually sank and died February 17, 1911. An autopsy was obtained which revealed nodules in both lungs, mediastinal glands, spleen, liver, kidneys, and pancreas. In addition, in the left iliac region,
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JOURNAL OF IOWA STATE MEDICAL SOCIETY
ascending from the 4th lumbar vertebra to the uppper end of the sacrum, was a tumor measuring 7x11 cms. On the vertex of the skull were two large, and several small tumors, the larger of which had invaded the dura but not apparently the brain underlying it. Microscopic examination of all the specimens revealed the same picture of a large round-celled sarcoma.
These case reports go to show that sarcoma may appear in many guises and is a condition to be reckoned with by the general practi- tioner and internist as well as the surgeon.
Just a word in closing; a diagonis of a primary bone tumor, particularly in a patient over thirty, should never be made with- out a very careful examination of the abdomen, mammae, thyroid and prostatic glands. Carcinomata of these organs are especially liable to metastasize to bones and there produce symptoms which may overshadow those of the primary growth. 8
LITERATURE.
1. Adami: Principles of Pathology. Vol. I: p. 763: (Lee & Pebiger: 1910.)
2. L. Buerger: Surg. Gyn. and Obst. 1909: Vol. IX, p. 431.
3. Turner & Stewart: Text Book of Nervous Diseases: 1910. p. 119: (Blakiston’s Phil.).
4. Osier’s Practice of Medicine: VUIth edition: 1912: p. 960: (Apple- ton & Co. N. Y.)
5. F. G. Lund: Annals of Surgery: 1913: LVIII: 206-
6. International Text Book of Surgery: 1900: II: p. 59: (W. B. Saund- ers & Co. Phil.)
7. H. A. Christian: Osier and McCrae System of Medicine: 19 08: III: p. 893.
8. Geo. Blummer: Yale Med. Jr.: 1911: XVIII: 152.
CARIES AND NECROSIS OF THE MAXILLAE*
C. W. EARNED, M. D., D. D. S., Des Moines, la.
Over 75 per cent of all diseases of the maxillary bones that I have been called upon to treat might properly be called caries, and have their origin in some infected root canal or otherwise diseased teeth.
I am more firmly convinced that true necrosis of the maxillae seldom, if ever, results from alveolar abscesses or similar infections, that when it does occur it is the result of some serious systemic disturbances, such as lues, mercury, arsenic, or phosphorus poison- ing, etc., and sometimes from extremely severe traumatisms ; but only in such instances as where the bones are comminuted and afterwards become infected. Or again, where pressure is brought upon the hard parts in such a manner that the blood supply and nutrition is dis- turbed.
If infection does not take place, and the parts are not disturbed by mechanical appliances, the most severe traumatisms will heal rap- idly even when the bones are splintered, providing the patient has
*Read before the Polk County Medical Society.
CARIES OF MAXILLAE— EARNED
23
fair resistance. In cases of fracture of the lower jaw, if the parts are not fixed a fibrous union may result, but seldom necrosis.
As it is not my intention, at this time, to discuss the above men- tioned conditions, we will not dwell upon this phase of the subject.
The cases that I shall show are mostly of true caries of the bone, and present to the examiner, a varied and peculiar train of symp- toms.
These carious areas in the bone are often difficult to locate, and may be easily overlooked by competent surgeons even while making a special examination for such conditions, for they do not always present a discharging sinus or other visible signs of disease.
Etiology. The exciting cause will usually be found in the infect- ious discharge from a previously formed abscess at the apex of a de- vitalized root, although it sometimes occurs from other causes, such as unerupted teeth, foreign bodies that become infected, etc.
The infectious agent is usually one of low virulence, and of a mixed variety, commonly of the staphylococcus group, also a certain spiral is invariably found, spirals similar to those described by Vin- cent in his description of angina. Personally, I do not place much pathological significance upon the presence of these spirals, as they are found in most all infections of the oral cavity. The character of the infectious bacteria account for the comparatively chronic course of the ordinary alveolar abscess. Occasionally, however, we see an infection of an entirely different character, it lights up rapidy, runs a very acute course, produces much inflammation, a diffuse swelling, high temperature, and a very prostrate condition of the patient. It is almost impossible to check the progress of this latter infection, which usually proves to be streptococcic in orgin. Incisions fail to disclose any localized collections of pus. However, deep incisions and perfect drainage with the closest attention to the general condition of the patient are necessary requisites.
Improper drainage together with low tissue vitality soon convert these acute abscesses into the chronic conditions of which I wish to speak more fully.
When a discharging sinus opening into the oral cavity or upon the face fails to heal after proper treatment by a competent dentist, it is evident that the infection has not only extended beyond the apex of the root but has devitalized the tissue around one or more of the teeth.
The root itself may have become effected, although this never occurs until long after the alveolar process has become softened and destroyed.
This affected area of the bone is not a hollow cavity nor does it feel “hard and roughened” nor have the “dead bone” feeling so much talked about, but on the contrary, it is invariably filled with a soft inflammatory tissue, nature’s method of trying to care for this destruction of the bone. It is distinctly a carious condition of the
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bone, a molecular death of tissue due to the irritating, devitalizing action of pus and bacteria.
The amount of tissue destroyed depends upon four factors: namely, —
First: — the length of time the active agent has been at work.
Second : — the strength or virulency of the infectious material or bac- teria.
Third: — the resistance of the tissue, the physical condition of the patient.
Fourth : — the promptness with which the surgeon establishes drain- age.
This is often delayed so long that considerable destruction of process around the apex of the root has taken place.
Symptomatology. The symptoms may vary from a very slight fullness, in the part affected, to the most nerve racking pain, also re- flex pains in the eye, ear, face and temporal region. There is usual- ly, but not always tenderness of the offending tooth, if it be struck a light, quick blow with a small steel instrument.
Pressure over a diseased area will not always elicit pain, but will sometimes cause pain in the ear, infraorbital, or some other remote region.
There may be enough toxins absorbed from a carious area to produce trismus and even rigidity of the muscles of the neck. Oc- casionally the pain takes all the characteristics of tri-facial neural- gia, and it may really produce this condition. The usual symptoms are dull ache over or near the site of the disease, tenderness of dis- eased tooth upon percussion, and slight tenderness over the areas upon deep pressure. The pain is worse while the patient is quiet or lying down.
Diagnosis. This is by no means as simple as it appears at first thought. There is not always a discharging sinus, and often when it is present it is not readily discovered. The sinus often heals for weeks, and even for months there is no external discharge, the exu- date being absorbed, then when the vital forces are again lowered, and the infection overpowers the resistance of the tissues the sinus will swell and open again.
There is seldom an abnormal temperature or pulse, unless in an acute stage or exacerbation. Extensive destruction of the bone will sometimes take place without producing enough pain or discomfort to cause the patient to seek medical advice.
The x-ray is of inestimable value, and will often show clearly the foci of caries when all other methods fail. The injection of bis- muth subnitrate into the sinus will assist in locating the seat of the disease when the conditions lead one to suspect that the principal area of caries is not near the opening of the sinus. While the radio- graph is indispensable there is a possibility of a carious area being so hidden by a dense plate of bone or roots of teeth, or the angle at
CARIES OF MAXILLAE— EARNED
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which the rays enter may be such that it will fail to cast a shadow upon the negative. Notwithstanding these possibilities the x-ray is the most reliable means we have of arriving at an accurate diagnosis.
Prognosis. The prognosis is favorable if cared for before it ex- tends to the antrum of highmore or other sinuses. Deformity is rare if the operation is performed through the mouth and the wound is kept packed until granulation tissue fills in the cavity.
New bone does not form as much as might be expected but it fills up nearly full, and cartilage will ultimately take the place of the granulation tissue. The mucus membrane should not be allowed to heal over too soon ; for as soon as the mucus membrane entirely covers the wound, it will cease to fill.
Treatment. We will all concede that it is impracticable if not impossible to treat and drain such a diseased area of bone through the root canal of the tooth. The injections of pastes and other treat- ment through the sinus has not proven satisfactory in my experience.
Obviously, the most rational method is an incision through the soft parts and a thorough mechanical cleansing of the diseased por- tion, which should afterwards be disinfected, and dressed with suit- able antiseptic agents and dressings. No doubt there are many ways in which this can be accomplished satisfactorily.
The use of the burr, I believe to be unskillful and not conducive to surgical cleanliness, in fact its indiscriminate and injudicious use in an infected cavity without checking the hemorrhage and thorough- ly cleansing the cavity under direct illumination is positively a seri- ous violation of the laws of aseptic surgery. It is a good rule never to use a drill, burr, or saw, when a knife, chisel or currette will ans- wer the purpose. To use a rapidly revolving and vibrating burr in an infected cavity and blindly manipulate it in all directions, depend- ing solely upon the sense of touch, macerating the soft tissue and leaving the debris to the care of nature is to say the least, very un- scientific and certainly cannot be called aseptic surgery.
The trend of modern surgery is more and more toward working by sight and never to depend upon the sense of touch when it is pos- sible to get the parts under direct observation. Here, as well as in the other cavities of the body it gives a sense of security nothing else can supply.
While it is true that the sense of touch can be developed to a remarkable degree and its skillful use is of great aid in the diagnosis and treatment of these and many other conditions, nevertheless, it should never be depended upon exclusively. It has been my privi- lege to operate on several cases that had been operated upon by the “ touch method” and usually a mistake had been made of so serious a nature as to necessitate a second operation.
In my experience, the best results have been obtained by mak- ing a free incision over the diseased area down to the bone, then with a periosteal elevator expose clearly and freely the necrotic area with
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a few firm movements, with a small blunt probe and a strong arti- ficial light, make a thorough exploration and determine by sight as well as by touch the extent of the softening in the bone.
With a suitable bone currette and a rongeur forceps clean out all debris, cutting out all softened bone, and curretting away all in- flammatory products down to solid, white, healthy bone. Control the hemorrhage and explore the walls of the cavity again under strong light, any softened areas should be followed out until all is thoroughly cleansed. Then sterilize the cavity with tincture iodine and carbolic acid, follow with alcohol, pack with gauze and seal over with a heavy tincture of benzoin.
This benzoin solution is water proof and will protect the wound from saliva, is very tenacious thereby greatly assisting in retaining the dressings and owing to the benzoic acid contained is markedly antiseptic. The dressings should not be allowed to remain in the wound over thirty-six hours, and it is better to replace them every twenty-four hours.
The packing may be discontinued as soon as the granulation tis- sue has fully covered the bone, but I prefer to pack as long as the gauze will be retained.
When treated in this manner there is very little swelling and never any pus after the first dressing, for all infectious material has been removed, the wound is practically sterile and should heal as such.
CASES.
No. 1.
This radiograph shows a lower molar tooth which is normal in every respect. Note the inti- mate relation between the alvoelar process and the cementum of the root. When the process be- comes affected by infection through the root this relation is disturbed or broken. This is plainly shown in the next slide.
No. 2.
The destruction of bony substance is nicely shown in this radiograph at the apex of a lateral incisor, although this not an excellent slide. Pa- tient 2 5 years old, housewife. Had been having trouble for several years. Pain in the region of the antrum of highmore, which extended to frontal and parietal region quite often. No sinus was present. Eyes had been tested and fitted with glasses. Antrum explored and pronounced normal. The crown on the adjoining tooth had been removed several times but no relief was obtained. This tooth seldom, if ever, became tender or caused any disturbance, and as it con- tained a beautiful gold inlay was not suspected at all. The x-ray discloses the location and ex- tent of the affection. Case was operated upon as described. Wound healed without complica- tions. Patient has been free from pain for over 18 months.
<
CARIES OP MAXILLAE— EARNED 27
No. 3.
Mrs. H. 32 years. Had a discharging sinus in region of second bicuspid tooth and in right nostral for six months. The second bicuspid had been extracted but discharge continued. No pain or tenderness upon pressure or percussion of the teeth. X-ray taken Jan. 31st, 1912 and operated upon the next day. Uneventful recovery with- out any more pus and very little swelling.
No. 4.
Mrs. G. Age 3 8. Pain in left infraorbital and temporal regions, pricking, stinging pain in left ear. Had an abscess on the left ' second bicuspid tooth two years before, which was lanced and treated by a dentist, but the tooth always tender upon percussion. No temperature or pulse in- crease. Had consulted specialists and had nose, ears, and eyes examined and glasses fitted. Also had the antrum washed out, but with no relief from pain. Diagnosed, tri-facial neuralgia. X-ray showed foreign body in root canal extending through the apex. Also rarefication of the bony tissue in the surrounding area. This also shows the anterior wall of the antrum of highmore which is quite intact and unaffected, but very thin and in close proximity to the carious area. Careful cur- rettment of the two areas resulted in permanent relief from pain and an ultimate cure without in- volving the antral cavity in the least. This case shows the value of the x-ray and how easy it would have been to infect the antrum had a burr been used.
No. 5.
Mrs. R. 33 Years. Patient was very nerv- ous and had suffered with pain in right side of head for many years. Diagnosed — tic douloureux. Examination revealed small sinus over right cuspid tooth which filled and discharged three or four times a year. No tenderness when percus- sed. Nerve alive. The lateral was slightly tender when percussed, however, and carried an illfitting shell crown. X-ray showred a very small area of caries over the lateral incisor, which was opened and curretted, the gold crown replaced with a properly fitting one. Wound healed kindly and patient is free from usual pain.
No. 6.
Miss L. 2 5 years. Had an enlargement or tumor under the body of the mandible for ten months, which seemed adherent to the bone. Scarcely any pain. Pulse 108, temperature 100F. No discharging sinus could be found. Had a gold crown on second bicuspid tooth which had never caused the patient any discomfort. Patient had rigidity of the muscles of the right side of the neck and shoulder for six weeks. Not much pain at any time. The crown was removed and the root canal opened, the broach passed down far beyond the apex of the root, it was left in position and a radiograph taken. This shows an area of caries about one centimeter wide and two long, about centimeters below the alvoelar bord- er. An incision was made in the mouth and the area exposed. It had a very thin external wall which was forced out causing the tumor like swelling which was palpable below. This was cleansed and packed as usual the root smoothed
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and allowed to remain in position, as the process surrounding the root was almost normal as shown by the radiograph. One interesting thing about this case was that the rigidity of the muscles of the neck and shoulder had all disappeared on the third or fourth day after the operation.
The next two cases I will show more particu- larly to demonstrate the advantage to be gained by injecting the sinus with bismuth subnitrate paste before the radiograph is taken as it out- lines the cavities quite clearly. I would like to state, however, that it does not always give as clear results as is shown in the first one shown.
No. 7.
Mr. F. 26 years. This case presented an enlargement on the left side of the lower jaw two teeth had been removed. Discharging sinus which was injected with bismuth subnitrate paste and picture taken. Incised and curretted. Heal- ed kindly without pus and scarcely any swelling.
No. 8.
Mrs. S. City. Aged 72 years. Poorly nourished. Had four or five sinuses discharg- ing along the ridge of the left lower jaw for sev- eral years. Had all teeth extracted below six months before I saw the case, said that the con- dition improved somewhat.
Injected bismuth subnitrate paste in a sinus near the second molar tooth, and it came out near the cuspid region. X-ray shows extensive caries but even this case there was no sequestrum and probably none would have formed. It was a typical form of caries of the bone. Note the sockets where the teeth were extracted, absorp- tion not having taken place as yet. This case was treated as the above mentioned cases. Ther/~ was never much pain. This patient had trismus which disappeared after the operation.
No. 9.
Mr. G. Age 45. Patient had a discharg- ing sinus in the region of the molar. Sometimes it would heal for several weeks at a time, only to open again. Some teeth were removed, but it failed to heal. Had a swollen jaw several years ago which was lanced. This case was seen by several competent dentists but as all the teeth seemed normal the case was referred to me. Rad- iograph shows a foreign body at the apex of the lateral incisor and a large area of caries in this region. Patient did not return for operation. Not much pain.
No. 10.
Miss M. Aged 2 9. Patient complains of severe pain of intermittent character in the infraorbital region which occassionally radiates over the entire side of the head. Has visited specialists in Chicago and Rochester, in regard to eyes and antrum. Glasses gave no relief, noth- ing abnormal found in the antrum. Radiograph reveals unerupted tooth (cuspid) with some car- ies or absorption around the enamel surface. This tooth is probably causing most if not all of her pain. Patient refuses operation.
CARIES OF MAXILLAE— EARNED
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No. 11.
Miss O. Aged 8 years. Patient had a discharging sinus under the body ot the mandible near the angle of the bone. Lower left permanent tooth had been filled several months or a year before. The nerve evidently died under the fill- ing, and the tooth abscessed. Was opened exter- nally. Filling was removed and treated by a competent dentist. It remained quiet for about six weeks, when it again opened and failed to close. X-ray shows areas of caries in the bifur- cation of the molar roots and at the apex of the anterior root. The external sinus was removed by desecting it out and closing it with several sutures. Curretted and packed for several days and there was no more pus. Healed kindly.
I have selected common cases, having pur- posely avoided the more complicated and serious ones. These are typical of the cases that the pyhsician sees in consultation with his dentist friend and for which he is often called upon to prescribe.
There are four points I wish to strongly em- phasize. They are:
1st. The remote symptomatology sometimes accompanying such cases.
3rd. The necessity for thorough mechanical cleansing and disinfection; if we expect prompt recovery with the least amount of swelling and and infection.
3rd. The need for accurate diagnosis.
4th. The advisability of using an antiseptic and impervious dressing to protect wound from bacteria of mouth. If these points are kept in mind and faithfully carried out you will be greatly gratified at the promptness with which these chronic cases recover and clear up.
Discussion
I have seen a few people in my life who seemed to enjoy life pretty well, and I did not know that everybody had troubles with the alveolar process. I would not like to say this in a dentisLs presence, but between us, I don’t believe 1 have ever seen a case of pyorr- hea entirely cured by a dentist. I have seen small abscesses on the gum cured; I used to cure them myself in my country practice by simply lancr ing them; but that was not pyorrhea. I noticed an article in the Journal of the American Medical Association in which the author states that he makes cultures and injects them, and claims to get good results. If he does, it is much simpler than surgical operations, but I have had no op- portunity of observing the effects of this treatment. Of course I know how a surgical operation could cure these cases, because I know all about surgery. The mouth is the filthiest portion of the body, and it takes in all kinds of infected substances, so that you can’t tell much difference between it and the kitchen mop. But people hate to pay twenty-five cents for a new brush, and they go on constantly infecting the alveolar process with the old one. There are also various other methods of infection.
The author traced the difficulty to the top of the head, but I didn’t notice that he got lower than the waistband in the other direction.
W. W. Pearson: I have learned quite a little from the paper this eve-
ning. A nose and throat specialist many times sees a case with indefinite, pain about the fifth nerve distribution. We have great difficulty in dem- onstrating empyema of the accessory sinus many times, and the x-ray unfortunately does not always clear up our diagnosis; but it occasionally happens that something of this kind is demonstrated and proves to be the cause of the discomfort.
One or two years since Dr. Dan Mackenzie had a very extensive article on osteomyelitis in which he referred more particularly to the form, either acute or chronic, following one of the external operations on the frontal sinus. It applies there more particularly than here, but the facts brought out in his article indicate how insidious may be the advance of a process.
Lewis Schooler:
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and how many patients do not locate their trouble at the focus of the disease, but the referred pain renders the case extremely confusing. When we meet with a case of this kind we have but one course to pursue, and that is to go step by step and eliminate every possible source of trouble. No doubt even with our present knowledge a certain number of cases will still have to be among the unknown, but work of this character reduces that uncertainty. I want to thank the author of the paper for his ex- position.
R. H. Parker: I feel that this is a field of medicine in which I am
rather a beginner. I was quite interested in the paper, and one point that the doctor brought out has been quite well emphasized to me the past month, namely, the difficulty of diagnosing these cases. I have recently had a case which was seen, I think, by Dr. Wertz and three or four of our dentists; a painful tooth and an enlargement at the end of it, which was opened and cleaned out by curetting and drill in which the results were perfect.
In thinking over the subject as the author presented it, it occurred to me that I had seen cases of rheumatism which were traced to diseased tonsils, and others which were traced to chronic diseases of the prostate gland; and I have even seen ingrowing toenails removed as a cure for rheumatism. I think in looking around for some focus of infection as the case of rheumatism it might be well to have in mind these processes oc- curring about the roots of the teeth.
W. E. Sanders: I was very much intrested in the doctor’s paper and
quite impressed with it. I never before realized so forcefully that den- tistry, after all, is a department of medicine and surgery. I have nothing to add to the discussion. There is one question which I would like to ask the doctor which has been impressed upon my mind by a case which we have had under observation for almost a year at the Methodist Hospital; the doctor may have seen it. The question is, whether or not these pro- cesses of infection, when they get into the cancellous tissue of the jaw from an infected tooth, ever become sufficiently extensive to involve the whole ramus of the jaw. We have had a case under repeated treatment for, I think, a year or more (history dates back for eighteen or nineteen months) in which there was a distinct history of a suppuration at the root of a tooth which was extracted, and subsequently fistulae formed which were opened externally; but this case has never recovered. It has kept on discharging, and eventually this man had almost complete ankylosis of the jaw. The muscles became involved, and he is in horrible shape at the present time. There has been a protracted series of operations on this man. I happened to be present at the next to the last operation, which was about the fifth or sixth, and at that time, the articulation was resect- ed. But the man has not got well yet. He has pus behind his ear and discharging from the orbit and under his temporal muscles, and he is gen- erally shot to pieces with pus. There is no question in my mind that this trouble originated in this man’s jaw bone. We took sections of the bone removed, and there were multiple foci in the tissue of the ramus of the jaw, even almost to the articulation, and whether or not this infection ever extends to the contiguous bones is a question I would like the doctor to bring out in his closing discussion. It is certainly a very interesting paper.
W. L. Bierring: I am very sorry that I only heard the last part of the paper; I was very much impressed by that part of it, however. I re- call at this time an instance of a chronic infectious endocarditis develop- ing after osteomyelitis of the superior maxillary, which always left an impression on me.
I should be interested to have the essayist explain how he gets those x-ray illustrations in that contracted form; if he puts the film in the mouth, or just how that is carried out.
T. F. Duhigg: I would like in particular to disagree with Dr. School-
er. Somebody ought to disagree with him, and I might as well do it as anybody else, in regard to his proposition about the mouth being such a dirty orifice. I believe the mouth is very clean if you give it half a chance. I think it has been demonstrated that the natural secretions of the mouth protect it to a wonderful extent. The contents of a normal stomach have been demonstrated to be almost bacteria free. I have the word of the dean of one of the leading dental colleges of the country that he has never seen a severe case of infection following the most careless operation on the mouth. There are three classes of men whose asepsis is not as nearly perfect as that of the general surgeon viz: dentists, opthalmologists, and
CARIES OF MAXILLAE— EARNED
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nose and throat specialists. There technic is all that is necessary for the average case in their special lines of surgery. It is not necessary to carry out the same degrees of asepsis in operation on the eye, nose, throat and mouth as in the internal cavities and tissues generally.
J. W. Bailey: I get a chance to see a good many of these cases of
caries, not in my own practice, but from the dentists who refer patients to me for radiographic work. Practically all of these patients are running from one doctor to another, and from one dentist to another, and when we get a good radiograph we usually find some faulty piece of dentistry or something of that nature to be the cause of the trouble. A crowned tooth without a root filling being the trouble in most of the cases.
Dr. Harned: In the first place I want to say to Dr. Schooler that I
do not treat cases of pyorrhea alone; I try to get some dentist to help me out with them. There is no question in my mind but what pyorrhea can be cured by thorough mechanical cleanliness. Whether or not there has been much destruction of bone around the roots of teeth greatly effects the prognosis. The administration of an autogenuous vaccine would appear logical, in cases where there is a continuous and obstinate flow of pus.
As far as cleanliness of the mouth is concerned, there is no question but what a large number of people do not pay proper attention to the mouth in the way of keeping it cleansed. If a person is vigorous and healthy, he will keep the mouth fairly proper condition, but there are con- ditions in which the mouth becomes exceedingly filthy. Where the vit- ality of the patient is low and he is run down in every sense of the word, the movements of the cheeks and tongue are sluggish and the secretion be- comes very thick and ropy, and it becomes a source of infection instead of a cleansing agent. I would like to say that I never saw a malignant tumor or very many other kinds of tumors in a perfectly clean, healthy mouth.
Dr. Pearson said a number of things that I would have liked to refer to, but I was rushed and did not make notes of them.
As to rheumatism, there is no doubt in my mind but that sporadic pains all over the body can be caused by infection in the jaws just as well as in the tonsils or any other place, and I think I brought that out when I mentioned pain running up and down the neck in case No. 8.
Dr. Sanders asks if we have seen cases where extension took place to contiguous bone. It often does in the upper jaw and there is no reason why it should not take place in the lower jaw if it gets up into the ramus of the bone; but that seldom occurs, because there is little cancellous bone tissue there; but if it did, and inflammation surrounded the articulation, there is no reason why it should not extend to contiguous structures and trismus often occur.
Dr. Duhigg mentions the fact that infection does not occur often in the mouth. I don’t think that is due to the fact that the mouths of peo- ple are particularly clean, or that antiseptics are formed there, but more likely to the fact that the extreme vitality of the tissue, and the extensive blood supply renders infection less probable.
32
HYDROTHERAPY*
H. A. HABENICHT, M. D., Des Moines, la.
Hydrotherapy is a term applied to the method of treatment whereby therapeutic results are obtained by the use of heat or cold as produced by water.
Usually mechano-therapy, masseau-therapy, electro- therapy and dietetics are associated with it, both abroad and in this country, however it is not our intention in this paper to discuss these asso- ciations.
The earliest accounts of the use of water are obtained from the Bible, which describes bathing as a healing procedure. Tin-, most distinguished physicians of all ages have been belie vrs in the use of water and have spoken of it enthusiastically as do the German physicians of today. Hippocrates relied on water extensively in the treatment of gout, fever, inflammations, rheumatism and many other ailments. Galen and Celsus recommended the free use of water in fevers, spasms, hemorrhages, billiousness, headache, constipation, cholera, plethora, ophthalmus, and numerous other complaints.
More than one hundred years ago we find recorded that Doctors Carrie and Wright of Liverpool treated scarlet fever successfully by the use of tepid or cool affusions. Medical history is full of accounts of water in the treatment of almost every malady known, but the above is enough to establish it as an old and tried procedure.
Twenty-five to fifty years ago the use of Avater as a remedy was almost wholly in the hands of the empiricists, among whom the chief, perhaps was Priessnitz. In 1859 Winternitz, then a naval surgeon, while treating a severe epidemic of possible influenza on the boat, exhausted his supply of drugs, the only agent at hand was water which he began using Avith great caution. To his surprise those so treated were relieved much more quickly than those treated with quinine and other antipyretic drugs. At the close of his ser- vice he immediately began scientific experimentation with Priessnitz to acquire a greater and more accurate knowledge of hyprotherapy. In 1865 he founded the first clinic, and institute of hydrotherapy with 18 beds, which has at the present time a capacity of 400 beds, with an immense out-patient list.
In this country Doctor Trail of New York City, and the phy- sicians connected with the Battle Creek sanatarium and the Dansville sanatarium of New York were the early advocates of scientific hydrotherapy. These institutes at present, and very many others are enthusiastic users of this and other phyical procedures. Among the individual practicing physicians perhaps Doctor J. H. Pratt, of Boston has done, and is doing more at the present time to place
*Read before the Polk County Medical Society.
HYDROTHERAPY— HABENICHT
33
hydrotherapy on a scientific basis in this country than any other man.
It is a most deplorable fact that this most effective and widely used of agents is so neglected and its uses is so little known by our physicians at large in this country. The fault, and fault it is, must rest someplace. There is no doubt but that we use what we are taught, or at least what we remember of it. We usually follow up what we have studied in our college days and develop along the lines most suited to us. It is no wonder that so little interest is shown in the use of water, since only one medical college in Amer- ica requires a course in hydrotherapy, and that in recent years. In Columbia the course is obligatory and that in the senior year only. In Jefferson, courses in hydrotherapy are given, but they are elective.
The quackery and the near quackery, or as one has expressed it “the yellow streak,” connected with so much of the socalled phy- sical therapeutics, has prevented the competent physician from inves- tigating hydrotherapy.
Perhaps the greatest mistake made by physicians who attempt to prescribe hydrotherapy is over-treatment; the next being incom- patible treatment. It is not necessary that we have a great space filled with elaborate and expensive apparatus, in order that results by the use of water may be obtained. A bath tub treatment table, and a bed to rest upon, with the necessary towels and basins. Hot and cold water alone with towels and blankets, are sufficient to get results if the method of procedure and results to be obtained are understood. The equipment of our hospitals with the expensive, more or less effective apparatus, does not solve the problem at all for by ignorant using much harm is done. Better invest much of the money spent, in the services of a competent individual to superintend the treatment than to leave the selection of the treatment to a nurse or a masseuer. The prescription must be definite as to kind and length of procedure, also temperature to be used. It may be under- stood by the attendants that the feet should be always kept warm, yet that does not excuse the physician for not prescribing the same. A tonic treatment may be prescribed which does not mean anything to an attendant unless the condition of the patient is known and def- inite directions given. The same is true of a sedative treatment. Hot and cold tonic and sedative are all relative terms depending upon the condition of the patient.
In all hydrotherapeutic procedures the result to be obtained is dependent upon reaction or the avoidance of it. e. g. if the blood flow is to be accelerated the alternation of very hot and very cold appli- cations are indicated. If not, then longer continued heat not follows! by severe cold.
Some idea of possible uses may be obtained by the statement of a few results : The size of the arm as first noted by Winternitz can
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be perceptibly increased by the use of the cold sitz, at 60 degrees for fifteen minutes. The face is flushed, and a sense of pressure produc- ed in the head; at the same time with a visable carotid pulsation. The size of the arm can be diminished, the face blanched and all sense of pressure relieved in the head by the hot hip and leg pack for 20 min- utes with cold to the neck. In like manner the circumference of the abdomen is increased and a sense of fullness in the chest can be pro- duced by the hot trunk pack. In cases of cardiac insufficiency, where there is low blood pressure, the effervescent bath given daily with a lowering of the temperature, and an increase of the ef- fervescence, will greatly relieve many patients, and perceptibly raise blood pressure. The same result may be produced but to a less de- gree, by the iced mitten friction. Many of the manias are relieved and quiet sleep produced by the wet sheet pack.
Disorders of the digestive tract are benefitted by the proper use of water. The stomach is stimulated, both in muscular tone and in its secreting power by the use of alternating hot and cold to the spine, or to the gastric region. The hot and cold percussion douche given at temperature of 125 and 60 degrees with ten to fifteen pounds pres- sure is a very satisfactory way of applying this treatment. The amount of hydrochloric acid is reduced by the hip and leg pack, ac- companied by an ice bag over the stomach for 30 minutes, daily, be- fore the larger meal. The effect of the hot and cold percussion douche can be demonstrated readily by using it on a patient suffer- ing from hypertrophic cirrhosis of the liver to the extent of some circulatory obstruction. In such a case severe jaundice can be pro- duced with nausea and vomiting in an hour, the discoloring of the skin occuring the next day. In such a case this procedure would not be indicated, but the hot fomentation for 15 minutes, followed by the heating compress would give much relief. This fact will show you at once that much can be done by an agent so potent as to cause such reactions. In many cases constipation can be relieved if not permanently cured by the hot and cold percussion douche. There are many more uses for this procedure which cannot be discussed here.
In the home the applications of water are of great service in the treatment of pneumonia, tonsillitis, croup, diphtheria, dysentery and fevers of all sorts.
The use of the cold full bath is well known to all of us in the treatment of the high temperature of typhoid fever, yet we have all been made to feel sorry for the weakened, exhausted patient who is subjected to this procedure. The same result can be obtained when the skin is cold and dry and the internal temperature is at its height by the use of the cold enema and an accompanying hot sponge bath.
In croup and in the annoying night cough of children as well as adults there is almost instant relief given by the application of the
HYDROTHERAPY— HABENICHT
35
covered cold compress. In tonsillitis the relief from pain and high temperature are very gratifying by the application of the same. The treatment of rheumatic and gouty affections by hydrotherapy is very effective and the results and much of the procedure is well known to all.
Generally speaking, hydrotherapy is to be used as an adjunct to other treatment, but in many cases we find it all that is needed to bring about the desired end. As a means of obtaining the best results, properly conducted treatment rooms should be at the dis- posal of every physician. A very satisfactory equipment for such a room has been described recently by Dr. Pratt of Boston. In Boston an institution of this kind has been equipped and conducted by the principal physicians of the city. It is a co-operative institu- tion and is more than self supporting. After maintainence, the funds go to extend the work and promote the study of hydrotherapy. Such an institution should be in every city of any size in our country. Our patients should not have to leave home for such treatment. Our patients should not be forced to go to mineral springs to drink dirty water and be soaked by illiterate and untrained attendants instead of being treated by skilled and educated nurses at home.
I have used partial quotations in expressing ideas from Dr. Pratt, Dr. Trail and others to whom I wish to give credit. Espe- cially thank Dr. Pratt for reprints furnished me.
Discussion.
N. C. Schilling: I enjoyed the payer very much. I always had a
little tendency to lean to hydrotherapy. I have never had an opportunity though, to follow it out very thoroughly in the practice of medicine. In my use of it I have had excellent results, in children especially; and I hardly ever use any sedatives with children. I use hot baths, usually the last thing in the evening, and they go to sleep. I have used them in a great many different kinds ol cases, and I always get excellent results. I only wish that I had the opportunity to take a special course in hydro- therapy; I think I would be very much interested in it.
M. G. Sloan: I remember when a small boy hearing our old family
doctor proscribing somebody who was treating a case of typhoid fever with baths; he was absolutely horror-stricken at the idea. I don’t know whether the patient got well or not; I rather think he did; but the old doctor thought it was simply murder. I have watched hydrotherapy with a good deal of interest since I have been practicing medicine. I have not used it as much as I would like to, I am sure there are much greater pos- sibilities in it than most of us realize, and it is something to be studied and handled as carefully as a dose of morphine, in my judgment. I en- joyed the paper very much.
W. L. Bierring: In regard to the sedative effect of hydrotheapy, I
recall a very interesting visit of Dr. Schooler and myself at the insane hospital at Cherokee about a year ago, where we were entertained (laughter) for a number of days. We were particularly interested in Dr. Voldeng’s demonstration of the new phychopathic ward where the latest hydrotherapy appliances have been installed, and particularly the method of controlling the acute mania cases. They place the patients in a large bathtub in wrhich there' is a constant flow of warm or hot water, the patient being supported by a form of suspended jacket. They rest comfortably and at the same time cannot get out of the tub. He keeps them in this running hot water from three to eighteen hours at a time, and maintains that they not only become quiet, but lose their tempera- ture, and that several days’ treatment by this warm bath is sufficient to quiet the most violent mania.
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I also recall the use of the hot bath in the treatment of extensive burns — the method first introduced by Kaposi of Vienna.
When a patient with an extensive burn is placed in one of these bathtubs with a warm water in it, he seems to be more comfortable than any other way. They naturally do not have a great deal of pain with an extensive burn; as it has a benumbing influence upon the nervous tissues;! but it seems to give them a great deal of relief to lie constantly in water.
One of the best things the essayist said was in closing, when he re- ferred to hydrotherapy as a valuable adjunct in various methods of treat- ment, particularly for functional nervous diseases; and again, that there is great need for the installation of hydrotherapy appliances in our hospitals, where patients could be under proper control; and that there was no ne- cessity for sending patients away to institutes where they were not under proper medical observation.
G. N. Ryan: It was my pleasure last summer to visit a number of
health resorts in Germany — eight in number, and I took a special interest in the mud baths as they are given. A few of our party participated in the demonstration of the mud bath. They took us through and showed us how the mud is prepared. It is taken from decayed vegetation and wood pulp into large vats, sterilized and dropped down into tubs, which are wheeled into the hydrotherapy room, and the patients are placed in the bath. It is very thick; I do not know the specific gravity, but it must- have been very high. In getting into the tub it seemed impossible to go to the bottom; it held the person suspended, practically speaking. It wasj not like the common mud, but if the arm was raised and the attendant poured water over it, the mud would come off without rubbing the flesh at all. It acted exactly like a poultice. I was told that it was very ef- fective in articular rheumatism and they claimed a great many other things for it. But in all these different health resorts the pysicians in charge of the bath houses examined the patients and wrote their prescrip-t tions as the doctor has spoken of, giving definite directions as to the length of time, the heat to be applied, etc. It was said that in mild cases of rheumatism a bath taken too hot would precipitate a very severe articular rheumatism which would sometimes become really serious; but by the use of the graduated bath, starting in at a rather moderate tem- perature and gradually increasing it, it was very much more effective.
I believe that we overlook hydrotherapy as a means of completing a cure in convalescent patients. I think if resorted to this method much more frequently than we do, many of our cases would not drift to the “opathists” in other lines, and that many cases of ankylosis, etc., could be prevented.
Dr. Habenicht: I think I have nothing further to say except that it
wasmy privilege to assist in installing the first hydrotherapeutic equip- ment in an insane hospital in America. I spent some weeks there in the treatment of cases, and there is no doubt but what a greater benefit can be obtained in the care of these cases by hydrotherapy than any other means.
I will say further that I can’t hear anybody mention a mud bath or mineral spring without raising a cry. I can’t see what on earth anybody; wants to get into mud for. It is simply another method of applying heat.) When the patient is immersed in mud his respiration is oppressed and there is nothing gained by its use. It does make an impression upon the patient, just as some of our mineral springs do. They will go and drink that water by the quart when it smells like rotten eggs, while good, pure, soft water would give them a great deal more benefit.
37
BLOOD PRESSURE: HOW TO TAKE IT, AND
WHAT IT SIGNIFIES*
G. E. CRAWFORD, Ph. D., M. D., Cedar Rapids, Iowa.
Among the many valuable diagnostic instruments of precision that have been invented in recent years, probably the most valuable since the perfecting of the microscope, is the sphygmomanometer for accurately measuring the blood pressure.
Up to twelve years ago little was known of the blood pressure, and its significance.
It is true that Poiselli invented a mercurial manometer as early as 1828, but it attracted little or no attention. He lived sixty years before his time.
I remember when a student at Bellevue Hospital in ‘76 and ’77 it was a favorite grand-stand demonstration of the great Physiolo- gist, Austin Flint, Jr., to show the blood pressure of the dog by in- troducing a glass tube into the carotid artery of the living animal.
About this time Marey invented an apparatus with which he was able to determine both systolic and diastolic pressure with remark- able accuracy. But his work attracted but little attention at the time ; and it was only in recent years that his pioneer work received due recognition.
Some ten years later von Bosch invented an instrument which consisted essentially of a small rubber bulb filled with water and communicating with a mercury manometer. The bulb was pressed directly against the radial artery until the pulse was obliterated, and this pressure was noted on the manometer. This instrument was modified by Potian who substituted air for water in the bulb. These instruments required too much skill in manipulation, and too much of the personal equation for great accuracy. Their use was confined to a few pioneer investigators, and attracted little attention from the profession in general.
Riva Rocci in 1896 invented an instrument which became the type of all modern sphygmomanometers. It consisted of a narrow rubber bag connected by tubing with a reservoir of mercury, having an upright capillary tube graduated in millimeters. The bag was placed over the brachial artery and held in place with a broad band- age. Air was pumped into the bag until the pulse was obliterated. All the mercury instruments now in use are but slight modifications of the Riva Rocci; and the anaroid instruments which are coming into such common use all retain the most essential part of it, the rubber bag for the compression of the artery.
The early Riva Rocci instrument had a very narrow cuff, or bag, only 5 cm. in width ; and after a time it was discovered that the nar- row cuff gave too high readings.
*Read before the Iowa State Medical Society, Sixty-third Session, Sioux City, May 13-15, 1914.
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JOURNAL OF IOWA STATE MEDICAL SOCIETY
During the early years of the use of the Riva Rocci instrument the readings were all too high, and led to an erroneous conception of blood pressure, which has scarcely yet been fully corrected. It fin- ally became established that the proper width for the compression cuff is 12 or 13 cm. or about 5 inches. This is neither too narrow or too wide.
For ten years after the Riva Rocci invention, its use was confin- ed to a few clinicians, and leaders in the profession, and a number of them made various improvements on the original instrument. Also the anaroid instrument was devised and gradually perfected, — doubtless suggested by the anaroid barometer. So by 1906 progress- ive men all over the country began to get sphymomanometers. A few years later insurance companies began to require the blood pres- sure in certain cases. And within the last two years this requirement has become so universal, that now almost every physician in the smallest country village has a good sphygmomanometer ; I say good, for this class of men, in Iowa anyway, usually buy the best of every- thing.
Although the ownership of a blood pressure instrument is be- coming quite universal, there are as yet comparatively few physi- cians who fully appreciate its value in every day routine work ; and its use is so new that many have not yet acquired skill in its manipu- lation. So that some definite directions, just how to take the sys- tolic and diastolic and pulse pressure, may not be deemed superflu- ous at this time.
A great majority of physicians still take the systolic pressure by palpation, and pay little or no attention to diastolic and pulse pressure. The oscillatory method of determining the diastolic pres- sure until recently in use was so uncertain and unsatisfactory, in new hands, that few ever brought it to sufficient perfection to make it of scientific value.
Although Korotkow discovered the method of taking the blood pressure by auscultation in 1905, its use has not become general, nor its great advantages realized until very recently.
The auscultatory method is equally applicable to the systolic and diastolic pressure ; and by it both the maximal and minimal pressure may be taken with as great certainty as the body temperature with a fever thermometer. These simple directions will enable any physi- cian who knows how to use a stethescope, — and every physician is supposed to know that, after a little practice to take the blood press- ure with certainty and satisfaction.
Seat the patient in a chair near a table or desk. Bare the arm, the left preferably, to the shoulder. Do not allow a tight shirt sleeve to partly obstruct the circulation/ Instruct the patient to relax all muscular effort, lay the back of the head comfortably on the table or desk. Place the cuff around the arm opposite the heart, leaving space enough below the cuff at the bend of the elbow to place the
BLOOD PRESSURE — CRAWFORD
stethescope over the brachial artery. Nothing is to be heard over the artery when it is not compressed, or when completely compress- ed. Inflate the cuff, while at the same time the fingers of the other * hand are on the radial pulse. Note the point on the scale when the pulse is completely cut off, as the pressure in the inflated cuff is slowly increased. This is the systolic pressure by palpation. Now verify this by auscultation. Push the scale ten or fifteen points above where the pulse ceased. Place the stethescope over the brachial ar- tery, and open the needle valve, allowing the air to escape very slow- ly, one or two points at a time. At first nothing is heard over the completely compressed artery. Suddenly a loud thump of a pulsa- tion is heard as the first blood is forced through the compressed ar- tery. This point marks the systolic pressure, and will be found to correspond very closely if not exactly with the point taken by pal- pation just before, perhaps one to three millimeters higher. Again allow the air to escape slowly, and following a few of these loud thumping pulsations which soon become duller, is heard in most cases, a more distinct murmur, much like a loud mitral murmur heard over the heart. As the air is still further released, again a loud clear thump is heard, often louder than the first thump heard before the murmur ; this thumping sound rapidly becomes duller and fainter as the restriction is released, and all sound suddenly ceases, as the artery resumes its normal caliber. The point where the loud thump becomes dull, and just before it vanishes, marks the diastolic- pressure. All this change, — the loud thump, the dull beat, and si- lence, takes place within very narrow limits of the scale, not more than three to five millimeters from where the first loud thump is heard, and where all sound ceases. So that it is possible to locate the diastolic pressure within one or two millimeters.
All this is done in a fraction of the time I have taken to des- cribe it.
These sounds, heard in the order given are present in all cases. The only variation in this being that the murmur heard between the first loud thumping and the second loud thumping sound is almost wanting in some cases, especially in young persons, but very mark- ed in most cases.
But these distinctly loud pulsations, the first following silence as suddenly as a pistol shot, marking the systolic pressure ; and the second, following the dull pulsations and murmur, as the scale goes slowly down, appearing as suddenly and quite as loud as the first, to be rapidly followed by a comparatively low dull sound, which marks the diastolic pressure, just before all sound ceases, are heard in all cases.
This method of taking the blood pressure is so superior to any other, that the older methods need not be discussed.
The systolic pressure can be fairly well taken in most cases by palpation by a skilled hand, but in cases where the radial pulse is not
i
40 JOURNAL OF IOWA STATE MEDICAL SOCIETY
»
very distinct, the personal equation becames an important factor, and a variation of five to ten points is liable to occur. But the aus- cultatory method is accurate for both systolic and diastolic pressure.
Heretofore little attention has been paid to the diastolic press- ure. This was due not to a lack of its importance, but to the diffi- culty of taking it with any degree of accuracy by either the palpa- tory or oscillatory methods.
But by the auscultatory method the diastolic pressure can be taken with the same certainty as the systolic. Care should be taken not to make pressure with the stethescope and thus compress the artery, which is very easily done. This method is equally applicable to either mercury or anaroid sphygmomanometer.
An anaroid instrument is more convenient and the scale is more easily seen while using the stethescope ; but with long tubes to the stethescope no difficulty is experienced in using a mercury instru- ment. A good anaroid instrument for general use and convenience Stands in about the same relation to a mercury instrument, that a good watch does to a clock.
Now just what is blood pressure, and what does it signify?
By blood pressure is meant the arterial tension or force of the blood stream within the arteries. It is evident that the systolic press- ure represents the intra-ventricular pressure, that is, the force of the left ventricle during its contraction ; and the diastolic pressure, or pressure remaining during the heart’s diastole represents the peri- pheral resistance to be overcome ; and the difference between the systolic and the diastolic, represents the pulse pressure, and indi- cates the extent to which this resistance is overcome. The pulse pressure, or range, or amplitude, denotes the head pressure in the arteries, or heart load, and shows the total variation in pressure oc- curring in a given vessel during a cardiac cycle.
The vascular system consists of a double series of closed tubes of progressively varying diameters, with a double force pump be- tween and connecting them, — the right and left heart. These tubular systems are each partially interrupted by a series of very minute vessels, the capillaries of the lungs, and the general circulation.
The heart is an intermittent pump, and if the blood vessels were rigid tubes the blood stream would be intermittent also ; and each stroke of the pump would have to move the entire volume of the blood.
But the elasticity of the vessels themselves overcomes this diffi- culty. The powerful systolic impulse which forces the contents of the ventricle into the arteries, dilates the elastic arterial walls, and their recoil carries the current onward in a more and more continu- ous stream as the smaller vessels are reached.
Arterial pressure is the degree of pressure exerted on the blood flowing through the arterial system ; and represents essentially the force of the left ventricle.
BLOOD PRESSURE— CRAWFORD
41
It depends on five factors :
1 — Cardiac energy, or the pumping power of the heart.
2 — Peripheral resistance in the vessels.
3 — The elasticity of the vessel walls.'
4 — The volume of the blood.
5 — The viscosity of the blood.
These several factors are of relative importance in perhaps the order in which they are named.
The heart during systole drives the blood out into the aorta ; the pressure in the aorta then reaches its maximum and the aortic valves close. The pressure is then maintained by the elasticity of the ves- sel walls, which have been largely dilated, their recoil forcing the blood on through the arterioles and capillaries. The pressure gradu- ally falls and reaches the minimum at the end of diastole. The press- ure depends mainly on the contractile power of the heart, and the peripheral resistance which it has to overcome.
This peripheral resistance depends on the calibre of the vessels, their contractibility and distensibility, whose balance is regulated by the vaso-motor centers of the nervous system.
A normal circulation is shown by a normal blood pressure, which indicates that the heart action, and the distribution of blood is tak- ing place in a normal manner.
This suggests the question, — what is the normal blood pressure ?
A study of all the vital functions of the body show that their normal activities are carried on within very narrow limits. For in- stance, the normal body temperature is 98.6. This applies to all ages and all climates, and only varies in health a fraction of a degree. A very few degrees elevation is a high fever, and a like reduction threatens collapse and death. The normal pulse rate in the adult, at rest is about 70. An habitual variation of 15 beats above or below this denotes disease.
So with blood pressure, its normal range is within narrow limits. It has been pretty well established that the average normal blood pressure for a man is about 125 mm., and a woman about 8 or 10 mm. less. A variation of more than 15 mm. above or below this is indi- cation of disease. I do not mean by variation, a transient functional elevation due to exercise, or excitement, but when the individual’s usual pressure is 15 mm. above or below the standard, it indicates, if not disease per se, that he has departed from the normal condi- tions, which are necessary to the continuance of good health.
This variation is somewhat modified by age. The blood press- ure in childhood and adolescence is considerably less than in mature life. The arteries in childhood are delicate translucent and collaps- ing. There is relatively a large amount of elastic tissue and little connective tissue. As adolescence advances the walls of the vessels become thicker, by the increase of muscular and connective tissue. But it is not until mature adult life that the arteries cease to be col-
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JOURNAL OF IOWA STATE MEDICAL SOCIETY
lapsable and the lumen of the vessels remain open. After the fifth decade there is usually a progressive thickening of the vessel walls with a relative predominance of connective tissue. These may be regarded as the ordinary physiological changes. With these may occur every degree of pathological changes as, atheroma or calcifi- cation, and arteriosclerosis, — which is an inflammatory hyperplasia.
The rule proposed by Faught has been, I think, practically estab- lished by a great number of observers, that the normal blood press- ure of a young man of 20 is 120 mm. ; with an increase of one mm. for each two years of age. Thus the normal blood pressure of a man of 30 is 125 mm. ; of 40, 130 mm. ; of 50, 135 ; and 60, 140 ; and we may take this as the limit of health at any age. A constant pressure above; this denotes abnormal peripheral resistance, whose tendency is to increase, and puts work on the heart which tends directly to degen- erative changes.
This rule, while perhaps not strictly correct, is a good working formula and represents what I have termed the ordinary physiologi- cal changes. These later physiological changes are however, to a degree pathological, as is all departure from the normal, whether due to age or other cause. But from the fact that they are the ordi- nary and usual accompaniment of age we speak of them as physio- logical.
We have in the blood pressure both a confirmation and demon- stration of that old classical saying, “A man is as old as his arteries. ”
There are many men of 50 and even 60 and 65, with healthy elas- tic arteries and unimpaired hearts and kidneys, whose blood press- ure is no higher than it was when they were 30 ; that is 125 mm. while there are many young men with the sclerotic arteries of ad- vanced age.
Fisher in an analysis of the blood pressure of a series of over 13000 men, accepted for life insurance at ages varying from 15 to 60, with an average age of 45, showed they had an average blood pressure of 130 mm. Those whose ages ranged from 15 to 39, a com- paratively few at the earlier ages, had an average pressure of 125 mm. While those of the series from age 50 to 60, about 3500 in num- ber, showed an average pressure of less than 133 mm. These were, of course, selected lives, and accepted as standard risks for insur- ance ; but it only emphasizes the fact, that perfectly healthy old men, have but slight increase in blood pressure over healthy young men. Other old men who have a high blood pressure have it not simply be- cause they are old, but because they have cardio-vascular disease.
What then is the significance of a high blood pressure? Faught answers this question, and expresses a most important truth in this sentence: “ Every case of persistent high blood pressure is potent- ially if not actually, a case of myocardial disease.” The same may be as truthfully said of the arteries and kidneys.
BLOOD PRESSURE— CRAWFORD
43
A persistent high pressure cannot continue for long without re- sulting in arterio-sclerosis, and interstitial nephritis.
Hypertension is both a cause and an effect. If once set in mo- tion by a disturbance of equilibrium, the effect in turn becomes a cause, and aggravates and perpetuates the condition.
It is not within the scope of this paper to take up the etiology of abnormal blood pressure. This is a deep subject, and not yet fully understood.
We know that the very intimate and intricate correlation of the cerebral vasomotor centers with the pituitary, adreno-thyroid, and the cardio-vascular systems, which normally maintains the equil- ibrium of metabolism, and all these vital functions, is liable to dis- turbances from various causes.
Probably the most frequent causes of hypertension and arterio- sclerosis are the various toxemias, especially gastro-intestinal tox- emia, known as auto-intoxications.
With a high systolic pressure, we know that the integrity of the heart muscles and the vessel walls are in danger ; and that it is only a matter of time when degenerative changes will take place.
Sir Lauder Brunton gives the diastolic pressure, under normal conditions, in the ratio of 3 to 4 with the systolic pressure. This gives the normal pulse pressure as 1-4 of the systolic. This is prob- ably too low. The fraction 1-3 of the systolic represents more nearly the normal pulse pressure. W. J. Stone maintains that under normal conditions the pulse pressure is approximately 50 per cent or one half the diastolic pressure. One third of the systolic, and one half the diastolic is found to be practically the same in normal cases. This applies to rest. During exercise, the systolic pressure is raised much more than the diastolic in the healthy person, with a consequent in- crease in the pulse pressure, and the fraction of ratio. The range of the normal pulse pressure is given by various observers as from 25 to 45 mm.
Pulse pressure also depends somewhat on the pulse rate. If the pulse is slow, the blood has more time to run through the arterial system during diastole ; diastolic pressure is lowered, and the pulse pressure increased. An increased pulse rate will have the reverse effect.
In a strong heart, the interval between systoles is longer, and there is consequently a larger pulse pressure. A weak heart will not raise the tension as rapidly as a strong one, and the time between the end of a systole and the beginning of the next will be shorter, with a resulting lower pulse pressure.
A low systolic pressure with a large pulse pressure indicates large dilated vessels and a presumably strong heart.
A high systolic pressure and a correspondingly high diastolic pressure, giving a normal pulse pressure indicates a normal balance between heart and vessels and a compensatory condition still present.
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JOURNAL OF IOWA STATE MEDICAL SOCIETY
When the systolic pressure approaches the diastolic, showing a diminished pulse pressure it indicates a failing circulation and a broken cardiac compensation.
When there is a high systolic pressure and a correspondingly very low diastolic pressure, showing a very large pulse pressure, it is almost pathognomic of aortic regurgitation.
The pulse pressure is of the greatest importance in estimating the cardiac muscular efficiency.
This has been demonstrated by Graupner, Gibson and others by noting the relative effect of sudden exercise, as ten bending move- ments, or running up a flight of stairs, upon the systolic and dias- tolic pressure.
In case of the normal or unimpaired heart both the systolic and diastolic pressure will be raised, but the systolic much more, giving an increased pulse pressure or amplitude, and indicating a heart strength capable of maintaining its tone under extra strain. While in a defective cario-vascular system the diastolic pressure is raised more than the sysytolic, and the pulse pressure diminished, showing myocardial weakness, and a heart losing its compensatory power. Gibson has expressed this graphically by taking the pulse pressure as the numerator of the fraction, and the systolic pressure as the de- nominator, before and after exercise. If the fraction is larger after exercise it denotes heart strength. If it is smaller it denotes a fail- ing heart. These exercise tests should be employed with caution in cases with a very high pressure as they are not devoid of danger.'
ITypotention, or low blood pressure, while not so common as hypertention has an important diagnostic and prognostic signifi- cance. Low pressure is indicative of debility, and low tone of the system.
It is of great diagnostic value in detecting incipient tuberculosis ; and is often present when there are as yet no other physical signs. A person with a low blood pressure should be very carefully investi- gated for this disease.
References.
Hirsclifelder D. A. — Diseases of the Heart and Aorta. Second ed. 1913.
Faught F. A. — Blood pressure, W. B. Saunders 1913.
Janeway Theo. C. — Clinical Study of Blood Pressure.
Fisher J. W. — Diagnostic Value o fthe Use of the Sphygmomano- meter in examinations for Life Insurance 1911.
Fisher J. W. — Blood Pressure Statistics 1912.
Nicholson Percival — Blood Pressure in General Practice Lippincott 1913.
Brunton Sir Lauder — Clinical measurement of Diastolic Blood Pres- sure and Cardiac strength. British Med. Jour. 1910.
Janeway Theo. C. — When should the General Practitioner Measure the Blood Pressure. Albany Med. Annals 1911.
Cook H. W. — Blood Pressure in Prognosis Med. Record Nov. 1911.
Stone W. J. — The Clinical Significance of High and Low Pressure with special Reference to Cardiac Load and Overload. Oct. 4, 1913 — Jour. A. M. A.
Young J. R. — Blood Pressure and Significance in Hypertension
BLOOD PRESSURE— QRAWFORD
45
Cases. Jour. Indiana State Med. Assoc. March 1914.
Nicholson Percival — Clinical Significance of Diastolic and Pulse Pressure. The American Jour, of Med. Sciences, Tpril 1914.
Significance of Pulse Pressure. Journal of Indiana State Med. Assoc. Ed. Apr. 1914.
Miller Joseph L. — Clinical Aspects of Hypertension. Jour. A. M. A. Oct. 4, 1913.
Warfield Louis M. — The Clinical Determination of Diastolic Pres- sure. Jour. A. M. A. Oct. 4, 1913.
Jackson Dr. E. W. Rochester, N. Y. Personal Communications.
Discussion.
W. L .Bierring, Des Moines: I would like to direct what remarks I
have to make to the diastolic blood pressure. As the essayist has well said, it is an indication of heart load. In another way it is really the best indication we have of the mass movement of the blood, and as the the mass movement of the blood becomes more difficult, the ratio be- tween diastolic pressure and systolic pressure will come closer together, and in that way, lessening the point between diastolic and systolic pres- sure, the heart load is correspondingly increased; and, singularly enough, the strain does not come upon the heart so much, but upon the cerebral circulation. So that a man who has a systolic blood pressure of 165 and a diastolic of 140, is not going to die a cardiac death but a cerebral death. It was well said that heart lesions and certain myocardial conditions bring about peculiar changes in diastolic pressure. For instance, the aortic insufficiency always presents a peculiarly low diastolic pressure and a correspondingly high pulse pressure. In the same way we meet it in certain instances of heart-block. I believe there are instances where this wide range or high blood pulse pressure is sometimes an indication of serious processes; at least I have observed one instance recently where it was followed by a cerebral circulatory accident within a few days after this wide range was first observed.
The essayist emphasized the importance or the advantage of the auscultatory method of taking diastolic pressure. There is no doubt that we can make a very fair estimate of systolic pressure by inducing the point when the pulse disappears from the radial artery on pressure over the brachial; but I am sure that the method of determining diastolic pres- sure by observing the vibratory motions of the needle in the anaroid in- strument, or the active instruments of the mercury column in the mer- cury manometer, is subject to considerable error, and that it is only by the diastolic method of inducing, as the author says, the point where the shock-like sound disappears, and where a slight murmur is noticed just before the sound is entirely lost, that we can most accurately recognize the diastolic pressure. Observation and special study seem to indicate that the proper interpretation of diastolic pressure, and particularly of pulse pressure, is of great practical value.
D. N. Loose, Maquoketa: The paper is certainly an able one, and
the subject one of distinct importance, which has not been fully worked out. We have all been taking the systolic blood pressure, but I think comparatively few of us have found any working rules to interpret the findings of the systolic and the pulse pressure. The ratio that Stone has brought out I think is the best working rule we have today, that the pulse pressure should be about fifty per cent of the diastolic pressure. I read somewhere— I think the article was by Gibson, that the important sign of value in pneumonia is the ratio of the pulse rate to the systolic pres- sure. When the systolic pressure is lower than the pulse rate it is a bad indication. A systolic pressure of 110 or 100 and a pulse rate of 12 0 is also a bad indication and shows a failing, myocardial muscle. I think Gibson also speaks about the tap instead of thump. I think that is better than thump. The sound you hear is a very distinct tap, tap, tap, and the longer you can hear that sound in exhausting disease the better is the con- dition of the circulation. Any variation of that distinct tap with low blood pressure is, I think, an indication of heart weakness.
Dr. Crawford: I have nothing particular to add except two points:
to urge on all who have not learned to take habitually the pressure by stethoscope, to learn to do it for the sake of its accuracy; and then to call attention especially to the value of the diastolic and the pulse pressure. This is comparatively a new study. We don’t get anything so very defi- nite from the old authorities, but we know that while the systolic pres-
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sure tells us a great deal, it may even be misleading; but if we check that up with the condition and know what the resistance is and what the ex- cess heart force is as represented by the pulse pressure, it gives an index to the condition. For instance, we may take a man of sixty who has a systolic pressure of 13 5, and we think that is fine. If we hadn’t anything else to go by, it would be fine, but we know there is something the matter with him. We take the diastolic pressure and find it 110 or 120, with a pulse pressure of 2 5 or 15, and we know there is something very serious the matter. He is losing his compensation and has a failing heart.
SOME SIMPLE BUT IMPORTANT THINGS OFTEN BADLY DONE*
L. W. LITTIG, A. M., M. D., M. R. C. S., Davenport.
To secure the best results in surgical work, many little “kinks” require careful consideration. Very often these “kinks” are indif- ferently done, and sometimes done so poorly as to bring disaster. I wish to call attention to some errors I sometimes see both in the hospital in which I do most of my work, and in hospitals in which I occasionally operate. All the points to which I shall refer may seem elementary; they are but none the less important.
Instruments should be boiled in a carbonate of soda solution, and this means that instruments should he boiled and not steamed. There was a time when it was an open question whether instruments should he boiled, steamed, or baked. But this question has long since been decided in favor of boiling. To have an inch or more of water in a boiler with the instruments on a tray above the water, or partially submerged, is not boiling. With this sort of a proced- ure the bicarbonate of soda becomes absolutely useless. Recently, I was told by the head nurse of a hospital that this was the proper way to sterilize instruments, that it was so done in every hospital. We agreed, each of us, to write twelve hospitals, asking how instru- ments were sterilized in the respective institutions, which we did. I handed the answers I received to the nurse without opening them, and the twenty-four replies were in favor of boiling, in not a single hospital were instruments steamed. There must be enough water to completely cover the instruments. Recently I operated in a san- atorium (I always dread sanatoria for surgical work) and was told that the instruments were ready. But I am from Missouri some- times: I removed the lid of the sterilizer. The instruments were
scarcely warm, and quite dry, the nurse having forgotten all about the water.
Gloves may be sterilized for ten or fifteen minutes in a pressure sterilized at fifteen pounds, but must be laid flat and straight, with the cuffs turned back. If boiled, they should be filled with water and wrapped in a towel, and should be completely submerged. But recently I saw a surgeon turn his gloves by blowing into them in- stead of turning them as every nurse is taught to do very soon after
♦Austin Flint-Cedar Valley Medical Society, Mason City, July 9, 1913.
IMPORTANT THINGS— LITTIG
47
she enters the training school. The nurse who was present at this operation and who saw the doctor blow into his gloves, wrapped the gloves into a very nice ball, and threw them into boiling water to sterilize them. Of course, they floated on the water. I have ab- solutely no confidence in such sterilization. I repeat : The gloves
must have the cuffs turned back and should be placed perfectly straight that steam may enter to the finger tips. If not steam steril- ized they should be filled with water and completely submerged. When gloves are mended, the patch should always be placed on the inside, indicated by the number and the hem. Have you ever seen ladies wear gloves with the number and the hem on the outside? The glove maker will tell you that rubber gloves are made over a form, and that the “hem” and the number are put on last, and con- sequently the band and number indicate the outside. According to this argument, I am wearing by coat inside out, and I have no right to wear it the way I think it should be worn, because the mak- ing was practically all done with the garment inside out. But just take up this question, and you will find that every doctor and every nurse knows exactly which is the inside, and which the outside of a glove. But unfortunately they are about equally divided. Augus- tana hospital nurses are sure that the hem and number are on the inside, Mercy Hospital (Chicago) nurses are equally positive that the hem and number are on the outside. Since the hem and the number indicate the inside or the outside of the glove, when mend- ed the patch should always correspond to the hem and number side, or it should not so correspond. If the gloves are put on dry, both the hand and the inside of the glove should be well powdered, and the glove put on with the hands held directly upAvard, that the ex- cess powder may not gather in the finger tips. Of course, the cuff should be turned back to shorten the gloves, and to facilitate the introduction of the hand. The operating room nurse has quite enough to do without standing attention, ready to hold the gloves while the operator thrusts his hands into them. I cannot recall hav- ing seen a surgeon permit a nurse to thus waste her time, except once, and that surgeon was wan and feeble at the time. He has since grown strong and is able to help himself and always does so. A really great surgeon lately told me that he would quit when he grew to feeble to put on his gloves without assistance.
Some five years ago I had two deaths due to post-operative dilatation of the stomach, this in turn due to acute streptococcus infection following clean, simple appendectomies. At the same time there were three other deaths in the house in the service of other men, and a dozen cases of severe infection. I believe that this in- fection was introduced into the house by a puerperal fever patient that had not been properly isolated, the nurse in charge caring for other surgical cases. Upon investigation, it was found that dress- ings were sterilized under a pressure of fifteen pounds for fifteen
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or twenty minutes, a large sterilizer being used. The point I wish to make is that fifteen or twenty minutes is entirely insufficient to sterilize the large amount of material a large pressure sterilizer will hold. In my office the Bramhall-Dean pressure sterilizer is run at fifteen pounds pressure for two hours, and one hour to dry. I know this is longer than is actually necessary, but I expect even the most faithful of nurses to occasionally shorten the time, and when the instruction calls for fifteen or twnety minutes this time may be fur- ther shortened. I am sure that the sterilizaion in my office is effi- cient. In a hospital nothing less than one hour ought to be accepted. Whether the sterilization was at fault in the deaths referred to I do not know, but there was no trouble after the operating room nurse was told that she must keep up steam for two hours, at least until the trouble was over.
The proper preparation of the hands is a procedure about which we know very little, except that a perfect method has not yet been formulated. There are three principal methods : that of Furbringer in which water, soap and brush, and bichloride of mercury are used in the order indicated; that of Ahlfeld in which water, soap, and brush, are followed by alcohol; and that of Meissner in which only alcohol is used, the soap, brush, water, and bichloride being elimi- nated. According to a recent experiment by Marquis, the best re- sults are obtained by the method of Meissner, the next best by that of Furbringer, and the poorest by the method of Ahlfeld. In the Meissner method, the alcohol method, alcohol only is used, and the alcohol must not be less than 70 per cent or more than 95 per cent and denatured alcohol gives results in every way as good as grain alcohol. I do not use denatured alcohol, preferring grain alcohol. Perhaps, this is only sentiment, but I do not like the odor of de- natured alcohol, and it creates the idea of economy in a direction where cost should not be considered. I have long since been divorc- ed from bichloride of mercury and the brush. It has been conclu- sively shown that soap, brush, and water, used for fifteen minutes, with five changes of brush, soap, and water during these fifteen minutes, leaves more microbes to a given area of surface than were present when the procedure was begun. This is like harrowing a potato field after plowing out the potatoes, the more harrowing the more potatoes are exposed. While conceding that there is no longer any good reason for using water and mechanic’s or marble dust soap, I have not been able to tear myself away from my early habits. I do not like the word “habit”, but that is about the only reason I can give for using soap and water, with a sponge. When I hear an operator say that he is in the habit of doing a certain thing in a cer- tain way, I think that he is about ready for the scrap heap. Habits are usually pernicious when they are the only reason for a given practice. The alcohol part of the sterilizing procedure requires time. So often I see doctors and nurses devote less than one-half a minute
IMPORTANT THINGS— LITTIG
49
to this procedure. I sometimes think that they have been to Chicago and have seen a great surgeon with lily-white hands devote ten sec- onds to the alcohol. But they forget that this great surgeon has the carefully manicured hands of the society lady, his skin is soft and smooth, and he keeps his hands clean, far different from those of us who have to do with horses or automobiles. To be efficient, grain alcohol should be used by you and by me, and by nurses, for not less than ten minutes, and should be used full strength. Only two or three days ago I was assisted by a nurse that devoted about one minute to the alcohol part of the hand disinfection process. I said, ’’You have done well for one minute, but please continue your efforts with the alcohol for at least nine minutes longer nothing less than ten minutes is to be trusted.” The stronger the alcohol up to 95 per cent, the better, although little is gained by a per cent higher than 95 per cent, as has been conclusively proven by Major Seeling, of St. Louis. Some years ago I had occasion to use alcohol in a lamp and helped myself to the contents of the alcohol bottle in the oper- ating room. To my surprise this alcohol would not burn, and on investigation disclosed the fact that it was a 25 per cent alcohol. Whether the substitution of his water and alcohol was due to econ- omy, or due to the teaching that 25 per cent alcohol is as efficient as 95 per cent alcohol, I do not know, but I do not believe that any up-to-date surgeon any longer uses diluted alcohol. The old state- ment that 70 per cent or even a 40 per cent alcohol is as efficient as a 95 per cent has been proven wrong time and time again. But we know so many things that are not true, and it is so hard to un- learn.
We may not wholly accept this no water, no soap, no brush method of preparing the hands, yet it is a great comfort to know that in an emergency alcohol alone is efficient. In an accident, say on the farm or in railway surgery in the field, alcohol will answer every purpose. If a sterile basin be considered necessary, alcohol burned in the same will sterilize as efficiently as steam. With a quart of 95 per cent grain alcohol, and tincture of iodin any emer- gency may be met.
Now we have out instruments, our dressings, and our hands properly prepared. We are ready for the patient.
In spite of all that has been said every now and then a patient is brought to the operating room with a moist bichloride compress over the operation site. When I see that moist bichloride compress, or any other compress, I feel that I am carried back to the very early era of antiseptic surgery, quite to the time it was born, with the operation under a carbolized spray. I regard those responsible for this compress as venerable hermits that have been living a life of seclusion and prayer, quite apart from their fellow men. I am quite sure about the seclusion. To these operators I should like to repeat the suggestion made by Jacobi at Minneapolis: 4 1 Watch
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more and pray less”. The man that carefully cleanses an injured hand or foot with water, soap, and brush, following this procedure with iodin is also entitled a place in the hermit’s class. Iodin disin- fection depends for its efficiency on tincture of iodin, any other addition only works harm.
Returning to the formal preparation, the best results are obtain- ed by giving the patient a bath the evening before, then clean bed and body linen, without all further preparation of the operation site. On the operating table, one coat of tincture of iodin should be applied just before anesthesia is begun, a second just before the incision is made, and a third just over the line of sutures when the wound is closed. If for any reason whatsoever there is not suffi- cient time to give the bath, the iodin must be applied without any preliminary preparation whatsoever. If necessary to shave the site of operation, the shave should be dry.
To be efficient, the iodin must be applied to a dry surface. To use soap and water immediately before operation, drying the sur- face with gasoline or alcohol is to be condemned. It is a question whether the removal of the fat from the skin, or the saturation of the cells with water interferes most with the efficiency of tincture of iodin. If soap and water cannot be used at least four hours be- fore the patient is to be operated upon, it should be omitted entirely. Tincture of iodin must be fresh, if blistering is to be avoided, and a fresh tincture of iodin means a fresh tincture. It does not mean that the tincture of iodin is necessarily fresh because it is bought in a drug store just before using. There is only one way, and that is the method of Reclus, who has seen much blistering with tincture of iodin. Reclus says, “I do not know why old tincture of iodin blisters, nor am I especially interested to know, because I always use a fresh tincture of iodin.” His method is to put a given amount of iodin into a small vial, and add the alcohol just before using. We had considerable blistering iu Davenport, and also in Iowa City, until this method was introduced.
Forty grains of iodin to the ounce of alcohol will give an ap- proximately 10 per cent alcohol solution of iodin. Forty grains of iodin in a four ounce graduate vial is very satisfactory. The ad- dition of one ounce of alcohol will give a 10 per cent alcoholic solu- tion of iodin, the addition of two ounces will give a 5 per cent solu- tion, three ounces will give a 33 1-3 per cent solution, and four ounces a 2 1-2 per cent solution. Of course, a larger quantity of iodin may be used, and a correspondingly larger quantity of alcohol, but never more than will be required during the next twenty-four hours. Recently, while casually present at an operation the operat- ing surgeon gave me a water tumbler, a bottle of iodin crystals, and a small bottle of alcohol, saying: “Prepare the iodin according to Littig’s method.” My reply was, “Impossible! Littig uses a pair of scales for the iodin crystals, and he carefully measures the alcohol.
IMPORTANT THINGS— LITTIG
51
He does not guess about this matter.” Iodide of potash need not be added if the alcohol solution of iodin be used promptly. I have seen absolutely no trouble from blistering since using the Reclus method, and I have applied six coats just to try it out. Some time ago a surgeon in applying tincture of iodin permitted some of the iodin to trickle between the thigh and the scrotum of the patient. The skin over one of the testicles sloughed away completely. Any one applying iodin in this way ought to have the skin over the tes- ticles slough, he ought to lose a testicle but it ought not to be that of his patient. There is no excuse for carelessly sopping iodin all over the map, and have it run in little rivulets onto the table nor between the thighs of the patient. Iodin must be spread over a gen- erous surface. So often do I see it painted over a surface as large as the hand, when it should be an area of at least twelve by eighteen inches. Ochsner uses one coat of a 16 per cent tincture of iodin, (Churchills) and it is always neatly applied, there are no rivulets flowing in any direction.
I believe that the use of wound cloths to prevent the hands of the operator from carrying the tincture of iodin on to the parietal or on to the visceral peritoneum is advisable. I cannot believe that it is a matter of no moment whether tincture of iodin be carried into the abdominal cavity or not. I believe that it tends to encourage adhesions. Incidenally, I do not like the Moynihan clamps, as they lie on top of the wound cloths. The ordinary towel clamp holds the wound cloth just as well, lies under the wound cloth, and is much to be preferred.
Incidentally, I had a patient on fire a few days ago. I made a free incision into a breast tumor to determine whether or not the growth was malignant. It was cancer. I applied a hot iron to seal the wound, there was a burst of flame. I had the same thing hap- pen on one occasion when using kalene for local anesthesia. I ap- pled the hot iron to the frozen area. My tincture of iodin experience is not unique. Recently, a noted French surgeon had a mal-practice suit based on the same accident. Of course, a little waiting would have avoided the accident.
Talking about accidents, let me tell of a recent experience. A patient to be operated for gall stones was assigned to her room at ,10 yAj, M. I made my first call at 1 P. M. Three hours later, I im- mediately detected the pungent odor of formaldahyde, and ordered the windows opened at once. The patient’s sister said, “We have all been crying, doctor, because our eyes hurt.” The operating room was rather cold, and there was a further wait of about one hour. The patient took the ether badly, coughing quite a bit. She was no sooner out of the anesthetic than she said, “I am all right, but I cannot get my breath.” And such efforts to breath for the next four days, such tugging of all the auxiliary muscles of respiration with loud, course rales heard without applying the ear to these, and
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such suffering, with final complete recovery. But the four days of worry due to the ether and formaldehyd I shall never forget. One year ago I should have considered this accident impossible. Some of you may have it before you attain my age, so please do not point the finger of scorn at me.
Conducive to the after comfort of the patient in all cases, is a quarter of a grain of morphine given immediately after he reaches the bed, that he may pass directly from the sleep of ether into the sleep of morphine. Equally conducive to comfort is the free use of water after the operation, by proctoclysis, a pint to a quart being given by the drop or the low gravity method just as soon as the pa- tient is put to bed, and a pint to a quart every two or four hours until water is taken freely by the mouth, a pint every two hours or a quart every four hours.
Continuous proctoclysis does not mean that water is given con- tinuously, but the bowel should rest half of the time. If the direc- tions be a pint every two. hours, the entire amount should be given in half of this time, or about 128 drops to the minute. If the order be for a quart every four hours, the rate should be the same, the time required being two hours, leaving two hours for rest.
Recently tap water has been advocated instead of normal salt, and we have been using this for some months, or whenever the thought is to relieve thirst. We have not yet ventured to substitute tap water for normal salt solution in cases of peritonitis, although there seems to be no reason for not doing so. Patients should be permitted to drink freely of water just as soon as they desire it, barring of course, operations on the stomach. If the water is vomit- ed, it tends to wash out the stomach ; if it is not vomited, it quenches the thirst, making it possible to discontinue proctoclysis all the sooner. Ice and ice water for quenching thirst should be banished from the sick room. I remember when we gave our patients tea- spoonsful of cracked ice, or a little iced champagne, later ice water. I hope that I may not be called to account on the day of judgment for these transgressions. My intentions were good, but my practice very bad.
I cannot understand why so many surgeons permit the nurses to ignore the respiration in the record sheet. The respiration gives most valuable and comforting information or timely warning. I do not see how a patient with eighteen or twenty respirations per min- ute can be going wrong, but any increase in the frequency of respi- ration is a signal that all is not quite well. I always insist that the record chart include the respiration.
Only a few days ago I was visiting a surgeon in Missouri, quite a man. With some pride he presented his patients, a breast case with the dressing over the gall bladder, and an appendix case with the dressing over the umbilicus. He did not use adhesive strips, and his dressings simply crept to the easiest position without regard to the
IMPORTANT THINGS— LITTIG
duty assigned them. This surgeon used bichloride gauze over the wounds, and such angry rebellious looking wounds, with the silk worm gut sutures drawn so tight they were almost buried. He actually removed a drainage tube with the finger, and took up a soiled dress- ing with his fingers. His colleague, also quite a man, graciously demonstrated other patients, one a twenty-four hour appendectomy. No adhesive strips were used, and no trouble to see the wound, as at least half of it was uncovered. After leaving the room, I said; “ Doctor, why do you put bichloride gauze over your wounds?” “But I do not,” he said. “Oh Doctor, I am quite sure that you have bichloride gauze over that appendectomy wound.” I have not, I am sure of that.” I persisted. “Let us take another look.” We did, and the irate doctor turned to the nurse, “Who put that bichloride gauze over that wound? You know that I do not use bichloride gauze over a wound, change it at once.” But after all, bichloride gauze is all right for a hospital where adhesive strips are not used, where dressings do not remain they are put, where one surgeon re- moves a drainage tube with his fingers, where the other does not know what kind of gauze is over the wound, and where the nurse is ordered to change the gauze at once, the wound already showing resentment because of the mal-treatment it was receiving.
I should like to repeat : A quarter of a grain of morphine im- mediately after the operation to relieve the unconscious manifesta- tions of pain and discomfort, and a quart of tap by the bowel to silence that pitiful plea for just a little water to moisten the lips. Water freely just as soon as the patient desires it. Of course, if the thought be to encourage vomiting tepid water should be given. Hot water has a place, but ice water is baned.
After a most tragic experience with post operative dilatation of the stomach, you are not surprised that I always keep an anxious eye on the condition of the abdomen, and any distention of the upper part as an indication of coming trouble, while a scaphoid abdomen, especially the upper part, is a signal that the surgeon may go to bed untroubled by that spectre, post operative dilatation of the stomach.
Before closing I want to make a plea for better surgery by call- ing attention to a means to make better surgeons and to prevent bad surgery, at least to a certain extent. I believe that every operation in every hospital should be bulletined, and that every member of the hospital staff or every physician who has the privilege of the hospital should have a standing and urgent invitation to witness the operation. Not only will this increase the practical experience of every man working in a hospital but will often prevent unjustifi- able and, sometimes, reprehensible operations, to use a rather mild term. That patients will not object, is evidenced by the success or those hospitals in which not only the operating room is open to all members of the hospital staff, but to all members of the profession.
THE JOURNAL OF THE IOWA STATE MEDICAL SOCIETY
EDITORIAL
Purchase of the Iowa Medical Journal By the Iowa State Medical
Society.
Under a resolution passed by the House of Delegates, the Board of Trustees purchased the Iowa Medical Journal, edited by Dr. E. E. Dorr, this purchase to take effect July 1st. Therefore the Iowa Medical Journal will close with the June number, completing Vol- ume 20 of said publication. The Iowa Medical Journal has become well known to the profession of the state, and for five years publish- ed the papers and transactions of the State Society. Dr. Dorr find- ing that the work on the journal interfered seriously with other business arrangements, concluded to sell his journal and made an offer to the State Society which was accepted by the House of Dele- gates at the Sioux City meeting, and referred to the Board of Trus- tees.
It has been decided by the Board that a short volume consisting of six numbers shall complete Volume 4 of the Journal of the Iowa State Medical Society, and Volume 5 shall commence with the Janu- ary 1915 number. The size of the page will be changed to 8x11, con- forming with nearly all of the larger state journals. The calendar year being made the fiscal year for the business of the Iowa State Medical Society, and as the membership begins with January, we thought best that the volumes of the journal should in the future begin with the January number. This will be more convenient for all parties concerned.
Carnegie Foundation Report,
The Carnegie Foundation in its recent annual report, makes some rather severe criticisms on education matters in Iowa, especially in relation to the State University. Criticism coming from this source should be very carefully taken to heart and considered prayerfully. The report not only touches upon the State University but includes the State Agricultural College at Ames and also our entire school system. It is made to appear from this report that neither the Legislature nor the Board of Education have been able to free themselves entirely from political consideration in all that re- lates to higher education. It is made to appear that the Legislature governed by good intentions and made up of good intelligent men, have been unable to make up a Board to conduct educational matters without being influenced by political consideration; that it has not
EDITORIAL
55
been possible for the Governor in selecting a Board to consider the appointee’s fitness to direct educational matters, but has taken into consideration the various political methods which are too well known to need any elaboration. The result is that the Board of Education, unconsciously it may be, sees things through political glasses and are governed accordingly, and it is to be feared that they have not been able entirely to overlook the influence of what is known as “vested interest.” We cannot for a moment think of the Board of Education being governed by other than honest methods, nor would they in- tentionally allow business interests to stand in the way of educa- tional development, but it is difficult to say how educational matters in Iowa can reach the highest standard of excellence unless differ- ent views are attained in the Board.
We have been advised by good authority that in the State Agri- cultural College, a professor in the Agricultural Department who had reached some distinction in the line of his work, had been designated by the Department of Agriculture to inquire into the respective value of certain live “stock food” products. The department placed at his disposal quite a large number of hogs and cattle. A part were fed on “stock food” products and a part on natural food, and a record made as to the results. The published reports were to the effect that the natural foods were the best. This, of course, was not agreeable to certain “vested interests” which were using the agricultural pap ers of the state for the purpose of creating a market for their pro- ducts. After repeated warnings which the professor did not heed, all the machinery of politics were set in operation to destroy him, and were successful.
We have sometimes wondered if certain interests intrenched at the State University were not responsible for the destruction of Presi- dent Bowman, not “vested interests” entirely’ but operated very much in the same manner. We know the fate of Dr. Wiley at the hands of the vested interest operating the great political machine, and we are impelled to inquire what would have been the fate of Dr. Geo. H. Simmons in his attack on so-called “vested interests,” if it had not been for the great body of intelligent medical men be- hind him. It is painful to reflect upon matters of this kind, and it is difficult to believe that the education interests of the great state of Iowa are to be held in check by political consideration, not always directed by special interests but probably more frequently governed by the curious and undermining influence of politics all of which creates a vague feeling of uncertainty in the public mind as to the fit- ness of the Board in directing educational institutions in such a manner as to secure results commensurate with the money expended by the state, and of the uncertainty as to the possibility of bringing up our educational institutions to the standard of similar institutions in our neighboring states. If any improvement is to be accomplish- ed it must be through agitation and enlightened public opinion upon
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these subjects. Any man who criticizes home institutions is apt to be regarded as a knocker when in fact he is a critic and is as earnest and zealous as anyone to secure better conditions, which he believes can only be brought about by publicity. It is to be hoped that the last report of the Carnegie foundation will be thoroughly read by all interested in educational matters, and that the influence of such criticism may be helpful in canvassing the question of the constitu- tion of the governing bodies of our state educational institutions.
Industrial Accident Work.
The California State Society through its House of Delegates adopted a plan recommended by the Council of the State Society re- lating to industrial accident work. AYe offer a part of the report of the Council which was adopted. It will thus be seen that the pro- fession of California are quite alive to the conditions that are surely coming about. In our editorial upon this subject for the June num- ber, we called attention to the desirability of having a committee appointed for the purpose of considering the question, but it will probably be better for the Council of the State Society to go over the whole subject and ascertain what is the best course for the profession in Iowa to take. It is utterly useless for us to say what we will or will not do because we are very likely to adopt the course that will give us a living. If the Council of the State Society would take up this subject and formulate a plan which could be passed by the In- dustrial Commissioner, it would accomplish much more than a flat refusal which is not adhered to, and the whole matter could, no doubt, be adjusted in a friendly way, and to the advantage of all parties concerned.
“B.” Contracts: No contracts at flat, fixed fees for all work are to be made and those now existing are to terminate at the earliest possible date.
“C. ” Schedule: The fee schedule which has been prepared as heretofore indicated and is herewith presented to you, is recommend- ed for the approval of the Medical Society of the State of California and of its various county units, as a schedule of the minimum fees to be charged for the services indicated in the schedule in the treat- ment of persons who may be injured as specified in the law. Ad- ditional compensation will be allowed in unusual services on proper representation.
‘lD.” Choice of Physician: The employer (or the company, if the employer is insured) is to have the right to a free choice of phy- sician and such selections are to be made from lists of names furnish- ed by the insurance companies, these lists of names to be the lists of members collectively compose the Medical Society of the State of California, but no member may be compelled to do the work if he does not wish to. Provided, that in counties where there is no county medical society, or in special cases where the employer may
EDITORIAL
57
desire to secure the services of some physician who is not a member of his county medical society, he reserves the right to do so ; also pro- vided that in the larger centers the societies are to prepare lists oi names of members who are willing to do the work and to arrange so that the services of some of them may be secured at any time, by means of a telephone exchange or some other plan by which their whereabouts may at any time be ascertained ; and also provided that the companies are to be permitted to advise their policy holders that certain physicians have, in the past, done work for them satisfac- torily. It is understood that an insurance company may have a reg- ularly appointed medical referee in any given locality.
“E.” Adjustment of Fees: In case a bill rendered by a mem- ber is regarded as excessive by the employer (or company) it shall be submitted to the county medical society for scrutiny and adjust- ment, and if there be still failure to agree, it may be submitted to the Council of the State Society or to the Industrial Commission.
“F. ” County Units and Professional Conduct. In order to carry out the provisions of this plan, it will be necessary for each county unit to approve the schedule so far as it applies to the work indicated and to persons whose income does not exceed the maximum indicat- ed in the law. Charges in excess of the proper ones, or bills unduly padded by ficititious or unnecessary visits, shall be deemed unprofes sional and subject to discipline by suspension or expulsion. — (Adopt- ed.
Some Interesting Information in Regard to Medical Defense by State
Societies.
The journals of some of the state medical societies are publishing reports of their annual meetings and offering some interesting facts in relation to the cost of defending suits.
The Journal of the California State Society shows that the cost of medical defense in California for the past year has been $5,213.10. From the same journal we ascertain that the income of the State So- ciety for the past year was $18,699.62 and disbursements $19,967.67. It appears that the cost of the journal and the cost of medical de- fense in California is $17,389.51. Net deficiency $1,881.35. The Jour- nal states “We would point out that the payments for medical de- fense for 1913 amounted to $5,213.10, against $3,242.87 for 1912.”
The Journal of the New York State Medical Society reports 57 new cases of malpractice for the year 1913, and the Finance Com- mittee of the Council has appropriated $6,500 for the defense of malpractice cases for the year 1914. The Journal gives the total of legal expenses for the last seven years. It shows that the expenses for 1906 were $3,461.75, and for 1913 $4,952.58. It will be seen that the cost of the California State Journal for the past year was $12.,- 176.41; its income from advertising $6,564.30. The cost of the Jour- nal of the New York State Medical Society was $10,728.93 ; advertis-
58
JOURNAL OF IOWA STATE MEDICAL SOCIETY
ing income $4,617.87. Tlie size of the California journal is 51 pages reading matter double column, size of page 8x11, 41 pages of adver- tising. The size of the New York State Journal is 58 pages reading matter, double column, and 19 pages of advertising including covers. Size of page 8x11. The Journal of the Iowa State Medical Society about the same amount of reading matter, has cost the State Society $3,758.79.
Boosters and Builders.
To boost is one thing, to build is another. The booster shouts and pushes and insists that all others do likewise. He resents criti- cism, no matter how impartial or how long over due. The builder carefully studies the proposition; he is especially anxious to discover weak parts that they may be strengthened or replaced. The builder knows that the stability of the structure depends on the elimination of weak features, because the entire chain cannot be stronger than its weakest link. The booster loudly heralds as “ knockers” those that do not agree with him, he offers a personal motive in explana- tion of every criticism which touches the weak point in his proposi- tion, and which has for its object its elimination. He regards as an enemy to his cause the individual that fails to endorse it in every detail. The booster always tries to discredit the motives of the most honest critic.
Liability of Surgeon of Charitable Institution for Leaving Spring From
Packer in Uterus.
(Wharton vs. Warner et al. (Wash.), 135 Pac. R. 235.)
The Supreme Court of Washington directs that a judgment be enter- ed against the defendant Warner for damages for malpractice. The court says that he was employed at a sanatorium as the surgeon in charge there- of and that in the treatment of Mrs. Wharton, by a curettement of the uterus, he used a uterine packer, and a spring therefrom, some 12 inches in length, became detached from the machine and was packed into the uterus and allowed to remain for a period of fifteen days.
Passing to the law of the case, it may be announced as one of the fundamentals of the law that negligence is never presumed, but that it must be affirmatively established by competent evidence.
It is equally well settled that, when a physician and surgeon takes charge of a case, he impliedly represents that he possesses, and the law imposes on him the duty of possessing and exercising, reasonable skill and learning, that is, such skill and learning as is possessed by the ordinary practitioner in that general locality, measured by the state of medical and surgical science at the time the service is rendered.
Tested by these principles, there was abundant evidence of Dr. War- ner’s negligence. Indeed, it would excite surprise had the jury returned a different verdict. The jury was warranted in finding (a) that he was guilty of negligence in leaving the spring in the uterus; (b) that he was negligent in failing to discover and remove it; and (c) that the packer with which he performed the operation was not then used by surgeons pos- sessing average learning and skill in that locality.
It was argued (1) that whether a surgical operation was unskillfully performed is a question of science and is to be determined by the opinion
EDITORIAL
59
evidence of surgeons; and (2), in effect, that a bad result standing alone is no evidence of unskillful surgery. From these postulates it was argued that there was no evidence to sustain a verdict against this defendant. Both propositions are sound when soundly applied. The reason is that in most cases a layman can have no knowledge whether the proper medicine was administered or the proper surgical treatment given. Whether a sur- gical operation was unskilfully or skilfully performed is a scientific ques- tion. If, however, a surgeon should lose the instrument with which he operates in the incision which he makes in his patient, it would seem a matter of common sense that scientific opinion could throw little light on the subject. So, in this case, when the surgeon loses a metallic spring about 12 inches in length, and about 1-16 of an inch in width, in the body of his patient, and fails to discover and remove it, it would seem that a jury would have abundant justification for inferring negligence without the aid of expert testimony. But, putting this view aside, the court thinks that the evidence set forth was insufficient to support the verdict.
But the medical missionary and benevolent society, organized for charitable purposes only, which conducted the sanatorium and which the evidence showed exercised reasonable care in selecting Dr. Warner, could not be held responsible for his negligence. The same rule applies when the plaintiff pays for the services rendered, where the amount received is not for private gain, but to accomplish more effectually the purposed for which the charity was founded.
1 Alumni Clinics.
The next Alumni Clinic of the College of Medicine of the State Uni- versity, will be held at Iowa City, October 22nd and 23rd, 1914. These are the two days immediately preceding the home-coming for the Iowa and Minnesota football game. — Henry Albert.
The Toronto General Hospital.
The cost of the new General Hospital at Toronto, when it is complet- ed, will amount to about $3,400,000. It will be one of the most modern and best equipped hospitals on the continent and will accommodate near- ly seven hundred patients.
Dr. James R. Guthrie was presented with a beautiful loving cup by his former students upon the completion of his twenty-fifth year as a pro- fessor in the College of Medicine of the State University of Iowa, June 17, 1914. The presentation was made at the time of the Alumni dinner.
Drs. Dean, Kessler and Rowan of Iowa City are among the Profession who attended the meeting of the American Medical Association at Atlantic City.
Rules Governing the Members of the Iowa State Medical Society with
Reference to the Defence Fund.
1. The object and purpose of maintaining a Defense Fund is not to aid in defeating any just claim which any person may have against any member of this Society for malpractice. The Society recognizes that sometimes mistakes may occur with the most careful and skillful physi- cians and surgeons, and the Society, through its committee, will use all just and honorable means to bring about a fair settlement of any such cases. The necessity of maintaining such fund arises out of the fact that nine-tenths of the suits brought against doctors for alleged malpractice are little less than blackmail. Experience shows that the great majority of such cases are brought without any purpose of prosecuting them to judg-
60
JOURNAL OF IOWA STATE MEDICAL SOCIETY
ment, but only with the view of forcing the doctor to settle rather than to go to the expense and publicity of a trial.
Every member of the Society is interested in such litigation because every dollar that is paid upon unjust claims in settlement thereof is en- couragement for further attempts to extort money by such methods. In the organization of the Defense Fund it is the purpose of the Society to aid its members in defending against these attempts at extortion. The expense of making a proper defense is a burden to many members of the Society, and inasmuch as all are interested in defeating unjust claims, it is no more than just that all members should contribute to aid in such defense.
2. It is not intended that the benefits of the Defense Fund shall be available for the purpose of aiding in controversies over bills for services, and in case an action is brought by a doctor to recover for his services and the defendant simply sets up a counter-claim to the extent of the bill or for the purpose of defeating the bill, asking no affirmative judgment beyond the amount of the bill, such doctor shall not be entitled to the benefits of the Defense Fund. Where, however, an action is commenced upon a bill and a counter-claim is filed for malpractice, or an independent action is filed for malpractice in which the patient claims a judgment against the doctor in excess of the amount of the bill, then in such case the doctor is entitled to the benefits of the Defense Fund the same as if no action had been brought by him.
3. Experience shows that many malpractice suits arise out of a con- troversy over bills for services. For this reason it is the judgment of the committee that in all cases where there is any serious controversy about a bill for service the doctor ought to submit the matter to the attorneys for the association before commencing suit upon the bill. The purpose of such submission is not that they shall render any service toward the collection of the bill, but that from experience in such matters they make suggestions with reference thereto which may avoid litigation and pre- vent the commencement of an action for malpractice.
4. Whenever an action is commenced or threatened, the doctor should write to the attorney for the Association — making a fulLfair state- ment of the facts so that they may advise the doctor at as early a time as possible with reference to the action of the threatened action. In many cases advice may be given which will avoid litigation.
5. In all cases where a notice is served upon a member of the So- ciety of a suit or contemplated suit, the same should be sent FORTHWITH to the attorneys for the Association, in order that no disadvantage may re- sult from delay.
6. Members will understand in the commencement of any action in the District Court a notice is served at least ten (10) days before the term for which suit is brought, and that this gives plenty of time to communi- cate with the attorneys for the Association so that rights may be fully pro- tected.
7. In connection with any notice so sent to the attorneys, the mem- bers should send at the earliest possible date a full statement of the facts pertaining to the case. The attorneys will communicate with the committee with reference to such statement of facts, and the committee will render such service as is possible, both to the attorneys and to the doctor.
8. While in most cases which actually come to trial it will be neces- sary to have loeal counsel to co-operate with the attorneys for the Associa- tion, such local counsel should not be employed until after communicating with the attorneys for the Association. In many cases the cases will be dis- missed or otherwise disposed of without trial, so that the expense of local counsel may be avoided.
TRANSACTIONS, 1914
61
9. It is of the utmost importance that members of the Association shall be guided by the foregoing rules, and IT IS HEREBY EXPRESSLY DECLARED that where the member of the Association does not comply with the foregoing rules he shall not be entitled to the benefits of the De- fense Fund, unless upon proper showing to the Medical Defense Committee satisfactory excuse for not complying with the rules is established.
10. The Association will pay for the services of local counsel, pro- vided they are employed under the direction of the regular attorneys for the Association, and not otherwise.
11. The Association will not pay court costs or any judgment or oth- er expense of its members.
12. Address all communications about cases to Wade, Dutcher & Da- vis, Iowa City, Iowa.
13. Members should carefully read these rules, because they must be strictly observed to obtain the benefits provided.
Members of the Committee. D. S. Fairchild, Chairman; L. W. Littig, Secretary; Lewis Schooler; M. J. Wade, Attorney for the Society.
HOUSE OF DELEGATES IOWA STATE MEDICAL SOCIETY
i. Sixty-Third Annual Session.
Sioux City, May 13-14-15, 1914.
First meeting, Wednesday, May 13th, 1914.
The House of Delegates of the Iowa State Medical Society held its first meeting in the Assembly room of The Martin Hotel, being called to order by the President, Dr. L. W. Dean.
The Roll was called showing the presence of fifty-seven members.
Dr. Wm. Jepson, on behalf of the Committee on Arrangements, pre- sented Dr. Dean with a gavel, which was accepted by President Dean in a brief response, expressing his appreciation.
The Secretary read his Annual report, which was upon motion ap- proved and ordered filed.
Secretary’s Report.
Your Secretary begs leave to submit the following report. The total number of members for 1913 was 2019, for 1912, 2000. This member- ship is gratifying because 1913 was the year that the dues were increased from $3.00 to $4.00, and your Secretary feels that to show even a slight increase is a matter for congratulation. The number of members to date for this year is 1831.
The following county societies have not reported officers for this
year.
Buena Vista, Delaware, Fayette, Hamilton, Jackson.
Buena Vista County has remitted the dues for four members for this- year. Delaware County, two; Fayette County, one; Hancock County, two; Mitchell four; Winnebago, four.
Clarke and Clayton Counties had their charters revoked last year, and both have been reorganized, and have their applications on file for new charters. Clayton County was reorganized immediately after the annual session last year, and has fourteen charter members. Dr. Throckmorton reports the reorganization of Clarke County, with ten charter members. I recommend that charters be granted to these two
62
JOURNAL OF IOWA STATE MEDICAL SOCIETY
societies, and their Delegates he seated. In compliance with a motion which was adopted by the last House of Delegates, a charter has been issued to the Palo Alto County Society. At the present time, every county in the state has a more or less active organization, there being one Society composed of two counties, Dallas-Guthrie. During the past year, in different parts of the state, there have been combined meetings of two or more county societies. Your Secretary was privileged to attend two of these, and he desires to express the opinion that this is a question which many of the less populous counties would do well to adopt.
The following orders have been issued since my last report:
No. 522 — Dr. T. M. Throckmorton, Councilor Expenses $ 5.00
No. 523 — Dr. G. C. Moorhead, Councilor Expenses 7.50
No. 524 — Dr. J. W. Cokenower, Councilor Expenses 5.00
No. 525 — Dr. Ira K. Gardner, Councilor Expenses 2.60
No. 526 — Dr. C. A. Boice, Councilor Expenses 18.35
No. 52 7 — Dr. Thos. F. Duhigg, Com. Public Policy and Legis- lation 46.55
No. 52 8 — Dr. C. A. Boice, Assistant Editor and Advertising
Manager 54.60
No. 529 — Woodford & Ainsworth, programs and badges 37.00
No. 53 0— Dr. J. W. Osborn, Salary and Expenses 745.03
No. 531 — Plymouth Cong. Church, Rent of church for 1913
meeting 75.00
No. 532 — Dr. G. E. Crawford, Councilor Expenses 3.80
No. 533 — Dr. H. C. Eschbach, Councilor Expenses 2.75
No. 534 — Dr. W. B. Small, Salary and Expenses 194.95
No. 535 — Dr. Thos. F. Duhigg, Registrars, Placards and banners,
Lantern & Operator & Ice 41.15
No. 536 — Washington Co. Press, Journal for May, cuts and ex- penses on cuts 210.76
No. 53 7 — Blaise & Blaise, To reporting Session and Transcrib- ing proceedings and Etc., Annual Session, 1913 83.60
No. 538 — The Press Co., The Journal, June 1913 206.31
No. 539 — Dr. D. S. Fairchild, Editor’s Salary, April, May, and
June, 1913 375.00
No. 540 — Dr. H. G. Langworthy, Expense Com. on Contract and
Lodge practice 6.25
No. 541 — Wade, Dutcher & Davis, Medico-Legal Services, April,
May, June, 1913 368.53
No. 542 — Dr. J. W. Osborn, Salary and Expenses 198.13
No. 543 — The Press Co., July and August 1913 issues of the
Journal . 361.62
No. 544 — The Press Co., September 1913 Journal 180.81
No. 545 — Dr. D. S. Fairchild, Editor’s Salary, July, August, and
September, 1913 375.00
No. 546 — Wade, Dutcher & Davis, Medico-Legal Expenses, July,
August and September, 1913 as per bill of October 1st, 1913. . 371.40 No. 547 — The Press Co., October and November, 1913 Journal. . . 300.32 No. 548 — A. E. Cook, Malvern, Iowa, Medico-Legal services as
per bill October 1st, 1913 20.00
No. 549 — The Press Co., December, 1913 Journal 181.36
No. 550 — Dr. J. W. Osborn, 2nd Quarter’s Salary and Expenses. . 186.95
No. 551 — Dr. C. A. Boice, Com. on Advertising 255.92
No. 552 — Wade, Dutcher & Davis, Medico- Legal services October,
November and December, 1913 928.98
TRANSACTIONS, 1914 63
No. 553 — Dr. D. S. Fairchild, Editor’s Salary, October, November,
December, 1913 .. . . . 375.00
No. 554 — The Press Co., January, 1914 Journal 151.66
No. 555 — The Press Co., February, 1914 Journal 203.98
No. 556 — H. F. Wagner, of Wagner and Updegraff, Medico-Legal
services 320.50
No. 557 — Dr. D. S. Fairchild, Editor’s Salary, January, February,
March, 1914 375.00
No. 558 — The Press Co., March, 1914 Journal 197.36
No. 559 — Wolfe & Wolfe, Medico-Legal services 87.95
No. 560 — Wade, Dutcher & Davis, Medico-Legal services January
3, April 1st, 1914 618.36
A curious defect in our By-Laws has come to our attention this year. Except for the President and Editor, there is no provision for filling any vacancy that may arise from any cause, between the Annual Sessions. The Committee on Constitution and By-Laws, has this matter under consider- ation, and will no doubt propose a remedy.
The post office authorities have changed the ruling in regard to the Journal, so that where not more than one-half the dues are used for Jour- nal expenses, it need not be optional. There never has been any rule in the By-Laws that it should be optional, but it was made so by the Trus- tees in order to comply with the post office requirements.
When planning for the collection of the 1914 dues, I conferred with the Trustees as to our attitude on this subject this year, and we agreed that I should accept dues without the Journal, subject to approval by the House of Delegates. Your Secretary would like some action by this body, on this subject, and he ventures to recommend that a resolution be adopt- ed approving the joint action of the Trustees, and the Secretary for 1914, and instructing the Secretary that hereafter the Journal shall be obliga- tory.
Your Secretary would also like an expression from this body as to whether members who are received by transfer from other states with the payment of no dues, are entitled to the Journal and to Medico-Legal defense.
Upon motion of Dr. W. B. Small, seconded by Dr. H. C. Esehbach, new charters were granted to the counties of Clayton and Clarke.
The report of the Treasurer was read by Dr. Small, and upon motion of Dr. Esehbach, was referred to the Finance Committee.
Treasurer’s Report.
Mr. President and Members House of Delegates of the Iowa State Medical
Society:
Your Treasurer begs leave to submit the following report for the year, May 1st, 1913, to May 1st, 1914.
1913.
May 1st, Balance on hand $4456.56
May 15th, Order No. 522, T. M. Throckmorton, Coun- cilor Expenses
May 15th, Order No. 523, G. C. Moorehead, Councilor
Expenses
May 15th, Order No. 524, J. W. Cokenower, Councilor
Expenses
May 15th, Order No. 525, Ira K. Gardner, Councilor Expenses
$ 5.00
7.50 5.00
2.60
64
JOURNAL OF IOWA STATE MEDICAL SOCIETY
May 15th, Order No. 526, C. A. Boice, Councilor
Expenses 18.35
May 15th, Order No. 527, Thos. F. Duhigg, Com. on
Public Policy and Legislation 46.55
May 15th, Order No. 52 8, C. A. Boice, Expenses Asst.
Editor and Advertising Manager 54.60
May 15th, Order No. 529, Woodford and Ainsworth,
Programs and Badges 37.00
May 15th, Order No. 53 0, J. W. Osborn, Sec’y Salary
and Expenses for year 745.03
May 15th, Order No. 531, Plymouth Cong. Church,
Rent for meeting of 1913 75.00
May 15th, Order No. 532, G. E. Crawford, Councilor
Expenses 3.80
May 15th, Order No. 533, H. C. Eschbach, Councilor
Expenses 2.75
May 15th, Order No. 534, W. B. Small, Treas. Salary
and Expenses 194.95
May 16th, The Press Co., Washington, Iowa, Printing
Journal for April 260.36
June 3rd. Order No. 535, Thos. F. Duhigg, Registrars,
Placards, Banners, Lantern, Operator & Ice .... 41.15
June 3 0th, Order No. 53 6, The Press Co., Washington,
la., Printing Journal for May, cuts and expenses. . 210.60
July 22nd, Order No, 53 7, Blaise & Blaise, Reporting
Session Transcribing Proceedings, etc. 83.60
August 1st, Order No. 53 8, The Press Co., Washington,
la,, Printing Journal for June 206,31
September 10th, Order No. 539, D. S. Fairchild, Edi- tor’s Salary for April, May and June 375.00
September 10th. Order No. 54 0, H. G. Langworthy,
Expenses Com. on Contract and Lodge Practice. . 6,25
September 10th, Order No. 541, Wade, Dutcher &
Davis, Medico-Legal Services for April, May and
June 368.53
September 20th, Order No. 542, J. W. Osborn, Sec’y.
Salary and Expenses for quarter 198.13
September 2 6th, Order No. 543, The Press Co., Wash- ington, la., Printing Journal for July and August. . 361.62
October 21st, Order No. 544, The Press Co., Wash- ington, la., Printing Journal for September.... 180.81
October 21st, Order No. 54 5, D. S. Fairchild, Editor,
Salary for July, August and September.. 375.00
November 6th, Order No. 546, Wade Dutcher & Davis Medico-Legal services for July August and Septem- ber 371.40
Dec. 15th, Order No. 547, The Press Co., Washington,
la., printing Journal for October and November. . 300.32
1914.
January 7th, Order No. 548, A. E. Cook, Medico-
Legal services 2 0.00
January 9th, Order No. 549, The Press Co., Wash- ington, la., printing Journal for December 181.36
January 14th, Order No. 550, J. W. Osborn, Sec’y and
Expenses 2nd quarter 186.95
January 14th, Order No. 551, C. A. Boice, Commission
TRANSACTIONS, 1914 65
on Advertising secured 255.92
February 7th, Order No. 552, Wade, Dutcher & Davis,
Medico-Legal services for October, November and
December 928.98
February 11th, Order No. 553, D. S. Fairchild, Editor
Salary for October, November and December. . . . 375.00
February 24th, Order No. 5 54, The Press Co., Wash- ington, la., printing Journal for January 151.66
March 10th, Order No. 555, The Press Co., Washing- ton, Iowa, printing Journal for February 203.9 8
March 10th, Order No. 5 56, H. P. Wagner, Medico-
Legal Services 3 20.00
April 14th, Order No. 557, D. S. Fairchild, Editor,
Salary for January, February and March 375.00
April 24th, Order No. 558, The Press Co., Washington,
la., Journal for March 197.36
April 29th, Order No. 559, Wolfe & Wolfe, Medico-
Legal services i 87.95
April 2 9th, Order No. 560, Wade, Dutcher & Davis,
Medico-Legal services for January, February and
March 618.36
May 15th, Wm. Jepson by donation, , $ 10.00
April 18th, P. B, McLaughlin, by fee exhibit
space, Sioux City meeting 25.00
April 30th, Interest for the year , , . 109,78
April 30th, D. S. Fairchild, Editor, by receipts of
Journal 793.42
April 30th, Membership dues for the year 7607.64
April 30th, Disbursements for the year 8439.89
April 30th, Balance on hand * 4562.52
1
$13002.41 $13002.41
Journal Statement,
Monies received from D. S. Fairchild, Editor Journal
from May 1st, 1913, to May 1st, 1914 $ 793.42
May 1, 1913, to May 1, 1914 Subscription receipts. . . .1859.00 Expenses of Journal from May 1, 1913 to May 1, 1914 3804.70
Difference between receipts and expenditures 1152.2 8
$3804.70 $3804.70
Medico-Legal Fund Statement.
May 1st, 1913, Overdraft $ 378.82
Medico-Legal expenses from May 1st, 1913, to May
1st 1914 2715.22
Medico-Legal Fund receipts from May 1st, 1913
to May 1st 1914 . 3832.00
May 1st, 1914, balance on hand 737.96
$3832.00 $3832.00
To whom it may concern:
I hereby certify that there is $4,562.52 on deposit in the Black Hawk National Bank in Waterloo, Iowa, to the credit of W. B. Small, Treasurer of the Iowa Statte Medical Society. H. E. RUGG,
Asst. Cashier.
66
JOURNAL OP IOWA STATE MEDICAL SOCIETY
The report of the Council was read by Dr. Boice, and upon motion of Dr. Osborn was received and placed on file.
Report of the Council.
First District, C. A. Boice, Councilor:
Seven counties in this district report 121 members, with an eligible list of 2 2 0. Interest is reported good in two counties, fair in three, poor in two. Louisa county seems to be unable to get together and stay.
Second District, D. N. Loose, Councilor :
Five counties report 150 members, with 194 eligible. Average at- tendance of all 86. Three counties report good interest, one fair and one increasing.
Fourth District, Paul E. Gardner, acting Councilor:
Ten counties report 120 members, with 183 eligible, and an average attendance of 51. Two counties report good interest, four fair, four poor.
Fifth District, G. E. Crawford, Councilor:
Seven counties report 193 members, with 279 eligible. Average at- tendance 12 8. Lynn county reports 77 members, and an average attend- ance of 85. In this county the interest is excellent. The other counties re- port poor interest.
Sixth District, H. C. Eschbach, Councilor:
Seven counties report 155 members, with 222 eligible. Average at- tendance, 74. Interest is reported good in two counties, fair in five.
Seventh District, J. W. Cokenower, Councilor:
All together, conditions, are improved over previous years. Interest extra good in two counties, good in two, better in one, poor in one. Five* counties, Madison, Marion, Polk, Story and Warren, report 214 members. Dallas county reports with Guthrie county in the Ninth District.
Eighth District, T. M. Throckmorton, Councilor:
Ten counties report 148 members, with 2 46 eligibles. Interest is good in seven counties, fair in two, poor in one.
Ninth District, A. L. Brooks, Councilor.
Six counties in this district report 109 members, with 149 eligibles. Interest good in two counties, fair in the balance.
Tenth District, M. J. Kenefick, Councilor.
Twelve counties reporting with an eligible list of 261, with a present membership of 178, and an average attendance altogether of 113. Inter- est is reported good in four counties, and fair in the other eight.
Eleventh District, G. C. Moorehead, Councilor.
The condition of the district this year is fairly satisfactory. Of the counties reporting, there are 192 eligible physicians, of these 132 were members last year. There has been a net increase of five, making the present membership 137. These societies have arranged four meetings a year, with an average attendance of seven at each meeting. But two deaths are reported. The reports show but little interest manifested at Society meetings, in nearly all the counties. Last fall I attended meetings at Rock Rapids, and Cherokee. Both these meetings were well attended, and reports and papers of much scientific interest were presented show- ing that there is no lack of ability to furnish instruction and entertain-
TRANSACTIONS, 1914
67
ment. The one thing that seems to deaden interest, in Society work, is the strenuous work demanded by the public to maintain better offices, supply new equipment, and meet the general increase cost of doing busi- ness.
Summary.
The report of all the districts except the Third shows an eligible list of 2163, with a present membership of 1594. Conditions in general vary but little from reports of former years. The Council again calls general attention to the often proven fact that as is the Secretary, so is the Society. Practically always is it the case where the Secretary is alive to his responsibilities and opportunities, the Society is interested and the meeting instructive. Many Societies have the bad custom of rotat- ing officers every year. Others fail to oust the Secretary who has proven neglectful. A good Secretary, when found, should be sentenced to his term of office for life.
Dr. Boice next read the report on Necrology.
Necrology report 1913-1914.
Since May 1st, 1913, the deaths of the following members of the Iowa State Medical Society have been reported to the Committee on Ne- crology.
Dr. T. H. Heffernan, Dubuque, May 7th, 1913.
Dr. A. L. Wright, Carroll, July 19th, 1913.
Dr. Ira K. Gardner, New Hampton, November 4th, 1913.
Dr. Lyman Hall, Springhill, December 4th, 1913.
Dr. W. W. Kerlin, Storm Lake, December 10th, 1913.
Dr. W, J. Bradley, Cedar Rapids, October 2nd, 1913.
Dr. E. M. Heflin, Calmar, December 20th, 1913.
Dr. E. C. Stanley, Des Moines, January 2, 1913.
*Dr. S. S. Lytle, Iowa City,