. U3RARY . . MARYLAND,/

BALTIMORE

MISSISSIPPI DOCTOP

Volume 23 - 24

1943 - 1947

VOL. 23

Mississippi Doctor

BOONEVILLE, MISSISSIPPI,. JI>NE,'. 1945 NO. 1

Tolerance

The most lovable and livable quality that any human being can possess is tolerance. Tolerance is the vision that enables us to see things from another’s point of view. It is the generosity of spirit that concedes to others the right to their own opinion and individual- ity. It is the breadth of mind that enables us to want those whom we love and respect to be happy in their own way and not in our way.

AO TILLYER

WITH “THE FRINGE ON TOP

Vue BIFOCALS

A “surrey with a fringe, oh t,op” is' a pleasUM,r< ‘nostalgic sight, but color fringes have no place when reading through bifocal segments — either top or bottom. Ful-Vue Bifocals are so designed that vision through them is not affected by annoying color fringes. This color reduction feature is accomplished in most Ful-Vue Bifocal seg-

c c r c C c t c

ments through the Use of Barium glass— in nigh minus corrections through the use of dense flint glass in the segments;

To give your patients full satisfaction, prescribe Tilly er Ful-Vue Bifocals for maximum comfort. Ask your American Optical representative for demonstration.

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Fulminating Abdominal Catastrophes*

GEORGE H. MARTIN, M.D. and AUGUSTUS STREET, M.D., F.A.C.S.

Vicksburg, Miss.

The title of this paper was selected in hopes of conveying to the mind of the reader a picture of the sudden, severe, and often overwhelming conditions that may oc- cur in the abdomen.

In no other field of surgery is there such a demand for quick thinking and sound judg- ment as is encountered in the so-called acute abdomen. Here is truly a surgical emergency requiring that we strive for the utmost in diagnostic acumen and the ultra in surgical judgment. Although a final diagnosis cannot be made until the abdomen is opened one must always attempt to obtain an accurate pre- operative impression for upon such is based the rational approach to the surgical prob- lem.9 Once a correct diagnosis is made the well trained surgeon has little difficulty in adequately treating a patient with acute ab- dominal manifestations.

Conditions which may produce a fulminating acute abdomen may be classified as follows:7 1) inflammation; 2) obstruction; 3) perfora- tion; 4) hemorrhage; and 5) trauma.

INFLAMMATION

Appendicitis — The most frequent cause for an acute abdomen is of course appendicitis. The usual syndrome of pain beginning around the umbilicus, radiating to the right lower quad- ran'; to become localized beneath McBurney’s point, together with nausea, vomiting, rigidity in the right side, moderate leukocytosis, and low grade fever is familiar to us all and needs no further discussion at this time. 2

We are interested however in the ruptured appendix and the ruptured appendiceal ab- scess, for here a relatively simple surgical problem of the acute appendix has been con- verted into a serious surgical emergency with a high mortality rate. The usual picture of a ruptured appendix following an acute in- f’ammatory appendicitis which has been neg- lected or abused by the giving of cathartics need give no great concern in the differential diagnosis, but there is one type of appendicitis which is especially treacherous. This is ob-

*From the Surgical Section of The Street Clinic, Vicksburg-, Mississippi. Read before Central Medical Society Annual Meeting-, Jackson, Mississippi De- cember, 1944.

structive appendicitis. In this condition the typical syndrome is not present. The patient may complain only of colicky pain which may not be severe. There may or may not be nau- sea or vomiting. The leukocyte count may be perfectly normal. There is little or no peri- toneal irritation and usually no rigidity. In spite of a lack of warning signs perforation usually occurs early due to the obstructive nature of the condition and rupture occurs into a virgin peritoneal cavity which has not become walled off by inflammatory exudate about the appendix. The picture is one of a sudden spreading peritonitis with few local- izing signs. One is then faced with the prob- lem of dealing with a generalized peritonitis rather than a local disease of the appendix which would have been easily relieved earlier by appendectomy.

The sudden intraperitoneal rupture of an appendiceal abscess can of course give a very similar picture to the above. Here there are the usual findings of an appendiceal abscess with tenderness and rigidity together with the presence of a mass in the right lower quad- rant with, evidence of localized peritonitis. If there is rupture of this abscess with extension info the general peritoneal cavity, generalized peritonitis results. The differential diagnosis should not cause a great deal of difficulty, but the diagnosis can be aided by doing a rectal examination. The presence of a mass in the right lower quadrant on rectal examina- tion together with fullness, induration and possible softening in the cul-de-sac points to- ward the diagnosis of ruptured appendiceal abscess.

Salpingitis — Occasionally acute salpingitis complicated by rupture of a tubo-ovarion ab- scess may cause confusion in differentiating it from an appendiceal abscess. However, the pain is usually localized in the pelvis, the leukocyte count is higher than in appendi- citis, and the febrile reaction is usually much higher in the earlier stages than in appendi- ceal complications. A careful pelvic examina- tion will usually reveal the difference in the two conditions. A tender palpable mass at- tached to the right side of the uterus in the region of the broad ligament is usually in- dicative of a tubo-ovarian abscess.

333

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Cholecystitis — Infectious cholecystitis with- out obstruction is usually of insidious onset and does not constitute an acute abdominal emergency as it is relatively free from the danger of rupture. On the other hand the acute obstructive type of cholecystitis is an emergency and 95 per cent of all gangrene and perforations occur in the acutely infected and obstructed gallbladder.1 A patient with acute obstructive cholecystitis usually presents a history of a rather sudden onset of colicky pain in the upper right quadrant which later becomes more severe and constant and may be referred to the interscapular region of the back. Nausea is rather severe with marked vomiting. There may be a history of previous gallbladder colic with or without jaundice. When perforation occurs there is a sudden flooding of the peritoneal cavity with infected bile, which at first produces a chemical peri- tonitis followed in eight to twelve hours by a bacterial peritonitis. Examination usually reveals the patient in shock or semi-shock. The skin is cold and clammy, the pulse is rapid and the blood pressure low. Jaundice may or may not be present. There is board-like rigid- ity of the abdomen and a mass can often be palpated in the upper right quadrant un- less it is obscured by rigidity or obesity. Dis- tention may be present if ileus has occurred from the peritonitis. Operation of course is im- perative but should be delayed until some restitution has been accomplished by the giv- ing of glucose together with plasma or blood.

Acute Pancreatitis — Acute pancreatitis is an infrequent cause of acute abdominal disease, being responsible for less than 1 per cent of cases.1 This may mimic the findings of perfor- ated gastric or duodenal ulcers, gangrenous and perforated cholecystitis and those of intestinal obstruction. Pathologically it may present an acute pancreatic edema, acute pancreatic ne- crosis, acute hemorrhagic pancreatitis and pancreatic abscesses, which are all phases of the same process. In general these patients might suggest a ruptured peptic ulcer, but they lack the board-like rigidity. They might suggest an acute gallbladder except for the fact that they are too ill, or an acute throm- bosis but for the normal pulse rate and blood pressure. Certain types of strangulated ob- structions might make differential diagnoses difficult as acute pancreatitis must also be ac- companied by a silent abdomen.13 The usual history is a sudden acute onset of severe epi- gastric pain accompanied by nausea and per-

sistent vomiting. The vomiting is usually so severe that it is not alleviated by morphine or by gastric suction as is the usual case of ruptured peptic ulcer. In the early stages the patient may have no fever, a normal blood pressure, and a slow pulse. Tenderness in the epigastrium may be very slight in the early stages. Recently interest has been shown in regard to x-ray diagnoses of acute pancreatitis. The x-ray findings suggestive of acute pan- creatitis consist of: (1) tender tumefaction of the pancreas found during fluoroscopy, (2) changes in the stomach and duodenum, and (3) evidence of localized or generalized ileus.13 The spot film may show some widening of the region between the gas bubble in the stomach and the gas in the tranverse colon. Pathognom- onic consideration is a loss or flattening of the greater curvature of the stomach found on fluoroscopy after digestion of barium. This is caused by displacement of the stomach due to edema or hemorrhagic cysts of the pancreas. Until recent years acute pancreatitis was con- sidered an indication for immediate operation, the indications being to relieve tension, to stop hemorrhage and leakage and to afford drain- age. At the present time most writers contend that the operation is best deferred until the acute pancreatic symptoms subside, however due to the difficulty of correctly diagnosing the condition there probably would be many ruptured peptic ulcers diagnosed as acute pancreatitis by the average surgeon and hence delay would in the majority of cases mean the death of the patient.19

Diverticulitis — Diverticulitis usually occurs in one of two locations, either in the small in- testines as an inflammation of a Meckel’s di- verticulum, or in the descending or sigmoid colon from inflammation of diverticulae in this region. Meckel’s diverticulitis may mani- fest itself in two ways, either as massive hemorrhage most often seen in children, or as a diverticulitis which mimics a midline or left sided appendicitis.11 A Meckel’s diverti- culum is usually lined with gastric mucosa in which a peptic ulcer may occur resulting in either perforation or hemorrhage. Massive rec- tal hemorrhage occurring in infants and chil- dren in which other causes of bleeding have been ruled out should be subjected to a laparo- tomy in view of finding a Meckel’s diverticulum from which hemorrhage is occurring.

Acute Meckel’s diverticulitis usually cannot be distinguished from acute appendicitis except

June, 1945

Abdominal Catastrophes — Martin and Street

335

by its location and most often must be proved by laparotomy.

Diverticulae of the colon may occur in any part, however, 60 to 85 per cent are found in the descending colon and sigmoid.is It is in this area that almost all of the complications re- quiring operative intervention rise. The most serious but least frequent complication of di- verticulitis is a sudden perforation into the peritoneal cavity causing generalized periton- itis. This is rare however, perforation and ab- scess formation being much more common, be- cause peridivertitulitis usually walls off the impending perforation by fixation of the sur- rounding viscera to the inflammatory area.

OBSTRUCTION

Intestinal Obstruction — Intestinal obstruc- tion can be primarily divided into two classes: large bowel and small bowel. Large bowel ob- struction is usually insidious in onset and characterized by increasing constipation and gradually increasing distention. Nausea, vomit- ing and even pain may be late manifestations. The most common etiological factors are car- cinoma and inflammation. The diagnosis is usually relatively simple. The x-ray findings to- gether with a careful digital and sigmoido- scopic examination will usually cinch the diag- nosis. There is one condition however which produces an acute abdominal emergency. This is volvulus of the sigmoid. In this condition there is an abnormally long sigmoidal loop with a long mesentery. A sudden twisting of the bowel upon itself produces a complete ob- struction of the closed loop variety with rapid embarrassment of the blood supply. In addition to the usual findings of large gut obstruction, the x-ray is quite characteristic showing a localized enormously distended sigmoid. Early operation is imperative to prevent gangrene and perforation.

Small bowel obstruction may be divided into two etiological factors, (1) intrinsic and (2) extrinsic. The intrinsic causes of intestinal ob- struction are usually due to foreign bodies such as gall stones, hair balls, persimmon be- zoars or boluses of worms in children.! o Ob- struction may be also caused by tumors aris- ing from the bowel wall but this is relatively rare in small intestines.

The extrinsic causes of small bowel ob- struction are much more important and are usually due either to hernia or adhesions. In- carcerated or strangulated hernias are the most frequent causes of intestinal obstruction

and may fee of two types, either external or internal. The diagnosis of intestinal ob- struction from external hernia is usually ob- vious either from the history or from the phy- sical findings of a hard indurated mass in either the inguinal, femoral or ventral regions. However, there is one type of particular im- portance and this is a Richter’s hernia usually of the femoral variety. 5 Here only part of the wall of the bowel is caught in the hernia. The obstruction is incomplete and the symptoms are usually of mild character and unless a careful examination of the hernial orifice is done the diagnosis may not become apparent until the perforation and peritonitis has oc- curred.

Internal hernias present an entirely different problem and are probably one of the most difficult diagnoses to make in the acute ab- domen. Fortunately this condition is rare but should be kept in mind when making a differ- ential diagnosis. The most common causes for internal hernia are herniation in the region of the paracecal fossa, the paraduodenal fossa, rent in the mesentery! or omentum and dia- phragmatic hernia. The patient with an inter- nal hernia may complain of vague pains and discomfort for a varying length of time until there is a sudden twisting or incarceration of the hernial mass. When this .occurs the ef- fects are disastrous because of the large a- mount of bowel involved in the hernia. The sudden disturbance to the blood supply of this long length of bowel produces a truly fulmi- nating abdominal catastrophe. These patients usually complain of severe abdominal pain which is followed in a short time by marked shock. Thrombosis of the mesenteric vessels occurs relatively early unless operative reduc- tion is accomplished. The diagnosis is par- ticularly difficult but is characterized by se- vere colicky pain, marked shock with rapid distention followed by rigidity and signs of peritonitis as thrombosis with gangrene pro- gresses. There may be vomiting of blood or bloody mucus in the stool. The blood count is usually normal until the later stages of peritonitis occur. An erect x-ray plate of the abdomen shows distention and fluid levels. Unless operation is done early the prognosis is usually hopeless.

Adhesions have long been known as a com- mon cause of intestinal obstruction and most often follow operations in which infection was a factor, but may also be due to faulty sur- gical technic. The failure to reperitonealize raw surfaces or properly close the peritoneum

T33:

336 Abdominal Catastrophes

O j- ; ; -i-J * ' - X~ - ■ ■ .

;.rj of the wound may result in adhesions. The picture of intestinal obstruction occurring in a patient with an abdominal scar and a history of peritonitis or a wound infection will most often be found to be due to adhesions.

Intussusception — Intussusception is charac- terized by certain findings which make the diagnosis relatively easy, mainly age incidents, bloody stools, and a palpable mass.3 It occurs most often in children under two years of age, usually between the ages of three and nine months. The onset is sudden and consists of severe cramping pains which cause the child to double up and scream with agony. This is followed by a remission in which the patient may even go tb sleep. One or two hours after onset the child begins passing bloody mucus in the stools and the tumor can be felt along the course of the colon. Distention and persistent vomiting occur relatively late. In question- able cases a barium enema under fluoroscopic observation will prove the diagnosis. Rarely intussusception occurs in adults with tumors of the bowel wall.

Volvulus — Volvulus of the intestinal tract fortunately is a rare occurrence. It may oc- cur at any age period from the newborn to the aged. Volvulus occurring in the early dec- ades of life is usually based on congenital de- fects such as failure of rotation of the intes- tines or incomplete fixation of the mesentery. Volvulus of the small intestine or cecum oc- curs most often in children while volvulus of the sigmoid occurs in the older age groups. Ob- struction of the small intestine by volvulus gives rise usually to copious and frequent vom- iting. The presence of a mass in the mid abdo- men accompanied by signs of intestinal obstruc. tion attended by tenderness should suggest the possibility of volvulus. 20 The scout x-ray film is usually of great value in revealing a markedly distended loop of bowel compatible with obstruction of the closed loop variety.

In general the diagnosis of intestinal ob- struction is based upon one or more of the fol- lowing findings. Colicky abdominal pain accom- panied by hyperhyperistaltic rushes, nausea, vomiting, obstipation, and distention, together with an absence of fever and leukocytosis in the early stages, and accompanied by x-ray evidence of fluid levels and gaseous distention. When confronted with evidence of intestinal obstruction it is well to remember, that in children intussusception is the most common cause. In the middle ages hernia and ad- hesion are most frequent and in older pa-

. SjZIjT..

—Martin and Street June, 1945

tients carcinoma is usually the etiological fac- tor.

Mesenteric Thrombosis — Mesenteric throm- bosis and embolism are rarely recognized pre- operatively. The important thing to recognize is that a serious surgical lesion is present that demands opening the abdomen. It occurs most often in persons between the age-s of 30 and 75 in whom there i§r,a history of myocarditis, endocarditis,.- pr arteriosclerosis. The superior mesenteric artery is most frequently involved, rarely the inferior mesenteric. The usual mani- festations of disease are the sudden onset of severe acute abdominal pain, vomiting, and diarrhea. The stools and vomitus occasionally contain blood. Shock is generally manifested and the pulse is frequently rapid and irregu- lar.i6 The temperature is normal or subnormal but occasionally there is fever even in the early stages. Distention of the abdomen is progressive though not extreme. An abdominal tumor may be observed in a small percentage of cases. The pain is distinguished from that of intestinal obstruction in that it is not colicky in type but is continuous and severe.

Twisted Ovarian Cyst — An ovarian cyst whose pedicle becomes twisted is character- ized by an abrupt onset of violent abdominal pain accompanied by nausea and vomiting to- gether with evidence of shock. The shock is caused by the excruciating pain. The abdomi- nal wall becomes rigid and tender and often a tumor can be seen in the pelvic region which increases in size. The diagnosis is aided by feeling an exquisitely tender cystic mass on bimanual palpation.

PERFORATION

Perforated Gastric and Duodenal Ulcers — The patient with a ruptured peptic ulcer will often give a history compatible with a gastric or duodenal ulcer, however occasionally rup- ture takes place in patients with a so-called silent ulcer without any prodromal symptoms. The onset is abrupt and is sometimes accom- panied by a history of trauma to the epigas- trium, sudden straining or lifting of a heavy object. The pain is excruciating and is at first confined to the pyloric region of the stomach but later spreads toward the right lower quad- rant as the acid gastric chyme flows down the right colic gutter. Later the pain becomes generalized all over the abdomen and is ac- companied by board-like rigidity, nausea, and persistent vomiting. Shock may be present in varying degrees. The patient is usually found

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lying perfectly still on the left side with the thighs flexed on the abdomen. He objects to being moved as he is in excruciating pain. This is in contradistinction to the patient with a urinary colic who rolls and writhes with his pain. In the early stages the temperature is normal or subnormal and there is no leuko- cytosis present. The diagnosis is confined by finding air under the diaphragm in the erect plate of the abdomen. If the patient is too ill to sit up an AP view taken in the left lateral decubitus position will reveal air between the right lobe of the liver and the right costal margin.

Typhoid Ulcer — Perforation of typhoid ulcer is by far the most important, the most dread- ed, the most fatal complication fever. In the majority of instances it occurs during the third week in the severe cases, particularly with those associated with diarrhea, distention, and hemorrhage. The most common site of per- foration is the lower portion of the ilium. As a rule it is single, but may be multiple. The most important single symptom is a sudden sharp pain referred to the right lower quad- rant. Shortly after the onset of pain a de- cided change is observed in the condition of the patient. There is nausea, vomiting, and increase in the pulse rate and the temperature falls to be followed by a rise. There is local rigidity of the abdominal muscles, particularly near the site of perforation, and after a short period the entire abdomen becomes markedly rigid. If gas escapes into the abdominal cavity the liver dullness becomes obliterated and pneumoperitoneum may be demonstrated by x-ray. In a patient presenting symptoms of such a lesion it is much better to advise an exploratory laparotomy rather than to delay too long for the development of a perfectly typical picture. Even under the most favor- able conditions the mortality is exceptionally high.

HEMORRHAGE

Bleeding Ulcers — Hemorrhage from a peptic ulcer requiring surgical intervention occurs usually in patients past forty years of age in whom arteriosclerosis is a factor. Bleeding in younger patients usually responds to con- servative treatment. When massive hemor- rhage occurs these patients vomit copious amounts of blood and pass frequent massive tarry stools. Shock is often severe but is de- pendent on the amount of blood loss. Anemia is apparent as paleness of the mucous mem-

branes, colorless nail beds, and a marked drop in the red cell count. The diagnosis is not often difficult as the patient usually gives a history of peptic ulcer, often with previous hemor- rhages. In the differential diagnosis rupture of an esophageal varix would have to be con- sidered but these patients usually have other findings compatible with cirrhosis of the liver.

Ruptured Extrauterine Pregnancy — Rupture of an extrauterine pregnancy is usually pre- ceded with the history of missing one or two periods followed by a slight spotting of vaginal blood. With the onset of rupture the patient often complains of a desire to void or defecate and may often go to the bathroom and faint. As the hemorrhage progresses the patient pre- sents all the signs and symptoms of acute blood loss accompanied by shock, paleness, rapid thready pulse, cold clammy skin and evi- dence of severe anemia. There is pain in the lower abdomen with tenderness over the pelvic region. There may be pain referred to the shoulder region. Vaginal examinations wiil usually reveal moderate softening of the cer- vix with other early signs of pregnancy such as increased blueness of the vaginal wall and softening of the lower uterine segment. The uterus may be slightly enlarged. There is of- ten a bloody flow from the cervix, sometimes with passage of clots or decidual membrane. Palpation reveals marked tenderness on man- ipulation of the uterus, the mass may be palpated in one of the adnexa which is ex- quisitely tender, and the cul-de-sac is often tender and bulging. In cases where the diag- nosis is not clear further information may be obtained during a vaginal examination under anesthesia. At this time an adnexal mass which has previously been missed because of abdominal pain and rigidity can often be felt when relaxation occurs under anesthesia. The diagnosis can often be aided by doing a cul- de-sac puncture with an aspirating needle. If bright red blood is obtained the diagnosis is confirmed.

TRAUMA

Traumatic Injuries to the Abdomen — Trau- matic injuries to the abdomen must primarily be divided into penetrating and non-penetrat- ing. If a penetrating open wound of the ab- domen is present then one must decide whether the injury is extra-peritoneal or intra-peri- toneal. If extra-peritoneal injury is present the prognosis is good and the treatment con- sists only of local treatment of the wound.2!-1 6

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Abdominall Catastrophes — Martin and Street

June, 1945

However, if penetration of the peritoneal cavi- ty has occurred then exploratory laparotomy is almost always indicated. is In attempting to determine whether a wound has penetrated the peritoneal cavity or not, several procedures may be helpful, the simplest probably is direct surgical exploration of the wound to determine whether the peritoneum has been injured. If the wound has been caused by a bullet, the x-ray is of value if there is no through and through wound. If a point of entrance is pres- ent but no point of exit, the x-ray or fluoro- scope will reveal the site of the missile and allow some speculation as to the possible course of the bullet and the viscera injured. An erect plate of the abdomen will also reveal the presence of air under the diaphragm if there has been rupture of the hollow viscera. Generalized abdominal tenderness, rigidity, marked shock or evidence of blood loss are usually indicative of intra-abdominal injury. Of course, if evisceration is present the diagnosis is obvious.

Non-penetrating or blunt trauma to the ab- domen presents a more difficult diagnostic problem. A decision must be made as to whether there is an intra-abdominal ruptured viscus or hemorrhage from torn mesenteric vessels. If intra-abdominal injury is present these patients usually complain of severe ab- dominal pain. Tenderness and rigidity is usual- ly marked and shock is often the predominat- ing symptom. There may be vomiting of blood or passage of blood per rectum if the intestine is injured.17 Trauma to the kidney or bladder is usually manifested in the form of hema- turia. The erect x-ray plate of the abdomen may reveal air under the diaphragm if there has been rupture of a gas-filled hollow vis- cus.1 4 Rupture of the spleen is characterized by marked pain in the left upper quadrant and tenderness over the twelfth rib posteriorly. Shock is usually severe and there may be shifting dullness in the abdomen indicative of a blood-filled peritoneal cavity. Rupture of the liver usually produces a similar picture but the most marked findings are confined to the right upper quadrant. Rupture of the intestines is usually characterized by vomiting of blood or passing of blood in the feces together with evidence of early peritonitis and marked ten- derness and rigidity. Rupture of the bladder is characterized by hematuria and may be con- firmed by the injection of sodium iodide into the’ bladder and the taking of an x-ray pic- ture. If there is any reasonable doubt as to

whether there is intra-abdominal injury or not the best policy is probably to explore the ab- domen rather than wait for more definite signs to appear.

EXTRA-ABDOMINAL CONDITIONS

Certain extra-abdominal conditions may so closely simulate symptoms of the acute ab- domen that often an accurate diagnosis is al- most impossible, however, a carefully taken history and a complete physical examination will usually lead one toward the correct diag- nosis.

Coronary Occlusion — Coronary disease is particularly likely to be confused with upper abdominal lesions such as cholecystitis, per- forated peptic ulcer and pancreatitis in that it may manifest itself as severe abdominal pain, nausea, vomiting, fever and leukocytos- is.15 A careful examination however usually will reveal evidence of coronary disease to- gether with the fact that rigidity is usually slight or absent and there is no increase in pain on making pressure over the affected area in the abdomen. Signs of peritoneal irritation are absent in that there is no rebound tender- ness or referred pain.

Pulmonary Conditions — Early pneumonia is often confused with acute intra-abdominal con- ditions, however, a careful examination of the chest will reveal a true diagnosis together with the fact that leukocytosis is marked, the febrile reaction greater, and there is a lack of peritoneal irritation.

Spontaneous pneumothorax may occasional- ly cause confusion but in this condition there is a normal temperature, the leukocyte count is not elevated and the typical chest findings together with an x-ray picture should lead to the correct diagnosis.

Renal lesions, especially those of the right side, are often confused with appendicitis. Renal infection with fever, leukocytosis and pain in the right side is often confused with a suppurative appendix. However, the pain is usually posterior over the twelfth rib and the finding of pus on urinalysis should avoid confusion. Renal colic may simulate an acute abdominal condition but the fact that the pain radiates down the loin toward the testicle together with the findings of red blood cells and hemoglobin in the urine should aid in the differential diagnosis. Often a flat x-ray of the genito-urinary tract will reveal the presence of calculi. Trauma to the kidney must often be distinguished from intra-ab-

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dominal injuries. Since renal trauma is often treated conservatively it must be differentiat- ed from intraperitoneal lesions which require a laparotomy. Characteristic findings are gross hematuria together with fullness and tenderness in the costo-vertebral angle.

Cerebrospinal — Certain diseases of the cere- brospinal system often cause confusion with acute abdominal diseases. The gastric crisis of tabes dorsalis may seem to counterfeit the acute abdomen. However, shock is absent, the temperature does not rise, the pulse may in- crease in frequency but the volume remains good and possibly most important, the ab- dominal wall is not rigid in the intervals of pain of a gastric crisis. A careful investiga- tion of the pupillary and tendon reflexes will facilitate the making of a correct diganosis.

SUMMARY

Some of the more frequent causes

of abdominal catastrophe have been dis- cussed under the heading of inflammation, ob- struction, perforation, hemorrhage and trau- ma together with the more common extra-ab- dominal conditions which simulate the acute abdomen. Points in the differential diagnosis have been stressed and laboratory aids in diag- nosis presented.

COMMENT

It is granted that often an exact

diagnosis can not be made. One must decide however whether an acute abdomen exists and if laparotomy is indicated. Only through a rational consideration of the differential diag- nosis can an intelligent decision be made and the proper surgical procedure planned.

BIBLIOGRAPHY

1. Abell, Irvin: Acute Abdominal Emergencies,

Southern Medical Journal. 31:39. 1938.

2. Adams, William E., and Olney, Mary M. : Mesen- teric Lymphadenitis and the Acute Abdomen, Report of Thirteen Cases, Annals of Surgery, 107:395, .938.

3. Cope, Zachery: The Early Diagnosis of the Acute Abdomen, Oxford University Press, 1937.

4. Cutler, George D., and Scott, H. William: Trans- mesenteric Hernia, Surgery, Gynecology7 and Ob- stetrics, 79:509, .944.

5. Eliason, Eldridge, L : Early Diagnosis in Ab- dominal Surgery, American Journal of Surgery, 31:275, 1936.

6. Ficarra, Bernard J. : Mesenteric Vascular Occlu- sion, The American Journal of Surgery, 66:168, 1944.

7. Finney, J. M. T. : The Acute Abdomen, New Or- leans Medical and Surgical Journal, 87:589, 1935.

8. Gordon-Taylor, Gordon: The Problem of Surgery in Total War, Surgery. Gynecology and Obstet- rics, 74:375, 1942.

9. Gucrry, LeGrand: Surgical Judgment in the Ap- proach to the Acute Abdomen. Annals of Surgery, 98:922, 1933.

10. Kirby, F. J. : Early Recognition of Acute Abdomi- nal Diseases, Southern Medical Journal, 23:5.2, 1930.

11. Ladd, William E„ and Gross, Robert E. : Ab- dominal Surgery of Infancy and Childhood, W. B. Saunders Company, Philadelphia, 1941.

12. Mann. Bernard: Acute Surgical Conditions in the Abdomen in Gynecology, Medical Record, 132:26. 1930.

13. Metheny, David, Roberts, Edward W.. and Stran-

ahan, Allan: Acute Pancreatitis With Special

Reference to X-ray Diagnosis, Surgery. Gynecol- ogy and Obstetrics, 79:504, 1944.

14. Mulhollond, John H., Bailey, Fred W., and Storck.

Ambrose H. : Abdominal Traumas, Panel Dis-

cussion, International Abstract of Surgery, 73:- 299, 1941, (October).

15. Ochsner, Alton, and Murray, Samuel D. : Pitfalls in the Diagnosis of Acute Abdominal Conditions, American Journal of Surgery, 41:341, 1938.

16. Sherman, William O’Neill: Abdominal Injuries,

Surgery, Gynecology and Obstetrics, 58:507. 1934.

17. Storck. Ambrose H. : Diagnosis in Abdominal Trauma. American Journal of Surgery, 56:21, 1942.

18. Thompson, George F., and Fox. Paul F. : Per- forated Solitary Diverticulum of the Transverse Colon. The American Journal of Surgery, 66:280, 1944.

19. Vaughn. A. M. : The Acute Abdomen The Ameri- can Journal of Surgery, 47:602, 1940.

20. Wangensteen. Owen H. : Intestinal Obstruction,

Charles C. Thomas, Springfield, Illinois, 1942.

21. Wright, Louis T.. and Wilkinson, Robert S. : and Gaster, Joseph L. : Penetrating Stab Wounds of the Abdominal Wall. Surgery, 6:241. 1939.

The aardvark is an ant-eater of Africa — singular and queer in appearance and habit, a long, narrow head, a long tapering tail with- out hair. It burrows into an ant hill and comes out at night looking for a new and better hill where ants erect a village. It suckles its young. Its name means “earth pig.”

Nature is prolific in its species, a wonder- ment to mankind.

Penicillin and Its Use in Some Infected Surgical

Cases* v ,, ,

■i '

V. B. PHILPOT, M.D., F.A.C.S Tupelo, Miss.

To begin with, I think I am correct in stating that there has never been a drug in the history of medicine, certainly not in the last generation, which is so effective as a bacteriostatic agent on many important pathological bacteria as penicillin. In fact, dur- ing the last two years this agent has been discussed and written about more than all other remedial agents combined.

HISTORY

I shall not attempt to give you much his- tory concerning this new drug, but the fol- lowing brief review from an editorial in the British Medical Journal published last year may be interesting. It seems apparent that in 1877, Pasteur and! Joubert were the first to observe that cultures of anthrax ceased to grow when contaminated with air bacteria; and was the first observance, according to Florey, that a substance produced by one or- ganism is capable of arresting the growth of another.

Fleming of England, in 1929, may be con- sidered the latter day, or real, discoverer of penicillin by noting a conspicuous inhibition of growth in a colony of staphylococcus con- taminated by mold, he subcultured the mold in broth and found that a strong antibiotic, non- toxic to animals, passed into the broth from the mold. The mold was later identified by Thom in this country as Penicillium notatum, and Fleming designated the antibiotic agent “penicillin.” He found that penicillin inhibited the test tube growth of many gram positive bacteria known to be highly pathogenic to man. Fleming and his associates abandoned further study of the agent. It was used only for laboratory procedures, until 1941.

The clear-cut proof of the clinical useful- ness of this drug, its essay and dosage, as well as the mode of its excretion from the body, are credited to Howard Florey and his associates at Oxford, England, in 1938.

In this same issue lof the British Medical Journal , the editor also generously gives (credit to American pharmaceutical and biological

*Read at the quarterly meeting- of the Northeast Mississippi Thirteen Counties Medical Society, Colum- bus, Mississippi, March 13, 1945.

houses and their research workers in the large scale production of this drug.

DOSAGE

There is considerable difference of opinion concerning the dosage, amount of drug neces- sary, and mode of administration; but accord- ing to the opinion of a majority of those using this drug, as well as the experience of those having done research with it for many months, the drug is eliminated rapidly by the kidneys and it is necessary to adminis- ter it as often as every three hours either intravenously or intramuscularly; or, what is still more preferable, to give it intravenously in a continuous drip.

I think the experience of most users has been to give about 20,000 units every three hours, until the infection for which it is given is under control, or 100,000 units in a con- tinuous drip intravenously in thirty hours. Just how long the drug should be given to a patient depends on the area and virulence of the infection, and the length of time necessary to overcome this infection. Generally speak- ing, the time runs from thirty hours to eight or ten days, and the amount ranges from 100,000 to a million units.

In addition to the intravenous and intra- muscularly methods of administration, it is frequently given intrathoracically, intraspinal- ly, intra-articularly and applied locally. I have had no experience, however, with any method except the intravenous and intra- muscular methods of administration, it is scarcity of the drug in civilian practice.

SUSCEPTIBLE AND INSUSCEPTIBLE BACTERIA

There is a great group of bacteria suscep- tible to penicillin and another group insuscep- tible to this drug. The following table from an article by Herrell, Nichols and Heilman lists the susceptible and insusceptible ones: Susceptible Organisms Diplococcus pneumonia Streptococcus pyogenes Streptococcus salivarius Microaerophilic streptococci Staphylococcus aureus Staphylococcus albus (some strains)

340

June, 1945

Penicillin — Philpot

341

mn

&

<6T&$

>a.n fcjpow

Mm :L

3 V <;

i/3-

Neisseria gonorrhoeae Neisseria intracellularis i n Actinomyces bo vis

rtx bacillus anthraci>3

•~i bacillus anthracis

bacillus subtilis Clostridium botulinum Clostridium tetani Clostridium perfringens (welchii) Corynebacterium diphtheria^

Vibrio comma

J • cv; -

Micrococci

Streptobacillus moniliformis Borrelia novyi (spirochete of relapsing fever

Treponema pallidum Leptospira icterohaemorrhagiae Spirillum minus psittacosis virus Ornithodorus virus

Insusceptible Organisms Eberthella typhosa Salmonella paratyphi (Salmonella enteritidis Shigella dysenteriae Proteus vulgaris

Pseudomonas aeruginosa (bacillus pyo- cyaneus)

Pseudomonas fluorescens

Serratia marescens (bacillus prodigiosus)

dlebsiella pneumonia

Haemophilus influenzae

Escherichia coli

Staphylococcus albus (some strains) Micrococcus albus (some strains)

Monilia albicans Monila Candida Monilia krusei Blastomyces

Mycobacterium tuberculosis Streptococcus faecalis Brucella melitensis Plasmodium vivax Toxoplasma

USES IN CIVILIAN PRACTICE

afrrwt ' c,-*

No, in order that a little clearer conception may be given as to the uses of penicillin over sulfonamides, I shall quote from a paper by Francis G. Blake, New Haven, Connecticut, read at the American Medical Association, which I had the privilege of listening to last June:

The infections which are curable or, if not cured, favorably modified by the chemothera- peutic agents under discussion may be divided

three groups with respect to etiology:

..k* 1. Those in which both the sulfonamides

penicillin ' are more or less effective, 1 . > though no^' necessarily equally so, namely,

certain gram positive and gram negative coccic infections: hemolytic streptococcus-; * pneumo- ®ai ^cocfms, staplfylbcoccus, streptococcus-’-viridans, -^ffingoeoccus and gonococcus. rlr\r-

2. Those in which the sulfonamides are of value but not penicillin ; namely, gram nega- tive bacillary ' infections such as those caused by the colon bacillus, dysehtery bacilli, hemo- philus influenzae, Friedlander’s bacillus and Ducrey’s bacillus.

3. Those in which penicillin is of value but not the sulfonamides ; namely, syphilis, yaws and possibly other spirochetal infection and those due to the Clostridia — gas gangrene.

Blake also concludes that in the less severe hemolytic streptococcic infections in which there is tissue invasion without suppuration, necrosis or bacteremia, such as erysipelas or lymphangitis, the sulfonamides are ordinarily sufficiently effective to be indicated as the drug of choice, if for no other reason than because of simplicity of administration. The same may be said of the milder upper respira- tory mucous membrane infections, such as tonsillitis or pharyngitis, although the real value of the sulfonamides in these infections is still debatable.

In the more severe hemolytic streptococcic infections with suppuration or necrosis with or without bacterium penicillin appears to be much more effective and, consequently, the drug of choice. It often succeeds in bringing about a cure when the sulfonamides have failed . Included in this group are severe cellu- litis, mastoiditis with or without intracranial complications, meningits, pneumonia empyema, pericarditis, endocarditis, peritonitis, puerperal sepsis, osteomyelitis, suppurative arthritis and infected wounds.

Also in the two important gram negative coccic infections — meningococcic and gono- coccic-penicillin is far more effective, as well as in ophthalmia, endocarditis and prostatitis.

USES IN WARFARE

In the January 27 issue of the J.A.M.A. on the editorial page, is a brief review of a symposium on penicillin in warfare from the July, 1944, issue of the British Journal of Surgery. I now give you a review of this re- view from Major General L. T. Ross, Florey and Jennings, Lieut. Col. Jeffery, Lieut. Col.

342

Penicillin — Philpot

June, 1945

Bentley, Lieut. Col. Brown, Furlong and Clark, D’Abreu, Major Robinson, and Wise, Pillsbury and Mahoney, which briefly is as follows :

When a soldier is wounded, frequently long intervals elapse before definite surgical meas- ures can be taken. Penicillin is used to bridge this gap and delay and modify, or prevent, the development of sepsis, and is found to be the most powerful antibacterial agent yet brought into clinical use by completely in- hibiting the growth of the most sensitive or- ganisms by its bacteriostatic effect. It is the least harmful agent to the human organism yet discovered, and is used many ways; name- ly, intramuscularly, intravenously for its sys- temic effect, locally in the wound itself, intra- articularly, intraspinally and intrathoracical- ly — in other words, every way possible.

These officers found that the drug has three main spheres in war surgery: 1) to pre- vent infection of the wound soon after wound- ing, 2) to control infection in the first two weeks, and, 3) to combat sepsis in the later stages. It is also found that in a consecutive series of 22 casualties with flesh wounds treat- ed by early secondary suture with penicillin, primary healing was obtained in 95 per cent. That even gas gangrene mortality was cut to 36 per cent with the surgery and antiserum treatment, and as far as gonorrhea was con- cerned, they treated a thousand cases of sul- fonamide resistant gonorrhea with approxi- mately 95 per cent cure.

PERSONAL USE

One may easily presume that the personal experience in the use of penicillin with any one person in civilian practice in this area would not be very great, if for no other reason than because of the scarcity of the drug. We have had only enough of this agent to use in the very worst cases of infection.

I began using it exactly seven and one-half months ago and have since used it in thirty- six cases. Before I report any of these cases, I emphasize the necessity of proper surgical or other treatments necessary while penicillin is being used. We may get some results in in- fection with penicillin alone, but we will get far greater results if we do whatever else is necessary at the time.

For instance: In wounds, take care of the shock, the proper debridement, cleansing, hemostasis and suturing; in empyema and lung abscesses, the proper drainage and irri- gation of the cavities; in peritonitis and other abdominal abscesses, either local or general, the removal of foci of infection, drainage and the open air treatment of wounds as advo- cated by our own H. A. Gamble of Greenville.

In fact, when there is pus, the proper pro- cedure is to drain. In all cases proper syste- matic treatments — fluids, saline, glucose, blood transfusions and other adjuncts — should not be neglected.

The following is a brief report of the thirty- five cases I have treated, which includes the diagnosis, operation where necessary and end results of each case:

Name		Age	Final Diagnosis	Operation	End Results
J. A.	L.	67	Cholecystitis with Stones	Cholecystectomy	Recovery
K. M.	F.	2	Peritonitis from Ruptured Appendix	Incision and Drainage of Abdomen	Recovery
H. S.		26	Placenta Praevia with Hem- orrhage, Potentially Infected	Ceasarean Section	Recovery
A. S.		50	Carcinoma of Cecum — Poten- tially Infected	Resection of Cecum and Ascending Colon	Recovery
N. D.		13	Suppurative Appendicitis; Rup- tured	Appendectomy	Recovery
R. M.	D.	20	Suppurative Appendicitis; Left Inguinal Hernia	Appendectomy — Repair of Left Inguinal Hernia Recovery
W. T.	B.	67	Cystocele and Rectocele follow- ed by Hypostatic Pneumonia	Repair of Cystocele and Rectocele	Recovery
E. C.		34	Appendiceal Abscess with Gen- eral Peritonitis	Appendectomy — Drainage	Recovery

June, 1945

Penicillin — Philpot

343

L. C. S.	44	Intestinal Obstruction of Ilium	Liberating Obstruction —
		and Part of Duodenum	Enterostomy	Recovery
J. D. U.	56	Fractured Rib — Traumatic Pneumonia		Recovery
R. S. P.	15	Large Abscess of Appendix,	Appendectomy — Right Salpingo-
		Right Tube and Ovary; Rup- tured— Local Peritonitis	oophrectomy — Drainage	Recovery
J. E. P.	9	Suppurative Appendicitis —	Incision and Drainage of
		General Peritonitis	Abdomen	Died
R. S. M.	14	Appendiceal Abscess — Rup- tured	Appendectomy — Drainage	Recovery
C. F.	37	Acute Suppurative Appendici- tis	Appendectomy — Drainage	Recovery
C. L.	38	Double Pyosalpinx — Double	Bilateral Salpingo — Oophrectomy —
		Ovarian Cysts — Fibroid Uterus	Hysterectomy— Drainage	Recovery
R. K. H.	23	Appendicitis- — Ruptured on
		Removal — Abscess on Right	Appendectomy — Right Salpingo-
		Tube and Ovary	Oophrectomy	Recovery
E. L.	19	General Peritonitis	Stab Wound a Few Hours Before
		Seven Days Delay	Death	Died
J. H.	16	Ruptured Appendix	Appendectomy — Drainage	Recovery
G. F. D.	65	Perforated Duodenal Ulcer	Repair of Duodenal Ulcer	Recovery
L. P.	37	Pneumonia — Phlebitis — Two Weeks After Appendectomy		Recovering
L. C.	23	Second and Third Degree Burns of Legs and Lower Half of Thighs		Recovering
D. M.	25	Second and Third Degree Burns of Legs and Lower Half of Thighs	Skin Graft	Recovering
C. C.	35	Third and Fourth Degree Burns of Entire Body, Thighs and Legs	*	Died
G. H.	15	Suppurative Appendicitis — Ruptured — Peritonitis	Appendectomy — Drainage	Recovery
G. F.	9	Appendiceal Abscess — Rup- tured— Peritonitis	Appendectomy — Drainage	Recovery
H. B.	39	Localized Empyema of Right Chest	Thoracotomy — Drainage	Recovering
G. C.	36	Double Pyosalpinx	Bilateral Salpingectomy —
		Suppurative Appendicitis	Drainage	Recovery
J. W.	3	Cellulitis	Appendectomy	Recovery
J. D. W.	13	Sinusitis		Recovery
B. P.	55	Gonorrhea		Improved
6 Cases				Recovery
(Lantern Slide Demonstration)	The last slides demonstrate	the bacteria

The following slides showing copies of the above cases will give you some idea of the temperature and pulse behavior following the use of penicillin.

present in a few typical cases.

I am indebted to Misses Lucas and Duno- vant, technicians at the Community Hospital, at Tupelo, for their drawing of the bacteria.

344

Penicillin — Philpot

June, 1945

-

mmmmm

m 1 Sputum

* t . Burt --- Pelvic Lap

♦» \ }Tgv ' —

f

, / s

"

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fsiiifia

I

A. C WWBWBM

Direct Smear: Gram positive Cocci,

Gram positive baolXXl

..

m

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*

Direct Smear; Positive from Gram positive Cocci

rfBr

^ m

/ . ■ ■■ w . - > . f,, . a

% f A , ji

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'•

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#

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Culture:

fXVfX ■■/■' X"- ■ : : ' . . ' !

Culture: Pos. from Staphylococcus

Aureus

,

GRAPHIC CHART

Room or

GRAPHIC CHART

June, 1945

Penicillin — Philpot

345

■ ' s

gjpgg

Direct Smear? Gram positive cocci. Gram negative bacilli

CLARK

Ruptured Appendix

r dk

A w 1

v;

<o

/<>,

/ m

l &

Direct Smear: Positive for Gram positive cocci and bacilli

Culture! Positive for Staphylococcus Aureus B-L

GRAPHIC CHART

_Z-?A

346

June, 1945

BURT

M1

' - 4 p<

J\ i'

&/

lisp

]M

/’!

” / Ky / .. '- ": ' !

Direct Smear: Gram positive oooci,

Gram negative bacilli

/

X-XX-.-VwM. .»W*<M*,V,>„AV»W ~ V '•<- -.W

/ 1

- , x V

GRAPHIC CHART

Culture : Balantidium Coll, staphylococcus

LIFE IS LARGELY WHAT WE MAKE IT

John Dale Kempster

Life Surely is a see-saw thing;

We never know just what ’twill bring. Sometimes it lifts us “high in air”

Where skies are blue, and all is fair; Sometimes it “bumps” us down to earth Mid gloomy days of little worth ;

But never mind how dark the clouds Nor blue the thoughts, that come in crowds, We know somewhere the sun is shining And every cloud hath silver lining;

So lift your head, throw out your chest,

Put on a smile and do your best,

Stand firm in will, there’s naught can beat it, For after all, Life’s what we make it.

Typhus Fever

O. P. STONE, M.D.

Ripley,

There are several reasons why typhus fe- ver is an appropriate subject for discus- sion at the present time. One of the chief reasons is that the prevalence of this disease has increased gradually in the United States during the past few years and has shown a rather marked increase in the state of Missis- sippi during the past two and one-half years. It is of importance to note that already ninety- one cases of typhus fever have been reported in Mississippi during 1944.

Another reason that typhus fever deserves some attention and discussion is that many of our soldier boys are at the present time fighting in areas where typhus fever occurs in epidemic form. These boys may soon return to this state and unless some precautions are observed they may bring the epidemic form of typhus to our own communities.

In a discussion of typhus fever one should observe that there are two forms of the disease namely, the epidemic and endemic forms. The epidemic form is seen mainly in Europe where it has ravaged the population of the Balkan States and parts of Italy and Russia for gene- rations, with marked increases in the preva- lence of the disease during each of the numer- ous wars that have occurred in this area. Th = vector of epidemic typhus is the body louse.

Endemic typhus fever, which is the form seen in the United States, differs from the epidemic type in that it is a much milder disease and has a mortality only about one- third as great. The vector of endemic typhus is the rat flea. It seems that the type of vector determines to a great extent the severity of the disease and this may account for the oc- currence of two forms of typhus fever.

Typhus fever is an acute specific infectious disease, occurring in epidemic and endemic forms. It is characterized by a sudden onset, maculopapular eruption, toxemia, high fever, and severe nervous symptoms. The disease lasts about fourteen days and terminates usual- ly by crisis. It is transmitted by the body louse or other insect vector and the convalescent period is usually prolonged. The exciting cause of typhus fever is the Rickettsia Prowazeki

*Read at Northeast Mississippi Thirteen Counties Medical Society, Amory, Miss., Sept. 12, 1944.

Miss.

which is a pleomorphic organism occurring as minute, paired ovoid bodies, and in filamen- tous forms. Therefore, it takes the classifica- tion of a rickettsial disease along with Rocky Mountain spotted fever, trench fever, and others. It will be noted that there is always a marked increase in the prevalence of typhus fever during wars, famines, and economic dis- tress when overcrowding, lack of facilities, and lack of attention to bodily cleanliness predis- pose to the spread of the disease.

The period of incubation is usually about twelve days, but variations from eight to four- teen days are not uncommon. During the lat- ter days of the incubation period the symp- toms of weakness, malaise, and slight rise of temperature may be noted. The actual onset is usually abrupt with chill, rapid rise of tem- perature to 103° and mild delirium. The tem- perature remains high with mild variations for about two weeks. In cases terminating favor- ably the temperature declines by rapid lysis or crisis. Cough, headache, muscular pains, loss of appetite, and nausea and vomiting are common symptoms.

In the early stages of the disease the erup- tion is the most diagnostic physical finding. However, this usually does not occur until the third to the fifth day. In contradistinction to typhoid fever the rash of typhus comes out in a single crop. These spots are macular in character at first but may become large pur- plish splotches as extravasation of blood oc- curs under the skin. With the onset of the rash, the signs of toxemia and especially cere- bral symptoms become more marked and may even lead to coma. The occurrence of red blood cells in the urine is not uncommon.

Typhus fever is accompanied by a milk leu- kocytosis averaging about 12,000 in uncompli- cated cases.

The Weil-Felix agglutination reaction, per- formed by using standard cultures of Bacillus proteus X19, is positive in almost all cases and either the macroscopic or the microscopic may be used. This procedure can be done by the Mississippi iState Laboratory at Jackson and is used as proof of the diagnosis.

The complications of typhus fever vary in different localities. In the endemic form the most common complications are bronchitis, bronchopneumonia, meningismus, phlebitis, and

348

Typhus Fever — Stone

June, 1945

otitis media. Occasionally such complications as suppuration of the salivary glands and gangrene of large areas of skin are seen.

The gross pathological changes as found at autopsy are not pathognomonic in typhus fe- ver. The distinctive lesions are microscopic. The skin shows the petechial rash persisting after death and may show areas of skin necro- sis and gangrene. The blood is of dark color and coagulates slowly. If death occurs during the first two weeks the spleen may be en- larged. Areas of bronchitis and bronchopneu- monia are commonly found in cases terminat- ing fatally.

Microscopically, the distinctive lesions of the disease involve the smaller vessels, notably those of the skin and of the brain, thus ac- counting for the two most characteristic symp- toms of the disease — the skin rash and the central nervous system manifestations. De- generation and necrosis are noted in the en- dothelial lining of the vessels succeeded by formation of thrombi and finally to loss of continuity of the wall and extravasation of blood.

The treatment of typhus fever is purely symptomatic. Good nursing care is known to affect the mortality rate materially. Absolute bed rest is essential; precautions should be taken to prevent the patient, in his delirium, from doing himself harm. His diet should be liquid or soft in nature and fluids should be forced. Constipation should be treated by enemata and the observation of retention and need for catheterization should be noted. Mor-

phine and codeine have been .found of dis- tinct value in controlling restlessness, cough- ing, and pain. Stimulants such as digitalis, camphor, and caffeine have their place. Bed sores should be guarded against by frequent change of position and by pressure pads. Especial routine care of the mouth is an ab- solute necessity.

The prophylaxis of this disease is of especial importance and may be summed up in the control of the insect vectors. This may not be a simple procedure, particularly where numer- ous cases are being handled. The United States Army has recently demonstrated that de- lousing can be effectively accomplished by a powder insecticide sprayed into the clothing by small spray guns. This was demonstrated when they recently deloused 80.000 inhabitants of Naples, Italy, in a matter of a few hours to stop an epidemic in that area.

The typhus fever present in Mississippi can only be controlled through the control of rats. This can be accomplished by poisoning, trap- ping, and rat proofing. To be effective, con- trol efforts must be continuous and wide- spread. It is well to remember that the rat acts as a reservoir for the disease and that more and more of our rats are becoming in- fected as the disease spreads. Stamp out the rat and the problem is solved as far as present information indicates.

There is a polyvalent vaccine for typhus fever that should be used in exposed areas. At the present time I believe this vaccine is not available for civilian use but probably will be immediately after the war.

It seems that President Truman strikes a home run almost every time an important mat- ter is tossed him across the plate. Maybe he will come out for a Secretary of National Health. In the health of the people is the strength of the nation. Surely we should have a secretary of health in the cabinet. The time is propitious for the entire medical profession to make a concerted effort to interest President Truman and our Congress in this very im- portant matter. The very large number found unfit for military service should add power to this request at this time. Our government, our medical profession, and our people should make definite plans to build a citizenship able to function in a superior way when the life of our nation is at stake. The building of health reserves should be the order, mental, moral, and spiritual.

June, 1945

Editorials

349

The Mississippi Doctor

Published monthly at Booneville, Mississippi Entered as second-class matter, January 19, 1926, at the post office at Booneville, Miss., under the Act of March 3, 187u. Annual subscription $1.00.

The journal with a vision which encourages a plan of delivering modern medicine to the masses at less cost to the individual and more profit to the prac- titioner. It champions the community hospital, the hub around which this service must be built.

Official Organ Of '

Mid-South Postgraduate Medical Assembly Mississippi State Medical Association

W. H. ANDERSON, M. D Editor-in-Chief

MILDRED P. ANDERSON Assistant Editor

David E. Guyton, Blue Mountain College Poet

Mid-South Postgraduate Medical Assembly Officers :

C. H. Lutterloh, M. D President

Hot Springs, Ark.

J. C. Pennington, M. D President-Elect

Nashville, Tenn.

L. S. Nease, M. D Vice-President

Newport, Tenn.

John Archer, M. D Vice-President

Greenville, Miss.

John A. Moore, M. D Vice-President

El Dorado, Ark.

A. F. Cooper Secretary -Treasurer

Memphis, Tenn.

Gilbert J. Levy, M. D Director of Exhibits

Memphis. Tenn.

Editors :

Fay H. Jones, M.D. E. M. Holder, M.D.

C. R. Crutchfield, M. D. C. M. Speck, M.D.

H. King Wade, M. D. F. M. Acree, M.D.

Mississippi State Medical Association Editor

Lawrence W. Long, M.D.

Associate Editors

T. G. Archer, M.D. W. Lauch Hughes, M.D.

Manuscripts and material for publication under the Mississippi State Medical Association should be re- ceived not later than the twentieth of the month preceding publication. Address material to Lawrence W. Long, M.D., Suite 412 Standard Life Building, Jackson. Mississippi.

It seems to be admitted even by officials of the American Medical Association that Mississippi has had one of the very best two- year medical schools in the United States for more than forty years. The record the two- year men from Ole Miss have made on exami- nations and in practice confirms this general impression. Mississippi has perhaps the best public health service in the United states. It also has an excellent distribution of hospitals

Mississippi is among the lowest states in death rates from appendicitis, South Carolina being the lowest and Nevada (which has the greatest number of beds per population) hav- ing the highest death rate for appendicitis. Nevada has bigger hospitals farther apart, the ideal system according to some, but a high death rate — “operation a success, but the pa- tient died.”

§

There are only two places a sound-bodied doctor should be found now — one in the armed forces, the other in practice up to his ankles with his head down.

We deeply regret the death of Dr. A. L. Blecker of Memphis. In every way he held high the banner of the profession, able, kind, and considerate. He was deeply devoted to the profession and made duty his watchword.

The return of a few thousand soldiers at this time to aid farming, industry, and business in general, and with them a few hundred doctors to fill in the places where the old doctors are falling in civil combat and where the people are without medical service, would be mighty good war economy.

§

Dr. V. B. Harrison of the University of Mis- sissippi observes that Mississippi is rapidly becoming a state of children and old people, the able middle aged seeking their fortunes in other states. We are quite sure that this observation is true.

Aside from the challenge such a situation creates for making our state one of greater opportunity, there is a special responsibility resting on the medical profession. In the specialty of pediatrics in Mississippi much has been done within the last few years, Dr. Harvey Garrison being looked upon as a leader, but we do not have a man in the state giving special attention to geriatrics. We should have. In fact the only man we know in this territory specializing in the practice of the aged is Dr. Piatt Anderson of Memphis. The culture, the refinement, the knowledge and the wisdom of the aged that is going to waste is enough to enrich our nation. We do not give due consideration to our aged. If a man keeps mentally and physically fit he should be worth more to human society every day he lives although he lives to be a full hundred. We also fail to appreciate the loyal sons who has stayed at home to help build Mississippi.

350

Editorials

June, 1945

In the proceedings of the staff meetings of the Baptist Hospital of Jackson, Dr. Harvey F. Garrison reports a case of influenza mem- ingitis which recovered and which was treated with sulfadiazine and rabbit haemophilus in- fluenza serum. We understand this is the only case of this type which has ever recovered at the Baptist Hospital.

§

We had a few lines recently from Dr. W. H. Scudder of Mayersville, the only doctor prac- ticing in Issaquena County. He is so busy making history that he did not have time to furnish the account we desired. Dr. 'Scudder has been right on the job for more than fifty years. He has the spirit of a real doctor and he is patriotic to the nth degree. He is deeply devoted to duty and in this time of doctor shortage he is holding the lines just as his Confederate father did in the War Between the States. All alone he holds on and stands at the switch to keep medical service moving in his county. We appreciate and admire him and so does the entire profession of the state. It is his kind which wins wars and makes a nation secure in peace.

The Future of a Four- Year Medical School in Mississippi J. K. AVENT, M.D.,

Grenada, Miss.

President-Elect , Mississippi State Medical Association

No state will progress farther than the health of its citizens. The past in the field of medicine in Mississippi has been relegated to the archives of history. The future will be what the physicians, legislators of Mississippi, and the public as a whole fix as their aim and duty.

The essential need of Mississippi today is a four-year medical school and a large state hospital for clearance of all complicated medi- cal cases. The most scientific and most thorough treatment for prevention, cure or al- leviation of disease — the science of medicine with lower mortality and lower morbidity — is taught in medical schools and practiced in their vicinity. In a modern state hospital, can- cer, a condition now so terribly neglected in Mississippi, could be treated with x-ray and radium, with less pain and the loss of fewer lives. Poliomyelitis cases could secure hospitali- zation until complete recovery, instead of the individuals so afflicted having to go through life paralyzed. A great laboratory for teach-

ing technicians and conducting bacteriological work is necessary.

Doctors could send their difficult cases from all locations in the state, by ambulance, for consultation. The postgraduate courses which could be offered to physicians of the state would be reflected in benefit to the laity. A home postgraduate course is essential. Some doctors will not go to other states for post- graduate work once in ten years, but if it were available at home, they would go once or twice a year.

With a large state hospital, the nursing problem could be solved. The best nurses in the world are those who graduate from small hospitals, yet they are not recognized, as evidenced by the fact that they are not ac- ceptable to the Army Nurses Corps. Mississippi nurses could spend part of their time in the state hospital and solve this essential prob- lem.

Mississippi boys do not desire to leave our state for study of medicine in other states, never to return to their home state, but that is the fate our state imposes upon them in not offering adequate hospital, medical school and internship training. We do not have to ask any other state for a so-called manufac- turing plant of doctors. We of Mississippi can decide our own fate. These boys are the long staple brains of our colleges. Let Memphis, New Orleans, Philadelphia, New York, etc., consider their assets in Mississippi boys forced away from home to attend professional schools. God forbid that it shall continue. We know our needs; we do not rely upon an out-of- state man to decide our problem. The medical profession in Mississippi needs its morale lift- ed, and that can be accomplished permanently by a large central hospital and the addition of two more years of medical school. Among other benefits is the fact that internal medi- cine and surgery would be elevated to a higher level with all other specialties.

We spend millions on highways, schools, and other public benefits, even hospitalization of the poor, but fail miserably to finish the job by obtaining the best scientific skill. The lives of Mississippians are placed in the palm of our hand — the hand of the medical pro- fession of the state. Will you strengthen it, or will you let it spill these lives? The pri- mary consideration is not the cost, but the need, and that need is apparent to the citizen with foresight now.

June, 1945

Editorials

351

May there be a beautiful sunrise in the medical career of Mississippi, and God’s eternal blessings on the sick, the medical personnel, and the public. With all our wealth and oil, we cannot go farther than our health. Health is the gold of our state that will not tarnish. May we in the near future be broadcasting medical science to the world from Mississippi, instead of listening in on stations of other states.

The question is not when can we attain this objective, or how. The quickest way is the best. May our excellent governor call a special session of the legislature and give promise to the sick and diseased citizens of Mississippi that our state may offer the facilities of a large, modern hospital and that we shall allow Mississippi’s medical students the opportunity of completing four years in medicine in their home state. Let us spend money on men, as well as on buildings.

Shall we continue to let disease take a high toll of our loved ones, or shall we conquer it? Shall Mississippi take her rightful place as a leader in the medical profession, or shall we continue to let surrounding states reap the honor and prestige of medical advancement? I say, we shall go forward!

EMERGENCY STATE MEDICAL MEETING

1945

The president, Dr. Crawford, the president- elect, Dr. Avent, the secretary. Dr. Dye, and the Council are to be complimented in the way that the Mississippi State Medical meeting was called and handled under the wartime re- strictions. The Constitution and By-Laws did not completely anticipate such an emergency, and it is hoped that the committee concerned therewith will study and make recommenda- tions to our next meeting for such changes as needed so that there will be no misunderstand- ing by anyone if ever such an emergency should again occur. This committee is com- posed of Dr. D. W. Jones, Dr. W. W. Craw- ford, and Dr. W. H. Frizell — all are able, capable and well grounded in the fundamentals of our medical organization.

Since this was an emergency session, only the necessary business was transacted. An open meeting of the Council was held in the morning which was converted into a meeting of the House of Delegates, with a quorum plus proxies from the delegates, which con-

formed to the ruling of the Office of Defense Transportation so that the meeting consisted of less than fifty people required to travel to the meeting. After selection of a nominating committee, the group adjourned for lunch at which Governor Thomas L. Bailey made an inspiring address with emphasis on the building of a medical center in Jackson. This seemed to meet the approval of the whole group. The nominating committee chairman, Dr. E. C. Parker, reported to the House of Delegates the nine men required to be nomi- nated to the governor, from which he will ap- point three to become members of the State Board of Health for a term of six years each. This was an absolute necessity as required by the laws of Mississippi. The committee then wisely reported that they recommended the retention of all officers in status quo until the next meeting of the State Medical As- sociation. After certain resolutions were adopt- ed, the meeting adjourned.

While it was unfortunate that we are en- gaged in a global war which prevented a regu- lar meeting of the State Medical Association, it was coincidental that this absolutely neces- sary type of meeting was held on V-E Day. It seems most likely that May of 1946 might find us under conditions which will allow us to convene in regular meeting as usual — we all hope that such will be the condition. It is also quite significant that these men who are and have been interested in organized medicine and its business activities were all present and interested as usual. Organized medi- cine is the bulwark and mainstay of the medi- cal profession as proved by the years. The sages are required as advisers and a stabiliz- ing influence, but I feel that the time has come, as the end of the global war in which we are involved approaches, for these men who have so long given their time, ability, and advice, to adopt and train an understudy, if you please. I believe that the younger men under forty who will return from the war soon, we hope, must be encouraged by indoctrination, training and advice from those who have been interested leaders so long to become interested and active in or- ganized medicine. This might well become an objective of the Past-Presidents Club.

Exchange of good ideas is necessary for progress. Therefore, the medical societies of the state and progressive doctors are request- ed to forward to the editor of the Association

352

News and Comment

June, 1945

medical essays and articles of interest. Re- view of the literature will become more in- teresting and complete than in the past. Your cooperation is needed and requested. Your suggestions are welcome.

L.W.L.

News and Comment

Dr. Edgar G. Ballenger, Atlanta, president of the Southern Medical Association, died Friday morning, June 1, and the funeral was held Saturday afternoon. His death was caused from a fall in his hotel.

Dr. Ballenger was born November 20, 1877, in the Blue Ridge Mountains near Tryon, North Carolina. He was graduated with the M.D. degree from the University of Maryland in 1901 and began practicing in Atlanta in 1904. He was one of the outstanding urolo- gists of the nation. A most cordial and mag- netic personality, he was a past-president of the American Urological Association and or- ganized and served as the first president of the Southeastern Surgical Congress. He leaves a son, Cpl. Edgar Ballenger, Jr., at Keesler Field, a sister, Mrs. J. B. Mosely, Atlanta, daughter, Mrs. C. M. Foster, Atlanta, and a brother, Claude W. Ballenger of Tryon, North Carolina.

A great spirit of the Southern Medical As- sociation is no more and the great city of Atlanta has lost one of her best loved phy- sicians.

Dr. E. Vernon Mastin, St. Louis, Missouri, who was elected vice-president of the Southern Medical Association at its last annual meet- ing, succeeded to the presidency of this great medical association on the death of Dr. Ballen- ger. He is worthy in every respect and will grace the position well.

Dr. William Bradley of Conway, Ark., died on June 1 at the age of 71. He was a native of Alabama and practiced at Blocton for forty years. He was an able practitioner and a good citizen.

It is with deep regret that we learn of the passing of Dr. E. C. Boyd of Amory. He was one of the anointed in general practice in the country, one of the best informed men in

medicine in the state. He lived a great life be- cause he served well with his heart and soul in the practice of medicine. He was indeed a war casualty in civil practice. Also, Dr. W. F. Coleman was another faithful practitioner and a fine citizen who paid the price.

JUNIOR COTTON QUEEN

Miss Martha Robins, daughter of Dr. and Mrs. R. B. Robins, is the new Junior Cotton Queen of Camden, Ark. Dr. Gus Street and Dr. W. H. Anderson recall the warm hospitality extended by the Robinses when these two Mississippi men were on program in this fine town.

REFRESHER COURSE

The University of Illinois College of Medicine announces its sixth semi-annual refresher course in laryngology, rhinology and otology, September 24 through September 29, 1945, at the College, in Chicago. The course is in- tensive and largely didactic, but some clinical instruction is also provided.

Write to Dr. A. R. Hollender, Chairman, Re- fresher Course Committee, Department of Oto- laryngology, University of Illinois College of Medicine, 1853 West Polk Street, Chicago 12, Illinois.

SIX-DAY PROGRAM

The Department of Legal Medicine of the medical schools of Harvard, Tufts, and Boston University in association with the Massachu- setts Medico-Legal Society will present a six- day program, October 1-6, 1945, of lectures, conferences, and demonstrations having to do with the investigation of deaths in the interest of public safety.

EYE BANK

The formation of the Eye Bank for Sight Restoration, New York City, which collects and preserves healthy corneal tissue from human eyes for transplanting to blind per- sons, is a forward step in medical and surgical education. The purpose of this organization is to make available to hospitals and surgeons healthy corneal tissue, removed by consent of the next of kin a few hours after death. This operation to restore sight to the blind is ef- fective in only one type of blindness — that caused solely by opacity of the cornea when the rest of the eye and optic nerve are normal.

Interpreting Medical Literature

Staff of Review

Dermatology — James G. Thompson, Jackson.

Ear, Nose and Throat — Edley Jones, Vicks- burg.

Obstetrics and Gynecology — J. F. Lucas, Greenwood.

Orthopedics — Thomas H. Blake, Jackson.

Public Health — Felix J. Underwood, Jackson.

Pediatrics — Harvey F. Garrison, Jackson.

Radiology and Roentgenology — Karl O. Stin- gily, Meridian.

Surgery — W. H. Parsons, Vicksburg.

Urology — Temple Ainsworth, Jackson.

DERMATOLOGY

Archives of Dermatology and Syphilology, Vol. 51; No. 3, March 1945, p. 210.

Cancer of the Eyelid. Lester Hollander and Francis J. Krugh, Am. J. Ophth. 27:244, March 1944.

In a group of 2,601 patients suffering from cancer of the skin in one form or another treated at the Pittsburgh Skin and Cancer Foundation, 239 had cancer of the eyelid. The authors, however, report only on 125 of the 239 cases. They first discuss the anatomic and the morphologic aspects of cancer of the eyelid and its differential diagnosis and classify it according to microscopic appearance in one of four groups: 1) the basal cell, or hair matrix type: 2) the squamous cell, or epidermoid, type; 3) the mixed cell type and 4) the mela- noma type. Of the 125 patients under dis- cussion, 79 were men and 46 were women. Their ages ranged from 25 to 80 years. It is the opinion of the authors that cancer of the eyelids should be excised whenever possible. In carrying out surgical repair the following considerations must be kept in mind: 1) that careful repair of the palpebral conjunctiva when it has been damaged is imperative; 2) that proper support of the eyelids depends on properly reconstructed tarsal plates; 3) that distortions of the margin of the eyelid which cause inversion of the cilia are to be avoided, and 4) that undue scaring is followed by retractions and formations of an ectropion, which also have to be avoided. Thirty-five of the 125 tumors were treated surgically, with thirty good and five bad results. Radio knife excision followed by repair with pedicle graft-

353

ing was carried out in twelve instances, with nine good and three bad results. In another group of cases, in which the growth occurred at the inner cantheus and was firmly fixed to the fibrous structures of the surrounding area, electrodessication was used. This was done in thirteen cases, with seven good and six bad results.

There were a number of reasons which prompted the use of methods other than sur- gical. These included the following: 1. The cancer was considered inoperable on account of its extension and size. 2. The patient was considered a poor operative risk. 3. The patient refused operation. In these instances roentgen irradiation was used. An eye shield made of soft lead alloy is used to protect the eyeball. It was sterilized by allowing it to remain in 70 per cent alcohol for ten minutes and then placing it in sterile water for five minutes to remove all traces of alcohol. Sterilized liquid petroleum was then dropped on the concave sur- face to act as a lubricant. The energy was ob- tained from a iShaoul type of tube which has a focal roentgen ray skin distance of three to five cm., depending on the length of the applicator used. Daily treatment of 500 r each were given, and these varied from ten to twen- ty, depending on the severity of the reaction produced. If the contact Chaoul tube for irra- diation is not available, low roentgen rays may be used. Hollander and Krugh gave 350 r of low voltage radiation to carefully shielded areas in daily treatments, usually ten consecu- tive daily treatments being required. Thirty- eight patients were treated with roentgen rays, seventeen with the Chaoul contact modality. Good results were obtained in twelve and bad results in five cases. Twenty-one tumors were treated with the ordinary low voltage eradia- tion, with fourteen good and seven bad results. There were instances in which several methods of treatment-excision, electrodessication, roent- gen rays and radium had to be used. All twen- ty-three patients were so treated, with seven- teen good and six poor results.

PEDIATRICS

Local Penicillin Therapy in Ophthalmia Neonatorum' — Sorsby, Arnold and Hoffa, Elizabeth: British Medical Journal, 1:114,

January, 1945.

354

Interpreting Medical Literature

June, 1945

“Unlike the sulfonamides, penicillin re- mains effective in the. presence of pus. It therefore has possibilities for the local thera- py of ophthalmia neonatorum as an alterna- tive to general sulfonamide treatment of this affection. To investigate this possibility 47 infants at the Ophthalmia Neonatorum Unit at White Oak (L.C.C.) Hospital were treated with penicillin.”

1. “Initially, penicillin was used in a con- centration of 500 Oxford units per cc. Eight cases received this treatment, one drop of the solution being instilled hourly during the first twenty-four hours, and continued two- hourly subsequently. Only three of these eight cases were cured. Two more showed an initial recovery, which, however, was not maintained. The three cured cases required treatment for two, three, and six days, respectively.”

2. “A second series of seven cases were treated with penicillin, this time in a concentra- tion of 1,000 units per cc., the method of application in three cases being as in the first series, and in the remaining four cases the penicillin was instilled at half-hourly intervals for twenty-four hours and hourly subsequent- ly. Four of this series of seven cases clinical clinical cure in two, four, two and five days, respectively; one case did not respond to treat- ment, while the remaining two cases both re- lapsed after an initial recovery.”

3. “A further ten cases constituted a third series treated with penicillin, this time in a concentration of 1,500 units per cc., (the drops being instilled half-hourly during the first twenty-four hours and hourly subsequent- ly). Six of these ten cases showed an excellent response, clinical cure being obtained in eight- een hours in one case, in two days in four cases, and in three days in the remaining case successfully treated. Two cases showed a poor response in spite of treatment for four and one-half and five days, respectively; in one case penicillin treatment was discontinued after three days as progress appeared inade- quate; in the remaining case of this series an initially satisfactory response which gave a clinical cure within two days was followed by a relapse which did not respond to further penicillin therapy.”

4. “Twenty-two infants were treated with penicillin in a concentration of 2,500 units per cc., the drops being instilled half-hourly for the first three hours, then hourly for twenty- four hours and two-hourly subsequently. In all

but one case there was an excellent clinical response, recovery in some instances being a matter of a few hours.” Clinical cure occurred in six cases in from three to twenty-four hours, in seven cases in from twenty-seven to forty- three hours and in seven cases in from fifty to one hundred hours. One case was omitted, as the complication of corneal ulcer — present on admission — delayed a return to normal. “One point deserves stressing. Rapidity of clinical cure does not seem to depend al- together on initial mildness of the condition. Of these twenty cases, four were severe; they cleared up in thirty-six, forty, forty, and thirty- seven hours, respectively, while all the seven cases that required fifty to one hundred hours were either mild or moderate.”

“Of the twenty-five cases in the first three series, only thirteen showed clinical cure, five more relapsed after apparent clinical cure, and seven gave a poor response or none at all.”

“No fine conclusions can be drawn from these results. So far as this series goes it would appear that none of the organisms met in ophthalmia neonatorum are completely re- sistant to penicillin. A rather surprising feature emerges with the three oases of inclusion blen- norrhea present; theoretically no result would be expected, but in two cases there was an initial recovery, only to be followed by a relapse.

“The twenty-two cases treated with penicil- lin in a concentration of 2,500 units per cc. bear out the efficacy of the drug for the vari- ety of causal organisms of ophthalmia. Treat- ment was successful in the five cases due to the gonococcus, the nine caused by staphy- locci, the three in which staphylococci and bacilli were present, and in the two in which inclusion bodies were found; two further cases in which no organisms or inclusion bodies were present also responded to penicillin treat- ment. No relapses were observed in this series, and the only failure was a case in which no organisms were found in the smear and the culture showed diphtheroids.

“It would therefore appear that penicillin is effective over the whole range of causal organisms with the possible exception of diph- theroids— though even here two cases respond- ed to penicillin in a concentration of 1,000 and 1,500 units, respectively, and a third case showed a partial response to penicillin (1,500 units per cc.) . . . Three of the seven cases

June, 1945

State Board of Health

355

treated with penicillin in a concentration of 2,500 units and requiring treatment for more than fifty hours showed diphtheroids — one of them in association with staphylococcus al- bus. In no case in which diphtheroids were found was there a rapid clinical cure.”

“Five cases among the first twenty-five were treated with penicillin after a poor or pro- tracted response to sulfonamides. Three of these were cases of gonococcal ophthalmia and responded well to penicillin, used in concentra- tions of 500, 1,000 and 1,500 units, respective- ly. In the fourth case Staphylococcus aureus, and in a fifth diphtheroids, were present; in both these cases there was a satisfactory re- sponse to penicillin in a concentration of 1,500 units per cc. Initially the first case had been treated by sulfathiazole for twelve days, and the four others by sulfamezathine for five and one-half, twelve, five and one-half, and twenty-three days, respectively. Clinical cure by penicillin took place in three, four, .two, and three days, respectively, in the first four cases

STATE FEVER THERAPY UNIT FOR NEUROSYPHILIS by

A. L. GRAY, M.D., Director Division of Preventable Disease Control The State Fever Therapy Unit, a project of the Mississippi State Hospital in collabora- tion with the Mississippi State Board of Health, has been organized for the purpose of treating early neurosyphilis, thereby pre- venting the serious manifestations from oc- curring which may eventually require com- mitment to an institution for the insane. The unit is located at the Brookhaven Public Health Treatment Center, Brookhaven, Mississippi, and is so arranged that there will be four six-bed wards to accomodate both colored and white patients, male and female. In direct connec- tion with the patient wards are six fever therapy rooms, fully equipped with the latest type of cabinets. The personnel will consist of the medical director and a complete staff of specially trained nurse technicians and staff nurses.

The county health officers are charged by law with the responsibility of referring pa-

and in eighteen hours in the fifth case.

“Method of treatment — On admission the infant’s eyes are irrigated with half-normal saline at room temperature and one drop of penicillin is instilled. Irrigation is also carried out before each further instillation of penicil- lin so long as there is any discharge. With penicillin in a concentration of 2,500 units per cc. irrigation is generally not necessary after six hours. Penicillin is continued for forty-eight hours after apparent clinical cure, at two-hourly intervals during the day and three-hourly at night. The drug is well tole- rated by the infant’s eye. Occasionally a mild transitory flushing of the conjunctiva is ob- served.”

COMMENT

This investigation and method of treatment with penicillin of ophthalmia neonatorum is quite interesting. It reveals a remedy which is new and now available and also one which may be used without fear of injurious effects to the eye.

tients from both public clinics and private physicians. Every effort will be made by the staff of the State Fever Therapy Unit to co- operate fully with county health officers and private physicians by rendering consultation service and by administering fever-chemo- therapy to those patients who fulfill the re- quirements for admission. It is recognized that patients with asymptomatic neurosyphilis with type III spinal fluid are prone to develop the more serious manifestations of neuro- syphilis, particularly paresis. Therefore, at the beginning, it is planned to select this group of patients for treatment, fulfilling the stipu- lated purpose of the State Fever Therapy Unit as set up by law. The present limited facilities will not make it possible to extend such therapy beyond this group, even though there are other types which might doubtless benefit from fever-chemotherapy. The ultimate aim of the program is to bring under control the neurosyphilis problem in Mississippi, which can be achieved only through the combined efforts and cooperation of ‘health officers, practicing physicians, and others responsible for the conduct of this program.

State Board of Health

Felix J- Underwood, M .D.

356

State Board of Health

-June, 1945

Dr. H. Worley Kendell of the United States Public Health Service has been appointed medi- cal director of the Chicago Intensive Treatment Center. Dr. Kendell is well qualified for the task confronting him and his staff and is in fact one of the country’s outstanding authori- ties on fever therapy. A graduate of the Uni- versity of Cincinnati medical school, he served his internship at Miami Valley Hospital, Day- ton, Ohio, where he was also resident physi- cian in pathology and did research work in fever therapy. Later he was associate director of the Kettering Institute for Medical Re- search. Dr. Kendell also served as director of the department of physical medicine at the Miami Valley Hospital. He has contributed numerous articles to medical journals both in this country and abroad.

The establishment of a State Fever Therapy Unit for Mississippi is a real advance in the control of neurosyphilis and should reduce con- siderably the number of cases which usually develop mental and paralytic symptoms and thus become permanent public charges at great

expense to the state.

*****

Mississippi’s Enrichment Program

The Enrichment Acts, passed by the 1944 session of the Mississippi Legislature, became effective on February 1, 1945. This legisla- tion requires that all white flour and bread and all degerminated corn meal and grits sold in the state must be enriched. It does not apply to whole wheat flour or home ground meal. A similar act requires that all oleomargarine must be fortified with Vitamin A.

The Mississippi State Board of Health, which is designated as the enforcement agency for the enrichment program, has allowed an ad- ditional six months after February 1 for the corn millers to secure necessary equipment and for the merchants to clear their stocks of the non-enriched products. The mills and the wholesale and retail merchants have given their whole-hearted cooperation in this pro- gram. As a result, the major part of the flour, bread, degerminated meal and grits being sold in Mississippi is already enriched; all of the oleomargarine has added Vitamin A. Complete compliance is expected well be- fore the final strict enforcement date of Sep- tember 1, 1945.,

“Enrichment,” points out Miss Mary Stan- sel, nutritionist, “means that that part of the vitamins and minerals lost in the milling pro-

cesses have been put back into the wheat and corn. Enriched products taste just the same, look just the same and cook just the same as the non-enriched. The only difference — and it is a big one — is that the enriched products supply more of the nutrients needed for good health. The enrichment program will no doubt mean a substantial decrease in the incidence of pellagra and certain deficiency diseases. The enrichment of white flour and bread with thiamine, riboflavin, niacin and iron, and the enrichment of degerminated corn meal and grits with thiamine, niacin, and iron is a sound, practical and inexpensive way to achieve better nutrition and thus better health for the people of Mississippi.”

“Bread enrichment should be continued,” states an editorial in the Journal of the Ameri- can Medical Association (January 20, 1945), in commenting upon this wartime measure which brought compulsory enrichment on a nation-wide scale. Following “the emergency the problem reverts to the individual states, many of which have already passed legisla- tion to insure continuance of these benefits to the nutritional standard of the people. “The enrichment of flour and bread is considered particularly desirable,” points out the editorial, “because these foods are consumed daily in significant amounts by practically every one . . . “The effect of the widespread increase in consumption of these enriching substances on the nation’s nutrition as a result of mandatory enrichment of all white bread and rolls is difficult to measure accurately at this time. All methods of appraisal, however, indicate a definitely beneficial influence . . .

“The benefits which accrue to the vastly greater number of individuals suffering from milder chronic degrees of deficiency states, in many cases unrecognized or attributed to other causes, can probably be considered the greatest contribution of enrichment. An im- provement in the general health and well being and an increased efficiency in the popu- lation as a whole may be anticipated, since carefully controlled experimental groups have shown measurable benefits as a result of dietary increases of enrichment materials to enrichment levels.”

The enrichment program has the endorse- ment of the Food and Nutrition Board of the National Research Council and the Council on Foods and nutrition of the American Medi- cal Association, the American Public Health Association, and others, who appreciate the

June, 1945

State Board of Health

357

important contribution it has made to health and efficiency.

*****

Mississippi Needs More Hospital Maternity Beds

In recent weeks the Division of Maternal and Child Health of the Mississippi State Board of Health has attempted to determine the total number of maternity beds available in Mississippi and the total needed. Dr. Vir- ginia Howard, director of the Maternal and Child Health Division, has estimated the state’s needs of hospital maternity beds at 1,600; whereas there exists at the present time only about 600. These are distributed as follows:

	White	Colored
Delta section	95	38
Bluff section	60	16
Coastal section	43	14
Northeast section	202	31
South central section	125	31
The increased number	of hospital deliveries

during the past two years seems a trend which will continue and is one which will have a profoundly beneficial effect on maternal health in Mississippi. As a result many hospitals in Mississippi have become interested in adding to their maternity facilities, making them more adequate to serve current needs.

Attention is again called to the fact that in 1943 the state had the lowest white mat- ternal death rate in its history — 2.3 per 1000. However, the Negro maternal death rate for 1843 was 5.3, the same as that for white eight years ago. It is believed that good hos- pital maternity facilities together with good obstetric care will make it possible with a few years to reduce these rates substantially. In the past five years Mississippi has lost 1400 women through deaths due to childbirth. Twenty maternity beds for every 25,000 popu- lation in the stats would go a long way toward insuring proper hospitalization and care for every mother at time of delivery.

Mississippi Emergency Maternal and Infant Care Program Completes Second Year

Through the assistance of 786 physicians and 117 Mississippi hospitals, the Mississippi Emergency Maternal and Infant Care Program has given help to more than 16,000 wives and infants of enlisted men now serving in the armed forces. According to Dr. Virginia How- ard, director of the Mississippi program, every maternity case has received medical services at the time of delivery, with more than two-

thirds of all cases being hospitalized at time of delivery.

The program has not only boosted morale among the men in the armed forces in know- ing that good care was provided their wives and infants; it has also proved a stimulus to hospitals providing maternity services to en- large and improve their activities. Many of the young mothers have, under this program, had their first babies, and they will have been taught to seek the same safeguards in any subsequent pregnancies which they were of- forded under EMIC. For the contribution which has been made to improved maternal and child health, appreciation is due the physician, the hospital, the nurse and the public health

worker who assisted in the program.

*****

One-Day Postgraduate Course in Pediatrics and Obstetrics

Physicians were most enthusiastic in re- gard to the five one-day postgraduate courses which were recently held in Mississippi through the cooperation of Tulane University School of Medicine. From all the comments which came in following these one-day courses, the physicians of the state consider them quite worth while and have expressed a desire for more. Consequently, an effort is being made to repeat these courses, holding them in five other parts of the state in the early fall. The earlier courses were held in Jackson, Hatties- burg, Tupelo, Greenwood, and Meridian, with Drs. Ralph Platou and George Mayer as lec- turers.

PREVALENCE OF COMMUNICABLE DISEASES IN MISSISSIPPI

Acute poliomyelitis	t^pr. 1945 2	Apr 1944 2	Apr-5 yr. avg. 2.4
Bacillary dysentery	544	482	440.8
Dengrue	0	0	.8
Diphtheria	29	11	26.0
Influenza	3223	3834	3450 8
Measles	2200	3865	3556.6
Meningococcus meningitis	20	22	29.8
Other forms meningitis	0	12	5.4
Pellagra	204	261	286.2
Pneumonia	1220	1510	1356.6
Pulmonary tuberculosis	107	117	135 8
Scarlet fever	49	16	42.6
Smallpox	0	0	2.2
Tularemia	7	15	96.0
Typhoid fever	5	5	7.0
Typhus fever	10	6	4.6
Undulant fever	7	5	3.8
Whooping cough	896	1458	1233.0

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Doctors, Democrats and Demagogues

J. A. RAYBURN, M.D.

Pontotoc, Miss.

have selected as my subject “Doctors,

I Democrats and Demagogues,” because of the tremendous impact of each group, separate- ly and collectively, upon our social, economic, and political structure, and because they are a part of the fabric of scientific medicine.

Doctors

From time immemorial doctors have played an important part in the lives of people. Primi- tive people, with their unorganized society, have depended much on their medicine men. They not only imbibed their concoctions when they were sick, but sought their advice on all matters pertaining to their own welfare even when they were well. Doctors have been in the vanguard of all organized and progress- ive governments, and sometimes have even carried the torch of enlightenment. They have kept pace with whatever progress humanity has made. Ethical practices and conduct have been observed with a reasonable degree of fidelity, in keeping with the society they rep- resent and serve. They seem to be an in- dispensable part of society on any level, in war or in peace.

Within the medical profession it has been our great good fortune to know men of the highest ideals and culture, and in general, to find in the profession a great friendliness. Our common interests bind us together, and although we frequently disagree, there is to- day, as there has been throughout the cen- turies, in Osier’s words, a “remarkable soli- darity.”

Great and indispensable as the medical art is, it is something more than skill that con- stitutes the genius of the true physician. It is love of humanity, a desire to do the ut- most, at any cost, to alleviate human suffer- ing and restore the afflicted to wholeness of being.

A doctor is not a superman or magician. He is a human being, with human sympathy

♦This paper was originally prepared to be read before the Section on Surgery at the Mississippi Medical Association in May, but due to wartime transportation difficulties the scientific sessions were pretermitted.

and understanding, working within the limits of scientific knowledge. But he achieves vic- tories today which, only a few generations ago, would have been called miraculous.

With the help of modern scientific equip- ment, with a fund of coordinated medical and surgical knowledge undreamed of even by our grandfathers, doctors can prevent dis- eases that were once supposed to be the natural heritage of mankind. They can cure diseases which were once unqualifiedly labeled “fatal.”

The service that medical science renders is often obscure and unnoticed. It receives little of the world’s applause and oftentimes too little compensation. The unwritten story of what transpires in the hospitals and frequent- ly in the homes of humble and neglected folk is one that has never been adequately told. There is no form of philanthropy of which we have knowledge comparable to that which is repeatedly exhibited by the healing profes- sion. Doctors and nurses render a service of such high order that we find it impossible rightly to appraise it.

Charity is an eminent virtue of the medical profession. Show me the garret or the cellar which its messengers do not penetrate; tell me the pestilence which its heroes have not braved in their errands of mercy; name the practitioner who is not ready to be the ser- vant of servants in the cause of humanity, and whose footsteps are found to every haunt of stricken humanity.

Rightly conceived and practiced, it is a ministry that deals with the whole man, body, mind and spirit. We have known physicians whose presence in the sick room meant as much if not more than all that they pre- scribed. In their approach to the sick they imparted both confidence and renewal. They penetrated the mind of the patient and dis- pelled both fear and anxiety. Their word of encouragement meant more than their medicine. They were restorers of the soul.

The physician’s ambition has ever been to relieve and prevent suffering and illness and the unhappiness that goes with such con- ditions. By precept and example it has taught the neophyte that it is his obligation to sacri-

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fice his comfort, yea even his health, if in so doing, he could alleviate the suffering of others. No group, and I do not except the clergy, has held higher the standards of moral- ity. No group has striven more earnestly for the advancement of science.

The letters “M.D.” are a symbol of civiliza- tion’s achievements in the protection of hu- manity.

What is it that has enabled the men of medicine to accomplish so much in blessing humankind by the alleviation of physical woes ? The question may well be answered in the language of an ancient sage, who once wrote these immortal words: “Interest does not bind men together: interest separates men. There is but one thing that can effectively bind people, and that is a common devotion.’’ There are a number of loyalties in life — those to a nation, to a college, to the community in which we dwell, to our family, and to our friends — “All of which are somewhat akin; yet there may be something of personal interest, pre- judice, or defense in these particular reactions which makes them not wholly unselfish.” De- votion, on the other hand, may be likened un- to that charity so beautifully delineated by the Man of Tarsus — for devotion suffereth long , and is kind; devotion envieth not.

Devotion is the doctor’s consecration to his task. It is a sort of blood kinship with these who have been led into the Temple of Pain.

This is the true spirit of medicine. It is this that casts out the devils of disease. De- votion, wedded to true science, has won for many a tortured soul freedom from agonies un- speakable, and restoration to the hearth of health.

My fellow physicians, we are servants of humanity and have a humanitarian service to perform which can be accomplished by or- ganization, cooperation, education, devotion and freedom.

Democrats

Democrats have been the free thinkers of the world, and whether they live in a society of free thinking people, an autocratic or to- talitarian state, most of the philosophy which has guided humanity towards a higher plane of living has been furnished by true democrats.

It is now 168 years since the brilliant pen of Thomas Jefferson gave us three brave dreams. They were dreams that shook the

complacency of a world of kings and foreign rulers, that were to light up the tired and broken hearts of men everywhere — “that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness.” I wonder if in all written language there is a phrase that match- es those last seven words. They cover man’s fondest hopes since the mist slowly lifted a million years ago and human beings began to ponder on the meaning of existence.

They express simple dreams. They want Only that man shall have his own life to do with as he chooses; they ask that man shall have personal liberty; and that he shall have the right to pursue such happiness as he wishes. They were put down on imperishable parchment and signed by fifty-six valiant men at a moment when it was not easy for com- mon man to have for himself or his family any of these three things. Life was cheap and could be all but bought and sold by the whims of distant rulers. Men were free neither to think nor to talk nor to act as they chose. And they could follow their stars of happiness at great risk and great cost.

These fifty-six sorely-tried men, and their countrymen who dreamed with them, pledged their all in order to build a new world based on an untried and imaginative theory called democracy.

It was vague then, and it is vague now after all these years. And it will always be vague because it is built in men’s hearts and ce- mented by men’s dreams. But this gives it a purpose and strength beyond measurement.

To us our democracy means the American way of life. After analyzing the American way, I find it embodies this principle: It is the free way of life. The individual is allowed to live in accordance with the dictates of his own conscience. He is free to aspire, to pro- test, to criticize, and to follow any vision in his heart or mind which leaves his neighbor equally free. In America a person may talk his way to the truth of things, realizing that although the governmental organization is the agency for the general welfare, it leaves full leeway for the talented person to attain the highest development of his talents commen- surate with neighborly, social conduct. He is assured this free spirit by the Bill of Rights.

The American way permits living by the rule of reason. It enables men to put into appli-

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cation mankind’s most important heritage intelligence. This aspect promotes fair govern- ment as contrasted with the oppression and suppression characteristic of autocratic gov- ernments.

It is the friendly way of life. It takes into consideration the rights and opinions of mi- norities, the underprivileged, and the least favored. It places restrictions upon the sel- fishness of the mass and class, so that they do not trample on the privileges of others. An individual at the very bottom of the scale can climb to the top — for success is judged in terms of growth and happiness.

It is the peaceful and cooperative way of life. It emphasizes service for the common good. Discrepancies are settled through en- lightened discussions, elections, or through court procedures. The use of armed force is a means of last resort.

The American way is the fair way of life. The democratic principle requires each per- son to recognize the equal rights of others. Here, individuals in determining the condition of their own lives, whether political, economic, religious, or social, are guided by the thought that their rights are everywhere limited by the equally valid rights of their neighbors; that their neighbors are always to be treated as human beings, as ends in themselves, never as mere instruments.

Finally, it 's the democratic way of life based on human brotherhood and the Golden Rule. In America attemps are made to bring the benefits of civilization to the common man, to give him a high standard of living, educational opportunities, and protection for his health and safety. In a word, the Ameri- can way epitomizes Christian philosophy.

In verity, I would not change our democracy with the life it entails for any other system in the world. But if our democracy is to mean as much to us tomorrow and a thousand mor- rows hence, we must fully understand it and fulfill our obligations. We must be educated in civic matters. We must obey our leaders, yet assert the responsibility of advising them. We must play fairly, yet be mindful of every op- portunity for free action and the exercise of initiative, for then only will the success of democracy be assured and insured forever. Then only will we continue to breathe every day a fresh delight in its generous attitude toward life, and the inspiration it affords its citizenry.

Demagogues

Demagogues flourish in all types of society, but they are in their zenith of glory in a democracy where they are allowed to expostu- late freely and often. Even though they some- times become nauseating to certain sections of society, they are possibly a benevolent factor in a democracy, because there are those of us who might become super important factors, and altogether too cocksure, if it were not for the flambouyant glamour of the demagogue.

It was Dr. Osier who said to a group of students entering Johns Hopkins: “If you

look forward to a lucrative practice, go home. If you enter medicine in exactly the same spirit that the missionary leaves for his foreign field, that is, believing that in medicine you best can use your talents for your fellow men, we welcome you.” In this day and age it is too much to expect doctors to have so pure a missionary spirit as to be totally indifferent to money and the comforts and security it can buy. But it may still be assumed that a doctor who is worthy of the name will find his greatest reward in the satisfactions he derives from pursuing a science and from im- proving the lot of humanity. The fact that many doctors have placed these satisfactions first justifies the conclusion that this is not an impossible human ideal.

The majority of the members of the medical profession are no doubt doing all that they can to raise the standards of medical practice.

The national phantasy of socialized medi- cine is to my mind a dream of the bleating heart of the demagogue. Those of us who be- lieve in a free and strong America must be on guard. Put agriculture, industry, and the professions in a strait jacket of regimentation and bureaucratic control, and the only possible result would be, we should lose the way of life which has given the people of this nation more of the worthwhile things than have been at- tained by the people of any other land.

What do we do about it? We cannot sit idly by and watch this system disappear be- fore our eyes. We cannot permit the inefficient and the incompetent, the crystal gazers and the experimenters to ruin this America of op- portunity for all of us.

In a republic all men and all women must be granted equal rights. If we do not adhere to this great fundamental principle of Ameri-

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canism, we are not worthy of the proud privi- lege of being American citizens.

There should be equality in the administra- tion of the law; there must be justice in the distribution of the tax burdens. A square deal to all must be the cornerstone upon which we build a continuous progressing America.

To those who have had experience with the muddling of government, the demand for more of it in medicine in the name of efficiency has an ironically humorous note. What city has not had scandals in its health department? Some state and county health departments are little better. It is said that one Southern state has had twenty-two state health officers in twenty-three yeans. Health department of- ficials may be appointed for their merits but are often selected for political “availability.” It is said that in one large city recently a dy- ing man was turned away from a city hospital by a receiving nurse because he was not ac- companied by a policeman! And the sick man happened to be an employee of the very hos- pital where he applied for emergency treat- ment. A tragic paradox indeed!

How dubious then the prospect of turning over all care of the sick to government.

Future medical progress would practically stop under socialized medicine, for, there being no competition, doctors would not strive to improve their service. Doctors would no longer be masters of their talents, but would have sold or bartered them to an unprofessional group of politicians. Many of our future great surgeons would be deviated from the hard road of a medical education to more promising lines. For the future of progressive medicine and for the welfare of the American people as a whole, may the doctors continue as in the past.

Let us all become true sentinels in the watch- towers of a free and untrammeled America. Let us see to it that the flag of personal ini-

tiative shall not be dragged down from the mast of private enterprise by the dirty hands of the disciples of Karl Marx, and in its stead run up the red flag of socialized medicine and state socialism.

We hope that we can persuade the general public to support us in our resistance to Senator Wagner’s new law which would place us completely under the control of the federal government. We say free evolutionary medi- cine not revolutionary bureaucratic medicine.

We need men and women, lots of them, who will stand up on their two feet before the world and say, “We do not intend to preside at the liquidation of the American way of life. We are going to maintain our American standards of living under representative, demo- cratic principles, free from government domi- nation.”

You may well ask, Why am I mixing these three segments of society in a paper to be read before a group of professional men? My answer is, that the three segments are a mix- ture of society, that the noble profession of medicine is interspersed with the medical dema- gogue, who considers medicine as a means to his own ignoble purposes. I am glad that there are so few such members within the pro- fession.

All doctors have not reached a state of idealism in their profession. But the majority of them are constantly striving to improve in quality and scope. I do not believe that social- ized medicine is the answer. Give them con- structive criticism and light, and they will find the way, because I believe in this country most of them belong to that class of demo- crats which has helped to guide humanity to- ward a higher plane.

Our salvation lies in the joined hand, the fused spirit, and the consecrated heart — to reject the false, examine the doubtful and ac- cept the true. Doctors and democracy will stand the test.

Where no council is, the people fall: but in the multitude of counselors there is safety.

— ISolomon (1000 B.C.)

Acromioclavicular Injuries*

JOHN D. DYER, M.D. Houston, Miss.

Separation of the acromioclavicular joint occurs often enough for it to be worthy of our consideration. About two years ago there was an article on this subject in the Journal of Surgery, Gynecology and Obstetrics. It was written by Dr. Boardman M. Bosworth and described a new technique for repairing these injuries. At that time he only reported four_ cases. Since reading Dr. Bosworth’s ar- ticle, we have repaired four cases of acromio- clavicular separation by the technique which he described.

Disability from acromioclavicular separation is marked when there is coincidental tearing of the coracoclavicular ligament. This ligament is very strong and if it were not present, there would be many more acromioclavicular separa- tions. There is only slight movement in this joint, but the fibers of this ligament are so placed that they reinforce it regardless of what direction it moves.

In the past there have been numerous major operative procedures used for repairing these separations. Fascia, silk and wire have proba- bly been used more than any other materials. All required general anesthesia and major orthopedic surgery which was technically diffi- cult.

The method described by Bosworth and which has been used in the cases being report- ed now consists of passing a single vitallium screw through the clavicle into the coracoid under local anesthesia. The operation is done with the patient sitting upright in a chair. A small incision is made over the outer third of the clavicle, parallel with the clavicle, and about one and one-half inches proximal to its outer end. The upper cortex of the clavicle is drilled through with a 3/16 drill. Novacain is then injected and the lower cortex is drilled through. Through this hole more novacain is injected into the torn fibers of the coracoclavic- ular ligament and into the periosteum of the coracoid. The dislocation is now reduced and held in position by an assistant who supports the arm and depresses the tip of the clavicle.

At this stage of the procedure it is well to check the position with x-ray. A hole is then started with a small drill in the upper cortex of the coracoid process. A vitallium screw is then placed through the clavicle into the cora- coid process. This screw will cut its own way through the coracoid process without pre- vious drilling.

The hole in the clavicle is made a little larger than the screw to allow free movement of the screw within the clavicle which allows limited motion of the acromioclavicular joint in all directions. The reduction must be main- tained until the screw is drilled through the coracoid and the screw should penetrate both cortices of the coracoid.

This operation is very simple but should be done in a hospital. No open bone surgery should be attempted in an office because of difficulty in carrying out a sterile technique. It is probably best to keep these patients in the hospital overnight, but this is not absolutely necessary. No sling or support is used, and the patient is advised to begin active use of the arm at once. However, lifting and pulling is not permitted for eight weeks.

The following cases are reported:

Fig-. 1. — J. M., age 75. X-ray before operation.

Case No. 1. J. M., age 75 — Injured in an automobile wreck. Was seen a few hours after

*Read at the Northeast Mississippi Thirteen Counties Medical Society, Baldwyn, Miss., December, injury. Was stuporous from a head injury,

363 1944.

364 Acromioclavicular

Pig. la. — Same patient after operation.

but it was noted that the outer end of the right clavicle projected above the acromian process of the scapula. Diagnosis of acromio- clavicular separation was confirmed by x-ray examination. Since there was an associated head injury, the acromioclavicular separation was not repaired until three days after ad- mission. The repair was carried out in the manner described. There was moderate pain in the shoulder for the first two days follow- ing the repair. After this, there was hardly any pain. At two weeks there was some drain- age from the incision, and it was thought that an osteomyelitis might be developing. How- ever the draining stopped after one week and the incision healed completely. At two months the patient had normal use of the shoulder.

Pig. 2. — J. S., age 34. X-ray before operation.

Case No. 2: J. S., Age 34 — Injured in an automobile wreck. Was seen about four hours after injury. Patient was complaining of severe pain in right shoulder. Examination revealed an acromioclavicular separation. Repair was done on the following morning. Recovery was

Injuries — Dyer July, 1945

uneventful. At six months there was normal use of the shoulder.

Fig. 2a. — Same patient as in Pig. 2 after operation.

Case No. 3: E. W., age 15 — Fell from bi- cycle on right shoulder three days before en- entering hospital. Examination revealed right acromioclavicular separation. Repair was done about two hours after admission. Recovery was uneventful. At four months function of shoulder was normal.

Fig, 3 — E. W., age 15. After reduction with screw.

Case No. 4: G. B., age 17 — Injured left shoulder while wrestling. On physical examina- tion there appeared to be a typical acromio- clavicular separation. However, x-rays showed a fracture of the outer extremity of the clav- icle. Since the clavicle was riding high, it was evident that the coracoclavicular ligament had been tom and that it could be treated as an acromioclavicular separation. The only dif- ference in the procedure was that the fractured ends of the clavicle had to be manipulated in- to position before insertion of the vitallium screw. At six months the function of the shoulder was normal.

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365

Fig-. 4. — G. B., age 17. Before operation.

Fig-. 4a. — After reduction.

THE MISSISSIPPI DOCTOR

David E. Guyton Blue Mountain, Miss.

The Mississippi Doctor!

Long may it live to lead,

With courage for its watchword, With candor for its creed.

Despite its small beginning,

It towers high today,

Respected, read and quoted,

With sovereign right to say.

Appearing in its pages,

Are features by the best

Of surgeons and physicians, Revered by all the rest.

All phases of the practice, Approved by tests of years . And every sane adventure Of sagest pioneers,

These are the sum and substance This journal joys to bring

And that is just the reason Its readers rise to sing:

“The Mississippi Doctor!

Long may it live to lead,

With courage for its watchword, With candor for its creed.

“And may God crown its efforts With service most sublime

And lengthen out its mission Until the end of time.”

Rural Health*

VERNON B. HARRISON, M.D.** University, Miss.

In reporting on the (pfuiblic health status of a community, it is customary in professional circles, to consider the subject from the standpoint of the four P’s ; namely, the popula- tion, the problem, the program, and the prog- ress. In the time at my disposal, both for preparation and presentation, I can do no more than generalize on these four ^points as they pertain to the rural health status of the ten counties represented today in this Area Rural Life Conference.

THE POPULATION

The total population of the ten counties in; this Area Rural Life Conference is approxi- mately one quarter million people, about one- eighth of that of the state of Mississippi. This population is composed of about half and half white and colored people, with a range of white to colored ratio of from three to one some counties, to a ratio of one to three in other counties. The popula- tion composition is important in any public health problem because of the significance of racial factors in disease, as well as its sociological and economic implications.

The age-group distribution of a population influences its public health problems. Missis- sippi is rapidly becoming a state of children and old people. This is due to the fact that our young people are migrating from the state to seek better economic and sociologic opportunities elsewhere. When the middle-age group is cut out of a given population it throws the public health problems of the younger and older age-groups into greater prominence. And, with the possible excep- tion of the venereal diseases, tuberculosis and conditions associated with childbearing, the younger and older age-groups contain the most public health problems ; for example, the acute communicable diseases, nutritional deficiency and developmental diseases, and the degenerative diseases and senescent states.

♦Read before the Area Rural Life Conference, Oxford, June 8, 1945.

♦♦Professor of Bacteriology and Preventive Medi- cine, University of Mississippi.

The social and economic status of a popula- tion also influences the state of its public health. It is a well recognized fact that where the sociologic and economic well-being of a population is high, its public health problems are minimal. Poverty and near poverty, if not the mothers, are, at least, the step- mothers of public health problems. I think that it is fair to state that the general social and economic level of the average rural fami- ly in this area is definitely below the average for the nation, although not nearly so low as that of some sections of so-called enlight- ened Northern cities. Nonetheless, we must recognize the facts for what they are.

Lastly, there is a direct correlation between the educational level of the population and its public health problems. The Scandinavian countries are a good example of this point. That is, where the general educational level is high, the public health level is also high, and vice versa. Here, again, we must admit that the general educational standard of our population is woefully deficient in certain par- ticulars.

THE PROBLEM

The public health problems of any com- munity can be classified into three divisions; namely, disease prevention, health mainte- nance, and health promotion. Of these three problems, health maintenance is the oldest in concept and most immediate in action. Fundamentally, it means repairing the “hu- man machine” when it “breaks down” and getting it back into operation as soon as possible. Naturally and logically, the responsi- bility for this service rests with the medical profession and its allied services; such as, the dental, nursing, and pharmaceutical professions and the hospital systems.

What is the health maintenance problem in this area? Serving a quarter million people iii this area are 93 physicians who are not doing full-time public health work or teaching in the medical school. This is a ratio of one physician to 2700 people. By comparison the ratios of , physicians to population in Mis- sissippi as ; a , whole and in the nation as a 366

July, 1945

Rural Health' — Harrison

367

whole are, respectively, 1 to 1640 and 1 to 800. If one accepts the standard of one phy- sician per 1000 population as satisfactory, then this area is short 156 physicians. I have no readily available data on the dentist and nursing situation, but I suspect on fairly good general evidence that in those fields the situa- tion is far worse.

The hospital aspect of the problem follows, in a general sense, that of the physicians. The ten counties contain six hospitals located in four communities possessing a total of 173 beds and admitting a total of 5628 patients last year. This is an average of one bed for every 610 people, or a ratio of 1.43 beds per 1000 population. By comparison, the whole state has a ratio of 1.5 beds per 1000 popula- tion and the average for the whole nation was 3.3 beds per 1000 population. The six hospitals in question are small, general-ser- vice hospitals, privately owned, and with a semi-closed staff. Insofar as I am aware, there is only one specialist in the area. With the exception of the state subsidization of the private hospitals, there is no other provision in this area for the indigent or near-indigent sick.

The problem of disease prevention is a de- rivative or outgrowth of the health mainte- nance problem. It was only natural that the inherently high cost of health maintenance — both in respect to money and life — be re- lieved by attempting to remove the hazards which caused or hastened the “break down” in the “human machine.” The responsibility for disease prevention should be shared joint- ly by the organized public health services and the allied medical profession. It is child- ish thinking to believe that the responsibility rests solely with one or the other of these two systems; in disease prevention these two services are not competitive but complemen- tary.

Eight of the ten counties represented here today have a formal full-time health service. Yet, in every case two counties share a health officer. No doubt, this, as well as other staff problems, is due to the exigencies of the war. It goes without saying that the unorganized counties should have the benefit of a full-time public health service. The major public health problems appear to be venereal disease con- trol, tuberculosis control, and maternal and child hygiene services. However, the formal organization of a county health department

is, in itself, no assurance that a sound and efficient public health service will be forth- coming.

Lastly, health promotion is the newer con- cept of public health. Even at their best, health maintenance and disease prevention are nega- tive and static, whereas health promotion is positive and dynamic. The objective of health promotion is to develop the greatest possible yield from the inherent potentialities of the human organism. To accomplish this one must apply methods of development, adaption and correction, as required. The responsibility for this service is broad, but fundamentally it must be divided between the medical pro- fession, organized public health services and the educational systems.

THE PROGRAM

The program necessary for solution of the aforestated rural health problems might be summarized under four titles ; namely, ex- panded medical service, organized public health service, health education, and improved general economic conditions. It might be truth- fully stated that improved general economic conditions could almost single-handedly solve the whole problem.

The problem of adequate medical service is fundamentally one of economics. Under pres- ent conditions it is questionable if this area could support enough physicians to bring the ratio to one physician per 1000 population. Medicine, like any other business, is largely governed by the law of supply and demand. However, there are ways and means of im- proving the situation concomitantly with (not independently of) the general economic eleva- tion of the population. In essence, this means the simultaneous creation and operation of a system of hospitalization and medical educa- tion for the state. In my opinion, a medical school program and a state hospital pro- gram are not independent alternative solu- tions to the problem, but rather the medical school program and the hospital program are complements of a single solution.

The public health program is so well es- tablished in the state that it might appear superfluous to dwell upon the point. However, it seems to me that two points need clarifi- cation, The first point is that the “house is no better than the material out of which it is built” and a public health program is no better than the quality of its personnel. In my

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humble opinion a health department should not be an asylum for professional misfits in the medical, nursing and engineering pro- fessions. Any county with a public health problem, regardless of its economic and politi- cal prominence or obscurity, is entitled to competent public health workers. It is the “backward” and “borderline” counties which have need of the most efficient and competent personnel, but all too often they are the ones which get the “second rate” workers. It is the second point is like unto the first; namely, if a county has a competent and efficient pub- lic health staff, that staff should be given a high degree of autonomy. During the last ten years there has been a growing tendency to centralize public health service in the state. There can be no argument with such bureau- cratic methods where the field staff is in- experienced or incompetent, but with the right kind of a field staff, decentralized public health service is the superior service. The people in these ten counties should demand a public health program commensurate with their pub- lic health problems and not accept an inferior substitute.

As previously stated, education is the natural enemy of public health problems. However, the elevation in the general educational standards, while unquestionably beneficial, is in itself not sufficient; it must be supplemented by special- ized health instruction. The term, “health edu- cation,” is confused in the public’s thinking. In the past it has been treated as a step-child by both our educational system and our public health services. Our schools have given it lip service and simultaneously violated its spirit, while our public health service has used it as

a cloak for propaganda purposes. It is hearten- ing to see a current concerted effort being made by the State Department of Education and the State Board of Health to organize this important field in public health.

Finally, an improved general economy is necessary for an improved public health, and vice versa. Pills and inspiring words can never substitute for food and shelter. Any measure which will increase the net family income will elevate its health status. This is, in essence, the purpose of the Rural Life Council, and it needs no further amplification at this point.

PROGRESS

It is too early to report any material prog- ress in the solution of the rural health prob- lems in this area. The greatest of all progress has been made by organized public health ser- vice, but much remains to be done. It appears that the state has been stirred by the crying needs in the field of medical service anti 4here is an undercurrent trend toward a state hos- pital and medical educational system. There is a strong sentiment and an increased inter- est in the problem of health education. The joint action of the State Department of Edu- cation and the State Board of Health in this field is making gradual headway. Finally, the postwar planning and industrial program fop Mississippi and the resurgent interest in the problems of agriculture all point to an im- proved regional economy.

Let us hope that our leaders will not be- come so engrossed in a single phase of the problem that they will lose their perspective for the overall picture. Let us not be guilty of not being able to see the forest for the trees.

American Red Cross chapters throughout the nation will be permitted to recruit blood donors for civilians under a program announced by National Chairman Basil O’Connor. The blood collected and the blood derivatives pro- duced will be made available without cost to physicians, hospitals, clinics and patients. This civilian program is entirely separate from the Blood Donor Service operated by the American Red Cross for the armed forces, and the civilian program will be available to chapters through the five Red Cross area offices.

Familial Progressive Muscular Dystrophy*

In three generations living in the same

NEIGHBORHOOD

W. A. EVANS, M.D., and C. H. LOVE, M.D. Aberdeen, Miss.

The Moffett Family

Case One. E. C. M. Twelve-year-old, rosy- cheeked, bright-eyed boy. Superficially observed, appears to be well developed mentally and even physically.

When this boy was about seven years of age and in his second year at school, it was noticed that he could not get into the school bus unless he had the help of the driver. His mother had some idea of the meaning of this weakness from her observation of the disease in some of her brothers, her maternal uncles, and her maternal cousins. The weakness in- creased so rapidly that it became necessary for the boy to stop school. There was no pain or tenderness or fever or other constitutional reaction. The disease was most marked in the muscles of the lower legs. It presently affected the muscles of the upper legs, the back and the arms. Although the muscles were so weak that the boy could not step up, or climb, or run, or jump, or walk any long distance, they appeared to be larger than normal. In the course of time the feet developed a tendency to toe-in and to turn downward so that the boy stood pigeon-toed or on his toes. No other tendency to contractures or spasm was noted. The boy fell frequently, but it was a slumping-down that did not expose him to danger of fractures. He would get up and try again, not much harmed or discouraged from the fall.

Due to involvement of the muscles of the back he had a characteristic exaggerated lum- bar posture. Appetite good, digestion good, functions of organs of thorax and abdomen not interfered with, vision good.

This boy was taken to clinics for examina- tion twice.

He was examined by Dr. H. B. Boyd in Mem- phis for the Mississippi Crippled Children’s Service in August, 1941. Dr. Boyd reported on August 29, 1941. “This child has a pseudo- hypertrophic muscular dystrophy. There is no orthopedic treatment. Has also been seen by Dr. Hamilton who is placing him on a high vitamin E diet. Has asked that the child re- turn in thirty days.”

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Dr. R. A. Knight examined this boy under the same auspices at Tupelo, March 25, 1943, seventeen months later. He wrote Dr. Boozer at Amory, Mississippi: “Gradual progression of the syndrome. Gower’s sign positive, some weakness in shoulder girdle. No treatment ad- vised. Diagnosis, pseudo-hypertrophic dystro- phy. To be seen at yearly intervals. There is gradual progression of the muscular disease and patient is now unable to arise from the floor and cannot lift his head from the bed. Obtained no benefit from vitamin E prepara- tion. No treatment advised.”

In January, 1945, the boy can hold his head up and can walk around somewhat both outdoors and indoors.

Case Two. Howard, now (January 1945) ten years old. Disease started when this boy was in his eighth year and in his second year at school. His difficulty in getting into the school bus called attention to the developing disease in this boy.

In this case there is no pseudo-hypertrophic feature. It is following the more typical course of progressive muscular dystrophy affecting about the same groups of muscles that were affected in the older boy. With that exception, what was said of the disease in the older boy applies. This one was not taken to any clinic and vitamin E pills were not tried on him. He is a ruddy-cheeked, well-nourished boy, bright and clear-eyed on superficial ex- amination.

Case Three. Walter, nine, years of age. In infancy this boy was noted as having very large intestines. There was constipation and much gas. For this condition the baby was taken to Dr. Williams in Aberdeen and Dr. Murfree in Amory. The condition was con- sidered to be congenital. It has improved and at the present time causes little trouble, but is responsible for an abnormally large abdomen and some resultant lumbar lordosis. The boy is ruddy, well-nourished and apparently in good health.

He is now two years older than his brothers were when they developed symptoms of pro-

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Familial Progressive Muscular Dystrophy — Evans and Love

July, 1945

gressive muscular dystrophy. The parents think he will escape and they have had ex- perience enough to qualify them as judges.

The fourth child, a girl, Dorothy Lou, aged seven years, is a healthy well -nourished child with no symptoms of progressive muscular dystrophy.

Case Four. Fifth child, a boy, Jerry, six years old. The disease is beginning to develop in this boy’s lower legs, having started after his fifth birthday. As in the case with the second boy, the disease is not of the pseudo- hypertrophic type.

The sixth child, James Edward, four years old, child is entirely normal. None of the children developed symptoms at four years of age. There is no way to tell whether or not this boy will escape.

The seventh child, Carroll, thirty-two months old, as in the case with the sixth child, is bright-eyed and healthy in appearance and nothing indicates whether he will or will not escape progressive muscular dystrophy.

The Meek Family

These are the children of Mr. Meek and his two wives who were sisters, named Carter. The first child was a son who died at seven- teen years of age from progressive muscular dystrophy. The symptoms of this disease were recognized when the child was seventeen years of age. His disease was of the pseudo-hyper- trophic type.

The second child, a daughter, remained in good health and became Mrs. Moffett, the mother of three affected and four unaffected children. After the death of the mother of these children, Mr. Meek married her older sister and she bore him four children.

The third, fourth and fifth children escaped.

The sixth child, a son who developed the disease at seven years of age, died at six- teen years of age.

The Tubb Family

The first, fourth, fifth, and seventh children escaped.

The second child, a son named Bennis, de- veloped progressive muscular dystrophy of the pseudo-hypertrophic type when he was nine years of age. He died from pneumonia at sixteen years of age.

The third child, Winfred, developed recog- nized symptoms of the disease of the pseudo -

hypertrophic type, at seven years of age. He died when twelve years old.

The Carter Family

Of eleven children, the first ten escaped the disease. The eleventh child, a boy, Robert, developed recognized symptoms of progressive muscular dystrophy when seven years of age and died at twenty-five years of age of the disease.

The Pickle Family

The first four children escaped. The first, a son, was born a deaf mute. He is now living and is about forty-five years old and in good health. He is married and has five children, three boys and two girls, all in good health and all normal as to speech and hearing.

The second child, a daughter, had two healthy children, a boy and a girl. She died six months ago, never developing any symp- toms of progressive muscular dystrophy.

The third child, a daughter, May, was born a deaf mute, but otherwise is normal and healthy. She is married and has two children, a boy and girl, both healthy and normal as to speech and hearing.

The fifth child was a girl, Mamie. When Mamie was between five and seven years of age, the family noticed that on the way to and from school her schoolmates had to carry her books. The road to school crossed a hill and after a few months it became necessary for her to quit school because of her muscular weakness. Within two years she was confined to her room, her chair and her bed. Her progressive muscular dystrophy was of the atrophic type. The wasting of the muscles of her legs and trunk became extreme as the years went on. Her posture became of the lordosis-square-shoulder type because of her need to use auxiliary trunk chest, shoulder and neck muscles. She had no contractures, no muscle spasms, tonic or clonic, no pains, no tenderness, no sensory phenomena and no con- stitutional reactions.

Her death certificate gave as the cause of death, “Immediate, acute endocarditis; con- tributing, paralysis,” age thirty-five years. Date: July 9, 1944.

We note that she suffered from the disorder for twenty-eight to thirty years. Her father is still living and is in good health at seventy- eight years of age. He has never had any symptoms of progressive muscular dystrophy.

July, 1945

Familial Progressive Muscular Dystrophy — Evans and Love

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So far as is known, none of his progenitors and none of his collateral relatives has ever had the disease. Mrs. Pickle was a Ray. After a life of reasonably good health, she died about five years ago when sixty-six years of age. The death certificate gave the cause of death as “pellagra.” One of us (W. A. E.) saw her in this fulminant rapidly fatal attack of pellagra. She never had any symptoms of progressive muscular dystrophy. There is no tradition of any case of muscular dystrophy in any member of the Ray or Pickle families and the families have lived for several genera- tions in this neighborhood.

Family Relations

In the case of the Moffett children, a super- ficial investigation of the family connections for five generations results as follows:

There is no family tradition of progressive muscular dystrophy in the Malone or Phillips families or any of their forbears or relations. This was the first generation developing the disease and the study covered superficially generations back of it.

In this generation, one ease developed and that is the youngest of seven children. In this generation, a Carter had married a Malone. There is no tradition of any other cases in Mr. Carter’s family or any of his forbears or relations. Of the children of the group of eleven, one son had progressive muscular dys- trophy and three daughters were the mothers of children who developed the disease.

In the next generation, two of the Carter sisters married Mr. Meek, one son of each sis- ter developed the disease, a son and daughter of the first wife escaped the disease, but the daughter bore three sons that developed it. Of the second wife, a son developed the disease and a daughter and two sons have escaped it. Mr. Meek says no progenitor of his or other relatives ever developed it. A Carter daughter married Mr. Tubb. Of the three Tubb sons, two developed the disease, one escaped. The four Tubb daughters escaped as have their children up to date. Mr. Tubb says that no progenitor of his ever had the disease.

In the next generation, a daughter of Mr. Meeks married Mr. Moffett. Three of their sons have developed the disease. Mr. Moffett says that no progenitor of his has ever had progressive muscular dystrophy. In this, the Moffett family, and their progenitors for at

least three generations, we find cases of pro- gressive muscular dystrophy as a familial sex linked disease affecting males only, trans- mitted only through non-affected females.

In each generation about one-half of the males escape and they never pass the disease on to their progeny. The affected males have no children. In each generation all of the fe- males escape the disease, but about one-half the females pass the disease on to their male children.

In the Pickle-Ray family the disease does not appear to be inheritable in either the di- rect or indirect sense. The case is a female.

Discussion

These are cases of progressive muscular dystrophy most of them of the familial type, sex-linked transmitted by clinically healthy fe- males to about half of their sons. The disease appears to a recognizable symptomatic extent of about five to ten years of age and death terminates life in the middle twenties or be- fore. The affected males do not beget chil- dren.

In the Pickle-Ray case, the person affected was a female. It was not passed on. Other than its sex relations and its familial character- istics, this case was identical with the other cases.

Etiology

No adequate cause of this syndrome is known. We limit ourselves to a discussion of one of the contributing causes.

Inheritance

Davenport says whenever the male parent is characterized by the absence of some charac- ter to which the determiner is typically lodged in the sex chromosome a remarkable set of inheritances is to be expected. This is called sex limited inheritance. The striking feature of this sort of heridity is that the trait appears only in males of the family; is not transmitted by them, but is transmitted through normal females of the family. Striking examples of this sort of heredity are found in cases of multiple sclerosis, atrophy of the optic nerve, color blindness, myopia, ichthyosis, muscular atrophy and hemophilia “(Not to mention normal conditions such as barring in Domineck and Plymouth Rock chickens, Polacheck says that growers recognized the hereditary charac- ter of the disease in 1879).”

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The Rh Factor as an Obstetrical Hazard — Patterson

July, 1945

A part of the very considerable literature dealing with this disease centers upon a dis- cussion as to whether it is a dominant or a recessive character. iSome hold that it is a dominant and in those generations in which

it is not found it is present but is so mildly symptomatic that it is overlooked.

The weight of the opinion is that it is a sex linked familial disease.

The Rh Factor as an Obstetrical Hazard*

CHARLES W. PATTERSON, M.D.

Rosedale, Miss.

he medical profession had seemingly ad- vanced to an unprecedented height when, by the great weapons of blood grouping, those barriers obstructing the safety of blood transfusions, were thought to have been sur- mounted. But, with the growing popularity of this life-saving method, many explosive re- actions began to occur from the mixing pot of those two liquids that normally should have been compatible and the increased scientific investigation which followed soon uncovered many interesting facts.

At Bellevue Hospital in 1937, a patient with pre-eclampsia was delivered of a macerated fetus and given a blood transfusion from a donor of the same type. The transfusion was followed by a severe reaction. After investiga- tion Philip Levine and his co-workers found that the patient’s blood contained an atypical glutinin which agglutinated about eighty per cent of all blood in this group.

In 1940, Landsteiner and Wiener discovered the Rh factor, the name being selected from the first two letters of the word “rhesus” (Rh). They derived an immune agglutinin which could be produced in rabbits or guinea pigs by repeated injections of the red cells of the rhesus monkey. By using this rabbit or guinea pig immune serum and suitably mix- ing it with human red blood cells, they were able to subdivide each of the four groups of human blood into two classes; the Rh posi- tive and the Rh negative. If there is an ag- glutination similar to that which occurs when the red cells from the rhesus monkey are mixed with the immune serum, it is known as positive Rh blood. If there is no agglutination, then it is negative Rh blood. The Rh factor is inherited as a Mendelian dominant, and it is either heterozygous or homozygous, depending

upon whether inherited from one or both par- ents.

Since the discovery of the Rh factor and the elimination of many preventable reactions that were caused from blood transfusions, our efforts should be focused now on the dangers confronting the mothers and infants when an Rh negative woman is married to an Rh posi- tive man. Frequently the Rh negative mother carries her first Rh positive baby to term and a successful delivery of a healthy child. The first pregnancy usually builds up a small per- centage of antibodies in the mother, and then each succeeding pregnancy increases the im- munization which produces more anti-agglu- tinins in the mother until the titre of Rh anti- bodies is raised to the level that produces erythroblastosis fetalis. Since the Rh factor is only present in the red blood cells, there must not only be an intermingling of the ma- ternal and fetal blood through the placental barrier, but an actual passage of the red blood cells from the mother to the fetus and the fetus to the mother, so that when the fetal red blood cells enter the maternal circulation, the action is as an antigen and causes the de- veloping of the anti Rh agglutinins which must then pass through the placenta to the fetal circulation with hemolysis of the fetal red cells and the development of the disease entity of erythroblastosis fetalis. If the father is heterozygous there is a slight possibility that the fetus will not contain an antigen and there- fore could not be agglutinated, which makes it possible for an Rh negative mother, when bearing twins, to have one entirely normal child and the other die from erythroblastosis fetalis.

Having recently had experience with a very interesting case, I will next give the case re- port.

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Case Report

Mrs. K. O. S. : Color white, female, age 30 years, married eight years. Past health has been exceedingly good, only having had the usual childhood diseases such as measles, mumps, chicken-pox, and tonsillectomy. A com- plete obstetrical record of this case will be presented that you may observe the manner in which the Rh factor, slowly but surely, works its hazard through multiple pregnancies of the Rh negative woman married to an Rh positive man. This woman has been pregnant three times and is the mother of two healthy living children and two dead infants.

First Pregnancy: On March 21, 1939, af- ter a normal nine months pregnancy, she was delivered of a normal baby boy weighing seven pounds, four ounces. At the present time he is living and in good health.

Second Pregnancy: From the beginning she suffered with more than the usual complaints of pregnancy until May 1942, when five months had lapsed, I was called and found her suffering from severe pains with intervals of about three minutes between uterine contrac- tions. After treatment and several weeks’ rest in bed, she went to term and was delivered on September 17 of twin girls weighing six pounds, the larger, and four pounds twelve ounces, the smaller. Within forty-eight hours both babies showed slight jaundice, but while the larger soon became normal, the smaller continued to become more jaundiced and anaemic until death, which occurred on the fourteenth day, re- gardless of special nursing care and treatment.

Third Pregnancy: The first examination on March 20, 1944, revealed a three-month preg- nancy and a very anaemic patient with a blood pressure of 96/50. After internal administra- tion of liver extract and iron to April 11, the laboratory report showed hemoglobin, 80 per cent, total red cells, 3, 500,000; white cells, 6,800: small mononuclear, 30 per cent; large, 4 per cent, neutrophils, 60 per cent; malaria negative; urine, normal. Following this report, the liver extract was given by needle for several weeks which caused her to appear and feel much improved even though the blood pressure continued at the same level of 98/52 until July 7, when it suddenly went to 130/80 with the urine very dark amber-colored but otherwise negative. After twenty -four hours of absolute rest in bed, strict diet, treatment

with no improvement, and a laboratory re- port of hemoglobin, 60 per cent; red cells, 3,100,000; white 10,000; small mononuclear,, 22 per cent, neutrophils, 74 per cent; urine, negative chemically and microscopically but very dark in color, I decided to call Dr. E. R. Nobles in consultation.

After a thorough study of the case, we de- cided that she should be given a blood trans- fusion, so July 9, from a properly typed and cross matched donor, 500 cc. of citrated blood were given and completed at 11:00 a. m. At 11:45 she had a hemolytic reaction with rigors, excruciating pains of the head, extremities, and over the cardiac region, also the sensation of a vise compressing the thorax with difficult respiratory action. Examination revealed a very irregular weak heart which gradually be- came normal after the administration of adren- aline, morphine, and oxygen. Following a very restless afternoon, although slightly over six months pregnant, she was delivered at 11:00 p. m. of a dead female [baby with the appear- ance of having no blood in the body and an extremely large pot belly, also ecchymotic spots on the buttocks, legs, and arms, with slight edema. The placenta was not only tre- mendous in size but had the consistency of jelly. The total amount of a twenty-four hours’ specimen of urine, to July 10, was only two ounces and contained blood, pus, albumin. She was then given 1,000 cc. of 10 per cent dextrose solution intravenously twice daily un- til there was a sufficient daily output from the kidneys. But on July 16, because of continued nausea, vomiting, pains in the head, and elevated temperature, Dr. Nobles and I de- cided, after a thorough examination, that she was suffering from a localized peritonitis, al- though delivery was accomplished without a vaginal examination, so we began a treat- ment of 10,000 units of penicillin every three hours intramuscularly. She seemed very much improved on July 18, but the following day a general peritonitis had developed and with it a very ill patient. It was than that 100,000 units of penicillin were given in 1,000 cc. nor- mal saline solution by the drop method in- travenously and completed after a period of three hours. At this time, Dr. R. A<. Gamble arrived and, after consultation, we agreed to ' continue the penicillin in 20, 000-unit doses in- tramuscularly every three hours and also give daily treatments with the Elliott machine.

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The Rh Factor as an Obstetrical Hazard — Patterson

July, 1945

The improvement was very gradual until she fully recovered and was discharged from the hospital on July 30.

Laboratory tests showed the blood of the father and the donor to be Rh positive, but that of the mother, having Rh positive cells from the donor in the circulation when sent to the laboratory reacted against the anti-Rh testing serum, as always happens, so the blood must be classified from the past clinical rec- ord.

If we consider the normalcy of the first pregnancy and child, the abnormalcy of the second with the death of one twin presenting all the symptoms of erythroblastosis fetalis, then the last pregnancy and the hemolytic re- action from an Rh positive blood transfusion followed by the birth of a six-and-one-half- month dead baby with erythroblastosis fetalis, surely there could be no doubt as to this mother having Jth negative blood. It is also a clinical fact that the father is heterozygous; otherwise, one twin could not have survived.

CONCLUSION

I will endeavor to enumerate a few of the recent trends of thought.

I. Eclampsia is related to a blood incom- patibility of the fetus and mother. The fetal erythrocytes being agglutinated in the ma- ternal circulation by specific agglutinins pro- duced by the immunized mother cause liver and kidney damage with the ensuing symptoms of pre-eclampsia and eclampsia.

II. If an Rh positive mother carries an Rh negative fetus the Rh antibodies may enter the maternal blood and destroy the red cells, causing a post-partem anemia.

III. The Rh factor is an antigenic substance

similar to others previously discovered and occurs only in the red cells, also there are no normal agglutinins against it.

IV. It is thought that placental injuries are the cause of the passage of red blood cell3 from the one to the other, but I believe it is the action of the antibodies and antigenic sub- stances within the placenta that creates the degenerative change by which this passage is accomplished.

V. Eighty-five per cent of all persons are Rh positive and cannot be immunized against the Rh factor. However, the fifteen per cent belonging to the Rh negative classification and occurring equally between the two sexes may acquire specific anti-immune bodies, and be- cause of this fact serious complications may develop. Pregnancy and repeated transfusions increase the Rh agglutinins, but pregnancy provides a far better antigenic stimulus than repeated transfusions.

The Rh positive fetus must inherit the factor from the Rh positive parent or the antigen- antibody response will not occur in the fetus.

VI. If an Rh negative woman is married to an Rh negative man and is impregnated with an Rh negative baby, then the antigens being of the same group will be neutral and not cause a hemolytic reaction, so she will give birth to a normal Rh negative child.

The same results will be had if repeated blood transfusions are given by properly matched and typed blood of the same Rh group.

Artificial insemination of the same Rh group, where the mother is Rh negative and father Rh positive, will prevent erythroblas- tosis.

All higher motives, ideals, conceptions, sen- timents in a man are of no account if they do not come forward to strengthen him for the better discharge of the duties which devolve upon him in the ordinary affairs of life.

— Henry Ward Beecher (1813-1887)

Thiouracil*

A. STREET, M.D. Vicksburg, Miss.

Kennedy and Purves in 1941 showed that rapeseed and ally! thiourea are potent goitrogens. Later the MacKenzies and Mc- Collum and Astwood showed that thiourea and thiourea derivatives, especially2 thiouracil, pro- duced morphologic hyperplasia, associated with inhibition of thyroid function1 and Astwood employed thiouracil in the treatment of pa- tients with toxic goiter.

There is now ample evidence that thiouracil can be depended upon to reduce thyroid ac- tivity of both the toxic and normal patient. The drug seems to stop the production of the thyroid hormone. Thyroxin already present be- fore stopping production is very slowly dis- posed of by the body processes, and therefore considerable time may be expected to elapse between the beginning of medication and the fall in metabolic rate. In dealing with toxic patients it usually requires three to eight weeks for the rate to fall within normal range.

Unfortunately the drug has serious proper- ties which have been manifest in five to twenty per cent of reported cases. The most serious toxic reactions are the result of bone marrow damage and consist of agranulocytosis, granu- locytopenia and leukopenia. This type of re- action may be incontrollable and fatal cases have occurred. However, the more serious type of toxic reaction is comparatively infrequent and the majority of reactions are not so im- portant. They include jaundice, drug fever, swelling of submaxillary salivary glands, dermatitis, arthritis and arthralgia, oedema of legs, nausea and vomiting, and diarrhoea.

Williams and Clute2 report results in the use of thiouracil in the management of 152 hyperthyroid patients, fifty-nine of whom were subjected to subtotal thyroidectomy after con- trolling the symptoms with thiouracil. Some patients with malignant exophthalmos showed an exacerbation of that symptom shortly after starting thiouracil. This was successfully com-

batted by giving dessicated thyroid in con- junction with the thiouracil. Dessicated thy- roid was also found to have a tendency to re- duce the size of the thyroid gland. Iodine was administered along with thiouracil to some patients pre-operatively in order to diminish vascularity of the gland at operation. Thiamin and brewers’ yeast were added to the treat- ment in an attempt to combat the possibility of leukopenia. The size of the gland and the micro- scopic picture of the toxic thyroid is not al- tered by thiouracil.

Our own experience with thiouracil has so far been very satisfactory. Of fourteen cases treated there has been only one toxic reaction which consisted of slight fever and skin erup- tion. Toxic thyroid symptoms have been well under control after three or four weeks of medication, subtotal thyroidectomy has been well tolerated, postoperative crises have been absent, and vascularity of the gland has not been troublesome. Frequent clinical observa- tions and blood examinations have been done during thiouracil treatment.

Thiouracil does not seem to be a medical cure for hyperthyroidism. It does not attack the cause of the disease, but it does stop the synthesis of the thyroid hormone and controls the symptoms. On stopping the drug the symp- toms will recur. It does not seem wise to con- tinue the drug indefinitely because of its toxic properties. Except for the small but definite risk of serious toxic reaction thiouracil seems to be the most efficient drug yet developed for the control of hyperthyroid symptoms and for preparation of thyrotoxic patients for surgical treatment.

BIBLIOGRAPHY

1. Gargill, S. L. and Lesses, M. F. : (‘Toxic Reactions

to Thiouracil,” J.A.M.A. 127: 890 (April 7) 1945

2. Williams, R. H. and Clute, H.M. : ‘‘Thiouracil in

the Treatment of Thyrotoxicosis,” J.A.M.A. 218:

65 (May 12) 1945.

When egotism goes out, true philosophy en- ters the soul.

— Anderson M. Baten

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376

Editorials

July, 1945

The Mississippi Doctor

Published monthly at Booneville, Mississippi Entered as second-class matter, January 19, 1926, at the post office at Booneville, Miss., under the Act of March 3, 187u. Annual subscription $1.00.

The journal with a vision which encourages a plan of delivering modern medicine to the masses at less cost to the individual and more profit to the prac- titioner. It champions the community hospital, the hub around which this service must be built.

Official Organ Of

Mid-South Postgraduate Medical Assembly Mississippi State Medical Association

W. H. ANDERSON, M. D Editor-in-Chief

MILDRED P. ANDERSON Assistant Editor

David E. Guyton, Blue Mountain College Poet

Mid-South Postgraduate Medical Assembly Officers :

C. H. Lutterloh, M. D. President

Hot Springs, Ark.

J. C. Pennington, M. D President-Elect

Nashville, Tenn.

L. S. Nease, M. D Vice-President

Newport, Tenn.

John Archer, M. D Vice-President

Greenville, Miss.

John A. Moore, M. D Vice-President

El Dorado, Ark.

A. F. Cooper Secretary-Treasurer

Memphis, Tenn.

Gilbert J. Levy, M. D Director of Exhibits

Memphis. Tenn.

Editors :

Fay H. Jones, M.D. E. M. Holder, M.D.

C. R. Crutchfield, M. D. C. M. Speck, M.D.

H. King Wade, M. D. F. M. Acree, M.D.

Mississippi State Medical Association Editor

Lawrence W. Long, M.D.

Associate Editors

J. G. Archer, M.D. W. Lauch Hughes, M.D.

Manuscripts and material for publication under the Mississippi State Medical Association should be re- ceived not later than the twentieth of the month preceding publication. Address material to Lawrence W. Long, M.D., Suite 412 Standard Life Building, Jackson. Mississippi.

TO HAVE OR NOT TO HAVE

About the most important question before the people of Mississippi right now is whether to have a four-year medical school or not to have one. For forty-two years this state has had what has been recognized as one of the best two-year schools in any state. Not long ago there were ten two-year medical schools in the United States, but only three or four

are now left, the others having been advanced to four-year schools or subsidized by another school. Some claim we do not have the clinical material for the other two years, but this is not true. It is not the number of clinical pa- tients that counts; it is how well the few are utilized for teaching purposes. Mississippi has a per capita distribution of funds for the in- digent sick. This is the biggest step forward ever made for the rank and file. And with a central hospital and medical school used as a means to apply medical service, clinical ma- terial from all over the state could be utilized for teaching purposes, all that is needed. Of course there must be an affiliation between the central hospital and all hospitals of the state. Interns might serve their last six months in the smaller hospitals over the state, making calls with practitioners who know clinical medi- cine, and finally find a place of leadership in the small town. In the big centers today interns are taught so much in terms of ex- pensive operating rooms, nurses, assistants, number and chart system of management, limited office hours, and big fees, that it is impossible to induce one to return to the country.

With the hospital system we have, insurance could be made available to the entire state, or a large portion of it. Many believe that we have to have a five-hundred-bed hospital if it it is to be operated economically. What about the expense to the patients who travel all this distance to the hospital ? Here is where the one- sided economist comes in. Nevada has the highest number of beds per population in the union, but poorly distributed, and she has the highest death rate for appendicitis in the na- tion, more than twice that of Mississippi. Dr. Time is the most successful surgeon this coun- try knows for acute appendicitis and many other conditions. Therefore a system of small hospitals and a plan of education for the laity will eventually assure an operation for acute appendicitis within six hours of the onset.

It is not the big hospital that we need; it is a better distribution of beds and the avail- ability of them to the very sick patient. Fur- thermore eighty-five per cent of the people of Mississippi get sick and die of ordinary diseases which should be handled just as well by eighty-five per cent of the rank and file of doctors. When both physicians and patients analyze the specialist’s strategy in “I am the only one who can do it” and “I must have

July, 1945

377

him in a five-hundred-bed hospital so more in- terns can see- me operate” it becomes obvious that his method is self-advertising. The time has come, medically speaking, that the people need to be able to get just a plain shave in- stead of a lot of expensive mud massages. A hospital in Mississippi does not have to be equipped for every kind of therapy known, nor does the medical school. Richmond, Ro- chester or Boston may still have a chair for aneurysm of the circle of Willis or Simmond’s disease. We shall continue to affiliate medical- ly with the rest of the world, even if we do have a medical school to serve ninety-five per cent of our population.

Others say, Give us a better hospital system first and then some time you can have the four-year medical school. Yes, but we have about decided now that we have waited forty- two years too long for a four-year medical school. A post office that does not deliver mail out to the folks on the rural route would not be tolerated; and yet we have a lot of medical schools that are content with just giving a diploma. Mississippi can have a school that can show the way to a better day in medicine for the people. If Tennessee can have three schools, Louisiana two, and Virginia two, why can’t we have one? The Lord is pouring out the oil in our state maybe just for this purpose. We have thirty millions in cash, and we al- ready have the best distribution of hospitals in the United States although they need to be improved a lot.

Some few seem to be afraid of a central hospital at Jackson. This is false fear. The idea we have of a four-year school and a hos- pital affiliation will help every doctor in the state, every town and every individual. The system we are thinking of will give more practice to every doctor and better service to every individual.

Our state is now drained from every side of the best practice, but with the proper ex- tension consultant service this would not be the case.

If our two-year school has to go, which we think it will probably soon, then we shall be indebted to other states as far as training our fine boys is concerned.

Last fall we asked Dr. Fishbein what he thought of our state having a four-year medi- cal school and he replied, “If we are to con- tinue to have states as units of government, I think you should have it.” We considered this statement fine food for thought.

It has been suggested that we send our Negroes up in Tennessee and get some Negro doctors “which is about all we need.” A few good Negro doctors would be fine, but have we stopped to think that our Negro population might not remain as it is very long? Finger picking of cotton is on its way out and indus- try in Mississippi is already in. This may change the color of our population.

Anyway we think Mississippi should have a four-year medical school used as a means to an end and the end would be to build total health assets, mental, physical, and spiritual in all the people.

§

Dr. Seale Harris, the spirit of Southern medi- cine, is writing a book on Dr. Marian Sims of Alabama, the father of gynecology. Every doctor will be anxious to have a copy of this book as well as his book on Dr. Banting. Dr. Harris has prepared an article on the life and work of Dr. Sims for the Alabama State Medi- cal Journal and he has very kindly sent it to us also. Our readers will be delighted to read what Dr. Harris has written on this international character in the field of gynecology. This will appear in the August and September issues of The Mississippi Doctor.

The casualty list among our doctors in civil life is keeping step with the rate on the battle- field. It is probably exceeding the combat list. Our doctors have displayed great patriotism and loyalty to duty and determination of pur- pose in their efforts to hold the civil firing lines in practice while their younger fellow doctors do their duty in a wonderful manner in the battle arena. Glory and honor to them.

In the death of Dr. S. J. Wolferman of Fort Smith, Arkansas, the Mid-South lost a fine spirit in the field of medicine. He was able in his profession, cordial in his relations to his fellow doctors, and always ready to give liber- ally of his time to organized medicine. Dr. Wolferman served on the council of the South- ern Medical Association, and was always active in the Mid-South Postgraduate Medical As- sembly. He was a delightful man to know, reasonable, cordial, and fair-minded. We deep- ly regret his going.

§

New Orleans has long set a pace in Southern medicine. Dr. Rudolph Matas is the medical sage of New Orleans, the dean of the surgical

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world, the master medical spirit of the last half century. But there was another in New Orleans, one very popular, very efficient, very able and self-sacrificing, Dr. James T. Nix, whose untimely death is mourned. Loved and revered, he was a great inspiration to the profession. He truly possessed the heart, the spirit and the mind of a true doctor, a great surgeon. He was not only loved in his own city, but he was known and admired through- out the South. A great surgeon, an able writer, and a powerful Christian spirit has left us, truly another war casualty. We are happy to have claimed him as a friend, and to have felt the power of his personality.

Dr. M. Y. Dabney, president-elect, Southern Medical Association, Birmingham, has an- nounced his appointments to the Council, ef- fective at the close of the annual meeting in November. From now until the annual meet- ing these names will be carried on the official roster as councilors-elect.

Florida — Dr. William C. Thomas, Gainesville, to succeed Dr. Walter C. Jones, Miami.

South Carolina — Dr. W. L. Pressly, Due West, to succeed Dr. J. Warren White, Green- ville.

Texas — Dr. Walter G. Struck, San Antonio, to succeed Dr. Curtice Rosser, Dallas.

Virginia — Dr. T. Dewey Davis, Richmond, to succeed Dr. Thomas W. Murrell, Richmond.

SOUTHERN MEDICAL ASSOCIATION EXECUTIVE COMMITTEE MEETING

The Executive Committee of the Council of the Southern Medical Association met at the Tutwiler Hotel, Birmingham, Monday, May 21, and went on record as favoring the usual an- nual meeting this year unless conditions in- dicate that a meeting should not or could not be held. The Executive Committee named a committee of three to handle a request to the Office of Defense Transportation for per- mission to hold the regular meeting in Novem- ber. Members of this committee are Dr. Oscar B. Hunter, chairman, Washington, D. C. ; Dr. James S. Simmons, Brigadier General, Medi- cal Corps, U. iS. Army, Washington, D. C. ; and Mr. C. P. Loranz, secretary and general manager, Birmingham, Alabama.

It was decided that it would not be proper in these war times to have non-medical ac- tivities, social, semi-social or entertainment

activities. If the meeting is held in November, there will be no president’s reception and ball, no alumni reunion dinners, no fraternity lunch- eons and no golf or trapshooting tournaments. There will also be no meeting of the Woman’s Auxiliary, since it is a semi-social organization. All Auxiliary officers will be held over until another year.

Two of the distinguished physicians attend- ing the Executive Committee meeting of the Southern Medical Association presented papers : Dr. Curtice Rosser, Dallas, Texas, “The In- fluence of Race on Ano-Rectal Diseases,’’ and Dr. Oscar B. Hunter, Washington, D. C., “The Clinical Significance of the Rh Factor.”

MEDICAL SEMINAR

An illustrated lecture seminar integrating the patho-physiological reactions of the hu- man being to the environment, and covering a wide range of medical problems of interest to the practicing physician, will be conducted by Dr. William F. Petersen commencing Mon- day September 17 and extending through Sep- tember 22. Sessions will be held from 9:30 to 4:30 each day in the Conference Room of the Institute of Medicine, Chicago. Detailed infor- mation, program, registration applications, can be obtained from the Secretary, Institute of Medicine of Chicago, 86 Randolph Street (Crerar Library Building) Chicago, 111.

All the people in our state deserve medical service. All can have it just like they have daily mail, farm service, public education, hard-surface roads and electric lights. They will if we establish a medical school to be used as an end, the object being to give all the people the best possible in medicine. The big medical schools have been too largely satisfied with just issuing a diploma and have not yet caught the vision of medical service to the people.

ANNOUNCEMENT

The Vicksburg Hospital, Inc., and the Vicks- burg Clinic announce the appointment of Dr. Robert M. Moore, professor of pathology and clinical laboratory, University of Mississippi, School of Medicine, as pathologist and director of clinical laboratories, June 4. 1945.

It is said that a river becomes crooked fol- lowing the line of least resistance. So does man.

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Deaths

dr. J. T. NIX

Dr. James T. Nix, New Orleans, Louisiana, died in May of this year at the age of 58. He was a graduate of Tulane University, (M.D.), Loyola Uni- versity (M.A., LL.D.). Dr. Nix served on the surgi- cal staff with Dr. Rudolph Matas several years, professor of surgery of Loyola, dean of Louisiana State Medical School, held many important civic and professional connections, member of numerous fra- ternities and medical societies, author of several treatises, poems and scientific articles. Dr. Nix was one of the most devoted of men to his profession, and one of the most beloved.

Dr. Nix is survived by his wife, a son and a daughter.

DR. WALTER FRANK COLEMAN

Dr. Walter Frank Coleman died June 12, 1945, at his home at Hickory Flat, Mississippi, at the age of 60. He had been ill several months.

Dr. Coleman was born at Wallerville, Mississippi, was graduated from the University of Tennessee School of Medicine in June, 1915. He practiced medi- cine in Tennessee before moving to Mississippi. He was a leader in religious and civic activities besides having served as president of the North Mississippi Medical Society in 1939.

Surviving are his wife, Mrs. Ada Caldwell Cole- man, a brother, I. M. Coleman, of Columbus, Miss., and a half-sister, Mrs. Clara Cornelius of Texas.

DR. SAMUEL H. HOWARD

Dr. Samuel H. Howard died at the home of his daughter, Mrs. Pugh Winborn, Durant, on June 19, 1945. He was 81 years of age. A pioneer citizen of Durant, Dr. Howard practiced medicine at A. & M. College for eight years, then operated a hotel for a number of years. He was a graduate of Memphis Hospital Medical College, Memphis, Tennessee.

Dr. Howard is survived by his daughters, Mrs. Winborn, and Mrs. E. H. Archer, of Nebraska; and two sons, D. M. Howard and B. H. Howard, of South Carolina.

DR. CLAUDE T. KEYES

Dr. Claude T. Keyes, born at Fulton, in 1870, died May 7 during an operation at a hospital in San Angelo, Texas. He was a member of one of the pioneer families of Lee and Itawamba Counties, a graduate of Memphis Hospital Medical College. He moved to Texas in 1911, and carried on an active practice until his health failed in recent years. He leaves six children, all living in Texas. Four sisters also survive: Mrs. D. S. Ballard and Mrs. George Thompson, both of Tupelo; Mrs. Wylie Frances of Nettleton and Mrs. Lige Ballary of Dallas. Services were held in San Angelo.

DR. C. M. DAVIS

Dr. C. M. Davis, 76, pioneer Laurel physician, died May 22.

Dr. Davis came to Laurel from Louisiana at the age of 24 soon after completing his medical training and had practiced there ever since. Dr. Davis was a graduate of Vanderbilt University, Nash- ville, Tenn. He operated a large clinic for several years. He leaves his widow and two sisters, Mrs. N. P. Vernon, Amite, La., and Mrs. A. W. White- man. New Orleans.

DR. C. W. PATTERSON

Dr. Charles W. Patterson, who practiced medi- cine in Pontotoc and adjoining counties for many years, died at Grenada Hospital. He was 73 years of age. He was living at Crowder when he became ill. He received his education at Memphis Medical College, Memphis, Tenn., and was licensed in 1907 to practice in Mississippi.

Burial was at Pittsboro following services at Cal- houn City. Dr. Patterson was a member of pioneer families of Calhoun County.

DR. C. E. BOYD

Dr. C. E. Boyd, of Hatley, died of a heart at- tack at the Baptist Hospital in Memphis Saturday, June 9, after an illness of only a few days, although he had been in a run-down condition from over-work for sometime.

The- last rites were held from the Quincy Bap- tist Church Sunday morning at 10 o’clock, with burial in Quincy Cemetery. He was a member of the Amory Baptist Church. Born at Quincy in 1882, he was married in 1905 to Eda Phillips, who survives. In 1911 he graduated from the Medical Department of University of Alabama, which was located in Bir- mingham. That same year he moved to Hatley where he has been a popular practicing physician until he was forced to take his bed a week before he died.

Two children survive, Olga Boyd, of Hatley, and Mrs. Dixie Brewer, of Amory. He leaves two grand- children, Claude and “Kim” Boyd. Brothers surviving are Ethel and Floyd Boyd of Quincy, and Wayne Boyd of Dancy, Alabama.

DR. EDWARD A. GRICE

Dr. Edward A. Grice, 64, who died at his home in Epps, La., was buried at Palestine.

He spent his early life in Clay County, where he practiced medicine at Montpelier.

Survivors include his wife, Mrs. Nora Murry Grice, of Epps, La., one son, Wilson A. Grice of Point LaHash, La., two grandsons, Billy and Sonny Grice, and one sister, Mrs. Lillian Skinner of Cleve- land, Texas.

DR. S. G. SCRUGGS

Funeral services for the late Dr. S. G. Scruggs, who died in Memphis, were conducted from the First Methodist Church. Burial was in Odd Fellows Ceme- tery, following funeral service.

Dr. Scruggs was 96 years old and practiced in Grenada as a specialist for many years, before going to Memphis in 1934 to reside with his daughter, Mrs. J. L. Findley.

God will not look you over for medals, de- grees or diplomas but for scars.

The longer I live, the more deeply am I con- vinced that that which makes the difference between one good man and another — between the weak and powerful, the great and insig- nificant, is energy — invincible determination — a purpose once formed, and then death or victory.

— Fowell Buxton (1786-1845)

Interpreting Medical Literature

Staff of Review

Dermatology — James G. Thompson, Jackson.

Ear, Nose and Throat — Edley Jones, Vicks- burg.

Obstetrics and Gynecology — J. F. Lucas, Greenwood.

Orthopedics — Thomas H. Blake, Jackson.

Public Health — Felix J. Underwood, Jackson.

Pediatrics — Harvey F. Garrison, Jackson.

Radiology and Roentgenology— Karl O. Stin- gily, Meridian.

Surgery — W. H. Parsons, Vicksburg.

Urology — Temple Ainsworth, Jackson.

DERMATOLOGY

Archives of Dermatology and Syphilology, V. 51; No. 4; April, 1945, page 272.

Treatment and Prevention of Dermato-

PHYTOSIS AND RELATED CONDITIONS. Joseph G. Hopkins, Arthur B. Hillegas, Earl Camp, R. Bruce Ledin and Gerbert Rebell, Bull. U. S. Army M. Dept., June 1944, No. 77, p. 42.

The work described in this paper was done under a contract, recommended by the Com- mittee on Medical Research, between the office of Scientific Research and Development of the National Research Council and Columbia Uni- versity. The findings, which should not be con- sidered final, are stated somewhat categoric- ally for the sake of brevity.

Inflammation of the skin of the feet may re- sult from many causes, of which the follow- ing were recognized by these authors: mycotic infection, pyogenic infection, allergy, hyper- hidrosis, trauma and hypostasis.

The authors stress two principals of treat- ment: (1) hygienic measures, such as cleanli- ness, dryness and aeration of the areas in- volved and elevation of the feet to relieve hypostatic congestion, and (2) active treat- ment as such, which must avoid injury and vary with the causation and type of involve- ment. Fungi have been found in about 70 per cent of cases on intertrigo of the toes and in over 90 per cent of dyshidrotic lesions on the soles. The most effective treatment agents in such cases are those which attack the fungi. In general, iodine, a number of mer- curials, thymol, and several essential oils have seemed low in effectiveness and irritating in a significant number of cases. The dyes, too, appeared weakly fungicidal according to these investigators. Of the familiar fungicides, ben- zoic acid, salicylic acid and sulfur were the

most useful drugs. Ointments should be used only at night and wiped off thoroughly in the morning and a powder applied to the toes. The addition of 10 to 25 per cent bentonite to talc powder increases its absorptive quality.

In cas&s of a simple intertrigo, an ointment or paint should be applied to the sides and webs of all the toes and the entire sole every night until the skin appears normal and should also be applied once a week throughout the warm season, to prevent relapse. A benzoic acid paint is recommended among others, the formula for which is benzoic acid 5 gm. acetone 15 cc. and cotton seed oil 85 cc. For obsti- nate infections sulfur and salicylic acid oint- ments are recommended. For fissured and denuded areas an ointment of zephiran chlo- ride (10 per cent) 5cc., water 22 cc., hydrous wool fat 25 cc. and petrolatum 50 cc., was very useful. For some obstinate infections, 5 per cent sulfathiazole ointment succeeded when zephiran ointment failed to bring improve- ment. Potassium permanganate baths are recommended (about 1:4,000) for acute or overtreated dermatoses with dyshidrotic les- ions on the soles. Zephiran (200 cc. of 10 per cent concentration of zephiran chloride) in 2 liters of water proved to be a very effective non-irritating foot bath.

The follow-up treatment after the active lesions have subsided is stressed and consists of hygienic measures and fungicidal paints.

Anychomycosis was treated by thorough re- moval of all portions of the nail that had be- come friable or loosened from the bed, and a chrysarobin paste was used among others. A satisfactory paint for lesions of the groin and trunk that are not eczematized is rec- commended. It consists of salicylic acid 3 gm. and tincture of merthiolate (1:1,000) 100 cc.

The authors discuss at length the symptoms and treatment of local hyperhidrosis and stress the importance of prophylaxis. There are numerous formulas in this paper which can not be given here on account of space. Physicians who know how difficult it is at times to treat dermatophytosis will appreciate the excellent report.

Trench Foot. Robert C. Berson and Ralph J. Angelucci, Bull. U. S. Army M. Dept., June 1944, No. 77, p. 91.

The critical temperature for cooling tissues according to Berson and Angelucci appears to

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381

be in the region of -5° to -7°. Tissues cooled below this temperature are killed.

The term “frost bite” should be reserved for the condition in which tissues have been cooled below the critical temperature, while the term “trench foot” should be reserved for feet which show evidence of damage due to cooling above the critical temperature, ac- cording to these authors.

In the 144 cases of trench foot studied by Berson and Angelucci there was presumptive evidence that a past history of symptoms from exposure, a family history of diabetes and hypertension and a past history of smoking were not important predisposing fac- tors.

A series of 88 consecutive patients was di- vided into three treatment groups. The first group was given a regular hospital diet, ab- solute rest in bed and as much codeine as required to keep them fairly comfortable. The second group was in addition given Buer- ger’s exercises four times daily. The third group was given no exercise but was given 50 mg. of thiamine hydrochloride hyperdermi- cally twice daily. There was no demonstrable significant difference in the comfort, the a- mount of sedation required or the rate of re- covery in the three groups.

The following suggestions for early treat- ment were given: 1) removal of all potentially constricting clothing and shoes, 2) prohibition of walking or weight-bearing on the feet, 3) immediate application of cooling by the most efficient method at hand and continuation of such cooling until its slow withdrawal does not cause the feet to become noticeably warm- er than the rest of the body, 4) strict avoid- ance of all warming agents (clothing, dress- ing, hot water bottles, stoves, etc), 5) strict prohibition of all massage. 6) avoidance of sympathetic block at the early stage. Stra- kosch, Denver.

PEDIATRICS

Alum-Precipitated Diphtheria Toxoid for Inoculation of Persons Exposed to Whoop- ing Cough — Munox Turnbull, Jorge. American Journal of Diseases of Children, 69. January, 1945.

While studying the clinical modification of whooping cough by the use of alum-precipitat- ed diphtheria toxoid, the writer had the op- portunity to observe nine children exposed to siblings with pertussis who were inoculated

with this toxoid at the time the siblings began to cough or before, and who were pro- tected from whooping cough in spite of the fact that they continued to live with the sib- lings who had the ailment. This fact at the time seemed significant, although not conclu- sive, and induced him to institute observations of other exposed persons under the same cir- cumstances. “The fact that the latter subjects obtained protection by inoculation with alum- precipitated toxoid supported the idea suggest- ed by the first nine cases.”

Up to the present time the writer has ob- served sixty-one exposed children under con- ditions that do not warrant the slightest doubt that opportunity for contagion existed, since all of these children lived in the same houses and many slept in the same bedrooms as one or more siblings who had whooping cough.

“In addition, there were four persons ex- posed to pertussis in whom the disease de- veloped despite inoculation at the time the siblings began to cough or before. Although these persons had a mild form of the disease, there is no question of protection. However, the clinical modifications of the disease in these patients should be noted: Its duration never exceeded three weeks, and the intensity of the disease was less than it was in chil- dren who had not been inoculated.”

The writer proposes the hypothesis of syn- ergy of two antigens — in these cases, Bacillus pertussis and diphtheria toxoid — to explain the improved immunization response. At the pres- ent time he believes that is how the diph- theria toxoid acts on children already infected with whooping cough.

“The criteria used in classifying a child as exposed were as follows:

“1. One or more of his brothers and sisters must have whooping cough with all its clinical characteristics.” These characteristics are: at least one week of spasmodic cough, vomiting, congestion of the face during the coughing spell, and a final loud inspiration.

“2. Another frequent factor of importance and essential was that of epidemic — the co- existence of two or more cases of whooping cough in the same house.

“3. A child was considered exposed if he had been living intimately with infected per- sons during the catarrhal period, especially if the contact was made at the beginning of the period of spasmodic cough.

“A child was considered protected if he had been inoculated before or just at the time that

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his cough began of course without spasms) and if he did not cough for more than ten days.

“The doses of alum-precipitated diphtheria toxoid used were as follows: 0.5 cc. for in- fants from birth to the age of 3 months; 1 cc. for infants from 3 to 12 months old, and 1.5 cc. for those above 1 year of age. The in- jections were made every week subcutaneous- ly in the deltoid region, with a maximum of three injections.”

“Most of the protected subjects who were exposed to pertussis coughed for several days after being inoculated, the maximum length of time being six to ten days. Others did not cough at all.”

In regard to subjects who coughed for a few days, it is the writer’s impression that they were protected in the best possible manner, because if they had, as a matter of fact, such a mild form of pertussis that it could not be recognized were it not for the antecedent pos- sibility of contagion, then they should have acquired definite immunity.

“A very important fact is that several of these children were just a few days or months old. It is known that the mortality rate is highest in infants under one year of age, since

at this age complications such as broncho- pneumonia, encephalitis, and especially con- vulsive conditions are frequent.”

“Not in all subjects was there complete absence of cough. However, as regards those considered protected, if they did cough it was never for more than six to ten days and al- ways in a manner that only vaguely suggest- ed pertussis.” The sixty-one subjects whom the writer has observed have demonstrated that the best results are obtained when the injection of diphtheria toxoid is done during the period of incubation. “If, on the other hand, the injections are made in the catarrhal period, then the disease can be favorably modi- fied in its evolution and intensity and in the frequency of the coughing spells.”

COMMENT

This article is of unusual interest since the study, as well as tests given in this experience comes from good authority and one can be assured that there is evidence of good results from such procedure. The remedy is accessible, its use very simple, and can be secured and given by any physician without delay im- mediately after exposure of the infants to the disease.

Felix J- Underwood, M .D.

MOUTH HEALTH ACTIVITIES IN MISSISSIPPI

The considerable number of dental defects disclosed through selective service examina- tions has brought into sharp focus the wide prevalence of such defects among the popula- tion of draft age individuals. That many of these defects might have been prevented had they received proper attention in early life, there can be no question. A number of fac- tors are no doubt responsible, such as economic handicaps in obtaining professional care, lack of accessibility to a good dentist, poor dietary habits, ignorance, and lack of personal hy- giene— much of which might be largely over- come through improved standards of living, a better distribution of dentists, and adequate and effective health education. '

Mississippi has for many years had a very good program designed to promote better mouth health. Dr. William R. Wright, dental- member of the Board of Health for the state- at-large, serving in this capacity since 1926, has given unstintingly of his time and abilities in furthering better mouth health for Missis- sippians. The close relationship of mouth health to general health and well-being is readily recognized in the public health pro- gram. Dentists and physicians acknowledge that they have much in common, so close is the relationship of dentistry to medicine. A broad knowledge of the important works in both sciences is essential to the rendering of good medical and dental care.

Worthy of more than passing note is the report of mouth health activities covering the

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period July 1943, to June 1945, submitted by Miss Gladys Eyrich, state supervisor of mouth health of the State Board of Health staff. “The aim of mouth health activities is to con- vince the people that it pays to have good mouths and to help them reach this goal,” Miss Eyrich points out. Recent objectives have been: to increase the number of dental hygien- ists; to make dental hygiene a real part of county health departments and school pro- grams; to supply sound mouth health teaching material; to supplement local funds for the correction of dental defects; and to work close- ly with organized dentistry both within and without the state.

When the mouth health program began in January 1923, it was planned as an educational program with the idea of using teachers and dental hygienists as the instructors. A law governing the practice of dental hygiene was passed by the legislature in 1922, and the first dental hygienist was brought into the state in 1924. It was never possible to secure as many dental hygienists as needed. In fact, during this biennium, the dental hygiene ser- vice was reduced to 46 per cent of that in the last biennium.

As an attempt to fill the need for mouth health workers, the State Board of Health offered in the summer of 1944, three scholar- ships of $1,000 each to college graduates for one year of dental hygiene study. Upon com- pletion of the course, the applicant signs an agreement to work for the State Board of Health for three years after passing the State Board of Dental Examiners. A graduate of Mississippi Southern College who is a primary teacher, received the first scholarship and completed study in June 1945, at Temple Uni- versity School