THE RHODE

Owned and Published by the Rhode Island Medical Society.

Issued Monthly

VOLUME IX Whole No. 201

PROVIDENCE, R. I., JUNE, 1926

PER YEAR $2.00 SINGLE COPY 25 CENTS

ORIGINAL ARTICLES

CONTENTS

The Treatment of Certain Suppurative Conditions of the Lung. Wyman Whittemore, M.D., F-A.C.S._. 83

The Care of Diabetics at the Rhode Island came Since 1910. A.M. Nasi Louis I. gsc Miriam

J. Carpenter and Helen S. Munro. 90 The State Sanatorium. 93 Contents continued on page IV advertising section

ENTERED aS SECOND-CLASS MATTER AT THE Post OFFICE AT PROVIDENCE, R. I., UNDER AcT OF MARCH 3, 1879

ALASKA

Including

Great Northwest Tours from $500 up, leaving weekly.

Including Yellowstone Park Tours from 4 to 6 weeks, $500 up.

Including Glacier Park $500 up. to six weeks,

Including California Four to six weeks, $600 up.

CRUISES

Around the World Raymond & Whit- comb k, Amer- ican Express, Clark, and others, $1200 and up.

NORTH CAPE Raymond &, Whit- comb and ‘others, $700 and up.

Land Cruises Ocean travel luxu- ries while on land. A new travel pleas- ure. Tours leaving June, July, and August.

May we help you help your patient ?

WHEN you suggest that your patient take an ocean voyage or change of scenery, with troubles and worries all left behind, our Travel Service can be of the greatest assistance. The Man Who’s Been There will give helpful information, make thoughtful arrangements, and

EUROPE

De Luxe Tours and Cruises Raymond & Whitcomb, American Express, Thos. Cook & Son, Cc. Clark, or independent arrange- ments. Leaving May to July. Covering all or part of Europe, $1000 to $2500. Clark, re and others, from $550 u Medium Priced Tours Operated by leading travel companies or in- dependent. Leaving May to July. $500 up. Student Tours Independent or all-ex- pense trips. Congenial companions. Tours from one month for $290; three months for ae or steamship alone, found” t $160

up.

personally attend to the de- tails of any trip to any part of the world.

To secure accommoda- tions for European voyages, cruises, tours, or independ- ent travel anywhere, this summer, reservations should be made now.

AYLSWORTH

TRAVEL SERVICE, INC.

36 Weybosset St. GAspee 7425 Affiliated with

pr Rhode Island Hospital Trust Company

15 WESTMINSTER ST.- PROVIDENCE,R.1. TEL. GASPEE 8300 ’

“9 |

RHODE ISLAND MEDICAL JOURNAL

Diarrheas of Infants

The ‘isual season for Summer Diarrheas of infants is just around the corner! For several summers past physicians have found

CASEC

MEAD’S POWDERED PROTEIN MILK

useful in the treatment of the common fermentative diarrheas. A formula is suggested for the physician’s consideration and approval:

Whole Milk............... 10 ounces

Mix the CASEC with coon of the cold water in a cup to make a thin paste. Add the paste to the balance of the water, in the milk, and heat the mixture over a slow flame to the boiling point, stirring constantly to avoid lumps. Allow mixture to boil actively for 1 minute, remove from stove, cool, and divide into bottles sufficient for the 24-hour feeding.

Suggested Amounts to Be Given at Each

Feeding Are as Follows:

Infants under Four Pounds may require 8 feedings, 2 ounces each, in the 24 hours

In two or three days add 1 level tablespoonful of Deztrt-Maltose No.

1, and increase one tablespoonful every other day until the baby is taking 5 or 6 level tablespoonfuls of Deatri-Maltose in the 24-hour Casec feeding.

The Casec feeding may be continued for 3 or r4 weeks, then a gradual return to the regular milk mixtures of either fresh milk or Mead’ 3 Pow- dered Whole Milk, with Dextri-Maltose additions, may be instituted.

Our Literature No. 109 entitled “Certain Types of Sick Infants” fully explains the use of CASEC in diarrheas.

Samples of Casec and copies of Literature No. 109 will be furnished immediately on request.

MEAD JOHNSON & COMPANY, Evansville, Indiana, U. S. A. Manufacturers of Infant Diet Materials Exclusively

Mention our Journal—it identifies you.

II

iv

ADVERTISEMENTS I]

“Bridging The Critical Time In Infancy

HE first summer—the time of regurgi- tation, colic, diarrhea, malnutrition —

may be successfully bridged by utilizing the ie protective colloidal ability of Knox Sparkling WHERE KNOX Gelatine in preventing the excessive curdling

EL ATINE of the milk in the infant stomach.

RKLING G

SPA ED This simple fact is one of the most impor- PROV tant of recent dietary discoveries. It is almost HIGHLY EFFECTIVE unfailing and the results are quickly notice- able. No change in the regular formula is

required—simply add gelatine in the follow-

tion of milkand the Preve™ | *FORMULA FOR INFANT FEEDING—

curds, regurgitation Soak for ten minutes one level tablespoonful

son in infant and of Knox Sparkling Galatine in 1% cup of cold

For growth promotio milk taken from the baby’s formula; cover

2. child feeding. es while soaking; then place the cup in boiling

n cases of malnutrition: water, stirring until gelatine is fully dis-

3, In stubbor isorders © solved; add this dissolved gelatine to the t of stomach disor quart of cold milk or regular formula.

he treatmen intestinal putrefaction

tetic treatment of diabetes. For this purpose, as for all dietary uses, Knox

Sparkling .Gelatine is recommended because of uniform purity, produced under constant bacteriological control. No coloring, sweeten- | ing or flavoring—the purest of bone gelatine.

KNOX

GELATINE

“The Highest Quality for Health”

5 In the die

In the dietary of tuberculosis patients.

Whenever liquid and so 7+ sential.

KNOX GELATINE LABORATORIES

Send This Coupon 436 Knox Avenue, Johnstown, N. Y.

Please register my name to receive, without charge, results

Register your name with of past laboratory tests with Knox Sparkling Gelatine,

this coupon for the lab- and future reports as they are issued.

oratory reports on the

dietetic value of Knox Sparkling Gelatine

Mention our Journal—it identifies you. :

| |

RHODE ISLAND MEDICAL JOURNAL

CONTENTS—Continued EDITORIALS SOCIETIES

‘BOOK REVIEWS

An Intermediate Textbook of Physiological Chemistry. 97

Proceedings of the International Conference on Health Problems in Tropical America 3 enw 97

Some Fundamental Considerations in the Treatment of Empyema Thoracis. ; i s ; 97 MISCELLANEOUS

The Management of an Infant’s Diet = Mellin’s Food—A Milk Modifier

In the selection of a milk modifier the following factors are worthy of serious consideration:

Quality of materials employed in the making of the product. Care exercised in every step of manufacture. Uniformity of composition of the finished product.

Anticipated results—based upon the character of the contained food elements and records of successful use.

During the long period that has elapsed since the introduction of Mellin’s Food to the medical profession, there has been ample opportunity for physicians to judge how well Mellin’s Food measures up to the above-stated outstanding points of importance. That the judgment passed has, in the main, been favorable is clearly indi- cated by the high standard of excellence accorded to Mellin’s Food by physicians generally and particularly by doctors whose practice embraces the field of pediatrics.

¢

Mention our Journal—it identifies you.

Vv + | | = : 3 } \ =A

ADVERTISEMENTS

1X

§ Small Sanatorium for the care of convalescent, semi- invalids and aged.

Excellent home, board and care .

HEATH SANATORIUM 438 Hope St., Prov.,R.I. Angell 2408-W

NURSING HOME MRS. HELEN D. TALBOT 243 Adelaide Avenue Maternity and Non-Infectious Diseases SUMMER HOME Invalids and Convalescents

SHORE ACRES on the BAY near WICKFORD, R. I.

Binder and Abdominal Supporter

(Patented)

For Men, Women and Children

For Ptosis, Hernia, Pregnancy, Obesity, Relaxed Sacro-lliac Articulations, Floating Kidney, High and Low Operations, etc.

Ask for 36-page Illustrated Folder. Mail orders filled at Philadelphia only— within 24 hours.

Katherine L. Storm, M.D.

Originator, Patentee, Owner and Maker 1701 DIAMOND ST. PHILADELPHIA

Licensed Boarding Home

for frail and ailing babies AGES 1 WEEK TO 1 YEAR Terms $8.00 to $12.00 per week REFERENCES

Mrs. Lydia K. Leathers 24 Angell Ave. Oaklawn, R. I. TEL. VALLEY 291-R-6

Pinecliff Sanatarium

A DELIGHTFUL RETREAT for Semi-invalids, Convalescents and Neurologicals

Situated in the Edgewood section of Providence, Pinecliff combines country quiet and accessibility to City

Telephone

37 Circuit Drive Broad 1321

Edgewood, R. I.

In Sickness — or in Health Horlick 8S the the Original

Malted Milk

Delicious—

Nourishing— Easily Digested

For more than a third of a century, Horlick’s Malted Milk has been the standard of purity and food value among physicians, nurses and dietitians.

Write for free samples and literature.

Avoid Imitations - Prescibe the Original

Horlick’s Malted Milk Corporation RACINE, WISCONSIN

Mention our Journal—it identifies you.

=| | | | | sy | | | | | JALTED Mi | * | | | | SSE | | |

RHODE ISLAND MEDICAL JOURNAL

WHOLE WHEAT BREAD

thy specialize in the production of this splendid article of diet.

If your patients are unable to obtain our bread, telephone us and we will see that they are supplied through their grocer.

GROCERS BAKING COMPANY

J. W. BOOTHMAN

298 Montgomery Ave. - + Refinisher of Automobiles Authorized Service Station for

Egyptian Automobile Finish

The Permanent Finish for Motor Vehicles

Does not readily Scratch - Fade - Check nor Crack Not affected by Acids - Road Tar - extreme Heat or Cold

In six days your car is finished and ready for the storms. Absolutely twelve thousand square feet of floor space with the finest facilities for Automobile Painting and Lacquering.

For (An Antiseptic Liquid)

fiope Private Hospital

Young Orchard Abe. and Gope Street

Send for free testing samples

THF NONSPI COMPANY 2660 Walnut Street, Kansas City, Mo.,

Send free NONSPI samples to: Name Street | City State

Mention our Journal—it identifies you.

- ‘ ; \ / 4 \ heeommend u | \ \ \ \ ff \

ADVERTISEMENTS XI

B-D PRODUCTS

‘Always Function Properly

B-D Manometers, for the accurate determination of blood pressure, are equipped with practically imperishable release valves which hold the mercury column toa fraction ofa millimeter. A special stabilizing cap at the top of the Manometer tube prevents undue oscillations of the mercury and provides greater precision and ease in reading the pressure.

MADE IN OFFICE, PORTABLE, HOSPITAL AND POCKET TYPES.

The Pocket Type, shown opposite, is designed to be carried conveniently in the pocket or bag ° without danger of spilling or breaking.

Sold by Surgical Dealers

BECTON, DICKINSON & CO. POCKET TYPE RUTHERFORD, N. J. Genuine Luer Syringes, Yale Quality Needles, B-D Thermometers, Ace Bandages, Asepto Syringes and Stethoscopes.

When You Need Good Printing—Call Gaspee 8637

E.A. Johnson Co

-PRINTERS— 71 Peck Providence Street RL

Mention our Journal—it identifies you.

XII RHODE ISLAND MEDICAL JOURNAL

EEGH

are usually correctable. FOR MANY YEARS I have success- fully corrected all kinds of speech defects. Individual instruction. Write for descriptive booklet.

SAMUEL D. ROBBINS

927 Hospital Trust Bldg. Providence, R. I. in the rooms of BARKER & GARLAND

Telephone Gaspee 7118

QUALITY PRODUCTS

NUGAS—The superior motor fuel GASOLINE-~—Straight run

MOTOR OILS—100% Penna. guaranteed FODOL—Correct lubricant for Ford Cars

DUTEE W. FLINT OIL COMPANY, INC.

PROVIDENCE, U. S. A. WHOLESALE RETAIL

ANTHONY’S DRUG STORE

178 Angell Street, Providence, R. I. has

Biological Products, kept at the proper temperature Hicks Clinical Thermometers American Clinical Thermometers ; Guaranteed Water Bottles and Syringes Bed Pans, Urinals, Rubber Sheeting and many other Sick-room Supplies

Doc tor! If you have a troublesome case that needs a well fitting appliance, carefully planned and made by specialists. Let us help you, over 20 years experience at your command. We want the difficult cases. ABDOMINAL BELTS, ELASTIC STOCKINGS, TRUSSES, ETC.

“Come and See Us Make them” H. MAWBY CO., INC., 63 Washington St., Providence, R. I.

PHONE UNION 8980

Mention our Journal—it identifies you.

we ¢ J

‘ADVERTISEMENTS XII

SA

> y=

RABIES VACCINE

(Cumming)

HE importance of preventing rabies is fully appreciated by the ff medical profession for the reason that not a single cure of a well nllenizas case of human rabies has ever been reported.

The prompt employment of Rabies Vaccine is imperative for the safety of the ap acai Rabies Vaccine (Cumming), P. D. & Co., is a product that represents the antigenic principle of rabies virus, but since it contains no living virus it can be administered with- out risk of precipitating an attack of rabies. The doses are not numbered, for they are all alike; 2 cc. of a harmless vaccine by hypodermic injection; no more exacting technique than that.

Rabies Vaccine (Cumming), P. D. & Co., is made by the method devised by Dr. J.G. Cumming. A one per cent suspension of rabic brain tissue (from rabbits dying of rabies induced i an injection of fixed virus) is dialyzed against running distilled sterile water until the infectivity of the virus is destroyed. The safety of the finished product is assured by injections beneath the dura of rab- bits and subcutaneously in guinea-pigs and mice. Sterility tests are also utilized to insure freedom from bacteria. The vaccine is standardized by weight so that 2 cc. of suspension, the contents of one of the syringe containers, contains sufficient material for one injection for an adult.

The safety and efficiency of Rabies Vaccine (Cumming), P. D. & Co., has been amply demonstrated by its employment in at least ten thousand cases of bites from rabid animals. The usual treat- ment consists of twenty-one injections—one injection daily for three weeks. A shorter course— one of fourteen injections only— suffices when the wound is only a slight scratch on the hands or lower limbs.

Rabies Vaccine (Cumming), P. D. & Co., is ee in packages of seven 2-cc syringe containers, complete, with needles, each syringe holding one dose. Orders for a 21- or a 14-dose treatment should be sent direct to Detroit (the home office) or the nearest branch or depot.

PARKE, DAVIS & COMPANY

CU. S. License No. 1 for the Manufacture of Biological Products) DETROIT, MICHIGAN

RABIES VACCINE (CUMMING,, P. D. & CO., IS INCLUDED IN N. N. R. BY THE COUNCIL ON PHARMACY AND CHEMISTRY OF THE AMERICAN MEDICAL ASSOCIATION

Mention our Journal—it identifies you.

NE NE NE aNE BNE

RHODE ISLAND MEDICAL JOURNAL

CEDAR TREE POINT GARDENS

HENRY W. BROWN, PROPRIETOR

MEMBER OF THE NEW ENGLAND GLADIOLUS SOCIETY MEMBER OF THE AMERICAN GLADIOLUS SOCIETY

309 OLNEY STREET CEDAR TREE POINT PROVIDENCE, R.I. APPONAUG, R. IL. ANGELL 0129 GREENWOOD 236-W FLORICULTURE

GLADIOLI ann DAHLIAS — FLOWERS anp BULBS GARDEN DESIGNING

ESTATES GIVEN SEASONAL CARE

After May 20th.

our retail and surgical departments will be located at

160 Westminster Street

Since 1849 the leading prescription store in Rhode Island

BLANDING & BLANDING, Inc.

Mention our Journal—it identifies you.

| | XIV | ; j : ‘ | > | : i > ‘

THE RHODE ISLAND MEDICAL JOURNAL

The Official Organ of the Rhode Island Medical Society

Issued Monthly under the direction of the Publication Committee

VOLUME IX NuMBER Whole No. 201

PROVIDENCE, R. I., JUNE, 1926

PER YEAR $2.00 SINGLE COPY 25 CENTS

ORIGINAL ARTICLES

THE TREATMENT OF CERTAIN SUP- PURATIVE CONDITIONS OF THE LUNG*

By Wyman Wuittemorg, M.D., F. A. C. S.

Boston, Mass.

The subject of thoracic surgery is a very large one. One much larger than the general surgeon, who is not particularly interested in it, is apt to” think. The drainage of acute empyema, the opera- tions for the closure of chronic empyemas, are only a very small part of the whole subject. This may be readily seen in looking over Lilienthal’s recent book on thoracic surgery, which is pub- lished in two large volumes each of which con- tains between six and seven hundred pages.

It seemed to me, this afternoon, that it might be of interest to speak of the treatment of certain of the suppurative conditions of the lung that surgery is trying to benefit and to bring out some of the things that surgeons interested in thoracic surgery are trying to accomplish in the face of many diffi- culties. It is only during the last 15 years that there has been any great advance made in the knowledge and treatment of these conditions, so men working in this field should still be considered pioneers. It may be, and it probably will be, that 10 or 15 years from now our ideas will have changed radically from those of the present, just as our beliefs today are very different from those of 10 or 15 years ago.

The two subjects that I propose to discuss, very briefly, are the simple lung abscess that is of a non-tubercular nature, and bronchiectasis. It is necessary for this purpose to have a clear idea of these two conditions and this is not very easy, at least for me, as I frankly say that it has only been within the last two or three years, that what I mean in using these terms has become reasonably

_ *Read before the Rhode Island Medical Society, March 4, 1926.

clear to me and I well realize that what I mean in using the term bronchiectasis, for example, may be quite different from what someone else may mean in using it. And, indeed, lung abscess and bronchiectasis may overlap one another and still a third condition may enter into the picture. By lung abscess, I mean, an actual breaking down of a localized area in the parenchyma of the lung and the formation of an abscess surrounded by in- flammatory tissue-pneumonitis — this may be a fairly thin wall or a very thick one. X-ray should demonstrate a cavity in this area with a fluid level that shifts with change in position of the patient. It is interesting to see what may happen to this condition if it does not get well by itself and has no treatment. One of the best ways of following this is by X-ray and it is remarkable to see in the course of a month, or two or three, that what was formerly a single abscess has entirely changed. The X-ray shadow is merely a dense one with no central cavity formation, there may be several small bright areas in this shadow that are probably small abscess cavities. As the condition persists, it is only natural that there should be some dilatation — of the bronchial tree leading to this part of the lung so that there exists a localized bronchiectasis If the lobe of the lung should be cross-sectioned it would show some dilation of the bronchioles with or without pus in them and many small abscess cavities, some draining and others not. This con- dition, then has become a pyemia of that region of the lung. What at first was a more or less simple abscess has now become a localized pyemia with a localized bronchiectasis. As I shall point out later what may have been a comparatively simple con- dition to operate upon has become a difficult and an extremely dangerous one to deal with. Of course all abscesses do not change their character- istics and become another condition as quickly as I have described, but I find that sooner or later this will take place if the patient lives, is not op- erated upon, and does not cure himself. It is well to bear in mind that there are many other compli- cations that may develop as time goes on. Brain abscess is not uncommon, the infection being car-

84

ried directly through the blood stream. Extension

of the infection in the lung, broncho-pneumonia in the same lung or in the opposite one, septicemia,

general pyemia, pericarditis, and perferation into pleural cavity are met with. Hemorrhage may take place at any time this varying in severity from a trivial to a fatal one.

Let us now turn to bronchiectasis. In this con- dition there is a dilatation of the bronchial tree. As surgery can only hope to deal with a process localized in one lobe of the lung the bi-lateral dis- ease cannot be considered in this paper. The bronchus leading to one lobe of the lung and the bronchioles become dilated. Sooner or later infec- tion will always take place, so that pools of pus form in these sacculations. Occasionally there will be a very large one which may contain as much as half a pint of pus. As the dilatation of the bronchus increases the wall thins out and the in- fection may extend in to the parenchyma of the lung so that an abscess or abscesses of the lung will form. These are often called bronchiectatic abscesses. I prefer to call these lung abscesses, as they truly are, and limit the term bronchiectatic abscess to the sacculation formed by dilatation of the bronchus containing pus. When, then, the con- dition is one in which there are dilatations of the bronchus and bronchioles containing pus and also many large or small abscesses in the parenchyma of the lung, there is a suppurative bronchiectasis plus a localized pyemia of the lobe of the lung. When the infection in the lung is very slight the condition may remain stationary for many years. Bronchiectasis may be divided into those cases that start in early childhood without any definite etiology and those that are acquired—the latter be- ing due to foreign bodies, including not only for- eign substances such as teeth, beans, etc., but also infected material that lodges in a bronchus. When the dilatation of the bronchus begins in childhood sooner or later infection will take place. As I have said this condition may exist for many years. I well remember one case—a man in the late sixties who had had this condition ever since childhood. He was a thin, frail man who quite naturally had become greatly interested in his condition, so much so that he kept a careful record of the amount of sputum raised each day. He weighed this and found that in the course of a year the sputum raised weighed more than he did. If I remember

THE RHODE. ISLAND MEDICAL JOURNAL

. June, 1926

“correctly he weighed about 95 and. the

sputum weighed several pounds more than this. If the infection works through into the parenchyma of the lung, complications such as I have already mentioned in speaking of lung abscess may take place and the span of life is not apt to be as long as it was in this remarkable case just mentioned. Let us now take up the treatment of these two conditions, considering lung abscess first. This may be divided into four possibilities. Medical, or “expectant” treatment, bronchoscopy, artificial pneumothorax, and operation. All cases should be given the opportunity of being cured by medical treatment before any other is considered. This con- sists of rest in bed, good food, fresh air, sunshine and postural drainage. Usually it will be found that there is some position in which the patient can be placed that will cause the abscess to be drained by gravity. This position varies with the position of the abscess, e. g., if the abscess is situated in the lower lobe, raising the foot of the bed, so that the patient’s head is downhill will aid in emptying the abscess. Or the patient may be taught to lean over the side of the bed with his head nearly down to the floor and this will bring about the desired re- sult. Of course this position cannot be kept up for any length of time at first, but gradually the length of time may be increased so that this position may be taken and the patient remain in it for some 15 to 30 minutes three or four times a day. Need- less to say co-operation on the patient’s part is very necessary for anything to be accomplished with this form of treatment. Just how long medical treatment should be kept up is largely a matter of opinion depending on each individual case. It is well to bear in mind how many cases may be expected to be cured by this method and how many will die if. no treatment is undertaken. In a series of 100 cases of my own, 11 per cent recovered spontaneously. Lord, (Diseases of Bronchi, Lungs, and Pleura), reports a series of 227 cases taken from the Massachusetts General Hospital and his own practice in which 11 per cent recovered. The total duration from onset to recovery in these cases, was usually within two months. The longest duration was ten months in one case. The fairly mild cases in which septic signs are few or absent, in which the sputum is small in amount, perhaps half an ounce in 24 hours, not foul, and in which the process is sit-

=. | | | : | } | | H j | |

June, 1926 uated close to the root of the lung are the most favorable ones for this form of treatment. While this treatment is being carried out, great care should be taken to check the progress made or to note the stationary course of the disease or its downward progress. If septic signs increase, or the amount of sputum increases, or the foul odor becomes more marked, other methods of treat- ment must be strongly cansidered. In continuing medical treatment over a long period of time the dangers of such complications as I have men- tioned should be always remembered. Narcotics to control cough must be used very sparingly. If cough is checked and sputum that should be raised, retained, septic signs will increase and the process may extend.

Bronchoscopy in the hands of men especially trained, who are able to do this under local anes- thesia, or without any anesthesia in children, may be tried in the very early cases after they have broken into a bronchus. I do not believe this form of treatment should be tried when a general anes- thetic must be used. This method consists of the aspiration of the cavity, dilatation of any partial stricture in the bronchus and possibly the lavage of the cavity with some mild solution. Cases in which the abscéss cavity is situated close to the root of the lung seem to be the most favorable for this treatment. A few successful cases have been reported. It seems only reasonable to me to expect few cures in those cases in which this treatment has not been instituted for several months after the formation of the abscess.

Artificial pneumothorax, in my opinion, is in about the same status as bronchoscopy. The only hope for this to produce a cure is to bring about a collapse of the lung early, before adhesions have ' formed. After the lung and the costal pleura become adherent no good, other than possibly a very temporary one, should be expected. In one quite striking case, it did temporary good. A woman entered the hospital in extremely poor condition, far too poor for operation to be con- sidered. She had almost continuous cough, could neither take any nourishment nor obtain any sleep. Injecting a small amount of air into the pleural cavity lessened the cough very much so that some rest and nourishment could be taken, although X-ray taken, following the pneumothorax, showed

SUPPURATIVE CONDITIONS OF THE LUNG 85

the lung to be firmly adherent. In any attempted cure by this method the lung must be kept col- lapsed for a long time, probably several months to a year. Of course there is an occasional “freak” case in any walk of life. Balboni and Churchill (“Boston Medical and Surgical Journal, January 5, 1924”) report a successful case following one injection of air. I. well remember this case. A small child had a lung abscess in an upper lobe and was too sick for operation to be considered. The temperature was high and the amount of spu- tum, large. Within 24 hours after one injection of air the cough had ceased and the temperature was normal. During her stay in the hospital, there was never any more cough or rise in temperature. On leaving, X-ray showed the cavity healed, the lung expanded, and she has remained well ever since. Abscesses situated near the root of the lung are the most favorable for this treatment. There are certain dangers that should always be remem- bered in using this method of treatment. If too much air is injected into the pleural cavity when the lung is adherent to the costal pleura, an ad- hesion may be stretched so that a tear in the lung will be brought about. If this tear takes place near the region of the abscess an empyema will be produced. In stretching an adhesion, air may enter a blood vessel and an air embolus lodge in the brain.

Abscess situated near the periphery of the lung in which X-ray demonstrates a fluid level is the most favorable one for operation. Drainage of a lung abscess may be a comparatively easy pro- cedure, or on the other hand, a difficult and trying one. Local anesthesia should be used when pos- sible. This is always possible when the lung and the costal pleura are adherent, unless the patient refuses to allow its use. Seldom can anyone be sure from physical examination whether or not the lung is adherent. If the X-ray shadow extends to the axillary line, for example, and the process has existed for several months, it is justifiable to assume in planning operation, that the lung: is ad- herent to the costal pleura in this region. A win- dow in the chest wall should be opened down to the pleura by the excision of a section of one or two ribs. This should be done in the region that seems, from the physical examination and X-ray, to be the nearest approach to the abscess. (Let me

say here that I do not believe it is ever justifiable to attempt to place an aspirating needle into a lung abscess through the chest wall.) If inspec- tion of the pleura shows it to be thickened, gray- ish white, with no movement of the lung with respirations beneath it, an opening into the lung may be made immediately, with confidence, that the lung and pleura are adherent. On the other hand, if the pleura seems normally thin, and the lung is seen moving with respirations, it is better to do the operation in two stages, granted the cor- rect approach to the abscess has been chosen. The lung can be made adherent to the costal pleura by placing a gauze sponge against the pleura and leaving it there for four or five days, when the second stage my be safely undertaken. Sutures may be used to sew the lung and pleura together, but this accomplishes no more than the simpler method anid in the process of placing the sutures, a pneumothorax may be created. Before suturing the lung to the pleura or packing gauze against it, further search for an adherent area should be made by excising a section of the rib above or below as seems best, and inspecting the pleura again. It is not uncommon to find that the origi- nal approach is a rib too low, or a rib too high. If no adherent place can be found, it seems to me, the best procedure is to give the patient some form of positive pressure anesthesia—to open wide the thoracic cavity, explore it, find the abscess area, and bring this to the chest wall and suture it there. A delay of four or five days to a week should follow this procedure before opening the abscess, in order that adhesions may form, so that an empyema will not follow the opening of the abscess,

An abscess may be opened in various ways. Personally, I do not believe in aspirating it, even with the adherent lung before me. I see nothing to be gained by this technique except a little moral support, as frequently the abscess will not be found with the needle, or it may be empty so that aspiration obtains no pus. Surely, then the oper- ator will not abandon any further search for the abscess. The lung must be opened and the abscess found. So why run the risk of a dangerous hem- orrhage by putting a needle into the lung. A small incision should be made into the lung and then, with the finger, that part of the lung ex-

THE: RHODE ISLAND MEDICAL JOURNAL

June, 1926

plored for the abscess. The finger can readily recognize the difference between normal lung and the thick, tough, pneumonitis which always sur- rounds the cavity and can easily tell when §it breaks through into the abscess. Often, when this takes place, the operator and his audience will be pleased by the sight of actual pus coming from the lung, but if the cavity happens to be empty at this moment there will be no pus seen. How- ever, if the surgeon is greeted with a foul blast of air on withdrawing his finger, or if the finger has the characteristic smell on its end, he may be sure that he has found the abscess. Some sur- geons prefer to open into the abscess with the cautery, but in doing this, any blood-vessels’ en- countered will be seared over by the heat so that when sloughing takes place a secondary hemor- rhage may follow. An abscess should be drained with a large, soft rubber tube. After two or three days its position should be slightly changed each 24 hours, so that it will not erode through the wall of any vessel that it may be resting against.

An abscess that has existed for a long time should be drained for a long time. It is better to drain for too long a time than for too short a time, as, if the tube is removed too soon, a recur- rence will surely take place. No irrigations can be used. At first, cough must be fairly well con- trolled by narcotics. The same complications that may occur with a septic condition in the lung be- fore operation may follow it, but the one to be most dreaded, is secondary hemorrhage. Fortu-

nately, this does not occur often. If it does occur, .

it is usually not very early in the convalescence. When this takes place it is a most distressing thing to the patient and surgeon. It is often difficult, and occasionally impossible, to control it, as the bleeding takes place both through the wound and up through the bronchus and mouth, so that the bleeding is in two different directions. When this takes place the tube should be removed and the cavity packed tightly with gauze. Morphine in fairly large doses should be given. Personally, I feel that the packing should not be disturbed for from one to two weeks and when it is removed, it should be replaced by another gauze pack. Some packing should be kept in the cavity until it is entirely obliterated. In the usual case, in which no hemorrhage takes place, the tube should be kept

-

86 + bre ‘ 4,

June, 1926

in until the cavity is also obliterated. In the chronic case, in which drainage has been kept up

for a long time with little or no evidence of the

cavity closing, I believe Graham’s method of par- tial lobectomy with the actual cautery should be done. Following this, the packing should be kept in until the cavity is entirely closed.

The immediate operative mortality is about 15% and I believe that 60 to 65% of the cases may be expected to be cured or permanently improved. By this latter, is meant that in a few cases it is neces- sary to continue the drainage by a very small tube, or by means of a permanent fistula indefinitely. It is far better to go through life with a small sinus discharging a few drops of pus each day, than to have a recurrence. These individuals can do any- thing in life except go in swimming. A very small number of cases, probably less than 5%, leave the hospital having made an excellent convalescence— they do well for several months and then have very slight bleedings, that gradually increase until a fatal hemorrhage takes place, if nothing is done for them. These patients should be returned to the hospital and a partial cautery lobectomy done.

The treatment of localized bronchiectasis may be divided into medical, bronchoscopy, artificial pneumothorax, and surgery. I think medical treatment can be dismissed in a word by saying that no patient will ever be cured by it. Ifa patient can devote his life to taking care of his health, spending his winters in a warm, dry cli- mate, he may live a long time. If a foreign body, lodged in a bronchus, is the cause of the bronchi- ~ ectasis its removal by the bronchoscope will often cure the disease, granted that the foreign body has not remained in the bronchus so long that a defi- nite suppurative bronchiectasis and local pyemia have developed. If this has taken place, the re- moval of the foreign body will have little bene- ficial result. I cannot conceive how aspiration or irrigation can do more than temporarily benefit ‘the condition. It should not be expected to pro- duce a cure.

It may not be out of place at this point, to men- tion the use of Lipiodol in these cases. Lipiodol is a solution of iodine and oil that is opaque to X-ray. Foriestier, of Paris, was the originator of this and its use in the various so-called closed cavities of the body. As far as the bronchial tree is concerned, it is used as an aid to making the

SUPPURATIVE CONDITIONS OF THE LUNG

diagnosis and also to a certain extent therapeuti- cally. It may be injected into the bronchial tree by various methods. 1. Through a curved metal tube that passes through the pharynx and larynx. 2. By the use of a laryngoscope. 3. By a bron- choscope. 4. It may be injected into the trachea by puncturing it in the neck with a large needle. I feel that, in certain cases in which the diagnosis is doubtful, in spite of physical examination made by a pulmonary expert and routine X-rays taken in various ways and positions, if Lipiodol is in- jected into the suspected part of the lung through a bronchoscope, and into this region only, X-ray, if taken immediately, before the Lipiodol is coughed out, will be of greater value than any of these other examinations. Dilatations of the bron- chus and bronchioles going to one lobe of the lung, for example, when filled with Lipiodol, stand out very distinctly in X-ray. The knowledge gained from its use in an occasional obscure post-opera- tive case may be great. In all cases that have had extensive thoracic operations the physical signs are almost entirely obscured and the ordinary X-ray examination is of practically no value. If, in these cases, Lipiodol is injected into the dis- eased side, X-ray may show very definitely just what the pathological process is. I can have no great enthusiasm for the use of Lipiodol thera- peutically, as it is inconceivable that its use can cure any chronic suppurative disease of the lung. On the other hand it has been stated, by men using it, that there is a temporary benefit obtained by its use. If it is used in a case of localized bron- chiectasis, for a short time following its injection, the patient will feel more comfortable and will not cough or raise as much sputum. Naturally, no case has ever been cured by its use.

I do not think that artificial pneumothorax can cure this condition, even if there are no adhe- sions so that a complete collapse of the lung can be brought about. The general condition may be temporarily improved, but never cured. The same complications may be encountered in keeping up artificial pneumothorax over a long period of time, as already mentioned in using this form of treat-_ ment in lung abscess; as for example, empyema, air embolus, and the occurrence of a non-infected fluid in the pleural cavity.

Surgery of bronchiectasis may be divided into operations that tend to permanently collapse the

lung by extra-pleural thoracoplasty, drainage operations, and those that remove the diseased condition of the lung. The only possible cure, as far as I know, is the actual removal of a part of, or the whole lobe. Before taking up this latter operation, I wish to mention the treatment by collapsing the chest wall, as certain surgeons be- lieve this to be the ideal procedure. In this tech- nique, sections of ribs are removed, from the Ist to 11th, in much the same way as in pulmonary tuberculosis. The operation should be done in

two, three, or more stages. I am quite ready to _

acknowledge that the general condition of the patient is often materially improved by this, but I do not believe any actual cure can be produced. It is often worth trying in certain cases, as it is a very safe operation, the mortality being about nil and certain benefits can be pretty well assured. If one will picture the pathology of this condition, it can readily be understood that no drainage oper- ation will ever cure it. Here again, the actual opening of a large abscess situated either in the bronchus or in the parenchyma of the lung will, of course, improve the general condition, but as there are manifold other abscesses not draining into this large one, it is unreasonable to expect a cure. It is quite justifiable to do this operation, but not with the expectation of producing a cure. Sometimes a combination of both a collapsing operation and a drainage one will be of some benefit. If this is done, the collapsing should be done first. No cure will be brought about, however.

As I have said before, the only cure is the actual removal of the diseased part of the lung. There are two methods. First, the removal by means of the cautery, Graham’s method, and second, the surgical amputation of the lobe or a part of the lobe of the lung. I have already alluded to Gra- ham’s cautery lobectomy, in speaking of the treat- ment of certain chronic lung abscesses. In these cases, I think the method ideal. In this method, a window in the chest wall is opened down to the pleura by the removal of sections of several ribs

' overlaying the diseased portion of the lung. If the

lung and pleura are adherent, the operation may be continued ; if not, steps must be taken to bring about adhesions and the cauterization postponed a few days. With an ordinary plummer’s cautery,

THE RHODE ISLAND MEDICAL JOURNAL

June, 1926

an area of the lung is opened and burned. Gauze packing then is applied tightly. This is removed and the lung wound repacked in a few days. In two or three weeks, further cauterization of the lung should be done and this process should be repeated until all the diseased area is destroyed. Graham does not have any fear of. either hemor- rhage at the time of operation or after it. This, | he largely accounts for by the fact that the pul- monary blood pressure is only 1/6 of the general blood pressure. But it should be remembered that the pressure in the bronchial arteries is the same as that of the general circulation. I have been much interested in this method and have tried it a number of times. To be honest, I am not enthusiastic over it, but, needless to say, this tech- nique in my hands is probably not the same as in Graham’s hands. Hemorrhage, both at the time of operation, and secondarily, has greatly upset me. I have had a patient have a secondary hem- orrhage at the end of two weeks and be dead in five minutes. I have had‘another patient have a hemorrhage on the operating table, the blood coming from the bronchus and out of the patient’s mouth ,but none from the wound. Fortunately, this was controlled. The technique of cauterizing the lung is a very blind one to me. It seems rather impossible to know just how much or how little has been done. I well remember an Italian woman, whose right upper lobe I tried to remove by this technique. I cauterized this four times and at the last operation, thought I had probably burned it all out. She died a week or two later. Autopsy showed this lobe to be an almost solid mass as large as a grape-fruit, with many walled-off ab- scesses, and the amount of lung that I had re- moved, in four sittings, was about the size of a hen’s egg. This showed me how futile my efforts had been. It is only fair to add that Graham has had excellent results, having cured a number of patients and his mortality is very low.

The last operative technique that I shall men- tion, and that only briefly, is the amputation of a lobe, or part of a lobe, of the lung. There are various methods of accomplishing this. Undoubt- edly, the safest is that done ‘in two stages. At the first, the thorax is widely opened, explored, and the diseased lobe freed from adhesions, if there are any, and there usually are. This is then sur-

: “ 4

June, 1926

rounded by rubber dam. Some method should be used to make the good lobe become adherent, such as rubbing it lightly with gauze, or placing a thin layer of gauze between it and the parietal pleura. (If gauze is used, it should be removed in forty-eight hours.) The chest wall is then closed. In about a week or ten days the wound is re-opened and the diseased lobe removed. The pedicle should be carefully tied off in sections. If a part only, of a lobe is to be removed, this is done in much the same way. The diseased area is clamped off, removed, and the stump carefully sutured. Unfortunately, the mortality resulting from the removal of a lobe, is almost prohibitively high. In Lilienthal’s hands, who has performed this operation more times than any other surgeon in this country, the mortality is 47%. I have done

this six times. One case, only, recovered and it.

may interest you to know what happened to the others. One did beautifully for 16 days, and then died in a few minutes from hemorrhage. One died in 5 days, the cause of death I do not know, except that he refused all nourishment during the entire time that he lived. Of course, rectal feed- ing was used. Another died 10 or 12 hours fol- lowing operation. In this case, at the end of the operation, she was transfused, not on account of loss of blood, but merely on general principles.

Her temperature steadily rose to 105. I cannot.

help but think that the transfusion may have had something to do with this death. One case died 5 or 6 weeks after operation, brain abscess being the cause. The first case I ever did, died soon after operation from shock. This was a very diffi- cult operation on account of adhesions. At the present time I should know enough not to attempt the operation under similar conditions. This is a sad story, but one well worth knowing. Recently, I have used a very different technique. In this operation, after freeing the lobe of the lung, sec- tions of the ribs overlying it are removed, so that the chest wall can collapse a certain amount, and then as much as possible of the lobe is brought out onto the chest wall and sutured there. In about 10 days this area will either slough off or it can be removed without any anesthetic. I have only done two cases by this method, but both made very nice convalescences and, naturally, I feel quite encouraged by this. However, I realize two

SUPPURATIVE CONDITIONS OF THE LUNG 89

cases is too little to base any opinion on. The pleural cavity, I believe, will always become in- fected after either of these operations and pro- vision should be made for this at the time.

Operations of this magnitude cannot be urged, but occasionally one meets with a patient whose life is so miserable and who finds that he cannot live at home, or with anyone, on account of the fearful odor associated with him: And it is this class of patient who, in spite of knowing the danger run, will be glad to take this chance. As the years go by, I firmly believe that a technique will be found that will reduce the operative mor- tality to a reasonable one. When this takes place, medical men in whose hands these patients are, will quite naturally be more inclined to urge, or at least allow their patients to be operated upon.”

I have tried to show you some of the manifold difficulties that Thoracic Surgeons are trying to deal with in just this one branch of chest surgery. If I have aroused your interest, I shall feel well satisfied.

Discussion

Dr. George A. Matteson asked Dr. Whittemore why brain abscesses are so prevalent after (opera- tions for) lung abscesses.

Dr. Whittemore’s paper was also discussed in part by Dr. Jacob Kelley.

Dr. Isaac Gerber took the floor and spoke to the effect that within the past ten days the agents in this country who have been supplying Lipiodol have stopped because several deaths have been reported, and for some time to come they will not furnish any for X-ray for bronchiectasis, or any more for treatment.

Dr. Gerber, further stated that he did not know whether it was a temporary condition or not. He stated that there is no doubt that it (Lipiodol) does very admirably to delineate bronchial cavities and in many instances brings out cavities, par- ticularly those back of the heart in ordinary visi- bility of X-ray films.

Dr. Whittemore replied to Dr. Matteson and also to Dr. Gerber as follows:

“The only explanation I have had given to me was that of direct connection of the blood stream from the lungs. I do not know just what the per- centage of cases was,—you see them very rarely ; I have once in awhile.

“The subject of Lipiodol is a new one. I was present when Dr. Forestier spoke at the Massa- chusetts General Hospital; and have been present when Lipiodol was injected. My impression is quite different. It is a very distressing thing,— 30 or 40 cc., and the patient tries to cough it off. Two or three patients had.to be held down to take the X-ray. They cough their heads off. How long it stays in the lungs seems to be matter of opinion, —some say it is expelled right away; some say five or six weeks ; some say two or three months.

“Dr. Lord in Boston feels very strong about this question of Lipiodol. He feels that he makes just as good a diagnosis without it as with it. In a recent publication the author mentions several cases where it has been injected into the spinal column (in three cases) and says that in one case which came to an operation on the spinal column and it was found that Lipiodol was present and had set up an inflammatory reaction in the cord, which was very unfortunate.”

THE CARE OF DIABETICS AT THE RHODE ISLAND HOSPITAL SINCE 1910*

A. M. Burcess, Louis I. Kramer, Miriam J. CARPENTER AND Heten S: Munro

Two great advances in the treatment of diabetes have recently been made. These are (1) syste- matic instruction of all patients and (2) the use of insulin. Now that the value of these methods is well established, it becomes of interest to attempt to estimate just what has been accomplished. It is the purpose of this communication to present a concise summary of the treatment of the dis- ease during the past sixteen years at the Rhode Island Hospital, a survey which is presumably typical of the changes in hospital treatment of diabetes throughout the country. The growing importance of the subject, we feel, is ample justi- fication for such a report.

That diabetes is, indeed, a more important prob- lem for the hospital as well as for the private

*Read at the meeting of the Rhode Island brass So- ciety on March 4, 1926.

THE RHODE ISLAND MEDICAL JOURNAL

June, 1926

practitioner, must be admitted. Now that the means to cope successfully with the disease are available, it becomes the duty of every physician to familiarize himself with these methods, where- as, formerly the bad general results of treatment — made a careful study of the details of the work scarcely worth while for the average medical man. Furthermore, it is pretty generally believed that the incidence of the condition has actually been i increasing in recent years. Mortality statis- tics appear. to support this view—Table I. But the real reason for the increased interest in the disease is the fact that the span of life of the average diabetic has been so lengthened that with new cases appearing at the same rate as formerly, the number of living diabetics in the community has become increased many times over. Diabetics, even the severest, do not die but live, and live on indefinitely if no complicating illness intervenes, providing they can be persuaded to master and adhere to the principles of treatment.

Table I

DeatuH Rate From DrAsetes 1880-1925 1n ProviDENCE, New YorK AND PHILADELPHIA

1880-4 1885-9 1890-4 1895-9 1900-4 Providence 6. 7. 11. 10. 17. New York 4. 6. 8. 10. az. Philadelphia 3. 9.

Continued

1905-9 1910-4 1915-9 1920-4 1925

New York 15. 17. 20. 21. Philadelphia 11 55. 15. 17.

The contrast, then, between conditions in this field in 1910 and 1925 is most striking. These sixteen years naturally divide themselves into three periods. The first, 1910-1915, was a contin- uation of the years which preceded it, and treat-_ ment for the most part was along the lines laid down by the earlier great investigators, Von Noorden, Naunyn, and others. The second period, 1916-1922, may be called the period of undernu- trition and the beginning of organized instruction of patients. 1923-1925 is the period of insulin. Even at the present time we must consider our work as crude when compared with the methods which will be in use when the next ten years have

passed.

fe

June, 1926

An illustration of one phase of the contrasting ~ conditions in 1910 and 1925 is shown in Table 11. Here are recorded the total number admitted to the hospital each year for the whole period under discussion. This is rather striking, as in 1925 the number is twenty-six times as great as in 1910. This table also shows the average length of stay in the hospital of the patients with uncomplicated diabetes—and this, it can be seen, has been re- duced markedly in the last few years. At the present time we regard the hospital stay of a dia- betic as a mere incident in the course of his treat- -ment, but at the same time as an opportunity to study the severity of his diabetes and to give him a short, intensive course of instruction in the nature and treatment of his malady.

Table II Deatus From Diasetes IN R. I. H., 1910-1925, INCLUSIVE

Year No. of Cases No. Deaths 13 2

543 74

What happened to the diabetic who came to the hospital in the years 1910-1915? First, let us con- sider the mild diabetic. He was put on a low car- bohydrate diet with a high protein and fat content and high caloric value. He became sugar free very readily, and though he often suffered from a mild acidosis, he usually gained tolerance and was relieved of his symptoms. He learned very little about his disease and, as he was not taught the simple test for sugar in the urine, could never tell how he was getting on except by visiting his doctor. Sooner or later, the irksome restrictions proved too much for his fortitude and, as he felt pérfectly well, he abandoned them, with an inevit-

_ THE CARE OF DIABETICS 91

able return of, first, his glycosuria, and then, after an interval of comparative well being, a return of his symptoms. When the symptoms became suffi- ciently severe he came back to the Out Patient Department only to be started again as before, on another cycle of treatment. Of course, many such cases eventually became severe or were rendered so by complicating illnesses.

The fate of the moderately severe and the severe cases cannot be accurately determined from the records during this period. We know, how- ever, that most of them received routine treatment similar to that mentioned above, in the Out Patient Department. The sudden deprivation of carbohydrates with the maintenance of a high cal- oric diet of proteins and fats undoubtedly caused much severe acidosis and hastened the death of many. When such patients were taken into the house, as rarely occurred, the records show that they were at times given “oatmeal days” to de- crease acidosis and “green days” to reduce glyco- suria, but usually without much success. No real instruction of patients, either in the house or Out Patient Department was attempted during this period.

By 1915, the epoch-making work of Allen was being generally followed. During the next seven years Allen’s principle of improvement in toler- ance by undernutrition was applied to the mild and most of the moderately severe diabetics with greatly iniproved results. At the hospital, patients were fasted until sugar free and then tolerance was tested by gradual increase in carbohydrates, proteins and fats, keeping the total calories very low. The mild diabetics did better than ever, and many of the moderately severe cases made marked gains in tolerance and were restored to some degree of efficiency. In the Out Patient Depart- ment, the special diabetic clinic was established and the systematic instruction of patients, that great principle of treatment which we owe es- pecially to the work of Elliott P. Joslin, was begun. During this period the really severe dia- betics were indeed pathetic figures. No longer allowed to rush merrily on to an early death in coma, these unfortunates were starved to mere skeletons in the vain hope that they might thus acquire enough tolerance to allow of a food in- take which would maintain some degree of physi- cal efficiency.

92 THE RHODE ISLAND MEDICAL JOURNAL

The Out Patient Clinic was at first very small, but good results were obtained in some of the mild, and a few of the moderately severe cases. At the present time there are three patients in the clinic who were in attendance in 1918 and five who were on the list in 1920. Patients were taught the Benedict’s test for sugar in the urine and some of the simple facts of diabetic dietetics. Visits to the patients in their homes were made by Miss Lydia Chace, the Social Service worker in charge of the clinic. During the last half of the year 1918 the clinic lapsed as a result of the war and the epidemic of influenza. In 1919, it was re-established and gradually built up so that in 1923, when insulin became available, it was much larger than at any previous time.

Table I mentioned demonstrates the phenome- nal growth of diabetic work in the wards of the hospital. In the Out Patient Department, the growth has been less striking because at the time of the introduction of insulin, the clinic was flour- ishing and counted approximately 60 active cases on it’s lists.

The figures for January 1, 1926, relating to the Out Patient Clinic are of interest. These are to be shown in Table III. This gives a total num- ber of active cases in the clinic of 177. (A case is considered active if the patient appears at the clinic at least once in six months). These cases have been classified as to their severity as follows:

Severe 18 Moderately severe 38 Mild 121

Of the 177 patients, 84, or about 50%, have at some time or other been on insulin and 18 (those rated as severe) are on “permanent” insulin treat- ment. 46 of the mild cases have had insulin tem- porarily, either to aid in rendering them sugar free or to re-enforce their tolerance during the pres- ence of some complication or other.

Table III Out Patient CLINIC (January 1, 1925)

2 17 7

June, 1926

Severe cases (all on “permanent” insulin)... 18 Those who have been in coma............. 4

Efficiency Classification

Working (including two doing Rated 90 to 100% physically

efficient

13 (or 72.2%) Rated 70 to 90%............ . 6 (or 33.3%) Rated below 70%............ 5 (or 27.8%) Sick in bed because of complications........ 2 With latent tuberculosis.................. 2

The efficacy: of modern treatment is illustrated by a study of the group of patients rated as se- vere and kept on “permanent” insulin. These are also shown in Table III. Of this group of 18 patients, 13, or 72.3% are working, including two who are doing housework. Seven are rated as 90 to 100% physically efficient, six, as 70 to 90% efficient, and only 5 as below 70%. Of these five, two are in bed suffering from complications. Two of the series have been diagnosed as harboring latent pulmonary tuberculosis and these are both rated as 90 to 100% efficient.

The satisfactory nature of these results is made more appreciable by the realization that every one of these patients would be dead were it not for insulin. Four of the group have been through diabetic coma, and two of these have survived a second attack. One man is of particular interest. He has been a very hard person to persuade to “play the game,” though he is very intelligent. Less than a year ago, while in Florida, he was successfully rescued from coma by the use of insulin. About four months ago he went into coma while living at his home in Providence. Here, he was treated by his brother, a layman, who, without troubling to call a physician, plied insulin and orange juice with the result that the patient, after forty-eight hours of unconscious- ness, recovered, returned to the clinic and told us the story which we have carefully verified.

An attempt to review the treatment of coma in the hospital fails to reveal a single case of re- covery up to the time when insulin was used. The

- Those who have been in coma twice......... 2 4 ;

June, 1926

figures for the past three years are as follows:

1923—4 cases—1 lived.

1924—6 cases—2 lived. :

2 recovered but died of com- plicating illnesses. . 2 died.

1925—4 cases—1 lived.

This gives a total for the three years of 14 cases of whom 4 survived. A study of the fatal cases shows that death has resulted either because the patient was admitted after coma had persisted so long that respiratory and circulatory failure were imminent, or because of the presence of a compli- cation, such as pneumonia, myocarditis, or the like. A large number of patients in the precoma- tose stage of severe ‘acidosis, received routine treatment and of these, but one that was uncom- plicated lapsed into coma, and none failed to recover.

Before the use of insulin, coma was treated by forcing fluids, enemas, heaters and blankets, stim- ulation, etc., and, in many instances, by the intra- venous infusion of soda bicarbonate or glucose solutions. Since early in the year 1923, sodium bicarbonate has been abandoned and insulin has been used in doses. which have increased with each

been administered by mouth, when possible, other- wise, by rectum or intravenously. An initial dose of 100 units of insulin, part subcutaneously and part intravenously, is not excessive, but in the cases treated in 1925, a smaller amount than this was given in every instance. —

With the more effective use of insulin, surgery has become more and more available for the dia- betic, so that by 1925 it had become our rule to advise the surgeons to carry out any operative procedures that they found to be indicated, irre- spective of the diabetes. In other words, we have reached the conclusion that diabetes does not add

materially to the risk of operation whatever the.

anesthetic or the type of operation contem- plated, so long as careful treatment with insulin

is possible. The danger of ether to the diabetic .

is acidosis, and in insulin, used with carbohy- drates, we have an absolute preventive of suc acidosis.

The past 16 years has seen greater and more

radical changes in the treatment of diabetes than

. THE CARE OF DIABETICS 93

will probably take place in the next century, This brief report deals with advances such as we may never witness again in this field. Yet now that the gains are made we have much to do in consolidat- ing our positions. In our own work at the Rhode Island Hospital we see much that can be improved. Better instruction of the patients during their stay in the hospital, a separate diet kitchen for diabetic work under the direction of an expert, better charting, a more accurate check-up on returned trays, a continuous follow-through of instruc- tion from house to Out Patient Department and the home kitchen, and better teaching in dia- betic work for the pupil nurse are all among im- provements that are vitally needed. Plans for the accomplishment of every one of these things are now being matured.

THE STATE SANATORIUM

The death rate from tuberculosis in Rhode Island has fallen in the last few years from 164 to about 90 per 100,000 living, and the number of active cases has probably correspondingly dimin- ished.

This lessening in the number of cases requires from the medical profession increased skill in di- agnosis if as. many favorable cases who need treat- ment are to be searched out and found.

If we of the medical profession are able to in- crease our efficiency in finding these patients, with fewer cases in the community to spread infection and with an increasing percentage of cases iso- lated, the mortality rate should fall even more rapidly.

We still receive a considerable number of pa- tients each year in whom tuberculosis has been overlooked by physicians. The giving of cough medicines to patients with chronic cough without chest or sputum examinations, so common a fail- ing 20 years ago, still accounts for a considerable number of mistakes in diagnosis.

Every patient with chronic cough and expecto- ration is entitled to sputum examinations.

Every patient with chronic cough and negative sputum is entitled to X-ray examination, and his lungs should never be pronounced free from tu- berculosis without a negative X-ray.

Continued on page 96

ANNIVERSARY NUMBER THE RHODE ISLAND MEDICAL JOURNAL

Owned and Published by the Rhode Island Medical Society Issued Monthly under the direction of the Publication Committee

aie N. Brown, M.D., Editor CreIGHTON W. Sketton, M. D., Business Manager 09 Olney Street, Providence, R. I. 184 Broad Street, Providence, R. I.

Asa S, M. D. ALtex M. Burcgss, M. D. W. Louis M.D. jose Freperick N, Brown, M.D., Chatrman J. W. Leecn, M.D. Associate Crgicuton W, M. ‘b,

NormAN M. McLgop,M. D. > Editors Committee on Publication Ww. A, Hirvarp.

ALBERT H. Miter, M. D.

DENNETTL. RICHARDSON,M.D. J. W. Lexcu, M.D. Guy W. WELLS, M. D.

C. S. Westcott, M. D. Advertising matter must be received by the 10th of the month preceding date of issue.

Advertising rates furnished upon application, to the business manager, CREIGHTON W. SKELTON, M.D., 184 Broad Street, Providence, R. 1.

Rapiete. will be fursiched at the following prices, providing a request for same is made at time proof is returned: 100, 4 pages without covers, $6.00; each additional 100, $1.00. 100, 8 pages, without covers, $7.50; each additional 100, $2.80; 100, with covers, $12.00; each ad- ditional 100, $4.80. 100, 16 pages, without covers, $10.50; each additional 100, $3.00; 100, with covers, $16.00, each additional 100, $5.50.

SUBSCRIPTION PricE, $2.00 PER ANNUM. SINGLE Copigs, 25 CENTS. Entered at Providence, R. I. Post Office as Second-class Matter.

RHODE ISLAND MEDICAL SOCIETY Meets the first Thursday in September, December, March and June

Providence PAWTUCKET

DEWoLF President _ H.G. PARTRIDGE 1st Vice-President Providence NorMAN M. MAcLEoD- 2nd “ Newport | A. MancHESTER President Saylesville James W. Leecu Secretary Providence | RoBext T. Henry Secretary Pawtucket . E. Mowry Treasurer Providence PROVIDENCE EB. Meets the first Monday in each month excepting 'y, August and September | KENT WASHINGTON Meets the second Thursday in each month Meets the second Thursday in January, April, G. Houston ; President Arctic July and October NEWPORT WOONSOCKET Meets the third Thursday in each month Meets the second Jared jr ben month excepting Witt1aM S. SHERMAN President Newport | J. v. O'Connor President Woonsocket Avexanper C. SAnForD Secretary Newport | J. M. McCartHy Secretary Woonsocket

+ Section on Medicine—4th Tuesday in each month, Dr. Charles A. McDonald, Chairman; Dr. C. W. Skelton, Secretary and Treasurer. R. I. Ophthalmological and Otological Society—2d Thursday—October, December, February, April and Annual at call of President Dr. Jeffrey J. Walsh, President; Dr. Francis P. Sargent Secretary-Treasurer. . The R. I. Medico-Legal Society—Last Thursday—January, April, June and October. Frederick Rueckert, Esq., President; Dr. Jacob S. Kelley, Secretary-Treasurer.

THE TALISMAN

I await on the threshold of life to welcome every living thing

I preside over the donting of every success and I am the inspiration of every achievement

I am the poor man’s wealth and the rich without me is in poverty

. Lam sought by all but appreciated by few, I am beyond price but I am everyone’s heritage

I am a necessity to hope and misery stalks in the path of my departure

Age like the mantle of night may steal upon us, but if I am present there is cheer and happiness

Desolated and destroyed empires, suicide and infamous crimes have been ascribed to my absence

I am sometimes repulsed but never subdued

lam always welcome, but have often been ignored, offended, imposed upon and insulted

I am in your power and subject to your direction—protect me therefore, guard me and be ever consid- erate of me for my worth transcends all else

I am HEALTH F.N. B.

‘ is ae

June 1926 EDITORIALS

THE RADIO NOSTRUM

It would be surprising indeed if, among the many benefits conferred by the new found inter- ests of “radio” there were not some disadvantages and possibilities of mischief. One of these, the broadcasting of the supposed merits of a nostrum concerns the medical profession directly. The ad- vertising power of the radio is enormous. A clear cut, decisive and convincing voice tells a plain and easily understood tale with perhaps a charming personal touch,—for the remedy has helped him too,—and the listeners make a note of the remark- able compound and seek its aid.

But underneath all this is the underlying truth that the great mass of mankind is unthinking, carefree and easily imposed upon. The same pub- lic that says “It says so on the bottle” and with the same trusting confidence “I heard it on the radio” places in its estimation the radio broad- caster with the artist and the literateur instead of in the grammar school where he may perchance more properly belong, will accept the message from the air, and the popular intelligence is there- by lowered. Occasional scientific talks under the direction of reputable medical societies are not enough to counteract this evil, it must be remedied by the censors of the whole system of broadcast- ing which will hopefully be organized under gov- ernmental regulation. So powerful an agent for good must be cherished and regulated. Publicity should not be vouchsafed anyone with the price “who engages the facilities of these stations” and the state and national societies should be up and ready to properly guide those measures which will safeguard the best interests of scientific medicine.

A VACATION WARNING

The near approach of warm weather renders timely a warning as to the best use to be made of the annual vacation period. The community as a whole has accepted the idea that a vacation is de- sirable from the point of view of health and ef- ficiency. The best results from this generally beneficent institution are not always obtained, ow- ing to the lack of judgment of the individual vaca-

EDITORIALS | 95

tionist. By many, a trip to the seashore or moun- tains is looked upon as an opportunity to indulge in the maximum amount of violent exercise, re- gardless of physical fitness.

Those fortunate ones who have most of the summer for play or who have kept in training during the winter months may with impunity un- dertake exertions which would be suicidal for the average man who must crowd all his recreation into two weeks. Fifty weeks at the desk do not fit one for a sudden transition to extreme exer- tion. It is best to resist the natural desire to crowd the maximum activity into the all too short vacation.

Also, the man over forty who tries to impress the youngsters with the fact that he is as good as ever, not only fails in that attempt but proves to those who know, and frequently to himself by sad experience, that his years have not brought wis- dom. A dilated heart is a poor souvenir to bring back from a mountain top.

THE HOSPITAL BEAUTIFUL

A traveler returning from a strange land recalls the scenes which he has visited principally by mental pictures of natural grandeur, mountains, lakes and rivers; but also by his memories of the man-made beauties portrayed in the architecture of the great public edifices of the communities where he has sojourned. Cathedrals, libraries, Houses of Parliament and the like remain in his mind as symbols of the character and achieve- ments of the people—and as such they descend to posterity, permanent records of the times in which they were created. So, too, the hospitals stand as great public monuments to the spirit and character of their times and have a share in making a deep impression, be it favorable or otherwise, upon the mind of the casual visitor. But far more than this, these hospital buildings, scarcely less holy as they are than the cathedrals themselves, leave indelibly impressed upon the minds of the people of the communities which they serve the picture of their exteriors—those buildings in which loved ones have suffered, recovered or passed out of this life. To fulfill such a purpose the hospital should in its external aspect be endowed with a true in- trinsic beauty and dignity appropriate to its place of honor in the hearts of the people.

%6 THE RHODE ISLAND MEDICAL JOURNAL

The graceful towers of the Rhode Island Hos- pital, rising above the green of the elms beyond the curving sweep of lawn, form a picture of which our citizens are justly proud and which we believe could hardly be excelled. Most of the newer hospital buildings in the state, on the con- trary, with their graceless severity of outline ex- emplifying the thoroughly utilitarian and factory- like simplicity that is the mode, can hardly be com- mended as appropriate or inspiring. This being the fact it is most satisfying to see in the newly erected Lying In Hospital of Providence a de- parture from such soulless simplicity and evidence of architectural genius of the first order which has produced a building both dignified and impos- ing, of which the people of the city and the state can be justly proud.

THE STATE SANATORIUM Continued from page 93

Of the first 2581 cases admitted to this institu- tion after its opening, in 27% there had been a previous case of tuberculosis in the family. Of the last 1000 cases admitted, in 247 or 24.7% there had been a previous case of tuberculosis in the family. Of 150 cases, 97 or 64% occurred within eight years following the death of or contact with the tuberculous relative.

If physicians would urge chest examinations an- nually on all family contacts for eight years after a case of tuberculosis has been discovered, many more patients would be detected in the curable stage.

The Sanatorium physicians are holding diag- nostic clinics in Apponaug, Bristol, Burrillville, Cranston, East Providence, Esmond, Newport, Warren, Westerly, and Woonsocket. Many of the patients attending these clinics will not employ any physician, many are contacts only, while a considerable number are sent to us for diagnosis by physicians to whom we report our findings.

Clinics perform a valuable service to patients who cannot pay and to drifters who will not stick to any physician or hospital and who should be followed up by nurses and reminded of the risk of infecting others. If physicians would make more use of clinics they would receive more aid in the diagnosis of doubtful cases. This is true of all

June, 1926

tuberculosis clinics in the state by whomever conducted.

In 1922 the Physicians Association of Westerly invited me to hold a clinic there. All the physicians co-operated cordially, sending their cases of tu- berculosis and suspect cases to the clinic for diag- nosis or advice. The Nursing Association has em- ployed nurses especially interested and experi- enced in tuberculosis who have given much atten- tion to the work. Previous to this time the Sana- torium admissions averaged only two or three per annum from this town. As a result of the in- creased zeal and effort on the part of physicians and nurses of Westerly, we have admitted 48 tu- berculous patients in three years and seven months or about five times the number previously ad- mitted in the same period. This does not include eight tuberculosis suspects admitted for observa- tion and treatment. Twenty-four of the 48 pa- tients were diagnosed before tubercle bacilli were found, and were therefore in a more hopeful stage. The experience in Westerly shows what we physicians can do when we all make a little extra effort and all help each other.

As a diagnosis of tuberculosis at an early stage is often puzzling to one who sees 500 new cases a year it must be much more so to the average prac- titioner who sees only five cases or even less. Since the Santatorium offered to help physicians in the diagnosis of tuberculosis three years ago, over 160 cases have been sent to Wallum Lake for examination and X-ray and as many more have been sent here through our clinics.

Many patients will come to Wallum Lake read- ily for examination and X-ray who at first will not consider coming here for treatment, but after see- ing the place they finally agree to come to take the “cure.” The Sanatorium management invites sug- gestions as to how we can render better service to the physicians and people of Rhode Island and we ask your active co-operation to the end that the mortality from tuberculosis may be still further reduced.

H. L. Barnes, M.D. Superintendent

P. S. Official figures are not yet available but the tuberculosis mortality per 100,000 for 1925 will be about 80.

arm e a4 ss

bate 20 ‘ I -

5

june, 1926

SOCIETIES

Ruope IstAnp Mepico-LecAL SOCIETY

The regular quarterly meeting of the society was held in the Medical Library, 106 Francis Street, Providence, on Thursday, April 29, 1926, at 5 P. M. The subject for discussion was “Psy- choanalysis and Its Effect Upon Modern Litera- ture,” by George W. Potter, editor of The Eve- ning Tribune, Providence. Guests were invited as usual.

Following adjournment, a light supper was

served. Jacos S. Kerrey, M.D.

Secretary

BOOK REVIEWS

An INTERMEDIATE TEXTBOOK OF PHYSIOLOGICAL CHEMISTRY, WITH EXPERIMENTS. Third Edition. By C. J. V. Pettibone, Ph.D., Asso- ciate Professor of Physiological Chemistry, Medical School, University of Minnesota,

Minneapolis. C. V. Mosby Company, St.

Louis, Mo., 1925. 404 pp.

_ The author shows excellent judgment in select- ing and condensing the essential facts of physio- logical chemistry. The chapter on physical chem- istry contains a surprising amount of information in its 15 pages. The succeeding chapters deal brief- ly but effectively with the chemistry of the body, food, digestion, urine, and metabolism.

The theoretical and descriptive part is followed by a section on experimental and analytical meth- ods, comprising the last third of the book. Quali- tative and quantitative methods are described with as much thoroughness as space permits. It is dis- appointing to see that the author employs the term “percent by volume” as equivalent to “grams per 100 cc.” The former is ambiguous, and should be discarded, though it seems to be in common use among biologists. The chapter dealing with blood analysis contains the Folin-Wu_ system, which has been found very satisfactory.

The book is presented as an intermediate text- book, and is to be recommended as such. Its value lies not in new material, but in brevity and clear- ness. “Lengthy discussions of debated points” are purposely avoided.

SOCIETIES 97

PROCEEDINGS OF THE INTERNATIONAL CONFER- ENCE ON HEALTH PROBLEMS IN TROPICAL America. United Fruit Company, Boston, Massachusetts, publishers.

Although the title and some of the subject mat- ter of this book is purely tropical, the greater part of the 1010 pages may be read with profit and pleasure by any general practitioner in the temperate zone. Had this book an index, it could have been published and sold very readily as a text-book on tropical medicine.

The papers and discussions have been arranged very well on the whole. The list of contributors to the papers and to the discussions contains the names of some of the foremost men in the field of public health and tropical medicine.

The mosquito borne diseases—malaria and yel- low fever—are well treated and suggestions for their control, well worth reading.

The value of bismuth subnitrate in large doses for the treatment of amoebic disease was stressed. Its value in conjunction with the simultaneous administration of emetine was emphasized.

Castellani brought out the value of the use of thubarb in the treatment of the bacillary dysen- tary of children.

The use of vaccines and sera is dealt with in some five papers. Park reports excellent results using 6-10 cc. of convalescent measles serum as a prophylactic. He also brought out the fact that serum drawn from a patient later than three months has lost much of its value as an antibody factor.

Like most of the United Fruit Company’s work, this book—the printing and illustrating—has been very well done; but although there is a wealth of material here, it is hard to get at, as there is no index.

SomME FUNDAMENTAL CONSIDERATIONS IN THE TREATMENT OF EmMpyEMA TuHoracis. By Evarts A. Graham, A.B., M.D., Member of ‘Empyema Commission, U. S. Army; Pro- fessor of Surgery, Washington University School of Medicine; Surgeon-in-Chief, Barnes Hospital, and St. Louis Children’s Hospital. Cloth: Thirteen Illustrations, pp. 110. St. Louis; The C. V. Mosby Company, Publishers, 1925.

This essay was awarded the Samuel D. Gross prize of the Philadelphia Academy of Surgeons

JA rly uns tu- ig- la- Der in- ‘hs \d- 7 de Te Ful we ra ge Ss. ns 0, or ve d- ot e- he to ve ne er ut

98 in 1920. The article was not intended as an ex- haustive study on the subject, but was written to bring attention to certain principles in regard to empyema rather than to the details of treatment. The author states that by following these prin- ciples worked out by the Empyema Commission of the U. S. Army, that the mortality of respira- tory hemolytic streptococcus infections compli- cated by empyema in the camps was cut from an average of over 30% and in some cases up to 70% to 4.3%.

The first principle is “Careful avoidance of open pneumothorax in acute stages.” Fifty-two of the ninety pages of reading matter are in this section which deals with the pathology of the in- fection, opened and closed pneumothorax, intra- pleural pressures, equality of relative densities of both lungs in unilateral pneumothorax, bilateral pneumothorax, erroneous conceptions of pneumo- thorax, experimental methods on human bodies

and dogs, relations of amount of air entering

pleural cavity to that entering lungs, experimental empyema and pneumonia, application of the ex- perimental results to the treatment of empyema and clinical confirmation of these results with reference to repeated aspirations compared with early continuous drainage and deferred operation. This section is of interest especially to technical laboratory men, with its descriptions of the experi- ments, its numerous formulas involving “Vol- umes of Air,” “Vital Capacity,” “Areas,” “Tidal Air,” “Negative Pressure,” etc., and with its many illustrated smoked drum tracings recorded during the animal experiments. On the other hand, the average busy practitioner would not spend the time to study out the details of this laboratory work, and if he did, he then would not expect to remember anything but the essentials or the conclusions. The citing of many erroneous con- ceptions of pneumothorax tends to confuse the reader.

A little more space given to the clinical side, especially in regard to repeated aspirations and deferred operation, would make this section more valuable to the average physician. Dr. Graham states that “In all probability a difference of a few days on one side or the other is not of very great importance in deciding when to operate.” This point is not conceded by the reviewer of this

THE RHODE ISLAND MEDICAL JOURNAL

June, 1926

article, from his own observations of numerous acute and chronic cases in different army camps. The author states that 13% of the cases treated by aspiration alone were cured. More recent sta- tistics have shown, however, that many of these “cured” cases have since had recurrences and operations, and Dr. Graham does not mention that many of the 13% were discharged with greater morbidity because of their general condition and deformities than those treated first by aspiration and then by operation.

The second principle is “The Prevention of Chronic Empyema by Rapid Sterilization and Obliteration of the Infected Cavity.” There are only thirteen pages on this subject. Mention is made of the importance of both the drainage and ‘the necessity of sterilization of the cavity at the same time, the failures being due to non-obliter- ation caused by the fibrosis of the lung resulting from the infection and the thick coat of inelastic exudate covering the lung.

There are a few words on the value of the sterilizing and solvent qualities of Dakin’s Solu- tion, which is the only solution to accomplish the desired results early as possible. Five of the thir- teen pages are on the exceptional cases of decorti- cation en massee with Dakin’s Treatment, while only one paragraph refers to that important fac- tor—the physical means of inflation of the lung and exercise. It also then gives a short -discus- sion of common operations for the cure of chronic empyema and the disadvantages of collapsing operations.

The third principle is “Careful attention to the nutrition of the patient.” A little over two pages is used to call attention to the fact that most of the empyema patients had a negative nitrogen balance, unless their diet was pushed up to 3300- 3500 calories a day, and that many fatalities and chronic cases resulted from the patients’ fighting gradual starvation and empyema at the same time.

The last chapter of the book briefly discusses the following: Fistulas which communicate with the lung; When is empyema healed; Adequate Drainage desirable in subacuate and chronic stages; No discord between experimental results on pneumothorax and clinical findings in war wounds of the thorax. This is followed by a summary and conclusion. The addendum has a

( t I t 1 4 t t a . Pp 0 a I cl a th te 0 Is SC t as ge

June, 1926

twelve-page discussion by the author on open pneumothorax, supporting his claim on the subject, as against those of some of his colleagues with other conclusions. This reader agrees with the author’s opinion on this subject. The volume finishes with a bibliography of 56 numbers.

PURPOSE OF INTERNSHIP

E, E. Irons. Chicago (Journal A. M. A., April 3, 1926), points out that the purpose of a hospital internship is not to supply deficiencies of the medical curriculum nor to complete a medical edu- cation. Nor is the function of an internship to make specialists. The fear that a year of intern- ship in internal medicine or surgery may con- tribute to premature specialization seems unwar- ranted by facts. The purpose of an internship is not primarily to afford opportunity for the formal investigation of a problem, although the atmos- phere of research and of desire for knowledge and truth in the hospital will influence the intern daily in making and recording his observations, and may lead him to undertake further independent study during his later residence. The purpose of an in- ternship is not to make possible the operation of the hospital nor to assist the hospital in meeting the technical requirements of some standardizing agency, although the maintenance of satisfactory intern service by the hospital does aid it materially in attaining both these ends. The intern is an im- portant part of the great cooperative enterprise of the modern hospital. He will work faithfully and grow in professional stature, if he is not over- loaded, and if he is early led to enter into that spirit of friendly cooperation between attending staff, nurses, administration and patients which characterizes the well ordered progressive hospital, a spirit that may be described as a hospital con- sciousness. A number of questions arise in the selection and organization of hospitals in which the student is to carry out the purpose of the in- ternship, among which are methods of supervision of this internship and the kind of internship that is likely to be most satisfactory. Some medical schools have undertaken to supervise one year of the internship by requiring a fifth or hospital year as a prerequisite to the medical degree, and dele- gating the supervision of this year to a group of

MISCELLANEOUS 99

faculty members usually called the fifth year com- mittee. This arrangement assures that all students will take internships in hospitals complying with certain minimum standards, and thus protects some of the less critical students from errors in selection of their hospitals. Fifth year committees have incidentally been of great assistance to hos- pitals, in pointing out, and in helping them to remedy, their defects. The administration of a fifth hospital year is, however, only one of the ways in which the student may be launched on his career on leaving the medical school, and there are those who prefer to have the supervision of the medical school cease at the end of the four years of study. There has been much discussion as to whether a rotational internship should be in- sisted on for all students, and some states have gone so far as to prescribe the character of the internship and the time to be devoted to medicine, surgery and obstetrics. According to Irons, the suitability of a hospital for the purpose of an internship depends on the ideals and character of its staff, on the ability and desire of its adminis- tration to provide the best care possible for the sick, and on the presence of a spirit of inquiry and progress, and not primarily on whether it has a rotational or a nonrotational system.

DIPHTHERIA IN 1925

The annual diphtheria summary in this issue (p. 1005) affords one of the most encouraging records of recent years in preventive medicine. From 1910 to 1920, little improvement could be demonstrated in diphtheria mortality in most cities. In 1910-1914, only thirteen cities averaged rates under 10; in 1915-1919 and again in 1920- 1924, there were only eighteen cities that could be so classed ; but in 1924 there were thirty-seven and in 1925 forty-nine with diphtheria rates prac- tically unknown anywhere before 1910. There can be little doubt that the amazing reduction in recent years is to be attributed in large part to the increasing immunization of school children with toxin-antitoxin mixtures or with anatoxin. This conclusion seems warranted, not only by the observations in individual cities like New York where the method has been extensively employed, but by the rapid decline in diphtheria mortality

| “ous nps. ated

sta-

and that

and tion

of and

are 1 is and

the ter- ‘ing stic the

the hir- rti- hile ung ‘us- nic ing

the ges

of zen O0- and

ing me. ses rith ate nic ilts var a

100

throughout the general population. In 1923, the diphtheria death rate in the large cities of the United States was 13.14; in 1924, it was 11.15, and in 1925, 9.88. Something may doubtless be credited to the curative side, since the use of anti- toxin is probably more widespread and more effec- tive each year; but the fact that since immuniza- tion measures began to be applied the diphtheria rates, previously almost stationary, have suddenly and decisively dropped, indicates that the latter is the main factor. If the improvement of the last three years continues, diphtheria may well be an almost negligible factor in the mortality returns of 1930.—Jour. A. M. A., April 3, 1926.

HYPODERMIC DIGITALIS PREPARATIONS

Harold E. B. Pardee, New York, Journal A. M. A., Oct. 31, 1925), found in the course of using intravenous injections of digitalis preparations in the treatment of patients with cardiac decompen- sation, that the manufacturers’ claim as to potency, and particularly their recommendations as to dos- age, were far from correct. It has never been properly demonstrated that any of these supposed advantages of the intravenous use of digitalis are actual facts, and so it seemed advisable to investi- gate the activity of these preparations. It seemed especially important because they are commonly

and widely used in the most severe cases and in.

emergencies, when the difference between a suffi- cient and an insufficient dose might be vital to the patient. It seemed best to do the whole work with the human heart, using the change in the “T” wave of the electrocardiogram as an indicator of digitalis activity and also the showing of the rate of a previously untreated auricular fibrillation. These two are the earliest digitalis effects to ap- pear after the administration of a sufficient dose of the drug, and the use of the “T” wave change as a method of testing various tinctures of digi- talis has been previously reported on by the author. He used as a measure of the potency of a digitalis preparation the smallest dose that will diminish the amplitude of the “T” wave, calling this “T*” wave unit. He has expressed this dose in fractions of a minim per pound of the patient’s weight, because Eggleston’s demonstration of the relation of body weight to digitalis dosage has been well proved by experience. It was found that the clinical activity of the different tinctures tested was inversely proportional to the size of the dosage that would effect the “T”’ wave. Less of the more potent tinctures would be needed than of the weaker ones.

THE RHODE ISLAND MEDICAL JOURNAL

June, 1926

At present he reports on the testing of digifolin Ciba, the digitan ampules of Merck, digalen (Clo- etta) and the Burroughs Wellcome tablets of amor- phous digitalin. The minimal effective dose of each of these preparations was found to be much larger than suggested by the manufacturer for the therapeutic dose, so much larger that if the printed suggestions as to dosage were followed, the patient would certainly fail to receive an effec- tive dose, and so to benefit from the medication. In the case of tincture of digitalis by mouth it has been found that the full therapeutic dose was from eight to ten times the minimal effective dose as determined by the “T” wave change. He does not believe it is ever proper to give the full cal- culated therapeutic dose of a digitalis prepara- tion at one time, because of the likelihood of pro- ducing a considerable degree of poisoning in some susceptible patients. One half of the amount by mouth, four or five times the minimal effective dose, is safe, however, and will produce definite digitalis effects. This works out to about 1 minim per pound of the liquid preparations, slightly more for the digifolin and digalen than for digi- tan, and 4/100 grain of the digitalin per 70 pounds, which would be eight of the 1/100 grain tablets for a patient of 150 pounds. It is always necessary, when suggesting large doses of any dig- italis preparation, to emphasize the need of making certain that the patient has not been receiving digitalis in any form during the previous two weeks. The drug is sometimes so slowly elimi- nated that a patient may retain an unexpectedly large proportion of a previous dose, and the addi- tional effect of the later dose may cause unpleas- ant toxic symptoms. The doses here recommended are only for patients who have not had any digi- talis within the previous two weeks. For patients who are under the influence of digitalis at the time, the dose should be reduced to one quarter or one half of that recommended, to from 30 to 60 minims, depending on the estimate of the de- gree of the patient’s previous digitalis saturation. This reduced dose should be repeated at six-hour intervals if needed. Further observations are needed to settle the question of promptness of action. The facts just noted make it seem likély that it is more dependent on a mass effect of digi- talis—the large size of the dose—than on the greater promptness with which the drug comes in contact with the heart muscle after intravenous administration. We must not rely then on mini- mal intravenous doses when in need of a prompt effect, though it is possible that somewhat smaller doses are needed by vein than by mouth.

‘ . \ - ~ j j