MEDICA

THE INDEX.

GENERAL SURGERY

J. R. WATHEN, F. H. MONTGOMERY

MENTAL AND NERVOUS DISEASES

CURRAN POPE

PROCTOLOGY

BERNARD ASMAN

This issue of the JOURNAL contains a complete index of Volume XII from January to December, 1914. All original articles are indexed from the leading title and crossed indexed so that it will be of value to any physician writing articles to readily refer to any subject desired. County societies and reports of officers of the Association are indexed and they can be used by the secretaries in preserving their records and for references.

All physicians who have written or discussed articles are listed in the Index as well as those who have attended or taken active part in the discussions.

RUSSELL COUNTY.

The December 15 JOURNAL contains the minutes of the 25th Anniversary of the Russell County Medical Society. Dr. J. B. Scholl Dr. J. B. Scholl read a most interesting paper on its history in which he stated that he was the only living charter member. Dr. Scholl is one of the younger and most active members of the profession of the State and it seems curious to think of him being the oldest physician in Russell county.

The Russell County Medical Siciety has the largest membership in its history, and its success is brought to the attention of other counties in the State because it is so richly deserved. They have good doctors, regular meetings, good programs and are doing real work to improve health conditions in their county. When it is considered that there is not a railroad nor a turn pike in this county, the example of Dr. Scholl and his associates is cordially commended to the organization in other counties with the hope that it will stimulate all of us to do our best work during 1915.

PRACTICE OF MEDICINE W. F. BOGGESS

No. 1

ANNUAL DUES.

As every member of the JOURNAL knows, each of you are an owner of it. Each of you are equally responsible not only for its maintenance and support but also for the character and extent of its scientific and other contents. We feel that our JOURNAL is the peculiar pride of the medical profession of Kentucky. Its democracy is evidenced by the fact that no contribution from a member of any county society of the State has been refused publication in ten years. Its integrity is evidenced by the fact that its Council stands ready to pay in cash for any failure on the part of any one of its advertisers to carry out in good faith any statement that they make in its advertisements.

In wishing a Happy New Year to each of you, the JOURNAL desires to take this opportunity for calling to your attention the larger importance of the local work you are doing in your county societies. We are sure you will be interested in knowing that every school child in Kentucky is being taught that competent doctors are practically always members of and regular attendants at their County Medical Society. We urge that each of you, who have not always had the constant stimulus to be gotten from regularly rubbing against your fellows at these meetings, will begin to participate in a real organization in your county. More county societies are doing actual work than ever before but there are still too many of them which are mere paper organizations and do no good to anybody. Will you not try to make your county society a more effective one this year? With this idea in view, begin now by sending your State dues of $3.00 in addition to your county dues, which vary in the different counties, to your county secretary to-day so that your county may be one of, at least, fifty, which will have their dues in the hands of the State Secretary by January 1st. It is well to remember that these dues not only pay for your State mem

bership but also bring all the issues of the JOURNAL, and give you all the protection the courts can afford against unjust malpractice suits, as well as increasing your prestige and standing with your people at home and with the profession of the United States as a whole. It is important to remember that no doctor will be accepted for reciprocity from Kentucky to any state in the Union, who is not a member in good standing in his county medical society and recommended by it.

Let's all pull hard and pull all together to make 1915 the best year in the history of Kentucky medicine, and to make the Louisville session the best and biggest any State Association has ever had.

DIPHTHERIA ANTITOXIN.

For a number of years the State Board of Health has been securing for the citizens of this Commonwealth high-class diphtheria antitoxin at the lowest possible price. Alexander's diphtheria antitoxin has been shipped from the laboratory of the State Board of Health at Bowling Green at exactly the wholesale cost. This plan has saved thousands of dollars to the people, while indigents in the ordinary sense of the term, could not afford to pay the regular retail price. Many cases of diphthereia have been prevented by this plan and many other cases cured.

In order to make the diphtheria antitoxin more quickly available to our profession and people, the State Board of Health has authorized the Alexander firm to arrange for a number of distributing stations which will distribute through the stations at the following conveniently located cities: Louisville, Lexington, Newport, Paducah, Henderson and Pineville. The antitoxin will be sold from these distributing stations at the same prices and upon the same terms as from the Laboratory of the State Board of Health at Bowling Green. Frequent inspections of these stations will be made by the State Board and the requirements that the antitoxin be kept in clean refrigerators; and that an adequate supply be kept on hand of reliable material will be enforced.

The mortality from diphtheria is higher in Kentucky than in any other state in the Union. This can only be because antitoxin is not used promptly. It is important for our members to remember that the Medical Defense Committee has ruled that it will not defend a member sued for malpractice for failure to use diphtheria antitoxin in a case of diphtheria as soon as the antitoxin can be obtained. The State Board of Health especially recommends that no child suspected of having diphtheria shall be permitted to mingle with

well children and especially not allowed to attend school or Sunday School until, at least, two negative reports have been received from the State Laboratory at Bowling Green. Containers for the examination of swabs from the throat of children with diphtheria can be secured at any time and these examinations are made without cost. We trust the physicians of Kentucky will take advantage of this opportunity to save our citizens the great difference between the price of the State Board of Health antitoxin and the same product sold at the regular retail price.

In this issue of the JOURNAL the announcement of the Alexander firm goes into the matter with a little more detail and we urge our readers to give it the attention its importance deserves.

SOUTHERN MEDICAL ASSOCIATION.

Those Kentucky physicians who were fortunate enough to be in attendance at the recent session of the Southern Medical Association in Richmond, Virginia, repeatedly expressed themselves as sincerely regretting that, at least, several hundred of our Kentucky brethren were not present to participate in the good times that were lavished upon them. Approximately, a thousand physicians were present and every Southern state was represented. The scientific sessions were excellent; in fact, we do not recall any previous medical gathering where the proportion between essays and discussions was so accurately balanced. The program never seemed to lag for an instant. The peculiar problems before the medical profession of the South were all brought up and the sincere interest and thought, and what is far more important, real work, which is being devoted to their solution was in evidence everywhere. For example, the discussions in regard to pellagra brought no real conclusions but presented a mass of testimony which will be of value in finally reaching the real cause of this baffling disease.

The presidential address of Dr. Stuart McGuire was particularly noteworthy. The ordinary presidential address is a pretty tame affair, but Dr. McGuire presented a real message direct from the heart and brain of one of the greatest constructive statesmen in the profession and after it has been published in the Southern Medical Journal, it is our purpose to re-publish it in this JOURNAL. So that all of our readers may have the benefit of it. Another special address was that of Dr. Cary T. Grayson, of Medical Corps of the United States Navy, on the old-time physician. It seems particularly fitting that Dr. Grayson, young, athletic, the personal and family physician of the President of the United States, representing all that is most modern in pro

fessional thought and action, should have laid this tribute to the memory of the great family physicians of the past.

Those of our members who are also members of the Southern Medical Association and who receive regularly the Southern Medical Journal will read with great pleasure and profit the scientific proceedings of this gathering. Those who have not yet become members, the JOURNAL extends a heary invitation for you to send your check for $3.00 to Dr. Seale Harris, the secretary, at Mobile, Alabama, and you will receive from him during 1915 twelve Southern Medical Journals each of which will be worth far more to you than the price of all. Only members in good standing in their county society are eligible to membership in the Southern Medical Association.

SCIENTIFIC EDITORIALS.

NERVOUSNESS IN CHILDREN.

That the American people as a nation are characterized by nervousness is the general verdict of the people, and that this nervousness is on the increase is affirmed by the leading neurologists. We may lay the blame of this on climatic conditions, the massing of people, the increasing of urban population, the high tension of business, and the strain and stress of keen competition in all walks of life. But whatever our explanation of the fact it may be conceded that the beginning of nervousness dates. in childhood. It is our duty, therefore, to give some consideration to the causes of nervousness in children. We hope that we may be able to remove certain of these factors and thus secure a saner and healthier youth and old age.

The prevailing trouble with American people affects the child equally,-the tremendous hurry that seems to predominate our lives. There is the rush to get through the meal, the rush for the street car, the rush to get to school on time, the rush to extra lessons, the parties or diversions. And thus the day has been spent without any calmness or repose. When this is kept up throughout the school years of a child is it any wonder that the nerve tension gets to the breaking point.

Nervousness may be only an expression of this storm and stress through which the child is passing, or it may be the beginning of organic nerve disease, or it may aggravate or intensify the difficulties and dangers of any of the childhood disorders not necessarily marked by nervous symptoms.

Certain of the factors in the production of nervousness cannot wholly be removed in the present state of our civilization. The rush of

life is ministered by all of the agencies in modern civilization; the telephone, the telegraph, the street car, the automobile, the morning paper, all intensify the demand upon our nerve resource. The child starts on the way to school in the morning keyed up by the strenuous life at home aided and abetted by the dangers to life and limb on every street, supervised, if not nagged all day by a nervous teacher until the tired jangled nerves hardly get relief from the sleep which is broken by street cars, fire engines, night hawks, joy riders, and the early milk man. These are the conditions that confront us and apparently cannot be removed. But the parent should be instructed by the physician to minimize in every possible way the friction that comes in every household. A self-controlled father and mother and well controlled children develop the power of inhibition that enables the child or adult to resist the impulses which impinge upon the central nervous system. Nervous energy is conserved because it is not wasted upon every excitement which may reach the organization.

give way to every passing thrill. The child should be taught early not to The in

hibitory centers of the brain should be called into play early in controlling any outward manifestations of nervousness or excitability. A child who controlls itself and one who gives rein to every excito-motor impulse show a differentiation which in late life may mean the difference between a sane and an insane career. It is necessary for a father and mother to exercise self control in order that they may teach their children self-control. An excitable temperamental mother makes it increasingly difficult for a child to develop inhibitory mechanism. Perhaps it is not too much to say that this self-control of the mother should be especially emphasized during gestation.

Conservation of nerve force, of strength and energy is best attained by regularity and order in the day's labor. The child who learns early to do routine work in a routine day is saved much friction. The regularity of meals, of exercise, of diversion and of play lessens the wear and tear. The modern business doctrine of efficiency tends to eliminate all the extraneous losses of time and strength. The same should be applied to the daily life of a child. Unnecessary worry over lessons and other things which break into a child's life use up vital energy. Fatigue from overplay, from over study, loss of sleep, improper food, eating too hurriedly, all take their toll in a child's nervous energy. Many nervous children are made so by too great demands upon their strength, the number of things they have to do in a day. The city child with its hours in school, its special lessons in music,

language and dancing in the afternoon, moving picture shows, and frequent parties leads a strenuous life and lays the foundation for an unstable nervous system in later life.

Parents feel that their children should be amused; they often over-stimulate a child's brain because they feel that a child should be entertained. "Happy is the nation that has no history," may be paraphrased, happy and fortunate is the childhood that has no excitement. PHILIP F. BARBOUR.

WHAT IS THE CAUSE OF FEVER IN LATE OR TERTIARY SYPHILIS?

One of the readers of our STATE MEDICAL JOURNAL proposed this question. The reader, a country physician, who is a keen observer as a good many country physicians are, should be congratulated, as he is only one of the few physicians who noticed this unusual phenomenon in tertiary syphilis.

It was thought for a while that syphilitics in the primary or secondary stage were wont to have fever. In the last few years attention has been drawn by some syphilographers that fever may be met with in the tertiary stage of syphilis. Mention is even made as far back as 1866 by Lancereaux, and in the seventies by several other wirters. In the last few years this question came up again and quite many reports as to this occurence are found in the medical literature. The question as to the causation of fever in the tertiary stage of syphilis has been asked frequently, but no definite or scientific answer has been given. Different theories were proposed, but all failed to give a true solution as to its cause.

What is then, the real cause of fever in late syphilis Kirchheim, Schleggelmann, Sobernheim and Stern are in accord with the great Fournier and attributed this phenomenon to accidental infection. But this theory must be repudiated since accidental infection, with fever following, would hardly yield to mercury treatment. A good many other theories have been proposed but all of them have been found wanting. Baumher's and Klamperer's theory that fever may be caused by absorption of necrotic masses is contradicted by the prompt and rapid influence of mercury therapy.

The most plausible theory was lately advanced by Jerome, Westphalen, Jordon and others that fever in tertiary syphilis may be caused by the presence of spirochetae and the toxins eliminated by them. Mannaberg claims that no matter in what phase a case of tertiary syphilis may appear, if febrile condition accompanies it, spirochetae pallida can be found circulating in the blood. If this be true, then, there is no difference between the tertiary and secondary stage. In autopsies

on patients with tertiary syphilis Strassman found spirochetae located in the central nervous system.

To me tertiary syphilis seems to be analogous to latent gonorrhea. As in latent gonorrhea the gonococci are often found to become active from some cause or other, so we find spirochetae suddenly become active in tertiary syphilis, and the latter, like gonococci, may create a condition often accompanied by fever. In two cases of tertiary syphilis accompanied by febrile condition, spirochetae were found by my asistant and pathologist. As the latter was very doubtful of the possibility of these cases being syphilis, the utmost care was used to prevent any possibility of contamination from the India ink used in staining. Several tests were made and spirochetae were invariably found. The patients, previous to having undergone a Wasserman test, were treated for malaria, intestinal trouble, rheumatic fever and ambulant typhoid with antipyretic, antirheumatic remedies without any improvement, until antisyphilitic measures were adopted.

The question of the possibility of reinfection was entirely eliminated in our cases. Somehow we could never believe in the claims of syphilitic reinfection made by some writers. Tertiary syphilis, or we should rather say, neglected and uncured secondary stage, is like latent gonorrhea, stubborn and not easily amenable to complete eradication. Even salvarsan which is claimed by its enthusiastic followers to be able to reach every and all pathological foci, has at times failed to fulfill its claims. Damage done by syphilis is far more serious than by chronic or latent gonorrhea. M. L. RAVITCH.

Arterial Hypertension and Hypotension.-In the management of hypertension cases Roberts disapproves of the use of vasodilators. If the tension is above the danger line and it is imperative that immediate action be taken to prevent hem

orrhage or acute dilatation, then, he says, there is nothing which will give more immediate or lasting effect than to resort to venesection. In all cases with marked hypertension the patient should be put to bed, and the eliminative forces should be increased and all fluids restricted. A low protein diet should be ordered and all those conditions which are intensifying the hypertenactivity treated. For the management of those cases of hypertension in which the danger line has not been crossed, a select diet which is nutritious, but low in animal proteins, should be given. Massage, selective hydrotherapy and a systematic form of exercise, preferably taken in the open air, should be advised.

ORIGINAL ARTICLES

THE QUESTION OF CONTAGIOUS EYE
DISEASES IN PUBLIC SCHOOLS
OF LOUISVILLE.

By J. MORRISON RAY, Louisville.

I want to apologize to this society for offering you a subject for discussion that I thought had been permanently and thoroughly threshed out and settled a number of years ago. Yet when I recently heard the declaration made by men of the highest class training in health matters, that my ideas were incorrect and that what I had, from training, study and observation, been led to consider a very simple disease was in fact the first stage of one of the most destructive and obstinate eye diseases known to the ophthalmologist, I was perforce inclined to stop, look, listen and then take stock. My mind naturally reverted not only to what I had been taught and had read as the opinion of men of the best training and of long experience, but of my own personal

observations.

In the thirty years of my work coming in daily contact with cases of conjunctival disease I cannot recall a single instance where a child in whom I had made the diagnosis of follicular catarrh of the conjunctiva, so-called follicular conjunctivitis had later shown the infallible signs of trachoma such as conjunctival cicatrization, pannus, or lid distortion.

While these pages were being written I saw Mrs. H., of Shelby county. In 1894 when she was twelve years old, she came to me with one of the most exaggerated conditions of folliculosis that I had ever seen. the lymphatic masses not only rolling out of the lower culde-sac the moment the lid was pulled down but the upper cul-de-sac was filled and in addition the inner caruncle and semilunar fold were covered with masses of lymphatic enlargement. The diagnosis I made was follicula trachoma but I was in some doubt as to its not being true trachoma. In order to be on the safe side I advised operation. This was rejected and local treatment requested. Under copper sulphate in stick, with alum and tannic acid drops, in a few months she was in proved. I saw nothing more of the case. She came to me now with two small children, one of whom has a mild catarrhal conjunctivitis. Examination of the mother shows a perfectly normal conjunctiva without a single evidence of the former condition and with normal vision and comfort.

* Read before Louisville Eye, Ear, Nose and Throat Society, November 12, 1914.

Diseases of the conjunctiva make up a large percentage of the eye diseases presenting for treatment, therefore their proper diagnosis and classification are of the utmost import

ance.

The difficulties encountered in differentiating between the different forms of conjunetival inflammation are many. In doing this we must consider the history, origin, symptoms, complications, duration and ultimate results. In investigating the history, the source of infection is often obtained. The presence of other cases in the same family, school or vicinity are of value. The condition of the eye and its surroundings, the character of discharge is present and the symptoms as obtained from the patient are important. The complications present are of the greatest value. The corneal involvement in trachoma is characteristic and pathognomic and few cases of this affection last any length of time without showing corneal complications. I recently heard a well-known ophthalmic pathologist say he did not think trachoma could last longer than a year without giving evidences of its presence by characteristic cor

neal changes.

It is not my intention to discuss all the different forms of conjunctival inflammation to-night but to take up a study of two in which the differential diagnosis and course have been the bone of contention, recently, not only in this city but, I understand, in many other parts of our country. I refer to trachoma and folliculosis, or so-called follicular catarrh.

A great deal of the trouble in the differentiation of these two conditions arises from the confusion in the description, and want of proper classification, found in modern text books. I have recently carefully examined ten of the most widely known and exhaustive text books published and the very latest editions, and while they differentiate between the two conditions, the whole description is unsatisfactory and evasive. I doubt if any one can make a distinction, clinically, after having read the description found therein. This confusion of description and unwillingness to clearly commit themselves has given rise to the suggestion that the chapter on trachoma should be re-written. Even in hand atlases, I can present you to-night with illustrations of each condition, and I am sure the illustrations are confusing and interchangeable.

The following facts in regard to the disease under consideration I offer you to-night.

TRACHOMA,

Much of the confusion found in literature in regard to trachoma is due to the fact that it appears in somewhat different clinical types