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OF THE
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| {{hube 3/alamè ſilehiral šnriettſ ||
. º º º Vol. VIII—PART I s t º
* º 1910 -
. - - - CONTENTS
PRoceedings: . . - -
Quarterly Meeting, March 3, 1910 - - - - - - 1
Annual Meeting, May 31, 1910 - - - - - -
Business Meetings, April 4, May 17, May 31, June 16, 1910 5, 6, 10
Quarterly Meeting, September 1, 1910 - - - - - 78
Quarterly Meeting, December 1, 1910 - • • * &e 79
Business Meeting, November 23, 1910 - - - - - 82
|| ANNUAL ADDRESS - -
By EUGENE KINGMAN, M.D. - - - - - - 12
Hemorrhage-Antepartum and Intrapartum - - " .
By H. G. PARTRIDGE, M.D. - - - - - - 16
The Manifestations of Syphilis in the Eye '.
By G. W. WAN BENSCHOTEN, M.D. - - - - - 24
The Incandescent Light as a Therapeutic Agent
By J. T. FARRELL, M.D. - - - - - * * 33.
Anatomical Works from the Society’s Library . - º * 37
The Tonsils - -
By HARLAN P. ABBott, M.D. - - - - - - 38
The Eye in the Diagnosis of General Diseas
By F. T. ROGERs, M.D. “º - - wº * sº tº: 43
Graves’ Disease -
By JAMES G. MUMFORD, M.D. . - - - * * 51
The Economic Aspect of Tuberculosis
By EDWARD F. MCSWEENEY - - - * - s 65
Modern Methods of Hospital Isolation
By D. L. RICHARDSON, M.D. . . . .
Typhoid Immunization by Means of Bacterial Vaccines
By LESLEY H. SPOONER, M.D. - - - - - - 90
Scabies
By HARRY W. KIMBALL, M.D. - - - - - - 97
The Proposed Building for the Rhode Island Medical Society
By ROBERT F. NOYES, M.D. - - - - - - 102
THE ANNUAL REPORTS-Treasurer, Library Committee - 106, 109
A LIST OF THE FELLOWS - * * * :- - * * 110
OFFICERS OF THE SOCIETY - º * - - - - - 118
OFFICERS OF THE DISTRICT SOCIETIES -. - - * 119
TRUSTEEs of THE RHoDE ISLAND MEDICAL Society BUILDING 119
• * 84

QUARTERLY MEETING
MARCH 3, 1910
A quarterly meeting was held in Rhode Island Hall, Brown
University, on Thursday, March 3, 1910, four P. M. The President,
Dr. Eugene Kingman, presided. Dr. George T. Spicer was elected
Secretary pro tem.
The minutes of the last meeting were read and approved.
The President announced that he had appointed delegates to the
United States Pharmacopeial Convention as follows: Drs. W. J.
McCaw, Charles W. Higgins and Simeon Hunt; alternates, Drs. W. E.
Wilson, James F. Duffy and George M. Bailey.
The President announced that the following Fellows had died
since the last meeting: December 17, 1909, Dr. Robert Millar; January
23, 1910, Dr. Alvin H. Eccleston, and February 19, 1910, Dr. Edgar
I. Hanscom.
The following physicians have joined the Society: From the Kent
District, Dr. Lionel Maximillian Archambault; from the Providence
District, Drs. Roswell Storrs Wilcox and Arthur Ruggles, and from
the Woonsocket District, Dr. Alfred Poirier.
Dr. W. L. Munro presented a resolution relative to the methods
of commitment of the insane in Rhode Island. Following an extended
discussion the resolution was adopted as follows:
WHEREAs, The Rhode Island Medical Society is in honor and
professional duty bound to protect the interests of the sick in the State;
and
WHEREAs, The rights of the insane were last year placed in
jeopardy by an attempt to establish as law a plan of commitment which
was at variance with the conception of insanity as disease; and
WHEREAs, Prevailing methods of commitment have of late been
challenged by members of the local branch of this Society, be it
Resolved, That the subject of commitment of the insane by
court procedure in the State of Rhode Island be and hereby is referred
to the Committee on Legislation of the Rhode Island Medical Society
for due consideration and investigation.
Resolved, further, That the said committee shall report to the
2 QUARTERLY MEETING
Society in due time its findings, if any they have, in particular relation
to a possible plan of court commitment which shall satisfy the demand
of law and at the same time be consistent with the dictates of medical
science and humanity; and be it
Resolved, in addition, That the said Committee on Legislation
shall be empowered, in the event of an unexpected attempt in legislation
concerning the commitment of the insane, to take such action as may
be deemed wise and best for an effectual protest in behalf of the insane
and the maintenance of their rights and privileges in relation to the
law.
- Dr. John T. Farrell read a paper entitled The Incandescent Light
as a Therapeutic Agent. :
Dr. George D. Hersey read a paper on Some of the Earlier
Anatomists with Exhibition of Their Work.
Dr. G. W. Van Benschoten presented a paper on The Manifesta-
tions of Syphilis in the Eye.
Dr. Herbert G. Partridge read on Antepartum and Intrapartum
Hemorrhage. -
Adjourned.
ANNUAL MEETING
MAY 31, 1910
The ninety-ninth annual meeting of the Rhode Island Medical
Society was held in Masonic Temple, Providence, on Tuesday, May 31,
1910, at four-thirty o’clock.
The president, Dr. Eugene Kingman, presided.
The minutes of the last meeting as published in the Providence
Medical Journal May 1, 1910, were approved. The records of the
meetings of the Council and House of Delegates on May 17 and 31,
1910 were read and approved.
Announcement was made that the following Fellows had died
since the March meeting: Dr. George F. J. King on April 12, 1910,
and Dr. George H. Kenyon on May 7, 1910.
Additions to the society have been as follows:
From the Kent District, Dr. John Edward Duffy, Natick;
from the Newport District, Dr. Harry Vincent Carroll, Newport;
from the Pawtucket District, Dr. Peter William Hess and Dr.
Charles Herbert Holt, both of Pawtucket;
from the Providence District, Drs. Frank Mears Adams, Harold
Granville Calder and Alfred Wanzer Love, all of Providence, and
from the Woonsocket District, Dr. James Aldrich King, Woon-
socket. -
Through Dr. Halsey DeWolf, Secretary, the Trustees of the
Caleb Fisk Fund reported that the prize of $200.00 offered last year
for the best essay on the subject, The Classification and Treatment
of the Diseases Commonly Known as Rheumatism, had been awarded
to Dr. Frank E. Peckham of Providence.
In 1911 a prize of $200.00 is offered for the best essay on the
subject, Vaccine Therapy.
For the Trustees of the Chase Wiggin Fund, Dr. G. S. Mathews
announced that no prize had been awarded this year as no essay suf-
ficiently worthy had been received. For the year ending May 1,
1911, a prize of $90.OO is offered for the best essay on the subject,
Tobacco and Its Injurious Effects in All Its Forms on Those Who
Habitually Use It.
Rev. Samuel H. Webb was recognised as an Honorary Member.
4 ANNUAL MEETING
Papers were read by Dr. Frederick T. Rogers on The Eye in the
Diagnosis of General Disease; by Dr. Harlan P. Abbott on The
Tonsils and by Dr. James G. Mumford of Boston on Graves’ Disease.
The annual address was given by the president, Dr. Eugene
Kingman, and at the close Dr. Augustine A. Mann was introduced
as the president for the ensuing year.
Following adjournment the annual dinner was given in the
building.
Dr. William F. Gleason served as anniversary chairman. The
speakers were Dr. Timothy Leary, professor of pathology at Tufts Col-
lege Medical School, on Immunity with Special Reference to Vaccine
Therapy; Hon. Edward F. McSweeney, chairman of Trustees of
Boston Tuberculosis Hospital on The Economic Aspect of the Treat-
ment of Tuberculosis, and Dr. J. Alex Hutchison, chief medical offi-
cer, Grand Trunk Railway System, Montreal.
BUSINESS MEETINGS
APRIL 4, 1910
A special meeting of the House of Delegates, called by the Presi-
dent on petition of Drs. White, Hersey, L. C. Kingman, Welch, G. S.
Mathews, McCaw, Burdick, Crooker, Spicer and Deacon, was held at
253 Washington Street, Providence, April 4, 1910.
The President, Dr. Eugene Kingman, presided. Other members
present were Drs. Mitchell, Hersey, White, Chapin, Welch, Stearns,
Akers, Swarts, G. S. Mathews, Doten, Barrows, Crooker, McCaw,
H. W. Burnett, L. C. Kingman and Burdick.
The resolution introduced by W. L. Munro, M. D., and passed at
the March quarterly meeting, relative to the methods of commitment
of the insane, was adopted in concurrence. Dr. Swarts said that the
committee appointed by the Providence Medical Association for the
Same purpose was ready to co-operate with the Legislative Committee
of this Society.
The resolution passed at the March quarterly meeting that a
committee of three be appointed by the President to meet the com-
mittee of the Providence Medical Association, to consider combining
the Transactions and the Providence Medical Journal with power to
act, was amended by increasing the number to five and passed. The
President appointed the members of the Publishing Committee not
already on the joint committee, namely, Drs. Godding and Swarts, and
Drs. Risk, Leonard and Welch as the committee.
A letter was read from Professor Henry B. Gardner, chairman,
in regard to the tenure of the Society at the Public Library Building,
and it was voted that the matter be referred to the Committee on Ways
and Means, Dr. Blumer, chairman, with instructions to meet as soon as
possible and to report to the House of Delegates at their next meeting.
On petition of the delegates present the President called a special
meeting of the Society for Tuesday, May 31, 1910, which in effect will
take the place of the annual meeting.
After considerable discussion it was voted that the exhibits be
omitted this year.
6 BUSINESS MEETINGs
MAY 17, 1910
The Council of the Rhode Island Medical Society met on Tues-
day, May 17, 1910, at 253 Washington Street, Providence, at 3.30 P.M.
In the absence of the president, Dr. J. W. Mitchell presided.
Other members present were Drs. White, Briggs, Akers, Mathews
and Welch. &
The report of the treasurer, Dr. George S. Mathews, was pre-
sented, accepted and ordered placed on file. The report showed that
the income for the year ending March I, was $2474.02 ; the expenses
$2O67.56, leaving a balance on hand March 1, 1910, of $406.46. Bal-
ance on hand March I, IQ09 was $644.27.
The funds are as follows:
Chase Wiggin . . . . . . . . . . . $6302.50
Printing tº e º ſº e º ſº tº e º & & e º & 6724.7O
Library * * * * * * * * * * a s • 347.45
Building * e e g º ſº a tº e g º ºs & 52O7.96
H. G. Miller . . . . . . . . . . . . 5OOO.OO
The following resolution was recommended to the House of
Delegates for adoption :
WHEREAs, The interest on the printing fund now amounts to
over $250.00 annually; be it
RESOLVED, That for the ensuing year, as far as it may be re-
quired or it will suffice, this interest be used to pay printing bills
such as those for transactions, programs, notices, diplomas, blank
forms and other printing requirements of the Society.
Adjourned.
S. A. WELCH, Secretary
The House of Delegates met on Tuesday, May 17, 1910, at 253
Washington Street, Providence, at 4 P. M.
In the absence of the president, Dr. A. A. Mann, first vice-
president, presided. Other members present were Drs. Mitchell,
Noyes, Hersey, White, Mathews, Welch, Doten, Swarts, Briggs,
Akers, Spicer, Matteson, L. C. Kingman, Crooker, Burdick, Pitts,
Burnett, Hess, Barrows and Risk.
The following were elected officers for the ensuing year:
President—Dr. A. A. Mann.
First Vice-President—Dr. F. T. Rogers.
Second Vice-President—Dr. A. B. Briggs.
Secretary—Dr. S. A. Welch.
Treasurer—Dr. W. A. Risk.
BUSINESS MEETINGS 7
Committee of Arrangements—Drs. A. A. Barrows, J. B. Fergu-
son and F. E. Burdick.
Committee on Legislation, State and National—Drs. G. T.
Swarts, W. F. Gleason, W. L. Munro, the president and secretary
ex-officio.
Committee on the Library–Drs. F. L. Day, G. D. Hersey, G. L.
Collins, G. S. Mathews and H. G. Partridge.
Committee on Publication—Drs. G. D. Hersey, C. M. Godding
and G. S. Mathews.
Curator—Dr. Wm. J. McCaw.
Committee on Necrology—Drs. E. E. Pierce, A. Mathews and
G. T. Spicer.
Alternate Delegate to the House of Delegates of the A. M. A.,
for 1910 and 1911—Dr. Wm. B. Cutts.
Auditor for two years—Dr. F. T. Fulton.
The president appointed the following committees: On Build-
ing–Drs. J. W. Mitchell, R. F. Noyes, F. H. Peckham, F.T. Rogers
and J. M. Peters; and on Medical Education for three years—Dr.
G. T. Swarts,
The record of the meeting of the Conncil held today was
accepted.
The annual report of the secretary was accepted. The report
covered the period from June I, I909, to June 1, 1910, and showed
that the society numbered 384 members, divided as follows: Resi-
dent, 345; non-resident, 27; and honorary, I2. Thirteen physicians
have joined, namely, Drs. Frank M. Adams, Lionel M. Archambault,
Harold G. Calder, Harry V. Carroll, Murray S. Danforth, John E.
Duffy, Peter W. Hess, Charles H. Holt, Alfred W. Love, James A.
King, Alfred Poirier, Arthur H. Ruggles and Roswell S. Wilcox.
Four have resigned or left the State, namely, Drs. William S.
Irvine, Donald B. Lyon, Frank W. Larrabee and Carlos G. Hilliard,
and six have been dropped for non-payment of dues. |
Seven have died : Drs. Frank B. Sprague, Donald Churchill,
Robert Millar, Alvin H. Eccleston, Edgar I, Hanscom, George F. J.
King and George H. Kenyon.
By mistake one name was omitted from the list published in the
Transactions, namely, Dr. Edward S. Parker of Pawtucket.
Ten papers have been read; the annual address given by the
president, Dr. F. B. Fuller; several cases reported and a number of
specimens shown and presented to the Society. Two addresses at the
annual dinner may well be added to the list.
8 BUSINESS MEETINGS
Dr. Swarts for the Committee on Legislation said that the most
important matter of national interest was the establishment of a De-
partment of Health, with a cabinet officer, as called for by the Owens
Bill introduced into the United States Senate. Such a department
would control the work now duplicated in various bureaus and carry
out health matters now ignored. The bill is favored by President
Taft and by many important societies and companies.
The following resolution was unanimously adopted :
RESOLVED, That the Rhode Island Medical Society endorses the
purposes of the Owens bill, which provides for a Department of
Health and urges the Senators and Representatives in Congress,
representing the State of Rhode Island, to bring every influence to
bear for its passage.
RESOLVED, That a copy of these resolutions be forwarded to each
Senator and Representative of this State.
For the Committee on State Legislation, Dr. Swarts reported
that the bill establishing a board of Osteopathy had been strongly op-
posed by representatives of the committee and by physicians from the
different counties. In spite of the overwhelming sentiment against
the bill developed at the hearings, the bill was passed in the Senate.
One offender against the medical practice act had been arrested and
fined.
For the Committee on the Library, Dr. Hersey reported that for
the year ending May 14, there had been 1327 visitors at the library
and 3265 books consulted.
Dr. Mitchell reported for the Building Committee, that several
meetings had been held and numerous sites for a building examined.
Most of the work had been in conjunction with the Ways and Means
committee.
The Committee on Ways and Means presented a written report
through Dr. G. L. Collins, Secretary. The report was accepted and
Ordered filed.
As recommended in the report, a Committee consisting of Drs.
Mitchell, Noyes, F. H. Peckham, Rogers, J. M. Peters, Hersey, Day,
Briggs and Wheaton was appointed to carry out the following resolu-
tions :
REsolved, That the committee be given power to select and
purchase a site suitable for a building. Also that the committee be
given power to delegate to sub-committees certain portions of its
work.
BUSINESS MEETINGS 9
It was further voted that the treasurer be authorized to procure
from the heirs of Chase Wiggin, a release from the present obliga-
tions of the Chase Wiggin Fund, so that the fund may be devoted to
the general purposes of the Society.
For the Committee on Publications, Dr. Hersey reported the
Transactions for 1909 had been distributed. This number completes
Volume 7.
For the Committee on Medical Education, Dr. Swarts reported
that the A. M. A. had gone exhaustively into the matter and had set
the standard for the country.
The committee appointed to consider the merging of the Trans-
actions with the Providence Medical Journal, reported through Dr.
Risk that several meetings had been held and an agreement reached
by which the proceedings of this society should be published as a
whole as promptly after a meeting as possible. A beginning had been
made in the May number of the Journal in which was a complete
record of the March quarterly meeting. In this way the Fellows will
receive the transactions in parts, and promptly after a meeting. No
copies of the transactions will be distributed at the end of the year
as the matter already will have been presented to each Fellow. The
society will save possibly $300 a year by this change and a double
printing of much of the society's work will be avoided.
On motion it was voted that the resolution approved by the
council be adopted. This resolution provides that the interest on the
printing fund may be used for the printing requirements of the society.
The thanks of the society were extended to Dr. George S.
Mathews for the eight years of faithful service which, as treasurer,
he had given to the society.
Adjourned.
S. A. WELCH, Secretary
A meeting of the Council was held at 253 Washington Street,
Providence, immediately after the adjournment, at which Dr. J. W.
Mitchell presided. Other members present were Drs. Noyes, White,
Welch and Briggs.
The action of the House of Delegates in appointing a committee
to buy a suitable site for a building was approved.
Adjourned.
S. A. WELCH, Secretary
IO BUSINESS MEETINGS
MAY 31, 1910
The Council met on Tuesday, May 31, 1910, at Masonic Temple,
Providence, at 4 P. M.
The president, Dr. Eugene Kingman, presided. Other members
present were Drs. Mitchell, Hersey, Barker, Mathews and Welch.
It was voted to recommend to the House of Delegates that the
sum of $7482.5o be appropriated to buy a building site. -
Adjourned.
S. A. WELCH, Secretary
The House of Delegates met in Masonic Temple, Providence, on
Tuesday, May 31, 1910, at 4. I5 P. M.
The president, Dr. Eugene Kingman, presided. Other members
present were Drs. Hersey, Fuller, Barker, Champlin, Mitchell, Briggs,
Mathews, Barrows, Burdick and Welch. *
As approved by the Council, the sum of $7482.50 was voted to
buy a site for a building for the society.
Adjourned.
S. A. WELCH, Secretary
JUNE 16, 1910
A special meeting of the House of Delegates, called by the pres-
ident on petition of Drs. Mitchell, Noyes, Hersey, Day, Risk, White,
Kingman, E., Kingman, L. C., Crooker, Spicer and Welch, was held
at 253 Washington Street, Providence, on Thursday, June 16, 1910,
at II A. M.
The president, Dr. A. A. Mann, presided. Other members
present were Drs. Noyes, Hersey, White, Chapin, Fuller, E. King-
man, Briggs, Crooker, Spicer, Risk, Akers, L. C. Kingman, N. D.
Harvey, Stearns, Burnett, Doten and Welch.
The special building committee reported through Dr. Risk that a
building site had been purchased on the corner of Francis and Hayes
streets, and that the building fund was insufficient to pay the pur-
chase price.
It was voted that the trustees of the printing fund be authorized
to pay to the treasurer for the purposes of the building committee a
sum not exceeding $4000. *
BUSINESS MEETINGS II
It was voted that the treasurer be directed to secure all dues now
in arrears and to report at the next meeting of the House of Dele-
gates, all then delinquent.
Adjourned.
S. A. WELCH, Secretary
A meeting of the Council was held at the close of the meeting of
the House of Delegates. The president, Dr. A. A. Mann, presided.
Other members present were Drs. Noyes, Hersey, White, Chapin,
Fuller, Kingman, Welch, Risk, N. D. Harvey, Briggs and Akers.
The action of the House of Delegates in appropriating $4000
from the printing fund for the purposes of the building committee
was approved. .
Adjourned.
S. A. WELCH, Secretary
THE ANNUAL ADDRESS
DELIVERED AT THE ANNUAL MEETING, MAY 31, 1910
BY THE PRESIDENT
EUGENE KINGMAN, M.D.
sº-º-º-º-º-º-mºms
Much attention is paid to-day to the conservation of our national
resources, notably our forests, our coal and our water power. The
greatest resource of all,—the national health, until recent times com-
paratively neglected in the rapid material progress of the country, is
gradually assuming a place of the first importance in the public mind
and conscience. Witness the Anti-Tuberculosis League; the develop-
ment and work of the Marine Hospital Service; Committee of One
Hundred; State Boards of Health; the large funds contributed for the
cure of cancer and hookworm disease; also the increasing demand for
the establishment of a Department of Health, with a Secretary of
Health in the Cabinet. Thus the country at large is realizing, through
a more elevated public sentiment, that health is the foundation of the
nation’s wealth and, therefore, must be conserved.
Your Society, perhaps the most important factor in the conserva-
tion of the health of Rhode Island, is my subject to-day. What was
the purpose of the creation of this Society? How can that purpose be
furthered amid the changed and complex conditions of the present
time P
Francis Parkman says: “There is a universal law of growth and
achievement. The man who knows himself, understands his own pow-
ers and aptitudes, forms purposes in accord with them and pursues
these purposes steadily, is the man of success.” A Society that knows
itself, understands its own powers and aptitudes, forms purposes in
accord with them, and pursues these purposes steadily, will meet with
success. Let us know ourself. How was this Society created P
In the year of 1812, A. D., the General Assembly of this State, for
the purpose of incorporating a Society of certain physicians and sur-
geons, passed an act which is in part as follows:
“As the Medical Art is important to the health and happiness of
Society, every institution calculated to further its improvement is
º
THE ANNUAL ADDRESS I3
entitled to public attention; and as Medical Societies formed on liberal
principles and encouraged by the patronage of the laws have been
found conducive to this end, Be it Therefore Enacted that Amos
Throop (and 48 others) be and are hereby formed into, constituted
and made, a body politic and corporate by the name of the Rhode
Island Medical Society.
By the further provisions of this act this corporation was given,
among numerous other powers, liberty to make its laws of conduct and
permission to hold property, both real and personal.
Thus it will be seen that we are a body politic and corporate, an
individual with better chance for longevity than Methuselah, and with
the powers necessary for a successful existence.
“Men may come and men may go,
But (we can) go on forever.”
The purposes of this Society’s creation, as expressed in its consti-
tution, are as follows:
Federation; association; friendly intercourse; extension of medical
knowledge; advancement of our Science; elevation of medical educa-
tion; securing the enactment and enforcement of just medical laws;
protection against imposition; enlightenment and direction of public
opinion in regard to the great problems of state medicine, so that the
profession shall become more capable and honorable in itself and more
useful to the public.
These several benign objects we have endeavored to accomplish
during the ninety-eight years of our existence. We have had our part,
directly or indirectly, in the creation and administration of health
boards; the founding and service of hospitals; the improvement of
food; the restraint of disease, and the enactment of wise medical laws.
Also by our prizes and publications, we have done something to
advance the art of medicine.
The problem now before you—and it is a very vital one—is, how
can we meet the complex and difficult conditions of to-day with modern
methods? Of this I am certain: the new times make greater demands.
To meet these demands most effectually we must have new and larger
equipment.
We have two great needs: first, a home; second, money.
We have no home. For ninety-eight years we have wandered from
place to place, hiring whatever hall we could get. We have met to-day,
May 31st, because we could not obtain this hall, or one suitable, on the
regular day of our June meeting. Besides a hall, we need
I4 THE ANNUAL ADDRESS
a place for our library. We have several thousand books and
Several complete and valuable files of Journals. The Providence
Public Library has kindly accommodated us for some time, but now
it is crowded, and unless we go to some expense we must leave there.
Our Building Committee has a fund in its possession. The rent
which we now pay annually for halls and the rent we soon will have to
pay for library facilities, if added to the amount we might receive from
Others for the use of our hall, would make a sum sufficient to pay the
interest on a mortgage of fair size. Let us then make it our earnest
purpose to procure at once a building appropriate for our use.
Our Second and greatest need is money, a large amount of money,
to further the purposes for which our Society was created.
Eventually, with sufficient means, we should have an audience
room, committee rooms, a salaried librarian with assistants and a
delivery system, by which any physician may order books by telephone
and may receive the same promptly by special express or messenger.
We should have the same system applied to the use of a complete
instrument room and laboratory, and to the services of a resident
pathologist or his assistants by day or night. We should do research
work; employ eminent counsel to draft just medical laws for the health
of the State, and to prosecute offenders promptly; pay certain of the
chairmen of our committees to give all their time to the work of their
committees, and have a committee of observation to search out all
infringements of health and to assist health boards. We should also
have an emergency fund. Legislators are Sometimes slow, and quick
relief of impending evil often seems impossible. In the Civil War, for
instance, Rhode Island men volunteered promptly, but the State was
not ready to clothe or equip them. Governor Sprague (the War Gov-
ernor too often forgotten) met the emergency by clothing and arming
them at his own expense. Our emergency fund could be used in cases
of dire peril to the public health, such, for example, as the recent dearth
of antitoxin for the poor, arising from a lack of appropriation.
The amount needed is too large to be raised from members of this
Society. Physicians, with few exceptions, after giving of their time
and sometimes money to various charities, and paying their professional
and living expenses, have too little left to contribute largely to this
cause. The endowment must come chiefly from the public, and when
the community understands that our work is to improve the physician,
advance our art and help the people, they will in time respond gener-
ously. It is a truth well demonstrated that if an object is shown to be
THE ANNUAL ADDRESS I5
worthy, eventually much will be given to it. At one time nearly one-
half of England's Soil had been acquired by gift or bequest for
benevolent purposes. The public loves a good object and will con-
tribute freely. In this country $150,000,000 was given last year for
philanthropy, in the last seventeen years $1,150,000,000. The city
of Providence furnishes many examples of organizations supported, in
part at least, by private donations; for example, our libraries, homes
for the aged, orphanages, the Dexter Asylum, our hospitals, the School
of Design, Brown University, the Cathedral, the churches and the
association buildings. Such organizations in this city are said to num-
ber more than fifty. We have only to make known our object and the
people of Rhode Island will respond in time. Respond in time, I say,
because history shows that such results often require years for their
accomplishment. Solicitors are usually in too much haste. The oak
grows slowly. First, let us build or buy a house. Let it be well known
that we have a proper mortgage, one which our income will care for.
Let it be well known also that we are not beggars, but that we can use
large gifts and bequests for the altruistic purpose of conserving the
lmealth of the State.
Fellows of the Rhode Island Medical Society, mathematicians, with
a few data, have accurately predicted eclipses of the Sun and moon.
Comets appear at the time foretold. Is it then too much for us, with
our knowledge of the human mind and the history of gifts and bequests,
to foretell that in two years we will celebrate our Centennial in our
own building, and that our one hundred and fiftieth anniversary will
find us in possession of a well-appointed library and pathological build-
ing, with an ample bank account and a future before us of great
promise?
And now is it not our duty to make it known, to proclaim from
the housetops, tell in Gath, publish in the streets of Askalon, write to
Carnegie and Rockefeller, mention to our friends, and whisper to our
patients that our Society, a Good Samaritan incorporated, needs the
gifts of the living and the bequests of those departing?
In the interest of the conservation of your patience I will stop,
taking only time to thank you for your attention to the exercises of
to-day and for the honor you have given me as President during the
past year, the fortieth of my membership in this Society.
HEMORRHAGE-ANTEPARTUM AND INTRAPARTUM
BY
H. G. PARTRIDGE, M. D.
PROVIDENCE
Of all the complications of pregnancy and labor, none is more fatal
to both mother and child, or more disconcerting to the physician than
hemorrhage.
This may occur before, during, or after labor, and when severe is
practically always a placental hemorrhage in a true sense, the first two
forms being caused by a separation of the placenta from its attachment
to the uterine wall, and the last being caused by a failure of closure of
the sinuses at the placental site.
The complexities of diagnosis and treatment are greatest in the
hemorrhages occurring before and during labor, and this paper will be
limited to those conditions.
From a practical standpoint, the only serious hemorrhage appear-
ing before labor is due to the premature separation of the normally
implanted placenta. The normal site of the attachment of the placenta
is in the upper segment of the uterus, i. e., in the portion of the uterus.
whose function during labor is to contract. When situated in the lower
segment, which has but little contractile power, the condition is termed
placenta previa. This will be considered later.
Premature separation of the placenta has also been termed accidental
hemorrhage, in contradistinction to the hemorrhage from placenta
previa, which was termed unavoidable hemorrhage. Ablatio placentae
is another synonym, but the longer term is the clearest and most
descriptive of the condition, and should be preferred. It is generally
considered a rare disease, and in private practice is undoubtedly such,
but in hospital work it is seen with much greater frequency. In the
Providence Lying-in Hospital there were seven cases in a total of
9I4 patients, or one case in 130. Various writers give the frequency
as from I in IOOO to I in 200 cases. Probably the latter is more near-
ly the correct figure.
Etiology. Two causes may be assigned for the condition, traum-
atism and endometritis. It is not improbable that there is at the bot-
tom of most of the cases an endometritis, which brings about a de-
generation of the decidua, and a consequent frailness of the attach-
ment of the placenta to the uterine wall. It is not unusual, however,
HEMORRHAGE-ANTEPARTUM AND INTRAPARTUM 17
to obtain a history of a sudden fall, or some over-exertion, which,
while not direct traumatism, acts indirectly as such. Without some
previous diseased condition of the endometrium, this would not ordi-
narily produce a separation of the placenta, as it is a not infrequent
occurrence for a pregnant woman to suffer traumatisms of this kind
without harm resulting, while a premature separation of the placenta
is a rather rare accident. The theory has been advanced that ne—
phritis and the toxemia of pregnancy are potent factors in the causa-
tion, but this has not been proven, and it seems hardly reasonable, in
view of the comparative frequency of toxemia. I have never seen the
accident in a woman suffering from toxemia or eclampsia. Whatever
the cause (and numerous others have been suggested), multiparae are
especially prone to the disease; in this all observers agree.
Pathology. These hemorrhages behave differently in different
cases. If the placenta separates in the center, while it remains at-
tached to the uterine wall on its periphery, the blood will accumulate
in the pocket thus formed, and there will then be present the condition
known as concealed hemorrhage, no part of the blood escaping beyond
the margin of the placenta. The blood may, however, push away the
edge of the placenta and yet be retained by the adherence of the mem-
branes to the mucosa. In this case, also, the hemorrhage is purely a
concealed one. In most cases, however, the blood escapes to a greater
or less degree from the os, and the condition is known as external
hemorrhage, but even in these instances there is almost always a large
clot in the cavity between the placenta and the uterine wall.
On examining the placenta, after delivery, the surface is found
smooth and shiny, with clots adherent to it. This area indicates
plainly the part separated, and the Smooth appearance is due to the
obliteration of the cotyledons by the pressure of the clot.
Symptoms. These hemorrhages may appear when the patient is
apparently in perfect health, and in my experience such has usually
been the case. There is at first, pain, severe in type, but not clearly
intermittent, like the pains of labor. This is in a short time followed
by the signs of hemorrhage, pallor, sighing respiration and weak
pulse. On examination the uterus is found to be larger than normal
for the term of the pregnancy, and presents a peculiar hard doughy
feel, which once felt is never forgotten. So far as I know, this is
seen in no other condition, and is therefore pathognomonic. Palpa-
tion also reveals abnormal tenderness, but fails to reveal the fetal
members, due to the fact that the uterus is over-distended by the blood.
Vaginal examination shows usually that the patient is not in labor, but
I8 HEMORRHAGE-ANTEPARTUM AND INTRAPARTUM
in the cases where there is bleeding from the vagina, fails to discover
any cause therefor within reach of the examining finger. The
cardinal symptoms are, therefore, sudden pain, continuous, and not
intermittent, signs of hemorrhage, and an enlarged, tender and boggy
uterus. As has already been intimated, there may or may not be
hemorrhage from the vagina.
Diagnosis. These symptoms, or any one of them, should at once
arouse a suspicion of a separation of the placenta. The only condition
with which it may be confounded is placenta previa, but the latter
condition is associated with neither an enlarged tender uterus, nor
with much pain. In addition, as already pointed out, when the pla-
centa is normally implanted, but separated, the examining finger de-
tects no cause for the bleeding per vaginam, while in most cases of
placenta previa the placenta can be felt.
Prognosis. This condition is one of the most fatal of pregnancy, for
both mother and child. As would be naturally inferred from the fact
that the separation of the placenta cuts off much, if not all, of the
circulation through the umbilical cord, practically all the infants die.
The mortality for the mothers is stated by different writers as from
30 to 50 per cent. Of the 7 cases occurring at the Lying-in Hospital,
2 died, a mortality of 28.5. The earlier the patient is seen after the
onset of the bleeding, the greater are her chances of recovery. Un-
fortunately, however, these cases are emergency cases in the truest
sense of the term, and medical aid is often not obtainable for several
hours, during which time the patient is becoming more and more
shocked. I have seen a patient almost in collapse five hours after the
very first symptom of trouble.
Treatment. The treatment differs somewhat according to the se-
verity of the bleeding, but in any case, the Sooner the uterus can be
emptied, the greater are the mother's chances for recovery. There
are cases in which the hemorrhage is slight, and the shock not great;
if labor begins when the hemorrhage takes place it may be allowed to
proceed without interference, a close watch being kept for symptoms
of severe hemorrhage or shock. In such a case, the patient should be
under skilled observation constantly, and I think the physician should
himself take the responsibility of this, and not relegate it to a nurse,
no matter how competent she may be. These are the rare cases, and
in most instances interference of the most active kind is demanded.
So long as the patient is undelivered, the uterus cannot contract, and
the hemorrhage will continue. Immediate delivery is, therefore, the
only means of checking the bleeding. In most cases, labor having be-
HEMORRHAGE-ANTEPARTUM AND INTRAPARTUM I9
gun, the cervix is soft enough to allow of the performance of a man-
ual dilatation and version, which should be done as rapidly as is con-
sistent with the safety of the patient. If the cervix is too rigid to
permit this, a vaginal Caesarian section will afford the quickest and
best method of delivery.
In most cases, the physician is confronted by a condition of pro-
found shock and anemia, which must be treated actively if the mother's
life is to be saved. Saline infusion, introduced subcutaneously, and
the administration of strychnia, digitalis and alcohol have given me
the best results. Whatever is done must be done quickly, and it is
important to begin the treatment for shock and hemorrhage before
or simultaneously with the operative procedures. After the delivery
it may be too late, and this accident is one of the most urgent emer-
gencies that the medical profession meets. The gist of the treatment
is, therefore, delivery as soon, and in the safest way possible, in the
urgent cases, and expectant treatment in the few cases in which the
symptoms are mild.
The chief cause of hemorrhage during labor is Placenta Previa.
It may also cause hemorrhage before labor. By placenta previa we
understand an implantation of the placenta in the lower uterine seg-
ment, near the internal os. Two varieties are generally recognized,—
placenta previa centralis and placenta previa lateralis. Some writers
mention also placenta previa marginalis.
In the first, or central type, the placenta is inserted directly over
the internal os, nearly or quite occluding it. In the second, the lateral
form, the placenta is located in the lower uterine segment, but at a
jittle distance from the internal os. In the marginal variety, the pla-
centa is felt at the edge of the os, but does not cover it.
Frequency. It is said to occur in the proportion of I to IOOO
cases in private practice, while in the work of hospitals to which many
abnormal cases are sent, it is seen in the proportion of I to 250. In
9I4 cases admitted to the Lying-in Hospital, we had I3 cases, or I in
70. It may, therefore, be considered a fairly rare condition, although
encountered more frequently than the premature separation of the
normally situated placenta.
Etiology. The causes of placenta previa are not well known, and
are no better known today than twenty-five years ago.
Multiparity predisposes decidedly to the condition, but how it
exerts its influence is not certain. It may be by reason of the fact that
the cavity of the uterus is larger, and the fecundated ovum is conse-
quently not retained near the orifice of the tube by closely apposed
2O HEMORRHAGE-ANTEPARTUM AND INTRAPARTUM
uterine walls, but is allowed to fall to a lower position. Other reasons
have been suggested, but we only know that whatever the cause, the
effect of multiparity is undoubted.
The fundamental cause of placenta previa is in most cases en-
dometritis, and this may so affect the implantation of the Ovum as to
permit it to take place in the lower segment. Williams states that the
probable cause is a primary implantation in the lower portion of the
uterus, associated with extensive cleavage of the decidua vera, allow-
ing an extension of the placenta to the region of the internal OS. It
may be noted that even this is given as only a “probable” cause, show-
ing well how uncertain is our knowledge at the present time. The
cause of the hemorrhage in placenta previa is a separation of the pla-
centa from its connection with the uterine mucous membrane. This
leaves open the sinuses of the uterus, which, under these circumstances
being located in the lower uterine segment, whose function is not
contraction, but dilatation, do not close as in a normal case, in which
the placenta is situated in the upper, contracting portion of the uterus.
Symptoms. The most striking and most important symptom of
placenta previa is the hemorrhage. This may occur before or during
labor, but so constantly is it associated with labor that the complica-
tion is usually thought of as one of labor. The amount of blood lost
varies greatly, and the onset of the bleeding varies in character. In
some cases there may be a slight bloody discharge for days, or even
weeks. This should always arouse a suspicion of placenta previa. In
other cases, there is a sudden gush of a pint or a quart or more of
blood, sometimes sufficient at the very onset to cause collapse. Usually,
however, this profuse hemorrhage ceases spontaneously, only to
recur later. As already intimated, the amount of blood lost varies
greatly in different cases, but in the severe cases it is so great as to
cause the usual symptoms of profuse hemorrhage, air hunger, rest-
lessness, pallor, and a rapid and soft pulse. I have in one case seen
the hemorrhage so great as to cause death. There is usually no pain
associated with the hemorrhage, and this is so characteristic that any
hemorrhage unaccompanied by pain, occurring during the latter months
of pregnancy, is almost certainly due to placenta previa. On vaginal
examination, the vault of the vagina is found to be boggy, and the
cervix soft and flabby, and sufficiently dilated to admit one or two
fingers. I have never seen a case in which the cervix was rigid,
but such have been reported. Through the cervix, in the vast ma-
jority of the cases, can be felt the placenta. When the placenta is
centrally implanted, it entirely occludes the os, and its attachment to
HEMORRHAGE-ANTEPARTUM AND INTRAPARTUM 2 I
the uterine mucosa can be felt throughout its entire circumference. In
other forms, the edge of the placenta is usually palpable. The -sur-
face gives a peculiar and characteristic sensation to the examining
finger, and one that is never forgotten. This palpation of the placenta,
of course, renders the diagnosis certain, and I repeat that it can be
felt in most cases.
Diagnosis. If the facts in the symptomatology already stated are
borne in mind, the diagnosis of placenta previa should be fairly easy.
The absence of pain, of enlargement and tenderness of the uterus, even
if by chance the placenta cannot be felt, should distinguish this con-
dition from premature separation of the placenta. The latter is the
only other condition which produces a severe hemorrhage during the
last months of pregnancy, and as already stated, hemorrhage is the
most constant and characteristic symptom of placenta previa. If pre-
mature separation can be ruled out, and there is still doubt as to the
diagnosis, Owing to the fact that the cervix is not patulous, and the
placenta has consequently not been felt, the cervix should be dilated,
under anesthesia, if necessary, and the finger passed through it, and
the lower uterine segment palpated. This may induce premature labor,
but so grave is the danger to the mother that this is justifiable.
Prognosis. This complication is in every instance a serious one,
if only from its possibilities. The mortality differs according to the
treatment, and according to the exact form of the disease present.
Under modern methods of treatment, the mortality is about 5 per
cent., whereas in former times it was about 25 or 30 per cent. The
causes of maternal deaths are hemorrhage, shock, from the operative
procedures undertaken, and sepsis. The earlier the patient is seen,
and the more skilled the operator, the lower will be the mortality.
Unfortunately, many patients do not call a physician until the bleed-
ing has gone on for a considerable length of time; still more unfor-
tunately, all physicians do not realize the gravity of the condition, and
temporize too long. Obviously both these factors tend to increase
the mortality. In the I3 cases at the Lying-in Hospital, some of which
came under the circumstances just mentioned, the mortality was 15.2
per cent. One of the two who died was moribund on entrance. For
the child mortality is even greater. This is due in part to the fact
that many of the infants are premature, and in part as a result of the
separation of the placenta.
Treatment. Most modern authorities are in accord that once the
diagnosis of placenta previa is made, the uterus should be emptied
at once 1n the most conservative manner. With this opinion I en-
*
22 HEMORRHAGE-ANTEPARTUM AND INTRAPARTUM
tirely agree. The danger to the mother of a severe hemorrhage,
without warning, is so great that the physician who temporizes is
assuming a grave responsibility. Even in the cases which are only
suspicious, the patient should be under skilled observation every min-
ute until placenta previa can be certainly ruled out. As soon as it
is determined that the condition is present, active treatment should be
instituted. If the patient is seen early, and this is done promptly, the
mortality will be greatly reduced, and a death will be an unusual Oc-
currence. I have seen several deaths in the hospital due directly to
the fact that the patient did not enter until she had had repeated pro-
fuse hemorrhages.
The exact method of treatment must vary according to the case
in hand. If the diagnosis is made before labor has begun, and the
child is viable, the cervix should be dilated, and labor induced by the
introduction of a Champetier de Ribes bag, the membranes having
been ruptured, or in the case of a central implantation, after perfora-
tion of the placenta. If the child is not viable, the time-honored method
of Braxton Hicks will accomplish the same end—bringing down a
foot, by podalic version, thus causing the thigh of the child to press
firmly upon the placenta, thereby checking the hemorrhage. This
method may also be employed if the child is viable, but sacrifices its life,
and for that reason should not be used, if the bags are obtainable.
It is, however, an effectual means of controlling the bleeding, and for
the practitioner who sees these cases but rarely, may serve to save
the mother's life. If the bleeding begins during labor, and the cervix
is only slightly dilated, either of the above procedures may be insti-
tuted with the assurance that the hemorrhage will cease. If the cer-
vix is fully dilated the child should be delivered at once, by forceps
or version.
Accouchment forcé is condemned by many writers because of the
extreme friability of the cervix, and the consequent danger of deep
tears. As a matter of fact, however, in the vast majority of cases,
the cervix is so soft that it dilates very easily, and if done carefully
tears do not result. Most of my own cases have been delivered by
manual dilatation and version—in several of them the intention at the
beginning of the operation was to bring down a foot, according to
the Braxton Hicks method, but the cervix dilated so easily that a
complete extraction was done. When this is feasible the infant mor-
tality is greatly reduced. Two methods of treatment, which in former
times had many adherents, may be mentioned. The tampon has been
employed as a means of checking the hemorrhage for I 30 years,
HEMORRHAGE-ANTEPARTUM AND INTRAPARTUM 23
but with the introduction of the more modern methods, this is grad-
ually falling into disuse. Its objectionable features are the increased
danger of sepsis, the fact that it does not always control the hem-
orrhage, and also that it may allow the bleeding to go on, but con-
cealed. This method of treatment may be employed as a temporary
one, until more radical measures can be undertaken, but if used, the
pack should be inserted very firmly. Barnes recommended separat-
ing the placenta from its attachments, by Sweeping the finger between
it and the uterine wall. The cervix retracts somewhat after this,
and the hemorrhage temporarily ceases. This may be repeated, and
thus the labor is conducted until finally all of the placenta situated
in the lower segment is separated. This treatment has been aban-
doned by most authorities, principally because of the infant mor-
tality. Caesarian section has of late been suggested by some obstet-
ricians. It seems to me, however, hardly feasible, in view of the
good results obtained by the methods of treatment here recommended.
The patients who are most likely to succumb to these methods are
certainly unable to bear the shock of an abdominal operation, and
the mortality to the mothers would be as great or greater.
The after-treatment consists in the general treatment of shock
and hemorrhage, and differs in nowise from such treatment in gen-
eral. In conclusion, the treatment of placenta previa may be sum-
marized briefly as follows:
I. As soon as the diagnosis is made, terminate the pregnancy in the
manner most safe for the mother.
2. If seen before labor has begun:
a. The child being viable, induce labor by the introduction of a
Champetier de Ribes bag.
b. The child not being viable, bring down a foot.
3. If labor has begun:
a. If the cervix is nearly or quite fully dilated, deliver at once by
version or forceps.
b. If the cervix is not dilated, employ either method, as before
labor.
4. Give constitutional treatment for hemorrhage.
THE MANIFESTATIONS OF SYPHILIS IN THE EYE
BY
G. W. VAN BENSCHOTEN, M.D.
It is not the intention of the writer of the following paper to
take up at this time the symptomatology or treatment of this dis-
ease as manifested in the eye, but simply to dwell briefly upon each
portion of the eye as it is involved in syphilis, giving the character-
istic pathological changes, if they may be so called, peculiar to that
part under discussion. All parts of which the eye is composed are
liable to the ravages of syphilis, with the exception of the chrystaline
lens, and that may be affected only indirectly, as will be shown later.
It is within quite recent date, beginning chiefly with the discovery of
the ophthalmoscope, that the connection between the constitutional
disorder and the local manifestations in the eye was recognized. The
“syphilitic eye” was known early in the last century, but the
involvement of the posterior segment was unappreciated and im-
perfectly, if at all, considered.
AFFECTIONS OF THE EYELIDS AND CONJUNCTIVA. The disease
may here present itself in the primary, secondary or tertiary form,
and the latter, as a gumma, is the form most frequently seen in this
location. As the primary or the initial lesion, or chancre, it shows
the usual ulcer with a hard, indurated base, swelling of the surround-
ing tissues and enlargement of Some of the neighboring lymphatic
glands, especially the pre-auricular and the submaxillary. Buckley
gives over 4 per cent. Of all extra-genital chancres as located in these
two regions. As can very readily be seen, the occurrence in this lo-
cality of the primary sore would be very liable to escape diagnosis
and be confounded with a Suppurating chalazion, a tubercular nodule
or ulcer, or possibly an epithelioma or even classed as a stye. Ball
says it is found more frequently located on the lower than the upper
lid, and gives one means of infection through a practice, common in
some Russian towns, of removing foreign bodies from the eye or
treating diseases of the conjunctiva, by licking the parts; other modes
of infection are kissing, or through the saliva, as in coughing, in
which manner some physicians have been inoculated, by infected in-
struments, hands or linen. Mucous patches are rarely seen on the con-
THE MANIFESTATIONS OF SYPHILIS IN THE EYE 25
junctiva, but when present show the same characteristics as elsewhere.
The usual syphilide eruption may make its appearance on the lid or
more rarely on the conjunctiva. Gumma appears in both these local-
ities, and as before stated, is probably the most frequent manifesta-
tion of the disease in the lids. The tarsal cartilage may be the seat of
a gummatous infiltration, with marked thickening of the cartilage and
great swelling of the lid; this runs a very chronic course and responds
but slowly to proper treatment. The gumma may break down, the
lids become ulcerated, the ulcer being infiltrated and covered with a
yellowish gray discharge, irregular in form and causing great destruc-
tion of surrounding tissues. Pain is not usually severe until ulcera-
tion is well established and the differential diagnosis must be made
from a rodent ulcer, tubercular process or a Suppurating chalazion.
Gummatous growths of the conjunctiva are much more rare than those
starting on the lid, but may be situated on the ocular conjunctiva,
forming small reddish-yellow smooth nodules without a sharply de-
fined border; as elsewhere these are liable to break down and invade
other structures of the eye.
LACHRYMAL GLAND. Syphilitic disease of this gland is rare, but
may cause a chronic enlargement, slowly increasing, usually quite
painless, with Some edema of the lid, and yielding to antisyphilitic
treatment. The diagnosis must be made from all tumors of this gland,
from periostitis of the orbit or lid abscess, and from tubercular dis-
ease. In the latter there is more pain, and this is present from the
beginning, the skin over the gland more frequently red and inflamed,
and usually tuberculosis can be demonstrated elsewhere in the body;
other forms of enlargement do not yield to antisyphilitic treatment,
and a positive diagnosis can only be made after removal of the in-
volved gland.
THE CORNEA. The syphilitic affections of the cornea are found
commonly in connection with the hereditary form of the disease, and
while the cornea is affected in acquired syphilis, it is much more of
a rarity, and until quite recently was not so recognized by the medi-
cal profession. The cornea, if affected in acquired syphilis, is usually
involved late in the disease, two or three years after the initial lesion,
and resembles in its characteristics that due to hereditary syphilis. It
appears as an interstitial parenchymatous keratitis, in which the deeper
layers of the cornea are involved in an inflammatory process, produc-
ing cloudiness, with small specks or spots appearing first at the center
of the cornea and extending toward its margin. There is no involve-
ment of the superficial epithelium, unless showing as a roughening of
26 THE MANIFESTATIONS OF SyPHILIS IN THE EYE
the external surface of the cornea. This process never goes on to
ulceration or purulent infiltration unless through a possibly mixed in-
fection. Later in the disease blood vessels appear to enter this cloudy
area from the corneal margins, and the whole cornea may become one
inflammatory mass, having the appearance of ground glass, or there
may be small punctated spots scattered in the substance of the cornea.
These are of varying sizes, and later they may coalesce, producing the
large opaque areas. In the hereditary form, which most commonly
appears about puberty, or may appear as early as the fourth or fifth
year, and cases have been reported as appearing as late as the thirty-third
year, one eye may be involved, but usually both become affected, either
simultaneously or successively. The duration of the disease varies
greatly from several weeks to many months, or even extending over
a period of years. The etiology of this interstitial keratitis is, in the
great majority of cases, hereditary syphilis. Horner reports fifty-one
cases, in which twenty-six were plainly due to hereditary syphilis.
Two were due to acquired syphilis, in ten, Syphilis was strongly sus-
pected. In some cases a definite statement and admission of syphilis
on the part of the parents can be obtained. In some cases the his-
tory of syphilis has been demonstrated in the grandparents. The
keratitis in acquired syphilis comes as a late symptom, usually from
two to four years after the initial lesion, and resembles that due to the
hereditary type. The cornea may, in rare instances, be affected with
a gummatous infiltration, which may involve the whole of the cornea
with great destruction.
THE SCLEROTIC. Syphilitic lesions originating in the sclerotic
are rare, and in fact their existence has been questioned by some ob-
servers, but may manifest themselves in three distinct ways. First,
as an episcleritis, which consists of a localized inflammation of the su-
perficial layers of the Sclerotic. The area involved is of a red or pur-
plish color, with thickening of the connective tissue, and a chemosis
of the overlying conjunctiva. These patches are usually of a small
area and rarely involve the deeper structures. Second, as a scleritis,
or an inflammation of the deeper layers of the Sclerotic; these areas
may be of fair size, usually localized and with marked swelling of all
layers of the sclerotic and of the overlying conjunctiva. This affec-
tion tends to run a more chronic course and involve the deeper struc-
tures. Third, as a gumma of the Sclerotic, occurring as a raised cir-
cumscribed area projecting under the conjunctiva, which is inflamed
but not usually involved in the process. This gumma may cause great
destruction of the sclerotic coat and final destruction of the eye. A
THE MANIFESTATIONS OF SYPHILIS IN THE EYE 27
condition which may be due to syphilis and simulating the above de-
scribed scleritis is an inflammation of the oculo-orbital fascia or a
tenonitis. Periostitis of the orbit may be due to syphilis appearing
first, as a rule, at the margin of the orbit, and is most frequent in
children; it takes either an acute or a chronic course. -
THE IRIS. Of all the structures of which the eye is composed,
the one most frequently involved in syphilitic disease is the iris. It
is said that iritis occurs in about eight per cent. of all cases of syphilis,
and it would appear from statistics that syphilis is the cause of from
sixty to sixty-five per cent. of the total number of cases of iritis, and
that iritis constitutes one-half to two-thirds of the eye affection due
to syphilis. Syphilitic iritis generally appears during the early stages
of the Secondary eruptions, but may appear at any stage of the dis-
ease. It is probable that certain external conditions, such as exposure
to cold and winds, may be an exciting factor of iritis in syphilitic sub-
jects. One eye is usually first affected, and after a short interval the
other eye is attacked, and more rarely both eyes are primarily affected
at the same time. It is rare that the disease is limited to one eye and
relapses are of unfrequent occurrence. It is an occasional symptom
of hereditary syphilis, but may manifest itself in a much less virulent
form. It may occur before the end of the first year, or later, usually
associated with interstitial keratitis. The typical syphilitic iritis is ac-
companied by a plastic exudate, which tends to bind all surrounding
parts of the anterior portion of the globe together.; the iris is swollen
and discolored, the pupil is small, reacting very slowly or not at all, to
light. There is marked ciliary injection and turbidity of the aqueous.
humor, and at the edge of the iris may be seen small exudations of
plastic matter tending to produce adhesion to the anterior surface of
the lens or the posterior surface of the cornea. These adhesions.
differ from those due to other causes in being broader, darker color
and more firm. In gummatous iritis, which is the only form pathog-
nomonic of acquired syphilis, there will be seen a yellow nodule or
mass, one to three in number, as a rule, projecting from the surface of
the iris and imbedded in it, and streaked with blood and blood vessels.
These gummata may vary in size from a small pin's head to that of a
bean, and in very exceptional cases, they may attain a much greater
size, filling the anterior chamber and protruding through the softened
sclera and project as a considerable tumor. They are most frequently
seen close to the margin of the pupil, but may spring from the ciliary
region of the iris. They rarely suppurate, but undergo softening and
absorption, and their position on the iris being Subsequently marked
28 THE MANIFESTATIONS OF SYPHILIS IN THE EYE
by spots of a lighter color. They probably occur in every case of
syphilitic iritis at Some stage of the inflammation. Gummata at
times occurring on the ciliary processes themselves and dipping back-
ward, involve the deeper structures, the choroid and the retina. The
progress of syphilitic iritis resembles that of other forms of inflam-
mation of the iris, with the usual nightly exacerbations lasting until
the early morning hours, and the usual tendency of the disease to
relapses during the attack, under the influence of any source of irri-
tation, and may end with the formation of fresh adhesions, the block-
ing of the pupillary space and its concomitant results. Usually in all
forms of syphilitic iritis the ciliary body and the choroid tend to be-
come implicated. In such cases where the involvement is extensive, we
have the typical symptoms of an added cyclitis with the /severe ciliary
neuralgia, rapid impairment of vision and a tendency towards a chronic
course, while now we have quite a characteristic deposition of pig-
tment on the anterior surface of the lens. In the favorable cases,
syphilitic iritis runs its course in from two to three weeks, but in the
unfavorable cases it may persist for weeks or months, and results are
often very serious as regards function of the eyes, with more or less
atrophy of the tissues of the iris, complete adhesion of the pupillary
margin to the lens, with the so-called exclusion of the pupil and dis-
tension of the eye ball. This distension may cause obstruction of the
circulation, degeneration of the retina, and the vitreous humor, and
atrophy of all the structures of the eye. If only one eye be thus af-
fected, a sympathetic iritis and inflammation may be set up in the
other eye. The prognosis in a properly treated syphilitic iritis is fairly
favorable, but in a chronic form, very rarely terminates in complete
recovery. As a general rule, the iritis which appears with the sec-
ondary eruptions is of a more acute character than that which occurs
at a later period. In fact, there is a form of irido-cyclitis occurring
many years after infection, chiefly marked by chronicity, yielding
but slowly to mercurial treatment, a hazy vitreous, involvement of both
eyes, and always gumma either in the iris or ciliary body.
In the acute inflammation due to syphilis, the anterior segment
is more commonly involved in the early stages of the disease, while
chronic affections of the posterior segment are more particularly dis-
tinctive of the later stages of the disease. Syphilitic affections of
the choroid and of the retina are more or less intimately connected,
and inflammation of one usually involves the other to a greater or
less extent as a chorio-retinitis, which not infrequently accompanies
a severe inflammation of the iris, due to the same cause. One eye
THE MANIFESTATIONS OF SYPHILIS IN THE EYE 29
is usually attacked in a chorio-retinitis, but sometimes both are affected
at the same time, and while there may be no symptoms indicative of
any specific origin, the existence of syphilitic lesions elsewhere may
assist the diagnosis, it being remembered, however, that the majority
of cases of chorioditis occur in specific subjects. One noteworthy
feature of the chronic inflammatory process in the choroid is the
great proliferation of pigment, especially in the border of atrophic
or inflammatory patches. In certain cases atrophy of the choroid
may ensue concurrently with connective tissue degeneration and cica-
tricial retraction of the retina. More common than atrophy is it to
find thickening of the choroid to a greater or less degree. Even at
the late stage of the disease we may find exudation between the vitre-
ous layer and the retina, and this may be as thick as the normal
choroid. In inflammatory processes of the anterior portion of the
choroid the principal sign upon examination of the fundus is a dif-
fuse cloudiness of vitreous humor, sometimes to such an extent that
vision is nearly lost. This haziness appears to be situated in the an-
terior part of the vitreous. When the inflammation tends to affect
more especially the posterior portion of the choroid, there is more of
a tendency toward exudations, and, upon ophthalmoscopic examina-
tion, minute red or yellowish spots or dots, not accompanied by any
marked pigment deposits, and with, at first, no signs of atrophy, are
scattered about the fundus. There may be little or no redness of the
nerve, and possibly now no great haziness of the vitreous. These
spots may disappear and no damage to the sight remain, but the con-
trary may prevail. Again we may have shining white spots, more or
less surrounded by pigment, and, later, extensive whitish or yellowish
areas occupying the center of the fundus with the surrounding areas
showing signs of exudation, and possibly a few hemorrhages with
connective tissue shreds reaching into the vitreous. Both the retina
and the choroid, probably, participate in this morbid process, and
at times it is difficult to distinguish which coat is the more involved.
Haziness of the vitreous humor is a frequent and most common char-
acteristic of all forms of syphilitic choroiditis. And syphilitic chorio-
retinitis is always characterized in its earliest stages by fine dust-like
vitreous opacities, with increased haziness and redness of the disc,
which is surrounded by grayish or yellowish exudations. The typi-
cal affection, first described by Forster, as pathognomonic of syphi-
litic chorio-retinitis, gives fine dust-like opacities in the posterior parts
of the vitreous, with the nerve head and its neighborhood appearing
as if veiled by this vitreous cloudiness and outlines, either indistinct
|
3O THE MANIFESTATIONS OF SYPHILIS IN THE EYE
or lost, and the surrounding retina appears uniformly diffusely opaque.
Circumscribed changes often appear in the fundus, more especially
in the region of the maculae, where they are seen as bright red, gray-
ish spots. Hemorrhages are rarely seen, but pigmentation produces
a spotted appearance. In about I2 to I3 per cent. Of cases, it is com-
plicated with iritis. In some instances the iritis appearing first, and
in other cases the choroiditis first makes its appearance. Syphilitic
choroiditis is usually chronic, improvements alternated with aggrava-
tions of the symptoms. If the maculae is involved, central vision will
probably be permanently lost, and the unfavorable cases are mostly
those in which there is considerable exudation in the fundus. When
appearing in the Secondary stages of the disease, it is usually sym-
metrical and curable, but during the tertiary stage it may improve,
but not be curable. The choroiditis appearing from inherited syphilis
may take the form of either of those above described, and the ap-
pearance of the choroid and retina may be very similar to that of
retinitis pigmentosa, and it is considered by some authors as an etio-
logical factor in this chronic progressive disease. Gummata are never
met with in the choroid alone, but as we have seen, a gumma of the
ciliary body may extend into the choroid.
SYPHILITIC RETINITIS. Syphilitic retinitis is much less frequent
than iritis, occurring in about five per cent. of all cases of syphilis,
and makes its appearance at a later stage of the constitutional affec-
tion, usually a year or more after the infection, and may appear from
hereditary causes. It is doubtful if there is a syphilitic retinitis per se
independent of involvement of the choroid. One eye is usually first
attacked, but unless the progress of the disease is stopped by proper
and immediately instituted treatment, the second eye Sooner or later
becomes involved. The early stages of syphilitic retinitis are marked
by hyperaemia, with a cloudy or blurred appearance to the fundus,
apparently due to a serous exudate forming a gray film Over the
surface of the retina and papilla; there is increased dilatation and tor-
tuosity of the blood vessels, especially the veins, and these may be
seen to have extending in streaks along their course this same misti-
ness or cloudiness. As in choroiditis, an iritis may precede the in-
volvement of the retina, and it is probable that in all severe cases of
syphilitic iritis, there is retinal irritation and congestion present. In
the advanced stages of retinitis we have whitish dots appearang first
at the periphery of the fundus, but less bright and glistening than
those due to the albuminuric type. The opacity of the retina mani-
fests itself mostly around the nerve and macula, and while there may
THE MANIFESTATIONS OF SYPHILIS IN THE EYE 3 I
The hemorrhagic spots, these are neither as frequent nor as pronounced
and typical as in albuminuric retinitis. We may have exudations
in the retina in the form of yellow scattered patches, and in this type
hemorrhages into the retina are more liable to occur as a consequence
of an endarteritis. A predilection is shown for the central portions,
Syphilitic disease of the blood vessels of the eye often produces in
the fundus such a typical picture that the diagnosis of syphilis can be
made from that appearance alone. It produces a peri-arteritis with
lateral white lines on the blood vessel walls, or apparently following
on the side of the blood vessel, due to visible opacities produced in the
walls of the arteries themselves, with a consequent narrowing of the
|blood column and extravasations into the retina. Such an appearance
in the arteries of the fundus has a peculiar significance to the general
practitioner, for it probably informs the observer that the same condi-
tion is present in the cerebral blood vessels, and he can form his own
judgment as to prognosis and so be guided in his advice to his patient.
It is possible that through this pathological condition of the blood
vessels the nutrition of the chrystalline lens may be affected and in this
way a cataractous condition established.
Syphilis may produce effects upon the eye when located at some
remote distance. A papillitis may be produced from gumma situated
along the course of the optic nerve fibres or in the brain. There is,
however, nothing characteristic of syphilis in the ophthalmoscopic
appearances, which consists mainly of Swelling and redness of the optic
papilla, with more or less tortuosity and stasis of the retinal veins.
There may be present swelling of disc and plastic infiltration without
much redness or, as it is called, a “woolly disc.” The condition has been
supposed to be due to an edema of the connective tissue uniting the
nerve fibers. Unilateral papillitis may be due to a lesion in the orbit,
while a bilateral papillitis is usually caused by increased intracranial
tension, often due to a centrally situated gumma. Atrophy of the
optic nerve in cases of syphilis may be primary or secondary. Primary
atrophy is met with in syphilitic locomotor ataxia and other syphilitic
spinal affections. Secondary atrophy may be due to a gumma or other
exostosis affecting some part of the optic nerve, or finally it may be
the result of either a papillitis or a descending neuritis, the nutrition
of the nerve being damaged because of degenerative changes in the
blood vessels. -
Paralysis of the muscles of the eye may be due to a syphilitic
lesion affecting either the motor nerves in some part of their course
or their nuclei. When the nerve is involved, the lesion is generally
32 THE MANIFESTATIONS OF SYPHILIS IN THE EYE
due to a gumma at the base of the brain, involving the nerve trunk
either secondarily or by pressure. The nerves most frequently involved
in this way are the third, fourth, and sixth. If the syphilitic lesion
involves either the pons corpora quadrigemina, the cerebral peduncles
or the cerebellum, paralysis of the ocular muscles may occur, but are
not frequent. They may also occur secondarily from patches of soft-
ening due to a syphilitic peri-or end-arteritis. In the nuclear palsy,
which is of common syphilitic origin, we may have a complete ophthal-
moplegia. All paralyses are not infrequently accompanied by retinitis,
choroiditis and iritis, and the co-existence of any of these sometimes
is strongly suggestive of a syphilitic origin of the paralysis. There are
a few symptoms connected with the eyes, such as amblyopia and
amaurosis, dependent upon syphilitic cerebral lesion, in which there are
no marked appearances or changes in the fundus. In these cases it
may be supposed that the symptoms are the result of changes taking
place in the vessels of the anterior portion of the brain, with conse-
quential injury to the nutrition of the optic nerve and impairment of
its functional capacities. However, these symptoms may be due to
more serious causes than mere changes in the blood vessels, such as
the formation of gummatous growths anywhere along the course of the
optic nerve or from intracranial lesions.
THE IN CANDESCENT LIGHT AS A THERAPEUTIC
AG ENT
BY
J. T. FARRELL, M.D.
PROVIDENCE
The beneficial action of light has been known from the earliest
times. The old Greeks were accustomed, on the grounds both of pleas-
ure and health, to expose themselves, after first annointing their bodies,
to the sunshine on the flat roofs of their houses. Cicero tells us that
the Romans after taking their baths basked in the sunlight, and fol-
lowed this delightful pastime by cold sponging. In later days they
had special buildings for this purpose. Herodotus made special men-
tion of sunbaths for persons with poor or enfeebled muscles, and this
method of treatment was recommended for many diseases, as dropsy,
sciatica, affections of the kidneys, elephantiasis, Swellings and many
diseases of the skin. In the middle ages this method of treatment
passed into oblivion, and we hear nothing of systematic light treat-
ment until the middle of the last century. From that time there has
been a constant accumulation of knowledge on the subject. The inves-
tigators were numerous and were the forerunners of our present use
of light for treatment.
By the physiological effect of light are usually understood, first,
its physical effect on matter, on the elementary particles of which the
tissues are composed. Second, its effect on the vital functions. Under
the influence of light living tissues may pass from a state of passivity
to one of activity, and change of form, of energy, of matter, may be
induced. In this sense light works like other physiological irritants,
under certain conditions awakening and strengthening elementary
forms of life, under others weakening.
Some of the effects of the light on the skin are:
First. It has an irritant effect on the skin, producing inflamma-
tion.
Second. It promotes perspiration.
Third. It has a direct effect on the blood and the blood vessels.
Fourth. If large portions of the body are exposed to strong light
34 THE INCANDESCENT LIGHT As A THERAPEUTIC AGENT
it causes a considerable rush of blood to the surface, and thus deple-
tion of the internal organs.
Fifth. It modifies, directly or indirectly, the transmutation of
matter.
Sixth. It incites movements.
Seventh. It exercises influence on the nervous system and the
mind.
Eighth. It has peristaltic power.
Ninth. Excessive light stimulus is destructive and paralyzing.
One peculiar phenomenon which I have observed is that if a person
exposed to therapeutic light does not show a tanning of the skin the
light will not benefit them.
The following cases will illustrate a few of the results which I
have obtained with the incandescent light, with instruments of from
fifty to five hundred candle power. The higher the candle power the
more marked the results. I use a fifty candle power Habbe lamp and
a two hundred and fifty to five hundred candle power Leucodescent
lamp.
Mrs. D., a stout, muscular woman of 52, consulted me in regard
to an injury to the shoulder joint of eight weeks' standing. Examina-
tion showed the parts about the shoulder swollen and painful. Motion
was very much impaired on account of its painfulness. Fracture or
dislocation being excluded, she was put under the light for twenty min-
utes, with relief. She had four treatments at intervals of three or four
days, with the result that she was free from pain and had the full use
of her arm. It has remained so for three years.
Dr. G. Has had an attack of lumbago each winter for a number
of years. I begged him to call and let me warm his back, which, by the
way, was a big one. He was relieved from pain at the first sitting and
was well after four treatments of thirty minutes each. He has had
one attack since, and was relieved in two treatments.
Dr. S. Sent by the last patient for treatment for the same trouble.
One treatment of twenty minutes each day for four days cured the
attack. He has had one attack since and received one treatment of
twenty minutes, with a request to call the next day. I did not see him
for a week, when I met him at the hospital, and asked him why he did
not return for treatment. His reply was: “I did not have a pain after
I left the office and I felt that I was all right.”
Mrs. P., 66 years of age, referred to me by the last-named physi-
cian, with a history of severe neuralgic pains of the face and fore-
head for the past twenty years. The pains were so severe as to deprive
THE INCANDESCENT LIGHT As A THERAPEUTIC AGENT 35
her of sleep. She had received almost continuous treatment from
various sources, professional and otherwise, with little or no benefit.
She had been advised to have her teeth extracted, which she had done
without any benefit. She had been advised by one of the best neurolo-
gists of this Society that an operation alone would relieve her. I
exposed her to the five hundred candle power light January Io, IQIO,
for thirty-five minutes. She returned January 12, and reported that
she had been greatly relieved and had had some sleep for the last
two nights. The treatment was repeated every three days until Feb-
ruary 2, with the result that she is free from pain and is better than
she has been at any time for years.
Mr. H., 71 years old, has complained of itching of anus
for the past twenty-three years. Has used many ointments and washes
with little result. At times has been unable to sleep. January 13,
examination shows a thickening of the skin and mucous membrane
about the parts. From the scratching he had produced great deep
furrows. The light was applied for twenty-five minutes. He reported
January 17, greatly improved, no itching since last visit. January 22,
parts showed marked improvement, furrows disappearing. February I2
says he is well and has no trouble and the parts look normal and
healthy. This case is a fair sample of the good results of the light
in this very disagreeable affection, eczema of the rectum.
I have had four cases of gall stones, the diagnosis of each case
being confirmed by at least one surgeon, and in the case I am about
to relate, by four surgeons, each advising operation. This patient was
a woman 39 years old, and the mother of ten children, and
at the time that I saw her first, seven and one-half months pregnant.
I found her suffering great pain in the region of the gall bladder, the
skin very yellow, the urine saffron color, and with all the classical
symptoms of gall Stones. She was suffering great pain. I gave her
a hypodermic of one-half grain of morphine and advised her to be
operated upon. She informed me that she had been to the hospital,
but had decided not to be operated upon until after her baby was
born. She herself asked for light treatment, as some of her friends
had been benefited by it. I told her if she were able to come to my
office she might do so the next day, October 28. She came, and was
a sorry sight, bent over with the pain, which had returned, and the
color of an Indian. I put her under the light for half an hour, until
the pain was relieved. November I, reported no pain since the last
visit, and was hungry and wished advice as to what she might eat.
Treatment was given November 4, II, 22, and 30. There was no
36 THE INCANDEscENT LIGHT As A THERAPEUTIC AGENT
pain after the first treatment. Her bowels were regular and her appe-
tite good and her skin was clearing. December 6 she sent me word
that her baby had been born that morning, after an easy labor. I
consider the result in this case better than I have ever had under any
other method of treatment. I do not think that I dissolved those
stones, but I produced results that enabled her to pass safely through
one of the most critical periods in a woman's life. The other gall
stone cases were nearly as remarkable.
Mr. F., referred to me by Dr. Gleason, suffering with a swelling
of the leg from knee to ankle. He was very lame, and the leg was
painful. He had not worked for six weeks. An X-ray picture was
taken to see if the bone was involved. The picture showed the bones
normal and the diagnosis was made of periostitis. He was put on the
table and the light used for twenty-five minutes. The following three
days it was used for one-half hour each time. He went to work on the
sixth day, the swelling and pain gone, and has remained well since.
I have used the light in a few cases of chronic eczema with good
results. I have also used it in acne with like results. In all cases of
pustular skin diseases it will do good. Pruritus ani, as related above,
and pruritus vulvae are soon benefited.
My method of applying the light is to remove all clothing about
the parts affected and to concentrate the light from a distance of
eighteen to twenty-four inches. If the heat is unbearable, a slight
rubbing of the skin dispels the feeling of warmth. I do not think the
light is a cureall, but I believe there is much to learn, and that, as an
auxiliary, we will find it of great assistance in the treatment of many
diseases which now tax us to the utmost and often result in failure.
OLD Books on ANATOMy 37
ANATOMICAL WORKS FROM THE SOCIETY'S LIBRARY
Exhibited at the Quarterly Meeting, March 3, 1910
Plater (Felix) [I536-1614]. De corporis humani structura et usu
libri iii, tabulis methodice explicati, iconibus accurate illustrati.
fol. Basilea, ex officina Frobeniana, 1583.
Vesalius (Andreas) [I514-64]. Librorum de humani corporis fab-
rica epitome, cum annotationibus Nicolai Fontani. fol. Amstelo-
dami, apud V.Janssonium, I642.
Opera omnia anatomica et chirurgica, cura Hermanni Boerhaave
et Bernhardi Siegfried Albini. 2 v. fol. Zugd. Bat, V. du Vivie
et /, et H. Verbeek, 1725.
Browne (John). Myographia nova sive musculorum omnium (in cor-
pore humano hactenus repertorum) accuratissima descriptio,
in sex praelectiones distributa, (etc). fol. Londini, J. Redmayne,
I684.
Eustachius (Bartholomew) [I52O-74]. Tabulae anatomicae. fol.
Amstelodami, I722.
The same fol. Editio Romana altera, Roma, I728.
THE TONSILS
BY
HARLAN P. ABBOTT, M.D.
PROVIDENCE
The term tonsil as ordinarily used designates the mass of lymphoid
tissue between the faucial pillars on either side of the throat. But there
is also the lymphoid tissue in the epipharynx or naso-pharynx, which,
when enlarged, is called adenoids, and the lymphoid tissue at the base
of the tongue, which, when enlarged, is called the lingual tonsil. These
four lymphoid structures taken together are sometimes called the
tonsillar ring of Waldeyer.
The tonsil has some points in common with the vermiform appendix.
First—It is thought by some scientists to be the vestige of an
organ, once useful, but now obsolete.
Second—Its exact function is still problematical.
Third—It is subject to microbic invasion, repeated inflammatory
attacks, and abscess formation.
Fourth—Its surgical importance is of recent date.
Fifth–Radical operative procedures on either organ are not
altogether devoid of danger.
The anatomy of all the tonsils is much the same. The faucial
tonsils are much more highly developed than the pharyngeal or lingual.
They are made up of masses of lymphoid tissue held together by a
stroma of connective tissue. The exposed surfaces are covered with
mucous membrane which in several places dips deep into the body
between the masses of lymphoid tissue forming crypts or lacunae.
Beneath the lacunar mucous membrane are rows of follicles. On the
exposed surface the mucous membrane is covered with pavement
epithelium, in the lacunae with pavement and columnar epithelium.
The faucial tonsil is attached loosely to the superior constrictor
muscle of the pharynx by an investing fibrous capsule. It is bounded
in front by the anterior pillar and behind by the posterior pillar; above
by the supra tonsillar fossa and the fold of mucous membrane called
the plica supra-tonsillaris; below by the fold of mucous membrane
called the plica triangularis. The folds are important in that they often
cover up large, open lacunae and prevent the escape of debris and bac-
teria which have collected therein.
The tonsils act as the first line of defence to catch bacteria and
prevent them from entering the system. When the tonsil is in a
THE TONSILS 39
healthy state the crypts receive the bacteria which crowd into them,
where they are destroyed by the phagocytic action of the leucocytes which
are thrown out in abundance at the apex of the crypt. The bacteria
are not able to gain access to the lymphoid tissue or parenchyma unless
the epithelium lining the crypt is broken. This may occur if the tonsil
is weakened by congestion or hypertrophy or if there is a general
weakened condition of the system. The bacteria crowded into the
crypt are not able to break down the barrier of epithelium except as
they give off toxines which destroy the vitality of the epithelial cells;
then it is easy for them to enter the parenchyma and there get into the
lymphatics and blood vessels and be carried to all parts of the system.
The lymphatics carry the bacteria to the cervical lymphatic glands, the
second line of defense, and the bacteria set up various kinds of lympha-
denitis according to the micro-organism absorbed. If they are not
destroyed here they go on further to deeper chains of glands, the third
line of defense, and so on. In this way tubercle bacilli may be con-
veyed through tonsil to glands under the plura near the apex of the
lung, setting up an inflammation of the glands and the adjacent plura,
which may become adherent to the apex of the lung, so that a direct
line of extension is formed to the lung tissue and you have implanted
there tubercle bacilli and pulmonary tuberculosis. Or by another route
the bacilli may pass through the tonsil along the lymphatics, blood ves-
sels, and glands, to the hilum of the lung and thereby reach the interior
of the lung and set up a tuberculous process therein. The blood ves-
sels may take bacteria to any part of the system which have entered by
the tonsillar road and set up an endocarditis or acute articular rheuma-
tism or other infectious disease
Sir Andrew Clarke wrote in 1889:-“If one will think merely of
the rapidity with which the tonsil manufactures and discharges lymph
cells, it will not be difficult to see how a sudden suppression of this
process, the accumulation of effete matter in the crypts and the filling
up of the lymph spaces with products of bacterial life and with matters
undergoing evolution may contaminate the blood and originate the
troubles considered as rheumatism.”
Ten years later Lenox Browne, commenting on the above quotation,
wrote: “Since that date this contamination of the system or blood
poisoning has been acknowledged to be of microbic origin by several
observers, notably Buschke, who recognizes the tonsils as the entrance
door for purulent micro-organisms, and Kraske, who alludes to acute
osteomyelitis as being due to organisms which found their first entrance
40 - THE TONSILs
to the system through the tonsils. The researches of Roos, Stabull and
Otto Leiffert seem to prove that after infecting the tonsils the micro-
organisms may migrate to the joints, synovial cavities and endo-
cardium, as in gonorrhea. It is also noticed that many such cases of
articular rheumatism do not yield to Salicylates—a fact supporting the
view that these infections are quite as often due to pyemic metastases
as to rheumatic dyscrasia.
Active primary tubercular tonsilitis is not common, but the follicles
of the tonsils and lymphoid tissue surrounding the tonsils is supposed
to harbor dormant tubercle bacilli, which under favorable conditions
make their way into cervical glands and set up a tubercular adenitis, so
that we see frequently repeated attacks of this disease. A large pro-
portion of patients with pulmonary tuberculosis do not have tuber-
cular infection of the cervical glands, which tends to show that tuber-
cular bacilli do not travel in reverse direction. The variety of bacteria
that may find lodgment in the lacunae of the tonsils is very numerous.
The more common are the streptococci and the staphylococci—also the
tubercle bacilli, the Klebs-Loefler bacilli, pneumococci, etc.
A healthy tonsil in a healthy person is able by the action of
phagocytes to destroy these various bacteria; and the dead bacteria,
along with the leucocytes, worn-out ephithelium and other debris, are
forced out of the crypts and cast off. At the present time investigation
is being carried on to prove that the tonsil has the function of taking
care of debris from neighboring organs. Dr. Wright puts forth a ten-
tative assertion that the tonsils help to dispose of the debris from the
teeth during the stages of dentition—especially at ages of 2, 6, 12 and
18. His theory is that at those periods the tonsils are functionally
enlarged, and after the full eruption of the teeth the tonsil subsides,
only to enlarge again at the next period, again to Subside.
The tonsils enlarge from colds, congestion, inflammation: I, Sim-
ple; 2, bacterial, and functional activity.
The tonsils are more or less large up to age of puberty, when the
retrograde process begins, and the great majority of them subside to an
insignificant size and give no further trouble.
Many tonsils do not subside, do not retrograde, but remain chroni-
cally enlarged. Many in the earlier years become a source of danger
from frequent inflammations and infections; many become so enlarged
as to be obstructions to breathing, talking and eating or interfere with
the circulation of neighboring organs, as the eustachian tubes, and so
interfere with the integrity and function of the ears. The large and
THE TONSILs - 4 I
diseased tonsils have very frequently left a train of obstructive and
inflammatory effects. -
Acute inflammations of the tonsils vary according to the part in-
fected. In a simple cold the surface mucous membrane is inflamed the
same as the mucous membrane of the general pharyngeal wall. The
lining mucous membrane of the crypts may be the seat of inflammation,
presenting the appearance called follicular tonsilitis, but more properly
named by Lenox Browne lacunar tonsilitis, or the parenchyma may be
inflamed and go on to abscess formation; then we have tonsillar abscess
or still further extending to the cellular tissues external to the tonsil,
causing peritonsillar abscess or quinsy.
As a result of acute inflammation or repeated attacks of acute
inflammation, especially parenchymatous, the tonsils may become
chronically enlarged or hypertrophied. This is specially to be noted
after diphtheria, Scarlet fever, measles, and whooping cough, and also
in strumous children. As stated above, tonsils are functionally enlarged
at times and will usually subside when the function is completed. The
great majority of all tonsils, faucial, pharyngeal and lingual undergo
retrograde degeneration at puberty and during the succeeding years of
youth until they reach an insignificant size.
TREATMENT OF HYPERTROPHIED TONSILs.
What tonsils shall be let alone, what trimmed, and what removed P
Tonsils that are functionally enlarged and not diseased should be let
alone unless they are causing symptoms, i. e. obstruction to breathing
or eating or interfering with the functions of other organs, when
enough can be cut off to relieve such obstruction or interference. Ton-
sils that are diseased or subject to frequent attacks of inflammation or
cause peritonsillar inflammation or are an open avenue of infection to
the system should be removed in toto, and in case of faucial tonsil
capsule and all, so that there will be no possibility of growth of any
more tonsillar tissue. Exception may be made of the lingual tonsil,
which should not be removed by radical use of the knife on account of
the difficulty in controlling an obstinate hemorrhage. An exception
should also be made of bleeders. For removal of faucial tonsils the
tonsillotome of the Mackenzie type may be used or the punch, the dis-
secting knife or the cold snare. For the complete removal of the tonsil
with capsule the cold snare is effective, and, on the whole, causes less
bleeding than the tonsillotome or punch, and there is less liability of
injuring the pillars. The pharyngeal is best removed by the basket
Curette.
42 THE TONSILS
: HEMORRHAGE.
The dangers of hemorrhage, primary or secondary, are to be
reckoned with even by the most experienced operators. Besides the
tonsil vessels proper there are vessls in the anterior and posterior
pillars and a bunch of veins at the inferior part of the tonsillar fossa,
any one of which may cause a very troublesome hemorrhage, even so
severe and persistent as to call for ligation of the external carotid.
Several fatal cases have been reported.
The enlarged pharyngeal tonsil, more commonly called adenoids,
almost invariably accompanies hypertrophied faucial tonsils. A predis-
position to the growth of adenoids is the excessive use of cane sugar.
The most common cause is an attack of one of the exanthematous dis-
eases due to bacterial infection of the lymph glands in the epipharynx.
Adenoids may cause obstruction to breathing, slow mental develop-
ment, catarrh in the epipharynx, deafness, inflammation in the ears and
otorrhea, insufficient aeration, poor blood, deformity of chest and face,
laryngitis, bronchitis, enuresis, etc. *
The only treatment is complete removal with the adenoid curette
or forceps. Hemorrhage may be profuse, persistent and serious—fatal
cases have been reported. It is to be borne in mind that adenoids may
recur—only the hypertrophied tissue is removed—remnants of .
lymphoid tissue remain.
Dr. Harmon Smith, in Keene's Surgery, says: “Unquestionably,
these growths recur at times, even when properly removed. This ap-
pears to happen more in children in whom there is an apparent tend-
ency to hypertrophy of the lymph structure. Frequently a recurrence
takes place where the growth is removed in very young children, but
this should not prevent their removal when they produce disturbances
in breathing and hearing.”
In summing up I would call attention to a few points:
I. That the tonsils are frequently an open avenue for local and
general infection.
2. That simply because a tonsil is moderately enlarged is not suf-
ficient reason to eradicate it.
3. That the full function of the tonsil is still subjudice.
4. That the tonsil as a rule should not be removed when acutely
inflamed.
5. That a diseased tonsil should be thoroughly eradicated, includ-
ing the capsule.
6. That the adenoids may return in young subjects, even if they
have been thoroughly removed.
7. That the operating surgeon should be prepared to control
obstinate bleeding, either primary or secondary.
THE EYE IN THE DIAGNOSIS OF GENERAL DISEASE
BY -
F. T. ROGERS, M.D.
PROVIDENCE
In this day and year of Our Lord, when no diagnosis is complete
without its laboratory findings, when we mystify our patients, and
Sometimes ourselves, as well as our confrères, by allusions to phago-
cytosis and leucocytosis, the opsonic index, and other terms unknown
to practitioners twenty years ago, and the clinical picture is over-
Shadowed by its complex and complicated pathological frame, it may
not be amiss to call to our attention some of the elements of diagnosis
which were of service to us in our earlier days of practice, and which
are not dependent on other than our own powers of observation and
experience.
The eye is not to be relegated to the oculist and considered as a
distinct organ, a knowledge of which is scarce to be expected of the
general practitioner; an acquaintance with the ordinary laws of refrac-
tion is not essential, nor is it necessary to utilize the findings of the
Ophthalmoscope, although of inestimable value, for us to appreciate
the Ocular conditions which form a part of the clinical picture of disease
and to recognize the fact that the eye is an important aid in diagnosis.
It is my wish to avoid technical terms, to forget the oculist, and
as the physician to recall a few of the conditions where a recognition
of the eye symptoms will be of Service in diagnosis and treatment of
systemic diseases.
The general expression of the eye may afford us valuable informa-
tion: the wide, lustrous eye of febrile excitement; the dull, vacant stare
of mental disease and of profound systemic disturbance; the furtive
and unsteady gaze of acute dementia are so familiar to all of us that
we do not think of the aid that it gives us in making our diagnosis.
Exophthalmos is commonly associated with goiter, but it may be
due to thrombosis of the superior longitudinal sinus, to orbital tumors,
or hemorrhages, to cardiac hypertrophy, or even to dyspnea from
cardiac or pulmonary disease. . .
Enophthalmos, on the other hand, is usually found in exhaustive
diseases, with a lesion of the cervical sympathetic or to the secondary
effects on the system of exhaustive hemorrhages or drastic diarrhea.
LIDs. Edema of the lids may be due to a nephritis, and so
44 THE EYE IN THE DIAGNOSIS OF GENERAL DISEASE
general is the belief in the value of this sign that patients frequently
consult us on account of it alone, but it may also be associated with
menstrual disorders, cardiac disease, myxoedema, trichinosis, or even
anaemia. .
Eczema of the lids should at once call our attention to the pos-
sibility of diabetes; discolorations and anesthetic patches to Addison's
disease, and locomotor ataxia; and the lack of tone in the orbicularis,
which causes Senile ectropion and lacrimation, demands attention to a
lowered constitutional condition and defective nutrition, while a
paralysis of this muscle should at once awaken suspicion of a posterior
spinal Sclerosis. -
In the absence of any disease of the cornea, whereby its senitive-
ness is impaired, persistent winking may be the sign of exophthalmic
goiter, or it may be due to a paresis of the orbicularis, associated with
syphilis, locomotor ataxia or aural disease, and inasmuch as this muscle
is innervated from separate nuclei, this symptom may occur without
other evidence of facial paralysis.
In the orbit are numerous unstriped muscle fibers—Mueller's
Muscle—supplied by the sympathetic. Stimulation of these fibers
causes a widening of the palpebral fissure and is noted in seventy per
cent. of the cases of exophthalmic goiter, constituting Von Graefe's
sign, while a paresis of these fibers—Jackson's sign or sympathetic
ptosis—occurs in posterior spinal Sclerosis.
Ptosis may be hysterical or reflex, and more than once have I seen
it associated with dental irritation.
CONJUNCTIVA. Subconjunctival hemorrhages are apt to be con-
sidered of little importance, yet their presence in young people is
strongly suggestive of diabetes and in elderly patients pathognomonic
of atheroma, and should be regarded as " danger sign of possible
cerebral hemorrhages; it is often the first thing which calls attention
to an arterio-sclerosis and its consequent dangers.
It has been my experienec that the average physician uses the term
conjunctivitis as a sort of “catch-all” for any inflammation of the
anterior segment of the eye, and has rather a vague idea of its dif-
ferentiation from iritis, scleritis, or corneal disease. Necessarily an
appreciation of the importance of an inflammation of either of these
structures implies an ability to make a differential diagnosis.
As a matter of experience, and I do not recall seeing it in text
books, there is a simple rule which will usually determine which of
these structures are affected. &
THE EYE IN THE DIAGNoSIS OF GENERAL DISEASE 45
In conjunctivitis there is a disturbance of secretion without pain or
photophobia.
In corneal disease there is no increased secretion, but marked
photophobia and Subsequent pain, while
In iritis pain is the predominant symptom, and photophobia and
lacrimation are dependent on its severity.
When conjunctivitis is present one must not forget that it is often
the prodromal stage of measles and epidemic cerebrospinal meningitis,
and that it frequently occurs during the administration of iodide of
potassium and not make the mistake of administrating local remedies
to combat what is not a local disease. In illustration of this point:
not long ago a man was treated by an eminent oculist, who had not had
experience in general practice and who was not familiar with the
exanthemata. He was treating a case of specific iritis in the head of
the family and administering iodide of potassium in good doses when
there developed an acute catarrh of the conjunctiva. He assured the
patient it was due to the medicine and was to be expected; soon an
eruption appeared. This, too, was ascribed to iodism, but the febrile
rise that followed was not expected, and when the symptoms were
transferred tothe wife and children he was surprised to learn that he
was treating a case of measles. .
Excepting these conditions, catarrhal conjunctivitis is usually
idiopathic or an extension of nasal catarrh ; a purulent conjunctivitis
can be traced to its exciting cause and the diphtheritic type of the
disease easily recognized, but the form known as phlyctenular is at the
same time most frequently not recognized and most likely to indicate
constitutional disturbance.
Phlyctenular conjunctivitis is so frequently associated with dis-
turbances of the digestive process that it is almost pathognomonic. In
children it occurs when there is an ingestion of an improper amount of
Sweets and pastry, or where there is irregularity in eating, and
especially where they are allowed to use tea. I have seen scores of
families where a bowl of tea was the invariable accompaniment of a
meal, and I have learned to question the parents on this point whenever
a phlyctenular case presents and have often effected a cure by forbid-
ding its use. -
The phlyctenular condition associated with nasal catarrh in its
various forms calls for appropriate treatment of the nose.
SCLERA. Aside from the symptomatic value of the color of the
sclera, from its yellow tinge from jaundice to the pearly white of
chlorosis or nephritis, the existence of a scleritis or even an episcleritis
46 THE EYE IN THE DIAGNOSIS OF GENERAL DISEASE
is significant of grave constitutional disturbance. Gout, rheumatism,
Syphilis, may give rise to Scleritis and to the resulting sclerokeratitis so
disastrous to sight, but I have learned from experience that auto-
intoxication from intestinal indigestion may cause this most troublesome
and obstinate disorder. - -
A girl of eighteen, of former perfect health and unquestionable
family history, suffered first from phlyctenular conjunctivitis, which
yielded readily to treatment. Some months later she developed a
scleritis of one eye, which rapidly extended to the cornea, causing not
only great pain and photophobia, but almost complete loss of vision.
In searching for a cause of the disorder, the advice of eminent counsel
was obtained in Boston, New York and Philadelphia. The possibility
of tuberculosis and syphilis was considered and appropriate treatment
was followed, but the disease lasted five months and finally cleared with
greatly impaired vision, and then promptly began in the other eye. The
same difficulty was experienced in this Second attack, and it was only
after nine months' illness that the eyes became free from inflammation.
The year following, a similar condition started in the eye first affected,
and at this time attention was paid solely to the question of digestion
and diet. The examination of the urine showed acetone and indican,
indicating defective intestinal digestion. Upon a strict diet, this second
attack, which bade fair to equal the first, yielded in a short time, and
during the last two or three years similar attacks have followed indis-
cretions of diet and have as promptly been relieved.
CORNEA. The cornea is an invaluable aid in diagnosis. Phlyc-
tenular keratitis and the ulcerative type are significant of a strumous
diathesis. The parenchymatous keratitis, termed interstitial, is in
seventy-five per cent. of cases specific, while the dendritic type, when
associated with supra-orbital tenderness, is probably malarial in its
Origin. -
The differentiation of corneal disease implies familiarity with the
method of examination known as oblique illumination, and is greatly
facilitated by the instillation into the eye of a drop of a one per cent.
solution of fluorescin which stains the cornea a bright green wherever
it is denuded of its epithelium.
Arcus senilis, so common in elderly people, is indicative of
arteriosclerosis.
LENs. Disturbances of the lens and the various types of iritis are
most frequently associated with syphilis, gonorrhea, diabetes or rheu-
matism. -
MUSCLEs. Paralysis of one of the extrinsic muscles of the eye
THE EYE IN THE DIAGNOSIS OF GENERAL DISEASE 47
may be apparent by the resulting squint or evidenced by the presence
of diplopia, and a determination of the muscle affected will sometimes
aid us in locating the exciting lesion. As a rule, however, it is not
easy and necessitates a careful study of the defective movements and
a knowledge of the action of each muscle, but a simple rule will differ-
entiate the affected muscle. It is always on that side of the eye towards
which doubling occurs and belongs to the eye that sees the object that
appears most distant. Thus, if doubling occurs when looking to the
right, the muscle affected is either the external rectus of the right eye
or the internal rectus of the left. If covering the left eye the nearest
object disappears, the first is the muscle concerned; if the farthest
one disappears, it is the internal rectus of the left eye. The same is
true of the superior and inferior recti when tested in a vertical plane.
If one of the images is tilted from perpendicular, the oblique muscle
affected is as easily determined. A knowledge of the third, fourth,
fifth and sixth nerves, the anastomosis occurring between their nuclei,
and their ultimate termination will help us to decide whether the lesion
is extra or intra cranial, peripheral or central, while a decision as to
whether the paralysis is conjugate or associate will determine its loca-
tion. The former is complete, the latter does not extend beyond the
median line. A paralysis of one or more branches of one nerve is
unmistakably nuclear in its origin as is also complete ophthalmoplegia.
Von Graefe is authority for the statement that one-third of all
Ocular palsies are specific in origin, and if we accept the Statement of a
famous syphilographer that all mankind is divided into three classes,
those who have had syphilis and gotten over it, those who have it and
are undergoing treatment, and those who are going to have it, it seems
safe to assume that an ocular paralysis of non-traumatic origin is
specific and to treat it accordingly. To tabes, however, we must
ascribe some of the cases if we recognize a non-specific type of that
disease.
We must differentiate also spasm of the extra Ocular muscles from
paralysis, and the strabismus noted in meningitis is usually spasmodic
rather than paretic.
Nystagmus assumes a lack of control of the voluntary muscles, and
when not due to imperfect vision indicates serious organic disease, and
this is doubly true when it occurs in adults.
PUPIL. The pupil under ordinary illumination is about four m.m.
in diameter, but may vary one m.m. in either direction without being
pathological; beyond this limit, however, it is usually indicative of
48 THE EYE IN THE DIAGNOSIS OF GENERAL DISEASE
disease. It contracts under the stimulus of light, with the effort of
accommodation, and convergence, and under the influence of myotics.
It dilates when there is insufficient light and after irritation of certain
cutaneous areas, and after the use of mydriatic drugs. It is larger in
children and myopes, and Smaller in old age and hypertropia. Dilation
of the two eyes is usually consensual after stimuli applied to either and
usually to the same extent.
- In the absence of drug mydriasis or myosis, departures from these
general rules are symptomatic of disease.
To correctly estimate pupillary reaction the patient should sit
before a moderate light, and by alternately covering each eye the
sensibility of the light reflex may be estimated, while by causing them
to look at an object at eight inches from the eyes, the stimulus of con-
vergence is noted. To estimate the accommodative reaction, one eye
should be covered while the other is tested. -
Contraction of the pupil is effected by efferent impulses along the
motor oculi, and hence when noted one may assume that conduction
fails either in that nerve or in the optic tract, and the same is true of
the contraction under accommodation, although in a lesser degree, as
part of this contraction is due to mechanical engorgement of the iris
by the contraction of the ciliary muscle.
Dilation of the pupil is due either to stimulation of the dilator fibers.
or inhibition of the sphincter. In the reflex mydriasis from cutaneous
irritation or various mental states, as fright, it is the former acting
through the sympathetic, and is to be differentiated from the paretic
type by the fact that the pupil still reacts moderately to light and con-
vergence.
Spastic mydriasis indicates either direct or reflex irritation of the
cilio-spinal center and is associated with spinal congestion, meningitis
and even spinal irritation, whatever that may be, a term so frequently
used in medico-legal cases that it deserves a more accurate definition.
It is also noticed in certain skin affections, as urticaria or herpes zoster
and sometimes from intestinal irritation by worms.
Myosis may also be spastic or paretic; in one, indicating hyper-
aemia or inflammation, with excitement of the brain or its coverings;
in the latter, chronic spinal disease.
Two tests of the mobility of the pupil are familiar to all of us.
Wernicke's sign, or Hemianopic pupillary reaction will demonstrate
the location of the lesion causing hemianopsia.
If when light is thrown on the blinded side of the retina there is
THE EYE IN THE DIAGNOSIs of GENERAL DISEASE 49
pupillary reaction, the lesion is beyond the thalmus; if there is absence
of reaction, it is between the optic thalmus and the optic nerve termi-
nation.
In the Argyll-Robertson pupil reflex activity with efforts of accom-
modation and convergence is not lost with light reflex, and its presence
is a characteristic symptom of tabes dorsalis and progressive paralysis
of the insane, occurring in from fifty to seventy-five per cent. of the
C2SCS. - *
The effect of certain drugs on the pupil must not be forgotten and
should lead us to make diligent inquiry concerning the possibility of
toxemia from this cause, and we must not forget that, although extreme
myosis is a Symptom of opium narcosis, the chronic opium eater will
often have widely dilated pupils. -
Anisocorea, or inequality in the size of the pupil, is usually asso-
ciated with tabes and progressive paralysis, while hippus is more
significant of epilepsy or hysteria. -
No discussion of this subject would be complete without reference
to the findings of the ophthalmoscope in its relation to organic disease,
but it is not my purpose to do more than recall to your attention the
necessity of such an examination in any case of suspected nephritis even
when the urinalysis is negative, for albuminuric retinitis is an infallible
sign and an invaluable element in prognosis; or to the necessity of
knowing the condition of the eye ground in anemia, pyemia, endo-
carditis and malarial fever.
The existence of a neuritis or neuro-retinitis in toxic amblyopias,
anaemia or diabetes and the significance of choked disc in disturbance
of the cerebral circulation with its positive value in localization are
factors of growing value since the efficacy of decompression has been
proved by scores of cases.
A discussion of the various neuroses referable to Ocular disease
would open a field entirely beyond the limits of this paper and call for
technicalities appropriate for an ophthalmic section and inappropriate
to this body, but I can in no better way close this paper, which I fear
has been about as interesting as a page of a dictionary to those who do
not pay especial attention to diseases of the eye, than by Summarizing
my experience in the value of ocular symptoms in the etiology of that
most distressing and very frequent symptom of headache. So distress-
ing and so frequent that I regret it cannot be called a disease instead
of a symptom, and to do that by a reversal of the Scheme of this paper.
Instead of reciting the ocular conditions likely to cause a headache, I
50 THE EYE IN THE DIAGNOSIS OF GENERAL DISEASE
wish briefly to call your attention to the means at our disposal of
determining whether a headache is ocular or not in its origin, and to
urge, as I have done many times in the last twenty years, that it is your
duty as general practitioners to familiarize yourself with the ele-
mentary methods of examination and determine for yourself whether
the case requires the services of an oculist rather than to assume that
such a case is beyond your skill and so lose the prestige of accurate
diagnosis and the good will of a patient by saying, “I have tried every-
thing else; this headache must be due to the eyes,” and then have it
ascertained that the eyes are entirely normal.
FIRST: Headaches which are due to the eyes will show themselves
by affections of the lids and conjunctivae, which indicate errors of
refraction, or by disturbances of vision. It is unnecessary for the
general practitioner to have all the paraphernalia of an oculist to test
the vision. He should be provided with, however, a Snellen chart, and
if the patient is unable to read the letters at their proper distances with
each eye, it is safe to assume that there is some defect of vision. Each
general practitioner should also acquaint himself with the method
known as retinoscopy. If in a dark room with a plane mirror which
has a central aperture, the light from a lamp or an electric burner be
thrown into the eyes of the patient at a distance of one meter and the
mirror gently rotated from right to left and up and down, there will be
seen a shadow moving across the pupil of the patient. If this shadow
moves with the mirror, there is hypertropia. If it moves against the
mirror, there is myopia. If it moves faster in one meridian than in the
other, there is astigmatism.
Ascertaining that there is a defect of vision, the physician is then
qualified to advise the patient that his eyes need attention.
SECOND: Muscular anomalies indicated by inspection or by a
simple test with a red glass. It the patient looks at a candle light some
distance away with a red glass over one eye, paralysis of one of the
external ocular muscles will be indicated by the resulting diplopia. If
there is no paralysis, but a functional paresis, by placing in front of
the other eye a strong cylindrical glass there will be seen a red image
and a white bar of light.
THIRD : A disturbance of tension of the globe, indicative of
glaucoma, a disease so frequently not recognized by the general physi-
cian that it is almost a criminal offence.
In the absence of either of these three conditions, it is not safe to
assume that the eyes are at fault.
GRAVES DISEASE"
BY
JAMES G. MUMFORD, M.D.
BOST ON
Visiting Surgeon Massachusetts General Hospita/
l
“Graves' Disease” means a definite thing to most physicians, and
the disease is being cured in spite of skeptics.” During the past eight
or ten years we've learned a great deal about it, something of its
nature, the chemistry and pathological anatomy of the thyroid gland,-
and we've succeeded in curing it by diverse means. Ten or fifteen
years ago attempts at cure were obstructed by men urging a singular
argument. They said that we need not disturb ourselves about the
therapeutics of the matter because the patients get well under any treat-
ment and under no treatment. For years this monstrous assertion
found favor and was used seriously as an argument for inaction.
Doubtless there are trifling cases of Graves' disease which come to noth-
ing, but a brief experience with the truly serious cases convinces doubt-
ers that we must often act vigorously if we are to Save our patients
from exhausting invalidism or from impending death. -
Whether or not Graves' disease is becoming more common than
formerly in this community, certain it is that those of us who are inter-
ested in the matter are seeing more and more cases. On looking over
my records I find that I saw my first case in 1896. There was another
in 1900, and three in 1902. They were all treated “symptomatically.”
In 1906 I began to take an active interest in Graves' disease, for I was
stimulated by the researches of J. M. Jackson, in Boston, and by the
reports of Huntington, Halsted, Kocher, Mayo and Shepherd. I have
now a series of some 40 cases, IQ of them treated by operation,--a
trifling collection, but enough to form the basis of a research balanced
and controlled by the collectively large experience of others.
I began this study without prejudice, and I believe I have carried
it through in that spirit. We know that earnest and responsible men
are curing Graves' disease by various measures. We have extensive
records of their methods and results. May we not, therefore, properly
*Address before the Rhode Island Medical Society May 31, 191o
52 GRAVES’ DISEASE
and Soundly draw conclusions which shall determine for us the appro-
priate treatment in given cases?
In order intelligently to approach the problem of treatment, let us
consider briefly the nature of hyperthyroidism, which Graves’ disease
properly should be called, and its pathological anatomy, glancing, too,
at the possible influence upon it of the parathyroid glandules and of
the thymus.
So experienced an observer as Louis O. Wilson states” that certain
changes in the thyroid gland bear a sure relationship to the varying
Symptoms of Graves' disease. One observes that early in the severe
acute cases of Graves' disease we find certain evidence that the gland
produces an excess of Secretion, which excess is rapidly absorbed into
the Organism. Wilson lays little stress on the histological appearances
of the gland's parenchyma in these cases; the important fact is that as
long as there is increase of cells and of cell-activity, and open lymphatic
connection with the general circulation, just so long will the symptoms
of hyperthyroidism persist, and the more active the secretion and
absorption, the more active and severe are the symptoms. Those are
Striking observations, and there follows the inevitable corollary—that
if there be diminished secretion or obstruction of the lymphatics and
consequent checking of the flow of poison from the thyroid into the
circulation, then there follows improvement in the symptoms and per-
haps a cure even of the patient. Some cases may progress farther, so
that serious permanent changes in the heart and nervous system are
established, even though the thyroid activity has ceased and though the
gland appears as a colloid goiter merely, its acini lined with flattened or
desquamating epithelium, the husk of an extinct hyperthyroidism.
Wilson makes this further notable statement: A large percentage of
simple goiter cases show unmistakable symptoms of Graves' disease,
while conversely, every case of Graves’ disease is destined hypothetically
to become a case of simple goiter. -
Other writers lay stress on the manner of increase of the cells and
note an infolding of those cells lining the acini as indicative surely of
Graves' disease, observations which Shepherd” is at Some pains need-
lessly to refute.
The fact is, as Shepherd demonstrates, that a particular histological
arrangement of the epithelial cells—an infolding or budding—is not
essential for the development of hyperthyroidism. The truly essential
requisite for the development of the disease is an overactivity of the
GRAVEs’ DISEASE 53
gland. Both the cells and the vesicles are multiplied. There is an
enormous overproduction of the gland's secretion. Moreover, this
great overproduction does not imply a great increase in the size of the
gland. The gland may be scarcely perceptible to the touch, yet the
patient may be alarmingly ill. Per contra, the victim of a mild Graves'
disease may carry a large goiter, but the bulk of such a tumor may be
a mere collection of colloid material. In discussing these interesting
facts, C. H. Mayo” said recently: “Then we have the other type of
exophthalmic goiter in which an individual has had for a longer or
shorter period a colloid goiter, and suddenly this takes on the worst
type of exophthalmic conditions. An effort is being made by nature for
the recovery of the life of the gland and the development of new
epithelium.”
The reflective student of the subject will perceive, then, that with
the cessation of activity of the gland, and with the consequent retro-
grade changes in the cells of its parenchyma, there must take place
changes in the patient’s symptoms. Indeed, the glandular changes
retrogress by reaction from hyperthyroidism to hypothyroidism, from
Graves' disease to myxedema; for be it remembered that myxedema is
due to a lack of thyroid secretion and is the antipodes of Graves'
disease." -
All careful recent observers are convinced that the complex symp-
toms to which we attach the name Graves’ disease are due to overac-
tivity of the thyroid gland. The various old theories"—the cardiac,
the compression, the sympathetic, the nervous, the parathyroid and the
thymus theories"—are now generally discarded, but there remain cer-
tain questions and factors connected with these theories which one
remembers: the relation of the parathyroids to the thyroid and the
necessity when performing thyroidectomy of preserving some of the
parathyroids if we are to avoid a subsequent tetany, and the persistence
of an enlarged thymus in fatal cases of Graves' disease. Some six
writers quoted by Heinecks have observed marked hypertrophy of the
thymus in such fatal cases. More lately Shepherd is emphatic on the
subject”; in discussing deaths in the paroxysms of acute hyperthyroid-
ism he says, “In all these cases of death, with or without operation, I
have found great hypertrophy of the thymus gland”; while Capelle”
also states that in autopsies on cases of Graves' disease a good-sized
thymus is nearly always found. He quotes elaborate statistics which
record 6o such autopsies, in 79 per cent. of which was a large thymus.
54 GRAVES’ DISEASE
Capelle believes that an enlarged thymus is an indication that the hyper-
thyroidism has progressed beyond the stage in which operation is safe.
He urges the surgeon always to look for the thymus before operating.
We know nothing further as yet regarding the relation of the thymus to
Graves' disease, but in the presence of a thymus one conjectures that
the disorder which immediately causes the death of these patients may
be status lymphaticus or may have some relation to that obscure ailment.
Although the histological changes in the thyroid of Graves’ disease
are various and not altogether definite, the blood changes in this disease
are strikingly characteristic. Kocher and his associates have shown
this.” They find that the erythrocytes are slightly increased in num-
ber; but most interesting is the variation in the leucocytes, which aver-
age about 5,000 to the cmm., but may be below 4,000. As a rule this
low count affects the polymorphonuclear leucocytes exclusively, which
often fall as low as 35 per cent. The most important blood feature,
however, is the absolute or relative increase in the number of lympho-
cytes. This lymphocytosis may reach 57 per cent. Such are the blood
changes in hyperthyroidism, and they are notable especially in the height
of the disease. w
There are two further observations worth recalling—observations
which demonstrate again, if such demonstration were needed, the imme-
diate relation of Graves’ disease to thyroid activity: Overdosing with
thyroid extract a normal person will produce in him symptoms of
Graves’ disease, while, conversely, the enlarged thyroid of Graves’ dis-
ease may be made to atrophy by ligature pressure, with a resulting
relief to the symptoms of hyperthyroidism. .
While we may not look for a regular and definite histological pic-
ture in Graves’ disease, still there are certain varying characteristics
always present, changes in the cells which produce the excess of secre-
tion; there are more cells than normal in the alveoli; there are more
alveoli; in existing colloid goiter there is a papillomatous increase of
cells. Later, when there occur those retrograde changes which I have
named,—changes leading at times to myxedema, there are often
associated terminal degenerations of vital organs and structures—the
heart and nervous system.
As we come to understand such manifold histological changes, we
come to recognize also the futility of looking always for the classical
symptoms of Graves' disease in order to establish a diagnosis. Bulging
eyes, thyroid tumor, rapid pulse, tremor, are not always and equally
conspicuous. The tumor may be trifling and the eyes may be normal in
GRAVEs’ DISEASE 55
appearance when first examined. Let us consider the symptoms, then,
upon which we may establish a diagnosis: Palpitation” is the com-
monest early symptom. Then comes slight enlargement of the thyroid,
but this often follows long after the patient has complained of palpita-
tion and dyspnea. Usually there is a thrill over the thyroid, and a
systolic murmur is commonly heard over the gland just above the right
sternoclavicular articulation. Goiter is not an essential sign, however.
Tachycardia is almost always present, associated with the palpitation;
and various irregular circulatory signs may be seen, cush as pulsations
and flushings.
There are the signs shown by the eyes also, signs which appear
rather late and last the longest. There is the exopthalmos, to be sure,
but there are those other useful signs too little regarded: Stellwag's
sign, widening of the palpebral fissure; Von Graefe’s sign, lagging of
the upper lid; Kocher's sign, lagging of the lower lid; Moebius's sign,
diplopia for near work; Landstroem's sign, recession of the lids when
fixing the eyes upon a near point.
Finally, there are the signs and symptoms shown by the nervous
System: the anxious face, pallor, tremor—tremor of all the extremeties
even ; I regard this tremor as one of the most important symptoms.
There are further signs of disease in other organs often, in the
kidneys especially, and in such ductless glands as the ovaries and testi-
cles, while the state of the skin and sweat-glands is suggestive.
We must be on the lookout for Graves' disease. It is common
enough to those whose eyes have been opened.
The foregoing reflections are prefatory. The natural history of
Graves' disease is a subject of serious interest to all physicians, to
internists, surgeons, gynecologists, laryngologists, ophthalmologists,
all of us, yet it is a disease singularly misunderstood by most of us,
while its treatment is still a matter of widespread skepticism. Although
the do-nothing attitude of previous years is still seen among large num-
bers of general practitioners, one finds, on the other hand, a keen and
almost rabid activity among certain Surgeons and medical investigators
regarding diverging methods of treatment. Surgeons often maintain
that the one course to follow in Graves’ disease is extirpation of the
thyroid gland, or, in some cases, ligature of the vessels, while certain
internists insist upon various forms of medication. Both groups of
men, surgeons and internists, show astonishing figures, with enormous
percentages of cures. What shall we say to them?
The unprejudiced physician may well be bewildered in the midst
56 GRAVES’ DISEASE
of the conflicting claims and find himself at a loss when face to face
with a given case of Graves’ disease. Shall he use a serum, or shall he
resort to thyroidectomy?
The men most active in this controversy—if so it may be called—
are leaders of the profession, Sound, serious, reliable physicians and sur-
geons. This fact makes the choice between them the more difficult, and
leaves one almost with the feeling that some explanation other than
statistics and figures is necessary for us before judging of their respec-
tive claims.
Let us take up briefly, then, some of the statements and figures of
those who affirm that Graves' disease may be cured by medicine or
Similar means—by drugs and by Sera. So long ago as 1884 the experi-
menters, Calzi, Fano and Zanda, treated dogs deprived of their thyroids
by the transfusion of blood from normal dogs, and the treatment seems
to have been successful. Later Vassale succeeded in relieving the
symptoms of myxedema in dogs with an extract of thyroid gland
injected into their veins. This was the beginning of serum therapy in
cases of Graves’ disease. It is needless to follow in detail the great
amount of work, and the names of those who performed it, on this
fascinating topic. Glancing rapidly down the list, however, we find
that in 1906 Rogers and Beebe, of New York, published an important
contribution on the subject in the Journal of the American Medical
Association. These investigators prepared a serum by grinding to a
pulp the normal thyroid gland, making an extract with normal salt Solu-
tion and straining. Treatment with acetic acid produced a heavy pre-
cipitate of nucleo-proteids. It is needless to dwell on the technic of
their method; suffice it to say that the precipitates obtained were com-
bined and injected while fresh into rabbits. Subsequently the rabbits
were bled to death and sera were obtained from their blood. Various
sera were secured in this fashion, and four patients, victims of Graves’
disease, in that year were treated by injections of these sera. Three of
the patients recovered perfectly and promptly, while at the time of writ-
ing the fourth patient was improving. When this report was made it
was accompanied by the statement that the initial dose of the Serum was
5 minims, which gradually was increased to IO or 15 minims. The
writers state further that the remedy must be used with great care, but
is capable of producing remarkable results. Here at the outset of the
work of these investigators were cases So Striking that they seem to
settle at once the question of serum therapy in Graves' disease.
Let us inquire briefly regarding the Subsequent work of Rogers
GRAVEs' DISEASE 57
and Beebe. Their fundamental proposition assumes the presence of an
active intoxication, due to the Secretion of the thyroid gland itself, a
proposition which most physiologists now recognize as Sound,-while
their method of treatment consists in fighting the intoxication by injec-
tions of an antitoxic serum. With the development of their work,
Rogers and Beebe have come to divide their cases into two general
classes (those favorable to serum treatment only, and those which may
require what they call a combined treatment). The first group of cases
includes the class of frank, active Graves' disease, in which hyperplasia
of the epithelial cells of the gland is taking place. In other words, their
first class includes the early typical cases. In these cases the experi-
menters obtain their best results. Many of the patients progress imme-
diately and promptly to entire recovery, while others recover symp-
tomatically, perhaps with their exophthalmos and their goitre the last
signs to disappear.
In their last report “Rogers and Beebe report 227 patients of the
first class, the acute class, with about 30 per cent, cured of subjective
Symptoms, about 50 per cent. improved, and about 20 per cent, unim-
proved, of whom Io per cent. died.
While such are the results in favorable cases, we can scarcely expect
equally good results in those cases which require the combined treat-
ment. This second class of cases are those in which hypothyroidism
and hyperthyroidism co-exist; that is, the transition cases which I
describe in an earlier part of this writing. The treatment in these cases
consists in giving sheep-thyroid proteid, while the abnormal products of
the patient's own gland are neutralized by the serum. The writers
state that each case must be studied and treated on its own merits.
This is not a very encouraging showing. In a later paper, published
in the Annals of Surgery for December, 1909, Rogers gives further
figures. He states that at that time he had had 480 cases, representing
all stages of Graves' disease. Of these he had cured by Serum I5 per
cent., while Io per cent. more had no subjective symptoms, though they
retained the goiter and occasionally showed exophthalmos; about 50
per cent. were improved,—by which he means that after a month or
two of treatment, with alleviation of symptoms, the patients passed
from observation; about 17 per cent. were unimproved, and 8 per cent.
died from the disease. Rogers remarks, cogently, “These statistics
emphasize the gravity of the prognosis of what is commonly believed to
be a benign affliction.”
Let us compare with the statistics of Rogers and Beebe the results
obtained by Jackson and Mead in their surprising series of cases at the
58 GRAVES’ DISEASE
Massachusetts General Hospital clinic.” These writers published two
years ago a striking and encouraging paper. They had come upon the
report of Forchheimer, in which that physician advocates the use of
neutral hydrobromate of quinine in the treatment of Graves' disease.
Jackson and Mead treated 85 cases with this drug and are enabled
to report gratifying results. They insist that the salt should be neutral
—a condition difficult to obtain—and they give it in 5 gr, capsules
three times a day. Here is their striking statement: “Usually after a
week or two of treatment the pulse-rate will be slowed, the thyroid
diminished and the Sweating and tremor lessened. It should be con-
tinued until all the symptoms have disappeared, which may be in four
months or as long as three years.” The rapid heart quiets down first,
then the Sweating disappears, then the thyroid gland shrinks and finally
the exophthalmos and the tremor subside, though these last two persist
longer than the other symptoms, as we have found in studying all cases
of cure by whatever means. The writers state that relapses are not
uncommon, but that they yield quickly to treatment if taken promptly.
They advance no theory as to the action of the quinine, though they
suggest that the drug probably is antitoxic to the poison which flows
from the hyperplastic gland.
The further report of results in the cases treated by Jackson and
Mead is interesting and stimulating. Here is a résumé of their figures:
They divide their statistics according as they have heard from their
patients by letter or have seen them personally. They have heard from
29 of their cases by letter; 20 of the 29 are practically well symp-
tomatically; 7 are unimproved; 2 are dead. In other words, 69 per
cent. of these cases heard from by letter regard themselves as cured.
While the reporters include the 29 letter-cases in their lists, they
dwell at greatest length on the cases which they themselves have ex-
amined after a lapse of time. They have seen and examined 56 such
cases; of these 56, 42 (75 per cent.) are cured ; that is to say, they have
no signs or symptoms of the disease after two years; 7 of the cases are
improved, 13 per cent; and 6 cases are no better, II per cent. None
of these 56 inspected cases have died.
The writers state frankly: “While we cannot claim that these
cures are permanent, yet these patients are sufficiently well to be with-
out signs or symptoms, and to perform their customary work in life;”
and they modestly remark further, “We have been very well satisfied
with the results obtained. . . . In extreme cases, with pathological
changes in the heart, a cure can hardly be expected, but we have seen
marked amelioration of symptoms following this treatment.”
GRAVEs’ DISEASE - 59.
The Sound, accurate and conservative paper of Jackson and Mead.
has received too little attention. Their good results are far the best I
have seen reported from any medical clinic. As is the case with all the
results of medical treatment in Graves’ disease, the permanency of a
cure is always open to doubt; time must elapse to decide this per-
manency, but a priori one feels that in spite of the successful dosage
the underlying cause of the disease remains in the thyroid gland itself,
which may at Some future time be roused into renewed pernicious
activity.
The reports of Rogers and Beebe, and the report of Jackson and
Mead, represent the only strictly medical methods of treating Graves’
disease that are worth considering among us at present. The two
methods of treatment show extraordinarily divergent results, though
one feels that a longer series from Jackson and Mead would be accept-
able. There are other methods of non-operative treatment which some
among us still follow, notably the use of the x-rays. I am convinced,
after a careful study of x-ray treatment in Graves’ disease, that it is
of little or no benefit, except occasionally in lessening symptoms prep-
aratory to operation. -
The operative treatment of Graves' disease, especially partial
thyroidectomy, has against it one notable and constant objection,-the
operation may kill. That is a consideration which is always shocking
to the patient and to her friends, though I doubt if the immediate death
from the operation for Graves’ disease is any more grievous to con-
template than the immediate death from other operations. The fact
probably is, one cannot help but feel, after an operative death in Graves’
disease, that possibly medical treatment might have cured the patient,
or at least have rendered needless the operation. The operative treat-
ment of Graves’ disease is not a new thing. So long ago as I886
ligature of the thyroid arteries was recommended by Woffler and has
been practiced by many surgeons since. Thyroidectomy, or, properly,
partial thyroidectomy, was first performed purposefully and intelligently
by Julius Wolff, of Berlin, in 1887, though other operators, including
Lister, had more than once removed the thyroid gland during the ten
years previous to 1887.
It is needless to discuss at length the operation of ligature of the
vessels, except to say that it is a useful procedure in many cases in
which the desperate condition of the patient renders thyroidectomy
impossible, or when the surgeon thinks fit to do the mild ligature opera-
tion as a preliminary step to the more serious thyroidectomy. All Sur-
geons experienced in thyroid operating to-day employ the ligature at
6O - GRAVES’ DISEASE
times, but advisedly and purposely, recognizing that the operation is
preliminary or palliative. Three years ago Heineck” published a
valuable résumé of published operative work done up to that time on
Graves' disease, 519 cases, an extremely informing essay. A number
of these cases were treated by ligature, with the result that certain facts
regarding the safety of the ligature were developed. It appears that
the ligature of two vessels suffices for the purpose in hand,-ligature of
both of the superior thyroid vessels, or ligature of the superior and
inferior thyroids of one side. Three ligatures have been followed by
serious trouble, while four ligatures, that is, the tying off of both the
superior thyroids and the inferior thyroids, have brought about destruc-
tion of the gland by necrosis, with tetany as a result of cutting the blood
supply to the parathyroid glandules.
Passing over this question of ligature, however, which one cannot
but think of as an inferior procedure, it is interesting to consider the
development of thyroidectomy, especially in this country. So long ago
as 1903, Huntington of San Francisco published an essay in the Annals
of Surgery on his experiences with partial thyroidectomy. He quoted
the cases collected by Starr, in 1896, with a 12 per cent, mortality, and
the cases collected by Kinnicutt, with a 7 per cent, mortality. Hunting-
ton himself showed excellent results from the operation in his four
reported cases at that time, and told of Rixford's 81 per cent. of cures,”
commenting also on Kocher's 5.6 per cent, mortality, with 90 per cent.
of cures. Other surgeons, some well known, some obscure, report series
of operations, with increasingly good results. A good recent collection
is that of Zapffe,” who recalls the paper of Alber Kocher,” reporting
254 cases of Graves' disease, with a mortality of 3.5 per cent, and 83
per cent. cured; Krecke” collected 888 cases from various clinics and
reported a mortality of 9 per cent; Klemm” reported operating on 32
patients, with no deaths; after eight years 78 per cent. were still well:
Garre” reported 35 cases, 20 of which were traced after five years and
showed excellent results, while by compiling statistics from various
clinics he ascertained that 85 per cent. of the patients of those clinics
were cured by operations. Again, in March, 1909, Albert Kocher
reported 32O cases of Graves' disease operated upon, with II deaths—
3.4 per cent. C. H. Mayo in his last 200 thyroidectomies had a mor-
tality of 5 per cent; 70 per cent. of his cases were cured and 19 per
cent, were improved; 5.8 per cent. were slightly improved, 5.2 per cent.
were not improved. That is to say, the percentage of failures in this
list of cases was extremely small. In this connection Mayo, like Jack-
son, reminds us again that many patients will not recover good health
GRAVEs' DISEASE * 6I
since the disease has been the cause of various terminal degenerations
before the operation was performed. A few suffer from hypothyroid-
ism or myxedema, the result of the destruction or loss of Secreting
epithelium. Operation in these cases will merely religve pressure
Symptoms. iº
Such figures are striking, but are they satisfactory and final? I
have searched carefully reports from Surgical clinics, and I regret to
say that many of the reports are partial and general in their nature,
while of the frequent discursive papers which have been written at
least one-half dwell on the operative mortality merely, and the recovery
from the operation, but say little of the results one, three and five years
after the operation. Accurate final figures are extremely important,
however; they must be collected and borne with if we are to reach final
conclusions in our investigation.
I have spoken of Heineck's valuable report of 519 cases. An
analysis of these cases, however, shows that we must accept as a basis
for end conclusions but 207. Two hundred and seven out of the 519
are reported in such detail that we learn the positive facts regarding
five vital points: (1) The number of operative deaths; (2) the num-
ber of late deaths; (3) the number of patients not improved; (4) the
number of patients improved; (5) the number of end cures. These
cases reported by Heineck are frcm a great number of clinics, which I
need not name here, clinics producing the best work in Europe, as well
as America.
Allow me, then, to present the following table, made up of the
reports collected by Heineck, and additional reports from seven other
operators. This table does not represent by any means the total avail-
able statistics on thyroidectomy. I have not endeavored to collect all
the cases reported, but I collect here and report enough cases to demon-
strate the value of the operation.
Number Operation Late Not End
of cases deaths deaths Improved Improved Cures .
Huntington, 1903, 4 None None . . . . . . . . . . . . 4 (IOO9%)
F. Curtis, IQo6, IO None None I (Io9'.) I (10%) º
Schultz, 1906, 5O 6 (12%) 1 (2%) 6 (12%), 1 (2%), 36 (72%)
Heineck, 1907, 2O7 13 (6.2%) 7 (3.3%) 50 (24.1%) 5 (2.4%) 132(63.7%)
Kocher, 1907 254 (3.5%) None (11%) (2.5%) (83%)
C. H. Mayo, 1908 177 Io (5.6%) None 32 (19%) 9 (5.2%) II6 (70%
Slightly
improved
(5.8%)
McCosh, Igo&, 2O I (5%) None 14 (70%) I (5%) 4 (20%)
Mumford, 1910, IQ None None 5 (26.3%) None 14 (73.7%)
74 I 4.03% o 66% 22 27% 3.38% 7o 3%
62 GRAVEs' DISEASE
The total results brought out by this table are large enough to
challenge attention and conviction. Here are 74I well-authenticated
cases, traced for more than a year, some few of them for as long as
fourteen years. The operative mortality shows an average of 4.03 per
cent, and that is an operative mortality higher than we are getting to-
day, with our improved technic and our greatly improved knowledge
of the disease. A few years ago operators attacked blindly these cases;
to-day they operate on properly selected cases only. The total number
of cures, with a percentage of 70.3 is good, though that is a percentage
lower than experienced operators have been getting during the past two
years. Yet figures are of little value, after all, in estimating the results
obtained by operating in Graves' disease. As Crile” says truly: “A
study of my series of 72 operations for Graves’ disease, presenting as
they do numerous and complex symptoms, and involving many organs,
as well as the most fundamental vital processes, impresses me with the
great, almost unsurmountable difficulty, I may add the impossibility, of
compiling any statistical table that accurately represents the net clinical
results. . . . I conclude, therefore, that, in the light of our present
knowledge, the results in these cases are incapable of anything like an
accurate statistical treatment.”
I have no intention in this paper of discussing the technic of
operations, especially the methods employed for avoiding shock and
controlling hemorrhage. I cannot forbear, however, from recording
here my appreciation of Crile's wise suggestion that we improve our
Operative Statistics by regarding and meeting the psychic factor in
Graves' disease. Crile's work on this psychic factor is well known;
it amounts to this: that, recognizing the extreme danger of bringing
to the operating table a patient terrified at the thought of operation,
a patient whose thyroid gland is in an unusual state of excitability and
is pouring toxic products into the circulation,-recognizing this danger,
Crile has shown the wisdom of “stealing away” the gland; drugging
the patient to such an extent that she does not appreciate the advent of
the operation, nor does she realize the taking of the anesthetic. To
promote this object Crile is using extensively heavy dosing with
bromides and with morphin and scopolamin, two hours before
the operation. Whether the actual operative anesthetic be gas and
oxygen, or ether, I believe is of small moment; whichever anesthetic is
used, the morphin and scopolamin have rendered the patient indifferent
to its employment. *
I have laid before my readers the evidence in the treatment of
GRAVEs’ DISEASE 63
Graves’ disease. I see no advantage in an elaborate argument by coun-
sel. It is interesting, however, to recall the clinical picture of a patient
recovering from partial thyroidectomy for Graves' disease: The pulse
rate falls—within three or four days it frequently approaches a normal
rate and rhythm ; the tremor subsides; sweating disappears; the diges-
tive organs reassert themselves; placidity supplants terror and anxiety;
refreshing and long-continued sleep is experienced; good color and
good appetite return; and constantly one sees, within ten days after
the operation, the patient appearing in better health than for years, she
will say, and astonished at the wonderful and rapid improvement in
her own appearance and feelings. The eye symptoms are the last to
mend; sometimes the eyes remain unchanged for many months; but in
the end the eyes also return to more nearly normal conditions. Watch
one of these patients for a series of years—for three, five or seven
years. One of the most interesting facts in surgical therapeutics is
the steady improvement which these patients show. They feel well at
the end of two weeks; they feel better at the end of two months; they
regard regard themselves as well at the end of six months; at the end
of a year there is still perhaps some exophthalmus and tendency to
palpitation; at the end of three years all symptoms of Graves' disease
lmave vanished and the patients are as well as ever in their lives.
Briefly, let me summarize this paper, with the urgent and final
reflection—Graves’ disease must be actively treated, for in the great
majority of cases it can be cured.
SUMMARY.
I. Graves’ disease is due to abnormal activity of the thyroid
gland. sº
2. In advanced Graves' disease, degenerative changes in the
thyroid gland, may lead to a shifting symptom-complex, ending at last
in the positive signs of myxedema.
3. The histology of the gland in Graves' disease indicates shift-
ing, advancing and retrograding symptoms.
4. An enlarged thymus is nearly always found post mortem in
patients dead of Graves’ disease.
5. Advanced Graves’ disease may exist without the presence of
all the classical symptoms.
6. Graves' disease can nearly always be cured if taken early.
7. The sera of Rogers and Beebe cure a goodly percentage of
C2S6S. -
8. Through hydrobromate of quinine (neutral), as used by Forch-
64 - GRAVES’ DISEASE
heimer and by Jackson, we find a great percentage of improvements
and of cures. It is a pity so few cases have been reported.
9. The great and increasing experience of qualified operators is
showing that more than 70 per cent. of Graves’ disease patients are now
being cured by partial thyroidectomy, and the percentage of such cures
is rising.
Io. Treat the cases seen early by rest, by sera and by hydrobro-
mate of quinine; if no improvement results in two months, operate by
thyroidectomy, and always regard the operation as the surest cure.
REFERENCES
I Basedow's disease, Graves’ disease, exophthalmic goiter, and now comes C. H. Mayo insisting that
we say “Hyperthyroidism,” because that word only is truly descriptive of the ailment. It's all true but
familiar terms stick. We can’t make people adopt the metric system, or use the word celiotomy; nor will
they substitute for Graves’ disease the sonorous “Hyperthyroidism *
2 Surg., Gynec, and Obst., June, 1909, p. 588.
3 Trans. Am. Surg. Asso., vol. xxvii, 1909, p. 56.
4 Józd., p. 69.
5. Rothschild and Leopold Levi (Bull. de l'Académie de Medecine, Paris, 73-20, page 583) discourse on
thyroid instability and on hyperthyroidism converted into hypothyroidism. During this metamorphosis a
curious and contradictory variety of symptoms is observed which may be controlled variously by varying
thyroid-extract dosage.
6 See an admirable discussion of theories by A. P. Heineck: Surg-, Gynec, and Obst., vol. v., 1907,
p. 623. -
7 Ward: G. G., Surg., Gynec, and Obst, December, 1909. p. 615.
8 Idem., p. 628.
9 Trans. Am. Surg. Asso., 1908, p. 398.
Io Münch. med. Wochenschr., vol. xxxv, 1908.
11 See also Axel Werelius: Jour. Am. Med. Asso., July 10, 1909, p. 175.
12 Jackson J. M. and L. G. Mead : Boston Med. and Surg. Jour., March 12, 1908.
13 Arch. Int. Med., Nov. 15, 1908.
14 Jackson J. M. and L. G. Mead: Boston Med. and Surg. Jour, March 12, 1908.
6 15 Heineck, A. P. : Surgical Treatment of Exophthalmic Goiter, Surg., Gynec, and Obst, vol. v., 1907,
p. 623.
16 Huntington, T. W.; Ann. Surg., vol. xxxvii, 1903, p. g. Y--
17 Zapffe, F. C.: The Surgical Treatment of Exophthalmic Goiter, Surg, Gynec, and Obstet., vol. x,
p. 30o, IQIo. *
18 Jour. Am. Med. Asso., Oct. 12, 1907.
19 München. med. Wochenschr., Jan. 5, 1909.
20 Arch. für klin. Chir., vol. lxxxvi, no. l.
21 Presse Méd. Feb. 20, 1908.
22 Post-Operative Results in Exophthalmic Goiter and Tumors. Lancet-Clinic, Feb. 5, 1910.
THE ECONOMIC ASPECT OF TUBERCULOSIS
BY
EDWARD F. MCSWEENEY
Chairman Board of Trustees, Boston Consumptive Hospita/
I come, not like the bard in the old nursery Song, to sing a song-of-
sixpence, but to intone a dirge for millions of dollars lost every year
through the failure, because of ignorance or neglect, of those charged
with the responsibility of building the community towards better health,
longer life, increased happiness and more prosperity, to do their duty.
James Bryce said that the government of municipal administrations
was the conspicuous failure of American democracy. The administra-
tion of health work by municipalities in practically all the States is,
with few exceptions, generally the worst and most inefficient feature
of city governments, and for this state of things the medical profession
must share a large burden of the responsibility.
The greatest asset of any country is the vital efficiency of its
citizens; disease has always been one of the great foes of mankind. A
well man is more susceptible to the influence of teaching than is a sick
man, and because of this it follows that the conservation of man's
physical resources is one of the first duties of the state. Preventable
death, preventable sickness, preventable conditions of low physical and
mental efficiency, and preventable ignorance are the four great human
wastes of our time, all playing their part in a cruel destruction almost
incredible.
It is self-evident that all deaths cannot be postponed or all illness
prevented. Seventy years ago the great educator, Horace Mann, made
an inquiry into the preventable waste from sickness and disease in
Massachusetts, and even at that time the medical men gave it as their
opinion that one-half of the existing sickness was preventable. With
the increase in medical knowledge during the last fifty years this per-
centage of preventable sickness should have decreased, but the best
authorities still believe that one-half of all sickness is still unnecessary
and avoidable. Pasteur said that all parasitic diseases could be exter-
66 THE EconoMIC ASPECT of TUBERCULOSIs
minated if man could be educated to take the necessary means to this
end, but while the medical profession are divided into different hostile
camps, each wishing to assume full charge of the crusade and health
boards, think more of their political jobs than they do of the health of
the people whom they are sworn to serve, the business man naturally
considers that the condition is one in which he cannot interfere. Until
the physician seeks and obtains the co-operation of commerce and
industry in this fight, it will never make real progress, because, after
all, the question is an economic one and to be approached from that
base. .
The increased vital efficiency of the citizens of any state which
would result if the fight against disease was organized properly, would
increase the income of the wage-earners by adding to their yearly
productiveness the time now lost in illness; it would in addition
relieve their families, friends or the state of the burden of caring for
them while ill; as I shall try to show, this loss of preventable disease
and death is one of the factors in the cost of living, which, when prop-
erly understood and intelligently fought, will lift a burden from the
shoulders of mankind, prolonging life, increasing productiveness and
adding to the world's happiness.
Human life, capitalized, is the most important asset of the world.
Every time an individual is taken out of industry by sickness an
economic unit on which prosperity depends is temporarily or perma-
nently destroyed, and the wealth of the state to this extent reduced.
There is a physical basis of citizenship as there is a physical basis of
life and health. Given a sound body we shall have small fear that
there will not usually result a sound mind, but it is surprising that the
physical basis of effective citizenship has hitherto been so utterly
neglected in this country. Medical men, more than any other class in
the community, should have full appreciation of the heavy financial
burdens of disease upon the family and the community, and the things
that might, and should, be done to prevent this loss.
Let us try to find what this loss is for the State of Rhode Island
and the city of Providence as far as it can be estimated. The figures
we quote are based on the work of the Committee of One Hundred on
the Conservation of National Health, compiled by Professor Irving
Fisher, head of the Political Economy Department of Yale University.
These estimates are based largely on the public health reports of
Massachusetts, a manufacturing State, which can be compared fairly
well with Rhode Island.
THE ECONOMIC ASPECT OF TUBERCULOSIS 67
Considering tuberculosis alone in Rhode Island, according to the
present ratio of deaths from this disease to the total death rate, more
than 50,000 people now living in this State are doomed to die of this dis-
ease. Applying the statistical results according to population of the com-
munities in this country and Europe where investigation of this subject
has been made, there are probably I5,000 people in Rhode Island, 5,000
of whom, who are in Providence, at present afflicted with tuberculosis
in one stage or the other.
In 1908 there were in Rhode Island 1,044 deaths from tuberculosis.
Each of these deaths represents a money outlay for loss of wages,
doctors' bills, attendance, medicine and, in addition, the potential loss
to the community of their wages capitalized for the amount of time the
lives were cut short. The shortening of life because of preventable
disease is an enormous economic loss to the State. Serious sickness is
that which is of such a nature as to prevent persons from doing any
work. The most reliable estimate as to loss of time due to sickness has
been made by William Farr. He found that, generally speaking, there
are about two persons seriously ill during the entire year to each person
that dies in the course of the year. Applying this estimate to the
number of deaths in Rhode Island for the year 1908, we have I6,534
as the number of persons constantly seriously ill in this State during
that year. This means that an average of two weeks at least are lost
each year because of serious illness by each inhabitant of the State.
About one-third of this number of sick people are in the working period
of life. This would mean that 5,511 persons in Rhode Island were
out of employment because of sickness in the year 1908. Assuming
that of these 5,511 persons in the working period of life only three-
fourths actually worked, the remainder being supported by others or
by income from capital, this would leave in Rhode Island 4,133 wage-
earners actually taken from employment during the entire year.
Estimating the earnings of these to average $525 a year, the loss in
earnings alone because of serious illness in Rhode Island in 1908 was
$2,169,825. -
Of economic importance also is the cost of medical attendance,
nursing, drugs, etc. The United States Commissioner of Labor in
1903 estimated that the cost per workingman's family for illness and
death was $27 per annum, but in the opinion of the Committee of One
Hundred on National Health this is only about one-third of what the
actual loss is; $75 a year per family would probably come nearer the
truth. Accepting the Bureau of Labor figures, and allowing IOO,OOO
68 THE ECONOMIC ASPECT OF TUBERCULOSIs
families in the State of Rhode Island, the minimum loss from serious
illness spent for medical attention, nursing, drugs, etc., would be about
$2,700,000, which, added to the cost of loss of earnings, would bring
the economic loss to wage-earners to $4,869,825 a year. From my
work in this line in Boston, I believe that this is not one-third of the
actual loss.
Every writer and authority on the question of preventive medicine
agrees that up to 50 per cent. of this sickness is preventable by intelli-
gent action, so that this means, on the minimum basis, that there is a
yearly loss to the wage-earners in Rhode Island, which could be pre-
vented, of at least two and a half million dollars, and this does not
include the economic loss from deaths,
No money value can be placed on the economic value of the
individual human life, but it is possible to calculate with considerable
accuracy the average economic value of a large number of lives. The
usual method is to estimate the income received by the average man
and deduct the cost of caring for him during infancy and old age.
This net income is capitalized, and from this the value at different
ages is found. Professor Fisher, by working out William Farr's tables
on the basis of the average earnings in the United States, estimates
that the average economic value of each of the inhabitants of the United
States is $2,900. The average economic value of each of the lives now
sacrificed by preventable deaths is $1,700. These are valuations for
the economic life and not estimates of the yearly income. By apply-
ing these estimates to the statistics of deaths in Rhode Island for
I908, it is possible to realize the enormous money loss to the citizens
of the State because of the failure to conserve the vital efficiency of
its citizens in the best possible manner. Rhode Island to-day has an
estimated population of 531,OOO. Multiplying this by the economic
value of each inhabitant of the State, we get $1,539,900,000 as a
minimum estimate of the vital assets of Rhode Island.
Taking 42 per cent, as the accepted percentage of deaths that
might be postponed by proper action by the State, and applying this
to the 8,267 deaths in Rhode Island in 1908, we get 3,472 as the num-
ber of deaths that might have been postponed if proper methods of
prevention and cure were in vogue. Using $1,700 as the economic
value of each of these lives unnecessarily shortened, we find the loss
to Rhode Island because of preventable deaths as being $5,902,400 in
1908.
THE ECONOMIC ASPECT OF TUBERCULOSIS 69
A summary of the estimated loss in Rhode Island because of pre-
ventable serious sickness and deaths in 1908 is as follows:
3,472 postponable deaths, valued at $1,700 each. . . . . . . . . $5,902,400.00
4,133 persons seriously ill during year, 50 per cent. of
whose illness could be prevented and who would earn
$525 each during the year if well. . . . . . . . . . . . . . . . . . I,084,912.50
$2,700,000 cost of illness, 50 per cent. preventable. . . . . . . I,350,000.OO
$8,337,312.50
No accounting is made in these figures as to the loss of wages or
the cost otherwise because of drunkenness, undue fatigue, pauperism,
crime, etc., but it is certain that the damage from these amounts to
much more than the loss as given above for illness. The size of these
figures will seem excessive to those who have never thought of the
1matter. To say that eight and a half million dollars could be saved
yearly in Rhode Island, and I2.3 years added to the average lifetime,
seems startling, but these figures are constructed from minimum esti-
mates of the best qualified authorities in the world, who have given
years of study to this matter, and if their maximum estimates had been
used, the figures would have been two or three times as large.
The old belief was that sickness was inevitable, and the doctor a
necessary evil of life, to be called in after the patient was stricken.
Disease in the old theory was like earthquakes, tidal waves, lightning,
etc., and due wholly from visitations from the Almighty and to be
borne with meekness and humility. We now know, however, that
religion, Science and business are in accord as to the need of the
preservation of health. Religion commands it because it means clean-
liness of mind, morals and body; science because it has learned how,
and business because it has now wakened up to the tremendous money
loss of sickness and death, and the economic advantages of pushing
the health economic policy. This crusade of health is older than the
Christian era, and the Jews were its first prophets. Most people who
know the Ten Commandments by heart do not know that the children
of Israel received from Moses at least ten other commandments as
binding upon them as those written upon the two tables of stone. The
sanitary regulations which governed the great camp of the wandering
Israelites will serve as models for use in our health work to-day. These
lealth laws of Moses are scattered through the Books of Exodus,
Leviticus and Deuteronomy. The first health law of Moses was “Be
Clean,” and even before the people were allowed to draw near to listen
70 THE EconoMIC ASPECT OF TUBERCULOSIs
to the Ten Commandments, they were directed to purify themselves
and wash their garments, and all tents and houses were obliged to be
kept from defilement. Moses also preached to the people to keep the
air they breathed clean, and so everything that could taint the air was
carried outside the camp and burned or buried. He said to them that
they must be clean in their food, their personal habits, their life and
morals; and to be temperate in their lives. This is in effect the aim
of all the health agitation of to-day, and if we could obtain these desired
ends, mankind would immediately be freed from one-half of the
physical ills which now beset it.
As I have said, the future of preventive medicine, and the greater
part of the work of medical science, will be directed to this end in the
future; to stop mankind from becoming sick, instead of devoting their
whole time to curing him after he is sick, and to solve this problem the
doctor must depend upon the help of the merchant, the manufacturer
and financier. The surroundings of the great mass of the people are
rarely of their own choosing. Economic, social and climatic features
determine largely the selection of village, town and city, and, if owing
to the condition of the soil or drainage, these are not healthy, the
wage-earner is practically helpless; the rich can always, of course,
choose their residence with due regard for its Sanitary surroundings.
Because, therefore, the wage-earner is bound to follow his opportunities
for employment wherever they lead, it becomes the duty of all the
public to safguard these surroundings as much as possible.
No class of professional men in the world give more of free
services to the community than do the medical profession. The average
compensation of medical men throughout the whole country is to-day
less than $600 a year, and in populous and wealthy States, like New
York, Massachusetts and Rhode Island, the average annual income of
doctors is estimated as being under $1,200 a year. Assuming that the
reduction of disease would still further reduce the physician's income,
and this is probably not true, because in the future the physician will
probably receive greater financial rewards than ever before for keep-
ing mankind well and not depend on his income for curing him after
neglect and ignorance have dome their worst, I firmly believe that the
right kind of doctor, and most of the ones I know are of this kind,
would still welcome the change. As a matter of fact, however, it is
not preventive medicine, but the abuse of medical charity which has
all but pauperized the medical profession. It is estimated that in New
York city from three to five thousand people who could pay their
THE ECONOMIC ASPECT OF TUBERCULOSIS 7I
physicians a fee are treated free in hospitals every day. It is estimated
that five hundred persons a day in Boston receive free medical care
for which they are able to pay. This form of petty larceny is more
contemptible than picking pockets, because the pickpocket has a form
of courage lacking in the fraudulent applicant for free medical treat-
ment, who not only steals from the city and the doctor, but takes the
time which should be given to the actually needy poor.
To the cost of sickness and death must be added a part of the cost
for crime, insanity and pauperism, because these are due more or less
to bad and unsanitary health conditions. The average taxpayer does
not feel the cost of disease or dependence, because he has no way of
knowing how much he pays for them. The Massachusetts Commis-
sion to investigate the reasons for the recent advance in the cost of
living, of which I had the honor to be a member, worked out for the
first time, as far as I know, the yearly cost to public and private charity
of the paupers, criminals and insane persons in the State. We found
more than $19,000,000 a year was spent directly in Massachusetts for
these three classes of dependents, amounting to a tax on each family
in the State of $30 a year. I have no doubt that an equal burden is
imposed on every family in Rhode Island. One-tenth of all the taxes
paid is spent to punish criminals many of whom have been started on
their downward career because of a poor physical condition which
Sane methods of treatment by the State might have done much to pre-
vent. The progress of preventive medicine will reduce the dependent's
bill on society by at least one-half.
What is the duty of the medical men in this matter? His financial
condition cannot be made much worse than it is to-day. The induce-
ment for the young men to go into the medical profession is far from
attractive, but much of this is the fault of the doctors themselves.
Doctors have been notorious for their opposition to the improvements
in medical science. The justification of this was doubtless due to the
fact that human life is too precious to be played with, but this opposi-
tion has gone far beyond the limits of proper conservatism, and since
Harvey's time, and probably before, practically every reform in medi-
cine and surgery has met its greatest obstacle in the medical profession.
The result of the withdrawal of the medical man into his professional
shell has enabled the faker and the charlatan to grow rich on the credu-
ity of human kind, and the constant squabbles between various branches
of the medical profession has made the layman indifferent to, if not
suspicious, of their work. Professor Sedgwick of the Massachusetts
72 THE EconoMIC ASPECT OF TUBERCULOSIS
Institute of Technology said not long ago that in the anti-tuberculosis
movement the medical profession has for the first time thrown off its
ancient mantle of professional exclusiveness in dealing with a medical
problem and inviting the public to share with them all of their profes-
sional knowledge—or otherwise. When we can bring this same feeling
by medical men into the fight for the other preventable diseases, includ-
ing sexual diseases, the misery and expense bill for which is almost, if
not quite equal to, that of tuberculosis, a great upward step will have
been made.
The result of this professional exclusiveness, the attempt to
monopolize everything that appertains to disease, is shown in various
ways, the present most conspicuous example being the indifference of
the public to the attack of the Christian Scientists and others at Wash-
ington against the proposal to create a department of public health.
Every such measure can be criticised in spots, but generally speaking,
this is one of the greatest reform movements of our time. We know
that tuberculosis has been cut down by one-half in thirty years and by
one-third in ten years; that cholera has been stamped out of our south-
•ern cities, yellow fever out of Havana and Panama, the hook-worm
parasite is being fought and prevented in Hawaii, Porto Rico, Cuba
and even in our own country; the sources of the bubonic plague have
been practically located and a remedy probably found; that typhoid is
an inexcusable disease and under proper sanitary conditions would
never occur, etc. When we see the splendid work that has been done
in Manila by Dr. Heiser, by Dr. White in Havana and Dr. Blue in San
Francisco, the ordinary man wonders why, when the government
attempts to systematize the agencies which are making the world
immune from the Scourges of humanity, a wicked opposition to this
measure promises to be successful. The fact seems to be that the con-
stant and frequently unreasonable opposition of physicians to every
branch of the medical profession except that which they are personally
interested and the average medical man's indifference to the other
public problems of the day, has given selfish interests an opportunity
to play politics, with the result that one of the finest public measures
proposed in recent years is probably doomed to defeat, largely because
of the opposition of Christian Scientists, who are fundamentally
opposed to any legislation which recognizes by law that disease in any
form exists. A layman like myself, who is interested in one phase of
medical work only, can not help but wonder what manner of men physi-
cians are that they allow such a great wrong to be done to humanity
THE ECONOMIC ASPECT OF TUBERCULOSIS 73
without exercising their undoubted power into an effectual and sub-
stantial protest to this opposition and a demand for the enforcement of
the proposed law.
The fight for preventive medicine will cost money, and a lot of it,
and it will not be easy to obtain. If we can apply some of the money
now being wasted by the government in other directions we can, how-
ever, get more than ample funds to do our work. Your distinguished
Senator from this State, Mr. Aldrich, stated recently in the Senate that
if he were allowed to run the government on a business basis, he knew
where at least $300,000,000 now wasted could be saved every year to
the people. Supposing that the Senator should save these $300,000,000
annually, and it could be used in our crusade for better health, is there
any doubt that consumption and the other preventable parasitic diseases
could not be wiped out in five years? One year's saving would give
three dollars per capita for every resident of this nation. It would
give the State of Rhode Island a million and a half dollars the first
year, with which to establish out-patient departments for tuberculosis
cases, to appoint district nurses to visit and instruct the sick. It would
equip day camps and complete and maintain hospitals where the
advanced consumptive could be taken away from being the source of
contamination to his fellows; and this Saving, if applied per capita,
would give seven and a half million dollars to Rhode Island, in five
years and result in a saving, because of diminution in Sickness and
prolongation of life, of at least eight or ten million dollars a year in
this State. Is it not worth while P
A few days ago there was a discussion at Washington Over naval
expenditures. Senators Hale of Maine and Owen of Oklahoma with
others protested unsuccessfully with all the force of intelligent states-
manship against the continuance of the absurd policy in trying to keep
pace with Europe in the construction of war-ships. In this particular
debate, history was perverted to justify a still further and unnecessary
naval expenditure. For the first time in the history of this nation we
find a lobby at Washington maintained for the purpose of encouraging
a war sentiment, which means new war-ships and profit for the Steel
companies. No patriotic citizen will object to adequate naval and mili-
tary protection for the nation, but when it reaches the point that 72
cents out of every dollar for national expenditure is, and has been,
spent for war, its preparation and its consequences, which expenditures
can be shown to be largely responsible for the increased cost of living,
making the cost in this country about twice as great as that for any
74 THE EconoMIC ASPECT OF TUBERCULosis
other country, with the result that it is difficult for the poor to make
both ends meet, forcing the use of poorer food, which is responsible for
the loss of vitality, ending in sickness and death, it is time we call a
halt; and the medical men above all others should be the first to come
to the front in this work. The best authorities agree that we have at
present a navy sufficient for ample protection. It is true that the
Dreadnoughts, which were built at a cost of $10,000,000 or so each five
years ago, are now outclassed and made worthless by the heavier ships
of Europe, and the new type which we are building to-day will be again
outclassed, because Europe is engaged in a mad race for naval
supremacy, as a result of which its people are industrially enslaved and
its statesmen put to their wits' end to devise new methods of raising
taxes to pay the bills. Aside from this, we must not forget that a day
or two ago a successful air-flight was made from Albany to New York
city, repeating similar foreign flights from London to Manchester and
over the English channel. With the establishment of a practical air-
ship, which now seems only a little way in the future, every naval
vessel in the world will be permanently tied to its dock, because they
will be at the mercy of the navigator of the air. The amount of money
paid for the new ship launched in Brooklyn, New York, the other day
would rebuild every college in New England and leave a substantial
sum for endowments, and yet this money is all being wasted. The two
ships authorized by Congress to be built this year will cost
$25,000,000, and will be old junk in fifteen years at the most,
if they are not put out of commission as their predecessors were, by a
better and bigger type of ship which is being built by England or Ger-
many. To build the ships which Congress has provided for this year
will cost an additional $25,000,000 to maintain during the time before
they are put in the scrap heap. If we will take the cost of these two
vessels alone and the money it takes to run them while in commission
to apply to health work, it would give Rhode Island a quarter of a
million dollars with which you could start a crusade in this State which
would prolong to happiness and economic usefulness thousands upon
thousands of lives. These questions are above politics; they concern
the future of civilization and are worthy the attention of all classes of
the community.
While I have devoted myself practically to tuberculosis, I realize
that there is danger of going too far even in a good cause; I have inti-
mated there are other diseases which are doing almost, if not quite,
equal damage and are getting practically no attention. But the extent
THE ECONOMIC ASPECT OF TUBERCULOSIS 75
of tuberculosis; the fact that its ravages have been known practically to
every family; the further fact that its treatment depends upon hygiene
and sanitation rather than upon medical attendance, has given oppor-
tunity for a host of charlatans to grow rich on the sufferings and cre-
dulity of the people. It has also given the occasion for medical adver-
tisers and politicians to exploit themselves, and in addition to this it
has been seized by well-meaning but unbalanced persons to be carried
to such an extent that it has been necessary to coin a new word to
describe a new disease called “phthisiophobia,” which is doing some
damage. While the health officers in all our States are neither specially
efficient nor progressive, they are doing Some parts of their work very
well, but they find it difficult to get proper appropriations sufficient to
carry on their regular work. The tuberculosis worker, on the other
hand, working independently because the health officers have failed to
do their duty, have money, in Massachusetts, at least, given to them
faster sometimes than they are ready to use it. Every politician wishes
to do something that will prove his love for the people by taking money
out of the public purse to furnish some particular fad in which he is
interested. This “phthisiophobia” has caused Nebraska to pass a law
forcing indigent consumptives to submit to a treatment not accepted by
the medical profession. In Oklahoma it has prevented from being
licensed doctors who have had tuberculosis or who have nursed or lived
in a house with a consumptive for three years before his application;
and so a foolish nonsense which has interfered with the real progress
of our work goes on and grows. Medical men have made the profes-
Sion ridiculous by accepting all sorts of strange and wonderful theories.
I saw a few days ago where a doctor in this State blamed alien immi-
gration for a great part of tuberculosis that exists in this country. The
greatest sufferers from tuberculosis in the United States are the Indians
and negroes. How aliens, who have no contact with either the Indian
or the negro, are to be blamed for these particular sufferers I confess
I am unable to work out. The Jew has less tuberculosis in Europe or
America than any of the races with whom he comes into contact; when
the Jews do get this disease they generally catch it from their Gentile
surroundings. Most of the other alien European races are freer from
consumption in Europe, where they work in the fields, than they are
after they come here. The second generation alien does develop con-
Sumption rapidly, due to the extra pressure on his vital resources trying
to keep up with the pace, but that fault is ours and should not be
charged to the alien, who is the one most entitled to make complaint.
76 , THE ECONOMIC ASPECT OF TUBERCULOSIS
Let us not be drawn into side issues. It is the inefficiency of health offi-
cers and the inertness of medical conservatism, added to public ignorance
and carelessness, that is to blame, and not the alien. For years, unless we
had the immigrants coming in in large numbers to dig our ditches and
work our farms, this work would not be done; and the crying need of
the time is for agricultural and other kinds of labor which cannot be
procured by the native population of this country, the result being
shown in the high prices which we are to-day paying for the commo-
dities of life. -
Social welfare is now a science, and the sole working hypothesis
that now underlies it is that men, whether alien or native, are largely
what their surroundings make them. When we improve the environ-
ment we improve the individual. Pregnant women who work in fac-
tories do not bring forth as healthy children as those working com-
fortably at home. Dark rooms and cellars and slums are not due to
the immigrant, but to those who are exploiting them after arrival.
Stunted children do not spring from tenement houses, but they are born
there of stunted parents incapable of supplying them with better homes.
The disease-breeding trades and occupations which incline to tubercu-
losis are the factors which are bringing about the results of which we
complain, and not the individuals afflicted, and it is only betterment
of the conditions under which our people in the poorer sections live
which will produce the results we seek and to which we should devote
Our energy.
The nineteenth century was the century of women; the twentieth
century will be noted for its advance in the duration of human life and
its freedom from sickness and disease. It will be made famous for its
treatment of the child, which, when it gets its rights, will insure the
health of the coming race. Man has come to realize that he is bound to
the little life he has produced by stronger ties than those of Society and
law. The belief held by many even to-day, who would get angry if
they were accused of being uncivilized, that the large death rate among
children of tender years is a wise provision of God to weed out the
unfit, has been proven to be absurd in countries leading in civilization.
The effort must be made to insure the health of the community by
beginning at the Source, rather than by trying to patch up a decrepid
manhood and womanhood upon whom neglect and deterioration have
already done their worst.
I have tried to speak plainly and I hope without offence, because I
think the time has come for plain speech. Medical men can profitably
THE EconoMIC ASPECT OF TUBERCULOSIs 77
take some of the time they now devote to technical hair-splitting to dis-
cuss the broader aspects of the great health problem, such as the
economic cost of disease and the duty of the physician to do his share
in watching the progress of national and State legislation, so that
wrong is not done to the community and that selfish interests do not
defeat wise laws. At a tuberculosis conference which I attended in
Sweden last summer most of the time was devoted to a razor-edge
discussion over the minute degree of tuberculin which would determine
the existence of the disease in a suspected case, while the fact that in
the streets of Paris, Stockholm, Berlin and Hamburg, from which
these learned physicians came, a layman like myself could in a casual
walk on the principal streets meet scores of people whose tuberculous
condition could be detected at a glance, who were constantly spreading
the disease by contact with their fellows, and for whom there were no
hospitals or other places of treatment, and the provision for whose care
received no consideration whatever from the medical men.
A great German has criticised American civilization and American
institutions by saying that we take our exercises, not primarily because
we love exercise, but because we can do our work better for it; that
we read not primarily because we love reading, but to rest our minds
from our work. This is only partially true. In the matter of pre-
ventive medicine we may stimulate our crusade for better health by
showing the enormous economic loss resulting from neglect, but after
all, to be truly successful this effort must be based on love, which is the
ladder by which we climb up to likeness to God.
QUARTERLY MEETING
SEPTEMBER 1, 1910
By invitation of the Trustees of Butler Hospital, the quarterly
meeting was held at Butler Hospital, Providence, on Thursday, Sep-
tember I, IQIO, at 4:50 P. M.
The President, Dr. A. A. Mann, presided. Dr. J. B. Ferguson was
elected Secretary pro tem. - &
Speeches of welcome and of the history of Butler Hospital were
given by Mr. Charles H. Merriman, President of Butler Hospital, by
Mr. Charles M. Smith, Secretary, and by Dr. G. Alder Blumer, Super-
intendent.
A paper on Modern Methods of Hospital Isolation was read by Dr.
Dennet L. Richardson, Superintendent of the Providence City Hospital.
This paper was discussed by Drs. W. H. Greene and F. N. Brown.
Dr. F. T. Rogers exhibited and spoke of the plans for the new
building of the Society.
The A. M. A. having abolished the committee on medical legisla-
tion, of which Dr. Swarts was elected a member from this Society, and
having established the national legislative council, Dr. Swarts was
accredited to this council.
On motion of Dr. White, a rising vote of thanks was extended to
the Trustees of Butler Hospital for their kind invitation and cordial
reception.
At 5:50 P. M. the meeting adjourned to enjoy an elaborate and
satisfactory collation. -
The exercises were preceded by an interesting game of base ball
between physicians from the Society and the internes of the Hospital.
QUARTERLY MEETING
DECEMBER I, 1910
The quarterly meeting of the Rhode Island Medical Society was
held in Rhode Island Hall, Brown University, on Thursday, December
I, 1910, at 4:30 P. M. The President, Dr. A. A. Mann, presided.
The records of the last quarterly meeting and of the meetings of
the House of Delegates and of the council, held November 23, 1910,
were read and approved.
Announcement was made that Dr. George B. Haines of Valley
Falls had died on October II, 1910, and Dr. George W. Porter at Bos-
ton, October 15, 1910, of pneumonia.
Drs. George A. Harris, Chepachet; Mary S. Packard, Rehoboth,
and Wallace M. Pierce, Providence, have resigned.
The President appointed the following delegates to the annual
meetings of other societies:
Maine, Drs. F. B. Fuller and B. L. Towle.
New Hampshire, Drs. F. N. Brown and G. W. Gardner.
Vermont, Drs. E. C. Bullard and D. B. Cox.
Massachusetts, Drs. W. R. White and J. L. Wheaton, Jr.
Connecticut, Drs. A. B. Briggs and R. P. Boucher.
New York, Drs. W. E. Wilson and O. W. Best.
New Jersey, Drs. A. R. Fenwick and M. Duckworth
Dr. Arthur Hollingworth was appointed anniversary Chairman.
Dr. William R. White read a paper entitled Cardio-vascular Con-
ditions in Pneumonia.
Dr. Lesley H. Spooner of Boston read a paper on Typhoid Im-
munity.
In discussion Dr. Chapin congratulated Dr. Spooner in arranging
a technique with so little reaction.
Under certain circumstances inoculation was very desirable, as in
military life, among nurses and hospital attendants and where epi-
demics were common, as in parts of the South and West. Here a wide-
spread vaccination is advisable. We ought not, however, to have so
much typhoid develop in hospitals. We need to knock into the heads
of doctors, nurses, ward tenders and exposed individuals that they
8O - . QUARTERLY MEETING
must not put other peoples feces in their mouths. In ten years eleven
nurses have had typhoid in the Rhode Island Hospital. We need to do
everything we can to teach that the disease is contagious. Tell the
nurse so plainly; put a card of any color on the bed to emphasize the
fact that special care is needed. Allow the nurse an opportunity to
wash up and in running water. If the strongest effort is made the inci-
dent can be reduced.
Dr. Garvin asked how many cases there had been in the Massachu-
setts General Hospital in the two years preceding vaccination.
Dr. Swarts thought that general vaccination of a community could
not be carried out nor health boards enforce its acceptance. Where a
family is threatened vaccination is possible. In the army it is difficult
to follow the matter out, but with nurses it is practical. As usual the
font of our knowledge is the Massachusetts General Hospital.
Dr. J. C. Parker said that he had recently visited an army camp.
of 20,000 men, where sanitary precautions were very perfect. There
40 per cent. Of the men had been inoculated and last year no typhoid
fever had appeared. -
Dr. White asked if the fact that they had been vaccinated influ-
enced nurses to be more careful than formerly.
Dr. Leonard inquired if after typhoid had been contracted inocu-
lation would have any effect. Dr. Chapin asked how many cases of
typhoid had been treated in the Massachusetts General Hospital in ten
years.
Dr. Fuller asked if inoculation had been tried in typhoid carriers.
In reply Dr. Spooner said that from 80 to IOO cases were seen at
the Massachusetts General Hospital every year. (In the Rhode Island
Hospital 970 cases had entered in ten years.) During epidemics the
treatment would certainly be a great aid. Two cases inoculated dur-
ing the incubation period had been studied. One ran a week and the
other two weeks. Moreover the nurse who was sick the week had
attended two very sick and fatal cases. The type was a most virulent
form of the organism we may say from the histories. The use of vac-
cine is one adjunct only, a wise means for adoption, not for the general
public but for specific cases. As for care against infection the system
at the Massachusetts General Hospital is rigorous. A nurse is in dis-
repute who gets typhoid fever. As much care is taken as can be
taken. Cases occurred, however. In the two years preceding inocula-
tion six nurses had typhoid. As for carriers, one such person was suc-
cessfully vaccinated, but many cases failed. There is no confidence in
QUARTERLY MEETING 8I
its use after the disease is developed or in complications, such as cysti-
tis or gall bladder infection. Many carriers are due to gall bladder
infection.
Dr. Harry W. Kimball read a paper on Scabies.
Dr. William R. White called attention to the subject of alkapto-
nuria, an abnormal urinary condition said to be of very rare occur-
rence. There is present in the urine a substance called alkapton,
which is supposed to result from a disorder of metabolism, but whose
presence causes no appreciable impairment of health.
When the urine contains this substance and a strong solution of an
alkali or an alkaline solution of a copper salt, like Fehling's or Haine's
test solution, is added, a brown discoloration occurs from the top
downwards in the test tube, and on warming, the color becomes deep
brown or nearly black. Hence alkaptonuria may easily be mistaken
for glycosuria unless the absence of sugar be shown by the fermenta-
tion test, or the bismuth, phenylhydrazin, orcin or polariscopic test, all
of which are negative in the presence of alkapton.
Really the greatest importance of alkaptonuria is in the matter of
examination for life insurance, glycosuria being wrongly suspected and
reported against the applicant’s insurableness.
Dr. White also applied Haine's test for glycosuria, the specimen of
urine being that of a man, age 50, who, it is believed, has had alkapto-
nuria for at least twenty years, and perhaps since birth. The urine
tested had a specific gravity of Io20, was acid and held no trace of
albumin or Sugar. *-
On adding a few drops of urine to Haine's solution in a test tube
a deep brown color at once appeared at the top and spread downward.
On being warmed the color became deeper brown and then a brownish
yellow precipitate became visible.
It is undoubtedly true that on account of their great infrequency
cases of alkaptonuria are seldom seen or recognized by the individual
practitioner. For literature on the subject the speaker referred to Dr.
Francis Carter Wood's book on Chemical and Microscopical Diagnosis;
also to a comprehensive article on alkaptonuria by Dr. Thomas B.
Futcher of Baltimore, published in the New York Medical Journal,
1898, Vol. LXVII, page 69.
BUSINESS MEETING
NOVEMBER 23, 1910
The House of Delegates met on Wednesday, November 23, 1910,
at 253 Washington Street, Providence, at 4 P. M.
The President, Dr. A. A. Mann, presided. Other members pres-
ent were Drs. Hersey, Day, King, Stearns, L. C. Kingman, Akers,
Noyes, Mitchell, Crooker, Fuller, Rogers, White, Welch, Risk and
Burnett.
The records of the meetings of the House of Delegates and the
council, held May 17 and 31 and June 16, 1910, were read and ap-
proved.
For the year beginning March 1, 1911, the annual tax was
made $5. - º
The special committee on site reported through Dr. Rogers. The
report was accepted, a vote of thanks given to the committee and the
committee discharged.
In accordance with the recommendations of the report, a com-
mittee, to be known as the Trustees of the Rhode Island Medical
Society Building, was constituted as follows: Drs. F. T. Rogers,
Chairman; Mitchell, Noyes, Day and J. M. Peters, one member of the
Society from each of the six district societies to be appointed imme-
diately by the district societies, and the President, Secretary and Treas-
urer, ex-officio. -
It was voted that the duties and powers of these Trustees shall be
as follows:
I. That they shall have authority to fill vacancies, add to their
members and appoint sub-committees from the Society in the further-
ance of their plans.
2. That upon completion of the building they shall by lot or by
mutual agreement choose one member to serve five years, one four
years, one three years, one two years and one one year, as permanent
Trustees of the building, and that annually afterwards there shall be
appointed by the President one member to serve five years.
3. That they shall have power to utilize the funds of the Society
transferred to them, to raise money by the sale of bonds or by a mort-
gage to be placed upon the property, and when in their judgment suf-
BUSINESS MEETING 83
ficient funds are at hand shall have authority to contract for and con-
struct the building for the use of the Society, substantially according to
the plans which have been presented.
4. That they shall have full control of the building until com-
pleted, subject to instructions of the House of Delegates.
- 5. That they shall make a report of their proceedings and give an
account of all expenditures of money at each quarterly meeting of the
House of Delegates and Society.
Also in accordance with the report it was voted that the Society
should transfer, for the purpose of erecting the building, the funds
now held under the wills of the late Drs. Chase Wiggin and Horace G.
Miller, the balance of the printing fund, the building fund and the
library fund, leaving, however, these funds intact and respecting the
terms of gifts of the various donors, the Society investing these funds
in the building and giving notes therefor to their present Trustees.
Also it was voted that if necessary the Society authorized the issu-
ance of certain bonds which shall have twenty years to run and which
shall bear interest at 5 per cent, after ten years. These bonds shall
revert to the Society in event of the death of the owner prior to the
interest bearing period and shall be subject to recall at any time after
that period at par with interest.
Adjourned.
A meeting of the council was held upon adjournment of the House
of Delegates. The President, Dr. A. A. Mann, presided. Other
members present were Drs. Mitchell, Noyes, Hersey, White, Fuller,
Risk, Welch, Stearns and Akers.
The action of the House of Delegates in appointing a special com-
mittee to be known as Trustees of the Rhode Island Medical Society
Building was approved, and their powers confirmed.
A communication from Dr. Risk in regard to delinquent members
was laid upon the table until the next meeting.
Adjourned.
MODERN METHODS OF HOSPITAL ISOLATION
BY
D. L. RICHARDSON, M.D.
Superintendent of Providence City Hospital
The hospital management of contagious diseases depends upon the
conception of the mode of their transmission. Of all these diseases
the etiology of one only, diphtheria, has been established. The labora-
tory method, therefore, of determining how the infecting agents are
carried from one person to another is of little avail except for this
disease. We must rely upon the clinical experience and accurate data
of progressive health departments and hospitals which are endeavoring
to minimize their dissemination. It is largely this experience which
has led some observers within recent years to doubt the theory of air
transmission and lay more stress on the idea of contact infection. In
the minds of those who have had the best opportunity to observe
hospital treatment on this basis, there is some doubt whether the
atmosphere cannot carry the contagion of measles and chicken pox, and
only by future experiments will the matter be settled.
The French were the first to make use of this modern idea in
their hospitals. Quoting from Dr. Chapin's new work, “Sources and
Modes of Infection,” in Paris Dr. Grancher introduced the methods
of strict asepsis, and “it was found possible to care for patients with
different diseases, even in a common ward, with far less danger of
transfer than before.” He employed wire screens around the beds to
impress upon the nurses the necessity for guarding against infection
by contact. During the years 1890-1900, 6,54I patients were treated
in Grancher's wards, and diphtheria was introduced forty-three times
and only once did a case develop it. Scarlet fever was introduced
nineteen times and seven cases developed it. Less success was obtained
in isolating measles, but infection was reduced two-thirds.” In other
French hospitals separate rooms or cubicles are used; in Some partial
or complete partitions between adjoining beds in the wards. Strict
asepsis is carried out. The Pasteur Hospital at Paris is the best
equipped for such work.
The same method has been tried in certain English hospitals. Dr.
Gordon, Superintendent of the Monsall Hospital, Manchester, in 1908
reported on an experience of five or six years with the “barrier” sys-
tem. Any bed in the ward is surrounded by a screen covered by sheets
which are kept wet with a weak solution of some disinfectant. Since
MODERN METHODS OF HOSPITAL ISOLATION 85
this report I believe that the wet sheets have been dispensed with and
only a tape is stretched about the bed to mark it. The patient has
within this barrier his utensils and toys. The nurse wears an overall
and rubber gloves when handling the patient. Everything which comes
out of the barrier is sterilized and everything that goes in is clean of
infection. By this method mild cases of scarlet fever, scarlet fever
and diphtheria, Scarlet fever and measles, chicken pox and whooping
cough had been treated, and during the preceding years only one infec-
tion occurred. Previously some cases of chicken pox had developed,
and Dr. Gordon was doubtful whether measles and chicken pox could
be handled safely in this way.
Dr. Caiger of the Southwestern Hospital reported in 1908 on an
experience of eighteen months with the cubicle system. Patients were
placed in them when the diagnosis was doubtful, when exposed to some
other infectious disease, when sick with mixed infection or with a non-
infectious disease. Out of seven hundred cases only sixteen took a
second disease, divided as follows: chicken pox six, scarlet fever six,
German measles two and measles two. Mr. Caiger would hesitate to
handle chicken pox in this manner. -
Dr. Thompson of the Northeastern Hospital in the same year
reports on two years’ experience with the cubicle system. Doubtful
cases of scarlet fever, some mixed infections and a few diphtheria
cases were isolated in these rooms. Out of I,290 patients, three cases
of German measles, two cases of measles, five cases of Scarlet fever,
three cases of diphtheria, and one case each of chicken pox and whoop-
ing cough developed.
The credit of introducing this method of handling contagious
diseases into the City Hospital and into this country belongs to Dr.
Chapin. When it was built, a building was especially constructed as
an isolation ward for this purpose.
In the treatment of all the contagious diseases contact infection is
avoided by strict asepsis, and air infection has been disregarded.
Nurses, orderlies, maids and all the help are carefully instructed, first
how to protect themselves and secondly how to avoid transmitting infec-
tion from one ward to another or from one patient to another. The
following set of rules is given to everyone:
Keep fingers, pencils, pins, labels and everything out of your
mouth.
Keep and use your own drinking glass.
Do not kiss a patient.
86 MoDERN METHODS OF HOSPITAL Isolation
Wash hands often, and always before eating.
Keep out of doors as much as possible and always sleep with
window open.
Do not touch face or head after handling a patient until hands
are washed.
Do not allow patient to cough or sneeze in your face.
Do not allow patient to touch your face.
Do not eat anything that patient may wish to give you.
If taking a drink or lunch be sure and use the nurse's dishes.
Put on gown or change uniform when going into the ward.
On leaving ward always wash hands.
Always remember that infectious diseases are taken and carried
by contact and not by air infection.
The nurses all occupy the same dormitory and eat in the same
dining-room. When ready for duty they go to a dressing room where
they put on a ward uniform. Each nurse is provided with two lockers,
one for her ward clothes and the other for the uniform worn when
off duty. On leaving the ward she changes again, washes her face
and hands and dries them on an individual towel. -
The ward maids live with the other female help and eat in the
help dining-room. They observe the same rules as do the nurses, with
the exception of wearing a long gown instead of removing the outer
garments.
The resident physicians, when making their visits wear white
suits and put on a gown in each separate ward. This is not always
done unless they are likely to examine patients. No caps are worn.
Great care is taken in washing their hands.
All new help and nurses have cultures taken from nose and throat
when they arrive at the hospital. Since the opening of the hospital
on March I, one nurse developed a very mild attack of Scarlet fever
and one maid developed the same disease. It is interesting to note
that a few days before taking sick the maid ate an orange, in violation
of rules, which was given to her by a patient in the scarlet fever ward
where she was working.
Soiled clothing is thrown down a chute and falls into canvas bags
which are regularly collected. One man is delegated to take the cloth-
ing to the laundry, where it is put directly into the ordinary washers
and washed in boiling water from forty to sixty minutes. The man
wears a gown and washes his hands thoroughly after handling the
MODERN METHODS OF HOSPITAL Isolation 87
\
infected clothing. The clean clothing is delivered to the wards in
bundles tied up in cloth.
The number of dishes which must pass between the main kitchen
and the ward kitchens has been reduced to a minimum, but such as do
are carefully boiled. All garbage is burned.
I believe that the most fertile source of contagion is the patient
himself. It is very important to make a correct entrance diagnosis, to
rule out mixed infections and, if there is any doubt, to isolate the case
until a decision is reached. Even if the diagnosis seems plain, all
patients are put into detention rooms for several days, where they are
considered suspicious. -
We have already found our isolation ward insufficient and have
been obliged to isolate some mixed and doubtful cases in the diphtheria
and scarlet fever wards. To fulfill the same purpose of the barrier
system of the English, we hang on the bed or put on the door a red
card on which is printed “Special Case.” Hands are washed before
and after handling the patient and a gown is worn. Every such patient
has his own bed pan, urinal, thermometer and all his dishes are steril-
ized. Every patient has cultures on the first two days of his hospital
residence, and one is taken in the admitting room before he comes in
contact with any other patient. If the cultures are positive in any but
the diphtheria wards, the case is isolated. Soap and water alone are
used for cleaning hands, floors, walls and furniture. Mattresses are
sterilized by steam. Rubber and glass goods are treated with carbolic
acid I-20. Fumigation is never done.
I have no record of the number isolated by the red card method,
but there have been a large number. Since March I we have had the
following diseases develop after admission. I have excepted two, of
which I will speak later. One case of diphtheria in the diphtheria
ward ten days after admission. After the first few days he was not
isolated because we supposed that he had diphtheria on admission.
His cultures had been positive, and a sister was sick in the ward at the
same time. -
One case of scarlet fever developed in a patient sick with
diphtheria five days after admission, and as there was no exposure to
scarlet fever we believe that he was incubating the disease on admis-
sion.
One case of rubella developed in the Scarlet fever ward at a
time when there was no recognized case in the hospital. Another
child took it from this one.
88 MODERN METHODS OF HOSPITAL ISOLATION
Three cases of measles in the Scarlet fever ward. We believe
these developed from a child which entered with scarlet fever during
convalescence from measles, a fact which we learned too late.
One child developed chicken pox in the measles ward two weeks
after admission at a time when there was no chicken pox in the hos-
pital. One other child in the same ward caught chicken pox.
One case of Scarlet fever developed diphtheria. Nine children,
mostly in the Scarlet fever ward, developed positive or suggestive
cultures without clinical symptoms.
Three cases of vaginitis which belonged to two families. Another
child of one family had a urethral discharge on admission, and we are
Satisfied that in each case it was an older process which lighted up in
the hospital.
I wish now to speak of the results of the treatment of cases in
the isolation ward, where are carried out the same precautions as are
practiced on the red card cases, but more effectively. On the first
floor of the isolation building are ten rooms, five on each side of a
common corridor. The doors are opposite to each other, and beside
each and opening into the same room is a full window, so that a nurse
may pass along the corridor and note what is going on in each room
without opening the door. Each is provided with running water
controlled by levers which are operated by the forearm to avoid
-contact by hands. The furniture consists of a chair, a metal bed and
bedside table so constructed that they can be easily and thoroughly
cleaned. The patient once placed in a room is not allowed out of it
unless taken out of doors and seated by himself. He is provided
with a thermometer, pus basin, hand basin, ice bag, etc., such things
as will be used constantly and can be kept in the room as long as the
patient occupies it. Utensils, dishes and trays after being taken from
the room are put directly into a large utensil sterilizer in the ward
kitchen and sterilized by steam and hot water before they are washed.
The ward kitchen is thus kept uninfected, and the trays of food are
made up and taken directly to the different rooms. All rubber goods,
glassware, bed pans and urinals are sterilized in I-20 carbolic solution.
Only physicians and nurses are allowed in these rooms. If they
simply go in and do not touch anything in the room no precautions are
taken. If the patient or anything in the room is touched, the hands
are washed with soap in running water and dried on individual towels.
If the patient is handled much or examined, gowns which hang in the
rooms are put on. The care of hands is rigidly insisted on. Toys,
MODERN METHODS OF HOSPITAL Isolation 89
books, etc., are either sterilized or burned after the patient goes home.
On discharge of a patient the bed and furniture, floor, door knobs,
wash basin and walls within reach are washed with soap and water.
Dirty clothing is sent to the laundry. The mattress is sterilized by
steam. The room is aired as long as possible until there is another
patient to Occupy it. •
These aseptic principles are laborious and require thought and
great care. Most of the credit and success of satisfactorily treating
cases in this way belongs to the nursing force.
The doors and windows are left wide open and the wind sweeps
freely through the rooms. Since the first patients were admitted,
March I of this year up to August 24, III cases, representing 163
diseases, were treated in this ward. The time that they were in the
ward ranged from 2 hours to II6 days. Twenty-six cases were
there less than a week, and 76 per cent. of the total number more than
a week. The 163 diseases were as follows:
Measles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4I
Scarlet fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Whooping cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Diphtheria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I4.
Positive cultures, not sick. ... . . . . . . . . . . . . . . . . . . . . . II
Suspicious cultures, not sick. . . . . . . . . . . . . . . . . . . . . . 5
Gonorrhea, vaginitis and urethritis. . . . . . . . . . . . . . . . 6
Chicken pox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Mumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Rubella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Erysipelas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I
Other diseases, not contagious . . . . . . . . . . . . . . . . . . . . 22
At all times there have been varying combinations of all the above
diseases. When there are only a few cases of chicken pox, measles
and whooping cough, they are put directly into this ward and kept
there until discharged, because it saves on nursing force and it has
seemed to be safe to treat them there. One case of measles and one
case of chicken pox have developed among the III persons treated in
this ward, although they are practically in the same ward and nurses
pass freely from one to another, observing the necessary precautions.
I hesitate to present so few cases as demonstrating beyond a doubt
that contagious diseases are not transmitted by air, but our experience
leads us to believe that the danger is very slight, even in the case of
chicken pox and measles.
TYPHOID IMMUNIZATION BY MEANS OF BACTERIAL
V ACCINES
BY
LESLEY H. SPOONER, M.D.
BosTON
It was Pfeiffer who first conceived the idea of immunization
against typhoid fever by means of bacterial vaccines. A simple
laboratory experiment upon two subjects originated a campaign which
swept over Europe and America during the following decade. He
found in the blood of these two persons the anti-tropic bodies which
have been known for several years to exist in the blood during typhoid
convalescence.
It is a well recognized fact that the blood of typhoid convalescents
and those recently sick with the disease show these substances; bac-
tericidal, agglutinating and phagocytic. Since a powerful specific
immunity is conveyed by an attack of typhoid fever, it was concluded
that it is evidenced by and can be measured by the presence of these
substances in the blood.
Sir A. E. Wright recognized the theoretical importance of
Pfeiffer's discovery, but he also saw its practical use in conveying
immunity, which could be used as a means of prophylaxis for those
who are intimately exposed to the disease, as soldiers must needs be in
the tropics. But when the credit of immunity by the bacterial vaccine
is given, Haffkin must not be forgotten, for it was because of his anti-
cholera inoculations that Wright first conceived the practical application
of Pfeiffer's laboratory experiment.
The resemblance of the cholera organism to the bacillus Eberth
had been long recognized, so that it is easily seen at the present time
how simple the problem appeared to the English investigator. -
Inoculations were started very soon in the British army, which
was at that time engaged in the Boer war. Thousands of inoculations
were performed, many of them by the hands of Wright himself. But
the whole work lacked any scientific foundation. The undertaking was
too stupendous to allow of any blood examinations to determine the
anti-tropic substances, and the records of incidence of the disease “at
TYPHOID IMMUNIZATION By MEANS OF BACTERIAL VAccINEs 91
the front” were so imperfect that it was extremely difficult to determine
the efficacy of the treatment even by means of the incidence of the
disease among the inoculated and the uninoculated. Soon skeptics
appeared who reported an incidence as great among the treated as the
untreated. Constitutional reactions of great severity were cited and
without doubt exaggerated. But to cap the climax Wright himself
reported the inoculation of 303 members of the Third Huzzars at
Lucknow in February, 1899. In nineteen days five of the above num-
ber contracted typhoid fever and two subsequently died. None of the
281 uninoculated were affected. This he attributed to the presence of
the “negative phase,” or period of diminished resistance following
inoculation. The existence of such a phase has been very much
doubted and is now believed not to exist. But such an explanation was
not sufficient to justify the continuation of inoculation, which was soon
stopped altogether in the British army.
The precise cause for this mishap is still unknown, but if one denies
the negative phase, one must accuse faulty technique. The matter, if
not settled, has been passed over and entirely obliterated by the work of
the British commission almost a decade later. At that time pressure
in favor of army inoculation was so great that the Royal Army Medical
Corps appointed a commission to investigate the question of immuniza-
tion against typhoid fever by bacterial vaccines. This commission, of
which Major W. B. Leishman was a prominent member, investigated
the subject in a thoroughly scientific manner. And their results have
given us the most valued aid in the preparation and administration of
the vaccine; its immediate and remote effects and its immunizing power,
as evidenced by animal experimentation. Having determined the
proper methods and established the safety of the procedure, voluntary
army inoculation was started for a second time. Their recording Sys-
tem was also perfected, so that in 1909 Leishman” was able to publish
the following most striking statistics:
Total strength . . . . . . . . . . . . . . . . . . . . . . . . . . I2,082
Number inoculated . . . . . . . . . . . . . . . . . . . . . . 5,473
Cases among inoculated . . . . . . . . . . . . . . . . . . 2I
Deaths among inoculated . . . . . . . . . . . . . . . . . 2
Number uninoculated . . . . . . . . . . . . . . . . . . . . 6,61o
Cases among uninoculated. . . . . . . . . . . . . . . . . 187
Deaths among uninoculated. ... . . . . . . . . . . . . 26
Qualifying the above report, he shows that of the infected
inoculated cases thirteen, with the two deaths, were among troops who
92 TYPHOID IMMUNIZATION BY MEANS OF BACTERIAL VAccINES
were given an old and hence powerless vaccine; that four of the others
had only one inoculation; and that of the other four two were reported
as mild cases, one so mild that the diagnosis was doubted, and that the
last ran a normal course with recovery.
While such brilliant work was going on in England, the German
army was having similar results on a Smaller Scale among their troops
in southwest Africa.
Inoculations were started in February, 1909, in the United States
Army under the supervision of Major F. F. Russell, and at the time
of the publication of his first report”, in December, 1909, I,400 inocula-
tions had been given. It is, as yet, early to expect any very striking
results from this work, but already reports are being received of a
marked diminution of the incidence of the disease among the inoculated
troops.
In the British army very large doses of the vaccine are employed,
and in many cases profound constitutional reactions have resulted. Five
hundred million organisms are introduced at the first inoculation, and
at the expiration of a week I,000 M more are given. The severe reac-
tion has a tendency to discourage a second inoculation and to check
the spread of such immunization where the procedure is, as is natural,
voluntary. Similar doses are used in our army, except that two inocu-
lations of 1,000 M are employed instead of one.
In 1856 Budd of Bristol brought forward his belief that typhoid
fever was communicated through the excreta. But the discovery of
the specific organism by Eberth in 1880 and the demonstration of the
bacillus in the feces, urine and less often in the sputa proved the cor-
rectness of the observation of the former. This absolute knowledge
explained the presence in all of our institutions, where typhoid is
treated, of cases contracted within their walls. The incidence of the
disease in the Massachusetts General Hospital has been of especial
interest to me. In a hospital where the means of prophylaxis is the
best I have found that during the last ten years—1899-1908—twenty-
seven cases were contracted. Furthermore, during the same period
of ten years, the records show that these were brought to the hospital
twelve nurses who had been engaged in outside practice, and who gave
a positive history of having cared for, within a few weeks, patients
sick with typhoid fever. Of the twenty-seven hospital cases, nineteen
were nurses, four ward tenders, one morgue tender, one kitchen hand,
one laundress and one elevator man. It will be seen that the vast
majority are among the nurses, who, of course, are most intimately
TYPHOID IMMUNIZATION BY MEANS OF BACTERIAL VAccINEs 93
associated with the sick. But it is to be borne in mind, at the same
time, that they represent an intelligent and well trained body, which is
thoroughly familiar with the dangers to which it is exposed and the
means to Secure protection by personal care.
Considering the number of employes of the institution, there
was a morbidity of typhoid fever, contracted within the hospital, of
I.6 per cent, among the nurses, 2.1 per cent. among the ward tenders,
or I.6 per cent. Of all those exposed to the disease. In concluding a
paper on this subject”, the aim of which was to start hospital inocula-
tion, I stated that “the disease contracted under such conditions seems
to run a course of more than ordinary severity, with a greater number
of complications and with a high mortality,” and “that the disease
among the hospital personnel is not diminishing in frequency.”
My first object in starting hospital inoculation was to diminish
such an incidence. But to do the greatest good, inoculation must
be widespread, and in order to bring about this result I started an
investigation, which I published in the early part of this year". The
aim to which I aspired was the reduction of the constitutional reaction,
which had been so troublesome abroad as well as in this country, and
for this end I believe two factors were necessary: (I) Small doses
frequently repeated, (2) of a vaccine of low virulence.
My work was started among the house officers of the Massachu-
setts Hospital, and an examination of their blood at intervals of weeks
and even months showed the presence of such high agglutination reac-
tions that I was firmly convinced that I had been able to immunize,
certainly to a great extent, without any great personal inconvenience
to the individual. Having established this point, I called for volunteers
among the nurses and ward tenders and began inoculation.
My report in January, 1910, covers IO3 cases; of these seventy-
four were Massachusetts General Hospital nurses, nine house officers
and six ward tenders. Fourteen were vaccinated at the Chelsea Naval
Hospital, because of a great influx of typhoid at that station. Of this
number 94.2 per cent. showed agglutination tests (Widal) in dilutions
of 1:25 or more, and 80.6 per cent. in I:50 or more. The presence of
such a high agglutinating power seems impossible without a reasonable
amount of immunity. Furthermore the local reaction was only slight
in almost all the inoculated; the constitutional Symptoms were absent
in 58 per cent. ; were slight—consisting of malaise and headache—in
36 per cent, and considerable in the remaining 6 per cent. All the
nurses who suffered from any pronounced symptoms had entirely
94 TYPHOID IMMUNIZATION BY MEANs of BACTERIAL VACCINES
recovered the following day, and only one nurse was incapacitated from
work, being “off duty” for a half day. Since then inoculation has been
conducted regularly under me at the hospital. To the present time I
have inoculated I54 nurses, IO house officers and II ward tenders.
We are now approaching the end of our second year of hospital
inoculation, and as yet we have had no bona fide case of typhoid fever
contracted within the walls. I have to make that qualification because
our otherwise clean record was broken in July, 1910, by a rather
peculiar case. A nurse who had been inoculated one year previously
was taken ill with headache, malaise and fever. The temperature
was IOI.8 (M) and she showed all the signs of an acute, but mild
infection. Physical examination was negative; the spleen was not
palpable and there were no rose spots. Blood cultures were negative,
and the stools showed no typhoid bacilli, but she presented a Widal
positive in I : IOO dilution, which became positive in I:200 dilution two
days later. The temperature fell on the third day to normal and was
never again elevated. It is of interest that this young woman showed
a Widal reaction of I :IOO two weeks following her inoculation.
Whether the positive reaction is to be taken as evidence of typhoid
in this case, in absence of any marked constitutional symptoms and any
of the typical clinical signs, is a matter of a great deal of doubt. It
suggested to my mind the fact that any infection, independent of
specificity, can stimulate the production of this reaction when the anti-
tropic substances—whether or not latest—are present in the body.
This statement, which originated in conjecture, is borne out by two
other cases which have been in the wards this month. Both nurses
had been inoculated two months previously. Now they are con-
valescing, one from pleurisy and broncho-pneumonia, and the other
from acute tonsilitis. Both nurses at the present time show positive
Widals in dilution of I:Ioo; a more powerful reaction than would be
expected naturally after such a period. Whether my point is true
remains for further work to develop. But, classifying this as our first
case, the inoculation must be given credit for its extreme attenuation—
to such an extent that it was no more troublesome than a “cold in the
head.”
The means of transmission of the disease indicates the extreme
importance of hospital inoculation. But physicians at large should not
hesitate to accept this simple means of protection, when it is so devoid
of danger and accompanied with such slight inconvenience. The pres-
ence of typhoid seems inevitable, in spite of the excellent work of our
TYPHOID IMMUNIZATION BY MEANS OF BACTERIAL VAccINES 95
Boards of Health, because the means of eliminating the “typhoid car-
rier” seems far from at hand. This individual who carries the bacilli
in his urine or stools or both is a constant source of danger to an unsus-
pecting public. He furnishes the cause for many of our epidemics and
makes the disease at all times endemic among us. In the times of
epidemic I consider it wise for those who have been directly or indi-
rectly exposed, or who expect to render themselves liable to the disease,
to receive preventive inoculation. This, I believe, to be perfectly safe,
Since I do not consider the so-called “negative phase” of enough im-
portance to contraindicate such procedure, provided small dosage is
employed. A striking proof of the unimportance of the negative phase
is the absence of typhoid fever among the inoculated of the Massachu-
setts General Hospital nursing force, who have been exposed to the
disease while inoculation was in progress. Secondly, I advise inocula-
tion for all those travelling in this country or abroad, where the source
of milk, water or other food is doubtful.
I have emphasized before, this afternoon, the safety of this treat-
ment. At the present time I have given over 650 injections without
untoward effect. But I wish to lay especial stress on the necessity of
assuring yourself of the absolute health of the individual before any
inoculation is given. I have been in the habit of taking a brief history
of the patient and noting the temperature. All those having a tempera-
ture over 99 degrees (by mouth) have been rejected or at least have
had inoculation postponed. In this way I have obviated several dis-
agreeable incidents, I believe. For it is my opinion that, just as any
infectious seems to precipitate the production of the Widal, once estab-
lished, so inoculation is very liable to intensify or “light up” any infec-
tious process, even when it is latent. Two cases have been most striking
instances of this theory. Through mistakes on the part of the patient
I inoculated two individuals who possessed latent seats of infection;
one in the urethra and the other in the knee joints. In the former case
the discharge, which had been quiescent for some weeks, reappeared
at once, and in the latter there was fever, malaise and all the local signs
in the knees of an acute infectious process. These cases may serve as
a warning to others as they have to me.
TECHNIQUE.
The vaccine is prepared from a low virulence, stock culture of the
typhoid bacillus, grown in the incubator for twenty-four hours, washed
into a sterile tube and thoroughly shaken. This is standardized by
96 TYPHOID IMMUNIZATION BY MEANS OF BACTERIAL VACCINES
means of the Zeis blood platelet counter and killed by an exposure in
the water bath to a temperature of 53° C. for one hour. The proper
dilution is made from this soup with salt solution and Lysol O.25 per
cent, added to prevent contamination.
Inoculations are given with glass “Tuberculin Subſ)” syringes,
which are boiled between injections. The commonly selected site for
inoculation was at the insertion of the deltoid on the left arm. This
was chosen because of its convenience, although I prefer the inter-
Scapula region, as at that point there is less irritation from muscular
action. Alcohol is used as a local antiseptic. -
I have attempted several doses, but have concluded that the most
satisfaction is derived from the use of four inoculations of 5o M, Ioo
M, 200 M and 300 M at five day intervals.
To conclude, it must be said that for nurses and physicians who
are constantly exposed to the disease, for travelers who may subject
themselves to it, for members of a community or even of a family
where typhoid is present, typhoid inoculation offers a safe means, with-
out very great inconvenience, of obtaining what seems to be a consider-
able amount of protection.
REFERENCES.
Wright: Lancet, 1902, II, p. 65.I.
Leishman: J. Roy, A. M. C., 1909, XII, p. 163.
Russell: J. Hopkins Hosp, Bull., 1910, XXI, No. 228.
Spooner: Am. J. Pub. Hyg., 1909, XIX, No. 4.
Spooner: Boston M. & S. Jour., 1910, CLXII, p. 37.
i
SCABIES
BY
HARRY W. KIMBALL, M.D.
PROVIDENCE
-*mº
In bringing the subject of scabies before you to-day I have not
chosen a dermatological curiosity, but an old, in fact, very old, disease
of the skin, one that was known more than three hundred years before
the Christian era, and one with which you are all more or less familiar.
The object of this paper, therefore, is not to present new facts, but to
review old Ones.
Scabies in Rhode Island is each year becoming more prevalent.
We are seeing more cases in our hospital work, and many more in our
private practice. A few years ago Scabies was scarcely ever seen
except in the very poor and more filthy members of the community,
and could safely be called a disease of the lower strata of society, while
now every walk in life contributes its quota of patients suffering with
this disease. /
As you all know, Scabies is caused by a minute animal parasite, the
acarus scabei. This industrious little animal is the whole etiology. It
is a contagious disease of the skin and may be contracted by contact, as
shaking hands, direct body contact, etc., or through articles of clothing,
bedding, towels, gloves, and the like.
The male acarus, which is smaller than the female, measures .3
to 4 m.m. in length. The female is from a third to a half larger than
the male, and is visible to the naked eye as a minute dot about the size
of the point of the finest cambric sewing needle. They are oval in
shape; have short front legs (4) and long hair-like hind legs, which
tilt them to the proper angle for burrowing. Only the impregnated
female burrows. She makes a tunnel into the horny layer of the skin
down to the rete mucosa, upon which she feeds. As she burrows along
she lays one or two eggs daily. The burrow is from one-eighth to
one-half inch in length, curved in outline, with the live female at the
blind extremity. The average life of the femals acarus is about one
month. She never leaves her burrow and dies when all her ova
are hatched. The ova develop and hatch out in from four to eight
98 SCABIES
days. The larvae slough their skin three times, and are prepared then
to burrow and take care of themselves. They may burrow to the
surface, but usually are liberated from their tunnel by scratching of
the patient or exfoliating of the epidermis overlying the burrow.
The male acarus does not burrow, but hides in the crevices of the
skin, under crusts and dirt, impregnating the female young as they
come to the surface. The male acarus usually dies after copulation
and therefore is not a causative factor. He causes no itching, and is
no more harmful to the skin than particles of dirt that lodge thereon;
but it is different with the female, and, by the way, it is only the preg-
nant female that burrows. As soon as she becomes impregnated she
starts burrowing, and immediately there begins trouble. Itching starts
from the minute she begins her life work, that of burrowing a tunnel
for herself, a home for her eggs, and larvae, until such time as they are
capable of caring for themselves. After she has done all these and
her eggs are all hatched, she quietly dies at the blind end of her tunnel;
her life's work being completed in from four to six weeks. This is
the life history of a single female itch mite.
Hebra has said, “That between two parallels, one drawn through
the nipples, the other drawn just above the knees anteriorly, are found
most of the cutaneous manifestations of scabies.”
Thus the axillary folds, the anterior surface of the arm, forearms
and wrists, the interdigital spaces, the breasts in the female, the penis
and scrotum in the male, and the abdomen and chest in children are the
usual sites of the eruption. Rarely do we have the face, back or legs
involved, although they may be in children.
It can be readily seen that the burrowing of the female acarus must
be followed by itching, and a dermatitis of more or less severity pro-
duced. The skin lesions of scabies are of an inflamatory type, papules,
vesicles and pustules may all be present over the sites of the burrows.
These, plus the excoriations caused by scratching and the infection
caused by dirt and surface bacteria, constitute the visible signs. Usually
there is a red, slightly elevated papule at the site of the entrance of the
acarus into the horny layer of the skin. The itching, which is intense,
does not seem to be relieved by scratching.
The time of the itching—usually when undressing and when warm
in bed. The tendency of the lesions, papules, vesicles and pustules, to
remain more or less discreet, although at times, in severe and neglected
cases, the burrows may be so close together as to form bullae and
SCABIES 99
Scabs, and the typical burrow which is hard at times to find, but can, I
think, in nearly every case be demonstrated if carefully sought for.
The type of the disease which is essentially a dermatitis; in fact, a
papulo-vesicular dermatitis; the papules being surrounded by an
erythematous halo. The scratch marks are characteristic. They just
Scratch off the tops of the burrows without goughing the healthy skin
between, while the Scratch marks caused by scratching in eczema or
pediculosis are apt to be long and excoreating. (These symptoms make
the diagnosis of Scabies comparatively easy.)
The eruptions may vary from the very mild cases with only a few
burrows up to the severe neglected cases where the eruption is almost
universal.
The diagnosis is based on the distribution of the eruption, follow-
ing closely Hebra’s parallels. The typical burrow, which can, in nearly
every case, be found if carefully looked for, and the fact that the
acarus can be demonstrated under the microscope.
Scabies is always curable, usually in comparatively short time, and
a positive favorable prognosis may always be given, no matter how
severe or neglected the case may be. In speaking of treatment I shall
mention only three or four methods. There is nothing new to bring
to your attention. but will suggest several formulae that have proven
useful in my hands. The two indications to be met in treating this
disease are, first, to destroy the parasite, thereby removing the cause;
second, to overcome the dermatitis resulting from the ravages of the
parasites, and relieve the lesions produced by scratching and infection.
Sulphur in some form or other stands at the head of the list of
useful drugs for the first indication, namely, to destroy the cause, but
we must use sulphur with caution or, while we may destroy the parasite,
we surely will start up a dermatitis, which will put to shame the one
caused by the acarus. My almost routine treatment of a case of Scabies
is as follows: I give the patient two ounces of Sapo mollis, tell him
to go home, take a hot bath, using one-half the soap, rubbing it well
into the skin before getting into the tub, then scrub vigorously for
fifteen or twenty minutes, washing off all the soap, dry himself, and
then rub into the infected areas the following prescription:
R Sulphur Precipitatis . . . . . . . is e e s = e e e two drams
Beta Naphthol . . . . . . . . . . . . . . . . . . . . one dram
Peru Balsam . . . . . . . . . . . . . . . . . . . . . two drams
M. Petrolati . . . . . . . . . . . . . . . . . . . . . . . . . O116 Oll11Ce
This ointment is to be rubbed into the skin morning and night for
IOO SCABIES
three days. The same underclothing to be worn during the meantime.
At the end of the third day a warm bath is taken, scrubbing with the
balance of the green Soap, clean clothing put on, and the patient ordered
to report for examination. The clothing, bedding, sheets, etc., should
be sterilized by boiling. This treatment will cure the average case.
The itching stops after the first application of the ointment.
Sherwell of Brooklyn in 1899 recommended a method of treating
scabies that is both cleanly and non-irritating. Before going to bed the
patient takes a hot bath, Scrubbing himself vigorously with soap and
brush ; he then dries himself and rubs into the infected areas about a
dram of precipitated Sulphur, sprinkling the same amount into the bed
between the sheets. In the morning more sulphur is rubbed in and a
little sprinkled into the underclothing. I have used the Sherwell
method with good results, but it has nothing except cleanliness to rec-
ommend it over the ointments, and it takes several days longer to cure
than by the ointment treatment.
In children we must use great care in the choice of our ointments,
as their skin is very sensitive, and sulphur must be used with caution.
Balsam Peru and beta naphthol with vaseline make an elegant and non-
irritating ointment for children and sensitive skinned adults. The pro-
portion should be one or two drams of each to the ounce.
The Italian method has much to recommend it, especially in dis-
pensary work among the poor, where there are no facilities for bathing.
Balsam Peru, in this method, is painted thickly over the infected skin,
the clothing put on and no bath taken. This is very effective and non-
irritating.
When we have been so unfortunate as to get up a moist dermatitis
from too strong or too prolonged use of sulphur, the best method is to
sop on a lotion of
Acid Carbol. 95% . . . . . . . . . . . . . . . . One dram
Zinci oxide . . . . . . . . . . . . . . . . . . . . . one-half ounce
Aquae Calcis . . . . . . . . . . . . . . . . . . . eight ounces
several times daily. This will stop the irritation promptly.
At the Hospital St. Louis, in Paris, the routine treatment is fric-
tion with soft soap for twenty minutes; vigorous Scrubbing in a hot
bath from thirty to sixty minutes, the clothing in the meantime being
sterilized by heat; the parasiticide rubbed in for fifteen minutes, the
patient told to take a bath within twenty-four hours, and the disease
practically cured while you wait.
Care must be used not to overtreat. Itching following treatment
SCABIES IOI
does not always mean that we have not cured the scabies. It may
mean we have caused a dermatitis or eczematous process by our too
vigorous treatment.
In closing, I would say, view with suspicion any papulo vesicular
dermatitis that comes within the confines of Hebra’s parallels, no mat-
ter what the social station of the patient may be.
Second—Be cautious in your treatment; use by preference mild
rather than severe methods, thereby preventing a drug dermatitis.
And lastly—if sure of your diagnosis—promise a prompt and
complete cure without fear.
THE PROPOSED BUILDING FOR THE RHODE ISLAND
MEDICAL SOCIETY
BY
ROBERT F, NOYES, M.D.
PROVIIDENCE
&
*-
On May 13, 1908, at a meeting of the House of Delegates of the
Rhode Island Medical Society the late Dr. H. G. Miller, then Chairman
of the Library Committee, knowing that the library could not indefi-
nitely be housed in the Providence Public Library, recommended that
a committee of three be appointed, to be known as the Ways and Means
Committee, which should confer with the Building Committee respect-
ing the future care of our library. In accordance with this recom-
mendation, Drs. G. Alder Blumer, John M. Peters and Halsey De Wolf
were appointed such committee.
In order that there might be a free and open consideration of all
matters germain to the whole question of the library this committee
invited the Library Committee to meet with it and the Building Com-
mittee at Brown University. After several meetings this committee
reported to the House of Delegates May 16, 1910, and was discharged.
This committee reported that it had conferred with the officers of
the Providence Public Library in order to ascertain what further
arrangement, is any, could be made with that institution as to the
accommodation of the Society's library. These gentlemen stated that
our library contained at present about 30,000 volumes and occupied
nearly one-fifth of the space of the whole building; that the Public
Library was becoming more and more cramped for room; that the
space now occupied by our library was at present much needed;
that by a rearrangement of the books, storing those not needed for
reference and restricting the space at present occupied, our library
could be accommodated for perhaps two years longer, but at the end of
that time the quarters must be vacated.
The committee thereupon considered the advisability of providing
a proper building to accommodate the Society's library and to provide
for the various needs of the Society. After due consideration and
after visiting several buildings, the committee became firmly impressed
THE PROPOSED BUILDING For THE R. I. MEDICAL Society 103
that it is necessary that the Society build and own a suitable building
for the library and the general uses of the Society, and made the fol-
lowing suggestions:
First. That the House of Delegates should appoint a commit-
tee, consisting of the Building Committee, the Treasurer of the Society,
the Librarian, the Chairman of the Library Committee and two other
Fellows of the Society, to formulate a plan for providing suitable
accommodation for the library in a building to be devoted to the
Society’s interests and uses.
Second. That the committee be given power to select and pur-
chase a suitable site for such building.
Third. That it be given power to delegate to sub-committees cer-
tain portions of its work.
In accordance with this report, a committee was appointed by the
House of Delegates on May 17, 1910, consisting of Drs. Mitchell, Day,
F. H. Peckham, Noyes, J. M. Peters, Hersey, Risk, Briggs, Wheaton
and Rogers.
From May 19 to November 14, 1910, twenty-one meetings of this
committee and the sub-committee were held, and it reported to the
House of Delegates on November 10, 1910, as follows: f
The committee appointed by the President on May 17, 1910, to
carry out the resolutions adopted by the House of Delegates at a meet-
ing held on that date, regarding the purchase of a site and the construc-
tion of a building for the use of the Society, beg to submit the follow-
ing report:
In accordance with the authority granted, the committee has pur-
chased a site for the building at the corner of Francis and Hayes Streets.
The same has been paid for and the deeds passed.
The question of financing such a building was left to a sub-com-
mittee under the chairmanship of Dr. R. F. Noyes, and at a meeting
held at II 7 Broad Street, on Thursday, November Io, this committee
recommended:
I. That the Society should transfer, for the purpose of erect-
ing the building, the funds now held under the wills of the late Drs.
Chase Wiggin and Horace G. Miller, the balance of the Printing Fund,
the Building Fund and the Library Fund, leaving, however, these funds
intact and respecting the terms of gifts of the various donors, the
Society investing these funds in the building and giving notes therefor
to their present Trustees.
2. That the Society should authorize the issuance of certain
IO4 THE PROPOSED BUILDING FOR THE R. I. MEDICAL SOCIETY
bonds, which shall have twenty years to run and which shall bear inter-
est at five per cent. after ten years. These bonds shall revert to the
Society in event of the death of the owner prior to the interest-bearing
period and shall be subject to recall at any time after that period at
par with interest.
A Sub-committee on Plans, under the chairmanship of Dr. F. T.
Rogers, reported:
I. That after a careful study they presented to the committee a
set of plans, designed by Messrs. Clarke, Howe & Homer, which they
believe cared for the requirements of the Society and afforded ample
accommodation for the library of the Society.
2. That this building could be erected at an approximate cost of
$40,000.
Upon the acceptance of these two reports from the sub-commit-
tees, the committee voted to recommend to the House of Delegates:
I. That a committee be appointed, to be known as the Trustees of
the Rhode Island Medical Society Building. This committee shall con-
sist of the President, Secretary and Treasurer, ex-officio, five members
and one member from each of the district societies, to be selected imme-
diately by the district society.
2. That this committee shall have authority to fill vacancies, add
to its members and appoint sub-committees from the Society in the
furtherance of its plans.
3. That upon completion of the building they shall by lot or by
mutual agreement choose one member to serve five years, one four
years, one three years, one two years and one one year, as permanent
Trustees of the building, and that there shall be afterwards annually
appointed by the President one member to serve five years.
4. That this committee shall have power to utilize the funds of
the Society transferred to it, to raise money by the sale of bonds or by
a mortgage to be placed upon the property, and when in their judgment
sufficient funds are at hand shall have authority to contract for and
construct the building for the use of the Society, substantially accord-
ing to the plans which have been presented.
5. That this committee shall have full control of the building
until completed, subject to the instructions from the House of Dele-
gates.
6. That this committee shall make a report of its proceedings and
shall give an account of all expenditures of money at each quarterly
meeting of the Society.
THE PROPOSED BUILDING FOR THE R. I. MEDICAL SOCIETY Io;
In accordance with the recommendations of the report, a commit-
tee, to be known as the Trustees of the Rhode Island Medical Society
Building, was constituted as follows: Drs. F. T. Rogers, Chairman;
Mitchell, Noyes, Day and J. M. Peters, one member of the Society from
each of the six district societies to be appointed immediately by the dis-
trict societies and the President, Secretary and Treasurer ex-officio.
It was voted that the duties and powers of these Trustees shall be
as follows:
I. That they shall have authority to fill vacancies, add to their
members and appoint sub-committees from the Society in the further-
ance of their plans.
2. That upon completion of the building they shall by lot or by
mutual agreement choose one member to serve five years, one four
years, one three years, one two years and one one year, as permanent
Trustees of the building, and that annually afterwards there shall be
appointed by the President one member to serve five years.
3. That they shall have power to utilize the funds of the Society
transferred to them, to raise money by the sale of bonds or by a mort-
gage to be placed upon the property, and when in their judgment suffi-
cient funds are at hand shall have authority to contract for and con-
struct the building for the use of the Society substantially according to
the plans which have been presented.
4. That they shall have full control of the building until com-
pleted, subject to instructions of the House of Delegates.
5. That they shall make a report of their proceedings and give
an account of all expenditures of money at each quarterly meeting of
the House of Delegates and Society.
The Trustees earnestly solicit the co-operation of the individual
members of the Society in this enterprise. It is also open to sugges-
tion from the members of the Society concerning the construction of
the building, its location and its equipment.
The Treasurer of the Society, who is also a member of the Trus-
tees, is ready to receive donations to the Building Fund. It is earnestly
hoped that this fund will be rapidly increased in order that the con-
struction of a home for the Society may be begun in the early Spring,
which is necessary if the Society would celebrate its centennial in a
home of its own.
Annual Report
Dr. RHODE ISLAND MEDICAL SOCIETY in Account with GEO. S. MATHEWS, Treasurer. {Cr.
I 910 - I909
Mar. I To quarterly collations. . . $151 49 Mar. I By balance from Jast
“ annual dinner. . . . . . . . . 262 50 report. . . . . . . . . . . . . $644 27
“ wine and cigars. . . . . . . I25 36 “ annual exhibits. . . . . . 87 50
“ music, annual dinner. 17 OO “ annual dues. . . . . . ... 1,725 Oo
‘‘ rent, Masonic Hall.... 75 Oo $631 26 “ interest on call ac-
“ library attendance and Count. . . . . . . . . . . . . . I4 25
work in library. . . . . . 627 7o “ guests’ tickets. . . . . . . 3 OO
“ books and new publica- - sºme $2,474 o2
tions . . . . . . . . . . . . . . . tº 74 OO *E*E*
“ binding. . . . . . . . . . . . . . . 267 75
“ telephone in library... 4O 45
‘‘ express and freight... 8 57. I, oi 8 47
“ printing transactions. . 258 76
“ printing notices, etc... 69 74 328 50
“ expenses, secretary,
postage, etc. . . . . . . . . 79 33 79 33
“ rent of safe deposit. . . IO OO IO OO
$2,067 56
“ cash on hand to balance 406 46 w
$2.474 oz $2.474 oz -
Examined and found correct,
FRANK. T. Fulton
May 14, 1910 WILLIAM H. BUFFUM
lsº
Dr. R. I. MEDICAL SOCIETY BUILDING FUND in
Account with GiBO. S. MATHEWS, Treasurer. Cr.
1910 I OO
Mar. I To Union Trust Co. “Con- Mº. 9 I By deposit Union Trust
tingent Certificate”. $995 82 o . . . . . . . . . . . . . . . . $3,983 30
“ deposit R. I. Hospital “ accrued interest. . . . . 1IQ 33
Trust Co. . . . . & = & º a tº 4 2 I 2 J4 “ deposit R. I. Hospital
— $5,207 of Co. . . . . . . . . . . . . . . . . 1,062 92
* “ interest on deposit R.
I. Hospital Trust
Co. . . . . . . . . . . . . . . . . 42 4 I
— $5,207 96
$5,207 96 $5,207 96
Dr. R. I. MEDICAL SOCIETY PRINTING FUND in Account with GEO. S. MATHEWS, Treasurer, Cr.
I9 IO I 909
Mar. I To 3 United Traction Co. Mar. I By 3 United Traction Co.
bonds . . . . . . . . . . . . . . $3,521 67 bonds. . . . . . . . . . . . . . . $3,521 67
“ Union Trust Co. “Con- ‘‘ interest on same Mar.
tingent Certificate”. 25o 88 1909 and Sept. 1909. I5O OO
“ deposit Citizens Sav- “ deposit Union Trust
ings Bank. . . . . . . . . . 1,891 ob Co. . . . . . . . . . . . . . . . . . I, OO3 52
“ deposit R. I. Hospital “ accrued interest. . . . . . 3O OI
Trust Co. . . . . . . . . . . . 1,061 of - “ deposit Citizens Sav-
— $6,724 70 ings Bank. . . . . . . . . . 1,670 IO s
sºmºmº sº. “ interest on deposit Cit-
izens Savings Bank. 7o 98
“ deposit R. I. Hospital
Trust Co. . . . . . . . . . . . 267 79
“ interest on deposit R. -
I. Hospital Trust Co. Io 63
— $6,724 70
$6,724 7o $6,724 70
Dr. R. I. MEDICAL SOCIETY LIBRARY FUND in Account with GEO. S. MATHEWS, Treasurer, Cr,
I 91 O
Mar. I To deposit Industrial Trust
Co. Mechanics Branch $347 45
$347 45
$347 45
I 909 -
Mar. 1 By deposit Industrial Trust
Co. Mechanics Branch $333 99
‘‘ interest on same. ...... I3 46
$347 45
gº-ºº-ººººººº.
$347 45
Dr. R. I. MEDICAL SOCIETY CHASE WIG GIN FUND in Account with GEO. S. MATHEWS, Treasurer, Cr.
$6,302 50
1 9 IO -
Mar. I To deposit R. I. Hospital
Trust Co. . . . . . . . . . . . $6,302 50
$6,302 50
gººmsºmºsºme
I OO
M. 9 I By deposit R. I. Hospital
Trust Co. . . . . . . . . . . . $6,057 8o
“ interest on same. . . . . . 244 7O
*=º $6,302 50
$6,302 50
Dr. R. I. MEDICAL society Horace G. MILLER FUND in acct, with GEO. s. MATHEws, Treas. Cr.
1910
Mar. I To deposit R. I. Hospital
Trust Co. . . . . . . . . . . . $5,000 OO
— $5,000 OO
$5,000 OO
I969
D. I4 By deposit R. I. Hospital
Trust Co...... . . . . . . $2,500 oo
I91O
Jan. 24 “ deposit R. I. Hospital
Trust Co. . . . . . . . . . . . 2,500 OO
$5,000 OO
$5,000 Oo
Examined and found correct
FRANK. T. FULTON
May 14, 1910 WILLIAM H. BUFFUM
REPORT OF THE COMMITTEE ON THE LIBRARY
From June I, I909 to May 31, 1910, the library received 438
bound volumes from the following sources :
United States Government º * * e II
Other gifts . te e e ſº g & 344
In exchange . . se & * * * 2O
By purchase * º * º * - * II
Transfer by binding . tº e * e * 52
Total, 438
We have also received 266 reprints and 408 pamphlets, the latter
including various local health reports and government publications.
The number of visitors at the library during the year was 1375,
and the number of volumes consulted, 3412. This does not, however,
include the books taken down by readers having access to the shelves,
of which no record could be kept.
Mrs. Churchill gave to the library a number of books and medi-
cal pamphlets from the collection of Dr. Donald Churchill, Mrs.
Sprague gave 30 volumes from the library of Dr. Frank B. Sprague
and Dr. Philip K. Taylor, removing from the state, gave his library
of 138 volumes besides a large collection of miscellaneous pamphlets.
We also received the books sent to the Providence Medical Journal
for review and all the exchanges of the Journal.
We received from the John Carter Brown Library, through the
librarian, Mr. George Parker Winship, 17 volumes of medical Ameri-
cana, books printed in America prior to 18OI. These form a valuable
addition to the historical section of our collection.
Gifts were also received from Dr. Francis H. Brown, Boston,
Drs. J. W. Robinson and A. Jacobi of New York, Rev. S. H. Webb
and Mrs. Daniel Henshaw of Providence, Dr. John W. Wainwright
of New York, the Department of Neurology of Harvard Medical
School, Dr. H. S. Lamson of Providence, and from the following
Fellows: C. O. Ballou, H. R. Brown, R. H. Carver, C. V. Chapin,
J. E. Donley, W. Fletcher, G. D. Hersey, C. H. Leonard, W. H.
Magill, G. T. Swarts, J. A. Webb, S. A. Welch, W. R. White.
A LIST OF THE FELLOWS
OF THE
RHODE ISLAND MEDICAL SOCIETY.
[Revised to December 31, 1910]
When elected. Name. Post Office. Street.
1888 Abbott, Edmund. . . . . . . . Providence. . . . . 148 Broadway
1890 Abbott, Harlan P. . . . . . . Providence. . . . .274 Benefit st.
1910 Adams, Frank _M. . . . . . . Providence..... 276 Weybosset st.
1888 Akers, Joseph H. . . . . . . . Providence..... 816 North Main st.
188o Albro, Christopher D... Milford, Mass. -
1876 Allen, Edward S. . . . . . . Providence ..... 292 Benefit st.
1904 Anderson, Alexander J.. Newport........ 123 Pelham st.
1909 Archambault, Jean B. . . Woonsocket ....6 Greene st.
191o Archambault, Lionel M. Arctic.
1907 Armington, Herbert H. . Warren.
1890 Arnold, Barnard. . . . . . . . North Scituate.
1883 Arnold, Henry......... Foster Centre.
1890 Bacon, Edward S. . . . . . . Providence.... .265 Benefit st.
1899 Bailey, George M. . . . . . Providence..... Journal Building,
1878 Ballou, Charles O. . . . . . Providence..... I ra. Daboll st.
1891 Baldwin, Mary E. . . . . . . Newport........ I 13 Touro St.
1906 Barber, Joseph D. . . . . . . Westerly . . . . . . . 50 Granite st.
1891 Barker, Christopher F.. Newport ....... 32 Bull st.
1906 Barnes, Harry L. . . . . . . Wallum Pond.
1904 Barrows, Albert A...... Providence. . . . . 27 Waterman st.
1894 Barry, William F. ...... Woonsocket .... Edwards Block.
1885 Baxter, John J. . . . . . . . . Woonsocket . . . .356 South Main st.
1906 Bean, Fred W. . . . . . . . . . Anthony.
1902 Beck, Horace P. . . . . . . . Newport. . . . . . . 122 Touro st.
1894 Bennett, Joseph M. . . . . Providence. . . . . 143 Broad st.
1903 Best, Oliver F. . . . . . . . . . Providence..... 90 Broad st.
1891 Black, Thomas F. . . . . . . Providence..... 207 Broadway.
1899 Blumer, G. Alder....... Providence..... Butler Hospital
1895 Bodwell, James M. . . . . . Phenix
1901 Boucher, Richard P.... Providence..... 116 Academy ave,
1863 Bowen, William H. . . . . . Providence. . . . . 74 Broad st.
1904 Brackett, Edward S. ... Providence. . . . . 262 Benefit st.
1903 Bradshaw, Arthur B. ... Providence.....49 Beacon ave.
1906 Brazill, Frank H. ...... Greenville.
1878 Briggs, Alexander B. . . . Ashaway.
1897 Brown, Byron J. Jr..... Providence..... 448 Hope st.
1904 Brown, Frederick N. ... Providence..... 1192 Westminster st.
1904 Brown, Henry R. . . . . . . Providence. . . . . 128 Broad st.
1895 Brown, J. Edmund..... Providence..... 133 Wesleyan ave.
1908 Browne, Wilfred W. ... Woonsocket . . . .65 Main st.
1876 Brug, George A. . . . . . . . Providence. . . . . 179 Washington st.
1903 Buffum, William H..... Providence ..... 276 Benefit st.
1902 Bullard, Ernest C. . . . . . Jamestown.
1898 Burdick, Frank E. . . . . . Providence. . . . . 6 Harrison st.
1876 Burge, William J. ...... Pawtuxet.
1899 Burke, Francis E. ......Wakefield.
I I I
When elected Name Post Office Street
1889 Burnett, Frank G. . . . . . . Pawtucket..... 77 High st.
190o Burnett, Henry W. ..... Providence . . . . . 274 Benefit st.
1884 Burton, Sanford S. . . . . . Providence . . . . . 20 Market square.
1884 Buxton, Gonzalo E. . . . . Providence . . . . . 1471 Broad st.
1898 Calder, Augustus W. ... Providence . . . . . 184 Angell st.
I9 Io Calder, Harold G....... Providence . . . . . I 14 Broad st.
1905 Calef, Frank T. . . . . . . . . East Providence. 62 Taunton ave,
1903 Campbell, Edward..... Providence . . . . . 85 Hope st
1880 Capron, Franklin P.. ... Providence . . . . . 18 Angell st.
1904 Capwell, Remington P.. Providence .....Journal Building.
1904 Carpenter, Elbridge G.. Fast Greenwich.
I9 Io Carroll, Harry V. . . . . . . Newport. . . . . . . . 297 Spring st.
1870 Carver, R. Herbert. . . . . Providence . . . . . I I I Broad st.
1886 Champlin, John...... ... Westerly . . . . . . . 3 Granite st.
1880 Chapin, Charles V...... Providence . . . . . City Hall.
1901 Chapman, W. Louis.... Providence..... 254 Benefit st.
1898 Chase, Julian A........ Pawtucket. . . . . .22 Park Place.
1891 Chesebro, Edmund D... Providence . . . . . 2 Hawthorne st.
1898 Christie, Charles S...... River Point,
1876 Clark, Charles K...... . Fiskeville.
1895 Clarke, Eiisha D. . . . . . . Woonsocket . . . . 68 Hamlet Ave.
1900 Clarke, Elliott M. . . . . . East Greenwich.
1886 Collins, George L...... Providence . . . . . 223 Benefit st.
1887 Cook, Irving S. ........ Georgiaville.
I907 Cooke, Charles O. . . . . . . Providence . . . . . 25 i Broad st.
1899 Cooke, Henry A........ Providence . . . . . 234 Benefit st.
1896 Cooney, John P......... Providence . . . . . 68 Jackson st.
1902 Corbett, Francis A. . . . . Newport. . . . . . . . 133 Spring st.
1909 Corrigan, Henry J. C. ... Providence . . . . . 242 Broadway.
I904 Corrigan, John P. . . . . . . Pawtucket. . . . . . to Maple st.
1902 Cottrell, Samuel P. . . . . . Newport. . . . . . . . to 5 Pelham St.
1890 Coxe, Dorran B........ Riverside.
1904 Crooker, George H. . . . . Providence . . . . . 1.59% Benefit st.
1901 Cutts, William B. . . . . . . Providence . . . . . 37o Broad st.
1909 Danforth, Murray S. ... Providence . . . . 242 Broad st.
1899 Darby, Thomas F...... River Point.
1902 Darrah, Rufus E. ...... Newport. . . . . . . . To Bull st.
1883 Davenport, James H... Providence . . . . . 21o Benefit st.
1890 Day, Frank L. . . . . . . . . . Providence. . . . . . 72 Waterman st.
1901 Deacon, Charles F. . . . . Providence . . . . . 48o Friendship st.
1898 De Wolf, Halsey....... Providence . . . . . 212. Benefit st.
1904 Donley, John E. Jr..... Providence . . . . .222 Broadway
1902 Doten, Carl R. . . . . . . . . . Providence . . . . . 583 Cranston St.
1906 Duckworth, Milton . . . . . Carolina.
1893 Duffy, James F........ Providence . . . . . 4Io Benefit st.
1910 Duffy, John E. . . . . . . . . . Natick.
1908 Dyer, William H. . . . . . . Providence . . . . . 6 Adelaide ave,
1891 Ecroyd, Henry...... ... Newport. . . . . . . . to 6 Touro St.
1886 Edwards, Frederick. . . . Providence . . . . . 1591 Westminster st.
1889 Farnum, Mary L. . . . . . . Woonsocket. . . . . 362 South Main st.
1888 Farrell, John T. ........ Providence . . . . . 68 Jackson st.
1906 Fenwick, Adolph R. V. . Central Falls. ... 250 Broad St.
1906 Ferguson, John B. . . . . . Providence ..... 369 Broad st.
1900 Fisher, Alva A. . . . . . . . . Providence . . . . 231 Broad st.
1905 Fisher, J. Leroy. . . . . . . . Providence . . . . . 789 Broad st.
1896 Fisher, Parnell E. .... ... Providence . . . . . 349 Smith St.
Igo7 Fishman, Abraham P. . . Providence . . . . . 91 Orms St.
1898 Fitzgerald, Vance L.... Providence . . . . . 236 Broadway.
1903 Flanagan, William F... Providence . . . . . 91 Hope st.
1904 Fletcher, William... . . . Providence . . . . . 128 Broad st.
I I 2
When elected Name Post Office Street
1894 Flynn, Harry S. . . . . . ... Providence ... ... 186 Smith st.
1891 French, Charles H. . . . . . Pawtucket ...... Io9 Broadway.
1881 Fuller, Frank B. . . . . . . . Pawtucket ...... III High st.
1903 Fulton, Frank T. . . . . . . . Providence ..... 96 Prospect'st.
1882 Gardiner, Henry K. . ... Wakefield.
1905 Gardner, George W. ... Providence . . . . . 26o Benefit st.
1868 Garvin, Lucius F. C. ... Lonsdale.
1904 Gaylord, Wm. A . . . . . . . Pawtucket . . . . . .25 Main st.
I895 Gilbert, James A. . . . . . . Providence . . . . .284 Thayer st.
1900 Gillan, William F. A... Pawtucket..... . Io97 Main st.
1909 Glancy, Charles A. . . . . • Bristol. . . . . . . . .399 Wood st.
1888 Gleason, William F. . . . . Providence ..... 59 Jackson st.
1883 Godding, Clarence M... Providence . . . . . 312 Benefit st.
1896 Gomberg, Max B. . . . . . . Providence . . . . . 61 Benefit St.
1894 Gray, Daniel F. . . . . . . . . Providence ..... 142 Broad st.
1906 Green, Herlwyn R. . . . . . Providence ..... 274 Benefit st.
1878 Greene, Willard H. . . . . . Providence . . . . . 23 Potter ave,
190o Griffin, Clifford H. . . . . . Providence ..... Io I Broad st.
1906 Haberlin, James H. . . . . Pawtucket...... Slater Trust Building.
I906 Hale, Robert C. . . . . . . . Providence . . . . . 1447 Broad st.
188o Hall, Henry C. . . . . . . . . . Providence ..... Butler Hospital.
1893 Hall, Nelson R. . . . . . . . . Warren. -
1870 Ham, Albert E. . . . . . . . . Providence . . . . . 199 Benefit st.
1905 Hamlin, Edgar F. . . . . . . Slatersville.
1905 Hammond, Roland. . . . . Providence . . . . . 266 Benefit St.
1907 Hardman, Margaret S ... Providence . . . . . 166 Broadway.
1908 Harrington, Arthur H.. Howard.
1896 Harrington, Francis M. Providence . . . . .446 Broadway
1909 Harris, William L. . . . . . Providence . . . . . 532 Broad St.
1891 Harvey, Edwin B...... Providence ..... 181 Broad st. N
1893 Harvey, Norman D. . . . . Providence I 14. Waterman st.
1905 Hasbrouck, Ira D. . . . . . Washington.
1903 Hawkes, Charles E. . . . . Providence . . . . . 55 Jackson St.
1898 Hawkins, Joseph F. . . . . Providence . . . . . Banigan Bldg.
1901 Hayes, Albert E. . . . . . . . Providence . . . . . 128 Broad st.
1906 Henry, James E. F. . . . . Providence . . . . . 61o Cranston st.
1875 Hersey, George D. . . . . . Providence ..... 148 Broad st.
191o Hess, Peter W. . . . . . . . . Pawtucket . . . . . . 210 Main St.
1896 Higgins, Charles W. ... Providence . . . . . 2 George st.
1905 Higgins, William H. ... Providence . . . . . 144 Dexter St.
1907 Hillard, William A. . . . . Westerly ....... 137 West Broad st.
1905 Hindle, William . . . . . . . . Providence . . . . . 334 Broad st.
190o Hollingworth, Arthur... Providence . . . . . 593 Broad st.
1910 Holt, Charles H. . . . . . . . Pawtucket...... 143 Mineral Spring ave.
1905 Hopkins, Henry W. . . . . Warren. * -
1893 . Howe, George J. . . . . . . Central Falls. . . .428 High st.
1902 Hoye, Henry j . . . . . . . . . Providence . . . . . 194 Broad St.
1868 Hunt, Simeon. . . . . . . . . . East Providence. 2 Second st.
1891 Hunt, William W. . . . . ... East Providence.95 Warren ave.
1908 Hussey, Frederic V..... Providence .... .259 Benefit st.
1906 Hussey, John P.......... Providence ..... 166 Cranston St.
1902 Jacoby, Douglas P. A... Newport........ 18 Bull st.
1895 Jenckes, Frank H. . . . . . . Woonsocket. . . . . 172 Main st.
1855 Jenckes, George W. . . . . Woonsocket..... 47 Spring st.
1898 Jewett, Fred B. ........ Howard.
1898 Jones, Arthur T. ....... Providence . . . . . 214 Benefit st.
1898 }: Henry A....... . Howard.
1902 Jordan, William H. ..... Providence ..... 182 Academy ave.
1887 Keefe, John W. . . . . . . . . Providence . . . . .259 Benefit st.
1898 Keefe, Patrick H. ... ... Providence . . . . .257 Benefit st.
I905
Kelley, Jacob S. ........ Providence . . . . . 153 Smith St.
II 3
When elected Name Post Office Street
1890 Kennon, Charles E. D’V. Providence . . . . . 117O Westminster st.
1890 Kerins, John F. . . . . . . . . Providence . . . . . 53 Governor st.
1908 Kiley, Edward S. . . . . . . . Pawtucket. . . . . . 23 Park Place.
1892. Kimball, Harry W. . . . . . Providence . . . . . 276 Benefit st.
1876 King, Dan O. . . . . . . . . . . Auburn. . . . . . . . . 1303 Elmwood ave.
188o King, Eugene P. . . . . . . . Providence . . . . . City Hall.
1906 King, Hamilton T. . . . . . Newport. . . . . . . . 19 Powell ave.
1910 King, James A. . . . . . . . . Woonsocket. . . . . 189 Harris ave.
1870 Kingman, Eugene. . . . . . Lisbon, N. H.
1908 Kingman, Lucius C. . . . . Providence . . . . . 212 Benefit st.
1903 Kirby, William W. . . . . . Providence . . . . . 377 Elmwood ave.
I902 Knapp, Harry J. . . . . . . . Newport. . . . . . . . 20 Catherine st.
1894 Latham, Daniel S. . . . . . Auburn. . . . . . . . .678 Park ave.
I906 Leech, James W. . . . . . . . Providence . . . . . 117 Broad st.
1881 Legris, M. Joseph E. ... Arctic.
1870 Leonard, Charles H. . . . Providence . . . . . 156 Broad st.
1908 Lewis, James N. . . . . . . . Ashaway.
1884 Lillibridge, Byron J. ... Providence .... 716 North Main st.
1907 Logan, Edward J. . . . . . . Providence . . . . . 1 134 Westminster st.
1907 Long, Samuel H. . . . . . . . Apponaug.
19 to Love, Alfred W. . . . . . . . . Providence . . . . . 221 Broad st.
1896 Lovewell, Henry P. . . . . Providence . . . . . 1266 Westminster st.
1904 Mack, John A. . . . . . . . . . Crompton.
1891 MacKaye, Henry G. . . . . Newport 16 Catherine st.
1898 MacKnight, Adam S. . . . Fall River, Mass. 355 North Main st.
1906 Magill, William H. . . . . . Providence . . . . . I 18 Broad st.
1892 Mahoney, Michael P. . . . Providence . . . . .63 East st.
1860 Mann, Augustine A....Central Falls.
1893 Marshall, Alexander. ... Berkeley.
1876 Mathews, Adrian. . . . . . . Providence . . . . . 131 Ocean St.
1890 Mathews, George S. . . . . Providence . . . . . 417 Cranston St.
1903 Matteson, George A. ... Providence . . . . . 276 Benefit st.
1905 May, John L. . . . . . . . . . . Westerly . . . . . .71 High st.
1881 McCaw, William J...... Providence ..... 28o Benefit St.
1906 McDermott, Bernard F. Providence . . . . . 52 Aborn St.
1902 McDonald, William, .... Providence .... 188Blackstone Boulevard
1906 McGraw, George B. . . . . Pawtucket. . . . . . 33 North Union St.
1894 McGuirk, William R. ... Providence ..... 391 Broad st.
1905 McKenna, Frank A. . . . . Pawtucket. . . . . .3 Broadway.
1890 McKenna, John B...... East Providence. 12 Summit st.
1898 McLaughlin, William H. Providence ..... 462 Benefit st.
1896 Merriman, Alfred M. ... Bristol.......... 597 Hope St.
1906 Messenger, Harry C. ... Providence . . . . . 260 Broad st.
1888 Metcalf, Harold. . . . . . . . Wickford.
1905 Milan, Michael B. ...... Providence ..... 1582 Westminster st,
1901 Miller, Albert H. . . . . . . . Providence . . . . . 279 Benefit st.
1872 Mitchell, John W. . . . . . . Providence . . . . . 227 Benefit st.
1876 Monroe, William C. . . . . Woonsocket. . . . . 99 Providence St.
1887 Moore, Elmer E. . . . . . ... E. Providence Centre.
1899 Moore, James S........ East Providence.8 Walnut St.
1875 Morgan, James R. . . . . . Providence . . . . . Io Franklin St.
1881 Morgan, John H. . . . . . . . Westerly . . . . . . . 43 High St.
1897 Mowry, Classen. . . . . . . . Providence . . . . .24 Greene St.
1897 Mowry, Jesse E. . . . . . . . Providence . . . . . 563 Cranston St.
1902 Munro, Catherine N. . . . Providence . . . . . 14o Pitman St.
1886 Munro, Walter L. . . . . . . Providence . . . . . 62 North Main st,
1902 Murphy, Edward V. . . . . Newport. . . . . . . . 50 Pelham St. ...
1904 Murphy, Thomas H. ... Pawtucket...... 2 Sheldon Building.
1907 Nestor, Michael J. ...... Providence ..... 728 North Main st.
1874 Noyes, Robert F. ..... . Providence . . . . . 53 Jackson St.
1904 O'Connell, Joseph C. ... Providence ..... 341 Smith St.
II4
Smith, George R. . . . . . . Woonsocket ..
When elected Name Fost Office Street
1888 O'Keefe, John A. . . . . . . Providence . . . . .355 Broadway.
1903 O'Meara, John G. . . . . . . . Providence . . . . . 547 Broadway.
1894 O'Neil, John E. . . . . . . . . Providence . . . . . 399 Prairie ave,
1905 C'Neil, Michael J. . . . . . . Providence . . . . . 120 Broad st.
1908 Page, Warren E. . . . . . . . Phenix, -
1872 Paine, Ara M. . . . . . . . . . Woonsocket. . . . . 383 South Main st.
1896 Palmer, Harold G. . . . . . Providence . . . . . 28 North Main st.
1904 Parker, Edward S. . . . . . Pawtucket. . . . . . 119 Broadway.
1907 Parker, John C. . . . . . . . . Providence . . . . . 266 Broad st.
1897 Partridge, Herbert G... Providence . . . . . 371 Broad st.
1907 Payne, Frank I. . . . . . . . Westerly . . . . . . . II Grove ave.
1891 Peckham, Charles F. ... Providence . . . . .6 Thomas st.
1866 Peckham, Fenner H. . . . Providence . . . . . 6 Thomas st.
1891 Peckham, Frank E. . . . . Providence . . . . . 266 Benefit St.
1895 Perkins, Jay. . . . . . . . . . . Providence . . . . . 1 of Waterman st.
1873 Perrin, Nelson . . . . . . . . . Pawtucket -
1889 Peters, Jonn M. . . . . . . . . Providence . . . . . R. I. Hospital.
1898 Peters, William H. . . . . . Providence ..... 195 Benefit st.
1904 Phillips, Frederick G. . . Providence . . . . . 315 Broad st.
1905 Phillips, James L. . . . . . . Providence . . . . . 421 Cranston St.
1891 Pierce, Edward E. . . . . . Providence ..... 328 Broadway.
1903 Pitts, Herman C. . . . . . . Providence . . . . . 2 Io Benefit st.
1909 Poirier, Alfred. . . . . . . . . Woonsocket..... 194 Main st.
1907 Porter, Lewis B. . . . . . . . Providence . . . . . 277 Benefit st.
1903 Potter, Henry B. . . . . . . . Wakefield. -
I902 Powell, Stephen C. . . . . . Newport. . . . . . . . 19 Beach St.
1892 Putnam, Helen C. . . . . . Providence . . . . , Rhode Island ave.
1889 Raia, Vito L. . . . . . . . . . . Providence . . . . . 272 Broadway.
1904 Ramsay, George D. . . . . Newport. . . . . . . . 3o Kay st.
1897 Randall, Arthur G. . . . . Providence . . . . . 20 Market square.
1878 Raymond, Charles N. . . Providence ..... 147 Reservoir ave.
1906 Remington, John A. . . . Central Falls. ... 139 Central st.
1904 Reoch,"William A. . . . . . Phenix.
1898 Richards, Byron U. . . . . Pawtucket . . . . . 8 Summer st.
1910 Richardson, Dennett L. Providence . . . . . City Hospital.
1907 Ricker, Carroll H. . . . . . Block Island.
1894 Risk, Winthrop A. . . . . . Providence . . . . . State Home and School.
1906 Robinson, Julius J. . . . . . Providence . . . . .247 Cranston st.
1894. Robinson, Rowland R...Wakefield.
1904 Rogers, Floyd W. . . . . . . Wickford.
1882 Rogers, Frederick T. ... Providence . . . . . 117 Broad st.
1904 Rose, Alanson D. . . . . . . Providence . . . . . 912 Manton ave.
1896 Roswell, Joseph T. . . . . . Woonsocket . . . . . 91 Main st.
1898 Rothwell, William P. . . Pawtucket...... 26 High st.
1901 Rounds, Albert W. . . . . . Providence . . . . .70 Broad st.
19 to Ruggles, Arthur H. . . . . Providence . . . . . . Butler Hospital.
1896 Rutherford, Jacob C. ... Providence . . . . . 58 Jackson. St.
1906 Savage, Chester G. . . . . Westerly . . . . . . . 41 Granite st.
1905 Scanlon, Michael H. . . . . Westerly . . . . . . . 45 High St.
190o Seymour, Walter E. . . . . Riverside.
1897 Shattuck, George L. . . . Providence . . . . .43 George st.
1892 Shaw, Ralph H. R. . . . . Thornton.
1906 Shea, Eugene F. . . . . . . . River Point. . . . . Allen st.
1904 Sherman, William A. . . Newport. . . . . . . . 51 Touro St.
1902 Sherman, William S. ... Newport. . . . . . . 5 Kay St.
1907 Siegel, Oswald R. . . . . . . Bristol.
1901 Simpson, George E. . . . . Howard.
1904 Skelton, Creighton W. . Providence . . . . . 589 Broad st.
188o Smith, Edgar B. . . . . . . . Providence . . . . . 68 Brown St.
1880 Smith, Frank B. . . . . . . . Washington. -
1884 ... 33 Collins St.
II 5
When elected Name Post Office Street
1894 Smith, Harry W. ...... North Scituate.
1891 Smith, R. Morton. . . . . . River Point.
1891 Smith, Russell B. . . . ... Westerly . . . . . . . Post Office Block.
1877 Smith, Sheffield. . . . . . . . Providence . . . . . 20 Market square.
1908 Smith, S. Newell, Jr.... Providence ..... 227 Waterman st.
1884 Smith, Thomas J. . . . . . . Valley Falls.... 292 Broad st.
I906 Spicer, George T. . . . . . . Providence . . . . . 158 Broadway.
1894 Sprague, John L. . . . . . . Providence . . . . .349 Elmwood ave.
1905 Squire, Abiram F. . . . . . Newport. . . . . . . .38 Catherine st.
1885 Stearns, Charles A. . . . . Pawtucket...... 29 North Union st.
I902 Steele, Minot A. . . . . . . Portsmouth. - .
1902 Stewart, Charles W. . . . Newport. . . . . . . . Kay St.
1873 Stimson, Edward P. . . . . Tiverton.
1902 Stone, Ellen A. . . . . . . . . Providence . . . . . . 28o Waterman st.
1904 Storrs, Berton W. . . . . . . Portsmouth.
1878 Sullivan, James E...... Providence . . . . .254 Wayland ave,
1902 Sullivan, Michael H . . . . Newport. . . . . . . 6o Touro st.
1898 Sullivan, Walter G. . . . . Providence . . . . . 319 Prairie ave.
1882 Swarts, Gardner T. . . . . Providence . . . . . 7o Waterman st.
1895 Sweet, Charles F. . . . . . . Pawtucket. . . . .38 North Union st.
1905 Sylvia, Charles A. . . . . . Providence . . . . .366 Wickenden st.
1909 Taggart, Fenwick G. . . . East Greenwich.
1883 Tanguay, John B. A.... Providence . . . . . 574 Broadway.
1905 Tanguay, Joseph E. . . . . Woonsocket . . . . 97 Cumberland st.
1883 Taylor, Philip K....... . New York, N. Y. 211 W. 139th, st.
1906. Tefft, Benjamin F, Jr.. Anthony.
1880 Terry, Herbert. . . . . . . . . Providence . . . . . 274 Weybosset st.
1898 Thompson, Edwin G. . . Providence . . . . .68 Pocasset ave,
I90I Tingley, Louise P. ..... Boston, Mass. . . .416 Marlborough st.
1898 Towle, Bernard L...... Pawtucket. . . . . . 2 Io Main St.
1868 Traver, William H. . . . . Providence . . . . . 5 Stewart st.
1909 Turner, Charles S. . . . . . Providence . . . . . 532 Prairie ave.
1901 Van Benschoten, Geo. W. Providence . . . . . 188 Broad st.
1875 Vinton, Fred A. . . . . . . . Providence . . . . . 73 Congdon St.
1878 Walker, Edward F. . . . . Providence . . . . . 256 Benefit st.
1898 Watson, William P. . . . . Pawtucket. . . . . . 2 ſo Main St.
1906 Webb, Joel A. . . . . . . . . . Providence . . . . . 7 Rodney court.
1906 Weeden, Allen A. . . . . . . Woonsocket . . . . 172 Main st.
1886 Welch, Stephen A...... Providence . . . . . 253 Washington st.
1904 Wells, Winfield S. .... '. Providence . . . . . 312 Washington ave.
1904 Westcott, Clinton S. . . . Pawtuxet . . . . . . . 2169 Broad st.
1896 Wheatland, Marcus F. . . Newport..... ... 85 John St.
1907 Wheaton, James L. Jr.. Pawtucket...... 2 Io Main st.
1882 Wheeler, George G. . . . . Pawtuxet. . . . . . . Fair st.
1908 White, George F. . . . . . . Pontiac.
1878 White, William R. . . . . . Providence . . . . . 7 Greene st.
1909 Wilcox, Roswell S. . . . . . Providence . . . . . 656 Broad st.
1885 Williams, Horace N. . . . Providence . . . . . 196 Broadway.
I899 Williams, Pearl. . . . . . . . Providence . . . . . 129 Broad St.
1905 Williams, William F. . . . Bristol. . . . . . . . . . 9 Byfield st.
1890 Wilson, William E. . . . . . Pawtucket. . . . . . 20 Park place.
1899 Wims, Dennis G. . . . . . . Providence . . . . . 456 Branch ave.
I907 Yates, Cora G. . . . . . . . . . Pawtucket. . . . . . 321 Main St.
|
When elected. Name, Post Office.
1889 Canfield, William C. . . . . . . . . . . . . . . . . . . . . . . . West Newton, Mass.
I903 Cheever, John H. . . . . . . . . . . . . . tº a º a g º . . . . . . . Everett, Mass.
1901 Crowell, George M. . . . . . . . . . . . . . . . . . . . . . . . . Canaan, N. H.
1892 Dillon, Philip F. . . . . . . . . . . . . . . . . . . . tº tº s a º º tº º Anacortes, Wash.
1885 Erskine, James B. . . . . . . . . . . . . . to º e º e º 'º º . . . . Colebrook, N. H.
1887 Flood, Everett. . . . . . . . . . . . . . . . . . . . . . . . . . . Palmer, Mass.
1890 Earle, Charles H. . . . . e c e g g º e º e º e º 'º e º e º 'º tº e º & Los Angeles, Cal.
1901 Gay, Clarence B. . . . . . . . . . . . . . . . . . . . . . . . . . . Fitchburg, Mass.
1904 Hathaway, George S. . . . . . . . . . . . . . . . . . . . . . . U. S. Navy.
1902 Jackson, Frank H. . . . . . . . . . . gº tº º º ſº tº dº e g º e º ºs e e Houghton, Me.
1891 Kenefick, Thomas A. . . . . . tº gº tº e º ºn tº dº º ſº e º a tº ſº e e
I907 Kerr, Robert W. . . . . . . . . . . . . . . . . . . . . . . . . . . U. S. Army.
1866 Palmer, William H. . . . . . . . . . . . . . . . . . . . $ 4 tº a tº
1902 Read, Willard F. . . . . . . . . . . . . . . . . . . © e º 'º e º 'º º *
1888 Richards, George L. . . . . . . . . . . . tº e º 'º e º e º dº ſº tº Fall River, Mass,
1884 Root, Mary Pauline. . . . . . . . . . . . . . & e º & e º e ... N. Attleboro, Mass.
1900 Russell, Walter A. . . . . . . . . tº ſº e º 'o e º dº ſº º ſº e º e © tº e
1895 Smith, Charles S. . . . . . . . . . . . . . . . . . . . . . . . . . . New York, N. Y.
1886 Storer, Horatio R. . . . . . . . . . . . . . . . . . . . . . . . . . Newport, R. I.
1885 Tomlinson, Sophronia A. . . . . . . . . . . . . . . . . . . Plainfield, N. J.
1896 Torrey, John P. . . . . . . . . . . . . . . . . . . . . . . . ... Andover, Mass.
1884 Tremaine, William A. . . . . . . . . . . . . . . . . . . . . . Camden, Me.
1872 Tyng, Anita E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pasadena, Cal.
1898 Weaver, H. Vernon. . . . . . . . . . . . . . . . . . . . . . . . Jersey City, N. J.
1901 Wentworth, Daniel W. . . . . . . . . . . . . . . . . . . . South Berwick, Me.
1893 Wilson, Erastus L. . . . . . . . . . . . . . . . . . . . . . . . . Lisbon Falls, Me,
1882 Woodbury, Charles E. . . . . . . . . . . . . . . . . . . . . Foxboro, Mass.
NON-RESIDENT FELLOWS.
HONORARY MEMBERS.
When elected. Name. Post Office. Street.
1889 Bryant, Joseph D. . . . . . New York, N. Y. . .
1898 Bumpus, Hermon C. ... New York, N. Y. . . . Amer. Museum,
1895 Cabot, Arthur T. . . . . . . . Boston, Mass....... I Marlborough St.
1905 Faunce, William H. P.. Providence. . . . . . . . . 18o Hope st.
1886 Fox, George H. . . . . . . ... New York, N. Y. . . . 18 E. 31st. st.
1905 Gorham, Frederick P. . . Providence. . . . . . . . . 151 Meeting st.
1902 Guiteras, Ramon. . . . . . . New York, N. Y... 75 W. 55 st.
1893 Keen, William W. . . . . Philadelphia, Pa... 1729 Chestnut St.
1905 Mead, Albert D. . . . . . . . Providence . . . . . . . . 283 Wayland st.
1897 Shattuck, Frederick C. . Boston, Mass. . . . . . . 135 Marlborough St.
I909 Webb, Samuel H. . . . . . . Providence . . . . . . . . 21 Adelaide ave.
Total Fellowship. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resident 346
Non Resident 27
Honorary Membership. . . . . . . . . . . tº e º e º e º e º e º e s e e e e º dº e e g º e º 'º t e s e I I
OFFICERS OF THE SOCIETY.
ELECTED MAY, 1910.
AUGUSTINE A. MANN, Central Falls, President.
FREDERICK T. Rogers, Providence, Ist Vice-President.
ALEXANDER B. BRIGGS, Ashaway, 2d Vice-President.
STEPHEN A. WELCH, Providence, Secretary.
WINTHROP A. RISK, Providence, Treasurer.
GEORGE D. HERSEY, Providence, Librarian.
ALBERT A. BARROWs, Providence, Chairman of Committee
of Arrangements.
The Council : President, A. A. Mann; Treasurer, W. A.
Risk; Secretary, S. A. Welch, ex-officio; the ex-Presidents,
G. W. Jenckes, J. W. Mitchell, W. H. Palmer, R. F. Noyes,
G. D. Hersey, W. R. White, C. F. Barker, C. V. Chapin, F.
B. Fuller and E. Kingman, and the Councilors: Kent, I. D.
Hasbrouck; Newport, N. D. Harvey; Pawtucket, C. A.
Stearns; Providence, J. H. Akers; Washington, A. B. Briggs;
Woonsocket, E. D. Clarke, -
House of Delegates: The Council as given above; Dele-
gates—from Kent, W. E. Page ; Newport, B. W. Storrs and ,
M. F. Wheatland ; Pawtucket, P. W. Hess and B. L. Towle;
Providence, H. C. Pitts, G. A. Matteson, F. G. Phillips, C.
R. Doten, G. H. Crooker, H. W. Burnett, G. W. Gardner, C.
F. Deacon, A. A. Barrows, G. T. Spicer and L. C. Kingman;
Washington, J. Champlin; Woonsocket, J. A. King; and the
Chairmen of the Standing Committees not already included,
F. L. Day, W. J. McCaw and G. T. Swarts.
OFFICERS OF THE DISTRICT SOCIETIES,
1910.
Kent—President, John A. Mack, Crompton. Secretary,
Thomas F. Darby, River Point.
/
Newport—President, Samuel P. Cottrell, Newport. Secre-
tary, Mary E. Baldwin, Newport.
Pawtucket—President, Byron U. Richards, Pawtucket.
Secretary, Charles H. Holt, Pawtucket.
Providence—President, Jacob C. Rutherford, Providence.
Secretary, Frank M. Adams, Providence.
Washington—President, Frank C. Pagan, Westerly.
Secretary, John H. Morgan, Westerly.
Woonsocket—President, John J. Baxter, Woonsocket.
Secretary, Joseph. T. Roswell, Woonsocket.
TRUSTEES OF THE RHODE ISLAND MEDICAL
SOCIETY BUILDING.
Drs. F. T. Rogers, Chairman, J. W. Mitchell, R. F. Noyes,
F. L. Day, J. M. Peters, F. B. Smith, D. P. A. Jacoby, J. L.
Wheaton, Jr., J. C. Rutherford, J. Champlin, W. C. Monroe
and A., A. Mann, S. A. Welch and W. A. Risk, ex-officio.