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mur to the terminal ophthalmic artery. I tion is extracardial, and the systolic murmay mention two or three instances of this mur takes place directly in the blood curkind:
rent. I can readily understand how a sysI saw a young patient this morning, 16 tolic murmur can be carried to the heart's years of age, who suffers from a chronic nearest terminal artery. endocarditis. The heart is enormous and To detect this orbital murmur the room fails on any extra exertion; the apex is should be free from noise and the murmur four inches external to the nipple line and is exaggerated by making the patient exerthe right heart is proportionally enlarged— cise a little before examination. The stetha true type of "bovine” heart. Murmurs oscope used by me has been the ordinary are heard all over the chest wall and a Bowles' stethoscope. This is placed over thrill is detected, but no murmur is heard the eyeball (either eye) with the lid closed, in the eyeball—the heart muscle is too weak a little to the outer side to be free from to propel this murmur to the ophthalmic nasal respiratory sounds. A little time and artery.
patience may be required to detect it at In a young woman of about 26 years of once, but one is surprised to find how readage, the heart muscle is found incompetent ily it may be detected with a little practice. and endocarditis is well marked and loud I imagine that a soft rubber end piece murmurs are heard all over the chest wall, could be readily manufactured to adapt but none in the ophthalmic artery.
itself to the shape of the eyeball. In other cases where the muscle is in Finally, I may add that this systolic murgood condition, altho a loud mitral or even mur in the orbit is never detected in conaortic systolic murmur is heard, I have nection with the normal heart. failed to hear this murmur in the ophthalmic vessel. I have placed the first case, the young
EXPERIENCE WITH BACTERIAL girl who suffered from Graves' disease, on
· VACCINES IN THE PNEU. tincture of digitalis and after some time the
MONIAS. pulse, which had been 200 to the minute, dropped to 72 and the eyeball murmur dis
GUSTAV GOLDMAN, M. D., appeared. I would have expected this
Baltimore, Md. result here, as in this disease we are not dealing with diseased valves, but with di- In the early fall of 1918, when the lated valvular orifices due to marked dilata- pneumonias and influenza were rampant, tion of the heart muscle, and as this child when all known methods of treatment improved, the heart muscle again con- seemed to be of little or no avail. I turned tracted and the murmurs disappeared in desperation, with a mind prejudiced
The two cases mentioned as having endo- against them, to bacterial vaccines. In the and pericarditis are interesting, as the sys- epidemic in Baltimore during October and tolic murmur in each instance was well November, 1918, I gave prophylactic doses marked in the orbit, but the loud pericar- of vaccine to over 300 patients. I treated dial friction was not heard. I would ex- some 586 patients with influenza, bronchopect this condition as the pericardial fric- pneumonia and lobar pneumonia and have
on a previous occasion made report of gions, thence to the lips and eventually to same. I am desirous in this paper of giving face, neck and chest; this phenomenon was a more accurate analysis and to call atten- present in all of my fatal cases. They pretion at this date to several phenomena sented no consolidated areas in the lungs; which I observed in the fatal cases, and pulse and temperature were no indication which I have not seen mentioned in the vast of the extremely serious condition, in that literature that has come to my hands since the temperatures rarely exceeded 103 and the severe epidemic of 1918:
pulse rarely over 110. Most frequently, The lobar pneumonias of the total cases cases showed a pulse of 60 and even as treated numbered 130. The bronchial low as 50, while temperatures were as low pneumonias totaled 187. The mortality in as 94 and not infrequently remained at 96 lobar pneumonia was six deaths. Broncho- to 97 thruout an attack. The usual ratio pneumonia, five deaths.
between pulse and temperature was totally Of the lobar pneumonia, two of those absent in my cases. succumbing were only seen within 24 hours Hemolytic streptococcus cases of bronof their demise and were in the seventh chopneumonia manifested their presence and ninth day of the disease, respectively. by hemorrhage from mouth, gums, conOne death was complicated with pregnancy junctivæ, and in one of my cases from of 18 weeks' duration. In the broncho- the mammæ. pneumonias dying, one was in the twenty- Bronchopneumonias of other bacterial second week of pregnancy and one about types, where the flora were more numerthe fourteenth week of pregnancy. All ous than in the hemolytic or streptococcus pregnant women seen by me in this epi- group, were never as serious as the types of demic of 1918, the duration of pregnancy these two groups, all responding promptly being under the fifth month, died; all seen to bacterial vaccine therapy. by me where either variety of pneumonia Duration. In a large percentage of my co-existed with a pregnancy beyond the cases of lobar pneumonia, crisis occurred sixth month were followed with miscar- on the fifth day and rarely extended to riage, and all mothers recovered
the seventh day. Incidentally, in the fall of 1919, I had Dosage, etc.—In the epidemic of 1918 two cases of bronchopneumonia, both oc- and 1919, I was in the habit of giving incurring about the eighteenth and twentieth itial doses, of mixed vaccine, of the folweek and both recovered, owing to altered lowing formula : pregnancy dosage, of which details follow. Influenza bacillus, 200,000,000; streptoMy cases of pneumonias should be classi- coccus, 100,000,000; pneumococcus, 100,fied as follows:
000,000; micrococcus catarrhalis, 200,000,Lobar, lobular, bronchopneumonia or 000; staphylococcus aureus, 200,000,000; mixed infection pneumonia. The staphylo- staphylococcus albus, 200,000,000; 7172 coccus or blue pneumonias were unques- minims as a maximum dose, and increasing tionably the most fatal types. One phe- daily until 15 m. (1 c. c.) was given. In nomenon observed by me was a peculiar 1919 and 1920 I had two bronchopneupurple coloring to the fauces, which within monia cases of influenzal origin with pregtwelve hours extended to the buccal re- nancies between fourth and fifth month,
and in both I gave an initial dose of 11/2 self to the needs of the community. Our c. c., with marked improvement after first individual welfare will receive but little dose and ultimate recovery of both pa- consideration at the hands of society if we tients and subsequent delivery of both fail to deliver the goods. If our present fetuses at full term.
system does not meet the demands upon it, as it does not now, it is idle to suppose that we can continue to exist indefinitely
as semi-parasites in the social structure. THE RELATION OF PEDIATRICS TO
The case may be more properly one for the PUBLIC HEALTH.1
neurologist or the psychiatrist, but assuming it to have been referred for diagnosis
I would have you consider it from the LAFON JONES, M. D.,
standpoint of the pediatrician. Flint, Mich.
As a novice in the field of pediatrics, We are living in a period of discontent who has been engaged for several years in and unrest and our profession has not a species of community practice, I have escaped its due share of criticism. There been somewhat of a hybrid, like Kipling's can be no question but that the public is marine, "a sort of a blooming hermaphrodissatisfied with the medical profession, dite, soldier and sailor, too." I have been and I venture to say that a considerable in a position to see both sides of the quesportion of the profession is dissatisfied tion and have been forced to give some with itself. We hear on every side propo- thought to the practice of medicine, at least sitions designed to complement or supplant as applied to children, as a public health the private practice of medicine. We view problem. I would like to have you conthese schemes with alarm or approval, as sider some of its phases and to have you the case may be, but on the whole our express an opinion upon the subject. Unattitude has been a passive one. There is til we reach some opinion among ourselves no doubt but that we are falling down badly we cannot hope to be very convincing to on certain aspects of our art. Whether we the layman. approve or disapprove of any of these It seems to me that 90 per cent. or more various schemes designed to remodel our of pediatrics is, or should be, prophylaxis, profession, we would be foolish indeed to and that 90 per cent. of our shortcoming remain indifferent to them and to close our is in just this field. I do not wish to undereyes to our own failings. And let us as- rate the importance of diagnosis and treatsimilate this fact at the start—any argu- ment, but the calls for these are but temment against socialized or state medicine, porary episodes in the lives of a part of based on our own financial welfare will our child population. The application of avail us little.
prophylaxis is universal and continuous. Regardless of the wishes of the profes- Assuming that stillbirths and deaths due sion, I believe that our present system will to pre-natal causes are without our sphere stand or fall on its success in adapting it- as pediatricians, our first problem chronoRead before Maimonides Medical Society,
vieta logically is that of infant feeding, and that Detroit, Mich.
this is a problem of any importance is in
itself an evidence of failure. Sedgewick, children we see chronic dental abscesses, of Minneapolis, has proven conclusively faces and chests deformed by obstructed that a large majority of all mothers can nasal respiration, uncorrected errors of renurse their babies, wholly or in part. This fraction with their sequelæ of strabismus being true, the bottle-fed baby should be and amblyopia, chronic suppurative otitis more or less of a medical curiosity. That media, chronic malnutrition, due more he is rather the rule than the exception often to lack of wisdom than lack of can be demonstrated at any baby clinic. money; all unnecessary. And of the babies who are bottle fed, a With school life these dangers are insurprisingly large number are poorly fed. creased and for the first time we feel the To say that most mothers institute artificial real force of the acute contagious diseases feeding on their own initiative and plan and, more important, their complications. their own formulæ does not absolve us in Here the chronic heart and kidney diseases the least. The problem is a medical one are added to the harvest. That we have and should be ours. I realize that many not taught parents to recognize the real mothers feel perfectly capable of feeding dangers of the so-called minor contagious their own children, that most mothers, per- diseases is a reflection upon our profession. haps, cannot afford to have advice, but I Smallpox has indeed been subdued and also realize that the physician, when called, diphtheria will be as soon as the Schick test has been all too ready to acquiesce in wean- and active immunization have been sold to ing and that all too many of them feed the profession in general. babies in the easiest way on patent baby It is in early school life, too, that we foods and according to the directions on recognize the mentally retarded and the the label. The extensive use of sweetened feeble-minded child, the epileptic, the concondensed milk, an unpardonable sin, is stitutional inferior and the child with the as much due to the medical profession as psychopathic personality. We can scarcely to the mother. There may have been a lay the blame for these conditions at the time when ignorance of baby feeding was door of the physician, at least not yet, but justified, a time when feeding was a maze he should have more interest in uncovering of mysticism and higher mathematics, but these cases and aiding in their proper disin these days, when feeding has been so position. If we can accept the teaching of simplified that enough can be learned in the endocrinologist, we will soon be asked two hours to feed successfully most babies, to accept the responsibility for these conthere is no excuse for ignorance on the ditions, hitherto classed as idiopathic. . part of any man who attempts it.
You may be ready by this time to object. Passing from infancy to that of no man's that I am accusing you of neglecting a duty land of early childhood, designated by so- that was never yours, that I am confusing cial workers as the pre-school age, the public health problems with those of prichildren passing thru this period accumu- vate practice, as indeed I am, if the dislate an appalling list of casualties. We tinction can be made. Nevertheless, all find them entering school life already at these problems are medical problems as this early age handicapped by many pre- well as administrative ones, and as such ventable conditions. In the kindergarten should be of vital interest to us. I can
conceive of no illness which is not in some schemes are constantly being proposed, in degree both a medical and a public health few of which does the doctor figure highly. problem. Here, then, is the nucleus of the What is to be our attitude toward these whole matter-just where do we wish to innovations? Ae we simply to hold ourstand in regard to preventive medicine and selves aloof, accepting in splendid isolation public health work, in the accepted defini- whatever is left to us of our private practions of these terms. For some hundreds tice? of years, in fact, since the divorce of med- Certain it is that the personal opinion icine and the church (you will remember of a handful of medical men cannot halt that the Kohens and Levites combined the evolution. I think our future lies rather offices of the clergy, the teacher, the law- in cooperation with existing agencies and giver, the physician and the public health in taking part in the development of new official) medicine has consisted largely of ones. As a profession we must develop the type we call private practice and has the social instinct and accept the responsiconcerned itself but little with social prob- bility that is ours. There is much that we lems. It has been strictly a retail business. obviously cannot do alone: the enforcement If after twenty centuries, more or less, of of quarantine, the development of popular a medical monopoly conditions are what medical education, the care of the indigent, they are today, I think I may justly say the establishment of clinics, the inspection that private, practice has failed to measure of school children, the institutional care of up to its opportunities. If you believe, as the subnormal—these are properly state or I do, that the sole justification for the ex- municipal duties. But we can and should istence of any individual or group lies in have an active voice in the operation of its ability to promote the welfare of the these things and a personal interest in some race, you must concur in the opinion that one at least. these thousands of afflicted children are I have no panacea to offer. I do have a serious indictment of the medical profes- a strong feeling that we cannot defeat sion. If you believe, as I do, that at least change by mere opposition, active or pasthree-fourths of all the ills that flesh is sive. If we do not approve the innovation heir to, find their origin in the preventable we must at least have something to offer maladies of childhood, we have a challenge in its place. I suggest active cooperation worthy of the best traditions of the noblest of the medical profession as a whole with of professions. Are we willing to accept those portions of the present order of the responsibility?
which we can approve and a sincere atDuring the past ten years there have tempt to offer something better for that come into existence many agencies, to fill which we believe to be bad. Public health the gaps we have left—the public health officials, social workers and legislators will officer, the community health center, the welcome our aid. state hospital, the charity clinic and, most A s to details, my ideas are still nebulous. recently, the public health nurse. These There is no denying that we have, whether have largely grown up independent of the from poverty or indifference, children negbulk of the medical profession. These lected certainly thru no fault of their own. agencies are broadening their scope, new How best to give them the care, how best