mur to the terminal ophthalmic artery. I may mention two or three instances of this kind:

I saw a young patient this morning, 16 years of age, who suffers from a chronic endocarditis. The heart is enormous and fails on any extra exertion; the apex is four inches external to the nipple line and the right heart is proportionally enlargeda true type of "bovine" heart. Murmurs are heard all over the chest wall and a thrill is detected, but no murmur is heard in the eyeball-the heart muscle is too weak to propel this murmur to the ophthalmic artery.

In a young woman of about 26 years of age, the heart muscle is found incompetent and endocarditis is well marked and loud murmurs are heard all over the chest wall, but none in the ophthalmic artery.

In other cases where the muscle is in good condition, altho a loud mitral or even aortic systolic murmur is heard, I have failed to hear this murmur in the ophthalmic vessel.

I have placed the first case, the young girl who suffered from Graves' disease, on tincture of digitalis and after some time the pulse, which had been 200 to the minute, dropped to 72 and the eyeball murmur disappeared. I would have expected this result here, as in this disease we are not dealing with diseased valves, but with dilated valvular orifices due to marked dilatation of the heart muscle, and as this child improved, the heart muscle again contracted and the murmurs disappeared.

The two cases mentioned as having endoand pericarditis are interesting, as the systolic murmur in each instance was well marked in the orbit, but the loud pericardial friction was not heard. I would expect this condition as the pericardial fric

tion is extracardial, and the systolic murmur takes place directly in the blood current. I can readily understand how a systolic murmur can be carried to the heart's nearest terminal artery.

To detect this orbital murmur the room should be free from noise and the murmur is exaggerated by making the patient exerThe stethcise a little before examination. oscope used by me has been the ordinary Bowles' stethoscope. This is placed over the eyeball (either eye) with the lid closed, a little to the outer side to be free from nasal respiratory sounds. A little time and patience may be required to detect it at once, but one is surprised to find how readily it may be detected with a little practice. I imagine that a soft rubber end piece could be readily manufactured to adapt itself to the shape of the eyeball.

Finally, I may add that this systolic murmur in the orbit is never detected in connection with the normal heart.

EXPERIENCE WITH BACTERIAL VACCINES IN THE PNEUMONIAS.

BY

GUSTAV GOLDMAN, M. D.,

Baltimore, Md.

In the early fall of 1918, when the pneumonias and influenza were rampant, when all known methods of treatment seemed to be of little or no avail, I turned in desperation, with a mind prejudiced against them, to bacterial vaccines. In the epidemic in Baltimore during October and November, 1918, I gave prophylactic doses of vaccine to over 300 patients. I treated some 586 patients with influenza, bronchopneumonia and lobar pneumonia and have

on a previous occasion made report of same. I am desirous in this paper of giving a more accurate analysis and to call attention at this date to several phenomena which I observed in the fatal cases, and which I have not seen mentioned in the vast literature that has come to my hands since the severe epidemic of 1918:

The lobar pneumonias of the total cases treated numbered 130. The bronchial pheumonias totaled 187. The mortality in lobar pneumonia was six deaths. Bronchopneumonia, five deaths.

Of the lobar pneumonia, two of those succumbing were only seen within 24 hours of their demise and were in the seventh and ninth day of the disease, respectively. One death was complicated with pregnancy of 18 weeks' duration. In the bronchopneumonias dying, one was in the twentysecond week of pregnancy and one about the fourteenth week of pregnancy. pregnant women seen by me in this epidemic of 1918, the duration of pregnancy being under the fifth month, died; all seen by me where either variety of pneumonia co-existed with a pregnancy beyond the sixth month were followed with miscarriage, and all mothers recovered.

All

Incidentally, in the fall of 1919, I had two cases of bronchopneumonia, both occurring about the eighteenth and twentieth week and both recovered, owing to altered pregnancy dosage, of which details follow. My cases of pneumonias should be classified as follows:

Lobar, lobular, bronchopneumonia or mixed infection pneumonia. The staphylococcus or blue pneumonias were unquestionably the most fatal types. One phenomenon observed by me was a peculiar purple coloring to the fauces, which within twelve hours extended to the buccal re

gions, thence to the lips and eventually to face, neck and chest; this phenomenon was present in all of my fatal cases. They presented no consolidated areas in the lungs; pulse and temperature were no indication of the extremely serious condition, in that the temperatures rarely exceeded 103 and pulse rarely over 110. Most frequently, cases showed a pulse of 60 and even as low as 50, while temperatures were as low as 94 and not infrequently remained at 96 to 97 thruout an attack. The usual ratio. between pulse and temperature was totally absent in my cases.

Hemolytic streptococcus cases of bronchopneumonia manifested their presence by hemorrhage from mouth, gums, conjunctivæ, and in one of my cases from the mammæ.

Bronchopneumonias of other bacterial types, where the flora were more numerous than in the hemolytic or streptococcus group, were never as serious as the types of these two groups, all responding promptly to bacterial vaccine therapy.

Duration. In a large percentage of my cases of lobar pneumonia, crisis occurred on the fifth day and rarely extended to the seventh day.

Dosage, etc.—In the epidemic of 1918 and 1919, I was in the habit of giving initial doses, of mixed vaccine, of the following formula:

Influenza bacillus, 200,000,000; streptococcus, 100,000,000; pneumococcus, 100,000,000; micrococcus catarrhalis, 200,000,000; staphylococcus aureus, 200,000,000; staphylococcus albus, 200,000,000; 71⁄2 minims as a maximum dose, and increasing daily until 15 m. (1 c. c.) was given. In 1919 and 1920 I had two bronchopneumonia cases of influenzal origin with pregnancies between fourth and fifth month,

and in both I gave an initial dose of 11⁄2 c. c., with marked improvement after first. dose and ultimate recovery of both patients and subsequent delivery of both fetuses at full term.

THE RELATION OF PEDIATRICS TO PUBLIC HEALTH.1

BY

LAFON JONES, M. D., Flint, Mich.

We are living in a period of discontent and unrest and our profession has not escaped its due share of criticism. There can be no question but that the public is dissatisfied with the medical profession, and I venture to say that a considerable portion of the profession is dissatisfied with itself. We hear on every side propositions designed to complement or supplant the private practice of medicine. We view these schemes with alarm or approval, as the case may be, but on the whole our attitude has been a passive one. There is no doubt but that we are falling down badly on certain aspects of our art. Whether we approve or disapprove of any of these various schemes designed to remodel our profession, we would be foolish indeed to remain indifferent to them and to close our eyes to our own failings. And let us assimilate this fact at the start-any argument against socialized or state medicine, based on our own financial welfare will avail us little.

Regardless of the wishes of the profession, I believe that our present system will stand or fall on its success in adapting it

1 Read before Maimonides Medical Society, Detroit, Mich.

self to the needs of the community. Our individual welfare will receive but little consideration at the hands of society if we fail to deliver the goods. If our present 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 case may be more properly one for the neurologist or the psychiatrist, but assuming it to have been referred for diagnosis I would have you consider it from the standpoint of the pediatrician.

As a novice in the field of pediatrics, who has been engaged for several years in a species of community practice, I have been somewhat of a hybrid, like Kipling's marine, "a sort of a blooming hermaphrodite, soldier and sailor, too." I have been in a position to see both sides of the question and have been forced to give some thought to the practice of medicine, at least as applied to children, as a public health problem. I would like to have you consider some of its phases and to have you express an opinion upon the subject. Until we reach some opinion among ourselves we cannot hope to be very convincing to the layman.

It seems to me that 90 per cent. or more of pediatrics is, or should be, prophylaxis, and that 90 per cent. of our shortcoming is in just this field. I do not wish to underrate the importance of diagnosis and treatment, but the calls for these are but temporary episodes in the lives of a part of our child population. The application of prophylaxis is universal and continuous.

Assuming that stillbirths and deaths due to pre-natal causes are without our sphere as pediatricians, our first problem chronologically is that of infant feeding, and that this is a problem of any importance is in

itself an evidence of failure. Sedgewick, of Minneapolis, has proven conclusively that a large majority of all mothers can nurse their babies, wholly or in part. This being true, the bottle-fed baby should be more or less of a medical curiosity. That he is rather the rule than the exception can be demonstrated at any baby clinic. And of the babies who are bottle fed, a surprisingly large number are poorly fed. To say that most mothers institute artificial feeding on their own initiative and plan their own formulæ does not absolve us in the least. The problem is a medical one and should be ours. I realize that many mothers feel perfectly capable of feeding their own children, that most mothers, perhaps, cannot afford to have advice, but I also realize that the physician, when called, has been all too ready to acquiesce in weaning and that all too many of them feed babies in the easiest way on patent baby foods and according to the directions on the label. The extensive use of sweetened condensed milk, an unpardonable sin, is as much due to the medical profession as to the mother. There may have been a time when ignorance of baby feeding was justified, a time when feeding was a maze of mysticism and higher mathematics, but in these days, when feeding has been so simplified that enough can be learned in two hours to feed successfully most babies, there is no excuse for ignorance on the part of any man who attempts it.

Passing from infancy to that of no man's land of early childhood, designated by social workers as the pre-school age, the children passing thru this period accumulate an appalling list of casualties. We find them entering school life already at this early age handicapped by many preventable conditions. In the kindergarten

children we see chronic dental abscesses, faces and chests deformed by obstructed nasal respiration, uncorrected errors of refraction with their sequela of strabismus and amblyopia, chronic suppurative otitis media, chronic malnutrition, due more often to lack of wisdom than lack of money; all unnecessary.

With school life these dangers are increased and for the first time we feel the real force of the acute contagious diseases and, more important, their complications. Here the chronic heart and kidney diseases are added to the harvest. That we have not taught parents to recognize the real dangers of the so-called minor contagious diseases is a reflection upon our profession. Smallpox has indeed been subdued and diphtheria will be as soon as the Schick test and active immunization have been sold to the profession in general.

It is in early school life, too, that we recognize the mentally retarded and the feeble-minded child, the epileptic, the constitutional inferior and the child with the psychopathic personality. We can scarcely. lay the blame for these conditions at the door of the physician, at least not yet, but he should have more interest in uncovering these cases and aiding in their proper disposition. If we can accept the teaching of the endocrinologist, we will soon be asked to accept the responsibility for these conditions, hitherto classed as idiopathic.

You may be ready by this time to object. that I am accusing you of neglecting a duty that was never yours, that I am confusing public health problems with those of private practice, as indeed I am, if the distinction can be made. Nevertheless, all these problems are medical problems as well as administrative ones, and as such should be of vital interest to us. I can

conceive of no illness which is not in some degree both a medical and a public health problem. Here, then, is the nucleus of the whole matter-just where do we wish to stand in regard to preventive medicine and public health work, in the accepted definitions of these terms. For some hundreds of years, in fact, since the divorce of medicine and the church (you will remember that the Kohens and Levites combined the offices of the clergy, the teacher, the law giver, the physician and the public health official) medicine has consisted largely of the type we call private practice and has concerned itself but little with social problems. It has been strictly a retail business. If after twenty centuries, more or less, of a medical monopoly conditions are what they are today, I think I may justly say that private practice has failed to measure up to its opportunities. If you believe, as I do, that the sole justification for the existence of any individual or group lies in its ability to promote the welfare of the race, you must concur in the opinion that these thousands of afflicted children are a serious indictment of the medical profession. If you believe, as I do, that at least three-fourths of all the ills that flesh is heir to, find their origin in the preventable maladies of childhood, we have a challenge worthy of the best traditions of the noblest of professions. Are we willing to accept the responsibility?

During the past ten years there have come into existence many agencies, to fill the gaps we have left-the public health officer, the community health center, the state hospital, the charity clinic and, most recently, the public health nurse. These have largely grown up independent of the bulk of the medical profession. These agencies are broadening their scope, new

schemes are constantly being proposed, in few of which does the doctor figure highly. What is to be our attitude toward these innovations? Ae we simply to hold ourselves aloof, accepting in splendid isolation whatever is left to us of our private practice?

Certain it is that the personal opinion of a handful of medical men cannot halt evolution. I think our future lies rather in cooperation with existing agencies and in taking part in the development of new ones. As a profession we must develop the social instinct and accept the responsibility that is ours. There is much that we obviously cannot do alone: the enforcement of quarantine, the development of popular medical education, the care of the indigent, the establishment of clinics, the inspection of school children, the institutional care of the subnormal-these are properly state or municipal duties. But we can and should have an active voice in the operation of these things and a personal interest in some one at least.

I have no panacea to offer. I do have a strong feeling that we cannot defeat change by mere opposition, active or passive. If we do not approve the innovation we must at least have something to offer in its place. I suggest active cooperation of the medical profession as a whole with those portions of the present order of which we can approve and a sincere attempt to offer something better, for that which we believe to be bad. Public health officials, social workers and legislators will welcome our aid.

As to details, my ideas are still nebulous. There is no denying that we have, whether from poverty or indifference, children neglected certainly thru no fault of their own. How best to give them the care, how best