Medical Society of the State of North Carolina. An.

Transactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) online

. (page 30 of 58)
Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 30 of 58)
Font size
QR-code for this ebook


must room alone and are subjected to careful medical surveillance."
Twenty-three institutions announce peremptory dismissal without regard
to the stage of the disease. One goes so far as to refuse admission to any
pupil "coming from a home in which there is or has been a case of tuber-
culosis." How few of us would obtain an education if this were really
carried out by all the schools ! In another case the school physician gave
the advice "to have removed from the school 2a\j one who had been
exposed to a tuberculous patient." But the principal very wisely consid-
ered this an unnecessary and cruel procedure, and decided "to watch any
such case, and at once remove it" if any symptoms should develop. One
optimistic principal informs me that he does not have to consider this
matter, because the atmosphere about his school is so pure (according to
his school physician) that no germs of typhoid fever, tuberculosis, or in-
flammatory rheumatism can live there.



PRACTICE OF MEDICINE. 259

The object of this paper has been merely to point out the general
lack of information concerning the amount of tuberculosis in our schools
and colleges, and also to indicate how insufficient are the present methods
of safeguarding our children during their adolescence and early maturity.
Criticism is of doubtful value unless it is accompanied by some con-
structive suggestions. Two questions immediately arise: Why do the
present conditions exist ? What can we as physicians do to improve the
situation ? The prime purpose of this preliminary paper is to provoke a
frank discussion of these questions.

Briefly, the problem to be attacked resolves itself into three divisions :

I. The proper construction of the buildings used (i. e., the dormitories,
the class-rooms, the dining-rooms, the boarding-houses).

II. The maintenance of proper nutrition and the avoidance of infec-
tion through the food.

III. An efficient medical inspection of all buildings, and an efficient
physical examination of the pupils, the teachers, and servants.

In order to obtain these desired results a vigorous but tactful cam-
paign must be waged. This must consist of the dissemination of the
necessary information as to the existing conditions among the teachers,
the boards of trustees, the pupils, the parents, and, sad to say, among the
doctors as well. Success is attainable only with widespread cooperation
between the different schools, between the schools and the boards of
health, and between the boards of health and the organized medical pro-
fession. I think we can confidently count upon the willing cooperation
of a large proportion, if not all, of the presidents, principals, and teachers
in any reasonable campaign we may attempt to wage.



DIAGNOSIS OF mciPlENT TUBERCULOSIS BY THE
GEI^ERAL PRACTITIONER.



Dr. Charles O'H. Laughinghouse, Greenville, X. C.



Public sentiment in iSTorth Carolina has the right to draw a bill of
indictment against the patient, the family, or some physician for every
case of tuberculosis which is permitted to progress beyond the incipient
stage, undetected and unreported to the State Bureau of Tuberculosis.
Some will say this is an indictment against the medical profession. It
is an indictment, based on evidence, that in the fiscal year 1914-1915



260 ]vrORTH CAROLINA MEDICAL SOCIETY.

there were 5,000 deaths from tuberculosis in North Carolina, and there
are today 15,000 to 20,000 cases within the confines of the State.

I realize that the diagnosis of incipient tuberculosis is no easy task ;
that a broad knowledge of incipient disease in general is essential to its
successful undertaking. I realize, too, that until the profession meets
this responsibility, with credit to itself, that the fight against this dread
disease has not even begun. Educational, sociological, and preventive
medicine may spread information abroad in the land ever so wisely and
ever so well; but the satisfying assurance of the medical man — his ''Go
along, my friend; you are just a bit run down" — will take from the
ammunition used in the fight against tuberculosis everything except the
big noise and the blinding smoke.

We general practitioners cannot hope to perfect ourselves in the art
of percussion and auscultation sufiiciently to ascertain from its practice
that information which comes to him who does this work exclusively ;
but if our training along this line is not such as to give us the ability to
gain from it whatever information it contains, we can send our patient
to an internist who will give us a report as to his findings. We send our
abdominal cases to a surgeon for an exploratory incision, without hesita-
tion. It is to our credit that we do it. Yet we dally with probable
incipient tuberculosis, leaving it to go from day to day, knowing that it
is a question of now or never, so far as our patient and his immediate
associates are concerned.

Lane's kinks, gastric ulcers, and the like, when opened for diagnosis
and relief, by surgical means, present a more dramatic picture than a
painstaking effort at diagnosis which reveals an incipient tuberculosis;
but I take the position that the successful detection of tuberculosis in its
incijjiency does more to prolong life, promote efficiency, and lessen the
State's death rate.

We do not wait for jaundice in cholelithiasis, or hemorrhage in gastric
ulcer, before making our diagnosis and relieving our patients, or having
them relieved by surgical means, even though these diseases rarely cause
death and are not catching; then why should we Avait until we find
tubercle bacilli in the sputum before making our diagnosis of incipient
tuberculosis ? I am a strong friend of the State Laboratory of Hygiene.
It does a tremendous service. It is managed by most capable men. But
I am positive in the conviction that it has proven more of a stumbling-
block than a stepping-stone in the prevention of tuberculosis. Not
through any fault of its own, but because too many of us fail to give ex-
pression to or act upon our diagnosis until we can confirm it by labora-
tory findings. Radiology, microscopical and chest findings are useful,
very useful, in the hands of an expert ; but the general practitioner can-



PRACTICE OF MEDICINE. 261

not hope to be benefited by tbem in the diagnosis of incipient tubercu-
losis, except in so far as to accept their aids as they come to him trans-
lated by those specially prepared to interpret their language.

Dr. Eichard Cabott makes the statement that not 10 per cent of the
physicians in the United States can make a diagnosis of incipient tuber-
culosis. If this be true, why is it true ? Is it because we lack a knowl-
edge of incipient diseases sufficient to permit us to sift our cases and
determine which is tuberculosis and which is not ? Or is it because we
are unwilling to give the painstaking, time-taking, and systematic atten-
tion to the undertaking that its importance demands?

I believe we can sift incipient tuberculosis from the mass of disease
that comes to us, at all times and under all circumstances, because the
composite information obtained from a careful and prolonged study of
an individual's history, temperature, physical examination, and symp-
toms, backed up by the tuberculin test, Avill in most instances put us in
position to do so.

History. — The history should be exhaustively minute, because, from
a general practitioner's standpoint, more can be gained from it than from
the physical findings. A family history that is entirely negative means
nothing pro or con, but a tubercular patient, brother, sister, relative, or
any person living in the house, gives grounds to suspect infection, past
or present.

A childhood history as to pleurisy, hydrothrorax, marasmus, grippe,
frequent colds, sequels to measles, whooping-cough, and the like, if they
reveal nothing else, surely they give us an idea of the resistance and
sequels to infectious diseases. A personal history should bring out as
clearly as possible the associates in school, office, store, factory, or farm,
for here it is that the 20,000 consumptives now roaming around within
our State are passing the disease along to those who can receive it. A
personal history will reveal illness, past or present, such as indigestion,
malaria, grippe, pleurisy, etc. It goes into the habits, a knowledge of
which ofttimes is essential to correct conclusions. It gets information
that can be obtained in no other way, as to appetite, sleep, "that tired
feeling," cough, expectoration, loss of flesh, other diseases, etc. So im-
portant is the personal history that we must not be content with what the
patient sees fit to tell, but we must quiz in such a way as not only to get
the patient's interest, but to suggest points from which useful data may
be elicited. Any cause of ill-health not definitely explained should at
least arouse the suspicion of tuberculosis. On the other hand, if a
patient's condition of poor health has remained stationary for a long
time, search should be made for some other etiological factor.



262 NORTH CAROLINA MEDICAL SOCIETY.

The possibility of a mixed infection should always be borne in mind.
I recall a patient of my own who died not many months ago with tuber-
culosis, hookworm, malaria, and gonorrhea.

Temperature. — Nothing is more important in the diagnosis of incipi-
ent tuberculosis than a study of the temperature. It should be recorded
every two hours. The thermometer should be held in the mouth not less
than five minutes, because a fraction of a degree means much. Fever
may be absent, remittent, or intermittent, but if it is taken early in the
morning, before getting out of bed, it is usually subnormal, rising and
falling during the day in accordance with the patient's physical efforts
and physical rest.

Physical Signs. — Every physical sign found in incipient tuberculosis
is produced by other conditions, and incipient tuberculosis may exist and
give no demonstrable sigiis that inspection, palpation, percussion, or
auscultation can ascertain. It is an incipient disease, so we need not
look for any other than incipient signs. Slight deviations from the
normal is all we can hope to get. Failure to realize this makes the
attempt at diagnosis a failure.

Inspection. — Possibly a slight flush of the cheek, not constant enough
to rely on; cyanosis of the fingers; widely dilated pupils, or a whitish-
gray pallor, while not constant, are, when present, very, very suggestive.
A slight flattening above the clavicle and a slight dropping of the shoul-
der, with some limitation of motion, may be present.

Palpation has proven of no service in my hands, other than to elicit
enlarged cervical glands and a rapid pulse, both of which are important
findings.

Percussion, to one long and adequately trained, is undoubtedly most
useful ; but it has proven useful to me only in those cases that have pro-
gressed beyond the incipient stage.

Auscultation is supposed to give evidence of the earliest abnormalities
to be elicited by physical examinations, though the general practitioner
finds many cases in which this does not hold true. Any abnormality of
the breath sounds is to be looked for, however; diminished breathing,
roughened breathing, granular breathing, prolonged expiration, and
rales, sometimes, not always, but often, brought on by coughing.

The tuberculin test, to my mind, gives promise of doing more toward
diagnosing incipient tuberculosis than all other methods combined. Cer-
tainly to the general practitioner it commends itself most strongly, in
that it is simple as to technique, harmless when properly used, all things
being considered, and sufficiently accurate to at least put us in position
to deny the existence of tuberculosis when the test is negative.



PRACTICE OF MEDICINE. 263

I have taken your time, gentlemen, but with the discussion of a subject
that is to ISTorth Carolina its most important subject. The battle against
this scourge is in your hands. Whatever has been done, whatever re-
mains to do, depends almost, if not entirely, on your proficiency in mak-
ing a diagnosis of this disease in its incipiency.

Dr. L. B. Morse, Hendersonville : The subject of the early diagnosis
of tuberculosis is one that is always most interesting, and one to which
a person is constrained to add what little he can. Dr. Dunn has dis-
cussed it well, but I want to comment briefly on Dr. Bullitt's paper. I
think it shows the all too often disappointing feature of questionnaire
letters. I want to speak also of the fact that throughout his paper, in
the paper of Dr. Laughinghouse, and in the paper of Dr. Frazer, who
spoke under the Section on Pediatrics, there obtains what is becoming
the older idea of the contraction of tuberculosis, i. e., the actual getting
of what is supposed to be an infection from an adult, or reinfection. I
do not mean that it is necessary to discard that idea, but if we are to
follow the most recent conception of the origin of tuberculosis, it is that
the chances are that the adult rarely contracts tuberculosis from without.
It is a metastasis from a child infection that accounts for the incidence
of a clinical tuberculosis later. Surely this is more than justified by the
evidence at hand.

One more point along that line. I would take exception to the remarks
of Dr. Frazer this morning, viz., that tuberculosis is essentially a child
disease. "We are bound to make a sharp distinction between the cases
that are infected and the cases that have a manifest clinical tuberculosis.
Following a word coinage of Dr. Fischberg, of New York, I think it is
best to call them tuberculizations, meaning that they are latently in-
fected, but not in the sense of having a clinical, manifest tuberculosis.
The great fight against tuberculosis, in my judgment, is not a fight
against adult reinfection nearly as much as it is upon bringing about
those hygienic measures which will prevent a metastasis from the latent
foci.

Dr. : I would just like to speak for the country

doctor about the diagnosis of tuberculosis. We have had most excellent
papers along that line, and I certainly agree with their conclusions.
But of all the aids a country doctor must have in the diagnosis of tuber-
culosis, I think the clinical thermometer comes first. When a doctor
lives in a malarial country, when a patient comes feeling run-down, with
loss of appetite and loss of flesh, give that man some quinine, and have
his temperature taken not less than five times a day. If his temperature



264 NORTH CAROLINA MEDICAL SOCIETY.

keeps on rising, he lias malaria; but if there are variations, subnormal
temperature in the morning and exacerbations in the evening, the case is
usually tubercular. I use tuberculin and find it of great value in diag-
nosing obscure cases; but a country doctor does not always have tuber-
culin, and I think the thermometer is the best guide.

Dr. W. R. Kirk, Hendersonville : I notice one thing especially to
which our attention was called in the paper, and that is the use of the
tuberculin test. I want to make a remark or two about the tuberculin
test. Too much dependence must not be put in it. iVs an aid to diagnosis,
it has its place, and a valuable place. In the case of children it is of
some value in the diagnosis of the activity of tuberculosis. Later it
does not tell us the main thing that we want to know, and that is whether
the case is a clinical type of tuberculosis or whether the tuberculosis is
active. In other words, it does not distinguish between active and latent
tuberculosis. I say that because we sometimes have a case referred to us
as tuberculosis merely because it has reacted to the tuberculin test. So
we cannot depend upon the test alone to diagnose the case; we must
dej)end upon the history and the symptoms. We must not look for ad-
ventitious sounds in early tuberculosis, but must regard the history, more
especially.



A PEESONAL ESTIMATE OF PSYCHO-AI^^ALYSIS AS A
DIAGNOSTIC METHOD IN NERVOUS DISEASE.*



J. Allison Hodges, M.D.. Richmond, Va.



Diagnosis by dreams is the theory of psycho-analysis. A most interest-
ing study, and holds enough of the mystic and scientific to stimulate the
enthusiasm of many advocates. It is dependent on two facts, namely,
that our dreams are the stories of our wishes and that our mental life is
divided into the conscious and unconscious, and that the unconscious or
subconscious repression of our desires is often the cause of subsequent
irritation and disease.

In my opinion, there is a great deal in the theory, but practically, and
especially for the average physician, its methods are uncertain and
inapplicable in many cases.

I believe that it is founded on a principle which has been long neg-
lected by physicians, for most of us are too prone to treat the disease that

*Abstract of remarks.



PRACTICE OF MEDICIXE. 265

is present and not consider the patient, or the patient's past history and
life outside of the clinical symptoms that have arisen in the progress and
manifestation of disease.

In other words, disease expressions are not ahvays due entirely to the
active cause, but may be due to underlying factors that are remote, and
yet a present irritant.

The function of the psycho-analyst is to unravel past impressions
■which have become subconscious to the patient and properly value them
as to their bearing upon the case in question.

The psycho-analyst believes that this can be done only by the proper
interpretation of dreams, but at the same time believes in the "confes-
sional" which he has established between himself and the patient, and my
purpose in directing attention to this subject is to affirm that I believe
that if the average practitioner would devote more time to a careful and
conscientious study of the past history and inner life of the patient there
would be less necessity for relying so much upon the dreams of the
patient.

In the hands of specially trained scientists, psycho-analysis is more
or less easy of application; but in the practice of the family physician
the method is difficult, precarious, and unsatisfactory.

I believe, too, that most valuable information is often lost because we
are frequently too rushed to devote sufficient time to the analysis of our
cases and are too ready to treat symptoms, irrespective of the past.

Furthermore, "He who thinks he is sick, is sick," in my opinion, as
Sydenham long ago dogmatically stated.

In fact, few reach maturity without discords having been struck upon
the delicate strings of the soul, and these discords later rise to nag
and vex.

By tracing present symptoms back of memoiy, back to their lodgment
in the subconscious mind, the practitioner is often able to effect a cure.

This is the hope and the therapeutic end of psycho-analysis : to un-
ravel the tangled web of life for those who, because of the pressure of
unconscious forces, are living less than a full, free life.

This system of soul analysis, meaning by soul the whole stream of
mind life, conscious and unconscious, comprises a study not only of dis-
ease, but of faults of character and errors in training as well.

It interests its disciples not so much in the study of symptoms as in
the cause of the symptoms, and its pathology concerns itself with origins.

Its first step is the negative determination that the symptoms have no
physical origin.

Its next step is to locate their beginning in the mental or nervous life
of the individual by a study of the patient's dreams, and claims that it



266 NORTH CAROLINA MEDICAL SOCIETY,

finds in sex-disturbance the focus and originating cause for a large group
of our miserable ills.

We may be incredulous, but must admit tbat there is a large group of
nervous disorders in which the physical derangement is perfectly real,
but the origin is purely mental.

As an example of physical effects from a purely mental origin is the
whole group of hysterias. Note, for example, a man lying flat on his
back for ten years, and all the result of hysteria; or a woman may go
totally blind because of a condition of mind.

This system, of course, does not seek to relieve those nervous or mental
disorders which have a physical basis or origin, such as neuritis, neu-
ralgia, paralysis from pressure or hemorrhage, brain tumors, arterio-
sclerosis of the brain, etc., all of Avhich show destruction of nerve tissue
and are due to direct physical causes. But outside of these there are
manifold nervous conditions which have no physical derangement, and
it is to these that the. diagnostician-by-dreams applies the theories of his
system ; and the amazing thing about it, the seeming miracle of it, is that
the analysis is the treatment and the cure.

When Shakespeare made Macbeth ask the doctor, "Canst thou not
minister to a mind diseased, pluck from the memory a rooted sorrow and
raze out the written troubles of the brain and heart?" and the doctor
made reply, "Therein the patient must minister to himself," Shakespeare
voiced the present-day therapy of psycho-analysis.

By this system the patient works his own cure when his mind is opened
to the true significance of some incident that may have happened years
ago, but left its irritating scars which have never healed.

The analysis is supposed to be made by a study of the dreams. The
harmful effect of past incidents and conditions is due to the fact that
they are unconscious. As soon as they are made conscious, they vanish,
it is claimed. For example, the paralyzed woman : the paralysis traced
back to disloyalty of her husband, etc.

In confirmation of the fact that many of our desires are repressed, it
is essentially true that a distinguishing feature of child-life is want-
life — day dreams. The child habit is duplicated in our night dreams;
if poor, we dream of wealth, etc. — every dream the expression of a wish.
Hence disease, says the Psycho-Analyst, is a wish gone wrong. Accord-
ing to Freud, we are thrown into life with an all-consuming want or
love-life (libido) within us. It is often suppressed in the child. It
grows by what it feeds on. It wants, wants, and yet is buried deep ; it is
silent, speaks no language, but just yearns. If it is satisfied, all is well ;
if not, beware !



PRACTICE OF MEDICINE. 267

Add to this the second fact alluded to, the conscious and subconscious
life, and the mystery of it all grows and enlarges.

The conscious mind is the educated, trained mind of our daily think-
ing. Memory and judgment rule. Everything that happens is chalked
upon the board so that we can read the score.

But that is not the larger part of our life — in fact, it is the least im-
portant. The unconscious or subconscious is a sort of basement of the
mind into which we throw all the rubbish, all the "don't cares," all the
"forgetables" that burden or mortify or annoy us and hinder our enjoy-
ment of life. To use a psycho-analytic term, we "repress" them. These
memories, naughty children of our minds, also (closeted in our cellars)
rise up in secession and produce conversion — hysterias, etc. We thought
they Avere gone ; but not so.

In my opinion, many of these buried facts Avhich are as much irritants
to the higher nerve centers as ulcers may be to the mucous membranes,
may be brought into the light of clinical consideration as certainly and
thoroughly by detailed study of the past life-history of the patient as by
the interpretation of the fragments of the patient's dreams.

To succeed by either method, however, patience, tact, and care must
be exercised wisely to make therapeusis effective.

Dr. : I want to ask Dr. Hodges to answer just

two questions : First, as to the principle of auto-suggestion ; second, to
give us an explanation as to why all these aberrant impulses arise from
the sex impulse.

Dr. J. Allison Hodges, Richmond, Ya. : Dr. Hyatt's first query is
one of such magnitude that it is impossible to take it up at present.
The greatest and most pointed criticism brought against this theory is
that there is a sex impulse, a libido, which seems to dominate and direct
all our actions as human beings. I am willing to admit that if we take
the word "sexual" in its usual application, it is false. But children are
born into this world not only with the sexual impulse, but with all their
want life developed to the utmost. The sexual impulse is the strongest.
Children at six years of age are cognizant of domestic events, and
parents should be warned not to handle and fondle and caress their
children excessively, and children at or about five to six years of age
should not be allowed to sleep in the same bed with a parent, because of



Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 30 of 58)