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

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the danger of arousing the sex instinct.

Psycho-analysis can be applied by the average physician in getting at
the absolutely dark facts in the past life-history of the patient, but a
great deal can be done with psycho-analysis without the necessity of



268 NORTH CAROLINA MEDICAL SOCIETY.

interpreting the dreams of the patient, if we can get en rapport with the
patient, and get him to tell ns the mortifying things that have ha])-
pened to him, perhaps years ago, and that have been repressed.

I had a case not many months ago of a highly educated woman in this
State who came to me. After I examined her thoroughly, I told her I
could find no evidence of physical disease and could do nothing for her
medically. Nevertheless, she was depressed and melancholiac, and she
refused to go home. Finally I told her that I could do nothing for her,
that she must have repressed something, and unless she was absolutely
honest I could not help her. Then she told me an amazing story of a
mortifying incident of her child-life.

Later, the neighbors found it out, and the Federal autliorities found it
out and told her father that they must remove from that section of the
State.

After getting her to make this confession, which is along the same line
as the interpretation of dreams by psycho-analysis, and after showing
this woman that the offense was not nearly so great as she had imagined,
and that it had come from idleness and lack of social life, etc., and that
it should not darken her w^hole life, that blot was removed from her
life and she has been restored to health and is able to live a happy-,
useful life.

I have given you the story of this case in order to show you the use
of psycho-analysis in getting down into the recesses of the heart and
mind of the patient through the confessional, and not necessarily through
the patient's dreams.



Dr. J. Howell Way, Waynesville : Mr. President, if in order, I de-
sire to call attention to the presence in the hall of the recent president
of the Medical Society of Virginia, Dr. Southgate Leigh, of Norfolk,
Ya. Dr. Leigh is also an ex-president of the Seaboard Medical Asso-
ciation, and of the Tri-State Medical Association, and a widely known
surgeon. I take pleasure in moving that the courtesies of the floor be
extended to him.

This motion was seconded and carried, and the president asked Dr.
Leigh to address the society.

Dr. Southgate Leigh, Norfolk, Va. : Mr. President, and members of
the North Carolina State Society, I appreciate very much your kind-
ness. I am delighted to have the opportunity of being with you today.
I bring from the Medical Society of Virginia the warmest fraternal
greetings. I am directed by our president to present to you his con-



PRACTICE OF MEDICINE. 269

gratulations and best wishes. We in Virginia have great admiration for
the wonderful work you have done, especially through your organiza-
tion. We feel that you are leaders in many things that go to uplift our
profession.

Although a little out of my own chosen line, I have been tremendously
impressed today with the magnificent Avork that you are doing in pre-
ventive medicine. It is something marvelous. The thought brings up
to me a problem that I believe is facing us in our State, and I was
hopeful that you had felt that the same problem was before you, and
that you would help solve it, as you have always been the leaders in
solving the problems of the past. That problem is this : We are coming,
we are bound to come, to contract practice. The Avord sounds harsh,
because of the use or abuse of it in the past. But without recompense,
Avithout financial return, Ave are saving the lives of our people and greatly
lessening the amount of sickness, and in doing so cutting ourselves out of
our OAA'n income. We do not begrudge this service, but Ave have to live.
I belieA^e this is a serious question, and T mention it purposely at this
time because I believe it aa411 be taken up by the Medical Society of Vir-
ginia in the near future. We must deA'ise ways and means AAdiereby,
legitimately and properly, the members of our profession may be em-
ployed by the families and individuals of our communities to keep them
AA'ell. What a magnificent work that Avould be, to be employed to Avatch
over our people from the cradle to the grave, to keep off sickness from
individuals just as we do from communities.

I say that this is a problem that we have to face, and we have to face
it in the near future. We are doing this preventive work, and we ought
to be paid for it. There is no reason in the world why men should giA^e
their time and talents for nothing, as so many of our general practi-
tioners are doing. I hope that you will take up this problem and try to
solve it, and tell us how to go about it in a professional way.

In Virginia we have another problem AA^hich I believe you have already
soh'ed, and that is the elevation of the standard of medical education.
In your State you have done nobly in raising your standard. In Vir-
ginia we have combined two of our colleges, and I hope that in a short
time unselfishness Avill prevail and we shall have only one medical
school, the medical department of the University of Virginia, located at
Richmond.

Another thing : West Virginia has a protectiA^e insurance plan which
our States might well consider. Its object is to protect the members of
the society from unjust litigation. It is something that aa'c will take up
at our coming meeting, and I hope that it will also meet with your con-
sideration.



270 NORTH CAROLINA IVIEDICAL SOCIETY.

Dr. L. B. McBrayer, President, Sanatorium : We are delighted. We
hope that the encouraging words of Dr. Leigh Avill enable us to move
forward along these important lines. We have a Committee on Medical
Defense, as we call it, that has been out for two years, but we have been
unable so far to get them to report. We hope that they may report at
this meeting.



THE CAUSE OF PELLAGRA AND TEEATMENT
SUGGESTIONS.



B. W. Page, A.B., M.D., Lumberton.



The cause of pellagra has not yet been settled to the satisfaction of the
medical profession, and the more one reads the many theories advanced
as to its etiology the more at a loss he becomes as to what is the correct
answer. I shall not attempt to review the many ideas already presented,
but shall endeavor to summarize briefly a little investigation I have
attempted to make for the past several months.

In July, 1912, while examining a supposed case of amoebiasis, I ob-
served a very small organism, oval in shape, that developed into a slender
bacillus. In the course of time I noticed the same organism in eleven
other cases of chronic dysentery, and associated it with the latter affec-
tion. In tracing my cases in the summer of 1914, I found that two had
died, three had moved away, five were being treated for pellagra since
other clinical symptoms had developed, and the remaining two were still
infected and did not reveal the cutaneous signs until spring of this year.

Omitting several specimens mailed to me without case histories, I have
examined up to the present time one hundred and twenty-six cases.
Ninety-two of these have revealed the cutaneous manifestations as well
as the digestive and nervous symptoms of the disease. The remaining
thirty-four have had nervous and digestive symptoms only. In sixty-
seven cases examined, more than one time I have found the organism to
be constant except after the administration of certain drugs, which re-
tarded their development and seemed to render them nonmotile. I have
been unable to find the organism in normal specimens or associated with
other diseases.

The organism presents itself in two forms, with variations of each.
First, a small oval, cell-like body, which develops into a slender bacillus
about as long as the diameter of a red-blood corpuscle. These often vary
in size, depending upon the artificial media on which they grow, and in



PRACTICE OF MEDICINE. 271

feces according to the variety of food ingested. As the rod develops from
the oval form it is very active. It seems to be without flagella and grad-
ually becomes less and less motile until the true form of a bacillus is
reached. The nuclear material at first seems to be evenly distributed
throughout the cytoplasm. As soon as the bacilli come to rest they in-
crease in diameter from two to three times, apparently. The hyaline cell
contents become turbid and small granules are visible with higher mag-
nification throughout the length of the rod. As these granules develop
into cells, the delicate membrane inclosing them gradually disappears
and the cells are freed. For a short time these small cell-like forms are
very sluggish, but in a favorable medium and temperature they soon be-
come distinctly motile and increase in size.

In feces the organism is best observed in very fresh specimens and as
near body temperature as possible. Even then we usually find one of the
forms predominating, generally the oval form. Occasionally we find the
slender rods outnumbering all other forms. Rarely do we find the beaded
form of the bacillus predominating, but when this is the case they often
include four-fifths of all forms of the organism. All forms are usually
seen in the majority of specimens examined. Old specimens that have
been exposed to different temperatures may be entirely unreliable, be-
cause of polymorphism. Every conceivable form of bacteria may be
present, and the field becomes very confusing. Warming the specimen is
not sufficient in every instance. A new specimen or cultivation of the
old one afford the only relief. During the summer season all specimens
are more reliable.

I have been unable to cultivate the bacillus except on special media.
A very good growth was obtained from a filtrate of corn meal,' Irish
potato, and cane syrup. The medium contained about 2 per cent of each
of these products. The best growth I have been able to secure was from
equal parts of agar bouillon and filtrate from boiled corn meal. From
this medium I was able to observe the cycle of the organism very
nicely. Beginning with the oval form early one morning, I found that
more than 90 per cent of them were rods by noon, and by 6 o'clock in the
afternoon the rods presented the beaded appearance. The cycle seems to
require from ten to twelve hours. By the addition of a 50 per cent solu-
tion of alcohol I was able to secure an agglutination of the bacilli.

On plating the bacillus, the groAvth appears as a grayish white. The
first growth is seen on the surface within eighteen hours after inocula-
tion of the medicine. Like the typhoid colon group of bacteria, it is
decolored by Grams' method of staining. The organism does not seem
to develop rapidly after the fourth or fifth day of cultivation.



272 NORTH CAEOLINA MEDICAL SOCIETY.

The organism seems to be confined for tiie most part to the contents of
the intestine. I have been unable to find it except in feces. Dr. T. E.
Sanders, in a paper published in the March issue of the Southern Medi-
cal Journal, reports finding them in abundance in a large number of
specimens of pellagrin feces. Dr. R. G. Rozier informs me that he has
found the organism in feces of thirty-seven cases of pellagra, and has
failed to find it in sixty-four healthy persons examined.

Animal inoculation exj)eriments have not been very successful. The
disease spreads rather rapidly in thickly settled communities where sani-
tary conditions are poor. I have known of five eases of the disease to
develop in a home soon after moving close to a family in which the dis-
ease was present. Three people previously free of the bacilli soon de-
veloped the disease after admitting a pellagrin into their home. Another
case seems to have developed as a result of contamination with cultures
of the organism.

Should this organism be an etiological factor in pellagra, the media
necessary for its growth would indicate that the diet is an essential
factor in the treatment of the disease, but not in its prevention. Since
the infection seems to be primarily of the food product or the intestinal
contents, and not the tissues per se, it seems necessary that the patient be
given a diet that will at least inhibit the growth of the organism and
thereby lessen the production of toxin to be absorbed into the system. It
has been observed that the elimination of corn bread, Irish potatoes, and
sweets, especially cane syrup, is of great value to the pellagrin.

Of the drugs in common use, arsenic is of great value in improving the
haemoglobin and affecting to some extent the toxaemia. Ichthyol has
a decided effect on the intestinal microscopic flora. The latter drug
should be administered in gelatin-coated pills before meals, and the size
of the dose should be increased.

In this brief paper it has been my purpose to emphasize the theory of
intestinal intoxication resulting from infection, with the hope that others
may be induced to investigate more fully along similar lines.



PRACTICE OF MEDICINE. 273

AN EXPERIMENTAL STUDY OF THE INTEASPINOUS
METHOD OF THERAPY IN SYPHILIS OF THE NERVOUS

SYSTEM.

Frederic M. Haxes, M.A.. M.D.

(Professor of Therapeutics, Medical College of Virginia. Richmond, Va. )



It is now well established that owing to the impermeability of the
choroid plexuses of the ventricles of the brain, medicinal agents intro-
duced into the blood-stream fail to reach the cerebro-spinal fluid. This
can be most clearly demonstrated experimentally by the intravenous in-
jection of vital stains such as isaminblau or trypanblau into lower ani-
mals. A rabbit, for example, whose blood and tissues have become
intensely stained by trypanblau shows absolutely no staining of the
sj^inal fluid. The spinal fluid in man likewise remains clear even in the
most intense cases of jaundice. In the treatment of meningeal infections
it is an entirely rational procedure, therefore, to attempt to avoid the
natural protective barrier of the choroid plexuses by the intraspinous
introduction of therapeutic agents.

The revival of a more hopeful interest in syphilis of the nervous sys-
tem, due largely to recent therapeutic advances, has led a number of
observers to attempt the direct application of antisyphilitic remedies by
the subdural route. Mercury and old and new salvarsan have been em-
ployed, and methods have varied widely, from the simple direct intro-
duction of the aqueous solutions of the remedies to the more complicated
technique employed in the use of vitally salvarsanized serum. Of these
methods I shall speak later. Despite the very widespread employment
of the intraspinous method of treatment, our experimental knowledge of
the fate of the substances thus introduced is deficient. Especially do we
lack exact information as to the degree to which they penetrate the
parenchyma of the brain and cord and the route of their elimination.
My attention was directed to this while working with the Swift-Ellis
method of intraspinous therapy, at the Rockefeller Hospital, in the treat-
ment of tabes and meningeal syphilis. The deficiency of our experi-
mental вАҐknowledge is particularly apparent when we consider the attempts
which have been made to treat general paresis by intraspinous injections.

The opportunity presented itself some months ago of investigating
this subject upon dogs, and in this communication I wish to present the
results of these experiments.

It is impossible to trace the course of such a substance as salvarsan
when injected subdurally into dogs, because of our lack of any micro-
chemical technique for rendering salvarsan visible in histological prepa-
18



274 NORTH CAROLINA MEDICAL SOCIETY.

rations. In order to trace the paths followed by a substance introduced
into the spinal fluid, a pigment should be used which will retain its color
even when absorbed into the tissues, and one that can be fixed in situ for
microscopic study. Some years ago, while working Avith vital staining
substances in the laboratory of Professor Mesnil at the Pasteur Institute,
Paris, a chemical substance was employed which seemed admirably
adapted to the present study. This is the dye "Trypanblau." When
injected intravenously it is almost devoid of toxic properties, but it is
readily absorbed by many types of cells in the body, producing the
remarkable effect of vital staining. This dye was employed in a large
series of rats, mice, and rabbits, and no toxic effects were observed be-
yond a transient rise of temperature, even when large quantities were
injected.^ The animals showed invariably no staining of the spinal fluid,
though the blood and tissues were intensely stained.

Two young dogs w^ere selected for the first experiment, and into each
2 cc. of a 0.5 per cent solution in normal saline of trypanblau were
injected subdurally. The injection proved extremely irritating, the ani-
mals showing such violent evidences of extreme meningeal irritation that
one was sacrificed at once and the other reanesthetized and allowed to
remain alive for half an hour;. upon regaining consciousness, he seemed
in great distress, and both hind legs were paralyzed. He was killed at
once, and the brains and cords of both animals were removed for histo-
logic examination. The details of the histological studies of all the ani-
mals used in the various experiments w^ill be considered presently. Very
much w^eaker solutions of trypanblau were now used for injection, but it
was soon apparent that a solution so weak as to cause only slight menin-
geal irritation likewise failed to stain the tissues sufficiently along its
path of absorption, and was therefore valueless.

The query naturally arose. Why should trypanblau be devoid of toxic
features when injected intravenously, but extremely irritating and toxic
when introduced into the spinal fluid ? It seemed probable that the well-
known collodial protective properties of the blood serum furnished the
explanation. Accordingly, in the next series of experiments a 1 per cent
solution of trypanblau in saline diluted one-half with rabbit-blood serum
was used for subdural injections. A solution of trypanblau was thus
employed Avhich was identical with that used in the former experiment,
but which contained blood serum.

Three young dogs were now given each 2 cc. of this mixture intra-
spiiiously. They all recovered from the anesthetic without giving any
evidences of meningeal irritation whatsoever, and remained in appar-
ently normal condition until they were sacrificed for histological exam-
inations of the central nervous system, one, two, and four hours later.



PRACTICE OF MEDICINE. 275

The anatomical and histological study of the central nervous system
of the animals injected subdurally with trypanblau was very instructive.
In animals killed one hour after the injection of 2 cc. of the trypanblau-
serum mixture the meninges of the cord were found to be diffusely
stained dark blue. The stain could be traced to the base of the brain,
from whence it had spread laterally for a short distance upon the tem-
poral lobes. The convexity of the brain was free from the stain. Ante-
riorly it had completely impregnated the sheathes of the optic nerves and
had extended over the sclerge to the limbus. Furthermore, the stain could
be traced into the nasal cavity, having reached this point by the way of
the well-known lymphatic connections between the nose and the arach-
noid spaces of the brain. As the spinal nerves were severed in removing
the cord, they were seen to be injected within the stain, and upon careful
dissection the stain Avas found to have penetrated quite to the dorsal gan-
glia of the posterior roots. All the cranial nerves were likewise deeply
stained. It will thus be seen that in dogs the entire cord, base of the
brain, and spinal and cranial nerves can easily be reached by means of
intraspinous injections of relatively small amounts of fluid.

Dogs sacrificed two and four hours after injection showed a very simi-
lar picture to that described, except that the cerebral hemispheres were
stained a little more upon the convexity than in the dog killed after one
hour. In no instance, however, was the convexity of the brain stained
up to the median line, the stain reaching only a short distance upon the
surface of the temporal lobes. This observation would seem to have some
bearing upon the intraspinous treatment of paresis, for in this disease it
is the cerebral hemisphere especially that one wishes to bring into contact
with the material injected.

With this in mind, two dogs were next injected through a trephine
opening with 2 cc. of the trypanblau-seruni mixture directly into the
lateral ventricles of the brain. This was a severe test of the detoxifying
power of blood serum for trypanblau, for when upon another animal a
0.5 per cent solution of trypanblau in saline was injected into the lateral
ventricle the animal died promptly with convulsions and respiratory fail-
ure. With the trypanblau-serum mixture, however, there were no un-
toward symptoms, the animals recovering from the anesthetic quite nor-
mally. Upon removing the brain and cord of one of these animals forty
minutes after ventricular injection, quite a different picture was seen
from that present after intraspinous injection. The pia-arachnoid spaces
of both hemispheres were deeply stained quite to the median line, and
the base of the brain and upper half of the cord were likewise deeply
tinged. As a means of applying therapeutic sera directly to the cerebral
hemispheres the intraventricular route is far superior to the spinal.



276 NORTH CAROLINA MEDICAL SOCIETY.

Having demonstrated that the pia-arachnoid spaces of the brain and
cord can readily be injected with serum, even to their terminations upon
the cranial and spinal nerves, the very important question remained as
to whether the parenchyma of the cord and brain had been reached by
the stain.

N^umerous frozen sections were made from various parts of the cord
and brain of each experimental animal, and paraffin sections were like-
wise made, using 10 per cent formol as a fixative. From a microscopic
study of the sections one may briefly say that in the dogs who received
the trypanblau-serum injections there Avas in no instance any evidence
of the stain having penetrated into the brain substance proper. The
meninges, pial-septa, and blood-vessel sheathes were difl^usely stained, but
the parenchyma itself remained untinged.

The only instances in which the parenchyma was stained were in the
animals receiving trypanblau dissolved in saline and without the addition
of serum. These animals, it will be recalled, exhibited signs of intense
meningeal irritation following the intraspinous injections, and some de-
veloped paralysis of the hind legs. In the latter the lumbar region of the
cord was intensely stained, and the stain had penetrated the parenchyma,
coloring the motor-horn cells in many places. Such staining, however,
means unquestionably the serious injury or death of the nerve cells, and
this was shown clinically by the paralysis observed in the animals before
death. Here again we encounter additional evidence of the extreme dan-
ger attending the subdural injection of a toxic substance without the
protective action of blood serum.

The experiments which have just been detailed prove in a very conclu-
sive manner the protective power of blood serum for a highly toxic sub-
stance injected intraspinously, and the analogy between the action of
trypanblau under the conditions described and that of salvarsan and neo-
salvarsan under similar experimental conditions is so striking that it
seems worth while to discuss critically at this point the various methods
which have been employed in the intraspinous use of the salvarsan prepa-
rations.

Because of the ease with which neo-salvarsan can be brought into solu-
tion it has been employed for direct subdural injection, but the results
have not been at all encouraging. Isotonic salt solution was used as a
vehicle by Ravaut^ and the later by Lorenz-^ and others. They report
rather violent root pains and frequently impairment of the sexual and
bladder functions following the injections. The opinion of workers in
this field seems almost unanimously against this technique.

The use of blood serum salvarsanized in vivo has been thoroughly
tested by Swift and Ellis'"' and many others^, '^, and the results are gener-



PRACTICE OF MEDICINE. 277

ally conceded to be favorable in certain cases. It has been objected, how-
ever, that with the Swift-Ellis technique only infinitesimal quantities 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 31 of 58)