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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time should not be extended on a paper unless to a person invited to
attend the society from another State. The discussions were limited to
a fixed time. When the time came for the meetings to commence, they
began, if there were only two persons in the hall. If a man was not
present when the time came for him to read his paper, it was placed at
the end of the program, and if the society reached it, it was all right.

XoAv, we must adopt some such system as this in order to get through
our program, and thereby increase the pleasure and profit of our society.



THE PHYSICAL FUXCTIO^^S OF THE NOSE.



De. C. N, Peeler. Charlotte, N. C.



This is an age of progress, and I am glad to say that it is becoming an
age of prevention. Our State Board of Health is making a strong fight,
along with the iDrofession, for the prevention of disease, and thereby
increasing the average life of the individual, at the same time increasing



46 NORTH CAROLIlSrA MEDICAL SOCIETY.

the earning capacity of the community and adding to its aggregate
wealth. Typhoid fever is rapidly becoming a disease of the past. Small-
pox is not the dread disease it once was, vaccination being the great
prophylactic treatment. Tuberculosis, the Great White Plague, is being
slowly but surely conquered. Preventive medicine is making great
strides — so great that typhoid fever is now regarded as a reflection on
the sanitary condition of a community.

For the well-being and longevity of the individual I might say that
four things are essential to his growth, development, and equilibrium :

1. Good nourishing food, properly prepared ;

2. Fresh air, night and day, with all of its invigorating qualities ;

3. Long hours of rest in refreshing sleep ;

4. Proper amount of exercise or work.

I^eglect any one of these, and a diseased condition of some part of the
body is a result. (A chain is no stronger than its weakest link.) In
this paper I shall endeavor to discuss the physical functions of the nose
and how important it is that it should be kept in a normal physiological
condition so that the fresh air may be prepared in such a way whereby
the interchange of gases in the lungs may keep the blood in good con-
dition.

Every person has a certain amount of inherent immunity against dis-
ease, and in order that this immunity may be increased it is important
to the individual that he should keep all the organs of the body in nor-
mal condition, so that they may properly perform their functions, that
Avhen he is attacked by disease he may be able to destroy the infecting
agent or to generate antitoxin whereby the pathogenic germs become
harmless and are easily thrown off.

From the anatomical standpoint the framework of the nose is made
up of bones and cartilages, and running through the center of the nasal
cavity we have the septum which divides it into two fossae. From the
viewpoint of this paper the outer wall of each fossa is the important one
for discussion. As was all Gaul, it is divided into three parts by the
inferior and middle turbinate bones. The area of this wall is thereby
increased about four times. In this outer wall we also have the openings
from the different cells and the sinuses, which are important aids to these
functions. Each cavity is lined with a thick layer of mucous membrane
containing glands, blood vessels, nerves, and lymphatics. The mucous
membrane covering the turbinate bones has a peculiar structure which
calls for a special description. Its spongy character has long been recog-
nized, and more than fifty years ago Cruveilhier defined it as true erectile
tissue. Later Bigelow, Zuckerkandl, and others established the true



PHYSIOLOGY AXD CHEMISTRY. 47

nature of this tissue. The deep layer of the mucous membrane forms
the periosteum. Distributed freely through the connective tissue are
lymphoid tissue and tubular glands of extraordinary length. Within
this lymphoid tissue are numerous venous sinuses surrounded by an
abundance of unstriped muscular tissue. This "erectile tissue" or swell
bodies is subject to rapid and extreme variations in size under the influ-
ence of atmospheric conditions and of mechanical irritation, as well as of
mental emotions. In dry air these bodies retract, in humid air they
swell. Besides a large quantity of lymphoid cells in the connective tissue,
there are also found a large number of lymphatic vessels. These vessels
not only communicate with each other, but have branches which have
numerous openings on the surface of the mucous membrane through
which lymph fluid is discharged into the nasal cavity.

Just a word in regard to the accessory sinuses. Besides the numerous
cells of the ethmoid and sphenoid we have the maxillary and frontal
sinuses. These sinuses have a lining continuous with that of the nose.
Their average combined capacity in an adult is about four cubic inches.
Besides contributing to the resonance of the voice, diminishing the
weight of the skull, and offering protection to the nerve centers, these
cavities are emptied on inspiration and filled during expiration in the
act of breathing, of which I shall speak later.

The two functions of the nose which I shall discuss are, first. Breath-
ing; second. Excretory or Bacteriaddal. I might also mention the part
the nose plays in speech. All sounds containing M, N, and jSTg are nasal ;
all others belong to other parts of the tract or combinations of these.
Also, I might mention smell. What we call taste is largely that of smell.
Taste gives us only sweet and sour, salt and bitter. A cold spoils not
taste, but smell. It is the sense of smell that recognizes tainted foods,
rather than taste.

I. BREATHING.

The air in passing through the nose undergoes changes which might
be divided into four parts :

1. It is filtered of its dust, coal smoke, bacteria, etc., by the nasal hairs,
the cilia of the mucous membrane and the mucous membrane itself.

2. Heat is added to the air. This heat comes from the "swell bodies,"
mucous membrane, glands, and accessory sinuses. The amount of heat
varies as the temperature of the external air varies. The elevation of
temperature equals five-ninths (the body temperature minus the external
air), giving us the rise of temperature. This air at freezing point is
raised from 32 F. to about 70 degrees F. in passing through the nose to
the pharynx — a very important point.



48 NORTH CAROLINA MEDICAL SOCIETY.

3. Moisture to the air. The air in passing through the nose hecomes
two-thirds saturated. This moisture conies from the mucous membrane,
the glands, tears from the eyes and sinuses. It is estimated that the nose
furnishes one quart of water to the air in twenty-four hours.
* 4. The sinus air is mixed with the external air to aid in the addition
of heat, and, contrary to what the text-books tell us, they empty on
inspiration and fill on expiration, as shown by operation. In addition,
the ethmoidal cells act as nonconductors of cold for the protection of
surrounding structures.

II. EXCRETORY OR BACTERIACIDAL.

This important physical function of the nose is brought about by the
normal nasal secretion. This secretion is formed by the mucous mem-
brane, glands, and the free lymph fluid discharged from the openings of
the lymphatic vessels. It is claimed by investigators that within one
inch of the nose there are found no bacteria. All the bacteria entering
the nose in inspiration are caught up by above mentioned secretion and
killed in greater or less time. Staphylococci and streptococci are killed
in twenty and thirty minutes. Tetanus bacilli are the hardest ones to
kill, requiring four to six hours, and other more common bacteria require
from thirty minutes to one and two hours. To recapitulate : the physical
functions of the nose are to filter, to heat, and to purify the air so that
the individual may receive the greatest amount of oxygen and be rid of
all the invading agents which reach the system through the respiratory
tract, viz. : pulmonary tuberculosis, epidemic meningitis, poliomyelitis,
the exanthemata, and the pneumonias, influenza, and the various colds.



THE KIDNEY rUNCTIOJSTAL TESTS.



Dr. Robert H. Lafferty, Charlotte.



The subject of the kidney functional tests is receiving more and more
attention each year, and rightly so, for when we consider the vast impor-
tance of these organs in the human metabolism, when we consider the
difiiculty that we experience in diagnosing kidney lesions, when we con-
sider the necessity and importance of knowing their functionating power,
we understand the avidity with which one seizes anything that will help
him to learn something of their activity.



PHYSIOLOGY AND CHEMISTRY. 49

I shall not attempt in this brief paper to discuss the many tests that
have been recommended from time to time. They all fall under one of
two heads : the estimation of the output and the estimation of the reten-
tion. I shall discuss with you only one test from each group, the one
that in the experience of most men and in our own experience has proven
most satisfactory.

FIRST, THE ESTIMATION OF THE OUTPUT.

The Phenolsulphonaphthalein test of Geraghty and Rountree, in the
experience of many and in our experience, easily occupies the first place
among the tests in this group. It is harmless, simple, accurate, and easy.
In our experience of hundreds of cases, although not followed by autopsy,
it has proven of inestimable value, not only in determining the total
activity, but also for estimating the relative power of the two kidneys.
In nephritis, by revealing the degree of functional derangement, it is of
the greatest value from a diagnostic and prognostic point of view, and in
the class of cases known as cardio-renal it gives the examiner an idea of
the degree in which the kidney is responsible for the symptoms. In diag-
nosing uremia, and also as a warning of impending uremia, this test has
proven its Avorth. It has been proven of untold value to us as a guide to
the best time for operation in cases of urinary obstruction, as is shoAvn
in the cases reported below. All in all, our experience has confirmed that
of Geraghty and Rountree and many others who have used this test suc-
cessfully, and we consider it an absolutely indispensable adjunct.

SECOND, THE DETERMINATION OF THE RETENTION.

For this, of course, we must go to the blood, and it has always pre-
sented majiy difficulties to the diagnostician. We know when the kidneys
fail to carry off certain of the waste products we may expect grave
results. We know that when the noncoagulable nitrogen, i. e., the end
products of protein katabolism, becomes excessive uremia results. We
do not know Avhich of these many products ("building stones," we some-
times call them) it is that produces this condition. We know it is not
urea. The difficulty has been to get a method simple and yet accurate
that could be applied to small quantities of blood. By determining the
total noncoagulable nitrogen by the micro-kjeldahl method of Dennis
and Folin, and the urea in the same specimen by various methods, espe-
cially by the urease method of Marshall, it has been shown that the urea
runs parallel to the total nonprotein nitrogen. So by determining the
urea in the blood we shall have an ideal method of estimating the reten-
tion. By this simple and accurate method we estimate the urea by con-
verting it into ammonia and determining the amount of acid it will neu-
4



50 NORTH CAROLINA MEDICAL SOCIETY.

tralize. The normal blood urea varies between .2 and A gram per
100 cc. of blood; .5 gram per 100 is not considered excessive, while .6
gram is viewed with suspicion and is considered grave if it is on the
increase. In rare cases the urea may run as high as 2 or 3 grams or
more before uremia appears.

This test we have found very reliable and serviceable, especially com-
bined with the phthalein, and it as a rule runs parallel with it. In
bilateral renal diseases the urea retention increases as the phthalein
decreases, although it is also a fact that it is possible to have some lower-
ing of the phthalein without any marked nitrogen retention. Agnew
claims that he finds retention when phthalein falls below 40% in two
hours. In renal congestion this does not apply, although in cases of
nephritis I think it does. When, however, our phthalein is low, our urea
retention increasing, we have a warning that we cannot disregard.

We find this test of value also for keeping tab on the functionating
power of the kidneys after prostatectomy, when the phthalein cannot be
determined on account of the difficulty in collecting the urine.

A few of the many cases in which these tests have been of value to us
may be of interest :

First case: Came in with retention 15 oz., January 22. Phthalein 10%
first hour, 22% the second. Urea .5 gram per 100. February 20, 20% first
hour and 35% the second hour. March 2, 12% first hour and 55% second.
Urea .4 gram per 100.

Second case: Retention 12 oz., relieved and bladder not refilled for several
days prior to examination on March 24. Urea .6 gram. Phthalein 12% two
hours. March 28, 29%^ two hours. April 15, 36% two hours. Urea .40%,.

Third case: Retention and irritation from catheterization for some time
before examination on April 12. Phthalein 6% two hours. Urea .6 gram.
April 20. phthalein two hours, 40%. Operation third day, after patient wan-
dering in mind, etc. Phthalein impossible. Blood urea shows .3 gram per
100 cc.

There are three points I should like to emphasize as illustrated by
these cases :

First. That the phthalein and urea run parallel, and that they are of
special value in determining when the kidneys are in condition for
operation.

Second. That in cases of retention the phthalein is generally low and
will show a decrease if the retention is relieved suddenly, due to renal
congestion, and in all cases where the retention is relieved gradually by
partially refilling the bladder the phthalein shows better kidney action.

Third. In case 3 the blood urea enabled us to be sure uremia was not
imminent, although symptoms seemed to so indicate on the third day
after operation.



PHYSIOLOOY AXD CHEMISTRY. 51



COjVCLUSIONS.



First. That althougli there are limitations to the renal tests, they are
of incalculable value, and that', combined with clinical studies, these two
tests furnish us with a clearer conception of renal conditions.

Second. That the urease method of Marshall for determining urea is
very satisfactory and furnishes evidence of impending uremia, and in
some cases is indispensable, but that it does not take the place of the
phthalein test, and should be used as an adjunct, since the determination
of the cumulative phenomena is of great prognostic value, although its
absence may be misleading.



MEDICAL JURISPRUDENCE AND STATE
MEDICINE.



SYMPOSIUM ON NARCOTICS.



THE KELATION OF THE MEDICAL PEOFESSION TO
STATE MEDICINE.



Charles T. Nesbitt, M.D., Health Officer Wilmington
AND New Hanover County.



When asked by the chairman of this section to present this paper as a
part of a symposium on government control of narcotics, I wrote him
and asked if he desired me to confine my remarks to the relation of the
physicians of JSTorth Carolina to the enforcement of the Harrison law.
He replied that he wished me to deal with the subject in a broader way,
covering the entire relationship of the medical profession to the enforce-
ment of the laws which are identified with its interests. I realize that a
volume could be written on this subject without exhausting its possibili-
ties. I shall try to discuss briefly those phases of the matter which seem
to me to be of the greatest importance to both the profession and the
public.

There are no peculiar conditions in ISTorth Carolina Avhich call for
especial consideration. The physicians of this State are just as con-
scientious and honorable as the physicians of any other State or Nation.
I shall ask, therefore, that my observations be received as applying to
the medical profession of the whole country, and that no one shall under-
stand me as criticising North Carolina nor any one in the State.

The law represents the effort on the part of society to control indi-
vidual action for the benefit .of the whole people. With the development
of civilization, with its necessities for close human relationships and
communal living, it has become necessary to abridge the so-called right
of man to regulate his life in accordance with his desires. Originally
each individual was compelled to undertake his own protection in every
way. Later individuals banded together in families and clans. The suc-
cess of this moA^ement led to the formation of tribes for still greater pro-
tection. Then came communal, State, and finally National organiza-
tions; and with each step further restrictions were made necessary. At
first these laws were expressed in the utterances of the tribal leader, and
were simply fortuitous commands. When living became more concen-
trated in certain parts of the world, and it became necessary to govern



MEDICAL JURISPRUDEJN'CE AXD STATE MEDICINE. 53

larger groups, laws were formulated and recorded. Until within com-
paratively recent times these laws were designed chiefly to control vio-
lence and to protect property rights. In the earlier conditions under
which humanity lived the continuance of life and the maintenance of
property rights were determined by physical fitness. The weak died and
the strong survived. As living conditions became more complex, and as
human learning and intelligence progressed, the realization came that
the weak must be protected, that they might not become a charge upon
the efforts of the strong. With the development of the knowledge of
disease origin it was learned that the weak produce the greater part of
the sickness, and still later it was learned that the sick are a dangerous
source of the diseases which so frequently attack the strong. These
truths which I have so crudely stated furnish the real basis for all the
legislation which has been produced for the purpose of enhancing tlie
physical Avelfare of mankind. It is with laws of this class that the medi-
cal profession is concerned. It has by its work and research laid the
foundation for every such enactment, and by the influence of its organ-
izations has promoted the passage of every such law. Personal interests
have been put aside in the interest of race betterment to the extent that
now the most potent influences in the profession are being used in an
effort which bids fair to destroy curative medical practice as a remu-
nerative profession.

There are influences still operative in the profession Avhich are ob-
structing its altruistic activities, but with the elevation of the standards
of medical education, and the elimination of the low-grade commercial
practitioner through the operation of the medical practice acts in the
various States, and the education of the public, the day will soon come
when the profession as a whole will strive with the earnest purpose of
preventing as well as curing human deficiencies. Modern conditions
and the so often sneered at ethics of our cult demand that we shall labor
for the welfare of humanity, no matter what the result to ourselves. We
must ignore the remunerative side of our work in order to preserve our
traditions.

Through the influence of medical organizations, the medical practice
acts of most of the States have been remodeled so that no person can
engage in the practice of medicine unless properly trained. Every
educated physician knows that Avherever an ignorant physician or quack
operates, the well trained physicians of the community find an appreci-
able increase in their work in taking care of the invalidism created by
these impostors.

The organized medical profession has been widely condemned because
of its attitude with respect to the practice of osteopaths, chiropractors.



54 NORTH CAROLINA MEDICAL SOCIETY.

mental healers, and Christian Scientists. Never at any time has there
been any rfiason to believe that the efforts of these so-called healers have
interfered in the slightest way with the scientific practice of medicine,
except by increasing the demand for it.

I have no doubt that the papers read in this section will indicate that
the attitude of the physicians of N^orth Carolina is decidedly favorable
to the Harrison Anti-lSTarcotic Act, and that they are perfectly willing to
submit to the inconveniences which its enforcement will produce for
them. The medical organizations not only made the passage of this law
possible, but they will give the weight of their great influence to secure
its rigid enforcement. Every drug habitue is a chronic invalid who
seeks medical aid frequently and who is, more often than not, good pay.

As a producer of disease, alcoholism stands at the head among the
habit causes. Medical organizations throughout the world have pro-
claimed this fact for years and have given their influence to the enact-
ment and enforcement of regulating laws.

The pure food laws which are now in force owe their existence to the
influence of medical organizations.

Public health laws are founded upon the experience and research of
medical men. It is true that the detail of sanitary science has been
developed by the efforts of engineers, chemists, biologists, and bacteriolo-
gists, yet the necessity for the work of these scientific allies was developed
in the research in the field of disease origin which is carried on by mem-
bers of the medical profession. The functions of the physician are so
diverse and so wide that it is difficult to find any legislation aside from
that which is specifically drawn for the protection of property rights,
governmental and social relations, and the prevention of violence, which
cannot be traced to his influence in some degree.

No further argument is needed to show that the medical profession as
represented by its organizations supports every effort for the betterment
of the race, no matter how much its commercial interests are destruct-
ively affected thereby. It has gone so far in its support of National and
State regulation of matters of this kind that it lias been accused of main-
taining a trust for the purpose of controlling all conditions affecting its
welfare. Those who have made these accusations have not taken the
trouble to investigate; if they had, they Avould find that the efforts that
have been made most persistently and forcefully have resulted in limit-
ing the financial and other advantages of physicians. Each new medical
law is an added restriction, and the plain tendency of the times is toward
the complete elimination of medical practice from the field of commer-
cial competition. This may seem a very remote possibility at present,



MEDICAL JURISPRUDENCE AND STATE MEDICINE. 55

but the State and ISTational support of the practice of preventive medi-
cine which is producing such splendid results will certainly suggest that
the same plan for the application of curative effort is equally valuable.

There are two forms of influence operating in the medical profession
■ which have yet to be directed into channels in which they will not con-
flict with the best interests of the general public. These are medical
society politics and the individual influence exercised by members of the
medical profession through their patients.

In every organization in which administration and control are de-
cided by vote, the selection of the officials and the fixing of administra-
tive and general policies are in the hands of a few members. These
members most frequently acquire their influence, not so much through
professional excellence as through their individual social qualities.
There is constant danger in every organization so governed that the
best interests of the public may be lost sight of in the scramble for
preferment; candidates for important public positions may be elected
through personal or political influence rather than by reason of ex-
perience and fitness. A striking instance of this sort occurred in one
of the northern States. Through the influence of the medical societies
this State established and financed an elaborate public health organiza-
tion. Having created a number of important offices, they were given
to physicians who had distinguished themselves in promoting the in-
terests of the political party then in power. These officials were selected
without sufficient regard for ability or professional attainment. The
medical societies took no action that was noticeable to prevent this



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 7 of 58)