HEALTH SCIENCES LIBRARY

OF THE

UNIVERSITY OF NORTH CAROLINA

Histo'^

"Rooits

Digitized by tine Internet Arcliive

in 2011 witli funding from

Nortli Carolina History of Health Digital Collection, an LSTA-funded NC ECHO digitization grant project

http://www.archive.org/details/transactions751928medi

JoHx T. BruRus. M D., F.A.C.S.

Prenidoit

TRANSACTIONS

OF THE

Medical Society

OF THE

STATE OF NORTH CAROLINA

DIVISION OF HEALTH SCIENCES LIBRARY

DIAMOND JUBILEE

SEVENTY-FIFTH ANNUAL SESSION

HELD AT

PINEHURST, NORTH CAROLINA APRIL 30th. and MAY 1st and 2nd

'^

Presidekt JOHN T. BURRUS, M.D., F.A.C.S., High Point

Secretary-Treasurer L. B. McBRAYER, M.D., F.A.C.P., Southern Pines

Reporters

MISS MARY ROBINSON, Raleigh

MASTER REPORTING CO., New York

COMMITTEE ON PUBLICATIONS

Dr. L. B. McBkayer, Secretary-Treasurer, Chairman ex-officio Southern Pines

Dr. p. p. McCain Sanatorium

Dr. J. S. MiLLiKEN - -— Southern Pines

"It is understood that the Society is not to be considered as indorsing all the views and opinions of authors of papers published in the Transactioxs of the Society." — Extract from By-Laws, CJiaper 10, Section 8.

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11 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

ROSTER OF MEMBERS OF THE VARIOUS BOARDS OF MEDICAL EXAMINERS OF THE STATE OF NORTH CAROLINA

FIRST BOARD

JAMES H. DICKSON, Wilmington 1859-18Gt)

CHARLES E. JOHNSON, Raleigh 1859-lb(ia

CALEB WINSLOW, Hertford 1859-1H06

OTIS F. MANSON, Townsville 1859-1866

WILLIAM H. McKEE, Raleigh 1859-1866

CHRISTOPHER HAPPOLDT, Morganton 1859-1860

J. GRAHAM TULL. New Bern 1859-18G6

SAMUEL T. IREDELL, Secretary 1859-1866

SECOND BOARD

N. J. PITTMAN, Tarboro 1866-1 872

E. BURKE HAYWOOD, Raleigh 1866-1872

R. H. WINBORNE, Edenton 1866-1872

S. S. SATCHWELL, Rocky Point 1866-1872

J. J. SUMMERELL, Salisbury 1866-1'^72

R. B. HAYWOOD, Raleigh 1866-1872

M. WHITEHEAD, Salisbury 1866-18(iS

J. F. SHAFFNER, Salem 1868-1 872

WILIJAM LITTLE, Secretary. 1866-186?

THOMAS F. WOOD, Secretary, Wilmington 18671S72

THIRD BOARD

CHARLES J. O'HAGAN. Greenville 1872-1S7S

W. A. B. NORCOM, Edenton 1872-1878

C. TATE MURPHY, Clinton 1872-1878

GEORGE A. FOOTE, Warrenton 1872-1 S78

J. W. JONES, Tarboro 1872-1878

R. L. PAYNE, Lexington 1872-1878

CHARLES DUFFY, JR., Secretary, New Bern 1872-1878

FOURTH BOARD

PETER E. HINES, Raleigh 1878-1 8S4

THOMAS D. HAIGH, Fayetteville 1878-18S4

GEORGE L. KIRBY, Goldsboro 1878-10S4

THOMAS F. WOOD, Wilmington 1878-li584

JOSEPH GRAHAM, Charlotte.. 1878-1884

iROBERT I. HICKS, MMlliamston 1878-1880

2RICHARD H. LEWIS, Raleigh 1880-1884

HENRY T. BAHNSON, Secretary, Salem 1878-1884

FIFTH BOARD

WILLIAM R. WOOD, Scotland Neck 1884-1890

AUGUSTUS W. KNOX, Raleigh 1884-1890

FRANCIS DUFFY. New Bern 1884-1890

PATRICK L. MURPHY, Morganton 1884-1890

WILLIS ALSTON, Littleton 1884-1860

J. A. REAGAN, Weaverville 1884-1890

W. J. H. BELLAMY, Secretary, Wilmington 1884-lSoO

SIXTH AND SEVENTH BOARDS

R. L. PAYNE, JR., Lexington 1890-1892

GEORGE W. PUREFOY, Asheville 1890-1892

GEORGE G. THOMAS, Wilmington 1890-1894

ROBERT S. YOUNG. Concord 1890-1894

WILLIAM H. WHITEHEAD, Rocky Mount - 1890-1890

GEORGE W. LONG, Graham 1890-1890

L. J. PICOT, Secretnry, Littleton 1890 1890

JULIAN M. BAKER, Tarboro 1892-1898

H. B. WEAVER, Secretary, Asheville - 1892-189S

^J. M. HAYS, Greensboro 1894-1897

*KEMP P. BATT1,E, JR., Raleigh 1897-1900

^Resigned before expiration of term. ^Elected for unexpired term of Dr. Hicks. ^Died before the expiration of his term. ^Elected to serve unexpired term of Dr. Hays.

ROSTER OF MEMBERS BOARD MEDICAL EXAMINERS IX

iTHOMAS S. BURBANK, Wilmington loo«"loon

2WILLIAM H. H. COBB, Goldsbom .^ ^^. |«Qfi1«n^

iRICHARD H. WHITEHEAD, Chapel Hill - !on^!nn^

3J. HOWELL WAY, Secretary, Waynesville lon^ ,. ,

DAVID T. TAYLOE. Washington _ Jon- ,n!o

THOMAS E. ANDERSON. Secretary, Statesville Jo^o In o

^ALBERT ANDERSON, Wilson - Joociono

*EDWARD C. REGISTER, Charlotte lnnn'i?no

^THOMAS S. McMULLAN, Hertford Jnnn'Jmw

*JOHN C. WALTON..- - 1900-1902

EIGHTH BOARD

A. A. KENT, Lenoir ,-.. J^n!'Jon«

CHARLES O'H. LAUGHINGHOUSE, Greenville J??^"!^^^

M. H. FLETCHER. Asheville Jn"^" ono

JAMES M. PARROTT, Kinston - I^noJnna

J. T. J. BATTLE. Greensboro l^^^rnr^o

FRANK H. RUSSELL, Wilmington ,^L"^"}'^^?

iGEORGE W. PRESSLY, Secretary, Charlotte 1902-I'.)n()

EG. T. SIKES, Secretary, Grissom 1906-1908

NINTH BOARD

LEWIS B. McBRAYER. A.«heville 1908-191 1

JOHN C. RODMAN. Washington 1908-1914

WILLIAM W. McKENZIE, Salisbury ,.1908-1914

HENRY H. DODSON. Greensboro - 1908-1914

JOHN BYNUM. Winston-Salem 1908-1911

J. L. NICHOLSON, Richlands 1908-1914

BENJ. K. HAYS, Secretary, Oxford 1908-1 91 !

TENTH BOARD

ISAAC M. TAYLOR. Morganton 1914-102O

JOHN Q. MYERS. Charlotte 1914-1920

JACOB F. HIGHSMITH, Fayetteville 1914-1920

MARTIN L. STEVENS, Asheville 1914-1P20

"CHARLES T. HARPER, Wilmington 1914-1915

'EDWIN G. MOORE, Elm City 1913-1920

8J0HN G. BLOUNT, Washington 1914-102.'>

HUBERT A. ROYSTER, Secretary, Raleigh 1914-1920

ELEVENTH BOARD

LESTER A. CROWELL, Lincolnton 1920-1020

WILLIAM P. HOLT, Duke 1920-192G

J. GERALD MURPHY, Wiiniington - 1920-1926

LUCIUS N. GLENN. Gastonia - 1920-1926

CLARENCE A. SHORE. Raleigh 1920-19J!;

WILLIAM M. JONES. Greensboro 1920-1920

KEMP P. B. BONNER, Secretary, Morehead City 1920-1920

TWELFTH BOARD

J. K. PEPPER. President, Winston-Salem 1926-1932

T. W. M. LONG, Roanoke Rapids - 1926-1932

W. HOUSTON MOORE. Wilmington 1926-1932

W. W. DAWSON. Grifton 1926-1932

PAUL H. RINGER. Asheville - 1926-1932

FOY ROBERSON. Durham - 1926-1932

JOHN W. McCONNELL, Secretan% Davidson 1926-1932

^Resigned before the expiration of his term. ^Elected to serve the unexpired term of Dr. Burbank. ^Elected to serve the unexpired term of Dr. V/hitehead. ^Elected for short term expiring in 1902. ''Elected to serve the unexpired tern, of Dr. Pres.sly. ^Died before the expiration of his term, f Elected to serve the unexpired term of Dr. Harper.

sDied a few months before the expiration of his term; such a short time that the vacancy was not filled.

NOTE: In 1890 the Medical Society of the State of North Carolina adopted the plan )f electing members of the Board in such a manner that the terms would expire at difl'eient intervals of two years. This practice was followed for twelve years, or until 1902, when the plan was abandoned; an equivalent of two legal terms of six years each. It is evident that the Society arranged to abandon the policy as early as 1898, as two members were elected for short terms, and two years later two other members were elected for still shorter terms. It is therefore impossible to separate the sixth and seventh Boards, since the ineuibership was overlapping.

THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

ROSTER OF MEMBERS NORTH CAROLINA STATE BOARD OF HEALTH FROM ORGANIZATION IN 1877 TO 1928

Name

S. S. Satchwell, M.D., President

Thomas F. Wood, M.D., Secretary

Joseph Graham, M.D

Charles Duffy, Jr., M.D

Peter E. Hines, M.D

George A. Foote, M.D —

S. S. Satchwell, M.D., President

Thomas F. Wood, M.D., Secretary

Charles J. O'Hagan, M.D., President.

George A. Foote, M.D

Marcellus Whitehead, M.D

R. L. Payne, M.D

H. G. Woodfln, M.D

A. R. Ledeux, Chemist

William Cain, Civil Engineer

R. L. Payne, M.D

M. Whitehead, M.D., President

J. M. Lyle, M.D

William Cain, Civil Engineer

W. G. Simmons, Chemist

J. W. Jones, M.D., President

John McDonald, M.D

S. H. Lyle, M.D

W. G. Simmons, Chemist

Arthur Winslow, Civil Engineer

R. H. Lewis, M.D

Thomas F. Wood, M.D., Secretary

William D. Milliard, M.D

Arthur Winslow, Civil Engineer

W. G. Simmons, Chemist

J. H. Tucker, M.D

R. H. Lewis, M.D., Secretary

H. T. Bahnson, M.D., President

Arthur Winslow, Civil Engineer

W. G. Simmons, Chemist

J. H. Tucker, M.D

J. L. Ludlow, Civil Engineer

J. H. Tucker, M.D

F. P. Venable, Ph.D., Chemist

J. L. Ludlow, Civil Engineer

J. A. Hodges, M.D

J. M. Baker, M.D

J. H. Tucker, M.D

F. P. Venable, Ph.D. Chemist

J. L. Ludlow, Civil Engineer

Thomas F. Wood, M.D., Secretary*

George G. Thomas, M.D., President..

S. Westray Battle, M.D

W. H. Harrell, M.D

John Whitehead, M.D

W. H. G. Lucas

F. P. Venable, Ph.D., Chemist

John C. Chase, Civil Engineer

R. H. Lewis, M.D., Secretary

W. P. Beall, M.D

W. J. Lumsden, M.D

John Whitehead, M.D

W. H. Harrell, M.D

W. P. Beall, M.D

R. H. Lewis, M.D., Secretary :....

F. P. Venable, Ph.D., Chemist

John C. Chase, Civil Engineer ,

Charles J. O'Hagan, M.D

John D. Spicer, M.D

J. L. Nicholson, M.D. -

R. H. Lewis, M.D., Secretary

A. W. Shaffer, Civil Engineer

Charles J. O'Hagan, M.D

J. L. Nicholson, M.D

Albert Anderson, M.D

R. H. Lewis, M.D., Secretary

Address

Rocky Point

Wilmington

Charlotte

New Bern

Raleigh

Warrenton

Rocky Point

Wilmington

Greenville

Warrenton

Salisbury

Lexington

Franklin

Chapel Hill

Charlotte

Lexington

Salisbury

Franklin

Charlotte

Wake Forest

Washington

Franklin

Wake Forest

Raleigh

Wilmington

Asheville

Raleigh

Wake Forest

Henderson

Raleigh

Winston

Raleigh

Wake Forest

Henderson

Winston

Henderson

Chapel Hill

Winston

Fayetteville

Tarboro

Henderson

Chapel Hill

Winston

Wilmington

Asheville

Williamston

Salisbury

White Hall

Chi pel Hill

Wilmington

Raleigh

Greensboro

Elizabeth City

Salisbury

Williamston

Greensboro

Raleigh

Chapel Hill

Wilmington

Greenville

Goldsboro

iRichlands

Raleigh

Greenville

Richlands

Wilson

Raleigh

Appointed by

State Society

State Society _

State Society

State Society _

State Society

State Society _

Gov. Z. B. Vance... Gov. Z. B. Vance... Gov. Z. B. Vance..

State Society

Gov. T. J. Jarvis Gov. T. J. Jarvis Gov. T. J. Jarvis

State Society

Gov. T. J. Jarvis Gov. T. J. Jarvis Gov. T. J. Jarvis State Board of Healtii

State Society

Gov. A. M. Scales Gov. A. M. Scales Gov. A. M. Scales State Society State Society

Scales..

Scales.. Fowle.. Fowle..

Gov. A. M

Gov. A. M. Scales

Gov. A. M

Gov. D. G,

Gov. D. G

Gov. D. G. Fowle

State Society

Gov. T. M. Holt .... Gov. T. M. Holt .... Gov. T. M. Holt ....

State Society

State Board of Healtii

State Society

State Board of Health

Gov. Elias Carr

State Society

Gov. Elias Carr

Gov. D. L. Russell. Gov. D. L. Russell. Gov. D. L. Russell. Gov. D. L. Russell Gov. D. L. Russell Gov. D. L. Russell Gov. D. L. Russell Gov. D. L. Russell Gov. D. L. Russell

Term

1877 tol87H 1877 to 18-'8 1877 to 187S 1877 to 1S78 1877 toldTfe

1877 to 187,S

1878 to 1884 1878 to 18.S t 1878 to 1882 1878 to 1382 1878tolS80 1878 to 1880 1878 to 1880 1878 to 1880 1878 to 1880 1881 to 1887 1881 to 1884 1881 to 1883 1881 to 18b:5 1881 to 1883 1883 to 188ft 1883 to 1889 1883 to 1885 1883 to l-iSS

1883 to 1886

1884 to 1886

1885 to I8s7 1885 tOl8!)l 1885 to 1891 1885 to 1837 1885 to 1887 1887 to 1883 1887 to l!-i?8 1887 to 1883

1887 to 1889

1888 tOlSiU 1888 tolSSJl

1888 to 1891

1889 to 1S!':J 1889 to 1892 1889 to 1893 1891 to 18ii;! 1891 to 1893 1891 to 1892

1891 to 1897

1892 tol8^7

1891 to 1895

1892 to 1895

1893 to ISO 1 1893 to 1895 1893 to 1895 1893 to 189.-

1893 to 1895

1894 to 1897

1895 to 1897 1895 to 1897 1895 to 1897 189i5 tol897 1895 to 1897 1895 to 1897 1897 to 1899 1897 to 1899 1897 to 1899 1897 to 1899 1897 to 1890 1899 to 1901 1899 to 1901 1899 to 1901 1899 to 1901 1899 to 1901

*Died in 1892, leaving a five-year unexpired term, which was filled by the Board.

ROSTER OF STATE BOARD OF HEALTH MEMBERS STATE BOARD OF HEALTH— Continued

Name

President-

George G. Thomas, M.D.

S. Westray Battle, M.D •

H. W. Lewis, M.D._

H. H. Dodson, M.D

R. H. Lewis, M.D., Secretary

W. P. Ivey, M.D •.• — -

George G. Thomas, M.D., President

Francis Duffy, M.D

J. L. Ludlow, Civil Engineer

S. Westray Battle, M.D -

H. W. Lewis, M.D

W. H. Whitehead, M.D

J. L. Nicholson, M.D

J. L. Ludlow, Civil Engineer

J. Howell Way, M.D

W. O. Spencer, M.D

George G. Thomas, M.D., President...

Thomas E. Anderson, M.D

R. H. Lewis, M.D -

E. C. Register. M.D

David T. Tayloe, M.D

James A. Burroughs, M.D.^

J. E. Ashcraft, M.D

J. L. Ludlow, Civil Engineer

J. Howell Way, M.D., President

W. O. Spencer, M.D

Thomas E. Anderson, M.D -..--.-

Charles O'H. Laughinghouse, M.D

R. H. Lewis, M.D

Edw. J. Wood, M.D

A. A. Kent, M.D.2

Cyrus Thompson, M.D

Fletcher R. Harris, M.D

J. L. Ludlow, Civil Engineer...-

J. Howell Way, M.D., President

E. C. Register, M.D.i

Thomas E. Anderson, M.D

Charles O'H. Laughinghouse, M.D

Fletcher R. Harris, M.D.^.

A. J. Crowell, M.D -■

Chas. E. Waddell, C.E.<

Cyrus Thompson, M.D -

R. H. Lewis, M.D

E. J. Tucker, D.D.S

J. Howell Way, M.D., President

A. J. Crowell, M.D

James P. Stowe. Ph.G

D. A. Stanton, M.D

Thomas E. Anderson.M.D

Charles O'H. Laughinghouse, M.D."-..

Cyrus Thompson. M.D

D. A. Stanton, M.D -

H. Lewis, M.D.i

J. Tucker, D.D.S

S. Rankin, M.D.* -

E. McDaniel

Chas. C. Orr

R.

E. W. L. Dr.

Address

Wilmington

Asheville

Jacksoni

Milton

Raleig'h

Lenoir

Wilmington

New Bern

Winston

Asheville

Jackson

Rocky Mount

Richlands

Winston

Waynesville

Winston

Wilmington

Statesville

Raleigih

Charlotte

Washington

Asheville

Monroe

Winston-Salem

Waynesville

Winston-Salem

Statesville

Greenville

Raleigh

Wilmington

Lenoir

Jacksonville

Henderson

Winston-Saleni

Waynesville

Charlotte

Statesville

Greenville

Henderson

Charlotte

Asheville

Jacksonville

Raleigh

Roxboro

Waynesville

Charlotte

High Point

Statesville

Greenville

Jacksonville

High Point

Ualeigh

Roxboro

Charlotte

Jackson

Asheville

Appointed by

Term

State Society

Gov. C. B. Aycock.

State Society

Sta'te Socioly

Gov. C. B. Aycock

Gov. R. B. Glenn....

Gov. R. B. Gleni...

State Society

Gov. R. n. Glenn....

State Society

State Board of Health ov. W. W. Kitchin. ov. W. W. Kitchin

Gov. W. W. Kitchin

State Society

Gov. Locke Craig

State Society

State Board of Health

Gov. Locke Craig

Gov. T. W. Bickett. Gov. T. W. Bickett.

State Society

Gov. T. W. Bickett I

Gov. Cameron Morrisonl

State Society

Gov. T. W. Bickett

Gov. Cameron Morrison Gov. Cameron Morrison Gov. Cameron Morrison State Board of Health

State Society

Gov. A. W. McLean Gov. A. W. McLean State Board of Health State Board of Health iGov. A. W. McLean

1899 to 1001 1899 to 1901 1899 to l!M»l 1899 to 1901 1901 to 190T 1901 to ICn-r 1901 to 1903 1901 to 1903 1901 to 1901 1901 to 1907 1901 to 1:>07 1901 to 1005 1901 fo 1903 1903 to 1909 1905 to 1011 1905 to 1011

1905 to ion

1905 to 1911 1907 to 1013 1907 to 1013 1907 to 1009 1907 to 1913 1909 to 191;'. 1909 to 1913 1911 tOlOi ; 1911 to 1017 1911 to 1917 1911 to 1917 1913 to 1919 1913 to 1919 1913 to 1913 1913 to 1010 1913 tOlOl:i 1915 to 1921 1917 to 1B23 1917 to 1923 1917 to 1923 1917 to lOiVS 1919 to 1923 1919 to 1923 1921 to 1023 1919 to 1923 1919 to 1923 1923 to 1023 1923 to 1920 1923 to 1020 1923 tOl9i7 1923 to 1025 1923 to lOiO 1923 to 1923 1925 to 1031 1925 to 1931 1925 to 1931

1925 to 1931

1926 to 1927

1927 to 1929 1927 to 1929

iDied leaving unexpired term. *,„„„,w,, .

^Resigned to become member of General Assembly. ^Resigned to become Health Officer Vance County.

^Rlsilnld' to become Secretary of State Board of Health.

STATE BOARD OF EXAMINERS FOR NURSES

„ . - . Fayettevillo

Miss E. A. Kelly, President :;--;,;""---,;V"" Greensboro

Mrs. Z. V. Conyers, Secretary and Treasurer. ^^^^^ ^j^.^

Dr" Robert M. Petrie (from State Hospital Association) 3 years Lenoir

THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA STATUS OF SOCIETY MEMBERSHIP BY COUNTIES FOR YEARS 1914-1928

County

I i ! I I I I I I I

1914|1915 1916 1917 1918 1919|1920 1921 1922 1923 1924

1925 1926 1927

Alamance-Caswell a

Alexander b

Alleghany

Anson

Ashe

Avery

Beaufort

Bertie .—

Bladen

Brunswick

Buncombe

Burke -

Cabarrus -

Caldwell

Camden c

Carteret

Caswell d

Catawba

Chatham

Cherokee

3howan-Perquimans

Clay e

Cleveland

Columbus

Craven'

Cumberland

Currituck

Dare /

Davidson

Davie

Duplin

Durham-Orange ....

Edgecombe

Forsyth

Franklin

Gaston

Gates

Graham

Granville

Greene

Guilford

Halifax

Harnett

Haywood

Henderson-Polk g..

Hertford

Hoke

Hyde

Iredell-Alexander....

Jaickson _

Johnston

Jones

Lee

Lenoir

Lincoln

Macon-Clay

Madison

Martin

McDowell

Mecklenburg

Mitchell-Watauga....

Montgomery

Moore

Nash

New Hanover

Northampton

'Onslow

'Orange h

Pamlico

Pasquotank- Camden-Dare

Pender

Perquimans j.

Person

Pitt _..

Polk j

Randolph

15| 27

5

14

9

3

1

105

13

19

10

5

17

8

7

1

102

11

21

14

6

8

6

17

8

1

118

11

22

15

12

III 16

8	11	9
14	14	15
7	7	7
69	71	74
2	2	2
6	10	9
16	15	18
19	18	26
28	33	41
12	11	10
10	8	9

161

10|.

17	12
8	7
63	49
1
9	8
10	15
27	21
30	29
14	11
11	7

5| 5| 4

17 191

15

-I. I-

19 14

7 12 14

5 107

8 11 17 26 46 11

7

14

7

80

24

16

12

13

10

6

2

20

6

26

1

10

20

13

7

8

12

5

110

10

21

30

51

11

7

25

2 10 17 14

7 11 13

6

115

10

9 20 30 46 10

5

93 21 15 13 13 10

9

2 20

8 25

1 11 20 16

7 11 10

7 109

7

9 20 33 44 10

6

13

5 107 20 13 14 14

8 11

1 26

7 24

4 13 18 11

6 11 10

8 121

7

8 19 34 42 10

12

5 112 16 12 14 17

8 10

1 29

7 28

4 13 20 11

8 11 10

7 117

8

9 21 32 40 11

5

12 5 119 14 16 13 19

11 1

34 6 24 3 13 22 12

10

S

104

12| 14| 11| 13|

5 1 11

-I I

101 111 10

24 19| 24| 23| 2

131 15| 14| i4j'""l

STATUS OF SOCIETY MEMBERSHIP

STATUS OF MEMBERSHIP BY COUNTIES— (Continued)

County

I I 1914119151]

I I

I I [ I I

17|1918|1919|1920(l921

I I I

1926

1928

Richmond

Robeson

Rockingham

Rowan

Rutherford

Sampson

Scotland

Stanly

Stokes

SuriT

S-wain

Transylvania

Tyrrell *

Union

Vance

Wake

Warren

Washington-Tyrrell

Watauga I

Wayne

Wilkes

Wilson

Yadkin

Yancey _...

19| 18

9 8

24 21

13	12
31	35
16	20
24	2S
18	20
11	13
9	10
11	15
5	10
27	28
2	3
1	1

■I

14	13	14
34	33	27
23	25	21
31	32	32
12	18	22
14	12	13
12	12	12
12	11	12
6	12	9
25	25	24
1	4	3
1	5	6

28	24	33
10	11	10
29	31	28
2	5	4
3	1	1

18 28 21 42 22 13 12 14

38

11

35

3

Totals 1 1220 1 1221 i 1228 1 1271 i 1087 i 1306 1 1497 11491 1 1571 1 1592 1 1606 1 1657| 1666 1 1691 1 1738

a The figures for 1926 are for Alamance-Caswell; for the other years, for Alamance only; b See Iredell-Alexander; c See Pasquotank-Camden-Dare; d For 1926, see Alamance- Caswell; e See Macon-Clay; / See Pasquotank-Camden-Dare; a The figures for 1926 are for Henderson only; for the other years, for Henderson-Polk; h See Durham-Orange; i See Chowan-Perquimans; j See Henderson-Polk for 1912-1925; k See Washington-Tyrrell; I See Mitchell-Watauga.

THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

HONORARY FELLOWS, MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

Abel, J. F - WaynesviUe

*Achorn, John W Pinebluff

Adams, M. R Statesville

Alexander, Annie L Charlotte

*Alston, B. P - -.- Epsom

Ambler, C. P Ashevllle

Anderson, Albert Raleigh

Anderson, Thos. Eli Statesville

*Archery, L. M ..-. Concord

*Asbury, F. E Asheboro

Ashworth, W. C Greensboro

*Attmore, Geo. S. -._ Stonewall

*Bahnson, H. T Winston-Salem

Baker, J. M Tarboro

*Barrier, P. A Mt. Pleasant

Bass, H. H Durham

Battle, J. T. J Greensboro

*Battle, Kemp P Raleigh

Battle, S. W Charlotte

Beall, Wm. P Greensboro

♦Bellamy, W. J. H Wilmington

Boddie, N. P ...Durham

*Bolton, Mahlon Rich Square

*Booth, Samuel D Oxford

Brown, G. A Mt. Ulla

Brown, J. S Hendersonville

Brownson, W. C. AsheviUe

*Bullock, D. W Wilmington

Burrus, John T High Point

Bynum, John Winston-Saiem

*Caldwell, D. G Concord

*Cheatham, Archibald , Durham

*Clark, G. L Clarkton

Council, J. B. Salisbury

*Covington, J. M Wadesboro

Cox, E. L Jacksonville

*Croom, J. D Maxton

Crowell, A. J Charlotte

Crowell, L. A. Lincolnton

Daligny, Charles Troy

Dalton, David N. Winston-Salem

Davis, Thomas W Winston-Salem

Davidson, John E. S Charlotte

DeArmon, J. McC Charlotte

*Denny, Wm. W Pink Hill

Dillard, Richard, Jr Edenton

*Dodson, H. H. ...Greensboro

*Duffy, Charles New Bern

*Duffy, Francis New Bern

Edgerton, Jas. L. Hendersonville

*Edwards, G. C Hookerton

Edwards, J. D Siler City

Ellis, R. C - Shelby

*Faison, I. W Charlotte

*Faison, Wm. W Goldsboro

*Fletcher, M. H Asheville

Flippin, Samuel T. Siloam

*Fox, M. F Guilford College

*Freeman, Richard A Burlington

Galloway, W. C Wilmington

Gibbon, Robert L Charlotte

*Gilmer, Chas. S. ..Greensboro, R. 6

Gilreath, Frank H N. Wilkesboro

Goley, W^m. R. Graham

*Goodman, E. G Lanvale

Goodwin, A. W. - ...Raleigh

Gove, Anna M. Greensboro

Grady, James C. Kenly

*Graham, Joseph Charlotte

Graham, Wm. A Charlotte

*Griffin, J. A Clayton

*Hall, Wright Wilmington

Halsey, B. F Roper

Hargrove, R. H Robersonville

Harris, F. R Henderson

*Harris, I. A. Weaverville

Harriss, A. H Wilmington

Hays, Benj. K Fort. Lyon, Colo.

(Granville Co.)

*Haywood, F. J Raleigh'

*Haywood, Hubert, Sr Raleigh

*Hicks, W^m. N... Durham

Hicks, Romeo Henrietta

Highsmith, Chas Dunn

Highsmith, J. F Fayetteville

*Hill, L. H Germantown

Holt, Wm. T Greemboro

Houck, Albert F Lenoir

*Hudson, Wm. L Dunn

*Hughes, Francis W New Bern

Hunter, L. W Charlotte

Ingram, Chas. B Mt. Gilead

HONORARY FELLOWS

Irwin, J. R. - Charlotte

Jenkins, Chas. L .....Raleigh

Jewett, Robert D Wilmington

Johnson, N. M .....Durham

Jones, Clara E Goldsboro

Jones, A. G Walnut Cove

Jordan, Chas. S..-. Asheville

Jordan, T. M .Raleigh

Julian, Charles A Thomasville

Kent, Alfred A Winter Park, Fla.

Kerr, J. Edwin Winston-Salem

*Knight, J. B. H Williamston

Kndght, Wm. P Greensboro

Knox, A. W Raleigh

Lamm, Isaac, W Lucama

Laughinghouse, Chas. O'H., Greenville

*Leggett, Kenelm Hobgood

Lewis, Geo. W Wilson

Lewis, H. W. Jackson

♦Lewis, R. H Raleigh

Linville, A. Y Winston-Salem

*Long, Benj. L Hamilton

*Long, Geo. W Graham

Long, H. F Statesville

*Long, J. W Greensboro

*Love, W. J Wilmington

Mc Anally, W. J High Point

*McDonald, A. D Wilmi.ngton

McGeachy, R. S Kinston

McGee, J. W Raleigh

*McKay, A. M Summerville

*McKay, John A. Buies Creek

*McKee, James Raleigh

McKenzie, W. W Salisbury

McLaughlin, J. E Statesville

McMillan, Benj. F Red Springs

*McMillan, J. D Lumberton

♦McMillan, J. L Red Springs

McMillan, W. D Wilmington

McNeill, J. W Fayetteville

♦McNeill, Wm. M Buies Creek

Manning, J. M Durham

Menzies, H. C Hickory

♦Miller, J. F Goldsboro

Minor, Chas. L Asheville

Misenheimer, C. A Charlotte

♦Misenheimer, Theo. F Morven

♦Monroe, W. A.. _ — - Sanford

Montgomery, John C- Charlotte

Moore, C. E. - ..Wilson

Moore, Edwin G _..Elm City

Morris, J. A _ ...Oxford

Moseley, Chas. W Greensboro

Munroe, J. P Charlotte

Nelson, R. J Robersonville

Nisbet, W. O. - Charlotte

♦Nicholson, J. L Richland

Nicholson, P. A Washington

Nicholson, Sam T Washington

Noble, R. J - .-..Selma

Parrott, J. M... Kinston

♦Pate, Wm. T Gibson

Pemberton, Wm. D Concord

♦Perry, M. P Macon

Pfohl, Samuel F Winston-Salem

♦Pharr T. F. Concord

♦Pharr, Wm. W Charlotte

♦Phillips, Matthew D Dalton

♦Picot 1j. J Littleton

Pressly, G. W Charlotte

♦Prince, D. M Laurinburg

♦Register, Edw. C Charlotte

Reid, Geo. P Forest City

Reynolds, C. V Asheville

♦Ritter, F. W Moyock

Rodman, J. C Washington

Rogers, Wiley A Franklin

Royster, H. A Raleigh

Royster, W. I Raleigh

Sawyer, C. J ...Windsor

Schaub, O. P Winston-Salem

Schonwald, J. T Wilmington

Sevier, D. E Asheville

Sevier, J. T Asheville

♦Shaffner, J. F., Sr Winston-Salem

Shamburger, J. B Star

Sikes, G. T Creedmoor

Smith, J. B Pilot Mountain

Smith, R. A Goldsboro

Snipes, E. P Jonesboro

Spainhour, Ellis H Winston-Salem

♦Speight, R. H., Sr Whitakers

Spencer, W. O Winston-Salem

Stamps, Thos.. Lumber Bridge

Stanton, D. A .....High Point

•Stevens, J. A Clinton

XVI THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

Stevens, M. L Asheville *Way, J. Howell Waynesville

Strickland, Edw. F... Winston-Salem Weaver, H. B Asheville

Strong, Chas. Moore Charlotte Wharton, L. D Smithfield

Summerell, E. M China Grove Whisnant, A. M Charlotte

Summers, Chas. L Baltimore, Md. *Whitaker, R. A Kinston

(Forsyth Co.) Whi':e, J. W -...Wilkesboro

Tayloe, D. T., Sr Washington *Whitehead, John Salisbury

*Taylor, I. M Morganton * Whitehead, W. H. Rocky Mount

Tennent, G. S .,. Asheville Whitfield, Wm. Cobb ._.._ Grifton

*Thomas, G. G. Wilmington Whittington, W. P Asheville

Tranthara, H. T Salisbury Williams, John D. -Guilford Station

*Tull, Henry Kinston *Williams, J. H Asheville

Van Poole, C. M Salisbury Wilson, A. R Greensboro

Vestal, W. J Lexington Wright, Jno. B. ...Raleigh

*Von Ruck, Karl Asheville Yarborough, Richard F. Louisburg

Ward, W. H Plymouth *Young, R. S Concord

HONORARY MEMBERS, MEDICAL SOCIETY OF THE STATE OF

NORTH CAROLINA

*L. McL. Tiffany Baltimore, Md.

W. W. Keen Philadelphia, Pa.

J. Allison Hodges Richmond, Va.

*R. L. Payne Norfolk, Va.

*J. N. McCormack _ _ Bowliulg Green, Ky.

R. L. Payne, Jr. Norfolk, Va.

J. L. Ludlow, C. E WinstoHrSalem

Paul V. Anderson Richmond, Va.

Stuart McGuire Richmond, Va.

William J. Mayo Rochester, Minn.

William Seaman Bainbridge New York, N. Y.

William Sharpe _ ......New York, N. Y.

William McKim Marriott . St. Louis, Mo.

James K. Hall Richmond, Va.

OFFICERS, 1927-1928

President — Dr. John T. Burrus High Point

First Vice-President — Dr. G. H. MACo>r _. Warrenton

Second Vice-President — Dr. R. F. Leinbacii Charlotte

Third Vice-President — Dr. W. R. Griffin Asheville

Secretary-Treasurer — Dr. L. B. McBr.wer (1927-1930) Southern Pines

OFFICERS 1928-1929

President — Dr. Tiixjrman D. Kitchin Wake Forest

First Vice-President — Dr. W. L. Dunn ...Asheville

Second Vice-President — Dr. D. T. Tayloe, Jr. Washington

Third Vice-President — Dr. W. D. James Hamlet

Secretary-Treasurer — Dr. Iv. B. McBrayer (1928-1031) Southern Pines

*Deceased.

CHAIRMEN OF SECTIONS, DELEGATES AND COMMITTEES XVU

COUNCILLORS, 1928-1931

First District— Dk. H. D. Waxkeh Elizabeth City

Second District — Dr. Grady G. Dixon Ayden

Third District — Dr. J. B. Cranmer Wilmington

Fourth District — Dr. W. H. Smith Goldsboro

Fifth District — Dr. E. A. Livingstox - Gibson

Sixth District — Dr. V. M. Hicks - —..Raleigh

Seventh District— Dk. T. C. Bost Charlotte

Eighth District — Dr. R. B. Davis — ...Greensboro

Ninth District — Dr. M. R. Adams Statesville

Tenth District — Dr. J. F. Abel Waynesville

CHAIRMEN OF SECTIONS 1929

Public Health and Education — Dr. W. A. McPiiattl Charlotte

Surgery — Dr. Donnell Cobm _ Goldsboro

Eye, Ear Nose and Throat — Dr. M. R. Gibson, Chm Raleigh

Dr. V. M. Hicks, Secretary.

Gynecology and Obstetrics — Dr. George Johnson Wilmington

Pediatrics — Dr. L. W. Elias Asheville

Practice of Medicine — Dr. Robt. T. Upchurcii Henderson

Chemistry, Materia Medica and Therapeutics — Dr. J. F. Nash St. Paul

Medical Veterans ofthe World War and Medical Officers

Reserve Corps — Dr. W. P. Herbert ._ Asheville

DELEGATES TO AMERICAN MEDICAL ASSOCIATIOON

Dr. J. G. Murphy, 1928 ......Wilmington

Dr. John Q. Myers, 1928-1929 Charlotte

Dr. C. T. Smith, 1928-1929 _ Rocky Mount

Dr. C. a. Woodard, 1929-1930 Wilson

ALTERNATES

Dr. E. S. Boice for Dr. J. G. Murphy Rocky Mount

Dr. W. S. Holt for Dr. C. A. Woodard Creensboro

Dr. J. R. McCracken for Dr. C. T. Smith Waynesville

MEDICAL SOCIETY OF VIRGINIA

Dr. J. G. Raby Tarboro

Dr. FixjYD WooTEN .Kinston

Dr. G. E. Newby Hertford

Dr. L. B. Evans Windsor

Dr. W. G. Suiter ^ Weldon

Dr. B. M. Nicholson Enfield

SOUTH CAROLINA MEDICAL SOCIETY

Dr. A. G. Brenizer Charlotte

Dr. McT. G. Anders Gastonia

Dr. J. E. Hart Wadesboro

Dr. J. D. Highsmith Fayetteville

XVIU THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

MEDICAL SOCIETY OF GEORGIA

Dr. C. F. Strosnider _._.. _ Goldsboro

Dr. Hubert Hatwood _. Raleigh

Dr. L. W. Korkegay Rocky Mount

Dr. John E. S. Davidson Charlotte

COMMITTEES

Medical Society Foundation

Dr. J. P. Mathesok, (5 year term) _ Charlotte

Dr. M. L. Stevens, (4 year term) Asheville

Dr. L. B. McBrater, (3 year term) Southern Pines

Dr. C. O'H. Laughinghouse^ (2 year term) Raleigh

Dr. E. J. Wood, (1 year term) Wilmington

Obituaries

Dr. C. M. Van Poole, Chairman Salisbury

Dr. C. a. Julian Greensboro

Dr. a. a. Kent - Winter Park, Fla.

Memorial for the North Carolina Physicians who Died in the World War

Dr. J. P. Munroe, Chairman . Charlotte

Dr. a. J. Crowell - Charlotte

Dr. L. B. McBrayer Southern Pines

Dr. J. M. Parrott Kinston

Dr. John T. Burrus _ High Point

Public Health Administration

President State Board of Health', ex-oflBcio; Dr. A. J. Crowell, Chairman, Charlotte; President State Board of Medical Examiners, ex-olficio, Dr. J. K. Pepper, Winston-Salem; President North Carolina Hospital Association', ex-officio, Dr. C. S. Lawrence, Winston-Salem.

Centralization of State Institutions

Dr. Robert L. Felts, Chairman Durham

Dr. p. p. McCain Santarorium

Dr. W. H. Dixon - — - Kinston

Dr. E. J. Wood Wilmington

Dr. Foy Roberson -— Durham

Dr. C. a. Woodard Wilson

Package Libraries for Physicians (Appointed in 1925 to serve two years; continued)

Dr. Foy Roberson Durham

Dr. W. C. Davison .— : Durham

Dr. Wm. deB. MacNider .„ Chapel Hill

COMMITTEES XIX

Award of Moore County Medical Society Medal

Dr. W. C. Mudgett, Chairman— Southern Pines

Dr. J. M. Parrott — Kinston

Dr. Johk Q. Myers — Charlotte

Harrison Narcotic Law

Dr. Albert Andersok, Chairman _ .....Raleigh

Dr. William M. Coppridge _ Durham

Dr. Thomas M. Parrott.— ...Kinston

Dr. J. Q. Myers — Charlotte

Dr. W. p. Holt Erwin

Printing and Supplies

Dr. L. B. McBrayer _ Southern Pines

Dr. p. p. McCain -. Sanatorium

Dr. J. S. MiLLiKEN Southern Pines

Re-Draft of Constitution and By-Laws

Dr. M. L. Stevens Asheville

Dr. J. M. Parrott - ..Kinston

Dr. L. B. McBrayer Southern Pines

Public Policy and Legislation

Dr. K. p. B. Bonner ....Morehead City

Dr. T. W. M. Long .- Roanoke Rapids

Dr. John T. Burrus High Point

Arramgem.ents

Dr. C. a. Jui>ian, Chairman Greensboro

Place of Meeting iGreensboro

Time of Meeting, 1929..._ _ April 15th, 16th, and 17th

PROGRAM GENERAL SESSIONS

First General Session — Opening Exercises, Tuesday, May 1st, 9:00 a.m., Ball Room, Dr. A. McNeill Blair, F. A. C. P., Chairman Committee on Ar- rangements presidinig:

Invocation: Rev. Elmer Willis Serl, Pastor the Church of Wide Fellowship, Southern Pines.

Address of Welcome: Hon. U. L. Spence, Carthage, for the Sandhills.

Address of Welcome: Dr. M. W. Marr, Pinehurst, for Moore County Medical Society.

Address of Welcome: Mrs. P. P. McCain, Sanatorium, for Women's Auxiliary.

Response to Addresses of Welcome: Dr. C. F. Strosnider, Goldsboro.

The President's Address: Dr. John T. Burrus, F. A. C. S., High Point.

Announcements.

Address (Invited Guest): Dr. Hugh S. Black, F. A. C. S., Spartanburg, S. C: "Pancreatitis with Fat Necrosis Following Gall Bladder Infection."

Address: From Section on Chemistry, Materia Medica and Therapeutics, "Therapeutic Considerations of the Thyroid Gland," Dr. Albert W. James, Hamlet.

Address: From Section on Eye, Ear, Nose and Throat, "What Ophthalmology should mean to the General Practitioner," Dr. V. M. Hicks ,F. A. C. S., Raleigh.

Address: From Section on; Practice of Medicine, "Infarction of the Myo- cardium" (with demonstration of specimens). Dr. C. C. Carpenter, Wake Forest.

Address

Address Monroe.

"Cancer Prevention in North Carolina," Dr. H. H. Bass, Durham.

"Pellagra," Dr. M. E. Street, Glendon.

"The Character and the Function of the Doctor," Dr. H. D. Stewart,

Second General Session — Tuesday evening. May 1st, 8:00 p.m., Ball Room. Report of Obituary Committee:

Dr. E. G. Moore, Chairman.

Dr. C. M. Van Poole, Secretary.

Dr. C. A. Julian.

Third General Session — Wednesday 2nd, 9:00 a.m.. Ball Room.

From Section Medical Veterans of the World War and Medical Officers Reserve Corps. Dr. W. L. Pyles, Lt.-Col. M. C. U. S. A.

Address (Invited Guest): "Splenectomy for Bleeding Cases, Presenting the Clinical Purpura Syndrome" (Lantern slides). Our own Dr. R. L. Payne, Nor- folk, Va.

2, THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

Address (Invited Guest): "A Thought About Addictions," Our own Dr. James K. Hall, Richmond, Va.

From Section on Pediatrics: "The Diagnosis and Significance of Juvenile Tuberculosis" (Lantern slides), Dr. P. P. McCain, Sperintendent State Sana- torium, Sanlatorium, N. C.

From Section on Gynecology and Obstetrics: "The Recognition, Prevention and Treatment of Pre-ec!amptic Toxemia of Pregnancy," Dr. Hubert Haywood, Jr., Raleigh, N. C.

From Section on Public Health and Education: Dr. Chas. O'H. Laughinghouse, Raleigh, N. C.

From Section on Surgery: "The Diagitosis of Chronic Appendicitis," Dr. H. A. Royster, Raleigh, N. C.

A Bit of History: Dr. George M. Cooper, Raleigh, N. C.

Medical Colleges of North Carolina: "Dr. J. Howell Way*, Waynesville, and Dr. L. B. McBrayer, Southern Pines.

12:00 m.: Adjournment for Conjoint Session of the Medical Society of the State of North Carolina and the State Board of Health.

Fourth General Session — Wednesday, May 2nd, 8:00 p.m.. Ball Room.

Report from House of Delegates.

UnfirAshed Business.

Report Board of Mediqal Examiners.

Presentation of New Officers.

Adjourn sine die.

HOUSE OF DELEGATES

Monday, April 30th, 8:00 p.m.. Ball Room, The Carolina. Wednesday, May 2nd, 4:00 p.m., West Parlor, The Carolina.

SECTION MEETINGS

SECTION ON GYNECOLOGY AND OBSTETRICS

TUESDAY, MAY 1, 2:00 P. M.

DUTCH ROOM

Dr. J. S. Brewer, Chairman, Roseboro

1. Indications and Methods in the Induction of Labor: Dr. Oren Moore, Char'lotte.

Discussion opened by Dr. Richard Spicer, Winston-Salem.

2. The Hemorrhages of Late Pregnancy: Dr. Seavy Highsmith, Fayetteville. Discussion opened by Dr. R. A. Allgood, Fayetteville.

3. How to Obtair Better Obstetrics in General Practice: Dr. Paul Grumpier, Clinton.

Discussion opened by Dr. J. F. Highsmith, Fayetteville. * Deceased.

PROGRAM 3

4. A Preliminary Report on Puerperal Septicemia Antitoxin: Dr. George Johnson, Wilmington.

Discussion by Dr. Ivan Proctor, Raleigh.

5. Diseases of the Female Uretha: Dr. W. M. Coppridge, Durham.

6. A review of One Hundred Caesarean Sections: Dr. E. S. Boice, Rocky Mount.

Discussion by Dr. Oren Moore, Charlotte.

7. Hemorrhage Into the Broad Ligament Following Labor: Dr. R. L. Pitt- man, Fayetteville.

Discussion by Dr. W. H. Moore, Wilmington, and Dr. R. D. McMillan, Red Springs.

8. The Diagnosis and Treatment of Sterility with Case Reports: Dr. Ivan Proctor, Raleigh.

Discussion by Dr. R. T. Ferguson, Charlotte.

9. Chairman's Address: The Responsibility of the Public in the Matter of Maternal and Infant Mortality, Dr. J. S. Brewer, Roseboro.

SECTION ON EYE, EAR, NOSE AND THROAT

TUESDAY, MAY 1, 2:00 P. M.

men's card room

Dr. S. D. McPherson, Durham, Chairman

Dr. V. M. Hicks, Raleigh, Secretary

1. Laryngeal Diphtheria: Dr. V. K. Hart S,tatesville.

a. Proper Management of Intubated Cases.

b. The Relation of Tracheotomy to Intubation. Discussion opened by Dr. H. C. Willis, Wilson.

2. Vaccines and Nonspecific Therapy in the Treatment of Diseases of the Eye, Ear, Nose and Throat: Dr. Conrad Berens, Invited Guest, New York, N. Y.

3. Mucuous Membrane Cysts of the Maxillary Sinus: Dr. J. P. Matheson, Charlotte.

Discussion opened by Dr. J. Gerald Murphy, Wilmington.

4. Complications of Common Colds: Dr. A. J. Ellington, Burlington. Discussion opened by Dr. H. C. Wolfe, Greensboro.

5. Mixed Deafness: Dr. M. R. Gibson, Raleigh. Discussion opened by Dr. J. D. Freeman, Wilmington.

6. Furunculosis of the Nose, as the Cause of Septicaemia: Dr. A. C. McGall, Asheville.

Discussion opened by Dr. R. S. Beam, Lumberton.

7. Some Observations in the Management of Otitis Media: Dr. B. W. Fassett, Durham.

Discussion opened by Dr. John B. Wright, Raleigh.

8. Epistaxis — Its Cause and Treatment: Dr. H. C. Wolfe, Greensboro. Discussion opened by Dr. David Sloam, Wilmington.

4 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

9. X-Ray Shadowscopy in Comparative Checking in Diagnosis: Dr. W. P. Reaves, Greensboro.

Discussion opened by Dr. T. C. Kearns, Durham.

SECTION ON PUBLIC HEALTH AND EDUCATION

TUESDAY, MAY 1, 2:00 P. M.

ladies' card room

Dr. C. C. Hudson, Greensboro, Chairman

1. Chairman's Address: The Importance of Closer Cooperation of the Prac- ticing Phyisician with the Public School Health Program — Dr. C. C. Hudson Health Officer, Greensboro, N. C.

2. The Prophylactic Use of Convalescent Measles Serum: Dr. Clyde M. Gilmore, Greensboro, N. C.

Discussion by Dr. C. A. Shore, Director of State Laboratory of Hygiene, Raleigh, N. C.

3. The Life Extension Unit of the Slate Board of Health: Dr. F. R. Taylor, Director, High Point, N. C.

Discussion by Dr. E. J. Wood, Wilmington, N. C, and Dr. J. L. Spruill, Jamestovn, N. C.

4. The Prevalence ar.d Diagnosis of Baccillus Abortus Infection in Man: Dr. John Hamilton, Health Officer, Wilmington, N. C.

5. The Practical Application of the Binet-Simon, Test: Dr. Wesley Taylor, Greensboro, N. C.

Discussion by Dr. C. A. Julian, Greensboro, N. C, and Dr. L. G. Beall, Black Mountain, N. C.

6. The Percentage of Immunity to Scarlet Fever and Diphetheria Among the Students of Duke University: Dr. Wilburt C. Davidson, Dean, Duke Uni- versity Medical School, and Walter B. Mayer, University of Pennsylvania.

SECTION ON CHEMISTRY, MATERIA MEDICA, AND THERAPEUTICS

TUESDAY, MAY 1, 2:00 P. M.

BALL ROOM

Dr. Carl P. Parker*, Seaboard, Chairman

1. Therapeutic Uses of Magnesium Sulphate: Dr. J. F. Nash, St. Pauls. Discussion by Dr. John E. Hart, Wadesboro.

2. Fulguration Method of Treatment of Tumors and Ulcers of the Bladder: Dr. W. W. Green, Tarboro.

Discussion by Dr. James W. Davis, Statesville.

3. Recent Investigations Concerning the Tuberculin Reaction and Some Gen- eral Conclusions: Dr. Edward W. Schoenheit, Asheville.

Discussion by Dr. P. P. McCain, Sanatorium.

'Deceased.

PROGRAM 5

4. Differential Diagnosis and Treatment of Ringworm of the Scalp: Dr. N. C. Daniel, Oxford.

Discussion by Dr. L. B. Evans, Windsor.

5. The Use of Tannic Acid in the Treatment of Burns: Dr. H. L. Johnson, Greensboro.

Discussion by Dr. W. T. Rainey, Fayetteville.

6. Toxin-Antitoxin — Some Clinical Observations Following Its Use: Dr. W. Ohio Suiter, Weldon.

Discussion by Dr. L. J. Butler, Winston-Salem.

7. The Treatment of Septicaemia: Dr. C. B. Herman, Statesville. Discussion by Dr. B. J. Lawrence, Raleigh.

SECTION ON MEDICAL VETERANS OF THE WORLD WAR AND MEDICAL OFFICERS RESERVE CORPS

WEDNESDAY, MAY 2, 2:00 P. M.

DUTCH ROOM

Dr. J. B BuHitt, Chapel Hill, Chairman

1. Some Aspects of the Early Diagnosis of Tuberculosis: Dr. J. M. North- ington, Charlotte.

2. Tuberculosis, Pulmonary Form, In. Childhood: Dr. S. M. Bittenger, Sana- torium.

3. Diagnosis of Renal Tuberculosis: Dr. W. M. Coppridge, Durham.

4. Surgical Treatment of Pulmonary Tuberculosis From the Internists Standpoint: Dr. W. L. Dunn, Asheville.

5. Phrenectomy and Thoracoplasty in Advanced Pulmonary Tuberculosis: Dr. W. P. Herbert, Asheville.

SECTION ON PRACTICE OF MEDICINE

WEDNESDAY, MAY 2, 2:00 P. M.

BALL ROOM

Dr. R. L. Felts, Durham, Chairman

1. Liver Diet in the Treatment of Pernicious Anemia: Dr. W. T. Rainey, Fayetteville.

Discussion by Dr. E. J. Wood, Wilmington.

2. Focal Infection: Dr. Joseph A. Speed, Durham. Discussion by Dr. D. W. Holt, Greensboro.

3. Observation of Diseases of the Thyroid Gland: Dr. C. T. Smith, Rocky Mount.

4. Hypothyroidism in the Adult: Dr. W. R. Stanford, Durham. Discussion opened by Dr. Paul Neal, Raleigh.

5. An Extraordinary Case of a Fatal Disease of the Central Nervous Sys- tem, with Autopsy Findings: Dr. Frederick R. Taylor, High Point.

Discussion opened by Dr. Wesley Taylor, Greensboro.

6 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

6. Spinal Cord Tumors: Dr. R. F. Leinbach, Charlotte.

7. The Analysis of a Gastro-intestinal History: Dr. Eugene M. Carr, Asheville.

8. Diagnosis of Peptic Ulcer of the Stomach and Duodenum: Dr. O. E. Finch, Raleigh.

Discussion by Dr. W. O. Nisbet, Charlotte.

9. Obscure Undiagnosed Fevers: Dr. William B. Dewar, Raleigh. Discussion by Dr. N. O. Spikes, Durham.

10. The Conquest of Fear: Dr. Wm. Redin Kirk, Hendersonville. Discussion by Dr. M. A. Griffin, Asheville.

SECTION ON SURGERY

WEDNESDAY, MAY 2, 2:00 P. M.

ladies' card room Dr. T. C. Bost, Charlotte, Chairman

1. Chairman's Address: Enterostomy — Its Surgical Importance, Dr. T. C. Bost, Charlotte.

- Discussion, Dr. L. A. Crowell, Lincolnton.

2. The Logical Incision for Appendectomy: Dr. R. B. Davis, Greensboro. Discussion, Dr. A. F. Mahoney, Monroe.

3. A few remarks Concerning Appendicitis: Dr. Albert D. Parrott, Kinston. Discussion, Dr. L. C. Booker, Durham, and Dr. D. A. Garrison, Gastonia.

4. Certain Clinical Features of Jaundice: Dr. J. W. Gibbon, Charlotte. Discussion, Dr. M. H. Biggs, Rutherfordton.

5. The Surgical Treatment of Pulmonary Tuberculosis: Dr. R. B. Ivey, Asheville.

Discussion, Dr. C. H. Cocke, Asheville.

6. Splenectomy for Purpura Hemorrhagica: Dr. Thomas M. Green, Wil- mington.

Discussion, Dr. Foy Roberson, Durham.

7. The Treatment of Prostatic Obstruction Due to Benign Hypertrophy of the Prostate: Dr. R. B. McKnight, Charlotte.

Discussion, Dr. A. B. Greenwood, Asheville.

8. Ureteral Stones — Method of Removal: Dr. Claude B. Squires, Charlotte.

9. The Treatment of Simple Fracture of the Femur: Dr. Walter F. Cole, Greensboro.

Discussion, Dr. J. W. Tankersley, Greensboro, and Dr. O. L. Miller Charlotte.

SECTION ON PEDIATRICS

WEDNESDAY, MAY 2, 2:00 P. M.

men's card room

Dr. Marion Y. Keith, Greensboro, Chairman

1. Chairman's Addpess: Congenital Hypertrophic Pyloric Stenosis, Dr. Marion Y. Keith, Greensboro.

PROGRAM '

2. Encephalitis in Childhood: Dr. Chas. R. Bugg, Raleigh. Discussion, Dr. W. C. Davison, Duke University, Durham.

3. Scarlet Fever and Its Treatment: Dr. Joseph Knox, Willard Parker Hospital, New York, N. Y.

Discussion, Dr. Le Roy Buttler, Winston-Salem.

4. Cysts of the Ahdomen in Children: Dr. S. S. Saunders, High Point. Discussion, Dr. R. O. Lyday, Greensboro.

5. Kidney Diseases of Children: Dr. W. C. Davison, Deam Medical Depart- ment, Duke University, Durham.

Discussion, Dr. J. B. Sidbury, Wilmington.

6. Brain Tumors in Children: Dr. A. A. Barron, Charlotte. Discussion, Dr. E. K. McLean, Charlotte.

7. Some Modern Pediatric Factors: Dr. L. W. Elias, Asheville. Discussion, Dr. La Bruce Ward, Asheville.

8. The Development and Care of the Temporary Teeth (Lantern slides): E. A. Branch, D.D.S., Raleigh.

Discussion, Dr. Aldert S. Root, Raleigh.

CONJOINT SESSION OF STATE BOARD OF HEALTH AND THE

MEDICAL SOCIETY OF THE STATE OF

NORTH CAROLINA

WEDNESDAY, MAY 2, 12:00 Dr. A. J. Crowell, President State Board of Health, Presiding

MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTH

A. J. Crowell, M.D., F.A.C.S., President, Charlotte.

Charles C. Orr, M.D., Asheville.

John B Wright, M.D., F.A.C.S., Raleigh.

E. J. Tucker, D.D.S., Roxboro.

James P. Stowe, Ph.G., Charlotte.

Thomas E. Anderson, M.D., Statesville.

L. E. McDaniel, M.D., Jackson.

Cyrus Thompson, M.D., Jacksonville.

D. A. Stanton, M.D., F.A.C.S., High Point.

EXECUTIVE STAFF

Chas. d'H. Laughinghouse, M.D., Secretary and State Health Officer.

Ronald B. Wilson, Assistant to the Secretary.

C. A. Shore, M.D., Director State Laboratory of Hygiene.

G. M. Cooper, M.D., Director Bureau of Health Education.

H. E. Miller, C.E., Chief of Bureau of Engineering and Inspection.

F. M. Register, M.D., Director Bureau of Vital Statistics.

H. A. Taylor, M.D., State Epidemiologist.

George Collins, M.D., Director Bureau of Maternity and Infancy.

C. N. Sisk, M.D., Director of County Health Work.

J. C Johnson, D.D.S., Director Oral Hygiene.

F. R. Taylor, M.D., Director Life Extension.

8 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

ORDER OF BTTSIXESS

Report of Work Accomplished and Recommendations.

Discussions.

New Business.

Adjournment.

THE ASSOCIATION OF COUNTY MEDICAL SOCIETY PRESIDENTS OF NORTH CAROLINA

WEDNESDAY, MAY 2, 2:00 P. M.

WEST PARLOR

President, Dr. J. R. Hester, Knightda^e. First Vice-President^ Dr. C. W. McPherson, Burlington. Second Vice-President, Dr. E. T. Dickinson, Greenville. Third Vice-Presiden,t, Dr. W. J. B. Orr, Smithfield. Secretary- Treasurer, Dr. H. L. Brockman, High Point.

WOMEN'S AUXILIARY TO THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

WEDNESDAY, MAY 2, 10:00 A. M.

WEST PARLOR

Officers

President, Mrs. B. J. Lawrence, Raleigh. President-Elect, Mrs. Guy Dixon, Hendersonville. First Vice-President, Mrs. John Q. Myers, Charlotte. Second Vice-President, Mrs. J. W. Dickie, Southeri? Pines. Third Vice-President, Mrs. Foy Roberson, Durham. Treasurer, Mrs. W. P. Knight, Greensboro. Recording Secretary, Mrs. P.P. McCain, Sanatorium. Corresponding Secretary, Mrs. V. M. Hicks, Raleigh.

Councilors First District, To be supplied.

Second District, Mrs. H. W. Carter, Washington. Third District, Mrs. Thomas M. Watson, Wilmington. Fourth District, To be supplied. Fifth District, Mrs. A. B. Holmes, Fairmont. Sixth District, Mrs. J. R. Hester, Kriightdale. Seventh District, Mrs. W. M. Scruggs, Charlotte. Eighth District, Mrs. J. L. Spruill, Jamestown. Ninth District, Mrs. C. R. Sharpe, Lexington. Tenth District, Mrs. Guy Dixon, Hendersonville.

PROGRAM Invocation.

Welcome to Visitors: Mrs. W. C. Mudgett, Southern Pines. Response: Mrs. A. Byron Holmes, Fairmont.

PROGRAM

9

Address: Dr. Charles O'H. Laughinghouse, Secretary of State Board of Health.

Roll Call.

Minutes.

Unfinished and New business.

Report of Treasurer.

Report of Councilors.

Report of Nominating Committee.

Election of New Nominating Committee.

Report of Delegates to A. M. A. and Election, of New Delegates.

In Memoriam.

Our Challenge: Mrs. Ben J. Lawrence, Raleigh.

Presentation of New Officers.

Adjournment.

NORTH CAROLINA PUBLIC HEALTH ASSOCIATION

EIGHTEENTH ANNUAL SESSION

PINEHURST

MONDAY, APRIL 30, 1928

ladies' card room

Papers Limited to Fifteen Minutes — Discussion to Five Minutes

President, Dr. John. H. Hamilton, Wilmington. Vice-President, Dr. C. C. Hudson, Greensboro. Secretary, Dr. F. M. Register, Raleigh.

PROGRAM 9:30 A. M.

1. Call to Order by the President.

2. Invocation: Rev. T. A. Cheatham, D.D., Southern Pines.

3. Presidenc's Annual Address: "Responsibilities of the Health Officer,' Dr. J. H. Hamilton, Wilmington.

4. Report of the Secretary: Dr. F. M. Register, Raleigh.

5. Report of Special Committees.

6. Appointment of:

(a) Committee on President's Address.

(b) Committee on Visitors and New Members.

(c) Committee on Resolutions.

(d) Other Committees.

7. Present-day Venereal Diseases: Dr. R. M. Buie, Greensboro. Discussion by Dr. L. J. Corbett, Goldsboro.

8. Scarlet Fever: Dr. E. R. Hardin, Lumberton. Discussion by Dr. A. C. Norfleet, Tarboro.

9. Child Welfare: Dr. J. H. Woodcock, Hendersonville. Discussion by Dr. A. C. Bulla, Raleigh.

10. Public Health Education: Dr. D. E. Ford, New Bern. Discussion by Dr. L. J. Smith, Wilson.

11. The Relationship Between the Maternity and Infancy Nurse and the

10 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

District Nurse: Miss Mary P. Oliver, Winston-Salem.

piscussion by Dr. J. Roy Hege, Winston-Salem.

Address: Epidemiology of Infantile Diarrhea: Dr. Wilburt C. Davison, Durham.

2:30 P. M.

1. Public Health and the Law: Dr. J. H. Epperson, Durham. Discussion by Dr. W. A. McPhaul, Charlotte.

2. The Next Steps in Child Health Education Program in North Carolina: Miss Theresa Dandsill, M.A., Director of Health Education of the N. C. Tuber- culosis Association, Southern Pines.

3. Vincents Infection, or Trench Mouth; Dr. J. S. Belts, Greensboro. Discussion, by Dr. J. S. Spurgeon, Hillsboro.

4. Sanitary Engineering in a Public Health Program: Dr. C. W. Armstrong, Salisbury.

Discussion by Dr. Z. P. Mitchell, Weldon.

5. Salt Marsh Mosquitoes in Relation to Public Health: Dr. T. H. D. Griffitts, Surgeon, U. S. P. H. S., Biloxi, Miss.

Discussion by Dr. D. E. Ford, New Bern.

6. Control of Measles: Dr. A. B. McCrary, Rockingham. Discussion by Dr. D. G. Caldwell, Concord.

6:30 P. M.

Health Officers' Dinner; Round Table Discussion: Dr. S. E. Buchanan, China Grove.

Discussion by Dr. J. R. Hege, Winston-Salem. Adoption of Resolutions.

TRANSACTIONS

OF THE

SEVENTY-FIFTH ANNUAL SESSION

OF THE

MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

PINEHURST, APRIL 30, 1928

GENERAL SESSIONS

FIRST GENERAL SESSION TUESDAY MORNING, MAY 1, 1928

The first general session of the Seventy-Fifth Annual Session of the Medical Society of the State of North Carolina convened in the Ballroom of the Carolina Hotel, Pinehurst, North Carolina, at nine-thirty o'clock. Dr. A. McNeil Blair, Chairman of the Committee on Arrangements, presiding.

Chairman Blair: The Seventy-Fifth Annual Meeting of the North Carolina Medical Society will come to order.

Will all ex-presidents kindly take seats in the front?

We will be led in prayer by the Reverend Elmer Willis Serl, Pastor of the Church of Wide Fellowship, Southern Pines.

Rev. Elmer Willis Serl: Our Father, gathered here this morning at the opening of these busy days, we are conscious that what we receive from this fellowship will be that which we bring, and we this morning are grateful for all the things that Thou hast given us with which we may appreciate the things Thou hast still to give. We thank Thee this morning, our Father, for the lure of service ; we thank Thee for the challenge to be helpers in this world; we thank Thee for our sense of mission in our profession; we thank Thee, our Father, for our knowledge of the Great Physician, Jesus Christ, whose knowledge of life made it possible for us in these days to approach life in a better way.

We ask Thee this morning that Thou would give to us the desire to be sincere in our motives, open-minded and willing to learn ; that Thou

12 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

would make us, we pray, those who appreciate the opportunities that are before them, and may we, our Father, be always clinched by the need in our lives of sympathetic understanding and by a buoyant faith.

We thank Thee, Father, that thus equipped life may unfold itself to us and through the opportunities that are before us we shall be serving our day, our generation, our community. In one sense we each pray our own prayer this morning as we are standing here and Thou knowest our hearts and our lives, but in the larger sense perhaps, we together pray that Thy will may be done on this earth, that we may have a part in that will. These things we ask this morning in the name of the Christ. Amen.

Chairman Blair: The front seats are reserved for past presidents who may be in the convention, and we hope that they will honor us by so taking those positions ; also, the vice presidents.

It seems especially fitting at this time that we should meet in Pinehurst for our Seventy-Fifth Annual Session. The Sandhills are rather unique, as you know, for various reasons. The Honorable U. L. Spence will voice a welcome from our people of the Sandhills to you of this North Carolina Medical Society. The Honorable U. L. Spence.

Honorable U. L. Spence: Mr. President and Gentlemen of the North Carolina Medical Society, Ladies and Gentlemen : There be that at every one of your conventions that you are called upon to endure, if not to countenance, and, too, with the deferential, polite courtesy and aplomb so characteristic of your great profession. It is the alleged local orator nominated and elected to deliver to you what is high-soundingly termed an address of welcome.

It is perhaps one of the well merited advantages a local community is entitled to enjoy at the discomfiture of the members of your body. While holding you under the duress of invited guests, you are thus compelled to take, by way of retaliation and without grimace, such medi- cine as may be administered on the occasion; and let us hope that it is as harmless as that usually prescribed by your cloth pending the time required to make a correct diagnosis.

Such a role on your program is the greatest sort of misfitting redund- ance. No language can adequately bespeak the inviting welcome humanity has always accorded your coming. Tradition, if not history, asserts that the ancient Greeks worshipped as one of their gods the first great physician, Aesculapius, the son of Apollo, and erected many temples for this service. His skill in the healing of diseases and raising the dead to life angered the great god Zeus, who fearing he might make all men immortal, slew him with a thunderbolt. Zeus manifestly desired to take no chances on the operation. (Laughter).

Aesculapius first inaugurated the scheme of the public and private hospital and required his patients to sleep in his temples. Because of the scarcity of skilled physicians and surgeons and internes in his day, he communicated remedies to his patients in dreams while they slept in his temples. His patients thereupon, as is now the custom, offered sacri- fices to the god of the temple hospital and advertised their wonderful cures by hanging up votive tablets on which were recorded their names, their diseases and the manner in which they were healed. My information is that this custom still obtains to a degree among you, but in the interest

1 ^

GENERAL SESSIONS ^^

of greater accuracy, the record is written by the physician himself and is read for the edification of his associates on occasions of this character, flauo-hter) after eliminating therefrom such features of the occurrence as mW be readily suspected was only the dream of the patient.

From the time'of Aesculapius down to this fair day in the wonderful accomplishments in the great field of medicine and surgery, open arms have always heralded your comings and grateful and blessed remembrance has attended your departures. At eyery initial, crucial, mysterious dawn of human existence, your understanding presence at the apprehensive sacrificial crisis is an angelic yisitation, ushering to new existence the constantly coming race appointed to fulfill the destinies of creation, and with deft and skillful hand and sympathetic heart, nursing back to lite and o-lorious motherhood the blessed members of our race who are willing to go'' down next unto the shadow of death to continue our existence.

In eyery yicissitude of life you take a major part; in the hour ot suffering you are humanity's comforter; you minister alike to the physical, mental, spiritual, social, domestic and business needs of man and stand bv the funeral bier at the end.

Are you welcomed? All the world inyites you eyery where and most deservedly so. Years ago some dreamer wrote—

We are liying, we are liying in a grand and awful time. In an age on ages telling; to be living is sublime. Great as had been the progress of the world when the writer penned those lines, he had seen at that time but little of the marvelous accom- plishments of the last few years. Those of us whom destiny has admitted to the stage of life for the past thirty years have lived ten thousand years longer than Methuselah of old. These wonderful accomplishments have made strikingly manifest the inspirational exclamation of Tennyson as applicable to the immediate history:

Through the shadow of the globe we sweep into the younger day: Better fifty years of Europe than a cycle of Cathay. In this great age of achievement, your profession has been on the front firing line; in devotion to your calling, in service to the cause ot humanity and the alleviation of suffering; in scientific accomplishments and the' application of this knowledge to the practical needs ot man. Your progress has kept pace with other world achievements and your advance to future objectives, point toward the flying fields and toward the

^ ""It is well that you journey to Pinehurst for this annual convocation. It is the mecca for such a purpose. From the barren desert of thirty years ago, it has kept pace and gone far past the rapid progress of the times and is now the beauty spot of the South and the greatest health resort and sporting field in the world.

The Sandhill section opens wide her arms to you. All the people ot all degree wave you hearty welcome. Everything is free for the taking and that without asking. The bankers will cash your checks ; the lawyers are offering their services, believing and hoping that your needs are few; the preachers have no fear that you require their ministrations, but are subject to your call; policemen are maintained only for the purpose ot

14 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

protecting you for the indulgence of any propensity suggested or arising from a care-free journey from your homes. (Laughter). The merchants will invite and solicit your trade. The taxi driver will carry you to any point in all the Sandhills for the price of a major operation. (Laughter).

If you can discover the devious ways to his transient and uncertain kingdom, the bootlegger will fill your prescriptions. If, after the manner of your hospitals, the hotels and club rooms wreck your bank account, the result will be brought about in the standard and well-understood way, by the extra charges upon your bills.

I point you with pride to this beautiful springtime country. Pinehurst, now a spot of rare beauty, invites you to its every nook and corner. The finest playgrounds in the world are yours. Orchards and honeysuckle and wild wood stretch away for miles and miles in dulcet ease along lovely roads. The doors of every home stand wide ajar. The entire demesne is yours — to have and to hold; to take and to enjoy. (Applause).

Chairman Blair: A welcoming address such as the Honorable U. L. Spence has given us shows the whole-heartedness of our people and the privileges that are with us. It is most gratifying that he has been able to say it so wonderfully well.

A question was asked a short while ago as to the relative age of Moore County Medical Society. A gentleman apparently well informed gave the early history of Moore County when it took in all of the adjacent counties, I believe Hoke, Lee, Chatham and Moore. At that time they were a part of this particular Moore County Society. Then later the counties were separated, believing they could do better work. Today our twenty-one members of Moore County, which is a greater number than the combined membership of the old relationship, bids you welcome by Dr. M. W. Marr, who will voice a special message of greeting and welcome. Dr. Marr. (Applause).

Dr. M. W. Marr read his address.

Mr. Chairman, Members and Guests of the North Carolina Medical Society:

In behalf of the Moore County Medical Association, I cordially bid you welcome to this the fifth meeting with us. Our latch strings are out, and our homes are wide open to you. I will consume but little of your time — as did our loquacious President, Mr. Calvin Coolidge, in elabo- rating on a sermon to which he had gone alone one Sunday morning. On returning home Mrs. Coolidge asked if he had enjoyed the service, to which Cal replied "Yes." When asked what the sermon was about, Cal replied, "Healing the sick." Mrs. Coolidge then asked what the pastor had said, and Cal replied, "He was for it."

It is not long since Moore County was considered about the poorest county in the state — sandy hills sparsely covered with forked leaf black jacks, and wire grass. The doctors had a hard time making a living; it was always a case of cutting down expenses; it even came up for discus- sion at one of the local meetings, and one dearly beloved old Scotchman claimed he had found a way to cut down on office supplies. He said he always gave his patients a tonic at the first visit but had found it necessary to require a specimen of kidney secretion at the last visit in order to get his bottle back.

GENERAL SESSIONS 15

Our Moore County Society is only 21 strong, and we expect you will leave much medical information for our help. The Sandhill folks and the Yankees make a pretty strong team — they think well enough of their medical profession to promise us a hospital — a place where we can do better work — a fully equipped Class A hospital. This means much to this section — the county must surely benefit — perhaps in spite of us — but we are overjoyed to have it. The money has been raised and a building committee appointed and at some near future date we hope to have you with us again when we can display this asset of the Sandhills,

We are delighted to see so many ladies at this Convention. Our wives and friends hope to give them such a good time that they will demand another meeting here.

Please be assured that we are glad to have you here — and we hope that you will — one and all — look back upon this meeting with a feeling of mental and physical gratification. May good digestions wait upon appetites — and professional progress be advanced at this, the 75th Meeting of the Medical Society of the Grand Old North State. (Ap- plause).

Chairman Blair: Ladies and Gentlemen: We also have the ladies with us 4n the person of Mrs. P. P. McCain, who will voice a message of welcome to the Auxiliary of this State Society. (Applause).

Mrs. p. p. McCain: Mr. President, Mr. Chairman, Doctors and Ladies of the Auxiliary : A few weeks ago as our children and I sat in the car in Lumberton while Dr. McCain examined a patient, a doctor's wife, by the way, a car came down the street which very soon attracted our attention. This car was not a Pierce-Arrow, a Packard, or a Lincoln; it was none other than a Ford coupe. Yet there was about this car some- thing that made it different from any other car we saw that day. This distinguishing feature, this dignifying feature, was none other than the simple round emblem on the radiator, the insignia of the world's most noble group of men.

A few weeks prior to this time at a meeting of our local D. A. R. Chapter, a friend introduced me to a visitor from far north of the Mason- Dixon line. The meeting was very casual until the friend in proceeding with the introduction said, "The reason I wanted you two folks to meet each other is that you are both wives of doctors and daughters of doctors."

Immediately there was a keener look of the eye, a firmer clasp of the hand, of which no mention was made but which was felt as plainly as one feels an electric spark.

And it is with this feeling of love and reverence for your — may I say for our profession that we welcome you to Pinehurst in this the year of Dr. John T. Burrus.

The purpose of the Auxiliary is given in the transactions of 1923, the Asheville meeting, of which Dr. J. W. Long was President, is as follows :

The object of this Auxiliary shall be to promote unity, harmony and concord between the members of the medical profession and between the wives of such members ; to assist in the local activities at state, district and county society meetings ; to interpret to the public the traditions, aims and objects of the medical profession; to fraternize with women's organi-

16 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

zations, of whatsoever kind, and to promote in every possible way the interests in general of the medical profession, locally and in the state and nation.

We of the Sandhills are hoping that this meeting will do much toward carrying out this object. May I go a step further than Dr. Blair and say the proverbial latch string is not hanging out, you do not need it, for the door is open. (Applause).

Chairman Blair: It is always a pleasure to have a representative from Goldsboro and especially when the personage is no less an indi- vidual than Dr. C. F. Strosnider, who will make response to the addresses of welcome. Dr. Strosnider. (Applause).

Dr. C. F. Strosnider: Ladies and Gentlemen: We have received such a whole-hearted welcome that most of the boys have by mental telepathy already accepted the whole-hearted generosity which this county has extended to us this morning and are now putting it into effect, judging from the number we have in our hall.

It is always a delightful pleasure for us to come to the Sandhills. It is an inspiration. It is true it is only a vanguard of us who come here, because our profession, as you know, is a profession that calls for service twenty-four hours in the day and from twenty-nine to thirty-one days in the month. Therefore, a large majority are on the firing line. We are allowed to go off on these trips that we may carry back home a message, and we always get inspiration and knowledge and encouragement by coming to a land which has done so much through the medium of improve- ment by man.

Only a few years back, as has been stated in the address of welcome, this was a barren spot. Now it has become world renowned for its beauty, for its health-giving qualities and for the production of one of the grandest fruits known to man, the Sandhill peach, which is known throughout our nation. Therefore, in coming here, we are stimulated and we are encouraged to better ourselves through the medium of contact. There is a bracing atmosphere here among the men that we do not get in many of the other sections of the state. It is indeed bright and cheerful and stimulating, and we feel in coming here and having the all-inclusive welcome which has been given us this morning from those wonderful dreams of Aesculapius, down to the whole-hearted reception given by the people here, we cannot help but take back to our homes the message that speaks progress, that speaks thoroughness, to stimulate the boys to carry on. Indeed, we come here right much like a battery run down, and we are recharged through the medium of the thorough work of our compan- ions throughout the state, a real medical stimulus, and we go back home full of vigor and energy and determination to do better work than we have done heretofore. Therefore, speaking for 1700 physicians in good standing in this state, I am trying to express our thanks. I am much like the old nigger preacher who had a brother holding a revival service for him. He said, "Bredern, I wants to thank this brother for coming here and holding all these services for us. The only way, B rudder, I can express my thanks to you for these bredern is by a little illustration, and dat is if I was to use the Adams Express Company, the Southern

GENERAL SESSIONS 17

Express Company and the Fargo Express Company, and all dem express companies, they could not near express the appreciation which we feel for you." (Applause).

Chairman Blair: It is my pleasure and privilege to be able to present a man of wide vision, of great accomplishments and of courage, a man whom we all love and whom the Society has honored by making him its chief member — Dr. J. T. Burrus. (The audience arose and applauded.)

PRESIDENT'S ADDRESS

1928 Dr. John T. Burrus, High Point, N. C.

Nothing is to be more highly prized by any physician in North Carolina than the office which, because of your suffrage, I occupy today — that of President of the North Carolina State Medical Association. No one can appreciate it more, and no one is, or can be, more keenly con- scious of the obligation and responsibility which it entails.

My endeavor has been to evidence an appreciation, not so much by my lips as by a period of continuous, self-forgetful service. Mistakes I have doubtless made, but I have at least the consolation and assurance of knowing that I have made an honest, earnest effort to perform the high duties of the office. My heart is right in this matter, and though my head may not at all times have been clear, I take a degree of consolation and comfort from the scriptural passage: "As a man thinketh in his heart, so is he."

The law of compensation by which Nature's balance sheet is made and kept has given me a year of intensive interest, immeasurable profit, and a hitherto unthought-of opportunity for my personal education. Sections of the state formerly thought of in a sporadic way have come to be known to me. Industries that were hazy have come to be clear and definite. People heretofore strange and worshiped from afar have rubbed my elbows. The state has been presented to me through the eyes of the plutocrat and pauper, taxor and taxee, saint and sinner, optimist and pessimist, materialist and idealist. Capital's fight has been thrust upon me. Labor's cry for a sqiiarer deal "for the man nobody knows" has been ringing in my ears. Statesmen with fearless faith and cautious counsel have advised with me. Politicians, professional and lay, whose selfish ends, in their opinion, justify sinful, soulless, mercenary means, have volunteered advice. Insanity, collective insanity, which the state like a thrifty, thoughtful mother is endeavoring to care for, has shown me itself in all its horror and all its need. Epilepsy and its meaning, feeble-minded- ness and the havoc it has played, have left a picture so clean-cut that it will go with me to my grave. Crime, youthful crime, committed by early adolescence, sick and made sinful by disease, sticks its malicious tongue in its cheek, leers and frowns and with ribald laughter shrieks out, "Here am I, the product of your failure and that of your profession !"

The State's million of children growing into men and women with potentialities for good or evil, marred or mouled for might and power by the foresight of legislatures passed and gone, has filled my mind as never

18 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

before with the intricate problems which, if one would be a really con- structive man of medicine, he must know. In going from one end of the state to the other, blessed as I have been by the annihilation of distances which the state's highways have brought about, visiting cities, large and small, feasting my eyes on the broad acres of tobacco, cotton, corn, and smaller grain, hearing the buzz of spindles and farm machinery, the whistle of railroad engines and of automobiles as well as the whirl of flying machines, I find myself astounded at the realization of the fact that all of this has come in practically half a century.

About sixty years ago North Carolina was a desolate waste of tangled weeds, without government, pauperized, "bled white of its man- power," inhabited by a people partly master and partly slave; women in widow's weeds, mothers with breaking hearts, patriots bound and gagged by the power and military rule of a conquering people. Is there a miracle in Holy Writ more wonderful than the progress between the then and the now? Can you imagine a greater privilege than that which has been mine to observe all this in this past year? Can you imagine a finer lesson in citizenship, civics, sociology, patriotism, and medicine?

You, gentlemen, gave me this opportunity, and furthermore, you gave me the privilege of coming in intimate contact with the medical profession of North Carolina. I have seen it individually and collectively, just as it is — the doctor in the city practicing his specialty, feeling secure in the knowledge that the service and assistance in other specialties were his for the asking immediately and always. The surgeon, for example, who, when confronted with the oftimes perplexing and baffling question, "When to operate?" has the oculist, roentgenologist, neurologist, rhinologist, bacteriologist, pathologist, blood chemist, and internist to give him valu- able information and priceless knowledge. They together pass upon the diagnosis, prognosis, and general condition of the patient; and when the operation has been decided upon, the hospital is there as are the operating room, the anaesthetist, and the nurse. I have also seen the men in the smaller towns measuring up to the standards inculcated in them by the Class A schools of this country, and I have seen men struggling alone to meet the demands of medicine ; without assistance, without confreres, without hospitals, without nurses, practically without everything with which to practice medicine, save conscience, training, self-reliance, energy, and resourcefulness.

Having seen it all, the thing I am proudest of is my ability to look the people of North Carolina in the face and say to them conscientiously that wherever the means are provided the North Carolina doctor can be depended upon to "carry the message to Garcia." I have found sections in which there is a physician to every four hundred people — that section always holding out every modern convenience known to modern medicine. I have seen other sections in which there was only one doctor to every four thousand people, and that section with the exception of good roads and the gray matter, courage, and Godliness of an isolated, lonesome man of medicine, had nothing with which to fight disease.

The environment of these two extremes is utterly different, but the diseases that deform, mutilate, and kill the people living there are exactly the same. Is there no way to equalize the problem? Is there no

GENERAL SESSIONS 19

way to bring the state to the realization of the fact that the men who are making the cities, the men who are occupying high places in the affairs of state, in the profession and in the business world are, many of them, born and reared in the blue of the sparsely populated mountains and along the blue of the surging sea? Can we not join hands and hearts in bringing this good state to a realization of its duty to the sparsely populated sections that are within its borders? Can we not impress upon prospective legislators the fact that the man in the country is "a man for a' that" and entitled to protection from preventable diseases?

There are men, and classes of men, who stand out before the people: ■ — the soldier, the sailor, the shepherd; not infrequently the artist;— rarely, the physician. In reality, however, the medical man is the flower of our civilization; and when the stage of man is over and remains as history to be marveled at, it will be said of him that he has shared as little as any in the defects of the period, and most nobly to have exhibited the virtues of his race. Generosity he has, such as is possible to those that practice an art, never to those who drive a trade ; discretion, tested by a hundred secrets, tact, tried in a thousand embarrassments ; and, what is more important, Herculean cheerfulness and courage. It is this type of North Carolinian that I am appealing to today. There are less than three thousand of us. If the three million population of the state were equally divided among us, each would have the responsibility of the physical welfare of more than three thousand human beings. How can we meet our obligations to society and to our profession unless we give ourselves unstintedly and whole-heartedly to the prevention of disease?

Some men say that the prevention of disease brings no pecuniary reward; that the time and money necessary to the preparation of a medical man makes it necessary to spend one's professional days earning what he can in order to live in accordance with the standards of the times and to put by a competence for old age. "He who does only what he gets paid for, gets paid for only what he does." I would not think of attempting to disprove the old adage "the laborer is worthy of his hire," I would not drop a word or thought that could suggest that medical men are not entitled to the best that life affords ; but money comes as a by-product of work well done. Show me a minister of the gospel who gives his days in an intelligent way to the service of his community, and I will show you a minister who will suffer no need when he is placed upon the superannuated list. Show me a lawyer, clean and square, who gives sixty minutes of every hour to doing his work well, and I will show you a happy man with an earning capacity sufficient to care for himself and his family. Show me a physician who intelligently and wisely gives all that is in him to his calling and I will show you a man with comfortable surroundings and with the abiding respect of all those whom he serves.

Lindbergh is but a boy. He began his climb to fame in an air mail car at about two hundred dollars a month. He has earned more in a year than most men accumulate in a life-time. He has spurned millions for vaude- ville contracts and millions more for movie royalties. He has refused to commercialize himself and his profession by declining to sit at glass top desks of inventors and corporations. He has put all of his eggs into one basket and has given undivided attention to keeping the Spirit of St.

20 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

Louis on an even keel. And yet money has "rolled in" to him. He has run away from more millions than any man in modern history, but fortune somehow has simply congealed itself about him at the average rate of one hundred thousand or more a month.

We need to look to the making of a healthy citizenship today so that a healthier people will be born ten or more generations hence. The gener- ations that are to be born will come from the parents of today. What can we as a profession do to improve mankind? What can we do to lessen the people's propensity to starve, steal, slough in the shadows, haunted by fear, hunted by the police ; the diseased people, in the gutter because of disease? When the multitude came to Christ, the apostles were dumb- founded and urged Him to send them away, because there was no food. But Christ had compassion on them. He divided the loaves and fishes among his disciples and bade them give. The more they gave, the more they had to give ; and so it is with you and your particular calling.

There is in the death chamber of the penitentiary today a youth who with anxious eyes and unshaven, hopeless face pressed against the prison bars, is before me as I speak; — an overgrown lad incapable of lofty purpose, a lad who has zigzagged his way through society seeking food and the gratification of other cravings, engaged in every kind of crimes until, outwitted by the law, he is where he is. He is the product of physical deficiency, ignorance, and vice. One of his kinsmen in this generation, however, is a gentleman of fine type. Out of the same soil and the product of the same seed two different men have come ; one cursed by physical ailment, the other blessed by physical perfection ; one cast down, the other lifted up. In the veins of him cast down is bad blood, freighted with error and physical disease, blood destined to trickle through the centuries, following the lines of least resistance, making ignorance mate with ignorance, crime with crime. Whether this boy should be electrocuted is an open question, but is not his life a challenge to you and to me that we more intently bend our energies to the making of better human machines? This boy has thousands of ancestors. He is descended from hundreds of families. There are countless other boys and girls, provided he has children, who are going to mate with his kith and kin and produce offspring. If the oak is in the acorn, this boy with his staring eyes and hopeless face, expecting to be pitched headlong into eternity, will becloud the blood stream of the race, provided he has chil- dren. There are countless other sons and daughters who are going to mate with and reproduce from that remote heir of his. Other youngsters are going to grow up, and contribute something to the progeny of that boy by indiscriminate mating. The blood of others may make his progeny succeed nobly, or it may be that his will mix with offspring of its kind. If so, failures are in store. Charges on the state will have surely been born.

The generation in which this young man's child now lives holds a thousand and more whose blood will mingle with his, two hundred and fifty years from now. The boy of 2178 is going to have in him the blood of more than two thousand different family strains. He will represent a cross section of society — descendants of lawyers, doctors, engineers, firemen, merchants, laborers, soldiers, preachers, tramps, and crooks.

GENERAL SESSIONS

21

Should we not be concerned about this boy and his heirs, as well as the two thousand or more whose blood is going to mingle with his and who are today and tomorrow playing around somewhere? We cannot endow the far-away children and heirs of this convict awaiting electrocution except by endowing the whole generation to which his children and your children belong. It were well that we stop and listen to the pregnant words of that great poet, philosopher and anatomist, Oliver Wendell Holmes, who, when asked when the training of a child should begin, wisely replied: "Two hundred and fifty years before birth."

With everything that medicine can do for the making of physical perfection, nothing is more important than giving due attention to serious educational enlightenment to those that are to marry and reproduce their kind. Make as much money as you will, the good that you can do with it compared with the good that you can do in exercising scientific effort in your daily work, looking to the upbuilding of strong human bodies, is infinitesimal. The state needs you to build its citizenship. Money is but a tool ; like the sword and the sceptre, it is of little use except in competent hands. You can transmit your skill, but it is the history of money that one generation assembles it, the next separates it, the next dissipates it. Place your reliance on the transmission of your skill in the making of better physical manhood for your state. It is your one grand chance to endow your own descendants with happiness. You cannot know the boys and girls to the right and to the left of your child and this convict's child. You cannot know who will share with them the bringing into being of human machines ten generations hence.

Think always of the children playing in the cities and the waste places of the State, working in the fields, mills, and shops — children of the rich and the poor, of the righteous and the erring — and in God's name have compassion on them. Give them your loaves and your fishes. When your own two year old reaches manhood, one of these may shine his shoes or he may shine theirs ; another drive his car or he may drive theirs. Your boy will flirt and dance with others as was done by you and me. Then one day, because of the democracy of compulsory education, out of the mystery of the future will come a girl with shining eyes and luscious lips to lay her hand in your boy's hand "for better or for worse." She may be a waitress, the daughter of blue-blooded aristocracy, or the progeny of a millionaire, or she may be of the slums. We cannot tell but that she will be the offspring of the hopeless convict waiting for his doom. We, ourselves, bear witness to the social changes occurring in tiiis country, and whoever the girl may be, your son will see her as the gift of the gods. And while not yet born, but as inevitable and resistless a5 the tide; they will stand at the matrimonial altar to inject their kind and the millions that are to follow.

Unless we as citizens of a state give due consideration to the mating of man, the races of mankind are going backward. Civilization as we have administered it is self-destructive, tending to destroy the very men that build it. Modern invention, instead of improving man's lot, is hastening the hour of his destruction. Biologists tell us that man's brain is not

22 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

growing; that as a breed of organic beings he is not advancing; that microbial diseases are the by-products of civilization; and that they are decreasing man's capacity to resist them.

We know that heart disease, Bright's disease, diabetes, cancer, degen- erative diseases of the arteries, liver and other vital organs are increas- ing alarmingly. We know that the functional neuroses that aifect man's mind and behavior, such as neurasthenia, hysteria, epilepsy, insanity and the multiform minor mental nervous derangements of the human sys- tem are also increasing. Weaklings, paupers, hobos, imbeciles, are becom- ing more common, while leadership and genius, great men and first class workmen are decreasing.

We recently called the picked youth of our nation to the colors and found that practically one-third of them were unfit to defend their coun- try, and that audit, as fearful as it is, conveys an under-estimate of true conditions. So far as that audit goes it may well arouse concern as to the physical state of civilized man ; but it is not complete until consideration of defects unrecorded which in later life impair efficiency and lower resistance to disease is taken into the picture.

Every physical defect in the human family is a challenge to the medi- cal profession. I beg you to accept it as such. If I were delegated as an evangelist to prepare for war against disease I would preach the fact that in order to see and appreciate excellence one must oneself have struggled for it ; that he who has never striven to surpass himself surrounds himself with the shoddy, the second-rate, and the cheap. I would preach that "By what judgment you judge, you shall be judged." I would preach that in selecting our preferences we pass judgment on ourselves; that shirking the effort necessary to real achievement is responsible for the practice of quackery; that the standard of living applies, not to what one wishes to possess, but to what one is willing to pay for in order to acquire the right kind of possession; that life has to do with quality, not quantity; that knowledge and training bring a new reverence for the real and the true ; that respect for the excellent is possible only to a mind that has learned to recognize, appreciate, and practice excellence. If I had to formulate a simple creed by which a medical man may best order his life and discover that which an intelligent mind may reverence and practice, it would be, in the recognition of worth.

When we emphasize excellence, good workmanship, sincerity, ability, virtue and wisdom, we emphasize the difference between superiority and inferiority. Lose sight of the distinction of worth as a social necessity, and all values decline to the level of mediocrity. Our daily choices deter- mine what we ourselves become, and the total of ideals and ideas diagnose the particular type of men we are.

Our worth depends upon our capacity to plan, upon the way we complete each little problem that comes to us in the day's work, and upon our conscience as citizens of our communities. It is what we give to the world, not what we get, that counts. Failure to report every communicable disease and to protect the public against it through every means known to medical science is a besmirchment of the medical cloth. Failure to give ourselves unstintedly to the education of the public, to the desirability of Grade A milk and pure water, is a sin of omission that we must answer

GENERAL SESSIONS 23

for. Failure to vaccinate our own clientele against smallpox, typhoid fever and diphtheria evidences a betrayal of trust which the public places in us. Failure to report cases that the law makes reportable evidences a contemptible ignorance of business methods. Failure to support our Board of Health in all its endeavors to make the citizenship of the state better and cleaner makes a physician appear in the role of a Judas when he betrayed the Christ, who undertook to develop and assist in making a respectable world in which Judas himself could more easily have become a decent and Godly man.

If I could direct the medical profession of North Carolina, I would first undertake to give it an armamentarium sufficient to accomplish the purposes for which it is intended. I would compel every practicing physi- cian in North Carolina to maintain an office neat, clean, and always in- viting to respectable people. The equipment in that office would be sufficient to carry on the practice of medicine in a scientific way — a real first aid station with a personnel trained and at all times available to meet every demand.

Lastly, I would endeavor to crystalize a conscience and ambition looking to perfection and would urge all medical men to do their utmost in the furthering of that knowledge which would stand for the conservation of lives, for the education of citizenship against the ravages of disease and with an effort to teach those who live that in the right living, in the cooperative living, there is increasing physical force reflect- ing man-power and ability to make the world serve better and love more.

"It is not the weight of the gift or plate Or the nap on the silk or fur It's the spirit in which the gift is rich

As the gifts of the Wise Men were And we are not told which gifts are gold And which the gifts of myrrh." (Applause).

Dr. W. S. Rankin, (Charlotte): Mr. Chairman, I have been attend- ing the sessions of this Society a long, long time and I have heard great presidential addresses. I have heard addresses brilliant and displaying the highest type of professional and scientific intelligence, but it has been a long time — and I say this with no reflection upon the splendid addresses we have heard in years past — that I have listened to an address of such fine professional idealism as I have heard here today. (Applause).

I go back in my mind in estimating the place of this address among the others, to a long line of life, to where we started from, coming up out of the slime, climbing ever a little higher and higher, until we have gone on up Jacob's ladder and stand in a place but a little lower than the angels. I think back when life began to gather together a little knowledge, before that instinct, mere vital tradition, is ingrained in the cell, and then knowledge, then a form of life that would put together knowledge and weave it into judgment. I come on up from that to where that finer part of the mind, higher than intelligence, the emotional part of the mind that recognizes the relationship between life of all sorts, is developed. This address has come out of the heart as well as the mind,

24 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

that higher development of the mind; not the intelligence only, but the emotions that cap intelligence. He has lifted us to the very heights of professional vision and shown us the larger view, the larger future to which we tend.

I don't know when I have heard a finer address in North Carolina or anywhere else, coming from this finer and higher type of professional thought, and it is a great pleasure, Mr. Chairman, that I move this address be referred to an appropriate committee for its consideration and report. (Applause).

The motion was seconded.

Chairman Blair: You have heard the words of Dr. W. S. Rankin in appreciation of our President's address. You have heard the motion and it is seconded. Are you ready for the question? All those in favor signify by saying "Aye." Contrary. It is carried.

This, then, will be referred to the House of Delegates. Dr. Cyrus Thompson, I believe, is the Chairman of the Committee on President's Address. Will you take notice of your duty. Dr. Thompson?

Dr. J. M. Templeton, Cary: Mr. President, right on the heels of that, if you will permit me, I want to make a motion.

Mr. Chairman and Gentlemen: I read in the morning paper that the Governor takes no action on the health fund, and in concluding the article, it said he will do so when the press of other business permits. I would like to ask before making the motion what business the Governor of North Carolina has that is more pressing than the health of the people over whom he presides. The motion I have to make is this, that the President of this body appoint a committee of five members of the North Carolina Medical Society to go before the next legislature and ask it to float a bond issue of not less than $50,000,000, (to ask for anything less than that after listening to that magnificent address would be mur- der) to be used for conserving and protecting the health of the people of North Carolina. That is my motion. (Applause).

Secretary McBrayer: Mr. Chairman, I want to second that motion.

Chairman Blair: Ladies and Gentlemen, it has been moved by Dr. J. M. Templeton, due to the knowledge brought out by the President's address, that a committee of five be appointed by the President of this Society to memorialize the legislature for a bond issue of $50,000,000 or more for the carrying out of the work as idealistically outlined in the President's address. Are there any remarks? If not, are you ready for the question? All those in favor signify by saying "Aye." Contrary- minded. It is so ordered. (Applause).

Announcements.

Secretary McBrayer: Will Dr. Carlton and Dr. Hege stand up, please? They are too timid, I mean too modest to mention this, so I wanted to call your attention to the morning's issue of the Winston-Salem Journal. It has the pictures of Dr. Carlton and Dr. Hege on the front page. This is May day, as you know, and child health day also. The Journal has gotten out a magazine edition on child health. They brought it down this morning by aeroplane and it is free to everybody who cares

GENERAL SESSIONS

25

to set a copy. I think we ought to commend the work of this paper m getting out such an edition as that, largely due, of course, to the spirit infused into the editor and management of the paper by these fine health officers.

I have a telegram here from Dr. Dave Tayloe:

I am badly disappointed the last minute. I fear my health will not permit going to Pinehurst. I love the North Carolina Medical Society and am with you in spirit. Best wishes for a successful meeting. My three boys will be with you. Dr Thompson: Mr. President, I just mentioned to Dr. Rankin the feebleness of Dr. Dave Tayloe and I just came back here to ask Dave how his father was. He tells me he is somewhat better than he was two or three weeks ago, but still his condition is precarious.

I wanted to move you, sir, that the Secretary be instructed to send a telegram to Dr. Tayloe, in appreciation of his remembrance of us and conveying to him our love and good wishes for his recovery and our regret that he cannot be here with us.

You men who know him, know I am telling the truth when I say that if Dave Tayloe falls, a prince will have fallen in our Israel. He is one of the most lovable men I ever knew, one of the men who comes up to the measure of the President's address of this morning as nearly as any man I ever knew.

The motion was seconded.

Dr. C. S. Lawrence, Winston-Salern: Mr. President, in seconding that motion, I would like to include Dr. A. Y. LinviUe, of Winston-Salem. It is the first time, I think, in years he hasn't been present at the State Medical Meeting. Dr. Linville had an automobile accident the other day and dislocated his hip. He is in the hospital. I would like to include a telegram to him in that motion. Dr. Thompson: I accept that.

Mr. President, I move the adoption of this motion by a rising vote of the Society.

The audience arose. Telegrams sent.

Chairman Blair: It is a pleasure and a privilege now to turn this Seventy-Fifth Session over to our President for executive action. President Burrus took the chair.

President Burrus: Members of the Society, we will now proceed with the program. I am going to ask you to just pep it up a little bit and put some life in this meeting and make it really worth while.

The first paper on the program is by Dr. H. S. Black, of Spartanburg, South Carolina, on "Pancreatis with Fat Necrosis Following Gall Blad- der Infection." (Applause).

26 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

PANCREATIC FAT NECROSIS ASSOCIATED WITH GALL BLADDER DISEASE

By Hugh S. Black, A.B., M.D., F.A.C.S. From the Mary Black Clinic, 392 East Main St., Spartanburg, S. C.

The stomach, duodenum, gall bladder, liver, bile ducts and pancreas in the human embryo, originate from a single tube, the primitive alimen- tary canal lined by columnar and cuboidal epithelium. From this tube differentiation into the stomach and intestines occur, and in an early stage of this evolution, a diverticulum appears from the duodenum which ultimately becomes the liver and the pedicle of this mass forms the ductus choledochus communis. From this diverticulum arises another which be- comes the cystic duct and gall bladder. The pancreas and pancreatic duct have a similar origin. It is evident that the functional cells of these organs have a close and common ancestry and are biologically closely related, but in higher organisms they have become rearranged with specialized cells performing various functions. These organs still remain connected by the same sympathetic, motor and sensory nervous S3'stem.

Diseases of the gall bladder, ducts, liver and pancreas comprise a group of pathological conditions in the human individual that physicians are called upon to treat. Some of these individuals are fortunate and seek advice early, others are unfortunate and consult late. Even though insulin has been discovered for the diabetic and the Lyon's drainage instituted in the treatment in all types of gall bladder diseases, there still remains pathological conditions of these organs that the above treatment will not relieve and surgery must be resorted to as the last resource.

In operating in the upper abdomen, diseased gall bladders with or without stones and lesions of the stomach and duodenum are well recog- nized but undoubtedly there must be many cases of pancreatitis not detected. This probably is a result of two reasons ; first, no attempt is made to examine this organ, especially if the gall bladder or stomach, or both, have pathology in them, and secondly, failure to recognize dis- ease of this organ when it is present.

The fact that Deaver* and Pheiffer demonstrated disease in the pan- creas in 33 per cent of cases of cholecystitis and Abell in 394 operated cases of gall stones showed pancreatitis in 13.9 per cent and that Judd found an associated pancreatitis in 20.8 per cent of gall bladder disease operated upon go to prove that pancreatitis must be a fairly common association with disease of the biliary track. In Judd's series there was one diseased pancreas to every five diseased gall bladders, though none of his cases clinically suggested pancreatitis. W. J. Mayo, 1911, (Cana- dian Medical Journal) in analyzing 4000 cases of gall bladder disease showed pancreatitis was a frequent complication and when present it was more common in cases where stones were in the common duct than when merely the disease (either with or without stones) was limited to the gall bladder and cystic duct.

Opinions vary as to etiology of pancreatitis. Some think it is due to a reflux of bile into the pancreatic duct (Archibald) others think it is

*Deaver's latest report of 903 crises of arall bladder disease reported the oancreas diseased in only 6% of the cases.

GENERAL SESSIONS 27

due to the duodenal contents being forced into the common duct through the Ampulla of Vater and entering the pancreatic duct causing an infec- tion. Many agree that it is a result of infection from a diseased gall bladder, duct, liver or occasional gastric or duodenal ulcer (Deaver) which travels by means of lymphatics into the pancreas. Others believe that pancreatitis is caused by direct blood infection, as Rosenow has taken the organisms from infected gall bladders and injected them into the veins of normal animals and in 70 per cent of the cases produced an infection in the gall bladder of these animals.

Jones suggests that in those cases of pancreatitis without fat necrosis the infection enters the pancreas by the lymphatics but when fat necrosis appears it is due to the reflux of bile in its ducts. It will suffice here to say that Jones' opinion in this matter is still debatable, even though Mann, has produced pancreatitis with fat necrosis, experimentally, in animals by causing bile to enter the pancreatic duct.

Whatever the etiology of pancreatitis may be there exist two groups which are classified as the acute and chronic. The acute type is usually described as occurring in three forms, the hemorrhagic, gangrenous and suppurative. The symptoms and signs in these types are more or less the same excepting in varying degrees of severity. Clinically in our experi- ence, it is not only impossible to diiferentiate the types before operation but it is almost impossible to be certain that we are dealing with a lesion of the pancreas, whether it be primary or secondary. At operation, not only may a hemorrhagic pancreatitis be present with blood stained fluid in the peritoneal cavity, but also there may be associated areas of gan- grene and suppuration. Fat necrosis is not uncommonly seen and Abell recently reported four cases of pancreatic fat necrosis in ten cases of acute pancreatitis in all of which the gall bladder was visibly diseased.

Chronic pancreatitis occurs in two forms, the interacinar and inter- lobular. In the latter type there is a preponderance of interlobular con- nective tissue with a compressed glandular structure, while in the former type there is an excess of connective tissue within the glandular acini. Chronic pancreatitis practically always is secondary to disease of the liver, gall bladder, and ducts and acute pancreatitis may likewise be secondary to these infections but on the other hand when in these severe and frequently fatal cases, it might, in itself, be the seat of primary infection.

In the chronic pancreatitis associated with gall bladder disease the pancreas is usually enlarged, hard, irregular and roughened, particularly in the head. This might be explained by the fact that the lymphatics from the gall bladder and pancreas anastomose around the head of the pan- creas (Maugeret) causing most of the inflammation in this area. It is worthy of mention to note that even though the inflammation in the head may be extremely marked that seldom does jaundice exist from this cause alone as was formerly thought.

The other type of pancreatitis associated with gall bladder disease is that producing a fat necrosis. When present the symptoms might be only those of a mild case of cholecystitis with digestive disturbances or might be a little more severe causing epigastric pains and colics with more or less soreness and tenderness, nausea, and vomiting, with a mild degree of

28 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

exhaustion and weakness and no loss in weight. In the more severe cases the above symptoms are exaggerated and frequently there is some degree of shock and collapse. It is in these former types of cases that the condi- tions are frequently diagnosed as gall bladder disease and one is cha- grined on opening the abdomen to find not only a diseased gall bladder with or without stones but an associated pancreatitis and occasionally a fat necrosis.

Fat necrosis, when present, varies in amount as well as in distribution, though commonly found in the peritoneum, mesentery, omentum and gall bladder region. The necrosis is not formed as a result of bacteria but it is a result of the pancreatic ferment which escapes from the pancreas caus- ing the fat in any of the surrounding tissue that it comes in contact with to be broken down into fatty acid and glycerin. The glycerin is absorbed but the fatty acid unites with calcium salts producing whitish yellow patches which remain in the tissues. Cases have been reported in which such areas have been observed in the pericardial and extrapleural fat. This might indicate that these ferments are capable of transportation by lymph or blood stream. Once seen, areas of fat necrosis will never be forgotten.

*From the records of three hospitals in the South and one in the East with which we either have been or are associated there were nine cases of pancreatitis with fat necrosis which were evidently secondary to gall bladder infection. From them a few facts will be taken. The average age of these nine patients was 45 years. The youngest was 24 and the oldest 64. Three of the nine cases occurred in the female and six in the male. The average time of onset of symptoms was 4.9 years while the shortest period was two months and the longest 24 years. The average number of days during the last exaccerbation of symptoms before coming for exami- nation was nine.

Pain was present in all of the cases, being crampy and colicky in seven and less severe in two. The pain radiated to the right shoulder in three cases and was confined to the region of the gall bladder and epi- gastrium in six. Six of the total number of cases required morphin for relief of pain and the others took medicine by mouth for it. Epigastric distress was noted in six cases, nausea and vomiting in five and in two cases a history of chills and fever could be elicited. Jaundice was present in two cases while the same number had clay colored stools. Eight of the cases had albumin, five had casts and two had bile in the urine, but no mention was made of sugar being found.

A leukocyte count over 10,000 was present in five cases and under 10,000 in four.

In none of the cases could a mass be detected in the abdomen though all revealed soreness and tenderness in the gall bladder and epigastric region with no evidence of it being more severe over the pancreas.

The preoperative diagnosis in seven of the cases was gall bladder disease and in two cases gall bladder disease with common duct obstruc- tion, probably stones.

*Mary Black Hospital, Spartanburg, S. C, Spartanburg General Hospital, Laurens Hospital, Laurens, S. C, Jeflferson Hospital, Philadelphia, Pa.

GENERAL SESSIONS

29

A cholecystectomy was done in five cases, a cholecystostomy in two and cholecystostomy and choledochotomy in two. All cases were drained but in none was a pancreas drained per se. There was one death due to peritonitis.

In the following chart will be seen the condition of the gall bladder and pancreas and the distribution of fat necrosis :

Condition of the Gall Bladder:

1. Chronic cholecystitis contracted and deeply placed with stone in com- mon duct.

2. Strawberry type, chronic cholecystitis.

3. Chronic catarrhal cholecystitis with thick- ened wall.

4. Acutely inflamed edematous and gangren- ous.

5. Thickened wall and inflamed.

6. Acute empyema with perforation with stones.

7. Edematous, stone in common duct.

8. Stones and edema- tous wall.

9. Chronic cholecystitis contracted without stones.

Condition of the Pancreas :

1. Acute pancreatitis head size of small orange.

2. Pancreatitis, hard- ened, edematous especi- ally the body.

3. Chronic pancreatitis, hard, irregular and nod- ular in head.

4. Acute pancreatitis, large and swollen.

5. Acute pancreatitis, large and swollen.

6. Acute pancreatitis.

7. Acute pancreatitis, large and soft.

8. Acute pancreatitis with swelling and edema of head.

9. Pancreas slightly enlarged, head irregular and hardened.

Distribution of Fat Necrosis:

1. Extensive in omen- tum and peritoneum.

2. Round ligament of liver.

3. Necrotic area around liver region.

4. Extensive over omen- tum.

5. Extensive out abdomen.

through-

6. Slight around the region of the gall blad- der.

7. Gastro hepatic omentum.

8. Transverse meso- colon.

9. Gastro hepatic omentum and gall blad- der region.

We realize that this number of cases are too few to draw any definite conclusions. In this series, however, of pancreatic fat necrosis one will note that the predominant symptoms were crampy and colicky pains in the gall bladder and epigastric regions, nausea, vomiting and epigastric distress, all of which pointed towards gall bladder disease rather than pancreatitis, particularly the acute type. No mention was made whether the acute cases were hemorrhagic, gangrenous, or suppurative, for after all they represent different degrees of the same infection. We emphasize the fact that in this series of cases as well as in Abell's recent series of ten cases, that the gall bladder was diseased in each case and that a gall bladder history was elicited, though in some of the cases the prolongation of gall bladder attacks should have led us to think of an associated pancreatitis.

It is interesting to note that the pancreas was described, as being acutely Inflamed in six cases while three were classified as chronic pan- creatitis, but from the recurrent history of attacks one would have expect- ed the reverse. The fact that six cases occurred in the male and three in

30 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

the female is of no significance and should be accepted as a coincidence for we know that gall bladder infections are twice as common in the female and probably a large series of cases would bear this out.

From a study of these cases no conclusions can be drawn as to what cases we might expect fat necrosis to be present in and we must not be surprised to find it at operation anywhere within the abdomen.

The operative mortality rate does not appear to be as high in the cases of pancreatitis with fat necrosis secondary to gall bladder infection as in those cases operated upon with little or no infection of the biliary track. Abell reported two deaths in 10 cases of acute pancreatitis, one of which occurred out of the four recorded cases of associated fat necrosis. In the above series of nine cases there was one death.

These statistics^ though few, lead us to believe that fat necrosis occurring in pancreatitis cases secondary to gall bladder and biliary dis7 ease does not seem to carry with them the same weight of severity and graveness as when occurring in primary acute pancreatitis.

REFERENCES

Abell: Surgical Treatment of Disease of the Gall Bladder, Southern Medical Journal, 1923.

Deaver: Gall Bladder Disease, Review of 903 Cases, A. M. A., Feb. 26, 1927.

Deaver and Pheiffer: Tr. Am. Surg. Assn. 39, Dec. 1921.

Cullen and Friedenwald: Pancreatitis. Archives of Surgery, July, 1927.

John B. Deaver: Personal Communication.

Dean Lewis: Personal Communication.

Scale Harris: Pancreatitis as Related to Gastro Intestinal and Gall Bladder Infection.

Judd and Herbst: Surgery of Acute Condition of the Gall Bladder. Minn. Medical, Dec. 1922.

Judd: Relation of Liver and Pancreas to Infection of Gall Bladder, A. M. A., July, 1921.

W. C. MacCarty: Pathology of the Gall Bladder and Some Associated Lesions. Annals of Surgery: May, 1910.

(Applause).

President Burrus: Thank you. Dr. Black. Vice President G. H. Macon took the chair. Chairman Macon: Dr. James will present his paper.

THERAPEUTIC CONSIDERATIONS OF THE THYROID

GLAND

Albert W. James, A.B., M.D., Hamlet, N. C.

Mr. President, Members of the North Carolina Medical Society: It shall not be the attempt of the writer to offer anything of a departure from the now commonly accepted methods of treatment of pathological conditions of the thyroid gland. Instead, it will represent an effort to compile a brief and concise resume of the most effective measures employed in those conditions seen most often by the general practitioner or surgeon. The anatomy and physiology of the thyroid gland

GENERAL SESSIONS 31

will not be touched upon ; likewise, no minute consideration of the various pathological processes will be made. We shall first take up those derange- ments which fall primarily within the field of general medical treatment.

Inflammation of the thyroid gland, thyroiditis, is now regarded as a complication of some primary infectious disease, such as scarlet fever, typhoid fever, or pneumonia. Occasionally, the thyroiditis may be the complication of some mild infection and the thyroiditis be so severe as to cause one to regard it as a primary infection. The cardinal symptoms render the diagnosis apparent, especially when difficulty in swallowing is present. Extreme enlargement of the gland may interfere with respi- ration.

The treatment of thyroiditis should be directed towards the primary disease. Simple laxatives and diuretics are indicated. For the relief of the pain and tenderness in the gland, an ice cap may be employed. While simple inflammations of the thyroid gland usually clear up in several days, the possibility of abscess formation must not be overlooked. If one or more small abscesses develop, they can be aspirated with a small needle. If the abscess becomes large and extends through the capsule into adjacent tissues, incision must be made and free drainage established.

Goiter, as differentiated from thyroiditis, is a chronic enlargement of the thyroid gland caused by a hyperplasia of its connective tissue and a proliferation of the cells of the acini, accompanied by an increase in the amount of colloid. The excess of colloid is not discharged and the acini are distended, producing either a diffuse and uniform enlargement or a circumscribed and nodular enlargement. The goiter of adolescence is the one most commonly seen. If observed early and treated with iodin in the form of Lugol's solution, or any other form of iodin, in the dosage of one and one-half grains of iodin three times a day, these goiters usually respond satisfactorily. Painting of the skin over the goiter with tincture of iodin has been employed, though the danger of irritation and blistering must be kept in mind. It is well to mention that in some localities prophy- laxis has been practiced by giving small amounts of iodin to everybody by placing it in the common water supply at the pumping or filtration plant. Recognizing the efficacy of such a procedure, some manufacturers of table salt in this country are now selling iodized salt. The iodin content of the salt affects the taste none at all, and it is to be hoped that the universal use of this iodized salt will prove a boon in the prevention of goiter. This same line of treatment is resorted to in goiter already well developed, though the results are not so encouraging. When medical treatment has proved of no avail and where pressure or superimposed toxic symptoms are present, surgical procedure offers the only relief.

The thyroid gland which has become goiterous is a potential field for the development of subsequent pathology; it is a locus minoris resis- tentiae, as it were. Given, a patient with a colloid goiter in which toxic symptoms have developed, the successful treatment depends upon an early recognition of the secondary toxic symptoms and prompt surgical intervention. Even with the early diagnosis, the mortality rate is some- what higher than in those cases of primary toxic hyperthyroidism.

Strumitis may be defined as an inflammation of a goiter. Not unlike simple thyroiditis in its etiology, it is the secondary complication of some

32 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

primary infectious disease. Paradoxical as it may seem, strumitis is observed after mild infectious diseases more often than after the more serious infections which we have enumerated as the causative factors of thyroiditis. Only a word need be said concerning its treatment. An ice cap or cold compresses applied to the gland may prove of comfort to the patient and hasten the resolution of the inflammatory process. If it goes on to suppuration, surgical measures are indicated.

Syphilis and tuberculosis of the thyroid gland are mentioned as examples of thyroiditis arising as secondary complications from systemic infection by these diseases. Syphilitic thyroiditis is characterized by a painless swelling of the gland occurring in the secondary stage of the disease. Gummata of the thyroid have been reported. Tuberculous thy- roiditis is a manifestation of general miliary tuberculosis. It is of rare occurrence and of no clinical significance in view of the fact that all therapy must be directed towards the primary disease. The same holds true in the consideration of the treatment of syphilitic thyroiditis.

Tumors of the thyroid gland usually arise as circumscribed and nodu- lar areas involving the epithelial cells. In this connection, the nodular colloid goiter may be regarded as a new growth, and, strictly speaking would be included properly in this grouping.

Adenomata constitute the majority of all thyroid tumors. They are best described as discreet neoplastic formations arising from hyperplastic changes in the glandular tissue and their line of demarcation is sharply defined from the surrounding normal thyroid tissue. There may be one or several of these encapsulated tumors present. They are subject to hyaline degeneration, hemorrhage, and cystic degeneration. The presence of an adenoma in the thyroid gland is a source of potential danger to the patient at all times for they are quite prone to undergo malignant changes. This is particularly true in the fetal adenomata, so called be- cause of their resemblance to embryonic thyroid tissue. Most carcinoma- tous growths of the thyroid gland arise from adenomata which have been present for many years and which have suddenly taken on changes inci- dent to malignant degeneration. Any growth of the thyroid which in- creases rapidly in size should be regarded with suspicion of malignancy. Sarcomata of the thyroid are of relatively rare occurrence, there being but few cases reported in the literature. It is quite difficult to diagnose the character of any thyroid neoplasm prior to operation. The irregularly shaped and rapidly growing tumor suggests malignancy. The symptoms of pain and pressure develop late. Medical treatment in thyroid tumors accomplishes nothing. Early operation, for excision of the tumor and for positive diagnosis, affords the patient the best chances for recovery.

Upon the secretory activity of the thyroid gland depend more func- tional relations of the body than upon any other of the endocrine glands. If it is absent at birth, or atrophic in size, or markedly fibrosed, the in- fant will exhibit the characteristic signs and symptoms of cretinism, resulting from absent or decreased thyroid secretion. If the secretory activity is impaired in later life by operative removal or by destruction by injury or disease, there is produced the condition known as myxedema. If a hypersecretion of the thyroid develops and there is an excessive

GENERAL SESSIONS

33

production of this secretion beyond the needs of the body, we are con- fronted with the well known clinical entity of hyperthyroidism or toxic

goiter.

The pathology of cretinism is manifested in a retarded and impaired development of the child, both physically and mentally. We are not pre- pared to state anything definite regarding its etiology. The theory has been advanced that it is the result of the thyroid gland becoming diseased early in life, with a resulting athyrosis. The signs of cretinism are observed largely in the retarded and imperfect development and growth of the bony skeleton, the myxedematous overgrowth of subcutaneous tissue, the atrophic degeneration of, or apparent absence of, the thyroid gland, the deficient growth and character of the hair and teeth, and the subnormal metabolism, together with the characteristic subnormal mental development. Cretinism may not be suspected in the early months of the infant's life due to the small amount of thyroid secretion which may be taken in in the form of nourishment in the mother's breast milk. Obvious- ly, the treatment of cretinism is to be directed solely at supplying the vital thyroid secretion which the body needs. Thyroid gland extract is administered in increasing doses to the point of tolerance, starting with a fifteenth of a grain three times a day. The point of tolerance and the progress of the condition of the patient are determined by a study of the metabolism, the pulse rate, and the temperature. The pulse rate and the temperature returning to normal are practical indices for determin- ing the thyroid gland dosage. A check up once a year with X-ray exami- nation of the bones is of value to determine the progress of the develop- ment of the bony skeleton. Best results from thyroid gland therapy are obtained if the treatment is discontinued at intervals and then resumed.

For general consideration, we may regard myxedema as presenting many of the same signs and symptoms as cretinism, only developing after the function of the thyroid gland has been destroyed or greatly impaired. Operative removal of too much of the gland is followed by the character- istic manifestations of myxedema, or it may develop from a diseased pro- cess or injury which destroys the secretory function of the gland to such an extent that there is a deficiency of the normal secretion. If it appears before puberty, there is a failure of development of sex characteristics. The growth of the bony skeleton and the muscles is greatly impaired. Epiphyses fail to unite and the muscles are inclined to atrophic changes. There is an increase in the subcutaneous tissue of the body to such an extent that the diagnosis is not likely to prove confusing. The mentality, the metabolism, the temperature, and the digestive system are below normal. As in the treatment of cretinism, so in myxedema, the missing thyroid secretion must be supplied and the dessicated thyroid gland is the derivative most commonly used. The dose may be started at one to two grains per day and gradually increased to the point of tolerance, careful observation being made for the development of any untoward signs of too large dosages.

That deranged function of the thyroid gland characterized by a chronic overactivity of its secreting substance is known as hyperthyroid- ism or exophthalmic goiter. There is produced an increase in the amount of the normal thyroid secretion in excess of the needs of the body for its

34 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

normal metabolic processes. It may develop at any age, but it is more common between the ages of twenty and forty. Females show a much higher morbidity rate, the incidence being eight to one. The etiology of hyperthyroidism is little understood. It has been observed to be more common in those sections where goiter is prevalent. The theory that the nervous system plays an important role in its production is to be dis- counted because it does not appear in any marked increase in those sec- tions where the environment and living conditions predispose the indi- viduals to live under increased nervous tension.

The signs and symptoms of hyperthyroidism vary directly with the amount of the excess secretion and the nervous tendencies with simple tachycardia and comparatively slight increase in metabolism to the classical picture with its cardinal signs of the increase in the size of the thyroid gland, the nervous tremor of the hands, the exophthalmus, and the greatly increased rate of metabolism, with the persistent tachycardia of an alarming degree. Such well developed cases oifer no difficulty in diagnosis.

The treatment of hyperthyroidism is directed towards the lowering of the processes of basal metabolism. We must appreciate the fact that we are not dealing with an ordinary acute disease which will terminate fav- orably under successful therapeutic proceedings. It is distinctly a chronic disease ; the parenchyma of the gland has increased in amount and in function, which has produced the excessive secretion with its attendant toxic symptoms. Theoretically, we should be able to destroy this excessive secreting parenchyma by roentgen rays or by surgical extirpation, leav- ing only so much of the thyroid gland as is necessary to carry on. Un- fortunately, this is not so easily accomplished. When skillfully treated and there is an apparent amelioration of symptoms, there is always the possibility of another derangement of the thyroid gland developing. The word "cure," as applied to treated cases of exophthalmic goiter, must be used with discretion and apprehension. Many tendencies to symptoms of nervousness, neurasthenia, hysteria, and other indications of nervous instability are left as permanent reminders of the seriousness of the disease which has reponded with an apparently happy ending.

As we are concerned with lowering a hyper-functioning metabolic process, our first and main effort should be concerned with a lowering of the physiological demands of the body. This is accomplished by putting the patient at absolute rest in bed, removed from all former activities, particular care being exercised that no mental strain be allowed to remain. For this reason, complete change of environment is advised, treatment away from home and in an institution being more efficacious. Whatever the form of treatment elected to be pursued, whether entirely medical, or by means of the roentgen rays, or by surgical measures, the initial rest period is of the greatest importance, for there is usually a marked improvement under this regime. The height of the improvement is manifested by a rapid fall of the basal metabolism, some 15 to 25 per cent, a slowing of the pulse rate, and a decrease in the nervous symptoms. After about two to three weeks of this absolute rest treatment, all of the aforementioned good results appear to have reached a maximum and there is a standstill in the improvement.

GENERAL SESSIONS 35

The X-ray treatment of hyperthyroidism cannot be directed along dogmatic lines as applicable to this particular case and unsuited for that one. Following exposure to the X-rays, there may be a flare-up in the symptoms due to the stimulative and irritative action of the rays. Obviously, then, the severely toxic cases are not to be treated by this means. The best results in X-ray treatment of hyperthyroidism are ob- tained in cases of mild severity, and then the dosage is best given in a single full strength exposure, staying just short of the erythema skin dose, rather than to invite the possibility of stimulation of the already hypersecreting parenchyma of the gland to even greater activity by the irritative action of fractional exposure dosages. The preliminary rest treatment followed by rest and an environment predisposing to physical and mental repose are of the greatest value if the best results are to be obtained from this method of treatment.

In recent years our conception of the role iodin plays in the treatment of exophthalmic goiter has been subjected to radical alterations. We had been following the teaching of Kocher that iodin was contraindicated. Now we know that iodin is not only indicated in the ordinary rest and general medical treatment of hyperthyroidism, but it is of distinct advan- tage in bringing about a general improvement of the symptoms prior to operation, if this method be elected. The theory of how iodin acts bene- ficially even in the presence of excessive thyroid secretion, containing thyroxin as its active principal and which is made up of 65 per cent iodin, is explained on the supposition that many molecules of the thyroxin are liberated into the body with toxic results because they have not been iodized. These conjectures have been borne out in the therapeutic tests of giving Lugol's solution or potassium iodide solution to cases of hyper- thyroidism with gratifying results. It is now the recognized procedure to give iodin therapy prior to operation and continue it post-operatively. If the case is one to be treated along general medical lines, there must be intervals of discontinuance of the iodin therapy, to be resumed again as before. It has been observed that there is a continual and gradual fall for one to two weeks in the metabolic rate to a decrease of some 35 to 50 per cent, after which there is an abatement and standstill in the improve- ment. This is the time to operate, if surgical intervention has been decided upon. If operation is not done at this time and the iodin therapy is con- tinued, the symptoms of increase metabolism and hyperthyroidism return as severe as formerly.

The surgical treatment of hyperthyroidism presents a problem which must be worked out by a careful study of each individual case. It is not within the scope of this paper to treat of the various indications and contraindications for operative procedure. With the advent of our com- paratively recent knowledge of the tremendous importance played by the administration of iodin in hyperthyroid states, we may reasonably con- clude that many severely toxic cases are being made amenable to radical operative treatment by virtue of the fact that they are transformed into fair operative risks with an attendant decrease in mortality. The key- note of iodin therapy is to be sounded in the admonition for a closer correlation of the internist and the surgeon in this treatment, for it will avail the patient nothing if the operative procedure is not done at that

36 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

opportune period when the most benefits are being received from the administration of the iodin. Likewise, there are many cases of mild hyper- thyroidism which may be benefited by the iodin treatment, in conjunction with the other enumerated procedures, to such an extent that the disease can be kept more or less under control and the patient apparently free from symptoms and no operation will be indicated.

The diseases to which the thyroid gland is subject to and the derange- ments of its secretory activities render this field one of the most alluring in modern medicine and one in which now we are beginning to appreciate the untold possibilities of accomplishing the greatest results. It is in the treatment of these conditions briefly outlined that the physician must avail himself of all the progress recently made and correlate his own intensive study of the case at hand with intimate association with the laboratory worker, the physicist, and the surgeon, if he is to obtain the highest rewards of labor well spent. (Applause).

Chairman Macon: Is there any discussion of Dr. James' paper .^

DISCUSSION

Dr. a. G. Brenizer, Charlotte: I want to congratulate Dr. James on his paper, and I am glad he has taken an interest in thyroid enlarge- ments. Commenting, not with the idea of criticizing very much; as to his recommendation that iodin in salt be dispensed rather freely for the reduction of thyroid hypertrophy, I think that is a great mistake. The hyperthyroidism in young people is appearing with us very much more frequently than formerly, and I think it is due to the free use '^f iodin in city water. A very mildly hyperplastic and hypertrophic thyroid is easily overdriven, and when once overdriven with iodin and hyperthy- roidism is produced, you have a condition that forces the operation. I don't think iodized salt can be dispensed from the grocery store. I think it should be dispensed by the doctor and frequent checks should be made on metabolism.

Thyroiditis would appear a simple story to begin with. There are several tj^pes of thyroiditis, the Rieol type where the gland is probably hyperthyroid, whether operated on or not, but if not, it will involve the structures of the neck, probably spoil the parathyroid glandules and affect the nerve. It is the consensus of opinion the second renal type should be operated on.

As to hyperthyroidism, I think there is where our work lies. Iodin in hyperthyroidism is certainly beneficial and beneficial only for a short time, as has been proven any number of ways. The thyroid gland will revert to the normal type of gland temporarily riire-v a period probably of about three weeks, and then the thyroid gland will become hyperthy- roid again, and once having become hyperthyroid, it is almost impossible to reduce that hyperthyroidism with iodin.

I think in no case of exophthalmic goiter should iodin be given unless on the way to operation. That is the most dangerous thing. Again, all cases of supposed exophthalmic goiter do not respond to iodin as they should because they are mixed in with adenomatous growths and while you are reducing your hyperthyroidism, you are also stimulating your adenoma. They can be made markedly hyperthyroid.

GENERAL SESSIONS 37

As to X-ray treatment, I think there is some difference of opinion. I have a right to have mine. I think there is no place for it at all. I can't conceive of how X-ray in like measure to surgery reduces the thyroid gland, say, represented by an eighty metabolism, where four-fifths or five-sixths of the gland is to be taken out and the other part of the gland unaffected is to be left to take care of the functions. How that dosage can possibly be so regulated that four-fifths to five-sixths can be destroyed and the other be left in the proper active, normal state as it should be, I don't understand.

Beyond that, Means and Aub of the Massachusetts General Hospital treated eighty-four cases with X-ray under the most careful observation. They got five cases of myxedema out of X-ray treatment ; they got sev- eral cases of shrinkage in the neck, some cases affecting the parathyroid gland. I think it is a most dangerous thing. I think usually X-ray treat- ment is not carried far enough ; the gland is rather stimulated and caused to atrophy ; when it is affected at all, it is reduced somewhat in its tox- icity, and those people go on half-poisoned rather than full-poisoned. I don't think any method in exophthalmic goiter is rapid enough except surgery to prevent many untold symptoms that the patient will get in try- ing to tide him on to operation. I think it is just as disastrous to allow exophthalmos, which is the most horrible deformity a woman could expe- rience. If you don't think so, talk to the people with exophthalmos sometime — with bug eyes and frog eyes. I think it is almost as bad as a hair lip. If you can save a woman that by an early operation, by rapid reduction of oversecretion of the thyroid gland, you have certainly done a thing greatly in her favor. I think anything that doesn't produce relief rapidly and save her a lame heart, a lame pancreas, bug eyes, is a mis- take. It is too slow. Those are conclusions that I have drawn over the last seventeen years in talking to many patients. (Applause).

Chairman Macon: The next paper is an address to the Society from the Section on Eye, Ear, Nose and Throat, "What Ophthalmology Should Mean to the General Practitioner," by Dr. V. M. Hicks, of Raleigh.

Dr. V. M. Hicks, Raleigh: Mr. President, Ladies and Gentlemen: I consider it an honor to be asked by the head of our organization to address the general session as a representative from the Eye, Ear, Nose and Throat Section. I am not unmindful of this responsibility. I realize quite well that it is the general thought that talks relative to defects of the eye are rather uninteresting to the general practitioner and those engaged in other specialties. We are prone to think of defects of the eye as being surrounded with technical and uninteresting details. Too fre- quently we think of the eye as being separate and apart from the rest of the body.

I wonder why we assume that attitude. Is it because eye defects are rare.? I believe I am perfectly safe in saying that of all the patients com- ing under the supervision of the general practitioner, more of them suffer from defects of the eye than of any other part of the human structure.

Let us call your attention to the report of the Provost Marshal General as to the causes of rejection in the selective draft of our recent war. Ten per cent of all the men were rejected because of eye defects. That percentage did not include a certain per cent of men who were cor-

38 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

rected by glasses and who had minor eye defects, nor did it include a rather large percentage of men who were rejected for other reasons before the eye examination was made.

Statistics which tend to prove the percentage of eye defects in our public school children are rather at variance, but I believe we can be very conservative in saying that at least twenty or twenty-five per cent of all of our public school children today are suffering from uncorrected eye defects.

Let me offer this as a possible solution of our apparent lack of interest in ophthalmology. It has been a long time since most of us graduated from medical school and the courses given in medical schools to the undergraduates are rather hasty and incomplete. Very few of us, if any, received any sort of working knowledge of the eye in our under- graduate days. As a result, we tended to drift into this position of rather disregard to the eye. I want to tell you, gentlemen, that no history is complete and no examination is complete without some consideration of the eye.

I realize, as I said in the beginning, that this subject in detail is rather technical, but I think we ought to have some sort of a working knowledge, some sort of information that we can give to our patients from day to day as to the importance of proper attention to their eyes.

Our North Carolina Board of Health has made rapid strides and the medical profession has been justly given credit for these strides. I believe it is our function to further instruct the general public along this particular line. It is my purpose to talk to you in language that you can yourselves use in talking to your patients about eye defects.

Suppose one of your patients in the daily routine of your office should ask you the question, "Doctor, how do I see? How does my eye function?" I wonder how may of you could intelligently answer that question. Let's see if this wouldn't be a satisfactory answer. Let's for a moment com- pare the eye to the action of a kodak or camera. We know that in the rear we have the photographic plate which is protected from the light by certain mechanical structures. We know that we have in front a lens which focuses the picture on the photographic plate behind. W^e know that still farther in front, we have the diaphragm of the kodak which has a little hole in it, allowing the light to go in, and you can enlarge or make that hole smaller, depending upon the intensity of the light. For bright sunshine, you would use a small hole ; on a cloudy day you would use a large hole. That is about all there is to an eye, considering it in a broad sense.

In the eye, we have behind the photographic plate which we call the retina. In front, we have the lens which we call the crystalline lens, and still farther in front, we have the diaphragm which we call the iris, and the hole in the diaphragm is the pupil. There is one fundamental differ- ence. In a camera or kodak, you can change the distance which is between the lens and the plate behind by simply moving it backward or forward. You can't do that with an eye, but nature has arranged that focusing power in the crystalline lens in front. We have a battery of lenses, so to

GENERAL SESSIONS 39

speak, all in one. The eye has within its own power the ability to make this lens large or make it small, depending upon the distance at which the picture is taken by the eye.

Let us have some general knowledge of the anatomical structure, and with this I want to show you a few of these lantern slides.

(Slide) I show in the beginning a picture to call your general atten- tion to the lids with the cilia and above the brow, which protects the eye from the shining light above, and here in front is the cornea. I like to speak of that structure to my patients as the watch crystal of the eye. The cornea in front is an inverted watch crystal, stuck right on the ball in front. Then behind you see the black iris and the pupil in the center.

(Slide) This slide gives you a notion of the extrinsic muscles of the eye, the muscles that move the eye around. I can assure you, my friends, that this perfection in this group of muscles has never, and I doubt if it ever will be, been surpassed by man in any sort of mechanical per- fection. It is perfection itself.

(Slide) This slide here I show you is a cross section of the eye. In front you have the cornea, the watch crystal, and here is the lens and here is the ciliary muscle ; behind is the photographic plate, the retina. Here is how the eye takes care of this change of focus. This ciliary muscle attached to this lens contracts at will, involuntarily, depending upon the distance of the picture. This ciliary muscle has its inervation from the fifth nerve and from also the sympathetic nervous system. You are all familiar with the sympathetic nervous system. We all know how intimately the tracts of the body are connected with each other by the sympathetic nervous system. We know what referred pain is. As my friend. Dr. Royster, says frequently, it is the idea with the sympathetic nervous system of referred pain, to use the principle of baseball — "hit where they ain't."

That is frequently what happens in referred pain through the sym- pathetic nervous system. The pain is referred where the condition does not exist. That is how frequently we overlook this probability of the eye.

(Slide) I call your attention here to a small pupil and to a large pupil. It is astonishing how rapidly one can produce a state of exhaustion in an individual by just doing this one thing, changing the state of light to which the subject is subjected and then subjecting him to dark and bright light at frequent intervals. It is astonishing how rapidly you become tired and feel generally exhausted. That has been carried on many times experimentally and very successfully and very conclusively.

(Slide) Here I show you the focusing of the rays of light; parallel rays of light entering the eye pass through the cornea, are refracted some there, then to the crystalline lens, and then come to a focus at a point exactly on the photographic plate, exactly on the retina. That is the normal state. Now, then, I call your attention, to this instance where the rays of light pass into the eye and come to a focus in front of the photo- graphic plate, in front of the retina. The eye is larger than the normal eye. That is nearsightedness, myopia. The more the ciliary muscle at- tempts to overcome that condition, the worse the condition becomes, the focus still coming farther forward.

40 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

(Slide) This condition, then, is corrected by the use of a concave lens which spreads the rays of light outward when they strike the lens and then they are in a state where they come to a focus back on the retina.

(Slide) Here is a far-sighted eye. These parallel rays of light have a tendency to come to a focus behind the photographic plate, and it is the function, then, of the ciliary muscle to overcome this defect and by contraction enlarge this lens, make it more magnifying and bring the focus forward to the photographic plate. That is the small farsighted, or hyperopic eye.

(Slide) That is corrected, don't you see, by the use of an additional magnifying convex lens which changes these rays before they enter the eye to the normal parallel state and then they are focused in a normal way on the retina.

(Slide) This slide shows the normal near vision, rays of light which emanate from a near object must of necessity be divergent and when they strike the eye, they are in a divergent state and must be refracted by a large lens here in order to bring the focus to the photographic plate.

(Slide) When a person reaches forty or more, the presbyopic stage is reached. The power of this muscle becomes less and less. As a result, this near vision becomes difficult. It becomes difficult for this muscle to enlarge this lens, to make it more convex to meet this requirement, and as a result the focus tends to come behind the photographic plate. That is presbyopia.

(Slide) That is corrected by the magnifying lens which brings the focus to the photographic plate behind.

(Slide) This slide demonstrates the essentials of astigmatism. You notice we have spoken up to now of only the crystalline lens. The watch crystal, however, does have refractive power, and it is in defects of the cornea that astigmatism occurs. These parallel rays of light that you see here in the horizontal and in the vertical positions, being perpendicular, come to a focus on the retina behind at exactly the same point.

(Slide) Now, then, if the cornea is more convex from above down- ward, the vertical meridian, than it is in the horizontal meridian, then the rays of light will come to a focus at two different points behind and as a result, you have the blur. This is astigmatism. It essentially occurs, as I say, only in the cornea and —

(Slide) It is corrected by the use of what is known as a cylindrical lens which only corrects one meridian of the eye. The other being normal, it is not touched.

(Slide) This slide here calls your attention to the two eyes being parallel in the normal state. This is complete muscular rest with the eyes looking for distance and is, of course, an ideal state of rest.

(Slide) The eyes in the convergent state, the muscles must pull these eyes together, to focus together here in the center, and any irregularity in these muscles, any undue strain of these muscles will, and frequently does, particularly in childhood, cause an eye that is overstrained to turn away from the field of vision, and for comfort's sake, and so-called cross-eye or convergent strabismus results.

GENERAL SESSIONS 41

(Slide) This slide calls your attention to the results of eye strain, headaches, nervousness, lack of interest, wrong posture, poor sight, irritability, sleeplessness, faulty digestion, poor work, backwardness in school and accidents.

(Slide) This slide here shows the astigmatic chart, and as you see here, each one of these lines is just as black as the other, and that is the way it would appear to a perfectly normal eye — the various letters here being sharply distinct.

(Slide) Now, then, in the case of astigmatism, however, when you use this chart, you will notice these lines are black and sharp and these lines here are blurred, which indicates the vertical type of astigmatism. Here is one a little bit more marked.

(Slide) This is the normal compared to the abnormal here. This is a slide that is supposed to show all the lines equally blurred where the high spherical error, the high far-sightedness exists with low astigma- tism.

I am sorry these slides don't show up well enough to compare the normal vision with defective vision. I have a series of slides which com- pare normal vision in a view of country with the abnormal vision, show- ing just what these people see. It is perfectly astonishing how poor the vision can become gradually and surely in an individual without his recognizing it.

(Slide) I had hoped with a series of fifteen or twenty slides to call your particular attention to the importance of light. I wish to compare the defective light in rooms with the good light to emphasize the impor- tance of proper illumination. I believe it should be the function of the physician to know what is good illumination and what is poor illumina- tion. The light in this room is so poor that I shan't burden you with that series of slides.

I have purposely omitted discussing some of the pathological condi- tions which every physician commonly comes in contact with such as conjunctivitis, diseases of the lid, and I have purposely omitted advising the use of the ophthalmoscope by the average practitioner. It is my per- sonal experience the average man will not do it. I only wish to call your attention to this fundamental condition known as eye strain which I believe we are commonly overlooking in our general routine examinations. (Applause).

Chairman Macon : He certainly knows his onions. I think we will have to get you to Warren County to address the Parent-Teachers' Association. I think they need your advice.

The next is an address from the Section on Practice of Medicine, by Dr. C. C. Carpenter, "Infarction of the Myocardium."

INFARCTION OF THE MYOCARDIUM By C. C. Carpenter, M.D., Wake Forest, N. C.

Great progress has been made in the last few years in the recognition and proper treatment of diseases of the heart. Formerly, great stress was placed on valvular lesions. The profession now realizes that more im- portance should be placed on degenerative or senile changes. Myocardial

42 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

weakness without valvular lesion has become of great practical impor- tance. It is of great importance economically^ and in certain instances medico-legally. Statistics would prove that coronary thrombosis and infarction of the myocardium is becoming more frequent. It is interesting to note that of the last one thousand autopsies performed by us at the Syracuse University morgue, 88 cases or 8.8 per cent showed coronary occlusion due to arteriosclerosis.

I might explain here that someone might question this high percentage and I would admit that it is probably a little higher than the average, because on this service we were doing autopsies for the county, and in that we found, of course, that we had to do a number of autopsies where it was from a sudden death, the cause of death was unknown. Realizing that one of the greatest causes of sudden death is infarcted myocardium, we would admit this percentage is a little high. However, we also know these cases actually occur.

Of the last 400 autopsies 101 cases showed gross heart change, 45 showed lesions due to arteriosclerosis of the coronary arteries. Such frequent findings at autopsy has put the clinician on guard with the result that this condition is being recognized clinically more often. An early diagnosis is of great importance. The distinction from other anginal pains, and confinement to bed may mean the difference between life and death.

Infarction of the myocardium, as in infarction elsewhere, is caused by complete stoppage of the vessel supplying the part. Death of the tissue follows. Although the coronary arteries are terminal arteries, there is some anastomosis, however not sufficient to supply the active circulation which is necessary for such an organ as the heart. The occlusion is brought about in the great majority of cases by a thrombus formed in the vessel, as a result of arteriosclerotic destruction of the endothelium. It is possible for an embolus to lodge in one of the vessels, but the ana- tomical location of the coronaries behind the cusps of the aortic valve makes this unlikely. There may be only a narrowing of the lumen, from arteriosclerotic thickening, or from puckering of the aorta as observed in syphilis. This would not produce an infarction, but it would produce a partial anemia of the heart muscle. In most cases there appears to be a small arteriosclerotic thickening in one side of the wall of the vessel. This causes no noticeable injury until destruction of the endothelial lin- ing takes place. Following this platelets adhere to the roughened area, and a thrombus is formed occluding the vessel. When the vessel is thus occluded, death and necrosis of the tissue supplied by this vessel follows. Such a necrotic area is soft and swollen. The cells as observed under the microscope reminds one of the appearance of charcoal as contrasted with that of living wood. That is, the cells break up and fade away. Such a mass of dead cells excites an inflammatory reaction. If the outer part of the heart wall is involved an exudate is formed producing a friction rub. Likewise, injury to the lining of the cardiac chambers, causes a de- struction of the endothelium and a thrombus may be formed.

Infarction of the myocardium produces all the different types of pain and anxiety experienced in disturbances of the coronary circulation from

GENERAL SESSIONS 43

any cause. The pain is usually very intense, but in some eases it is slight. The patient is upset and feels that death is near. As the great physician John Hunter said about his own case, "To have any other affliction is to be sick, to have this is to be dying." The pain may be precordial, sub- sternal, in the left shoulder and neck, or in the epigastrium. The attack may or may not be associated with exertion. Where there is only a nar- rowing of the coronary, the patient may complain of attacks of varying intensity over a period of years, at such time when there is a demand for an increase blood supply to the myocardium, which cannot be sup- plied. Finally there is complete occlusion with severe pain and collapse. Or there may be complete occlusion at the first attack. It may well be compared with "Intermittant Claudication," in which there is a narrowing of the arteries supplying the leg. The patient is in comfort while sitting but on walking rapidly intense pain in the leg is experienced, because the demand for more blood cannot be met. These vessels may go on to complete occlusion which in the extremity is called gangrene. I want to call your attention especially to the patients who complain of pain in the epigastrium with belching of gas. Following a big meal and some slight exertion the patient complains of severe epigastric pain, with dis- tension and belching of gas. The physician neglects to examine the heart carefully and for want of something better to say tells him he has "acute indigestion." He may recover from this attack only to drop dead a few days later from occlusion of other branches or rupture of the heart.

The age at which infarction of the myocardium should be expected is that of arteriosclerosis. It is rarely seen before the fortieth year. It is about four times as frequent in men as in women. It may be looked for more often in those who give a family history of early arteriosclerotic changes. Those who have lived a high pressure life are more frequently its victims, such as business men, lawyers, and physicians.

During the attack, on physical examination, we may find the patient collapsed or fairly well composed according to the size of the infarct. The blood pressure varies according to the weakness of the heart and to the presence or absence of general arteriosclerosis. In a large infarct, without a previous high blood pressure it is low during the attack. If it was already high, it may even go higher during the attack. The heart is irregular in the great majority of cases. This may be only slight and should be looked for carefully. The temperature goes up following the attack to around 100 degrees. A precordial friction rub may be heard at this time. The friction rub and arrhythmia may be fleeting but the heart sounds will remain distant for several days. Along with cardiac weakness rales may be heard at the base of the right lung. We have autopsied cases in which this sign became quite marked and a diagnosis of pneu- monia had been made. A few cases present nothing on physical examina- tion of very great value in making a diagnosis. These can be diagnosed only by elimination of other possibilities and observation over a period of time.

In the differential diagnosis we have to consider, thoracic aneurysm, intercostal neuralgia, the so-called indigestion, which includes gastric ulcer, gall-bladder disease and appendicitis, and ordinary angina pec- toris.

44 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

In thoracic aneurysm, a dull area may be mapped out in the region of the aorta. There is usually a pulsation and a murmur double in time. There is a diastolic shock and a tracheal tug. The pain is more likely to come on at night and be continuous.

Intercostal neuralgia occurs at all ages. The pain is short and not associated with exertion, although quick movements may increase the pain. There is tenderness along the intercostal nerves.

In gastric ulcer, gall-bladder disease or appendicitis, there will be the characteristic symptoms of these conditions.

Ordinary angina pectoris is more often associated with exertion or excitement. It is likely to develop in those who have had friends or rela- tives die of heart disease, or who, know that they have a heart murmur. Heart disease to them means sudden death. In this type of angina pectoris the temperature does not go up following the attack and a friction rub is not heard. This is usually relieved by the inhalation of amyl nitrite. But any attack of angina pectoris which is not relieved by amyl nitrite but requires repeated doses of morphine for its relief should be considered as a case of infarction of the myocardium until the diagnosis is definitely established.

Three interesting cases have been selected from a series of autopsies representing different types :

1. Autopsy No. CM-2468, Male. Age 52. Occupation, Manager of hotel. Previous history revealed nothing, aside from the usual childhood diseases and pneumonia at 30 years. Present illness began six months ago. While hurrying across the street in front of traffic, he was seized with moderately severe pre- cordial pain and shortness of breath. He sat down for a few minutes after which he was able to go on home. Felt exhausted that evening but was able to continue his work the next morning. His health was good during the next few months aside from an occasional tightness in his chest, which he attributed to excessive smoking. Twenty-four hours before death he was found at the head of the steps by his wife. He had an ashy grey color, and was groaning with intense precordial pain. He was rushed to the hospital. Morphine gr. l^ was given and repeated in about twenty minutes. Temp, was normal. Pulse 88 with an occa- sional dropped beat. Blood pressure, 110 systolic, 80 diast'olic. The cardiac ir- regularity did not appear alarming during the night. His temperature rose to 100 2-5. Morphin gr. Vg was given hypo every three hours. The following morn- ing he suddenly died. At autopsy the heart appeared to be about the usual size. Epicardium was without evident lesion. On section, the myocardium in the ante- rior wall of the left ventrical was dark reddish in color and slightly softer than the surrounding tissue. In the anterior branch of the left coronary artery, about Vs inch from its bifurcation with the circumflex branch, there was a thrombus com- pletely occluding the vessel. Beneath this was a yellowish anteriosclerotic plaque.

I have not recorded the percentage, but I would estimate that at least ninety per cent of the arteriosclerotic plaques appear in the anterior branch of the left coronary, just beyond where it joins the circumflex. Why this is, of course, I don't know. I haven't heard anyone who does know. (Applause).

2. Autopsy No. CM-2496, Male. Age 58. Occupation, Real estate dealer. Previous health. Had measles, whooping cough and mumps as a child. Fractured

left forearm at age of 26 years from a fall.

GENERAL SESSIONS

45

Present illness began six years ago, at which time he began to have what hie called attack of "Wind on the Stomach." During this time he had one attack of transient hemiplegia and two attacks of transient aphasia. One one occasion six months ago he was found suffering intense epigastric pain, and was in a state of terror, begging those around him not to let him die. This attack came on suddenly, as other less severe attacks had done. A few hours after the attack his systolic blood pressure was 190 m.m. mercury. After three days rest in bed it was reduced to 150. His heart sounds were impure but only slightly irregular. His attacks became more frequent until his sudden, death in an attack six months later.

At autopsy there were dense fibrous adhesions between the visceral and parietal pericardium, at the apex of the left ventricle. In this same area, the wall of the heart was thin, measuring Vs inch in thickness as compared with V2 inch in the remainder of the ventricle. This area was greyish in color and apparently made up of fibrous connective tissue. It produced an aneurysm two inches in diameter, on the inner surface of which there was a thrombus about the size of a hen's egg. The orifice of the left coronary artery was narrowed, and the right was almost completely occluded by arteriosclerotic thickening. In the anterior branch of the left, % inch from its bifurcation with the circumflex branch, there was an arteriosclerotic thickening occluding the vessel.

3. Autopsy No. CM. 2tl26. Male. Age 60. Occupation, Farmer. Previous history revealed nothing of importance.

Present illness began two years ago. At this time he began to have attacks of precordial and substernal pain, very sharp, and at times radiating to his left shoulder. Went to see a doctor who found his heart irregular and weak. He was tdld to give up work for a few months, which he refused to do. Eight months later he became very short of breath, staying in bed a good portion of the time. Two months before death, he was admitted to the hospital. His heart at this time showed marked irregularity. His pain was of moderate severity. He was given digitalis and morphin as necessary. He failed to show any marked im- provement at any time, and died two months after admission.

At nutopsy, the pericardium was apparently normal. The ascending aorta showed several arteriosclerotic thickenings. Valves were without evident lesion. On opening the coronary arteries the branches of the left showed marked arterio- sclerotic thickening as far as they could be followed. The myocardium of the left ventricle showed on section, several greyish fibrous areas from Vs to 1/4 inch in diameter.

In the treatment of these conditions during the attack, the first thing of importance is to keep the patient absolutely quiet. Morphin should be given hypodermically as needed to control the pain. If the blood pres- sure is high an attempt should be made to reduce this as rapidly as possible. Digitalis is contraindicated in all cases of fresh infarction. The period of rest in bed should be long enough to allow the area to completely heal with scar tissue and become firm. This takes from four to six weeks. Unless these patients are kept in bed a sufficient length of time, many cases will end in sudden death from rupture of the heart wall. Between the attacks he should be instructed to live a well regulated life free from mental and physical strain.

46 THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA

SUMMARY

1. The clinical recognition of infarction of the myocardium is of great prac- tical importance in prognosis and treatment.

2. Most cases are caused by arteriosclerotic thickening and subsequent throm- bus formation in a branch of the coronary artery.

3. It may be expected at any time after the fortieth year.

4. Every case of intense precardial or epigastric pain requiring morphin for relief should be studied carefully.

6. Prolonged rest in bed is necessary to allow complete healing of the damaged myocardium.

REFERENCES

1. Parkinson, John & Bedford, D. Evans: Cardiac Infarctiar.i and Coronary Thrombosis, The Lanteet 214:-11 (Jan. 7.) 1928.

2. Frothingham, Canning: A case of Coronary Thrombosis, The Medical Clinics of North America, Vol. X, No. 5, March, 1927.

3. Monographic Medicine, Vol. V.

4. Willins, Frederick A.: Infarction of the Interventricular Septum with com- plete Heart-Block and Slokes Adams' Seizures, The Medical Clinics of North America, Vol X, No. 3, Nov., 1926.

6. MacCallum: A Text-Book of Pathology.

6. Luten, Drew: Coronary Thrombosis of Lesser Severity with Special Refer- ence to the value of Electrocardiography in the Diagnosis. The Medical Clinics of North America, Vol. XI, No. 2, Sept., 1927.

7. Smith, Fred M.: The Coronary Circulation, Archives of Internal Medicine, Vol. 40, No. 3.

Dr. John W. MacConnell. of Davidson, took the chair. Chairman MacConnell: This very interesting and instructive paper of Dr. Carpenter's is now open for discussion.

discussion

Dr. J. B. Bullitt, Chapel Hill: Dr. Carpenter called attention to change in our attitude toward the valve and heart muscle, and that change in emphasis is a very important one, not a considerable difference in our management of these cases. The heart muscle might in a general way be compared to the gas in our entrails that furnishes the motive power, and it doesn't matter how good a condition the valves may be in. I think that we ought to beware against the importance of valvular lesions in our changed attitude, or added emphasis on the importance of the myocardium. I think we sometimes overlook the real importance of lesions. I have known some very good physicians in recent years to pass up cases of valvular trouble, saying, "It's nothing but a valvular leak, we needn't worry about that." That is very important. If the valves in your engine are leaking, you are at least wasting a good deal of gas and you are in considerable danger of having the engine stop. We all know injury to valves is serious in heart conditions.

GENERAL SESSIONS 47

Dr. Carpenter was good enough to let me read his paper before he presented it this morning. I was very much struck in reading it, with the figures he gave 8.8 per cent of marked sclerotic conditions in the cardiac arteries at autopsy. In his reading, he explained it is not a general run of sections. I think he ought to put in his paper at least a note that that is the findings in certain selected cases, because in the general run of deaths, we certainly don't find anything like eight per cent showing marked sclerosis of the cardiac arteries. His cases were largely selective because of persons having sudden deaths, persons with cardiac deaths, which would account for the very high percentage he found in those autopsies.

One of the most interesting things to me in connection with this subject is the amount of sclerosis that we can frequently have in these coronary vessels without serious injury— I say without injury, I mean without symptoms of cardiac conditions.

In case No. 2, I believe it was, he cited that while that man had the symptoms for six years, he probably had more or less a somewhat chronic fibrous myocarditis. He was still able within two or three months of his death to continue at work. We frequently find marks at autopsy of per- sons who die without having cardiac symptoms at all. Also, we find now and then, not very often, pretty heavy scars with which a person has lived quite a number of years and performed perhaps a good deal of active work in spite of having had a good big infarct with a heavy scar resulting from it. I suppose in all sudden cases there must have been some symp- toms at the time of the infarct, but we often have no record of that; at any rate, the person may live for a long time and live pretty actively in spite of having an infarct. In other cases, with even a lesser infarct, death may come suddenly.

I am not prepared to state very much on the treatment. I don't know very much about it. Dr. Carpenter stressed the importance of this. I don't believe there is anything hardly in which it is more important for the physician to give very close supervision of his patients, even after they recover from this acute condition, than in these infarcts of the heart. The taking on of physical activity and checking up constantly of the heart action during the period of graduated exercises are things of very great importance.

I am sure Dr. Carpenter recognizes that, but he didn't mention it in his paper. (Applause).

Dr. Macon resumed the chair.

Chairman Macon: I will ask Dr. Carpenter to close the discussion. Dr. C. C. Carpenter, Wake Forest: Mr. Chairman, I have nothing of very great value to add. I want to thank Dr. Bullitt for his discussion. It was not my idea in making a special study of myocardial lesions to lean over backward. I realize the importance of valvular lesions, but I do feel that myocardial lesions require a more careful study. In recent years it seems to me that we have a satisfactory control of infectious diseases. However, we have not started to control degenerative changes. Of course, we were held up because we didn't know how to go about it. I would agree with Dr. Bullitt very heartily that the supervision of the

48 THE MEDICAL SOCIETY OF

14	13	14
34	33	27
23	25	21
31	32	32
12	18	22
14	12	13
12	12	12
12	11	12
6	12	9
25	25	24
1	4	3
1	5	6

14	13	14
34	33	27
23	25	21
31	32	32
12	18	22
14	12	13
12	12	12
12	11	12
6	12	9
25	25	24
1	4	3
1	5	6

14	13	14
34	33	27
23	25	21
31	32	32
12	18	22
14	12	13
12	12	12
12	11	12
6	12	9
25	25	24
1	4	3
1	5	6