COLLECTED REPRINTS 
OF 
MEDICAL COMMUNICATIONS 
BY 
WILLIAM SYDNEY THAYER. M. D. 
SERIES IV. 1911-1920 
BALTIMORE, MD. 
19 2 1 CONTENTS 
CV1. Address to the Nurses. Graduation Exercises of the Johns; 
Hopkins Hospital School, May 25, 1911. 
Johns Hopkins Hosp. Nurses Alumnae Mag., 1911, x, 65-77. 
CVH. President's Address, Eighth Ann. Meeting of the Am. Soc. 
Trop. M., N. Ori., May 18-19, 1911. 
South M. J., Birmingham, 1911, iv, 457-461 ; also N. Ori. 
M. and S. J., 1911-12, Ixiv, 69-79. 
CVIH. Observations on Sepsis and Antisepsis in (Medicine. 
Kentucky M. J., Bowling Green, 1911, ix, 697-705; also 
Johns Hopkins JJosp. Bull., Balt., 1912, xxiii, 16-22. 
C1X. Ameboid Movements in Macrocytes and Megaloblasts. 
JZogcr S. Morris, M. D., St. Louis, and William S. Thayer, 
M. D., Balt. Arch. Int. Med., Chicago, 1911, viii, 581-590. 
CX. Instances of Bradycardia. 
Tr. Ass. Am. Physicians, Phila., 1911, xxvi, 166-168. 
CXI. On Malarial Fever with Special Reference to Prophylaxis. 
Harvey Lectures, Series 1911-1912. 
CXI I. Some Questions Concerning Medical Education. 
Ohio M. J., Columbus, 1913, ix^ 1-9. 
CXIH. On Some Functions of the Free Dispensary. 
Boston M. and S. J., 1913, clxviii, 185-188. 
CXIV. Discussion by W. S. Thayer, M. D., following the reading 
of a paper entitled: "On the Study of Renal Function; 
the Prognostic Value of Studies of Renal Function,'' by 
L G. Rowntree. 
Tr. Cong. Am. Phys, and Surg., N. Haven, 1913, ix, 47-50. 
CXV. Integer Vitae Scelerisque Purus. In Memoriam: Eugene F. 
Cordell. 
Hosp. Bull. Univ. Maryland, Balt., 1913, ix, 146. 
CXVI. In Memoriam: Reginald Heber Fitz. 
Johns Hopkins Hosp. Bull., Balt., 1914, xxv, 87. 
CXVII. In Memoriam. Two iMen: George Alexander Gibson; 
Hugh Angus Stewart. 
Johns Hopkins Hosp. Bull., Balt., 1914, xxv, 89. CXVIII. In Memoriam: Rupert Norton, 1867-1914. 
Johns Hopkins Hosp. Bull., Balt., 1914, o-.rz/, 242-243. 
CXIX. John Shaw Billings. 
Johns Hopkins Hosp. Bull., Balt., 1914, xxv, 249. 
CXX. A Comparison of the Results of the Phenolsulphoneph- 
thalein Test of Renal Function. 
William S. Thayer, M. D., Balt., and Roy R. Snowden, 
M. D., Pittsburgh, Am. J. M. Sc., 1914, cxlviii, 781. 
CXXI. Remarks by William S. Thayer on the Occasion of the 
Presentation of the Crayon Portrait of Sir William 
Osler by Sargent. 
Johns Hopkins Hosp. Bull., Balt., 1914, xxv, 369. 
CXXII. Remarks by L. F. Barker and W. S. Thayer on the Dedi- 
cation of the Medallion to the Memory of Dr. John 
Hewetson. 
Johns Hopkins Hosp. Bull., Balt., 1914, xxv, 371. 
CXXIII. On the Importance of Fundamental Methods of Physical 
Examination in the Practice of Medicine. 
South. M. J., Nashville, 1914, vii 933-942. 
CXXIV. Remarks on Dr. Chew, the Physician. 
Hosp. Bull. Univ. Maryland, Balt., 1914, x, 170-171. 
CXXV. Reflections on Modern Methods of Treatment by Sera and 
Vaccines. 
J. Florida M. Ass., Jacksonville, 1915, ii, 97-111. 
CXXVI. Adams Stokes Syndrome-Persistent Bradycardia Involv- 
ing both Auricles and Ventricles. Remarkable Prolon- 
gation of the As-Vs Interval. 
Arch. Int. Med., Chicago, 1916, xvii, 13-24. 
CXXVII. Remarks at Memorial Meeting to Dr. E. L. Trudeau. 
Johns Hopkins Hosp. Bull., Balt., 1916, xxvii, 107. 
CXXVIII. Teaching and Practice. 
Science, Lancaster, Pa., 1916, n. s., xliii, 691-705. 
CXXIX. Observations on the Teaching of Tuberculosis. 
Nat. Ass. Study and Prcv. Tuberc. Tr., 1916, xii, 92-108. 
CXXX. Presentation of the Medallion Portrait of Dr. Rupert 
Norton. 
Johns Hopkins Hosp. Bull., Balt., 1917, xxviii, 229-230. 
CXXXI. Scholarship in Medicine. 
Boston M. and S. J., 1917, clxxvi, 519-524. CXXX1I. Observations on Some of the Commoner Deviations from 
the Ordinary Met with in the Examinations of the Heart 
of Supposedly Normal Individuals. 
Med. Rec., N. Y., 1917, xci, 617-623. 
CXXXIII. The Management of the Early Stages of Hypertensive 
Cardio-vascular Disease. 
South M. J., Birmingham, 1917, .r, 367-377. 
CXXXIV. Osler, the Teacher. 
Johns Hopkins Hosp. Bull., Balt., 1919, xxx, 198-200. 
CXXXV. Introduction to the Preliminary Course in Physical 
Diagnosis. 
South M. J., Birmingham, 1919, xii, 374-381. 
CXXXVI. Laennec-One Hundred Years After. 
Canad. M. Ass. J., 1919, ix, 769-782. 
CXXXVII. Nursing and the Art of Medicine. 
Am. J. Nursing, Phila., 1919, xix, 187-192. 
CXXXVIII. The Medical Aspects of Reconstruction. 
Am. J. M. Sc., Phila., 1919, clviii, 765-773; also Tr. Cong. 
Am. Phys. and Surg., N. Haven, 1920, cxv. 
CXXXIX. Osler. 
The Nation, January 24, 1920; also with additions Bull. 
Med. Chi. Pac. Md., 1920, xii, 72-7^. 
CXL. Introduction. 
Nelson Loose-Leaf Medicine, Vol. I, July, 1920, 3-5. 
CXLL On Some Unpublished Letters of Laennec. 
Johns Hopkins Hosp. Bull., Balt., 1920, xxxi, 358. [Reprinted from The Johns Hopkins Nurses Ahimner Magazine, June, 191l.j 
ADDRESS TO THE NURSES 
Graduation Exercises of the 
Johns Hopkins Hospital Training School, 
May 25, 1911, 
BY 
William Sydney Thayer, M. D. 
THE opportunity to say a word to the graduating class today 
on the occasion when the Training School may be said to 
have attained its majority,-for this, if I mistake not, is the 
twenty-first class to graduate,-is peculiarly agreeable to one 
who can say that he has known as a pupil nurse everyone who 
has graduated from this school. Indeed, it seems but yesterday 
that Miss Nutting was a pupil nurse! How many changes 
have occurred since that time! Twenty years ago, this was a 
rather small community. In the training school there were 
but two classes, in all, about forty nurses. The nurses' home 
consisted of the three lower floors of the present main building. 
The annex, as you know it, was given over to the house maids. 
There were rarely more than two or three special nurses on 
duty at one time. The private wards, of two floors only, 
were rarely or never filled. " B " was occupied wholly by 
gynecological patients. The large middle room on the second 
floor was then Dr. Kelly's operating room. 11 C " was a 
combined male and female medical and surgical ward. The 
colored wards were not yet planned, and the negroes were 
cared for in the small rooms now used for isolation at the 
back of the open wards. What is now the Maternity ward 
was part of a large isolating pavillion, to which used to be 
admitted the occasional cases of contagious disease which pre- 
sented themselves at the Dispensary, in addition to those which 
happened to break out in the house. 66 
THE JOHNS HOPKINS NURSES 
The Surgical building did not exist, the operating room 
occupying what is now a part of the Surgical Out-patient 
department. The pathological laboratory consisted of two 
floors only. The Clinical laboratories were not built, and the 
Phipps' Institute was a stable occupied by an hypothetical 
ambulance. There was no medical school. With a few post- 
graduate students, Dr. Osler or Dr. Lafleur used to go through 
all the wards every morning. The training school in those 
days was a small affair, so far as numbers were concerned, 
but Miss Hampton was then the Superintendent of Nurses, 
and was already infusing into her assistants and pupils the 
admirable ideals which have continued to actuate her successors 
and have contributed so largely to the development of this 
institution. 
Mrs. Robb's great service to the d'raining School and to nurs- 
ing in general was, it has always seemed to me, her consistent 
upholding of the thesis that nursing, like every other art, could 
be practiced better by the well educated and carefully trained. 
Miss Hampton, and afterwards, Miss Nutting, always insisted 
that one could not attempt to teach a nurse too much,-that 
an elementary course of instruction in anatomy and in physi- 
ology and the general principles of pathology in its broadest 
sense, with explanatory lectures by the members of the Hospital 
staff were of invaluable assistance to the nurse in the satis- 
factory discharge of her duties. The nurse should, so far as 
possible, comprehend and understand the significance of the 
various measures in which she is required to co-operate. With 
these ideals, the effort of the directors of this Institution has 
always been to demand somewhat higher educational qualifica- 
tions for admission to the school, and to offer to the nurse 
a somewhat broader general instruction than in most other 
Training schools. The value,-indeed the necessity,-of more 
experience than a two years course could offer for the develop- 
ment of a nurse of a character equal to that aimed at by the 
Superintendent of this School, led soon to the adoption of a 
compulsory three years course. The pursuit of these ideals ALUMNAS MAGAZINE. 
67 
by this and other institutions has called forth a good deal 
of criticism. Men and women in positions of considerable 
importance have taken the ground that this was an attempt 
to overeducate the nurse; that this overeducation was a dis- 
advantage and a danger in various ways. Their main objec- 
tions are the following: 
1.-In the first place, the elevation of standards of admission, 
tends, they say, to keep out of the profession worthy women 
who may have exceptional aptitude for nursing. 
2.-By teaching the nurse too much about medical subjects, 
-knowledge which must of course be elementary-there is, it 
is believed, grave danger that she may be filled with the 
idea that she knows far more than she really does,-that she 
may be led, as the result of this fancied superior knowledge, 
to assume duties and responsibilities not properly her own,- 
that she may be prompted to presume to suggest and to meddle. 
A good deal has indeed been written on this subject, and 
this is an exceedingly welcome opportunity to the speaker to 
say that he has little sympathy with those who object to 
high standards of admission to training schools, and to the 
three years course, and distress themselves with the fear that 
the nurse may thereby be injured through over-instruction. 
With regard to the standards of admission,-no one of 
the several superintendents of this school would probably deny 
the great importance in the equipment of the nurse played 
by the natural aptitude of the individual. We all know what 
this means in the case of the lawyer, the physician, the clergy- 
man. There are lawyers, doctors and clergymen who are sadly 
lacking in early education,-indeed in the special education 
which fits them for their calling,-whose natural abilities and 
aptitude have, however, made of them successful and useful men. 
There are many nurses with insufficient early education and de- 
ficient training who are yet admirable nurses in many respects, 
but it should be remembered that there are duties, and very 
important duties which a woman of this class cannot fill as she 
should. Of many positions, it is true that a well trained, intel- 68 
THE JOHNS HOPKINS NURSES 
ligent and conscientious maid may fill all the demands. To 
carry out exactly routine orders, to acquire the practical tech- 
nique of nursing, does not require any particular breadth of 
education,-and these are very important parts of the func- 
tions of the nurse. We all, I am sure, know many excellent 
and useful women whose abilities and attainments qualify 
them for little more than this sort of work. 
If, however, you ask the physician who has had the good 
fortune to be thrown with nurses who are also educated and 
refined women, the reasons for which he selects the nurse 
who is to take care of his patient, he will tell you that in 
a very large proportion of cases the considerations which 
govern this selection have to do with the personal influence 
which the nurse may exert upon the patient and with her powers 
of observation, judgment and discrimination. To interest, to 
encourage, to stimulate the weary and despondent, to distract 
the selfcentered mind and tactfully to turn it into proper 
channels, to suggest healthy and wholesome thoughts to the 
disillusionized and depressed; to fill the sickroom with an all- 
pervading but unobtrusive atmosphere of optimism, these 
duties, among the most delicate and grave that fall to the 
nurse, demand a woman of refinement, of delicacy, of resource, 
of real elevation of character,-a woman who can interest her 
patient in and attract her to herself, who can, by her own 
example and through the admiration and affection which she 
inspires, lift the invalid out of the valley in which she is 
wandering and start her on the upward path. The good that 
such a woman can do is incalculable, but an influence of this 
nature can be exerted only by one who possesses those refine- 
ments of character and manner and speech, which allow her 
to approach and gain the confidence of the patient,-qualities 
which depend largely on her fundamental education. But to 
have had a good general education, and to be well trained in 
the practical technique of nursing is not enough. A nurse 
should be an exceptionally intelligent, comprehending and 
exact observer. It is she, alone, who is continually at the ALUMNA MAGAZINE. 
69 
patient's side; it is she upon whom the physician should be 
able to depend for information upon the thousand little points 
which might and would in all probability, escape the less 
educated eye of the untrained attendant. 
Time and time again, the early detection of the slight, 
almost imperceptible changes in the condition of the sufferer 
from typhoid fever may lead to the discovery of the perforation, 
and save the life of the patient. 
On the other hand, it is to the nurse that the alarmed family 
turns for reassurance in the oft-recurring spasms of needless 
anxiety and fear. 
Properly to discharge such duties, the nurse must be at the 
outset, a woman of more than ordinary ability and alertness, 
with superior powers of comprehension and judgment, a woman 
who is able to weigh and digest her experience, who is capable 
of determining the relative importance of symptoms,-who is 
able to bear responsibility. Such women only, are able to 
gather the full benefit from the careful training and experience 
of three years in a school such as that through which you 
have passed. 
Few who have been associated with women of this class, 
who have had these advantages can fail to recognize their 
superiority. The danger that such a nurse develop into an 
all-knowing and presuming and meddling individual, is a 
theoretical rather than a real danger. The speaker has had 
a reasonably wide experience with nurses who have had a 
training of various different sorts, and he has yet to find that 
the nurse responds to wider education and higher training in 
a manner in any way different from that of the rest of mankind. 
In every profession, in every sphere of life, there are those, 
like the old Oxford Don, whose foible is omniscience, but it 
is far rarer to find this fault among the better educated than 
it is among the more illiterate. The more men and women 
really know, the more modest they are, as a rule. If you 
look among the medical profession for those individuals who 
are the most self-satisfied and the most presumptuous, you 70 
THE JOHNS HOPKINS NURSES 
will generally find them among the good fellows whose friends 
tell you with awe: " is a most wonderful man, he gradu- 
ated from this, that or the other school in one year." 1 hese 
are the men who know it all, and so it is with nurses. I he 
woman most apt to meddle, most prone to be over-sensitive, 
most likely to be sure that her way is the only way, is the 
woman who has had the least opportunity and the most limited 
experience. That despite the lack of education and training, 
some women are yet capable of developing into successful and 
useful nurses, is no argument against aiming at higher and 
better standards. 
That you are graduates of an institution which has been 
one of the foremost in upholding these ideals, places upon 
you a special responsibility. You should leave this school 
with a sense of superior knowledge, only in the sense that 
you are very conscious of how little you really do know. 
You ought, through the very fact that you have had a three 
years training and that you have had a good deal of work 
with private patients, to realize that there are many other 
physicians in this world as good or better than those with 
which you have been associated; that there may be various 
ways of accomplishing the same end, some of which you will 
have to learn. You ought, already to have come to realize 
that the vast majority of physicians are earnest, faithful men, 
who have but one aim in view and that is the relief of the 
patient, and you should appreciate that this end is to be 
reached only by a loyal co-operation with the physician, even 
though, at the moment, you cannot see the end of the road. 
You will soon find that there are many valuable things 
to learn from outside men and outside nurses, of which you 
may never have heard in the course of your training, and 
you ought to know that the worst turn you can serve your 
school is to vaunt unduly the methods of procedure which you 
you have learned here. If you feel that you have missionary 
work to do, it is much safer to do it by practice than by 
precept. ALUMNA MAGAZINE. 
71 
There is one thing upon which I would especially insist, 
and that is, that you remember that in your nursing you are 
dealing with human beings and not with automatons. There 
are rules which you have learned for giving a pack or a sponge 
bath, for taking a temperature or making a bed, but there 
are no rules which you can learn for doing that to which 
I have already referred as one of the most important parts 
of your work, namely, that of gaining the confidence and the 
affection of your patient, of infusing into him self-reliance 
and courage and optimism. This side of your work is filled 
with difficulties, for we human beings are often very perverse 
and childish,-more than ever when we are ill. You may not 
fancy your patient. Alas, too often he is a most unlovable 
character! But you must not show it, and you must realize 
that if you do your duty quietly nothing that he can do can 
really hurt you. You must remember, moreover, that he may 
not like you, and if he does not like you he does not have 
to bear it. He can, and often under these circumstances, he 
ought to change his nurse, just as under similar circumstances, 
he ought to change his doctor. The best or wisest physicians 
or nurses cannot possibly do justice to the patient who dislikes 
and distrusts them. If such a patient discharge you,-and 
you are perfectly sure to have these experiences,-hold your 
peace and thank your stars that you have escaped the worry 
and care which would surely have followed had you been 
obliged to continue on duty. It may be disappointing, but 
if you have done your duty, it is not your fault and you. 
will not suffer. You must remember that you are dealing 
with ill and abnormal individuals, whose families are often 
under a mental strain which leads them into actions and words 
strangely perverse and unaccountable. No argument, no 
reason, sometimes, can eradicate from such individuals a pre- 
judice which you and others may know to be utterly without 
foundation. Under such circumstances you may be subjected 
to criticism, not only private, but public; you may indeed, be 
the subject of real persecution. The nurse who has, through 72 
THE JOHNS HOPKINS NURSES 
some such prejudice or misapprehension, been discharged from 
a casq and subjected to unjust and cruel misrepresentation, 
feels sometimes, as if her career were broken, but it is not so. 
If she has done her duty and held her peace, the words of the 
persecutor will often do her more good than harm. She will 
not be misunderstood by those who know her, and her dignity 
and restraint will only commend her to a larger circle 
and increase, in the end, her sphere of usefulness. Meet the 
assaults of prejudice and pettiness with silence and pity, never 
with resentment. To show resentment places you on a level 
with your persecutor. 
Old Cotton Mather, in a book published one hundred and 
ninety years ago, gave like advice to some candidates for the 
ministry in language more forceful and far more picturesque 
than that which flows from the pen,-or rather, falls from the 
typewriter of the twentieth century: 
44 If Calumnious Quills have publickly scratched you,-An 
Respondendum semper Calumniis?-No. Look as far back as 
Two Thousand years ago and you will even find a Plato 
giving a Pattern to a Christian, in his declining to take any 
Notice of the Invectives which a Xenophon had used upon 
him.-It may be, the Scribblers, are sorry Scoundrels, and such 
vile Children of Sheth, as it is beneath you to let them know 
that you have so much as read their Follies,-Or be they 
what they will, for the most part, the best way will be to, 
Shine on, Regardless of what the Batts and Owls may mutter 
against you. Or, if that Metaphor be too Sublime, let me say, 
at least, As the Moon among the lesser Fires, keep a steddy 
Pace, Walking in your brightness, notwithstanding the unre- 
gardable flvllatrations of your Adversaries. ... 44 That what 
I am driving may stick, you shall have it in the Form of 
two old Rusty Nails; The One, Magnum Contumeliae Reme- 
dium Negligentia; the other, Site, et funestam dedisti Plaganu" 
If you feel a lack of confidence in the attitude of the 
family, tell the physician, and let him know that you are 
willing to give up the case if he wants you so to do. If ALUMNAE MAGAZINE. 
73 
you honestly feel that another could do better than you, let 
the physician know it. You may, however,-it is very likely 
you will have to stay, continuing your work despite these 
feelings. 
On the other hand, by forbearance and tact and charity, 
and by the ability to see the humorous side of the situation, 
which so often exists, you can, time and again, gain the con- 
fidence of the most unpromising patient, and the most dis- 
trustful family, and you may find that not only for the moment, 
but perhaps for years, your sound sense, your courage and 
your optimism, may turn the scales on which balance the 
fortunes of that family. 
It is, however, not only in your connection with patient 
and family that these questions of human relations affect the 
trained nurse. Even in her private functions, the nurse is 
often called upon to direct, to manage, to assume responsi- 
bilities of very considerable importance. Outside of this, how- 
ever, the trained nurse today is often placed in public positions 
of serious responsibility. In connection with her work as a 
teacher of nursing, her duties are often very largely adminis- 
trative. Many nurses occupy positions of great executive res- 
ponsibility, in connections with hospitals, public institutions, 
government service,-national, state and city-institutions of 
learning. And you will perhaps forgive me if I repeat to you 
in this connection, that in all these positions your ability to 
understand, to bear with, to tolerate your seemingly unreason- 
able associates will influence your success in a very material 
manner. 
Tn institutional work, for example, it is all important for 
the nurse to remember that her duties are co-operative and that 
a hospital or a training school in which the constituent staffs 
are at odds cannot prosper. 
We are all familiar with able men and women whose use- 
fulness is hopelessly hampered by that over-sensitiveness which 
is ever leading them to misunderstand or suspect the motives 
of their associates. Misunderstandings inevitably arise from 74 
THE JOHNS HOPKINS NURSES 
time to time, between medical and nursing staffs. If, however, 
you are tactful and tolerant and conciliatory and above all, 
charitable, and if you see to it that your position is clearly 
understood, you will, as a rule, have little difficulty in gaining 
the confidence and support of the authorities of the institution. 
The commonest causes of misunderstandings between hospital 
physicians and nurses are impatience, over-sensitiveness and 
secretiveness. If one is willing to be open and frank, to try 
to find out the reason why before allowing the interest of 
resentment to accumulate, much trouble may be avoided. The 
success of the trained nurse in many of the important public 
duties to which she may be called depends very largely on 
her ability to deal tactfully and openly with her fellow. You 
cannot succeed if you start with an attitude of distrust, sus- 
picion or of reticence. If, however, you realize what is the 
truth, that most politicians and public servants are good men 
who want to do their best, if you will deal with them openly 
and patiently and frankly, you will find that though your 
lights may be different, their ideals and ambitions and yours 
are very much the same, and you will secure their ready 
support and co-operation. 
One more bit of advice you will perhaps forgive me. You 
have spent three years under a rather strict regime;-it has 
been a matter of obeying orders almost in a military fashion. 
You are now going to find yourself more or less independent. 
Alas!-'tis but a very relative independence! You will find 
that most of the rules of life and conduct under which you 
have been living and against which you have perhaps been 
tempted at times to rebel, will govern you just as rigidly as they 
have in your days as a pupil nurse. For you will, by this time, 
have appreciated that the object of these rules is to preserve 
those standards of character and efficiency, to inculcate into 
the pupil nurse those ethical principles which you like to 
think distinguish the graduates of this school. You will, there- 
fore, feel doubly bound to continue in the path along which 
you have been led because you will realize that the good name ALUMNAE MAGAZINE. 
75 
and the reputation of the institution depend on the example 
set by you its graduates. From the very nature of your 
profession and your position you will find yourself always 
closely tied to your old school and hospital, in that the cri- 
ticisms called forth by any indiscretion, any mistake that you 
may make, is often enough rather of the school or of the 
hospital than of yourself. It is after all, not so much you 
who are criticised and judged as the " Johns Hopkins Nurse." 
The woman who is lax in her practical technique, indiscreet 
or uncharitable with her tongue or careless of those many little 
details of niceness and precision upon which success in all 
her professional relations so largely depends,-details, which, 
during your training have been insisted upon until you are 
really very tired of hearing of them,-this woman is bringing 
her school directly into disrepute. 
Do what you will, hereafter you will be to a large proportion 
of your patients not so much " Miss " as a " Johns 
Hopkins Nurse," and this, you should never forget. Happily 
or unhappily, the graduate of this school is expected by the 
public to be especially well qualified, and you should feel 
obliged to live up to the reputation which your forerunners 
have made. 
In going forth, as you are now, into your different careers, 
I doubt very much whether most of you realize how closely 
and with what interest and sympathy you will be followed 
by your old teachers and by the medical staff under which you 
have served. 
Some years ago, a friend occupying a teaching position in 
a large institution said to me: " I am inclined to think that it 
would be a great surprise to most students if they realized 
what an important position they occupied in the interest and 
thoughts and conversation of their instructors,"-an observation 
which is perfectly true. It is hardly likely that any of you 
know how real and personal an interest all of us will take 
in your future course and progress,-how glad we shall be 
to have you come back and work in our midst, what pride 76 
THE JOHNS HOPKINS NURSES 
we shall take in your successes elsewhere, and what a personal 
sense of disappointment we shall feel in your possible mis- 
fortunes or mistakes. 
There is another great duty, a true public service, which 
falls upon the nurse as well as the physician. You have been 
trained in precise methods of medical and surgical prophylaxis. 
This technique, in so far as it is applied to the surgical opera- 
tion you will find comparatively easy to carry out in private 
as well as in hospital cases. 
This, however, is by no means true with regard to the 
medical case. It will not be so easy for you to enforce, in 
your care of the patient, with regard to the bedclothes, the 
eating utensils, the excreta,-those rules necessary to protect 
the rest of the household in cases of tuberculosis, typhoid fever, 
dysentery or pneumonia. In order to take the proper measures, 
you may need the permission and assistance of the physician 
in charge, and this must be sought with tact and discretion. 
In most cases, you will have little difficulty in securing his 
full co-operation. 
In any case, by adhering to the rules of medical prophylaxis 
just so closely as you would to the methods of asepsis and 
antisepsis in prepartion for a surgical operation, you will go 
far toward teaching the family, and through them the public 
at large, the manner of the spread of contagious disease and 
the steps which they should take to protect their friends and 
the general community. 
Remember that while a slip in your surgical technique may 
involve one human life, a slip in your medical antisepsis in 
typhoid fever for instance, may result in a wide-spread epi- 
demic, with all its dreadful consequences. 
And now in conclusion, I would say to you as I have said 
on another occasion with regard to the physician,-that one of 
the most important of your duties is the duty of optimism. 
Thrown as you are among your fellows of all sorts and kinds, 
in positions in which you find yourself of necessity a confi- 
dante; you will gain a knowledge of human nature which ALUMNAE MAGAZINE. 
77 
could scarcely come to you in any other way. This, after all, 
is the great privilege of the life of the physician and of the 
nurse. You will gain a wide familiarity with human weak- 
nesses, but you will find that the human being, after all, is a 
rather lovable animal, and that often enough obvious defects 
are compensated by rare larval virtues. 
If this life and this experience do not fill you with a broader 
charity, a truer love of your fellow man, and a more confirmed 
optimism, you should seek another profession. But whatever 
your course in life may be, all of you can hardly fail to feel 
that the training and experience through which you have 
passed during these three years have made of you, broader, 
freer, happier, better women. REPRINT FROM 
THE SOUTHERN MEDICAL JOURNAL 
JULY, 1911, PAGES 457-461 
PRESIDENT'S ADDRESS, DELIVERED AT THE EIGHTH ANNUAL MEETING 
OF THE AMERICAN SOCIETY OF TROPICAL MEDICINE, 
NEW ORLEANS, MAY 18 AND 19, I9H 
By DR. WILLIAM SYDNEY THAYER, 
Baltimore, Md 
With the territorial expansion brought upon 
our country by the events of 1898, the neces- 
sity for a more general knowledge of those 
diseases which prevail in tropical climates 
became evident, and with the necessity for 
such knowledge came greatly increased oppor- 
tunities for study and the obligation that those 
opportunities should not be neglected. What 
has been done by American students since this 
time is known to all. 
The noble work of Reed,'Lazear, Carroll, 
Agramonte and Leonard Wood-I say Leon- 
ard Wood, because it was his wisdom and 
generosity that rendered this work possible- 
the extraordinary results accomplished by 
Gorgas, in the prophylaxis against yellow 
fever, malaria and plague at Havana and in 
the Canal Zone; the successful prophylaxis 
against the spread of cholera, plague and beri- 
beri in the Philippines-these are accomplish- 
ments to which we point with just pride. 
With a recognition of the work which was 
to be done, and of the advantages to be gained 
by bringing together students in this especial 
field of medicine, and by encouraging the 
study of tropical disease at home and abroad, 
a small group of men in Philadelphia, seven 
years ago, conceived the idea of founding 
a Society of Tropical Medicine. 
The object of this society, as set forth in 
the constitution, was "to advance the knowl- 
edge of tropical diseases by encouraging origi- 
nal research by its members and others; col- 
lecting and recording facts ascertained by 
such researches, and disseminating informa- 
tion thereof by discussion among its mem- 
bers, and by the publication of papers read be- 
fore the society." 
This society was conceived at first as a 
purely local organization, but the founders 
soon realized that its functions were properly 
national, and so it has become a truly national 
body. 
In the eight years past there have been 
held seven meetings at which papers of in- 
terest and value have been read and many 
excellent discussions have been held. The 
society might, however, take a more active 
part in the discussion of matters of immediate 
public importance, and should occupy a more 
prominent position among the special medical 
societies of this country. It should, for in- 
stance, be one of the constituents of the Con- 
gress of American Physicians and Surgeons. 
This should and does bring before us the 
question of what the proper functions of this 
organization should be; as to whether there 
may not be public or other duties which we 
might fulfil to the more general advantage 
of all; as to whether our constitution and 
conditions of membership are such as best to 
further those interests for the benefit of 
which this society was founded. 
The first function of such a society as this 
should be, it would seem, to gather together 
at its meetings those men who are doing active 
work in the study of the pathology, prophy- 
laxis and therapy of those diseases which 
occur, or may occur, in our tropical posses- 
sions, and in the southern part of our coun- 
try, and are, or may become a menace to the 
health of our people abroad and at home. SOUTHERN MEDICAL JOURNAL 
In addition to these active workers in trop- 
ical disease, it would be well that this organi- 
zation should include others whose positions 
may prevent them from becoming immediate 
contributors to our knowledge on this subject, 
but whose attainments or interests are such 
that their opinion and counsel might con- 
tribute to progress in this branch of study. 
The second important function of a society 
of Tropical Medicine should be its public and 
educational influence. This association ought 
to bring before the public, medical and lay, 
those prophylactic measures against the 
spread of various grave epidemic diseases with 
which we are constantly menaced. Our voice 
should actively be raised, not only in warning 
but in the proposition and explanation before 
the American Medical Association and 
through this, before State, county and muni- 
cipal authorities, of practical protective meas- 
ures. 
The first question which we might profitably 
consider, relates, it seems to your President, 
to the matter of membership. There are at 
present upwards of one hundred and twenty- 
five members of the Society of Tropical Medi- 
cine. The membership is limited to two hun- 
dred. This is a large society, but no larger, 
it seems to me, than is justified by the nature 
of the organization. 
The qualifications for membership have, in 
the past, been few, little beyond an interest in 
tropical medicine, and a good general standing 
in the profession. 
Many of our members and officers have 
been men who, while rqanifesting a deep in- 
terest in the objects of the society, have yet 
contributed little to the subject themselves. 
Your present President regrets that for some 
years his contributions to this branch of med- 
ical study have been exceedingly small. He 
is inclined to believe, nay, he is sure, that 
some of those who have done most valuable 
work on subjects pertaining to Tropical Med- 
icine, whose cooperation we need most urgent- 
ly, have tended to hold aloof from this Asso- 
ciation, because they have felt that it was 
rather a local society composed of members 
from the Eastern cities, than a representa- 
tive national organization, and I must say, 
from their standpoint, that of one looking on 
from without, and ignorant of the truly dis- 
interested motives of those who founded the 
body-from this standpoint, I say, there has 
been some justification for such a sentiment. 
They know, for instance, that the require- 
ments for admission to many, indeed most of 
the special societies are such that only those 
who have devoted themselves to the study 
of the problems which occupy the association, 
and have published original contributions of 
real value, are eligible for membership; they 
know that, even then, the special qualifica- 
tions of each individual proposed are carefully 
considered by the council before his name is 
presented to the society. This results in the 
practical limitation of membership to such 
men as are truly active students. 
Again, in some associations, in order that 
the limited membership may not be overbur- 
dened by non-productive associates, rules are 
made which permit: 
i. The placing upon the honorary list of 
those whose membership has lasted for more 
than a certain number of years, and 
2. The dropping from the list of member- 
ship of such persons as shall have been absent 
from say three consecutive meetings of the 
society, without proper excuse, or who shall 
have failed to produce a piece of medical 
research within a given period of years. 
Is it true that some such measures are nec- 
essary and essential for the preservation of an 
active special society? Are there not advan- 
tages in having the society open to all ? Look, 
for instance, at that which is accomplished 
yearly in the various sections of the Ameri- 
can Medical Association. Is this work not, 
after all, as good as that accomplished by any 
of the special societies? What, then, is the 
field for a special society? This is a problem 
which might well admit of discussion were 
it a question of founding a new society. What 
admirable work is done in the special sec- 
tions of the American Medical Association 
is known to all. But this is not a new THAYER: PRESIDENT'S ADDRESS. 
society, and the remarkable quality of the 
papers and discussions at the meetings of the 
American Medical Association have not been 
regarded as a sufficient reason for the aboli- 
tion of other special societies, such, for in- 
stance, as the American Neurological Society, 
the Association of American Physicians, the 
American Surgical Association or the Amer- 
ican Paediatric Society. These societies 
bring together annually, a limited number of 
special students. There are advantages, and 
great advantages, in an organization so large 
that it may include all who have a real interest 
in the subject to which its researches are de- 
voted. The American Medical Association, 
that true centre of all matters medical in this 
country, represents such an organization, and 
it is highly probable that the day will come 
when a special section of the American Medi- 
cal Association is devoted to the consideration 
of tropical diseases. But along with the work 
which we do in the American Medical Asso- 
ciation, many of us find valuable opportuni- 
ties for effort in the various special societies, 
where the active workers in each field are 
brought together in a quiet way and freed 
from the distractions of a large assembly. I 
believe that there are duties which a special 
society of limited membership is peculiarly 
fitted to undertake. Some of these functions 
which are distinctly of a public nature I shall 
touch upon later. 
The council, considering these questions 
at its annual meeting, concluded: 
1. That in the future they would present 
to the society as candidates for membership 
only such individuals as have published orig- 
inal work of real value in the field of tropical 
medicine, or who, through other special attain- 
ments or position, are peculiarly fitted to give 
valuable counsel to the organization. 
2. That every applicant for membership 
shall be proposed by two members neither 
of whom are officers of the society; each of 
these proposers shall write personal letters to 
the council, setting forth the special qualifica- 
tions of the individual proposed. With this 
proposal there shall he submitted to the coun- 
eil a full list of the contributions of the indi- 
vidual whose name is suggested, upon sub- 
jects allied to tropical medicine, with full 
titles and references to the year, volume and 
page of the publication in which they have 
appeared, together with reprints of each arti- 
cle whenever possible. All proposals for mem- 
bership shall be made at the annual meeting. 
So soon as possible after the annual meeting 
a complete list of those nominated for mem- 
bership are to be sent to each member of 
the society. 
3. That a stated meeting of the council 
shall be held on the evening before the annua, 
meeting of the society. At this meeting the 
names and qualifications of those individuals 
proposed for membership shall be discussed 
and a selection made of those who shall be 
submitted to the society. At the same time the 
names of nominees for the various offices in 
the society shall be prepared. 
A grave difficulty in connection with the 
selection of the officers for this society lies in 
the fact that many of the most valuable mem- 
bers are stationed at distant points, and are 
therefore unable to attend meetings of the 
council. The majority of members of the 
Association of American Physicians, for' in- 
stance, cofne from large centres of the East 
or Middle West, and can easily be brought 
together. Some of these difficulties might be 
remedied by fixing the annual meeting at a 
time when it may be especially easy to bring 
the members together. Such a date would 
seem to be the day before the meeting of the 
Ameerican Medical Association, excepting, 
perhaps, on those dates when we may hope 
to gather with the Congress of American 
Physicians and Surgeons. If, in the future, 
a special section of tropical medicine should 
be organized in the American Medical Asso- 
ciation, we may then arrange our meeting at 
some other time. 
Your President believes that by the adop- 
tion of these or similar measures this society 
may be made more homogeneous, more repre- 
sentative and more useful. SOUTHERN MEDICAL JOURNAL 
The second great end which our organiza- 
tion ought to serve is a more definite public 
function. A body such as this association 
should be particularly fitted to educate and 
advise on matters of public health in its rela- 
tion to those special conditions in the study 
of which we are engaged. And what need 
there is for just such advice! In the few 
moments which remain I would suggest, as 
examples, but two problems with regard to 
which this body might render real public 
service. 
1. The first is the old but ever new ques- 
tion of the prophylaxis against malarial fever. 
When we look at what has been done in Italy, 
Suez, many points in India and Africa and in 
Panama, and then turn to the article of Dr. 
Howard in Ross's recent book upon the 
prophylaxis of malaria, we may well hide our 
heads for shame. There has been scarcely a 
single public measure taken in the most ma- 
larious districts of America to save the hun- 
dreds of lives which are being sacrificed yearly. 
We sit with folded hands and wait for some 
one else to take the initiative. Why should we 
not, as a body, appoint a committee to make 
a complete report as to those measures which 
might be most practical, and easy of adop- 
tion, in different parts of this country?-a 
report which might set the matter clearly be- 
fore government, city, county and town offi- 
cials. Such a report, setting forth defiinte 
advice as to measures which should be taken, 
with estimates as to the expenses and means, 
might be presented to the American Medical 
Association, and to its constituent branches, 
might be published in the newspapers, and 
might well bring about action in many re- 
gions. It would certainly help in the educa- 
tion of the public and in the saving of human 
lives. The committee should be small, con- 
sisting of no more than three members, all of 
whom should have had practical experience 
in the study and application of prophylactic 
measures against malaria. 
Perhaps in this way we may help to save 
some of the many lives lost yearly and the 
vast sums of money which are needlessly 
thrown away, largely through the lack of 
knowledge of our people. 
There is another question which we, as a 
people, ought to have very much in mind at 
the present time. I refer to the question as 
to what measures should be taken against the 
possible entrance and spread of bubonic 
plague. There are many reasons to fear that, 
at any time, this scourge which, at the present 
moment, is peculiarly widespread, might ap- 
pear amongst us on the Southern or Eastern 
coast. What an easy foothold plague might 
gain in some of our old, rat-infested cities 
is not hard to imagine. What was accom- 
plished in San Francisco and on the Pacific 
Coast largely under the lead of one of our 
members who is with us today, is well known 
to all. But when one thinks of the difficulties 
under which he and his associates worked at 
first-of the extremities to which private in- 
terest, blinding the eyes of those in power, 
lead a misguided public in a community so 
wide awake and progressive as San Francisco, 
one trembles to think what might happen un- 
der similar circumstances elsewhere. Ought 
we not, as a society, to endeavor to impress 
upon the public the dangers to which we are 
exposed and the measures of protection which 
we ought to take. 
I had hoped to be able to announce the ap- 
pointment of a committee to report next year, 
if possible, upon the subject of bubonic 
plague, but various unavoidable events have 
unfortunately delayed the arrangements. I 
hope most sincerely that some such body 
may later be constituted. 
There is another matter of public impor- 
tance which I would lay before the Society. 
In 1915 the Panama Canal, the construction of 
which was rendered possible by the work 
directed by our distinguished member and late 
President, Col. Gorgas, will formally be 
opened. At a recent meeting of the Medical 
and Chirurgical Faculty of Maryland a reso- 
lution was passed urging that a Congress of 
Tropical Medicine be held at the same time 
to celebrate the triumphs of preventive medi- 
cine which have made this great work possi- THAYER: PRESIDENT'S ADDRESS. 
ble. It would seem to be our special duty to 
take the initial steps in this matter. The sug- 
gestion seems most apt and most fitting, and 
your President would suggest that negotia- 
tions should immediately be undertaken with 
the authorities in charge of the Panama Expo- 
sition to ascertain whether such a Congress 
might not be made an important part of the 
official program. In order best to assure the 
most general and distinguished cooperation, 
the organization of such a congress should, 
if possible, be undertaken in connection with 
the International Society of Tropical Medi- 
cine, of which this body is a member. 
Nothing could be more fitting than such a 
gathering on such an occasion. 
And now the time has come to enter upon 
the excellent program which lies before us, 
but before we begin I would express a word 
of appreciation to the local committee for the 
admirable arrangements which have been 
made for this meeting. 
For a number of years it has seemed to 
some of us that a gathering of this Associa- 
tion in New Orleans might be of particular 
value. New Orleans, the metropolis of the 
midi, as our Gallic friends so happily call the 
South, is particularly interested in the objects 
of this Society. This city has furnished the 
country and the world with- an inspiring exam- 
ple of what can be done by honesty, alertness, 
courage and energy in stamping out a terrible 
epidemic, and in the program in which your 
local committee has so generously prepared 
for us, there is ample promise that the mem- 
bers of this Society will not regret that New 
Orleans was chosen as our meeting place to- 
day. 
But one disappointment mars the pleasme 
of the charming greeting which you have ac- 
corded us in New Orleans-and that is that 
we have, as yet, heard no announcement of a 
substantial bequest or donation to Tulane Uni- 
versity for the foundation and maintenance 
of a Department of Tropical Medicine. 
No greater service could be rendered to 
this city, this State or to our common coun- 
try than the fitting endowment of such a chair. 
One thing more. The extremely happy in- 
spiration of the Committee of Arrangements 
in suggesting the invitation of the members 
of the societies of this and neighboring States 
to attend this meeting should add greatly to 
the value of the gathering. 
The Society of Tropical Medicine welcomes 
you, gentlemen, most cordially-you should 
bring to us knowledge and experience in many 
of the matters in which we are especially in- 
terested. We appreciate your presence and 
we shall welcome your counsel. 
Soycz les bienvcnus! OBSERVATIONS ON SEPSIS AND ANTI- 
SEPSIS IN MEDICINE. 
By William Sydney Thayer, M. D., 
Professor of Clinical Medicine, The Johns Hopkins 
U niversity. [From The Johns Hopkins Hospital Bulletin, Vol. XXIII, No. 251, 
January, 1912.] 
OBSERVATIONS ON SEPSIS AND ANTI- 
SEPSIS IN MEDICINE.1 
By William Sydney Thayer, M. D., 
Professor of Clinical Medicine, The Johns Hopkins 
University. 
In answer to the cordial invitation to speak before you this 
evening, I am going to ask your indulgence for a few reflec- 
tions upon two phases of antisepsis in internal medicine. 
The thoughts that I am going to try to bring before you to- 
night, though by no means original, have, however, haunted me 
more and more during the last several years and seem worthy 
of expression. 
To one who is familiar with the history of medicine for 
the last fifty years, the transformation of surgery is a never 
ending source of satisfaction and of wonder. From the fun- 
damental ideas of Lister, the evolution of our modern knowl- 
edge of the nature and causes of wound infection and of the 
measures necessary to prevent it, has progressed rapidly until 
the art of surgery has reached the remarkable position which 
it occupies to-day. 
Twenty-five years ago, when I was a student, a surgical 
operation which involved the opening of a large joint or a 
serous cavity, was looked upon almost in the nature of an 
experiment. The critical " third day " was anxiously awaited. 
If that period were passed without fever, we drew a deep breath 
and felt that the main danger was over. How changed is all 
this to-day! 
[16] 
1 Address delivered before the Jefferson County Medical Society, 
March 30, 1911, and reprinted, with permission of the editor, T)r. 
A. T. McCormack, from the Kentucky Medical Journal, August 15, 
1911. 
1 [16] 
Time and again, twenty-five years ago, I have heard one of 
the most eminent of American surgeons say, in discussing 
some operative procedure: " If one be not careful, the first 
thing he knows he will find himself in the peritoneal cavity- 
fatal peritonitis! " Now that surgeon is opening the peritoneal 
cavity every day of his life with perfect assurance and with 
almost absolute safety. The dangers of infection are hardly 
considered. 'Tis only the question of the loss of blood, the con- 
dition of the heart and lungs and the effects of the long anaes- 
thetization-and operations, of the possibility of which one 
barely dreamed, are performed with perfect security every day. 
With these facts we are all familiar. There is however one 
phase in the development of modern surgery which has not 
received the attention that it would seem to deserve, and that 
is the change in the character of the surgeon himself. One 
used to think of the surgeon of the past as a courageous, manly 
fellow with a good knowledge of anatomy, a steady and clever 
hand, skilful in the setting of the limbs and the application of 
bandages-a technician-not especially a student. 
In many countries the surgeon used to be looked upon as be- 
longing to a class somewhat lower than that of the physician- 
one who used his hands rather than his head. Not long ago it 
was the physician who was the more careful student, who was 
rather more likely to attend to minutiae in the practice of his 
art. The surgeon was the strong, vigorous, highly trained 
technician who, when the physician said " go ahead," was not 
afraid to bear the immediate responsibility of what was often 
an hazardous undertaking. 
This relation does not, certainly, exist to-day. With the 
initiative of Lister, the surgeon has applied carefully, and con- 
scientiously, the teachings of the laboratory to the practice of 
his art. He soon learned that the antiseptics which were de- 
structive to the infectious agent were likewise injurious to the 
human organism; that the important question was not the 
application of antiseptics to the wound, but the prevention of 
the entrance of the infectious agent; not the treatment of the 
infection after it was present, but the prophylaxis against in- 
fection. 
Hand in hand with this knowledge, a great change came 
2 over the practice of surgery and over the surgeon. From the 
dashing operator of a generation or two ago, the surgeon has 
become a man highly trained in the most careful and minute 
laboratory methods of prophylaxis. Every step in his extensive 
preparations for an operation must be carried out with exact- 
ness. These methods, many of which he and his asso- 
ciates have elaborated themselves by study in the bacteri- 
ological laboratory, are absolutely necessary for the success and 
safety of the operation. If he neglects one point in his pre- 
cautions, the fatal infection may occur, and if it do occur, he 
feels that it must be his fault. Moreover, the public knows 
this, and the public, and, in some instances, the law, may hold 
him responsible. The average surgeon has become a very 
different man from his ancestor of fifty years ago. He is not 
only an exact and careful artist, but, far more than this, these 
habits and methods of work have led him into fields of research 
as a technician and as an investigator of which his forebears 
had little idea. Wherever the best surgery is done, other 
studies, not only in technique of the surgical art, but the path- 
ology and etiology of disease are almost always pursued, and 
the leading surgeon of to-day is commonly an eminent physi- 
ological and pathological investigator. 
Let us enter, for a moment, a modern surgical operating 
room: 
In the ante-room, the sterilizers and autoclaves for the pre- 
paration of all material and instruments to be used in con- 
nection with the work-the surgeon himself going through a 
long, deliberate and exact process in the mere cleaning of his 
hands; donning his rubber gloves; his freshly sterilized coat; 
the cap upon his head; the sterile gauze about his nose and 
mouth; the operating room and table, both of material such as 
can most easily be kept clean and aseptic. The patient is 
placed upon the table-the region about the point of operation 
thoroughly cleansed and sterilized and covered with sterile 
gauze and towels. The nurse and the assistants, all prepared 
with like care in their sterile garments; the on-lookers, obliged 
to keep at a proper distance themselves, but even they, wearing 
clean linen coats, those few who are to stand close to the sur- 
geon, clad as he, in a sterile gown, but perhaps without arm- 
[16] 
[171 
3 [17] 
holes, so that even the temptation to touch is frustrated; their 
mouths and noses covered with sterile gauze, caps upon their 
heads; the absolute, scrupulous cleanliness of everything. Then 
note the freedom and safety with which the surgeon explores 
the most vital parts I 
About the surgical operation of to-day there is a truly 
scientific exactness. Indeed, I am often moved to the reflection 
that we rarely feel the anxiety about any operation to-day that 
we used to feel about every operation when I was a house 
physician twenty-three years ago. All these preparations, all 
this experience, all these exact prophylactic methods are di- 
rected to save the life of the single individual patient on whom 
the surgeon is about to operate. 
We look at the great achievements of surgery with unusual 
satisfaction and pride. We are fascinated and bedazzled by 
their magnitude. But when the layman asks us internists what 
we can show him in our branch of the medical art which can 
compare with the progress of antiseptic surgery we, on our own 
side, are not slow in pointing to the immense progress which 
has been made in our knowledge of the nature and causes of 
infectious diseases; of what we have learned as to many of the 
internal secretions, and as to their relations to various forms of 
disease; of the application of his knowledge to the treatment 
of diphtheria, of cerebro-spinal meningitis, of tetanus, of 
myxoedema and cretinism; to the prophylaxis of cholera and 
plague. 
Is there anything more wonderful in surgery than our 
achievements in the prophylaxis against yellow fever? This 
progress is indeed wonderful and hopeful. Like the surgeon, 
we internists are giving ourselves to the careful study in 
laboratory and clinic of many pathological and etiological prob- 
lems. But is there not perhaps another phase of the situation 
which we sometimes forget? The surgeon has banished hos- 
pital gangrene and wound infection from his wards by his own 
individual, careful, exact, prophylactic methods. Have we in- 
ternists introduced like methods for the prevention of disease 
into our daily practice? 
Let us go back to the operating room: While the surgeon, 
surrounded by his corps of assistants and nurses, is carefully 
4 at work, his medical colleague enters with his staff. Among 
them he passes into the room to take a glimpse at the work of 
his associate. He knows that the rules for the ordinary on- 
looker are not for him. He has not time for such excess of 
precaution; neither have his assistants. Making his way to the 
elbow of the operator while the assistants stand aside with 
their hands raised in the air, in order to avoid touching him, 
and forgetting that he has no gauze over his mouth, he talks 
freely with his face near the wound or over the tray in which 
lie the sterilized instruments. Then he leaves the room on his 
way to his special precincts, the wards. 
It is summer time, the sun is shining through the open and 
unnetted windows. In the long line of beds lie the patients pre- 
pared for the visit. The polished floor, the white coverlets, 
the nurses in their trim white dresses and caps, the plants and 
flowers, lend an air of freshness and brightness to the room, 
which is cheering and enlivening. 
The first patient is suffering from cardiac disease. Soon, 
however, we come to the bed of an individual with pulmonary 
tuberculosis. He should not be in the ward. Cases of pul- 
monary tuberculosis are not admitted to the wards of this hos- 
pital which is intended to care only for acute and curable 
diseases-but somehow or other this case has slipped in, and 
here he is. On the table nearby is his sputa cup-on its edge, 
a little of recently expelled sputa lies exposed, and on this bit 
of sputa is clustered a group of flies. 
A short distance away, sitting up in bed and smiling, is a 
convalescent from typhoid fever with his thin chicken-like 
hair and that delicate complexion which suggests the scrub- 
bing of frequent baths. A little farther on lies his neighbor, 
at the height of the disease, dull, apathetic,' somnolent, with 
his eyes and mouth half open. About his lips and teeth are 
crawfling flies that have come from whence-we know not, and 
are going-heaven knows whither. The doctor sits on the 
edge of the bed while making a physical examination. In the 
course of this examination, his hand, introduced under the bed 
clothes, detects the fact that the vesical sphincter has involun- 
tarily relaxed. The doctor has a cold in his head, and inter- 
rupts his examination frequently by blowing his nose, his 
[17] 
5 [17J 
handkerchief in the hand which a moment ago was under the 
bed clothes. On leaving this patient he may, or may not, re- 
member to wash his hands before passing on to the bed of a 
convalescent from influenza, who, interested in the progress 
of the visit, has put down his half-finished glass of milk, about 
which flies are already gathering. 
The nurses, clean and bright in aspect, are called quickly 
from bed to bed-from the typhoid patient to the comsump- 
tive, to the convalescent from influenza; when they can, they 
wash their hands, but it is often impossible. 
On the wall of the ward is posted a notice setting forth the 
precautions which should be taken with regard to bed clothes, 
eating utensils, excreta and bath water of the patient with 
typhoid fever. As we pass out of the ward we look into the 
lavatory-how many of the precautions set forth in the di- 
rections upon the wall are here carried out? Sometimes, 
especially in a female ward, where the work is wholly under 
the charge of nurses, they may be observed strictly-too often, 
however, we find that the bed clothes of the typhoid and tuber- 
culous patient are put into the common receptacle, and handled 
by more than one individual before they are sterilized. The 
directions for the disinfection of the stools and urine, of bed 
pans and urinals are carried out, alas, neither according to the 
letter, nor the spirit of the directions. The orderly, untrained 
and unimpressed with the importance of his work, moves from 
patient to patient without washing his hands, and carries out 
the printed precautions in a most perfunctory manner. The 
bath water, rarely sterilized, is allowed to run into the drain. 
At the end of the visit, the physician washes his hands with- 
out removing his coat, and passes from the wards to his motor. 
Next, perhaps, he visits a case of dysentery in a private 
family. Here again, the house is unnetted, the flies are omni- 
present, Few or no precautions are taken with regard to the 
disposition of the excreta. A few directions may be given to 
the family with regard to the washing of their hands or to the 
sterilization of the excreta, but too often this advice is purely 
perfunctory, and is neglected by the family. 
How rare it is to see really careful antiseptic precautions 
carried out in hospital or in private house! When we have 
(18] 
6 seen these things, may we not well pause and reflect upon the 
difference between the procedure of the physician and that 
which we have seen in the operating room. What a contrast! 
On the one hand the cleanliness, the careful, rigid observance 
of most minute antiseptic and aseptic details, time-consuming 
though they be; on the other, lack of any adequate antiseptic 
measures. Patients with contagious diseases lying side by side 
with others in conditions peculiarly susceptible to infection; 
flies everywhere, ready to spread the contagion from individual 
to individual or from one patient to the nutriment of another; 
-physician, nurse and orderly circulating freely among all 
these patients-the physician in his ordinary clothes, sitting 
perhaps on the bed of a typhoid or dysenteric patient, using his 
handkerchief which he carries from place to place with him 
in his dirty hands; chaos and lack of system in the lavatory! 
Verily the contrast is striking! There may be, there are, ex- 
ceptions to this picture, but too often it is true, and 'tis hardly 
to our credit as physicians. 
" But," we object, stirred by this odious comparison, " the 
problem is different. You are comparing a ward with an 
operating room. Look at the surgical ward-are the con- 
ditions there essentially different ? " Yes, they are different. 
There is, perhaps, much to desire in the surgical ward. The 
windows may be unnetted, the flies may be there, the con- 
ditions in the adjoining lavatory may not be essentially better 
than in the medical ward, but the typhoid, the tuberculous, 
the dysenteric patients, where are they? There is no one in 
the surgical ward with a contagious disease and those parts 
which might especially be subject to contagion are protected 
by elaborate bandages and dressings. 
" Ah, yes," says the objector, " this is all very well, you 
know, however, what I mean. I am talking about individuals. 
Does not the medical man do his duty by the individual just 
as well as does his colleague, the surgeon ? In the care of his 
patient with typhoid fever does he not give the same attention 
to minutiae? Is he not just as particular and just as con- 
scientious? Is he any more open to criticism?" 
Well, let us see. Where are the dangers of infection in the 
surgical wards? "In wounds," you answer. But these are 
[18] 
7 [18] 
protected in the most careful and scrupulous manner. " In the 
medical ward the patient with typhoid fever is already in- 
fected/' you say, " and the problem is different." Very true, 
but when he is convalescent, is it not reasonable to believe that 
he is more subject to infections of other sorts than another? 
Is he not then more or less comparable to an open wound, and 
if so, how about his tuberculous neighbor and the flies? Are 
we protecting him as the surgeon protects his wounds? 
Hardly! 
" But," says the objector, " this comparison is unfair. You 
are praising the surgeon because of his attitude to the indi- 
vidual case, and blaming the physician because he is not taking 
like measures to protect all of the rest of the world." In this 
assertion there are elements of justice, for the problems before 
the physician and surgeon to-day are somewhat different in 
detail if not in principle. 
The surgeon, for the most part, is dealing with the wound 
which, with study and care, he has learned to make cleanly, 
and to preserve from infection. His duty to-day is more 
particularly toward a single individual. The physician is 
dealing with patients who are already infected. That infection 
he can in no way eradicate. His duty is to maintain the forces 
of the patient until he himself has overcome the invader, and to 
protect him from further injury. The great difference, how- 
ever, between the duties of the physician and the surgeon, lies 
in the fact that every one of the infected individuals is a source 
of danger to those about him, and it is the obvious and neces- 
sary duty of the physician to use every means in his power to 
prevent the spread of the disease from the individual who is 
under his care-not only to the special case in his immediate 
vicinity, but to the many unknown individuals who may be 
reached by the dissemination of the infectious agent. 
But has the problem before the surgeon never been similar? 
Consider for a minute the story of hospital gangrene, once the 
infection was there, the condition was almost beyond relief, 
but by the application of antiseptic and aseptic methods the 
surgeon has done far more than save the individual case, he 
has eradicated the disease. How has he done this? Not only 
by the exercising of scrupulous cleanliness in his operative 
8 technique, but in the careful protection of his patient from 
any sort of association with an infected individual. 
Let there be an instance of streptococcus infection in a 
surgical ward-how quickly his removed to the isolating pa- 
vilion. " Ah, yes," says the objector, " this is true, but that 
case of streptococcus infection is a source of immediate danger 
to those about him, and if the infection spreads, it is almost 
certain to end in the death of one of the individuals who is 
under the special care of the surgeon. In the medical ward, 
however, contagion from typhoid fever or dysentery is not 
very likely, and if it does occur, the chances of a fatal issue 
are so very much less, that it is not unnatural that such rigid 
precautions should not be taken." 
This objection again has elements of truth, and contains, 
doubtless, the kernel of explanation as to why we physicians 
have been and are so careless in these matters. The main 
reason for our negligence is the relative infrequency of con- 
tagion-the relative mildness of the infection when it does 
occur. An occasional case of typhoid fever breaking out 
among nurses and physicians in a large hospital is passed al- 
most unnoticed. We hardly realize until we look carefully into 
the matter that our own negligence is responsible for its de- 
velopment. 
But there is another side of the question which lends a very 
grave aspect to the situation. The lack of proper antiseptic 
and aseptic precautions on the part of the surgeon is followed, 
as a rule, by evil results with regard to one individual alone, 
or at the most to a few patients in his ward, or his own prac- 
tice. The lack of antiseptic precautions on the part of the 
physician, in the care of a single case of typhoid fever, may, 
under proper circumstances, give rise to an explosive epidemic, 
followed by hundreds of deaths. 
Regard it as we may, we must come to the painful conclusion 
that physicians as a body have been content to limit their prac- 
tice to the treatment of infections after they have occurred, 
while the surgeon has long since passed beyond this, and has 
recognized that his most important duty lies in prophylaxis 
against this infection. 
That it should be more natural for the surgeon to perceive 
[18] 
[191 
9 119] 
and appreciate this duty from the character of his practice, in 
that negligence affects him more directly, may be true, but this 
detracts in no way from the great and important duty which 
lies before the physician-a duty with which, at the moment, 
he has hardly grappled. 
What steps then, ought we to take ? Some of us, I am sure, 
must feel like saying to ourselves, " Go to the surgeon, thou 
sluggard ! " Indeed, we might do worse. The work must prob- 
ably begin in the large clinics where such problems can best be 
attacked, where the example can best be set. What should 
we do? First, we should see to it that contagious diseases, 
such as pulmonary tuberculosis, typhoid fever and dysentery, 
should not be treated in the general wards. 
1. There should be special typhoid wards, special tubercular 
wards and special isolating wards in which diseases such as 
bacterial dysentery may be cared for. 
2. Precautions such as those now supposed to be taken in 
connection with typhoid fever should be taken in the care of 
patients with diseases such as pneumonia or influenza. 
3. Orderlies and nurses with bad colds or tonsilitis should 
not be allowed to attend regularly to susceptible individuals 
or to those in whom the contraction of the malady might pro- 
duce grave results, such, for instance, as patients suffering 
with mitral disease. 
4. Every hospital ward should be thoroughly and effectively 
netted against flies and mosquitoes. The omission of a pre- 
caution so elementary in its necessity as this should be re- 
garded as criminal negligence. 
5. Not only nurses and orderlies, but attending physicians, 
should wear clean uniforms or gowns, whenever attending 
wards containing contagious diseases, and should remove them 
on leaving the wards. And among contagious diseases I in- 
clude such maladies as typhoid fever, tuberculosis and dysen- 
tery. 
6. All attendants should invariably and thoroughly wash 
their hands on leaving a ward or a bed containing a patient 
suffering with an acute infectious disease. 
7. The observance of the necessary precautions of sterili- 
zation of the clothes, eating utensils, excreta and bath water 
10 of all patients with infectious diseases, should be as rigidly and 
thoroughly enforced as are the antiseptic rules in the surgical 
operating room. 
8. Cultures should be taken from the urine and faeces of all 
typhoid patients before their discharge from the hospital and, 
as a rule, no patient should be discharged until his excreta are 
free from the infectious organism. 
Similar steps should be taken with regard to dysentery. 
If precautions such as these were uniformly adopted in our 
large hospitals, a great step would be taken, not only toward 
the immediate protection of the population of that institution 
and of the surrounding community, but toward the education 
of the medical and lay-public at large, for similar precautions 
should also be taken in connection with patients whom we are 
attending at their homes. 
Suppose the patient be a sufferer from typhoid fever. The 
first step should be exactly that which was taken in the 
campaign resulting in the eradication of the epidemic of 
yellow fever from Havana, viz: 
1. The house should be thoroughly netted. No flies from 
that patient should infect the food of his neighbors. Further- 
more, when possible, 
2. No one but the attendants should be allowed in the room 
of the patient. 
3. If, however, it is necessary for one member of the family 
to be present, that individual should adopt all the precautions 
observed by physician and attendants. 
4. The physician should wear'a fresh, clean gown whenever 
he visits the patient. A sufficient supply of these garments 
should be kept, so that a fresh one may be worn at every visit. 
The gown should be placed immediately in a tin boiler and 
boiled after every visit of the doctor, so that in most cases one 
or two gowns would suffice. 
5. The rules for the sterilization of the bath water, excreta, 
clothes, and eating utensils should be carried out in the same 
manner as in the hospital. 
6. Final cultures should be made in the same way. 
" Theorist and dreamer ! " cries the objector. " This is all 
very well to talk about, but how about the expense and the time 
(191 
11 L19] 
involved in such measures? Neither our shallow pockets nor 
our full days can suffice for such demands. This is a pleasing, 
but quite unrealizable fancy." 
What a natural utterance I But reflect for a minute: What 
would the average surgeon of fifty years ago have said if one 
had suggested to him that, in the near future, it would be 
necessary to make the preparations which are now called for in 
connection with an ordinary surgical procedure-if one should 
have told him of the equipment required for the operating 
room-of the precautions of sterilization to be adopted with 
regard to instruments, ligatures, and indeed everything that 
touches the patient.-if one should have suggested to him the 
preparations that the surgeon himself must make-the care of 
the hands, the costume, the gloves and the other minutiae con- 
nected with the preparation for an ordinary operation-if one 
should have assured him that all his wooden and tortoise shell 
instruments would be discarded in a few years as dirty and 
dangerous ? If one had said these things to one of the best of 
surgeons fifty years ago, he would probably have regarded the 
individual who made such suggestions as a madman, and 
laughed at the absurdity of it all. 
And one of his first objections might well have been the 
enormous expense which such preparations would involve, and 
the utter impossibility of considering for a moment that such 
an extraordinary procedure should be practicable. And yet, 
to-day, we think of these preparations as a matter of necessity 
and duty and the man who fails to observe them is regarded 
as criminally negligent. Now procedures such as I have out- 
lined are very far from being so elaborate or expensive as those 
which are recognized as wholly necessary in the surgery of to- 
day, and although the surgical antisepsis seems more urgent 
because of the immediate consequences of its non-observance, 
yet the neglect of proper medical antisepsis may mean, in any 
individual case, a result infinitely more serious. 
The notorious and discreditable prevalence of typhoid fever 
in our country will continue until the time comes when we 
medical men and the public realize that it is to our careless- 
ness, negligence and unclean habits that it is due. When we do 
realize this as a body, and when we attack the problem as our 
[20] 
12 colleague, the surgeon, has done in connection with his branch 
of the healing art, then, and only then, can we begin to look 
forward to the day when we shall really control the prevalence 
of typhoid fever and similar infectious diseases as the surgeon 
has controlled wound infection. 
This is but the beginning of the work that lies before us. I 
have not even touched upon the milk question-one of the 
gravest from the standpoint of public health-one toward 
which we physicians have been shockingly indifferent. Think 
again, of the conditions which exist among the poor and igno- 
rant and of the scantiness of the measures which we adopt 
to-day to prevent the spread of typhoid fever by contagion, 
after all the lessons of the Spanish War and the admirable and 
illuminating studies of the German Health Bureau! 
These problems must be dealt with by a thorough organi- 
zation of our departments of public health-state, county 
and municipal-but the first step toward this end must be our 
insistence as individuals in each individual case on those 
measures which are necessary for the .protection of the house- 
hold and the public. Individual effort is the keystone of the 
prophylactic arch which spans the road to better days. 
Let us turn now to another aspect of medical antisepsis- 
quite different from that which we have just been considering: 
Some months ago a distinguished English physician said to 
me: "There is an immense amount of sepsis in medicine." 
To what, you may ask, did he refer? The observation was 
made in the course of a conversation upon the frequency with 
which small local foci of infection are overlooked-foci of in- 
fection which lie often at the root of grave general systemic 
disturbances-foci, which, of themselves, may produce little 
or no subjective, or, indeed, sometimes objective, disturbances. 
The speaker was referring especially to the anaemia and gen- 
eral debility which may be associated with the inflammatory 
processes occurring about teeth in interstitial gingivitis with 
tartar formation and the eventual development of pyorrhoea 
alveolarum-that common malady which may almost be re- 
garded as an incident of advancing years, a condition to which 
few practitioners of medicine, and by no means all dentists, 
pay sufficient attention. It was indeed this casual remark 
[20] 
13 [20] 
which suggested to me the subject of my observations this 
evening. 
Thorough oral antisepsis, particularly in regard to the 
gums, is a point of really great importance to which the phy- 
sician, and indeed too often the dentist, pays far too little at- 
tention. The physician who insists that the patient with ex- 
cessive tartar formation and bleeding gums place himself 
under the conscientious care of a competent dentist, will often 
be more than gratified to see the surprising effect upon the 
general health of the patient. More than this-he may avoid 
truly serious complications, for there can be no doubt that at 
times pyorrhoea and alveolar abscesses give rise to grave gen- 
eral results. 
Let us then, for a moment, consider this aspect of sepsis and 
antisepsis in medicine: 
The discovery of a local focus of infection which has been 
at the bottom of some puzzling general disturbance-anaemia, 
debility, fever, is an everyday occurrence in the practice of 
medicine-inflammatory disease of the adnexa in the pale, 
nervous woman who has made no complaint of local trouble- 
the chronic prostatitis or posterior urethritis or fistula-in-ano 
in man-the nasopharyngeal adenoids in the undeveloped, fee- 
ble child. 
The variety of symptoms, however, which may result from 
such chronic foci of septic absorption is not always fully 
realized, nor is it generally understood that these local foci 
may really be difficult or even impossible to recognize in the 
course of the ordinary routine physical examination. 
Again, it is interesting to note the frequency with which we 
have been in the habit of misinterpreting the significance of 
our own wise acts. The remarkable effect of removing naso- 
pharyngeal adenoids on the development and growth of some 
children is an old story. The brilliant result, the transfor- 
mation of a pale, feeble, dull youngster, with palpable glands 
in his neck and frequent unaccountable febrile attacks, into a 
healthy, robust child, is commonly attributed to the simple re- 
moval of a mechanical obstruction to respiration. As a matter 
of fact, however, this improvement is due in many, if not in 
most instances, to the elimination of a focus of chronic infec- 
14 tion from which there has been a constant absorption of toxic 
substances and perhaps even of pathogenic micro-organisms. 
That symptoms of chronic septic absorption from simple 
debility, languor, anaemia, and slight unaccountable febrile 
manifestations to sharp, intermittent fever, ague, arthritis, en- 
docarditis and grave septicaemia, may be observed with chronic 
infections of the lymphatic tissue of the fauces and pharynx, 
is well known, but the frequency of such symptoms in the ab- 
sence of any objective or subjective local manifestations is not 
so widely appreciated as might be desired. 
'Tis especially to the work of J. L. Goodale, of Boston, that 
we owe our increasing knowledge of the importance of local 
disease of the upper respiratory tract as a cause of general 
systemic disturbance. 
The first and main point upon which I would insist is the 
importance of a thorough investigation by a competent laryn- 
gologist of the faucial and pharyngeal tonsils in all cases of 
general systemic disturbance, the cause of which is obscure. 
We are prone to pass by without consideration tonsils which 
are small and appear clean on the surface, forgetting or ignor- 
ing the fact that often enough 'tis the small buried sclerotic 
tonsil with crypts narrowed or closed at their orifices which 
is the most serious menace to the possessor. Such tonsils, mere 
shells filled with cheesy or purulent contents, are often as- 
sociated with exceedingly grave general disturbance. 
What a variety of manifestations may occur with un- 
suspected tonsillar infections may be illustrated by a few of 
my own experiences. 
1. A young woman of 29 had been subject for two years to 
unaccountable febrile attacks which had finally led to a slight, 
regular, daily, evening rise of temperature. There were fre- 
quent " colds " and a rather annoyingly persistent cough. 
Tuberculosis was suspected, and the patient was sent to a sani- 
tarium where she spent several months. The fever continued. 
Physical examination of the chest was wholly negative. The 
pelvic organs were free from disease. On inquiry it was found 
that there had been several attacks of tonsilitis in the preced- 
ing six years. The tonsils, not remarkable on superficial exami- 
nation, were found to be badly diseased. Their removal was 
[20] 
[21] 
15 [21] 
followed by the immediate disappearance of fever and a rapid 
return of good health. 
2. A young woman of about 25 had had for nearly six 
months slight evening fever with debility and loss of weight. 
Her physician, suspecting tuberculosis, had put her under a 
rigid rest and open air treatment, during which, after several 
months, she had gained much weight, and the fever had dis- 
appeared. She had not had tonsilitis for at least ten years. 
The tonsils were rather large, the surface glazed, the crypts 
evidently closed; small pin-head yellowish spots were seen be- 
neath the mucosa. On removal, they were found to be badly 
diseased. Moreover, the naso-pharynx contained a large cyst 
full of foetid cheesy and calcified material. In neither of 
these cases were the tonsils tuberculous. 
3. A boy of twelve had been subject for several years to un- 
accountable febrile attacks with nausea, headache and general 
aching pains. Two weeks before I saw him one of these at- 
tacks was associated with transient albuminuria. There was 
no history of tonsilitis. The tonsils were, however, large and 
evidently diseased. Their removal was followed by imme- 
diate recovery-no return of albuminuria or fever. 
4. A boy of seven had had for some months frequent, often 
daily, attacks of fever, accompanied by chills in the late 
afternoon or evening. There was marked emaciation and de- 
bility. His father, a physician, suspected tuberculosis-no 
history of tonsilitis. The tonsils, not remarkable on super- 
ficial examination, were found to be badly infected and on the 
day of their removal the fever disappeared. A year later, re- 
currence of chills and fever. On examination, it was found 
that a small island of lymphatic tissue which had been left had 
become hyperplastic. A single rather deep crypt had become 
infected and closed, forming a cyst containing pus. The 
fever disappeared upon its removal, and the boy has remained 
well now for nearly two years. 
5. A young man of twenty-four had had in five years 
several attacks of sub-acute arthritis, which, at one time, was 
regarded as arthritis deformans. He had had hydrothera- 
peutic treatment at Wiesbaden and had been advised to re- 
peat the course of baths every summer. Last summer, recur- 
16 rence of the arthritis. No history of tonsilitis. The tonsils 
were, however, badly infected and since their removal last 
June he has been quite well. No recurrence of the arthritis. 
6. Boy of eighteen; for a year, weakness, debility, slight 
albuminnria. No history of tonsilitis. The tonsils did not 
appear to be enlarged, and were apparently clean. On exami- 
nation they were sclerotic, atrophic and filled with retained 
material. Removal resulted in complete recovery with disap- 
pearance of the albuminuria. 
7. A young woman of twenty-three. For three years, 
general debility and loss of 27 pounds. Aching sensation in 
throat. No knowledge that she had had tonsilitis. Trace of 
albumin and hyaline casts in the urine. Tonsils small and 
apparently clean, but on examination found to be sclerotic and 
badly infected. Two weeks after removal the patient was 
much better; the urine free from albumin. Four months 
later the urine was still clear and the patient in excellent 
general condition. Eight months after this the patient re- 
ported that she had gained thirty-five pounds in weight. 
8. A lady about forty-five years of age was seized last June 
with a rather sudden high fever and marked prostration. The 
condition was regarded at first as influenza. There was a 
well marked leucocytosis, no local symptoms-continued 
fever with exacerbations. The throat was rather injected; 
there was no tonsillar enlargement, and no complaint relative 
to the throat. In the absence of any evident cause for the 
fever, Dr. Bordiey was requested to make a special examina- 
tion of the tonsils, which revealed a small abscess of the left- 
tonsil, which broke during the examination. The tempera- 
ture fell almost immediately. Complete recovery followed. 
There were absolutely no local subjective symptoms. 
9. A woman of about 35; ten years before slight haemop- 
tosis, followed by a long continued, slight, regular evening 
fever, for which she had been under treatment, at a sanator- 
ium, for tuberculosis. In the fall of 1908 there developed 
again an unaccountable regular slight evening rise of tem- 
perature to a point about 100° F. or a little under. Re- 
peated physical examination revealed no local cause for the 
fever. There was no cough. The patient, the wife of a 
[21] 
17 121] 
physician, was kept at absolute rest, in bed, in the country, for 
nearly six months. In the early summer of 1909 partial 
hemiplegia, associated with symptoms on the part of the 
nervous system, which suggested to her physician a possible 
disseminated sclerosis. An examination of the tonsils, of 
which there had been no complaint, showed marked disease. A 
thorough emptying of the infected crypts resulted in imme- 
diate disappearance of the fever and rapid improvement in 
the general condition and complete disappearance of all 
symptoms relative to the central nervous system. In the 
course of a month there was a slight recurrence of the fever 
which disappeared again on a thorough cleaning of the tonsil- 
lar crypts, which had refilled. Removal of the tonsils in the 
fall of 1909 was followed by complete and permanent recovery. 
This patient had no evidence elsewhere of arterial disease, 
and the cerebral symptoms have been attributed by all who 
followed the case to an infectious arteritis. I had seen this 
lady on various occasions during the fall of 1908 and the 
spring of 1909. I had examined her tonsils, raised the ques- 
tion of a possible infection, and dismissed it. 
In not one of these cases was the patient aware that there 
was any tonsillar infection. In many, the ordinary routine 
examination suggested little or nothing. In all, however, the 
infection in faucial or pharyngeal tonsils was at the root of 
more or less grave general disturbances-arthritis, endocardi- 
tis, anaemia-debility, albuminuria, suspected tuberculosis, 
cerebral thrombosis. 
Ten years ago I am sure that I should have passed over 
many of these cases. While the tonsils, faucial and pharyn- 
geal, are perhaps the commonest seats of cryptic infection, the 
careful observer will, however, be considerably surprised to 
find how often in chronic conditions of debility, anaemia, 
arthritis, slight unaccountable persistent fever, unsuspected 
disease of some one of the sinuses, ethmoidal, sphenoidal, 
frontal, may be found, the proper treatment of which will 
have a striking effect upon the general health of the patient 
and perhaps on other local manifestations which at first 
glance would seem to be quite unconnected with it. 
The importance of the removal of such foci in chronic de- 
[22] 
18 forming arthritis has been much emphasized of late, but it 
is not only in cases of arthritis, acute or chronic, or marked 
febrile disturbances, that one should look for larval infec- 
tions, but also in every otherwise unaccountable condition of 
debility. 
The discovery and removal of badly infected tonsils while 
the symptoms are yet but slight, may save the affected indi- 
vidual from a fatal endocarditis or a deforming arthritis, or a 
chronic nephritis. The early detection and treatment of inter- 
stitial gingivitis may not only save the teeth, but may per- 
haps, if we are to believe the teachings of Hunter, prevent 
the development of a fatal Addisonian anaemia. 
The cursory consideration of this phase of sepsis and anti- 
sepsis in internal medicine leads us to realization of 
how much truth there was in the observation of our English 
colleague of whom I have spoken. There is an immense 
amount of sepsis in medicine, and one of the most important of 
our duties is to suspect it, to seek for it, and not to tire until 
we have found it. If we search conscientiously we shall find it, 
sometimes, where we least expect it, and in so doing we 
shall perform another of the great prophylactic duties of our 
art. 
Let us emulate our colleague, the surgeon, in our methods 
of antisepsis in relation to contagious diseases in the broadest 
sense of the word, and let us further recognize the frequency 
with which small foci of infection are responsible for grave 
general symptoms, and the importance of their early recogni- 
tion and elimination. 
[22] 
Principiis obsta, sero medicina paratur. 
19 Ameboid Movements in Macro- 
cytes and Megaloblasts 
HOGE R S. M 0 R R [ S, M.D. 
ST. LOUTS 
AND 
WILLI A M S. T H A Y E R, M.D. 
BALTIMORE 
Reprinted from the Archives of Interryil Medicine 
Nov., 1911, Vol. 8, pp. 581-590 
CHICAGO 
American Medical Association 
Five Hundred and Thirty-five Dearborn Avenue 
1911 AMEBOID MOVEMENTS IN MACROCYTES AND 
MEGALOBLASTS * 
ROGER S. MORRIS, M.D., and WILLIAM S. THAYER, M.D. 
ST. LOUIS 
BALTIMORE 
Since the observations made by one of us1 of ameboid movements in 
a megaloblast, the opportunity has presented itself to study the fresh 
blood of five severe anemias. 
In three of the bloods examined by us, ameboid motion was striking 
not only in many of the megaloblasts but also in the macrocytes. The 
absence of ameboid activity in the two remaining cases was probably 
attributable to the almost complete lack of unusually large cells in the 
blood. (For the blood findings, see the accompanying table.) 
Two of the bloods (Cases 1 and 2) were demonstrated to the class 
and the changes described below were observed by practically all of the 
ninety-odd students. In addition, we made prolonged observations on 
each of the bloods. Our specimens were sealed at once with petrolatum 
to prevent drying and to avoid currents in the plasma as far as possible. 
In Case 1, preparations of the blood were studied during a megalo- 
blastic crisis. The megaloblasts were quite numerous and were so 
frequently irregular in outline that they were found without difficulty 
with low magnification (Leitz ocular No. 3, objective No. 3). When 
examined under the oil immersion they often showed a striking change 
in form (Figs. 1-3, 7-10, 13-17, 18-22, 23-34, 51-66, 67-97, 103-105 
126-138), and at times, though not often, the change was so rapid 
that the successive alterations in shape could not be sketched. The 
phenomenon consists essentially of a change in form due (1) to small, 
often numerous, serrations in the outline of the cell which may latei 
be smoothed out or which may develop into a large, prominent projection 
or pseudopod; or (2) to the protrusion of one or more blunt, rounded 
pseudopodia, often large, which may be accentuated by a constriction at 
the base; or (3) to a combination of these appearances at one time in 
the same cell. At times rather deep indentations appeared at one or 
more points on the rim of the cell. Sometimes these nicks appeared to 
be bridged over in part by a delicate, colorless film, showing at times a 
slight wrinkling, as if the coloring-matter were at this point retracting 
*From the Clinical Laboratory the Johns Hopkins University and Hospital. 
1. Thayer, W. S.: The Ameboid Activity of Megaloblasts, The Archives 
Int. Med., 1911, vii, 223. All drawings are made from specimens of fresh blood with Leitz ocular No. 3, 
objective 1/12" oil immersion. The drawings are not made to scale. The 
numerals above each sketch denote the number of the sketch; those below, the 
time intervals. 
Figs. 1 to 3.-Case 1-Megaloblast. Figs. 4 to 6.-Case 1-Macrocyte. Figs. 
7 to 10.-Case 1-Megaloblast. Fig. 11.-Case 1-Macrocyte. Fig. 12.-Case 1- 
Poikilocyte. Figs. 13 to 22.-Case 1-Megaloblast. Figs. 14 to 21.-Case 1-A 
poikilocyte which showed no change during time of observation. Figs. 23 to 34.- 
Case 1-Megaloblast. Figs. 35 to 37.-Case 1-Macrocyte. Fig. 38.-Case 1- 
Poikilocyte (small). Figs. 39 to 45.-Case 1-Macrocyte. Fig. 46.-Case 1-Poikilocyte (small). Fig. 47.-Case 1-Megaloblast. Figs. 
48 to 50-Case 1-Megaloblast. Figs. 51 to 66.-Case 1-Megaloblast. Figs. 67 
to 97.-Case 1-Megaloblast. Figs. 98 to 102.-Case 1-Macrocyte (rather small). Figs. 103 to 105.- 
Case 2-Intermediate. Fig. 106.-Case 2-Normoblast. Fig. 107.-Case 2-^Poi- 
kilocyte. Figs. 108 to 112.-Case 2-Macrocyte. Figs. 113 to 118-Case 2.- 
Macrocyte. 5 
from the stroma. Indentations such as these were often obliterated by 
very sudden movements, the colored substance springing back instantane- 
ously and restoring the former contour of the cell or even forming a 
slight protrusion. The appearance at these points suggested somewhat 
the appearance of some infected corpuscles in estivo-autumnal malaria 
Figs. 119 to 125.-Case 3-Macrocyte. Figs. 128 to 138.-Case 3-Megalo- 
blast. Fig. 138.-Case 3-The cell shown in drawings 126 to 137, the following 
morning. 
in which the brassy-colored protoplasm recedes from the colorless out- 
line of the cell. The malarial cells are, however, often deformed and 
obviously degenerated. But these motile elements showed no abnormal 6 
change in color or general appearance. No cell, indeed, w'ith a sugges- 
tion of crenation or of the ordinary changes of shape observed in 
poikilocytes showed ameboid motion. 
We have not been able to demonstrate propulsive motion in an 
ameboid cell, which remains practically in the same relative position 
during several hours' observation. In this respect the ameboid move- 
ment of the megaloblast differs from that often seen in the leukocytes. 
Indeed, the megaloblast protrudes its pseudopodium, only to retract it 
again. Inclusions or other evidences of phagocytosis in megaloblasts 
have not been seen. 
Examination in Case 2 revealed the identical conditions observed 
in Case 1. Typical megaloblasts are not abundant, but normoblasts and 
intermediates are numerous. It is noteworthy that it is only the larger 
cells (megaloblasts and intermediates) which have shown unquestion- 
able changes of form. In normoblasts (Fig. 106) we have not seen 
such alterations, though they have been looked for with considerable 
patience. Again, in Case 3, ameboid activity was very striking in the 
megaloblasts. Not all megaloblasts, of course, exhibit ameboid activity; 
and this is quite what one would expect from analogy with the leuko- 
cytes, some being inactive, others active. 
That it is the large cells which are chiefly concerned in ameboid move- 
ments we have just seen. Further evidence in support of this fact is 
furnished by the results obtained in Cases 4 and 5. Here, though the 
reductions in the number of erythrocytes were quite as great or even 
greater than in the preceding cases, the absence of very large red cor- 
puscles was conspicuous. In Case 5, in fact, no megaloblasts were seen 
at any stage of the disease, and they were scanty in Case 4. In neither 
of these cases was active ameboid motion demonstrable in the red cells. 
AMEBOID ACTIVITY IN MACROCYTES 
The observations just recorded confirm the findings previously 
reported.1 In addition, we have observed exactly the same changes in 
shape in macrocytes (Figs. 4-6, 35-37, 39-45, 98-102, 108-112, 113-118, 
119-125). The rapidity of change may be quite as great as in the nucle- 
ated red corpuscles and may present all the variations observed in the 
latter. There was no discoverable difference in kind or in degree. As in 
the case of the megaloblasts, not all of the macrocytes exhibit ameboid 
movements (Fig. 11). That non-nucleated cells should do so at all seems 
strange. But if the motility of the megaloblasts is in reality ameboid- 
and to the writers there appears to be no other explanation-then there 
can be no doubt that certain macrocytes, too, are possessed of it. Numer- 
ous ameboid macrocytes were observed in the blood of Cases 1, 2 and 3. 
A single, sluggish, rather small macrocyte was found in Case 5 in the 7 
examination of many specimens, this cell appearing at the time of the 
blood crisis. 
To determine the effect of temperature, specimens were examined 
on the warm stage at body heat. It was impossible to see any difference 
in the ameboid activity of cells studied in this way and those at room 
temperature (about 70 F.). 
Two specimens from Case 1 were allowed to stand over night, the 
one in the incubator at 37 C., the other at room temperature, both sealed, 
as in all instances, with petrolatum. On reexamination, about twenty 
hours after the specimens had been prepared, it was found that the red 
corpuscles were remarkably well preserved, little, if any, laking having 
occurred, though there were crenation in a few cells and endoglobular 
degenerations in many. The most striking fact noted was that it was 
no longer possible, as it had been when the smears were fresh, to select 
megaloblasts with low magnification, since nearly all of them were now 
circular or oval in outline and therefore less conspicuous. A sluggish, 
almost imperceptible change in form was observed in one megaloblast 
(Figs. 48-50), and in one only, though many megaloblasts and macro- 
cytes were watched over considerable periods of time. In Case 3, in a 
specimen of blood which had been prepared and sealed at 11 a. m., a 
megaloblast, actively ameboid, was fixed in the field at about 12:45 
p. m. It remained very active until 4:20 p. m., when the observations 
were temporarily interrupted. The following morning at 10:25, the 
cell was almost round (Fig. 138) and the ameboid activity had entirely 
ceased. This megaloblast showed no endoglobular degeneration and no 
apparent loss in color. Its nucleus, as is the rule in such cells, showed 
practically no change in shape throughout the observations (Figs. 126- 
138). In these specimens examined after twenty or more hours, the 
leukocytes also showed a cessation of ameboid activity, though, unlike 
the red corpuscles, they frequently retained their irregular shape. 
The cells, both megaloblasts and macrocytes, exhibiting ameboid 
movements were for the most part well colored, many seeming to be 
richer in hemoglobin than the average cell. A few, paler than the major- 
ity of the surrounding reds, were seen to change form, but no difference 
was determined in the motion of such cells and those more highly colored. 
No suggestion of crenation was observed in the ameboid cells. That the 
alterations in shape observed were not the result of osmosis is made 
probable by the absence of shadows or crenated erythrocytes in the neigh- 
borhood of those studied, and, further, by the fact that smaller red cells 
and many which were large remained immobile. 
Many poikilocytes and normocytes were studied. In no case was 
there the least evidence of change in form while they were under observa- 8 
tion. (Figs. 12, 14, 21, 38, 46, 107). Rolling of the cells was, of course, 
excluded. Currents were practically eliminated by sealing the speci- 
mens. 
It occurred to us that it might be possible to demonstrate proto- 
plasmic currents in the ameboid red cells by means of the so-called vital 
staining methods. It is the young cells which have shown ameboid activ- 
ity and in these cells particularly, as Vaughan2 and others have shown, 
the reticulofilamentous substance is demonstrable. The dyes used were 
Unna's polychrome methylene blue and neutral red in physiologic salt 
solution. Of the bloods possessing ameboid red cells, only that from 
Case 3 was studied in this manner. There was no difficulty in finding 
macrocytes and megaloblasts with well-stained reticula but in none of 
them could we see even a suggestion of ameboid movements, though con- 
trol preparations made at the same time, unstained, contained very active 
ameboid cells. The neutrophilic leukocytes retained their ameboid activ- 
ity well in the vitally stained specimens. Though our experiments with 
vital staining are limited to one case, it seems probable that the staining 
solutions used abolish the ameboid movements of red cells. This is all 
the more likely, since there is no description in literature of active move- 
ments of the vitally stained particles in erythrocytes, so far as we can 
discover. 
The movements which we have described in macrocytes and megalo- 
blasts were similar to those which were observed in the first case reported, 
but the protrusion and coalescence of small pseudopods were not so strik- 
ingly evident and the similarity of the movements to those of leukocytes 
not so apparent. The megaloblast originally described was a large, pale 
form, apparently a very immature cell, while, as has been said, these 
megaloblasts and macrocytes were all corpuscles of quite the normal 
color. 
As a probable evidence of ameboid activity in megaloblasts, the occa- 
sional irregularity in outline seen in stained blood films may be recalled. 
That ameboid activity in the red corpuscles may have considerable 
biologic significance is made clear by recalling the theories advanced to 
explain leukocytoses. It is not improbable that the "blood crises" are 
due to an active wandering out of the red cells from the marrow, the 
result of some unknown stimulus. Should this prove to be the case, it 
is likely that it will be found to be a departure from the normal, an 
unusual method of responding to increased normal or pathological stim- 
ulus, though for the fetus this may well be physiological. As yet, how- 
ever, -we have been unable to study blood from the fetus. 
2. Vaughan, V. C., Jr.: The Appearance and Significance of Certain Granules 
in the Erythrocytes of Man, Jour. Med. Research, 1903, x, 342. 9 
The counts given below coincide with the dates of examination. 
Case 1.-E. D. P., male, aged 41, white, med. No. 26,575, admitted to the 
hospital Nov. 22, 1910. Diagnosis: Pernicious anemia; erysipelas; streptococcus 
septicemia.* 
Dec. 1, 1910: Blood examination: 
Red blood-cells, 900,000. 
Hemoglobin, 20 per cent. 
White blood-cells, 8,100. 
Differential count of 402 cells gave: 
Lymphocytes 25.7% 
Large mononuclears and transitionals 4.7% 
Polymorphonuclear neutrophils 59.6% 
Eosinophils 1.2% 
Mastzellen 0.0% 
Myelocytes, neutrophilic .. , 4.2% 
Unclassified 4.2% 
In counting the leukocytes, 40 megaloblasts, 36 intermediates, and 24 normo- 
blasts were seen. 
The red cells showed marked anisocytosis and poikilocytosis. There were many 
large cells. The stained film revealed polychromatophilia, basophilic granula- 
tion, nuclear particles, and Cabot's ring bodies in large numbers. Marked signs 
of regeneration were, therefore, present. 
Case 2.-J. S., male, aged 17, colored, med. No. 26,868, admitted Jan. 25, 
1911. Diagnosis: Severe anemia (pernicious?). 
Feb. 21, 1911: Blood examination: 
Red blood-cells, 1,750,000. 
Hemoglobin, 38 per cent. 
White blood-cells, 21,000. 
Differential count of 800 cells gave: 
Lymphocytes 24.7% 
Large mononuclears and transitionals 8.7% 
Polymorphonuclear neutrophils 59.0% 
Eosinophils 6.3% 
Mastzellen 0.7% 
Myelocytes, neutrophilic 0.7% 
Nucleated red cells were present in the proportion of 350 to 1,000 white cells, 
normoblasts predominating. There were considerable anisocytosis and poikilocy- 
tosis. Macrocytes were numerous but were not so large as in the preceding case. 
A Romanowsky stain showed much the same changes in the erythrocytes as in 
Case 1, but to a less degree, though the nucleated forms were more common. 
Case 3.-T. P. J., male, aged 43, white, med. No. 27,438, admitted May 28, 
1911. Diagnosis: Pernicious anemia. 
June 16, 1911: Blood examination: 
Red blood-cells, 1,544,000. 
Hemoglobin, 33 per cent. 
White blood-cells, 3,200. 
Differential count: 
Lymphocytes 43.0% 
Large mononuclears and transitionals 4.0% 
Polymorphonuclear neutrophils 53.0% 
*The infection occurred about one month after the present study of the blood 
was made. 10 
Nucleated reds were present in the proportion of 230 to 1,000 leukocytes. Poi- 
kilocytosis and anisocytosis were marked, some of the cells being unusually large. 
The evidences of regeneration of the red cells were striking. 
Case 4.-H. M., male, aged 45, white, med. No. 27,336, was admitted May 4, 
1911. Diagnosis: Aplastic pernicious anemia (autopsy). 
May 4, 1911: Blood examination: 
Red blood-cells, 1,280,000. 
Hemoglobin, 20 per cent. 
White blood-cells, 1,200. 
Differential count of 100 cells: 
Lymphocytes 60.0% 
Large mononuclears and transitionals 17.0% 
Polymorphonuclear neutrophils 16.0% 
Eosinophils 0.0% 
Mastzellen 1.0% 
Myelocytes, neutrophilic 3.0% 
Unclassified 3.0% 
Two megaloblasts and one normoblast were found. The blood showed a con- 
siderable degree of anisocytosis and poikilocytosis but the absence of many macro- 
cytes and, indeed, of any very large ones was striking, the morphology of the 
cells suggesting a severe secondary rather than a primary pernicious anemia, 
except for the megaloblasts. Aside from the scanty nucleated reds, there were 
no signs of regeneration in the red cells. The occurrence of myelocytes and a few 
nucleated red corpuscles indicates a futile attempt at regeneration. 
Case 5.-P. H., male, a^ed 56, white, med. No. 27,337, was admitted May 4, 
1911. Diagnosis: Severe secondary (toxic) anemia (?), pernicious anemia (?). 
(The patient was employed in a dye factory and it is possible that the anemia 
was the result of his occupation; conclusive evidence is not yet at hand.) 
June 7, 1911: Blood examination: 
Red blood-cells, 900,000. 
Hemoglobin, 15 per cent. 
White blood-cells, 2,400. 
Differential count: 
Lymphocytes 37.0% 
Large mononuclears and transitionals 3.0% 
Polymorphonuclear neutrophils 57.4% 
Eosinophils 2.0% 
Mastzellen 0.0% 
Myelocytes, neutrophilic 0.2% 
No nucleated reds were found and there were no other evidences of regenera- 
tion of the red corpuscles. The absence of large cells is striking. Except for the 
lack of nucleated red cells and the presence of only slight poikilocytosis the blood 
bore a striking resemblance to that of Case 4. On vital staining with polychrome 
methylene blue, very few erythrocytes showed the reticulo-filamentous substance. 
After the red count had fallen to 530,000, defibrinated blood was given intra- 
venously by Dr. W. L. Moss (who will include the case in a forthcoming report), 
and on June 13, 1911, an examination of the blood showed: 
Red blood-cells, 1,580,000. 
Hemoglobin, 19 per cent. 
White blood-cells, 4,000. 
There was now a normoblastic crisis, 143 nucleated red cells per 1,000 whites. 
No megaloblasts were found and the intermediates were small. 
1806 Locust Street, St. Louis - 406 Cathedral Street, Baltimore. INSTANCES OF BRADYCARDIA 
by 
William Sydney Thayer, M. D., 
Reprinted from the Transactions of the Association 
of American Physicians, 1911, XXVI, 166-168 
Dr, Thayer demonstrated sphygmographic trac- 
ings and electrocardiograms from several instances 
of bradycardia. 
Case I. - Halving of the Ventricular Rate Follow- 
ing Physical Exert ion. 
A man, aged seventy-five years, with arterioscler- 
osis and a somewhat dilated and hypertrophied 
heart, showed, at the time of his first examina- 
tion, a pulse rate of about 60 when at rest. After 
any physical effort, such as sitting up in bed, the 
rate of the pulse was exactly halved. 
On examination of tracings from the radial 
artery and jugular vein, controlled by auscultation 
of the heart, this change in rate was snown to be 
due to the dropping out of every other ventricular 
contraction, the auricular pulse continuing essen- 
tially at its original rate. The a-c time was 
always normal. 
There was never, at other times, evidence of 
pulsus al te mans. 
Pressure on the left vagus in the neck pro- 
duced, on several occasions - ss shown by tracings- 
a complete intermission of both auriculer and 
ver.triculer contractions. The pause following 
the beginning of pressure amounted to almost ex- 
actly double the length of the ordinary pulse 
period. Following t^is, during the period of 
pressure, the pulse was irregular and somewhat 
slower than usual, with occasional interpolated 
auricular systoles, not followed by ventricular 
contractions. The a-c time remained normal. Rest was followed by decided improvement, and 
after a few days it became impossible to call forth 
these phenomena. 
A year later the patient remained in f irly 
good condition without return of the bradycardia. 
Electrocardiograms at this time showed nothing ab- 
normal . 
Dr. Thayer was inclined to regard the brady- 
cardia in this instance as dependent on a diminished 
irritability or contractility of the heart muscle 
due to sclerotic changes. 
Case II. - Permanent Bradycardia, with no Apparent 
Cardiac Abnormality. 
A young man, aged thirty years, who had been a 
heavy smoker, and had been under rather severe 
business strain, had complained, during the spring 
of 1910, of several attacks of dizziness and faint- 
ness, during which his nulse had been found to be 
exceedingly slow - on several occasions below 30 
to the minute. On one occasion his physician 
thought that he could count mere jugular than 
radial pulsations. • After a long rest and vacation, 
the patient improved greatly, but his pulse remained 
very slow. When seen in October, 1910, examina- 
tion revealed no physical abnormality. The rate 
of the pulse, however, when he was at rest, was 
always below 40 - usually about 37 to the minute. 
At times, when the patient was in bed, the pulse 
was as low as 28. 
Numerous sphygmographic tracings showed normal 
auricular and ventricular centractions , with no 
delay in the a-c time. 
Exercise accelerated the nulse, ut never to a 
rate above 60 - rarely above 50. 
Respiration was associated with the normal 
changes in rhythm. , 
Atropine, gr.^yf and gr.~had no effect 
on the rate of the pulse. After atropine, gr.^" 
subcutaneously, the pulse rose in twenty minutes 
to 60. Continuous tracings of radial and jugular 
pulses for periods of as much as half an hour were 
taken on several occasions without revealing any 
abnormalities. 
Radiographic examination of the chest showed 
nothing of note. This was the first instance in the speaker's 
experience in which he had observed a pulse per- 
sistently under 40 without auriculo-vent ricular 
dissociati on. 
Case III. - Permanent Bradycardia with Auricular 
Fibrillation and Heart Block, 
A physician, aged about sixty years, had had, 
during the summer of 1910, a severe break in car- 
diac compensation, associated with periods of brady- 
cardia, during which the pulse was as slow as from 
20 to 30 to the minute. These periods had finally 
been succeeded by a permanent bradycardia of about 
40 beats to the minute. 
When first seen, during the winter of 1911, 
there was great dilatation of the heart with mitral 
and obvious tricuspid insufficiency. 
Jugular tracings shewed a positive venous pulse 
with no trace of auricular c ait ract ions , while elec- 
trocardiograms showed the waves characteristic of 
auricular fibrillation. It was unfortunately, 
impossible to make the atropine test. 
The history of the case, the condition of the 
patient, the sphygmographic tracings, and the elec- 
trocardiograms justified, however, the diagnosis of 
heart block with auricular fibrillation - so-called 
"Modal Bradycardia." 
Dr. Thayer then demonstrated for Dr. G. S. Bond 
an electrocardiogram showing an au r i cul ove ntric ular 
dissociation in which the ventricular contractions 
were more rapid than the auricular. The case was 
one of cardiac dilatation following coronary throm- 
bosis and myomalacia. The record was taken shortly 
before the death of the patient when the patient 
was in ext remis. On Malarial Fever, with Special 
Reference to Prophylaxis 
by LL 
uwn- 
WILLIAM SYDNEY THAYER, M.D.. F.R.C.P.I. 
Johns Hopkins University, Baltimore 
Reprinted from the Harvey Lectures, 
Series 1911-1912 
Press of 
J. B. LIPPINCOTT COMPANY 
Philadelphia ON MALARIAL FEVER, WITH SPECIAL 
REFERENCE TO PROPHYLAXIS * 
WILLIAM SYDNEY THAYER, M.D., ^F.R.C.P.I. 
Johns Hopkins University, Baltimore 
IT is now over thirty years since that patient and careful 
student Laveran discovered parasites in the blood of suf- 
ferers from malarial fever, and recognized their significance; it 
is over twenty-five years since Golgi pointed out the relations 
between the life history of the parasites in their human host 
and the manifestations of the malady; it is nearly fifteen years 
since Ross's discovery of the development of the microorganisms 
in the body of the mosquito, which, along with the studies of the 
Italian school, revealed the manner in which the disease is 
spread and the way in which infection takes place. In the ten 
or twelve years w'hich have followed these discoveries, the ad- 
vances in our knowledge of the aetiology, prophylaxis, and treat- 
ment of various other infectious diseases, such as yellow fever, 
cerebro-spinal meningitis, syphilis, poliomyelitis, have been so 
rapid and so absorbing, that here in America, at least, the 
lessons which we have learned with regard to the nature of 
malarial fevers and the methods of prophylaxis and treatment 
by which they may be controlled, have not been taken to heart 
as they have been in some other parts of the world. 
A brief consideration, therefore, of the present state of our 
knowledge concerning malaria, and of some of the problems 
which concern us, as a profession and as a people, with regard 
to questions of prophylaxis and treatment, may be worthy of 
consideration before this society. 
* Delivered March 23, 1912. 
277 278 
HARVEY SOCIETY 
ETIOLOGY. NATURE OF INFECTIOUS AGENT. 
MANNER OF INFECTION 
The infectious agent we now know to be a sporozobn of the 
order Haemosporidia, sub-order, Acystosporea, genus, Plas- 
modium. 
These haemosporidia have two cycles of existence-one, asex- 
ual (schizogonia), takes place in the blood of vertebrates; the 
second, sexual (sporogonia), in the viscera of certain insects. 
The vertebrates appear to represent the intermediate hosts, the 
insects the definitive hosts. In the case of Plasmodium, the de- 
finitive hosts are various mosquitoes belonging to the sub- 
family Anophelinae. 
The genus Plasmodium is represented by three distinct 
species, differing not only in their morphological and biological 
characteristics but in the character of the manifestations to 
which they give rise in the infected individual. These species 
are: 
Plasmodium vivax (Grassi and Feletti, 1890), the parasite 
of tertian fever. 
Plasmodium malaria (Laveran, 1881), the parasite of 
quartan fever. 
Plasmodium falciparum (Welch, 1897), the parasite of 
ffistivo-autumnal or tropical fever. 
In the human being, the parasite passes through its asexual 
cycle (schizogonia) in the substance of the red blood-corpuscle, 
dividing, at maturity, by segmentation, into a fresh brood of 
young parasites, merozoites, which in turn attack new corpus- 
cles, and pursue again their cycle of existence, a process which 
may be continued for an indefinite period of time. Alongside 
of the parasites pursuing this asexual cycle of development, 
there appear, however, in most cases, other organisms-dis- 
tinguishable, in the younger tertian and quartan parasites, 
mainly by differences in their nuclear structure, but in the 
aestivo-autumnal parasite, by gross differences of form-which 
early begin to take on sexual characters. These gametocytes 
show, in all forms of malaria, a resistance to quinine, greater 
than members of the asexual cycle, but slightly greater in P. 
vivax and P. malaria, very markedly so in Plasmodium 
falciparum. MALARIAL FEVER 
279 
Immediately after the removal of the parasites from the 
human host by the anopheline mosquito, actively motile fila- 
ments {microgametes) escape from the male element {micro- 
gametocytes) and penetrate the female organism. The fecun- 
dated female element {ookinete) develops then the power of 
active locomotion, penetrates the wall of the stomach of the 
mosquito, and there becomes an oocyst, from which, after about 
eight days, at maturity, escapes a brood of newly formed 
sporozoites {sporonts) which collect in the salivary glands of 
the mosquito, from which they are discharged into the succeed- 
ing human host. 
On entering the blood of the human being, the sporont 
attacks a red blood-corpuscle, enters it, and thenceforth becomes 
indistinguishable from the product of asexual division 
(schizont). In the red blood-corpuscle it enters immediately 
upon the ordinary cycle of asexual development (schizogonia). 
The length of the sexual cycle of development in the mosquito 
host depends upon the conditions under which the insect is 
placed, amounting, under favorable circumstances, to about 
eight days. 
The anophelines which may act as definitive hosts for the 
parasite belong to several genera and a variety of species. In 
the United States, two genera and eight species have been 
recognized, namely: Anopheles punctipennis (Say) ; Anopheles 
pseudopunctipennis (Theobald) ; Anopheles crucians (Wiede- 
mann) ; Anopheles occidentalis (Dyar and Knab) ; Anopheles 
atropos (Dyar and Knab) ; Anopheles walkeri (Theobald) ; 
Anopheles maculipennis (Meigen) ; Coelodiazesis barberi 
(Coquillet). 
In Panama, the commonest hosts of the malarial parasite 
are: Anopheles albimanus and Anopheles tarsimaculata 
Anopheles pseudopunctipennis is apparently but slightly con- 
cerned in the transmission of malaria, and it has not yet been 
proven that Anopheles malefactor transmits the disease.1 
1 Darling: Transmission of Malarial Fever in the Canal Zone by 
Anopheles Mosquitoes. J. Am. Med. Ass., Chicago, 1909, liii, 
2051-2052. 280 
HARVEY SOCIETY 
It is a question whether, in the temperate parts of this 
country, the common Anopheles punctipennis plays any part in 
the transmission of malaria, and in temperate Europe and in 
America the main agent of transmission is Anopheles maculi- 
pennis. 
The anophelines are essentially country mosquitoes, breeding 
by preference in shallow pools, especially those containing a 
growth of algae; they rarely develop in water standing in tubs 
or about houses as do Culices, the common house mosquitoes 
of the city. Several species, however, breed in marshes with 
brackish water. The anophelines are, as a rule, night-biting 
mosquitoes, that is, they bite only at night or at dusk, morning 
or evening. In daytime, they retire to dark places, behind 
curtains or clothes or even into holes in the ground. This has 
led to the construction of rather interesting mosquito traps. 
The simplest of these are boxes lined with black or dark blue 
cloth. The mosquitoes seek the dark recesses and are suddenly 
shut in by a lid-and later destroyed. Blin,2 who noticed that 
mosquitoes often repaired to crab holes by day, dug small 
holes in the ground about 16 inches deep at an acute angle 
to the surface. The holes, protected from direct light, are soon 
filled with mosquitoes which are burned by torches. 
The oocysts will not develop in their mosquito host at all 
temperatures and under all conditions; they grow best at a 
temperature from 20° to 30° C. They are killed in tem- 
peratures steadily under 16°. Exposure, however, to a temper- 
ature as low as 10° or 13° for an hour will not kill the oocyst 
if the insect later be placed under favorable surroundings. 
Anophelinag may bite at a season considerably earlier or later 
than that which is suitable for the complete development of 
oocysts (Jancso)3. 
2 Blin: Destruction des moustiques par le procede des trous-pieges. 
Caducee, Par., 1909, ix, 163. 
* Jancso: Der Einfluss der Temperatur auf die geschlechtliche Gen- 
erationsentwickelung der Malariaparasiten und auf die experi- 
mentelle Malariaerkrankung. Centralbl. f. Bakt., etc., I Abt., 
Orig., 1905, xxxviii, 650. MALARIAL FEVER 
281 
The parasite is not transmitted to the offspring of the 
mosquito. The average length of life of the anopheline mos- 
quito is difficult to determine. Artificially cultivated, they have 
been kept alive for 56 days.4 Ross calculates that the average 
natural life of an anopheline is of about three weeks' duration. 
During the cold weather, a certain number of adults, especially 
females, hibernate in lofts, cellars or dark rooms, coming out 
again with the return of warm weather. The length of time 
during which a mosquito may contain viable sporozoites in the 
salivary glands cannot be stated with positive certainty. The 
observations of Jancso above mentioned would tend to suggest 
that in temperate climates few mosquitoes can be infectious at 
the beginning of the succeeding season. 
Among mosquitoes collected at the beginning of the malarial 
season, the number of infected insects is extremely small. It 
cannot, then, be regarded as proven that the hibernating mos- 
quito may be a carrier of infection. 
SEASONAL INCIDENCE OF MALABIA; RELAPSES; LATENT INFECTIONS 
Relapses.-Although the infection of a human being can 
occur only as a result of a bite by an infected mosquito, yet the 
curve of seasonal prevalence of the disease is remarkably mod- 
ified by the fact that relapses, which are apparently commonest 
in tertian malaria, have a definite seasonal relation, being espe- 
cially frequent in all climates at the onset of warm weather in 
spring, and notably preceding the appearance of anophelines, 
which initiates the annual epidemic. 
The seasonal occurrence of malaria in Baltimore, which 
corresponds very closely with the figures reported by the 
observers in Rome, may be illustrated by the following table: 
4 Nuttall and Shipley: Studies in Relation to Malaria-The Structure 
and Biology of Anopheles (Anopheles maculipennis). J. Hygiene, 
Cambridge, 1902, ii, 58-84. 282 
HARVEY SOCIETY 
SEASONAL DISTRIBUTION OF MALARIA IN BALTIMORE 
Jan. 
'o 
Mar. ! 
April 
May j 
June 
July 
Aug. 
Sept. 
Oct. 
Nov. j 
6 
Q 
Q 
Total 
Tertian 
12 
12 
28 
51 
76 
68 
131 
161 
153 
168 
54 
17 
931 
Quartan 
3 
1 
0 
1 
0 
0 
3 
0 
2 
1 
4 
2 
17 
JSstivo-autumnal 
5 
1 
2 
5 
2 
3 
37 
99 
191 
203 
63 
22 
633 
Combined 
0 
1 
1 
0 
0 
1 
3 
3 
4 
11 
6 
2 
32 
20 
15 
31 
57 
78 
72 
174 
263 
350 
383 
127 
43 
1613 
It was further found on questioning these patients, who, for 
the most part, were ordinary ward patients, people who might 
well have forgotten a previous malarial attack, that about two- 
thirds of the individuals who had consulted us during the first 
half year had had previous attacks, and might therefore be 
suffering from a relapse, while only about one-third of those 
suffering with malaria during the second half year could 
remember a preceding affection of the same sort. 
It would thus appear that the greater part, if, indeed, not 
all of the cases occurring early in the season in temperate 
climates, are relapses from previous attacks. 
The causes of relapses have been much discussed. Un- 
treated malaria often disappears spontaneously, but these dis- 
appearances are usually followed by recrudescences and re- 
lapses at varying intervals through months and years. Caccini5 
finds that in tertian fever, relapses and rallies alternate in 
periods of from two to three weeks. In sestivo-autumnal fever, 
the relapses and rallies in untreated cases occur at rather 
shorter intervals, amounting usually, according to Carducci,6 
to about seven days. Often, however, spontaneous recoveries 
may occur, particularly in tertian fever, followed by relapses 
after intervals of months or indeed even years. The condition 
here is indistinguishable from that which occurs after more or 
6 Caccini: Duration of the Latency of Malaria after Primary 
Infection, etc. J. Trop. Med., Lond., 1902, v, 119; 137; 159; 172; 
186. 
'Carducci (A.): Sulla cura e sulla causa delle recidive nella malaria. 
Atti d. Soc. per gli stud. d. malaria, Roma, 1905, vi, 27. MALARIAL FEVER 
283 
less incomplete treatment by quinine. From a seasonal stand- 
point, as has been said, relapses occur with beginning warm 
weather, or, in the tropics, after the onset of the rainy season; 
but in any individual with latent malarial infection and some- 
times after it has apparently been eradicated by long continued 
and careful treatment, a relapse may occur following sudden 
changes of climate, exposure, fatigue, emotional excitement, 
or infectious disease. 
The cause of such relapses is still uncertain. No evidence 
exists in support of the old assumption that the parasite per- 
sists somewhere in the organism in the shape of encapsulated 
spores. Ross7 believes that it is, on the whole, more probable 
that certain more resistant parasites of the asexual cycle may 
persist for very long periods of time, in numbers so small as to 
produce no definite symptoms, but ever ready to multiply under 
circumstances which lower the resistance of their hosts. 
Bignami8 is inclined to believe that the persistent relapses 
in some cases may be due to the acquisition, by certain strains 
of the parasites, of a tolerance for quinine such as has been 
observed, for instance, in the case of trypanosomes toward prep- 
arations of arsenic. 
Others have suggested, however, as a possible cause of re- 
lapses, the parthenogenetic sporulation of the more resistant 
gametocytes. Grassi,9 Schaudinn,10 and others describe pictures 
which they interpret as a parthenogenetic sporulation of macro- 
gametes. It is well known that gametocytes are more resistant 
against treatment with quinine than organisms of the asexual 
cycle, and it is suggested by these observers that the partheno- 
genetic sporulation of macrogametes which have persisted for a 
long time after treatment may well be the cause of the reawak- 
'Ross: The Prevention of Malaria. 8° London (Murray), 1910, 115. 
' Bignami: Sulla patogenesi delle recidive nelle febbre malariehe. 
Riv. ospedal., Roma, 1911, i, 305-317. 
'Grassi (B.) : Die Malaria. Studien eines Zoblogen. 2 ed., Jena, 
1901. 
10 Schaudinn (F.): Studien uber krankheitserregende Protozoen. II, 
Plasmodium Vivax, etc. Arbeit, a. d. K. Gesndhtsamt., 1903, xix, 
169. 284 
HARVEY SOCIETY 
ening of latent infections. Similar pictures of segmentation in 
crescents were described many years ago by Canalis.11 This 
process, though apparently confirmed by good observers, is still 
doubted by a student so reliable as Bignami.12 
Craig13 contends that these so-called parthenogenetic 
sporulating forms are, in reality, more resistant elements, re- 
sulting from the early conjugation of two young parasites. 
This conjugation, first described by Mannaberg,14 who, as is 
well known, has long believed that it is a regular step in the 
formation of crescents, and Ewing15 in young forms of the 
tertian parasite, has been repeatedly observed by Craig, who 
regards the resultant zygote as a more resistant body destined 
to remain in the human organism after other forms of parasite 
have disappeared as the result of treatment or of the natural 
destructive powers of the blood. It is to the reawakening and 
segmentation of such bodies, he believes, that the relapses are 
due. 
Mary Rowley-Lawson 16 has recently described and pictured 
that which suggests a process of impregnation of macrogametes 
within the body of the human host in sesti vo-autumn al infec- 
tions, and has apparently followed every intermediate stage 
from impregnation to segmentation (schizogonia). Such a 
diversion of the usual process of development might well 
account for some relapses. The recent remarkable studies of 
Bass,17 who asserts that he has succeeded in cultivating the 
11 Canalis (P.): Studi sull' infezione malariea, etc. Arch, per le sc. 
med., Torino, 1890, xiv, 73. 
12 Bignami: op. cit. 
13 Craig (C. F.): Intracorpuscular Conjugation in the Malarial Parasite 
and its Significance. Am. Med., Phila., 1905, x, 982; 1029. 
"Mannaberg (J.): Beitriige z. Kenntniss der Malariaparasiten. 
Verhandl. d. Cong. f. innere Med., Wiesb., 1892, xi, 437-449. 
13 Ewing (J.) : On a Form of Conjugation of the Malarial Parasite. J. 
Hopkins Hosp. Bull., 1900, xi, 94. Also, Malarial Parasitology. 
J. Exper. M., N. Y., 1901, v, 475. 
16 Rowley-Lawson: The 2Estivo-autumnal Parasite, etc. J. Exper. 
M., N. Y., 1911, xiii, 263-289. 
17Bass (C. C.) : A New Conception of Immunity, etc. J. Am. M. Ass., 
Chicago, 1911, Ivii, 1534. MALARIAL FEVER 
285 
malarial parasites outside the human body, should, if con- 
firmed and extended, shed a flood of light upon the develop- 
ment of the organism. 
However this may be, the malarial season in all countries 
is almost invariably preceded by an outbreak of relapses. These 
relapses, at the beginning, occur at a time when the anophelines 
are not yet active. The true epidemic follows shortly after the 
appearance of anophelines. But it is not necessary that there 
should be an active outbreak of relapses, for it has been shown 
that latent malaria is by no means uncommon. This was 
brought out especially by Koch 18 in his malaria expedition to 
the East. Koch called attention particularly to the fact, which 
has been confirmed by many other observers in all parts of the 
world since that time, that in malarious localities the proportion 
of children who are infected is very large, but more than this, 
a large proportion of these children carry the infection without 
signs so striking as to be recognized by the ordinary individual. 
It is not an uncommon thing for a child to be playing about, 
apparently in reasonably good condition, with active parasites 
demonstrable in the circulation. 
But children are not the only malaria carriers, and the 
number of adults who may keep at work with considerable 
numbers of malarial parasites, especially of aestivo-autumnal 
gametocytes, in the blood is, in malarious districts, very large. 
For instance, in the Panama Canal Zone, where so much has 
been done, Darling,19 a few years ago, reported that in several 
18 Koch (R.): Erster Bericht uber die Thatigkeit der Malariaexpedi- 
tion. Deutsche med. Wchnschr., 1899, xxv, 601. Zweiter Bericht 
iiber die Thatigkeit der Malariaexpedition. Ibid., 1900, xxvi, 88. 
Dritter Bericht iiber die Thatigkeit der Malariaexpedition. Ibid., 
1900, xxvi, 296. Vierter Bericht iiber die Thatigkeit der Malaria- 
expedition. Ibid., 1900, xxvi, 397. Fiinfter Bericht iiber die 
Thatigkeit der Malariaexpedition. Ibid., 1900, xxvi, 541. Schluss- 
bericht iiber die Thatigkeit der Malariaexpedition des geh. med. 
Raths. Prof. Dr. Koch. Deutsche med. Wchnschr., 1900, xxvi, 
733. Zusammenfassende Darstellung der Ergebnisse der Malaria- 
expedition. Deutsche med. Wchnschr., 1900, xxvi, 781; 801. 
18 Darling: op. cit. 286 
HARVEY SOCIETY 
regions where the malarial sick rate did not fall to zero and 
where no anophelines were breeding, 10 per cent, of the men 
who were at work without symptoms had parasites in the blood. 
Thirty per cent, of these were aestivo-autumnal, 70 per cent, 
tertian. Among the Spanish and West Indian families, the 
latent malarias amounted to 30 per cent. Darling observes: 
"It is this latent malaria in every tropical community that con- 
tributes largely to the preservation of malarial parasites, and 
to the infection of anopheles when, after the rainy season, 
mosquitoes have begun to breed in numbers." 
Craig,20 who had previously made important observations 
tending to show that the proportion of malarial carriers among 
adults is nearly as high as that among children, has recently 
brought together in one table the observations as to latent 
malaria made by a variety of observers in different parts 
of the world (Koch, New Guinea; Thomas, Manos, North Brazil; 
Annett, Dutton and Elliott, Nigeria, Africa; Craig, Philip- 
pines ; Ollwig, Dutch, East Africa; Panse, Tongo, East Africa; 
Sergent, Algeria; Plehn, Kameruns, W. Africa. 
TABLE I (From Craig). 
Prevalence of Latent Infection at Various Ages. 
Consolidated Table. 
Age. 
No. Examined. 
No. Infected. 
Per cent. 
Infected. 
1 to 5 years 
1684 
502 
29.8 
5 to 10 years 
1645 
463 
28.1 
10 to 15 years 
1390 
437 
31.4 
adults 
4931 
1139 
23. 
Totals 
9650 
2541 
26.3 
These figures appear to indicate that there is no great differ- 
ence between the number of malarial carriers among children 
and adults. 
" Craig: Important Factors in the Prophylaxis of the Malarial 
Fevers. Southern M. J., Nashville and Mobile, 1912, v, 50-57. MALARIAL FEVER 
287 
Craig estimates that about 50 per cent, of latent cases are 
gamete carriers. The existence of these latent infections, 
especially among individuals who have lived long in infected 
districts, is generally regarded as evidence of a certain 
acquired immunity. But the fact that parasites are to be dis- 
covered in the blood opens the question as to how far the 
immunity is to the parasite or to its toxic products. Some have 
assumed that the latter alone is the case, and true it is that the 
number of parasites found in these individuals is sometimes 
no less, apparently, than that associated in other instances with 
severe symptoms. On the other hand, the number is usually 
rather small, and the immunity may well consist, in part at 
least, in the power of the organism to destroy the parasites so 
as to keep them always at a minimum below that necessary to 
produce symptoms. Although all efforts artificially to pro- 
duce immunity have failed, yet there would seem to be a certain 
acquired immunity in some individuals who have lived long 
in malarious regions. 
TREATMENT AND PROPHYLACTIC METHODS 
From this summary of our knowledge concerning the nature 
and manner of spread of malarial fever, it is quite clear that 
the prevention of the malady is possible, theoretically, by 
breaking the chain of existence of the infectious agent at any 
point in its cycle in mosquito or in man. Abundant proof of 
this proposition has been afforded by a series of practical 
experiments. 
1. Various Italian 21 and English 22 observers have shown 
that thoroughly carried out mechanical protection against the 
bites of mosquitoes will permit individuals to remain for in- 
21 Crassi: op. cit. 
Di Mattei. La profilassi della malaria eolla protezione dell' uomo 
dalle Zanzare. Atti d. Soo. per gli stud. d. malaria. Roma, 1901, 
ii, 24-32. 
" Sambon and Low: British Med. Jour., Lond., 1900, ii, 1679. 288 
HARVEY SOCIETY 
definite periods in regions where the infection is extremely 
prevalent. 
2. Ross 23 and others in Ismailia, Port Said, and elsewhere 
have shown that by thorough drainage and removal of the 
breeding places of anophelines, together with measures such as 
oiling the surface of pools which cannot be drained, the de- 
velopment of the larvae may be prevented and the mosquitoes 
thus entirely removed from certain localities. And this results, 
as might be expected, in the immediate disappearance of the 
disease. 
3. Koch and his students24 in New Guinea and elsewhere 
have further shown that by carefully seeking out the relapses 
before the outbreak of the malarial season and by thorough 
treatment of these, together with any new cases that may break 
out, the parasites may be so far destroyed in their 
human hosts that when the season characterized by the prev- 
alence of anophelines comes on, the malarial epidemic re- 
mains absent. 
With these practical demonstrations, why, then, is not the 
eradication of malaria an easy problem? Why have we not 
taken our malaria in hand as we have yellow fever? Why can 
we not, by isolating and thoroughly treating infected individ- 
uals, while protecting them from the bites of mosquitoes-why 
can we not by these methods easily eradicate the disease? 
The reasons are obvious. The mildness of the manifestations 
in many cases, the frequency of latent infections, the length 
of time during which treatment and precautions must be con- 
tinued, make it very difficult to carry out such measures ex- 
23 Ross: The Prevention of Malaria. 8°, London (Murray), 1910, 
496 et seq. 
21 Koch (R.): Berichte uber die Thatigkeit der Malariaexpedition. 
Op. cit. 
Frosch, P.: Die malaria bekampfung in Brioni (Istrien). Ztschr. f. 
Hyg. u. Infectionskrankh., Leipz., 1903, xliii, 5-66. 
Schilling: In Ross: The Prevention of Malaria, 8°, London (Mur- 
ray), 1910, 496 et seq. MALARIAL FEVER 
289 
cepting in small communities and under practically military 
surveillance. 
There have been ardent partisans of each individual method 
of prophylaxis, and many interesting experiments on larger 
or smaller scales have been carried out. From these experi- 
ences several conclusions may definitely be drawn: 
1. The methods by which malaria may be attacked, may be 
divided into: (a) individual prophylaxis-that relating to the 
patient himself; (b) public prophylaxis-those general meas- 
ures for the protection of the inhabitants which should be 
adopted by countries, states, counties, cities, and towns. 
2. There is no one sovereign method of malarial prophy- 
laxis. Different methods vary in their applicability according 
to the physical geography and climate of the locality, according 
to the denseness and nature of the population, and according to 
the form of government. 
At the base of the prophylaxis of malaria, in a civilized 
country, stands the individual practitioner. If every prac- 
titioner of medicine should recognize and treat thoroughly every 
case of malaria that came to him, and should take precautions 
so that relapses might early be recognized and treated in their 
turn; if, in other words, each practitioner sterilized each in- 
dividual patient, much of the work would be done. 
What does thorough treatment mean? How are we to 
recognize the early relapses and the latent cases of malaria? 
Much of the prevalence of malaria depends upon insuffi- 
cient and incomplete treatment of the disease, and the very 
brilliancy of the specific action of quinine is indirectly the 
cause of much carelessness in treatment, based upon the lack 
of general knowledge as to the best method of giving the 
drug and as to its effect upon the parasites. 
Different salts of quinine vary greatly in their solubility 
in water, with regard to which also the statements of different 
authors vary extraordinarily. The following table compiled 
from several works will give some idea as to these points: 290 
HARVEY SOCIETY 
Table Showing Equivalents of Quinine, Solubility, and Rate of 
Elimination of Different Salts of Quinine. 
Salt. 
Equivalent 
of quinine. 
Solubility. 
Appearance 
of Urine. 
Per cent. 
Minutes. 
Bihydrochlorate 
72.0 
1/1 
15 
Hydrochlorate 
81 8 
1/40 
15 
Hydrobromate 
. 76.6 
1/45 
Bihydrobromate 
60.0 
1/7 
Acetate 
84.0 
30 
Citrate 
67.0 
1/820 
30 
Bisulphate 
59.1 
1/11 
30 
Sulphate 
73.5 
1/800 
45 
Tannate 
20 0 
slight 
180 
Euquinine 
81.0 
1/12,500 
Phosphate 
76.2 
1/420 
V alerianate 
73 0 
1/120° 
Lactate 
78.2 
1/110 
Salicylate 
70.1 
1/225 
Arseniate 
69.4 
very slight 
The rapidity and completeness of absorption of quinine 
vary greatly according (1) to the salt used; (2) to the form in 
which it is administered; (3) to the method in which it is intro- 
duced into the body. Most quinine (MacGilchrist)26 is absorbed 
by the small intestine; a very small amount by the stomach, 
when the drug is introduced during fasting and in an easily 
soluble form; and a relatively smaller amount yet from the 
large intestine. The absorption is somewhat retarded when 
quinine is given with or after food, and also if the less soluble 
forms of the salt are used. 
Rapid action is best obtained by administration of the soluble 
salts while fasting; gradual and prolonged action by the less 
soluble salts given during or after meals. Under the latter 
circumstances the quinine in the circulation may be maintained 
at a considerable level for as much as eight hours. 
As a rule, from two-thirds to three-quarters of the quinine 
introduced into the organism is destroyed by the metabolic 
processes of the body, and, through them, is probably deprived 
25 MacGilchrist (A. C.) : Quinine and its salts; their solubility and 
absorbability. Paludism, Simla, 1911, No. 2, 27-30. MALARIAL FEVER 
291 
of most if not all of its activity. It has generally been assumed 
that one may estimate fairly well the efficacity of our methods 
of giving quinine by the amount eliminated as such by the urine 
and faces. Giemsa and Schaumann 26 appear to have shown 
that a given quantity of quinine administered daily in several 
fractional doses is eliminated more completely than a similar 
amount administered as a single dose (23.8 per cent.: 27.8 per 
cent.). MacGilchrist, however, asserts that larger doses 
administered three times a day give better results in treatment 
than fractional doses administered at two-hour intervals. The 
same observer, estimating the absorbability of quinine by the 
study of the minimal lethal dose in guinea pigs, arrives at 
essentially the same conclusions as Mariani27 and Giemsa and 
Schaumann, who studied only the urinary elimination. Accord- 
ing to MacGilchrist quinine is absorbed best: (1) subcu- 
taneously, in solutions of a dilution not less than 1 to 150; (2) 
in soluble form by the mouth on an empty stomach; (3) by 
the mouth with or just after a meal; (4) subcutaneously in the 
ordinary dilutions 1: 2-1: 8. 
The first method is, of course, impossible. Subcutaneously 
in the ordinary dose, the absorption of quinine is not very com- 
plete, for a large proportion of the salt is precipitated in com- 
bination with proteid substances. But, practically, this method 
of administration is often necessary to obtain immediate action 
in individuals with pernicious malaria, where the drug cannot 
be administered by the mouth. 
Here one is obliged to resort to subcutaneous or better deep 
intramuscular injections of soluble salts, of which the dihydro- 
chlorate is unquestionably the best, in doses no larger than 
1 Gm. diluted in the proportion of 1 to 10. 
The most rapid method of introduction of quinine is, un 
26 Giemsa and Schaumann: Pharmakologische und chemische Studie" 
uber Chinin. Arch. f. Schiffs u. Tropenhyg., Leipz., 1907, xl, 1-8.1 
27Mariani: L'assorbimento e Feliminazione della chinina e de' suci 
sali, etc. Atti d. soc. per gli stud. d. malaria. Roma, 1904, v, 211. 
SulF assorbimento e sulF eliminazione della chinina e dei suoi 
sali, etc., ibid., 1905, vi, 72. 292 
HARVEY SOCIETY 
doubtedly, the intravenous injection. I have seen cinchonism 
produced within a few moments after the injection, while yet 
standing by the bedside. But the intravenous injection of 
quinine in the ordinary doses and dilutions is not devoid of 
danger, and MacGilchrist insists that it should never be given 
in dilutions less than 1 to 150. This, however, is perfectly 
possible and easy to do in an emergency. 
By the mouth, it is better to give the salts of quinine in 
solution rather than in capsules, and the salt most fitting for 
this method of administration is the dihydrochlorate, which is 
soluble in less than its own volume of water. The salt most 
commonly used in this country, the sulphate of quinine, may 
however easily be administered in solutions to which a little 
diluted hydrochlorate or sulphuric acid is added. 
The objections raised by MacGilchrist to the administration 
of soluble salts in tablet or capsule form, that they may cause 
gastric disturbances, is, as a matter of fact, more theoretical 
than real, and except in urgent cases quinine may be given in 
this fashion with wholly satisfactory results. 
From these considerations it is easy to see that the form and 
manner in which one gives quinine should vary according to the 
conditions existing in the patient. It has been a time-honored 
custom in intermittent fever to administer quinine in an inter- 
mittent manner. Torti advised large doses in the period 
immediately preceding the paroxysm. Sydenham gave large 
doses immediately after the paroxysm. Experience shows that 
to obtain the most rapid action it is well to have quinine in the 
system at the time of the paroxysm, namely, at that period 
when the fresh young brood of merozoites is present in the 
circulation. Practically, however, excepting in pernicious 
cases, experience to-day favors the administration of quinine 
in regular, daily, broken doses at frequent intervals. As 
Mariani and Giemsa and Schaumann have pointed out, a 
steady quantity of quinine may then be maintained in the cir- 
culation without the discomfort often following individual 
large doses. 
Single doses of more than 1 Gm. (gr. xv) are never neces- MALARIAL FEVER 
293 
sary, and in all excepting pernicious cases, 2 Gm. (gr. xxx), 
in fractional doses of 0.32 Gm. (gr. v) every four hours, are 
quite sufficient. 
The length of time under which treatment should be con- 
tinued varies materially with the case. For ordinary tertian 
fever in temperate climates, the dose may soon be reduced to 
1 Gm. a day, and, in the course of a few days, to one-half that 
amount. But in this quantity it should be continued for long 
periods of time, not less than three months. In this way alone 
may we hope to avoid a large percentage of relapses. 
In aestivo-autumnal fever it is often necessary to continue 
treatment with as much as 2 Gm. (gr. xxx) a day for a week, 
and the diminution of doses thereafter will depend largely upon 
the appearance or non-appearance of crescents. Darling28 
appears to have shown that 2 Gm. a day will reduce the gametes 
of asstivo-autumnal parasites to a non-infective minimum* in 
two or three weeks. 
To one who has not observed it, the difference in the 
efficacity of treatment in an individual on his feet and attending 
to his affairs, and in one who is kept at rest in bed is incredible. 
It is always desirable that a patient with malarial fever 
should be kept in his bed until all symptoms of fever have 
gone. It is highly desirable that the patient with jestivo- 
autumnal fever should be kept in his room until gametocytes 
have been reduced to a non-infective minimum. The recent 
observations of Thompson 29 emphasize the importance of vigor- 
* Darling concludes from experimental studies, that patients with 
more than one crescent to every 500 leucocytes, or 12 to a cu. mm. 
of blood, are infective. If the crescents are scantier than this there 
is little chance of their developing in the mosquito. 
28 Darling: Transmission of Malarial Fever in the Canal Zone by 
Anopheles Mosquitoes. J. Am. M. Ass., Chicago, 1909, liii, 2051- 
2053. 
28 Thompson (D.) : I. Research into the production, life, and death 
of crescents in malignant tertian malaria, in treated and un- 
treated cases, by an enumerative method. Annals of Trop. Med. 
and Parasitol., Liverp., 1911, Series T. M., v, 57. 294 
HARVEY SOCIETY 
ous initial treatment of a patient with sestivo-autumnal gam- 
etocytes in his blood. 
The patient with fever or with demonstrable malarial para- 
sites in his blood should always be isolated and protected with 
a net. A regular daily search for mosquitoes should be made 
in the house, and every method for their extermination by traps 
and fumigation should be employed. 
All evidence goes to show that it is only by treatment con- 
tinued through long periods of time, that relapses can be pre- 
vented, and even then a certain percentage of cases, especially 
of tertian malaria, reawaken with the succeeding season. 
How are we to recognize the early relapses and latent in- 
fections? Only by careful observation of the patient, by the 
study of the temperature, by frequent examination of the 
blood, and by determining the presence or absence of splenic 
enlargement. This latter method has been much employed, 
following the investigations of Koch, and it is of very con- 
siderable value in the carrying out of large public measures 
of prophylaxis. It is, however, obviously a much more uncer- 
tain procedure than that of careful examination of the blood. 
A very remarkable observation has recently been made by 
David Thompson,30 which, if confirmed, may be of real assist- 
ance in the recognition of latent cases. Ordinarily in acute 
malaria there is a leucopenia, but in latent malaria, where the 
number of parasites sporulating is small, there is a leucocytosis 
which increases, at the time of sporulation, to a very remarkable 
degree. Thompson has found often from 30,000 to 50,000 
leucocytes, and once even 125,000, a leucocytosis which rapidly 
falls after the period of sporulation. In acute malaria the 
relative proportion of mononuclear leucocytes is low at the time 
of the paroxysm, becoming high with the fall of temperature 
and apyrexia; this same fluctuation persists without regard to 
the total number of leucocytes for months, even years, after 
apparent cure. 
30 Thompson (D.) : II. The leucocytes in malarial fever. A method 
of diagnosing malaria long after it is apparently cured. Ann. 
Trop. Med. and Parasitol., Liverp., 1911, Series T. M., v, 83. MALARIAL FEVER 
295 
As has been said before, the corner-stone of the edifice of 
malarial prophylaxis is the work of the individual practitioner 
in protecting his patients and in detecting and properly disin- 
fecting the affected individual. But while nearly every case of 
typhoid fever, yellow fever, or cholera falls into the hands of 
a physician, and while in most of these diseases the danger is 
over with the disappearance of the acute symptoms of the 
malady, in malaria the condition is radically different. 
Immense numbers of patients in rural districts never consult 
a physician, and many more, imperfectly treated, are carriers 
of the disease through long periods of time. 
The question, therefore, is not purely one of thorough treat- 
ment ; in every malarious district the healthy must be protected 
from the dangers of infection, which are always more or less 
present. The duties of the individual practitioner toward the 
patient and the general public are therefore greatly com- 
plicated. 
Let us consider, first, the question of the measures of 
individual prophylaxis which one should adopt when in a 
malarious region. 
A. The first principle is the avoidance, so far as possible, 
of infected houses or infected individuals. The hunter or 
traveller in the wilds should, when possible, avoid sleeping in 
recently inhabited houses. A tent so far removed as possible 
from the infected population is the safest place. 
B. The house and the bed should be thoroughly netted, the 
house, if possible, with wire netting. The bed net should be 
strong and should never be allowed to fall to the floor, but should 
always be tucked under the mattress. Loose folds shut out the 
air. The meshes should not be too large. Eighteen threads to 
the inch (seven to the cubic millimetre) are sufficient. There 
should be no slit for entering. The substance should be white, 
so that the insects may readily be detected. Holes are fatal. 
C. The thoroughly netted house should be searched daily 
for mosquitoes. This should be the regular duty of some mem- 
ber of the household. These may be killed by hand and may 
be caught from ceilings or walls by a small butterfly net on a 296 
HARVEY SOCIETY 
pole. In some instances fumigation may be desirable. This 
may be carried out as follows:31 
"To fumigate a room thoroughly for mosquitoes all the 
chinks in the doors and windows should be closed by pasting 
paper over them. Then burn the culicide as follows (Sir 
Rubert Boyce) : 
"1. Sulphur. Allow 2 lbs. of sulphur to 1,000 cubic feet. 
Use two pots, place them in a pan containing 1 inch of water 
to prevent damage, and set fire to the sulphur by means of 
spirit. 
"Duration, Three hours. 
"2. Pyrethrum. Allow 3 lbs. to 1,000 cubic feet, and divide 
amongst two or three pots, using the same precautions as with 
sulphur. 
"Duration, Three hours. 
"3. Camphor and Carbolic Acid. Equal parts camphor and 
crystallised carbolic acid are fused together into a liquid by 
gentle heat. Vaporise 4 ozs. of mixture to each 1,000 cubic 
feet; this can be done by placing the liquid in a wide shallow 
pan over a spirit or petroleum lamp; white fumes are given 
off. To avoid the mixture burning, the fumes should not come 
in close contact with the flame of the lamp. 
"Duration, Two hours. 
"Few of these methods actually kill the insect. After 
fumigation, floors should be thoroughly swept and all stupefied 
insects burned. ' ' 
D. One should look out for all stagnant water on ground and 
plants, in any receptacle in the neighborhood of the house, "in 
cisterns, drains, gutters, tubs, jugs, flower-pots, gourds, broken 
bottles and crockery, old tins, or other rubbish, or holes in trees 
or in certain plants, such as the wild pineapple." As Ross 
suggests, an inspection of the premises once a week is an admir- 
able plan. Cisterns should be screened so that mosquitoes can- 
not lay eggs on the surface. 
E. For those obliged to work in the neighborhood of in- 
31 R >ss: op. cit., 59. MALARIAL FEVER 
297 
fected localities at dusk and by night, personal protection by 
means of nets hanging from the hat and bound about the neck, 
thick gloves, etc., have been shown to be of great value, espe- 
cially by the Italians, in the case of employees on the State 
railways, and by the Japanese army in Formosa. 
These methods, however, are most uncomfortable and try- 
ing, and very difficult to enforce. Ross points out the consid- 
erable value of the ordinary hand fan consistently agitated by 
an intelligent individual. 
F. Protection by medicinal substances applied to the skin, 
such as oil of lavender, oil of citronelle, oil of eucalyptus, 
familiar to all fishermen in this country, is of considerable 
value where one cannot carry out other precautions. He, how- 
ever, who has used these substances by night, knows well their 
inconveniences. They soil the bed, and usually give out to such 
an extent as to need at least one re-application before morning. 
G. Finally, the method of quinine prophylaxis is of really 
great importance. There is abundant proof that the regular 
ingestion of small quantities of quinine is an excellent pro- 
tection against infection. Koch,32 as a result of his East Indian 
and African experiences, advised 1 Gm. (gr. xv) every seventh 
and eighth day. Such intermittent treatment is, however, easy 
to forget, and large doses often cause unpleasant symptoms. 
Mariani33 has shown that small divided daily doses accomplish 
as much and are easier to take. From 0.4 to 0.6 Gm. (gr. vi to 
gr. x) daily in divided doses is usually advised, and in most 
cases this prevents infection, particularly if associated with 
other measures of protection. 
If such methods as these be carried out by the individual 
and in the household, there is little fear, even in the worst 
regions, of other than occasional mild and easily treated 
infections. 
It is especially interesting to note that regularly carried out 
quinine prophylaxis is as valuable in combating malarial 
32Koch: Berichte uber die Thatigkeit d. Malariaexpedition. Op. cit. 
33 Mariani: op. cit. 298 
HARVEY SOCIETY 
haemoglobinuria as it is in the case of any other manifestation 
of the disease (Reynaud).34 
But the important point in connection with prophylaxis of 
malaria is the question of public measures of protection. Here, 
as has already been said, we in America have so far made a 
poor showing in comparison to what has been done in other 
countries and in our own colonial possessions. Let us for a 
moment consider some of that which may be done and has been 
done elsewhere. 
The measures of public prophylaxis which should be adopted 
in a malarious district are many, but unquestionably the most 
fundamental are those directed toward the extermination of 
mosquitoes. These measures consist: 
1. In the removal, so far as possible, of all breeding places, 
namely, collections of stagnant water. 
2. In the treatment of those collections of water which 
cannot be removed in such manner that they are no longer 
suitable for the complete development of the larvae and pupae 
of the mosquito. 
3. In the removal of all underbrush, grass, etc., which might 
serve as resting or hiding places for the insects, from consider- 
able areas surrounding all human habitations. 
In some localities these procedures alone may suffice to 
eradicate the disease. 
ISMAILIA 
One of the most brilliant examples of the eradication of 
malaria as a result of mosquito destruction is the achievement 
of Ross 35 at Ismailia. 
The mosquitoes here all came from a canal which conducts 
the water of the Nile to the town, and from the standing water 
associated with it. The country surrounding the town is a 
desert. The climate is rainless. The canal company is all- 
powerful in the government of the town. The flow of water in 
84 Reynaud (G.) : La quinine preventive contre le paludisme et la fievre 
bilieuse hemoglobinurique. Marseille med., 1911, xlviii, 49; 81; 
126; 151; 177. 
"Ross: The Prevention of Malaria. 8° Lond. (Murray), 1910, 499. MALARIAL FEVER 
299 
the canal was regulated; leaks were stopped. The marsh was 
drained. Irrigation canals and channels were cleared of weeds 
and the wyater made to run swiftly. "When a certain garden 
had received its proper supply of water, the flow was stopped 
and the wTater allowed to soak in. ' ' All receptacles for standing 
water were emptied. A regular mosquito brigade visited each 
house once a week and treated the cesspools with petroleum. 
In September, 1902, this work was begun. By 1906 the disease 
was eradicated, as may be appreciated by reference to the 
following table:36 
Malaria at Ismailia. 
Years 
Cases. 
1899 
1,545 
1900 
2,284 
1901 
1,990 
1902 
1,551-antimosquito war begun. 
1903 
214 
1904 
90 
1905 
37 
1906 
No fresh cases. 
1907 
No fresh cases. 
1908 
No malaria contracted in Isma'ilia. 
HAVANA 
With the American occupation of Havana in 1909, a gen- 
eral cleaning up of the city was undertaken under military 
direction, and in February, 1901, Gorgas began his famous 
campaign against yellow fever, a campaign the essential feature 
of which was extensive mosquito destruction. This work has 
been continued since then by the Cuban authorities. As is 
well known, yellow fever disappeared from Havana seven 
months after the initiation of this work. 
The striking effect of these measures on the malarial mor- 
tality of Havana may be seen by reference to the following 
table: 
30Ross: op. eit., 503. 300 
HARVEY SOCIETY 
Deaths From Malaria at Havana. 
1890 170 
1891 203 
1892 202 
1893 240 
1894 201 
1895 207 
1896 250 
1897 811 
1898 910 
1899 909 
1900 325 
1901 151 
1902 87 
1903 51 
1904 44 
1905 32 
1906 26 
1907 23 
1908 119 
1909 6 
1910 15 
This is unquestionably the ideal method of prophylaxis, and 
it may often be carried out successfully, especially in cities and 
centres of population. But in large areas of swampy, uncul- 
tivated, sparsely populated land such as exist in some of our 
Southern States, these measures are difficult in their application 
and do not suffice. Here we must combine and concentrate all 
known methods of prophylaxis. 
panama 
The great example of what may be done under such condi- 
tions is afforded by the work of Gorgas at Panama. Here 
conditions were as difficult as may well be imagined. The 
whole district was terribly infected, not only with yellow fever 
but with the gravest forms of malaria. The death rate had 
baffled even those enterprising Frenchmen through whose fore- 
sight and energy the waters of Europe had been married to 
those of the Indies. The population to be dealt with was 
a large body of workmen living in the country within half a 
mile of the railroad, in small villages and camps and sometimes 
in isolated dwellings. Fresh from his work in Havana, Gorgas 
was given sanitary control of the Canal Zone in 1904. The 
results of his campaign are remarkable. The last case of yellow 
fever occurred in 1906. The death rate has steadily fallen MALARIAL FEVER 
301 
until it compares most favorably with that of the cleanest of 
civilized nations, as may be seen by reference to the following 
table: 
Death Rate per 1000 Inhabitants in Panama Canal Zone. 
1905 49.94 
1906 48.37 
1907 33.63 
1908 24.83 
1909 18.19 
1910 21.18 
1911 21.46 
The deaths from malaria have fallen from 16.21 per thou- 
sand in July, 1906, to 2.58 per thousand in December, 1909. 
Among employees the deaths have fallen from 11.59 per 
thousand in November, 1906, to 0.99 per thousand in Novem- 
ber, 1911. 
The admission rate per thousand among employees to the 
hospitals for malaria has fallen also in a most encouraging 
manner. 
Admission Rate to Hospitals for Malaria. 
(Per Thousand) Canal Zone. 
1904 125 
1905 514 
1906 821 
1907 424 
1908 282 
1909 215 
1910 187 
1911 184 
The cost of this sanitary work in the canal for a population 
amounting to something over 100,000 inhabitants is $3.50 a 
head, of which about $2.00 is spent on anti-malarial work. 
And this work is but a beginning. A sure and steady im- 
provement must follow its continuance. A certain relapse to 
the old conditions will follow its abandonment. 
A word as to the nature of this work perhaps is worth while. 
The 47 miles of the Panama strip are divided into 18 districts, 
each under the control of an inspector, under whom are em- 
ployed 50 men. 
Drainage.-All pools within 100 yards of individual dwell- 
ings or within 200 yards of villages are done away with either 
by subsoil or open (concrete if possible) ditches. 302 
HARVEY SOCIETY 
Brush and Grass Cutting.-Within the same areas all trop- 
ical undergrowth is cut. Brush and grass shelter adult mos- 
quitoes, while anophelines will not as a rule cross a clear area 
of 100 yards. 
Oiling is used where drainage is impracticable. Where oil 
will not spread, a poison which is called "larvicide" is used. 
This consists of crude carbolic acid, resin, and* caustic soda. 
Quinine in prophylactic doses is offered to all employees. 
Screening is carefully carried out on all government build- 
ings. 
Killing Mosquitoes.-Each morning all mosquitoes found in 
buildings are killed by special men. 
ITALY 
Conditions not dissimilar to those in the United States 
exist in Italy, where the problem has been approached in a 
somewhat different manner. Here, as everywhere, the main 
mortality occurs among the peasants, especially on rice planta- 
tions and in the fields, in the army, and among the employees 
of the railways, who are obliged to live in infected and un- 
healthy localities. In 1890, a Society for the Study of Malaria 
was founded, supported by contributions of generous citizens 
headed by the Queen. 
Inspired by the activities of this society presided over by 
one whose name has long and honorably been identified with 
the study of this disease,* a most important and active cam- 
paign has been conducted. 
While endeavoring in every way to educate the public and 
to encourage all measures directed toward the destruction of 
mosquitoes, their larvae, and the breeding places, the society 
at the outset directed its attention especially to personal and 
household protection from the bites of mosquitoes, and later 
toward quinine prophylaxis. 
The experimental demonstration of the value of the netting 
* Prof. Angelo Celli. The work done by this society is presented 
annually in the admirable Atti della Soc. per gli studi della Malaria, 
and is summed up at the end of each volume by Prof. Celli. MALARIAL FEVER 
303 
of dwellings and the personal protection against the bites of 
mosquitoes, carried out by this society, has already been men- 
tioned. Its impracticability, however, on a large scale in rural 
communities, was early recognized, and the great value of 
quinine prophylaxis under such circumstances has been admir- 
ably brought out by the Italian campaign. 
By means of lectures and demonstrations and publications 
widely distributed, and with the help of many district phy- 
sicians and school masters, and through the formation of local 
anti-malarial committees, a campaign of education has been 
steadily conducted for over ten years. 
In 1902, at the instigation of the society, the State began 
the manufacture of quinine, which is placed on sale at every 
tobacco store in Italy. The price is nominal. The preparations 
are pure and easy to take, and are supplied gratuitously to the 
needy, partly through the funds of the society and partly as a 
result of laws recently passed by the government, through which 
the profits from the manufacture of the drug, already consid- 
erable, are employed in furthering the anti-malarial campaign. 
The results as set forth by the following table are most 
striking: 
Italy:* State Quinine and Mortality from Malaria. 
Consumption of State Quinine 
Mortality from Malaria. 
Net profits of 
Adminstration 
of State Qui- 
nine in Lire. 
Financial Year 
Kilograms Sold 
Solar Year 
Total Death 
1895 
16,464 
1896 
14^017 
1897 
11,947 
1898 
11,378 
1899 
10,811 
1900 
15365 
1901 
13361 
1902-3 
2,242 
1902 
9,908 
34,270 
1903-4 
7,234 
1903 
8,513 
183,039 
1904-5 
14,071 
1904 
8,501 
183,382 
1905-6 
18,712 
1905 
7,838 
293,395 
1906-7 
20,723 
1906 
4,871 
462,290 
1907-8 
24,351 
1907 
4,160 
700,062 
1908-9 
23,635 
1908 
3,463 
769,809 
1909-10 
21,656 
1909 
3,535 
720,000 
* Compiled from Atti della Soc. per gli stud, della Malaria. 304 
HARVEY SOCIETY 
An especially valuable part of the work of the Italian So- 
ciety for the Study of Malaria has been the preparation of 
chocolate confections of tannate of quinine. The tannate, a 
salt but slightly soluble and rather slow of absorption, is never- 
theless absorbed in the end nearly, if not quite, as completely as 
the more soluble preparations. The cioccolatini, agreeable to 
the taste and practically free from the bitterness of quinine, 
are peculiarly valuable in connection with large general 
measures of prophylaxis, as they are well taken by children. 
The objection that the constitution of the preparation is sub- 
ject to some variations in its quinine content has little impor- 
tance in the light of the Italian experiences. 
The work in Italy to-day has opened up to agriculture 
regions which had previously been practically abandoned, and 
is saving, as may be seen from the chart, thousands of lives 
every year. 
GREECE 37 
In Greece, in 1903, a similar league was formed which is 
doing good work. The studies on the Plain of Marathon em- 
phasize the value of small, daily, prophylactic doses of quinine 
in association with other measures, while other studies in the 
same region have furnished an excellent demonstration of what 
may be accomplished by careful diagnosis and thorough treat- 
ment alone. 
INDIA 38 
The British Government in India has recently started a 
campaign of a similar sort, the results of which must soon be 
apparent. A conference was held in October, 1909, at Simla, 
at which there was founded a committee for the study of 
37 Savas (C.): Le paludisme en Grece, etc. Atti d. Soc. per gli stud, 
della Malaria. Roma, 1907, viii, 136-170. Also, similar communi- 
cations in the same publication: 1908, ix, 95-105; 1909, x, 291- 
298; 1910, xi, 129-136. 
33 Paludism, being the Transactions of the Committee for the Study 
of Malaria in India. Simla, No. I, July, 1910. MALARIAL FEVER 
305 
malaria in India. The organization of the campaign in abstract 
was as follows :39 
1. A committee in each province of three or more members, 
personally interested in the malaria problem, enjoying the 
confidence of the local government and prepared to obtain and 
supervise local inquiries. They should perhaps control the 
agency for the distribution of quinine. One of their first duties 
would be (in association with provincial sanitary department) 
to ascertain the real causes of death in different localities, and 
to set in motion an inquiry in each district regarding the rela- 
tion of the fever season to the drainage and rainfall. 
2. Every autumn each provincial community would dele- 
gate, under the orders of the local government, one of their 
members to attend a meeting of a general committee in Simla. 
This general committee would consist of the provincial delegates, 
the sanitary commissioner representing the Governor of India, 
with Major James as Secretary. The Government of India 
would appoint a general scientific committee 
A class of instruction was held in March, 1910, presided over 
by one of the members of this general committee, which was 
attended by various medical officers and subordinates from each 
province. This work has been most valuable. At the first 
meeting, a series of special subjects to be inquired into was 
settled upon and the reports which are appearing in a publica- 
tion entitled "Paludism," edited by the scientific committee, 
already contain much valuable material. 
There can be little doubt that this movement will bring 
great results in India. 
In many other regions, especially in Algiers and in British 
and German Colonial possessions, enlightened campaigns 
against malaria have been conducted with excellent results. 
When, however, we turn to our own country, we find, alas, 
that but little has been done. Local anti-mosquito campaigns 
undertaken here and there, of which those in the neighborhood 
AMERICAN CONDITIONS 
39 Abstracted from Paludism, op cit. 306 
HARVEY SOCIETY 
of this city have been notable, have had good results. Local 
attempts at educational movements, of which that conducted 
by Dr. Lankford 40 in San Antonio, Texas, is a striking example, 
have been of great interest and are most creditable. 
In Pennsylvania 41 and Florida42 special bulletins have been 
issued by the State societies and, in the latter State, a most 
creditable beginning has been made toward a thorough State 
campaign. Nowhere, however, have systematic anti-malarial 
measures been taken on any large scale. 
The first problem which confronts us when we consider the 
steps which should be taken is as to the determination of the 
prevalence and distribution of the disease. Here, immediately, 
we meet with a difficulty. We know that malaria exists in 
certain parts of New England and New York; that it increases 
in prevalence along the coast, southward; that it prevails with 
particular virulence in the Mississippi Valley and in the val- 
leys of its tributaries; that it occurs to a certain extent on the 
Pacific Coast and about the great lakes. The conditions asso- 
ciated with registration of morbidity and mortality are, how- 
ever, so imperfect that it is a difficult matter to form an 
adequate idea as to the malarial mortality, not to speak of 
the morbidity. 
In the interesting study by the Florida State Board of 
Health, it is estimated that the rural malarial death rate for 
the South for 1908 was approximately 54.52 per 100,000 inhab- 
itants, or 11,326 deaths. The registration of the deaths in 
this area is so imperfect that this is but an estimate. But if 
this estimate even approaches the truth, it is probably safe to 
say that the actual mortality in this country is as high as 
10,000 a year, and probably considerably greater. And be- 
side these fatal cases, there is an enormous number of individ- 
40 Lankford (J. S.) : Public School Children and Preventive Medicine. 
N. York M. J. (etc.), 1904, Ixxx, 1124-1126. 
41 Malaria: How it is Caused and How to Get Rid of It. Pa. Health 
Bull., Harrisburg, March, 1911, No. 21. 
41 Malaria: Its Prevention and Control. State Board of Health of 
Florida. Publication 84, Jacksonville, June, 1911, pp. 1-43. MALARIAL FEVER 
307 
uals, hundreds of thousands certainly, whose lives are made 
miserable and whose physical and moral development are re- 
tarded and perverted by a preventable and easily treated 
disease; and we, as a people, with just pride in what we have 
done in Havana and Panama, sit complacently and allow this 
to go on. 
A few' years ago, it was discovered that much of what had 
been called malaria in the South was in reality due to infection 
with the hookworm-Necator Americanus-and straightway, 
through the philanthropy of Mr. Rockefeller, a commission was 
established, which, working in unison with State boards of 
health through the South, is doing a great work in the eradica- 
tion of this plague. 
But the old plague, that which calls for a greater toll of 
human lives every year, a malady easily prevented and easily 
treated, still holds its sway practically unattacked. It is the 
old story that "familiarity breeds contempt." 
That no more general measures are taken in this country for 
the study and control of malaria is a national disgrace. 
The problem is one which demands national consideration. 
Although the actual prophylactic measures must, under our 
form of government, be undertaken by State and local author- 
ities, the first step should be a wide-spread and general study 
of conditions as they exist in the various localities. 
Harris of Mobile and recently Craig 43 of the Army have 
suggested the formation of a national commission for the study 
of the disease. The creation of such a commission would be 
an admirable plan. 
Just such measures as this would be rendered possible by 
the establishment of that National Bureau of Health so urgently 
necessary and so long struggled for by all who have the health 
and welfare of the community truly at heart. Such a commis- 
sion working in harmony with the health authorities of the 
43 Craig (C. F.) : Important Factors in the Prophylaxis of the 
Malarial Fevers. Southern M. J., Nashville and Mobile, 1912, 
50-57. 308 
HARVEY SOCIETY 
various States could rapidly accomplish results of inestimable 
value. 
For the accomplishment of much that is to be desired in 
the attempt to control malaria in this country, the initiation 
of a popular campaign, a campaign of education, is absolutely 
necessary. 
This might be accomplished through the establishment of a 
National Society for the Study and Prevention of Malaria, a 
society analogous to that existing in Italy. Such a society might 
be formed as an adjunct to a national or endowed commission. 
It would, in the beginning, have to depend upon individual 
subscriptions as in the case of the Italian organization, and 
these would have to amount to an appreciable sum, if it were 
hoped to enter immediately upon valuable work. But if a 
foundation could be established, such as that w'hich exists for 
the study of the hookworm problem, it would be safe to proph- 
esy that within a few years the results in the saving of human 
lives would be very appreciable. Such an organization should 
have its central office somewhere in the midst of a malarious 
country, i.e., in the South. An excellent place would be in 
New Orleans, a great centre in the immediate neighborhood 
and within easy access of gravely malarious districts. More- 
over, New Orleans is already the seat of a school of tropical 
medicine. The campaign should be deliberately planned under 
the direction of a carefully chosen and well qualified and 
salaried director. The first point for study would be the dis- 
tribution of malaria in one State after another. This work 
should be undertaken in connection with the local health 
authorities, as is being done by the hookworm commission. 
Through the foundation of a central Society for the Study and 
Prevention of Malaria, with branch organizations in each State 
analogous to the anti-tuberculous leagues or to the excellent 
organization in India, a vigorous campaign of education should 
be conducted. 
It is especially important to instruct, to interest, and to 
enlist the support of school teachers and later to arrange for 
systematic instruction of the children. In this connection one MALARIAL FEVER 
309 
cannot do better than quote the words of Craig :44 ' ' The teach- 
ings of the essentials of malarial prophylaxis in public 
schools, in regions in which these fevers are endemic, is a most 
useful method of public education. The young are receptive 
and there is no better way of interesting the parent than by 
instruction of the children. Not only is this true, but what one 
learns in youth becomes a matter of habit and will be prac- 
ticed throughout life. The adage that 'You cannot teach an 
old dog new tricks,' is often exemplified when attempts are 
made to instruct the adult population in modem views of the 
tetiology and prophylaxis of disease, and for this reason it is 
most important that the young be thoroughly taught regarding 
the prophylaxis of malaria. ' ' 
Above all, it should not be forgotten that an educational 
campaign of this nature has a far wider effect than the in- 
fluence upon the specific malady against which it is directed. 
It should and would lead to the more general instruction in 
public schools as to matters of general and personal hygiene, 
and such instruction, if given in the proper manner, not by dry 
lectures and recitations but by practical demonstration, cannot 
fail to go far toward making this country a better and safer 
place in which to live. 
By such a campaign the interests of the community would 
soon be awakened, and active public support would be gained 
for measures insuring proper registration of the malarial mor- 
tality and morbidity, as well as for active prophylactic 
procedures. 
But it is not only in spreading the propaganda that chil- 
dren may be of use in an active anti-malarial campaign. They 
may at times be employed in putting into effect some of the 
fundamental measures of malarial prophylaxis. School chil- 
dren, in the course of their instruction, may be of real assist- 
ance in detecting the breeding places of anophelines-as is 
testified to by the interesting results obtained in San Antonio 
under the leadership of Lankford.45 
44 Craig: op. cit. 
45 Lankford: op. cit. 310 
HARVEY SOCIETY 
There is another interesting manner in which a good deal 
might be accomplished. The organization of Boy Scouts is 
spreading rapidly through the country. But no part of the 
instruction of the soldier is more important than that which 
relates to the hygiene of the encampment. The employment 
of boy scouts in the course of their instruction in the detec- 
tion of the breeding places of anophelines, as has already been 
attempted in Pensacola,46 perhaps, indeed, in the actual treat- 
ment of these localities, might well be of great assistance in 
local anti-malarial campaigns. 
Exactly how the work of such a society alone, or better as 
an adjunct to a central commission, might best be accomplished 
could be determined only as the investigation continued. In 
some regions, the main prophylactic effort would probably be 
directed toward drainage and mosquito destruction; in others, 
toward measures of personal protection and quinine prophy- 
laxis. It is, however, quite certain that the first and principal 
work would be one of investigation and education. So soon as 
our legislators-and that means the people-understand the 
true conditions, just so soon may they be counted upon to lend 
a hand and assist in the good work. It is the belief of the 
speaker that the establishment of a scientific commission, ap- 
pointed by the Government or established through private 
endowment, for the study and prevention of malaria, supported 
by an active popular campaign conducted by national or State 
anti-malarial leagues, would bear results of no less brilliancy 
than those which have been accomplished in other parts of the 
world. And this means the annual saving of thousands of 
human lives and the restoration to health of hundreds of thou- 
sands of suffering human beings, with all the influence that this 
has on the physical and moral character of the race and on the 
efficiency and prosperity of the community. 
I have said before, and I wish to repeat it now, that no 
more measures are taken in this community for the study and 
40 Malaria: Its Prevention and Control. State Board of Health of 
Florida, Publication 84, June, 1911, 30. MALARIAL FEVER 
311 
control of malaria is a national disgrace. Such a condition 
could not long exist with an efficient National Bureau of 
Health, through which the initiative in the necessary statistical 
investigations and suggestions as to the proper prophylactic 
steps should come. That no such body should exist in our 
country to-day is a sad reflection on the general intelligence and 
education of the public. But if we are not as a community 
sufficiently intelligent to realize that the health of our fellows 
approaches in importance that of the sheep and the hog so dear 
to our representatives in Congress-that is to us-it is well at 
least for us as physicians to recognize the fact and to do what 
we can to show the way. Some Questions Concerning Medical 
Education 
W. S. THAYER, M. D., HON. F. R. C. P. I. 
BALTIMORE, MD. 
Reprint from 
The Ohio State Medical Journal 
January, 1913 SOME QUESTIONS CONCERNING MEDICAL 
EDUCATION 
W. S. THAYER, M. D., HON. F. R. C. P. I. 
BALTIMORE, MD. 
Reprinted from The Ohio State Medical Journal, January, 1913 
THE STONEMAN PRESS, COLUMBUS, OHIO SOME QUESTIONS CONCERNING MED- 
ICAL EDUCATION. 
ing country of ours, we have had in the past, litt 
time for early education and college training. Ot 
leaders, our successful men in most branches c 
life, have been strong characters, who have, i 
many instances, absorbed that experience, that et 
ucation, if you will, which has' enabled them 1 
ripen into the fulness of their strength, in a scho< 
of adversity. Often men of considerable strengt 
of character, and of real attainment, they have yi 
been rugged and rather rough men, dealing with 
rugged and sometimes rough people. 
But conditions have changed with surprisin 
rapidity. In every state, the mass of the public : 
receiving a more or less thorough common schoi 
education. 
In nearly every state, well equipped universitie 
readily accessible to all, offer opportunities ar 
alogous to those in the older European centre 
The people with whom we have to deal today, ar 
of a far more complex, sensitive nature than thos 
with whom our grandfathers came in contact. TI 
science and art of medicine is ever expanding an 
ever demanding more and more fundament; 
knowledge of the natural sciences, of mathematic 
and languages and history and philosophy, tha 
has been the case before. It is today desirabl 
nay, important, that the young man who intends t 
enter upon a medical career should have a goo 
elementary training, such a training as used t 
lead to the degree of A. B. This training, whic 
should not be limited to the natural sciences, bi 
should include an elementary knowledge of math< 
matics, history and ancient and modern language 
has a value far beyond the mere technical sid 
An elementary knowledge of history, of philosc 
phy, and of that literature to which some study c 
the ancient languages is the only sure introductio 
gives a man a knowledge of mankind which is < 
the greatest importance to him in his caree 
After all, let us not forget that the physician 
greatest power for good lies in his human inflt 
ence. The power to inspire, to uplift, to infus 
confidence into his fellow men, is one of the mo 
necessary attributes of the true practitioner c 
W. S. THAYER, M. D., HON. F. R. C. P. I., 
Baltimore, Md. 
[Address delivered before the Ohio State Med- 
ical Society at Dayton, Ohio, on May 8, 1912.] 
When your secretary so kindly delivered to me 
your invitation to speak before you today, I could 
hardly see my way, among the many engagements 
which beset me, to accept, much as I desired so to 
do; and so I put the letter aside and wrote to him 
that I must think about it. And as I thought about 
it, it seemed to me that you might be willing to 
listen to some rather random reflections, bearing 
upon the ever living question of medical educa- 
tion, reflections which have been for some time 
more or less on my mind. 
A great ferment is at work in American medi- 
cine today. The requirements for admission to 
our schools are constantly being raised, and 
through the establishment of state examinations, 
an earnest effort has been made to elevate the 
standards of medicine. The work of the commit- 
tee on medical education of the American Medical 
Association, and the investigations made by the 
Carnegie Institution a year or so ago, have been 
of especial value in awakening the public and the 
medical profession to the necessity of further co- 
operation and of a more general standardization 
and elevation of our methods of instruction in 
medicine; and the improvement in the general con- 
ditions has been widespread and rapid in the last 
several years. 
But the conditions are still far from ideal. 
The lack of uniformity, for instance, in the regu- 
lations in different states of our common country, 
with regard to requirements for practice, is little 
less than ludicrous. 
That which is demanded from a practitioner of 
medicine today differs in many ways from what 
was necessary a century ago. In this great, grow- 4 
edicine. No depth of knowledge, no refinement 
: treatment can atone for the lack of this ability 
inspire hope and confidence and affection. That 
hich educates, softens and refines the physician 
! a man gives him an immense advantage over 
s cruder neighbor. It teaches him to understand 
id to approach and to influence people with 
horn he is thrown in contact, and until he can do 
is his work is often gravely hampered. 
Such an elementary training can today be ob- 
ined easily by most boys in public schools and 
ate universities at a moderate expense and with- 
it undue retardation of their course. It is equally 
□portant for one who would be a practitioner, 
> for him who would, more strictly speaking, be a 
udent or a teacher. 
The man who is to succeed as the adviser and 
rector of the public in matters of health must 
ive an education better than that of the average 
f his fellows; if he have not, his patients will 
;el that they have a superior general informa- 
on; they will doubt his judgment, often, perhaps, 
□justly, look down upon him as a man, and one 
reat source of his influence will be gone. 
But if there be today reasons which make it 
jsirable that the physician should receive a 
•oader general education than in times past, there 
■e other imperative reasons which make it neces- 
iry that he receive a far wider special training 
t the natural sciences. 
As I have said before, the art of medicine is 
ipidly coming to rest upon a firm scientific basis, 
roperly to comprehend the nature of many of 
le functions of the human body, not to speak of 
ithological changes of function, demands a fun- 
imental knowledge of biology, mathematics, 
lysics and chemistry, of which even twenty-five 
'ars ago, we barely dreamed. 
To attempt to offer instruction in the art of 
edicine without demanding such a fundamental 
ientific basis is, it seems to me, not only unwise, 
it wrong. 
The cry is often heard, "How can a poor boy 
ve the time that such an education demands- 
)w can he stand the expense?" The answer to 
is question is, that we must see to it that our 
liversities offer a sufficient number of scholar- 
lips and similar opportunities to those boys who 
ive it in them to make the most of these advan- 
ges. A general elementary education is neces- 
.ry for the man who would use his whole in- 
lence; a sound, fundamental education in the 
itural sciences is indispensable for the practi- 
oner of medicine today. 
This applies as well to the man who intends to 
actice in a rural district as to him who means 
take up his life in a large center of population. 
We hear much from time to time of the dangers 
of over-education of the physician, just as we hear 
of the danger of over-education of the public in 
general. So often one hears the assertion that 
one must turn out a class of men especially in- 
tended to practice in rural communities, rough and 
ready men. If we give such men, we are told, too 
many opportunities, they will not be satisfied with 
the isolation and hardships associated with country 
life. "If you refuse such men as these," they say, 
"or insist that they have a sound, thorough, ele- 
mentary education before they enter the medical 
school, there will be no doctors to go to the coun- 
try. Better a poor doctor, than none at all." 
These statements, I believe to be exaggerated 
and wrong. In the first place, the poor doctor, 
the weaker character, is not, today as a rule, found 
in the country. The average country doctor, I 
very sincerely believe, is of better quality than the 
average city doctor. 
Where education demands a large sum of 
money, where the graduate is a man who can 
afford to live in or near a large centre, and wait 
for a considerable length of time before his prac- 
tice grows, it may well be that he will wait and 
will hesitate to go to the distant rural district. But 
offer freely the opportunities of a thorough foun- 
dation, offer a good general education to the 
many, open the gates, demand higher standards 
for all, and I doubt whether the country people 
will be deserted. 
But suppose it should prove to be the case that 
the more thoroughly educated physician will hesi- 
tate to go to distant rural districts, is it not better 
that the public should realize this so soon as may 
be and provide for the emergency in some manner 
more thorough and more humane than in leaving 
these people to the mercy of avowedly inefficient 
men? 
It is true that there are sparsely populated, re- 
mote districts in the country today where the in- 
habitants suffer materially from the lack of proper 
medical attention. Why? Largely because the 
remote, sparse, farming or fishing population is 
really quite unable to offer to a man who has had 
the advantage necessary to equip him for the prac- 
tice of his profession, the support sufficient to 
allow him properly to care for and educate his 
family. And what is the result? Sometimes the 
doctor is a bright young fellow, of limited experi- 
ence, indeed, but yet with energy and good char- 
acter. Such a man is of immense value to the 
community. Too often, however, these unfortu- 
nate districts are asylums for the old, decrepit and 
dissipated. In just such a region where the phy- 
sician at the time was a bright, fine young fellow, 
a countryman unwittingly described to me a year 5 
or so ago, the class of man to whose tender mer- 
cies these poor people are too often left. In a 
quaint dialect, which I shall not attempt to repro- 
duce, he said: "There was an old doctor, which he 
died last year; seemed like he was kind o' weak- 
minded ; he took morphine, or somethin' or other; 
he always was half crazy, anyhow; but he cer- 
tainly was the best doctor we ever had here." 
Seriously, there really are districts where the 
people are laid open to this sort of thing, and 
here, sometimes, it is needless to say, typhoid, ma- 
laria, dysentery and like preventable infections 
hold full sway, stretching forth from time to time 
their arms to infect other localities, a scourge to 
the district, and a constant menace to the country 
at large. 
Now suppose it be true that with the uni- 
versal requirement of higher standards, the more 
educated man cannot be induced to live in these 
distant localities. May it not be a blessing in dis- 
guise? May it not induce the state or the country 
to see to it-and in some instances I think 
it should be seen to today-that the proper physi- 
cian is provided. If, of their own accord, 
suitable physicians do not seek distant rural com- 
munities, then state or county must see to it that 
the right man is obtained. They not only must 
see to it, but they will see to it. The public will 
not hesitate in the end to offer the necessary ad- 
vantages to provide for all people sufficient and 
competent medical attention. 
I can see some of my friends throw up their 
hands and cry aloud: "But this is socialism," as 
if it meant the advent of the devil on earth. All 
of which means that we human beings are terribly 
fond of words. There is nothing which we enjoy 
more than to coin a word to describe some condi- 
tion and then to forget the condition and enter 
into throes of ecstasy or agony as the case may 
be, over a thousand irrelevant fancies springing 
from the magic of a name. 
Now it may be or may not be that, in the future, 
states and counties may have, in part, to subsidize 
physicians in some rural districts. I know some 
regions where such an arrangement might be wise 
today. But to hold back the progress of medical 
education voluntarily, to send out knowingly, in- 
sufficiently educated doctors for the country peo- 
ple in order that we may put off this hour, seems 
to me the height of folly. 
There is, however, another point of view from 
which this whole question must be regarded-the 
point of view of public health. The little focus of 
typhoid fever, of dysentery, of malaria, is not only 
a burden to itself, but is a menace to the country 
at large. We owe it, not only to the simple 
farmer, or fisherman or mountaineer that he 
should be taught to protect himself and his farm 
from the dangers that surround him, but we o\ 
it to ourselves and to humanity in general th 
these foci, from which at any time a devastatii 
epidemic may spring, should be cleared away ai 
removed so far as possible. And this means t. 
education of the community in matters of hygier 
Now the man whose duty and privilege it is 
educate the community in these respects, is tj 
doctor. An ill-equipped and ignorant physician 
of little value in such a locality. We must for t! 
sake of the inhabitants, for the sake of the cou 
try, for the sake of humanity in general-we mu 
make it possible that properly educated physicia 
be available for such districts. 
Practice in a distant rural community is by i 
means devoid of its advantages. If it be assoc 
ated with isolation, yet it offers pure e 
and a healthy out of door life for t' 
growing family and opportunities for refle 
tion and study which are by no means to 1 
laughed at. It is in such localities that the ve. 
best advantages are sometimes offered for tl 
study of certain infections, such as malaria or t 
phoid fever or dysentery, and the opportuniti 
for the investigation of questions relating to pu 
lie hygiene and for the experimental institution < 
measures of public and private prophylaxis a 
often considerable. Some of the greatest nam> 
in medicine are attached to men who began ; 
country practitioners. 
Passing on now to more strictly medical trai: 
ing, it is a matter of great importance that tl 
instruction of the student of medicine in the fu 
damental scientific branches should be of the be; 
We have heard a great deal as to the necessity < 
proper clinical training of the student before 1 
should be entitled to enter upon practice, a mo 
important point upon which I shall speak late 
But that which I would emphasize at the minu 
is the grave importance of a thorough training 
the fundamental branches. Any one who reat 
the recent report issued by the Carnegie institutic 
cannot fail to be impressed with the great defic 
ency, in a number of schools, of opportunities f( 
the teaching of anatomy, physiology, physiologic 
chemistry and pharmacology. Such branches ce 
properly be taught only in connection with wt 
endowed laboratories, such as can scarcely exi 
excepting under a good university foundatic 
The existence in this country and in England t 
so many schools of medicine built purely at 
simply about the hospital as a nucleus, rather ths 
in connection with the university, is a relic of 
day when medicine was an art with little scientil 
basis-when the one essential feature of a medic 
education was the clinical observation of disease 6 
The teaching of these fundamental medical 
iences, as they should be taught,' requires today 
very large endowment for the maintenance of 
boratories, and for the salaries of professors 
id assistants-a sum of money utterly beyond 
lything that the fees of students could possibly 
ipply. The time has long since passed when it 
as possible for a practitioner to conduct a de- 
irtment of physiology or anatomy or pharma- 
ilogy as it ought to be conducted. And the day 
near when the attempt so to do will be aban- 
3ned generally, in America, at least. The solu- 
on, I believe, is not to be the abandonment of 
le teaching in those hospitals which now main- 
lin proprietary or independent schools, indepen- 
ent, I mean, in the sense that they are indepen- 
ent of any university foundation; on the con- 
ary, it is highly to be desired, indeed it is 
rgently necessary that more of our hospitals 
lould open their doors to the student and teacher 
f medicine-important for the hospital and for 
s patients as well as for the public in a broader 
ense. What must happen ere long, however, is 
le abandonment of the attempt to maintain a 
umber of independent schools of medicine, in 
'hich the important fundamental branches of the 
ledical sciences cannot effectively be taught, but 
ie maintenance of independent clinics for investi- 
ation and instruction in the science in the art of 
ledicine and surgery; clinics independent in name 
nd perhaps in their management, but yet asso- 
iated through their directors with some central 
niversity which provides for the instruction in 
le fundamental scientific branches. 
How discouraging it is to see, as one may see 
i many cities in this country, old and respected 
istitutions, independent of university connections, 
eeking to maintain a whole school of medicine 
n an endowment utterly insufficient, and to rival, 
erhaps, a neighbor, which, with clinical advan- 
iges in no way superior, is yet a branch of a well 
quipped university. The result is inevitable. The 
tandards of the hospital medical school, if I may 
o call it, must inevitably fall below that of its 
eighbor-the students fatally lacking in thorough 
oundation, and, little by little, the prestige of the 
istitution falls. What a difference there might 
e, if all this waste of money were abandoned, 
' the instruction in the fundamental branches 
■ere left to the university and if the hospital de- 
oted itself to the study and teaching of matters 
trictly pertaining to its normal activities. The 
aoney expended on anatomical and physiological 
epartments, for instance, should be turned pver 
o pathological and clinical laboratories, devoted 
3 the study of problems directly connected with 
the science and art of medicine and surgery in 
all their branches. 
The central university, then, teaching the funda- 
mental sciences in its well equipped laboratories 
might send its students to a variety of clinics in 
which the practical branches might be taught. The 
rivalry between hospitals would still exist-it is 
well that it should-but it would be a rivalry be- 
tween equals, between members of one family, 
rivalry which would rapidly place on its old foot- 
ing many a clinic which, in recent years, has been 
slowly losing its historical prestige. The advan- 
tages to the student would be obvious. 'Twould 
insure in the beginning equal training in the fun- 
damental branches for all; it should offer in large 
cities the chances that now exist in Europe. The 
student might select the clinic in which he prefers 
to take his medical and surgical work. With the 
disappearance of the proprietary schools in the 
sense of their abandonment of the attempt to 
maintain departments for instruction in the funda- 
mental medical sciences, and their persistence as 
special clinical departments, allied with central 
universities, an immense step would be taken to- 
ward the standardization of the medical teaching 
of the country. 
And this opens the way for a few words as to 
the educational duties of hospitals-so little under- 
stood and so often misunderstood in this country. 
No nospital is doing its full duty toward its pa- 
tients or toward the community, that is not a 
centre of medical study and instruction. In the 
present state of medical science, the hospital can- 
not be the sole nucleus of the school of medicine, 
but it should be the nucleus of a more or less in- 
dependent department of medicine and surgery, 
an integral unit in the composition of the greater 
school of medicine, fostered by the central uni- 
versity. 
It is absurd to expect that the university which, 
alone, can give the early and fundamental train- 
ing necessary for the practice of medicine-it is 
absurd to fancy that this university can build, 
equip, maintain, control and fill hospitals sufficient 
to afford the training necessary for all the stu- 
dents. Here, as elsewhere in the world, the large 
city and state institutions for the care of the sick 
must furnish many of the opportunities; but in 
addition, especially in this country, many institu- 
tions independent of city and state control must 
soon recognize and are indeed recognizing that 
they have a great part to play-a great duty to 
fulfill, that a hospital, to accomplish its whole 
function, must always be an educational institu- 
tion. 
The time will come when the student may, as 7 
he can now in Germany, pursue, uninterruptedly, 
his medical course in a number of different cities 
and states-when he may take his physiology and 
anatomy perhaps in one university, let us say at 
Harvard; his medicine in New York, and his 
surgery in Cleveland; when he may graduate, per- 
haps, where he will. This may seem a dream- 
but it is a state of affairs which some of us in 
this room may well live to see. 'Twould be folly 
to deny that there are many obstacles in the way 
of immediate realization of such a plan as this. 
Jealousies between different schools, the influence 
of political stupidity and corruption in our public 
institutions, ignorance, prejudice and misconcep- 
tion on the part of hospital trustees-all of these 
have to be contended with. But these are, I be- 
lieve, purely incidental obstructions in the course 
of certain progress. 
In a hospital, perhaps, with honorable history 
and traditions which, in the struggle to uphold all 
the machinery of a school of medicine, has in- 
evitably fallen, in its personnel, somewhat below 
its relative standing in the past, there will be, 
doubtless, professors whose petty jealousy will 
block the way. But alongside of these few, there 
will always be a body of able, alert men longing 
to grasp the really greater opportunity, as well as 
others, far more numerous than some may fancy, 
who with generosity and magnanimity and self 
abnegation will help toward the improvement of 
conditions. 
Here and there a stupid or corrupt mayor may 
seem for the moment a hopeless obstruction in 
the path, but in matters pertaining to public health 
the power lies in the end with the people, and 
where the issue is made clear, no party, no faction 
will long stem the tide. I, for one, have a sincerely 
optimistic feeling with regard to the future of 
hospitals under public control. In my own state 
we have witnessed with great satisfaction, despite 
the dismal prognoses of a number of doubting 
Thomases, the maintenance of a state sanatorium 
for tuberculosis for six or eight years without a 
shadow of suspicion of objectionable political in- 
terference. 
Hospital trustees may fancy that by shutting the 
doors on opportunity for study and teaching, they 
are protecting their patients, but the folly of this 
not unnatural misconception is easily explained, 
and the day will soon come when the hospital 
will seek affiliation with the university as a priv- 
ilege for the benefit of the sick within its walls. 
The abandonment of small unattached colleges, 
and a more general utilization of well equipped 
hospitals as clinical units will offer greater oppor- 
tunities for that practical medical experience which 
the student must have before he is fitted to ei 
upon his medical career. 
There is another question which is closely c 
nected with medical education, on which you 
perhaps pardon a few remarks. I refer to 
question of the determination of the qualificat 
necessary for graduation from our medical sch' 
and for the admission to the practice of medic 
The laxity of our requirements in America 
long and justly been a by-word of reproacl 
England and in Europe, and although the ad\ 
tages which we are able to offer in our be 
schools are in many ways second to none, yet 
methods for determining qualifications for g; 
uation and for practice are crude in the extrer 
As my colleague, Barker, observed the o 
day most discriminatingly, there are two dist 
things to be considered in the examination c 
student for a medical degree or for the lic< 
which should entitle him to practice medicine 
the one hand, the test of learning-on the o 
hand, the text of capacity. A man may have < 
siderable book learning and yet be quite incap 
of applying it to practice. No man, for insta 
could learn the art of physical diagnosis fro 
book although he might know the lines by i 
On the capacity to make sufficiently accurate c 
noses hangs the most vital part of the pra< 
of medicine. Now in my day absolutely no 
of the practical diagnostic capacity of the stu 
was demanded. Our examinations were all a 
ten-and today, twenty-four years later, there 
I fancy, a good many schools where the quali 
tions for the degree of Doctor of Medicine 
determined by little besides written examinat: 
Now irrational as it is, one might attemp 
defend this, academically, by the assertion tha 
examination for the degree of M. B. or M. 
is a test of learning, and not of practical cap 
-that the degree of M. D. does not in itself 
title one to practice; the test of capacity sh 
come in the state examination. 
Well what do we find in this country in 
state examinations? We find a conditioi 
anomalous, so absurd, that the foreigner 
knows our country only by its accomplishmen 
other fields, finds it difficult to believe. N> 
fifty states, each giving a different set of e. 
inations-the majority purely written exan 
tions. In but few states, among which, t 
honor, is the state of Ohio, has any real step 
taken to test the practical capacity of the c; 
date for a license. A majority of the staff 
our common country which is today just as t 
one in fact as any kingdom or republic of Eu 
a majority of our states, with requirements v 8 
er often considerably, demanding, as a rule, 
y a test of a man's book learning as a guar- 
ee for his fitness to practice medicine! Nearly 
y states issuing licenses to practice, each one 
which is recognized by b>ut a few of its sis- 
I. Could anything be cruder or more extrava- 
t? And yet we must acknowledge that this 
i great advance over the conditions which ex- 
d but yesterday when a degree from any school 
medicine entitled one to practice, when there 
•e no state requirements whatever. This opens 
of the most important questions in relation 
nedical education today. How can we improve 
. standardize our state requirements for prac- 
? 
Vhat are the chief defects of our present sys- 
? They are, I should say, in the main: 
The absence of uniformity of requirements 
reciprocal agreement between states. 
. The character of the examinations, that is, 
absence of tests of practical capacity and the 
levant, archaic and eccentric character of the 
stions often set in the written examinations. 
, The character of the examiners. 
; is, as I have said, intolerable that in a country 
homogeneous as this, no arrangement should 
it by which a single examination should entitle 
to practice throughout the country. There is 
ent need for a further reciprocal agreement, 
ational agreement, between all the states as 
the character of the examinations and ex- 
ners, and as to reciprocity in the recognition 
tate certificates. 
he present character of our examinations 
es much to be desired. In the first place, as 
been said, there is, in general, an absolute 
of any test of capacity. Practical clinical 
ninations should be provided for at the earliest 
nent. Again, the questions given at the exam- 
ions are very often of a stereotyped and old 
lioned kind, which from their very form, be- 
a sad lack of appreciation on the part of the 
niner of the conditions and problems of mod- 
medicine. This type of examination is easy 
repare for, and the spectacle of books of state 
•d questions for sale on the market for the 
purpose of allowing the candidate to learn 
sck by which he may answer an expected ques- 
put for the purpose of determining whether 
s an individual in whose hands it is safe to 
ust precious human lives-the knowledge that 
e are actually individuals, nay, even so-called 
iols, which are entirely devoted to preparing 
lidates to pass state examinations-these are 
filiating things to realize. The mere existence 
;ood practical examinations to test the capacity 
of the student would go far toward remedying 
such scandalous conditions. 
But there is another important factor in the 
case, namely, the character of our state examiners. 
It should be obvious to the most simple minded 
that if one desired to test his proficiency as an 
electrical engineer he would seek counsel from 
the most skilled electrician that he could find. 
And if he should wish for a test of his proficiency 
in an ancient or modern language or mathematics, 
'twould be to an expert in these special subjects 
that he would turn, a leading investigator in the 
science or art or branch of learning in question. 
. It is perfectly obvious that the individuals most 
capable of determining the learning or capacity 
of any candidate for a license to practice medicine 
must be those men who have not only given their 
lives to the study and practice of the special 
branches in question, but who have also paid spe- 
cial attention to just this sort of problem-namely, 
the teachers of medicine. But in some states, con- 
nection with any school of medicine is a bar to 
service on the state examining board. Why? 
Mainly, because of rivalry and jealousy and dis- 
trust between different local schools and colleges. 
And what is the result? The considerations upon 
which members of the medical examining board 
are chosen are often rather those of geographical 
locality than of fitness; and sometimes one sees a 
manifestly well qualified man turned aside be- 
cause, forsooth, some other section of the state 
desires "representation" upon the examining 
board. Could anything be more stupid-more dis- 
creditable to the medical profession? Such exam- 
ining boards, in many states, consist largely or 
entirely of busy practitioners of medicine or sur- 
gery. Now a busy practitioner of twenty or thirty 
years' standing is no more fitted today to give an 
examination in physiology or chemistry than I 
should be fitted to give an examination in Greek. 
In many subjects, in many states, practical ex- 
aminations could not properly be given, even if it 
were desired so to do, because the examiners 
would not be capable of giving them. This is in 
no way remarkable; it is perfectly natural, and 
to be expected under the present conditions. 
The examination, then, is a purely written test, 
and in many of the subjects on which candidates 
are examined, the examiner who is dealing with 
matters with which he is not immediately occu- 
pied, is obliged himself to prepare for the exami- 
nation, and in the end, he is very likely to set 
questions which he culls from books rather than 
from his own experience, questions which are not 
fitting, which are irrelevant and are no test what- 
ever of the real learning of the candidate, not to 
speak of his practical capacity. These are things 9 
which we all know and it is well to say them 
aloud. 
Is this a criticism of the capability of the prac- 
titioner, or the individual character of the men of 
which our medical boards consist? No; a hun- 
dred times, no! 
Our medical boards in great part consist of a 
high order of men who, at a considerable sac- 
rifice, are laboring earnestly to improve condi- 
tions. But how can a practitioner of medicine 
who graduated, say fifteen or twenty years ago, 
and is busied with the all-absorbing exigencies of 
family practice-how can such a man keep step 
with all the advances which are taking place in 
physics and chemistry and histology and physi- 
ology and the varied refinements of physical diag- 
nosis, in the rapid progress of the hour? He can- 
not. At the best, he follows those which have to 
do with his special interests. 
How many of us in this room, forty-five to 
fifty years of age, would be capable of conducting 
today, an examination in chemistry? I, for one, 
could not. It is quite as absurd to hand over ex- 
aminations in many branches of the medical 
sciences to the busy general practitioner as it 
would be to expect me to conduct an examination 
in Greek. Nay, more so; for no matter how 
much I may have forgotten, the Greek language 
has remained unchanged throughout the ages 
which have passed since my college days, while 
our knowledge of the natural sciences has ad- 
vanced by leaps and bounds. 
It cannot, I think, be denied that the toleration 
of the present condition is, in part, due to the 
feeling that the state tests should not be too se- 
vere, to a general feeling that the man who has 
no connection with a medical school while he has 
had to meet the exigencies of practice, may appre- 
ciate better than another, those things which are 
really necessary for one to know, and that he 
will be more tolerant and lenient with the candi- 
date. This argument is, I believe, fundamentally 
wrong. Firstly, because the man unaccustomed 
to giving examinations is almost always more 
severe than his more experienced colleague, and 
moreover, because a written examination given as 
the result of book study, while it may be easy to 
pass for the man who has prepared himself for 
the examination, rather than for practice, is yet 
much more difficult for and sometimes incompre- 
hensible to men who have been trained in practical 
efficiency. And more than this, there is often the 
danger that the examiner himself may not com- 
prehend the more advanced point of view of the 
well instructed candidate. Some method, then, 
should be adopted by which the examinations for 
the qualifications for practice should be conducted 
largely by recognized authorities in spe 
branches, by students and teachers of medic 
the practical branches naturally by practitior 
but by practitioners of recognized ability, and [ 
ferably with experience as teachers or examin 
If the element of jealousy and distrust foste 
by the existence of so large a number of 
equipped medical schools were removed, the c 
rection of these evils would be greatly sitnplif 
and this, in the end, will go far toward bring 
about a solution. 
One of the chief obstacles in the way of 
general introduction of practical examinations 
day is the fear of favoritism-the fear that 
examiner, meeting one of his own students, n 
perhaps unconsciously, be influenced in his o] 
ions. This might perhaps be provided for as 
England by having a sufficient number of ex. 
iners with provision that no man examine a : 
dent from his own school. I see no reason w 
with a little good will and open cooperation, 
might not be arranged everywhere today. ( 
tainly you in Ohio are meeting matters squa 
and well. 
It might be objected that in some states tl 
are schools of medicine quite unfit to be rec 
nized on examining boards. This, alas, is t 
but if no other arrangement could be mad< 
should question whether a committee of ex 
iners on which even such schools were represer 
might not meet together and arrange practical 
aminations which at least might be an advance 
the written tests given in so many states toda 
But there might, it seems to me, be a more < 
nomical and satisfactory method which shoulc 
applicable to our American conditions. It is 
known that in the English universities and sch 
of medicine, the examinations are carried on 
only by the teachers themselves, but in part 
especially appointed examiners from other ii 
tutions. A large part of the responsibility in 
determination of the qualification of the applL 
for degrees in medicine in English school 
shared by specially qualified men from o 
schools-men who, unacquainted with the 
dents, approach the question with unbiased rr 
It is interesting to see how strongly some of 
English colleagues feel about the matter. T 
years ago, for instance, in conversation with 
of the leading clinical teachers of London, I 
served that we, in our schools, had not their 
tern of examination by outside men - that 
conducted our own examinations. "Yes," he 
quickly and rather sharply, "Yes, that is just \ 
I consider rotten about your system." A ra 
severe judgment, but not uninteresting. 
Now it has always seemed to me that one n 10 
in which the difficulties connected with the 
iblishment of practical tests in our state exam- 
tions might beovercome, might be by the selec- 
i, as examiners, of recognized authorities from 
er states. If, for instance, we in Maryland 
e to invite Dr. Reichert of Philadelphia to 
mine in physiology; Dr. Crile of Cleveland, in 
gery; Dr. Janeway of New York, in medicine, 
i so forth, no local jealousies would be excited 
all laboratories and hospital wards would 
iingly be thrown open for purposes of exam- 
don. Such a plan would, 'tis true, demand a 
siderable financial outlay, but a considerable 
ncial outlay is, it seems to me, necessary and 
1 worth while in so grave and important a case. 
Jut whether by this method or by another, the 
airement of practical tests of learning and 
:icncy and a uniform reciprocal agreement be- 
en the states which shall bring it about that 
state license to practice may be valid through- 
this country, must come and must come soon. 
Icmbers of the Ohio State Medical Society, I 
e spoken of the importance of a sound general 
nentary education for him who would enter the 
lical profession; of the necessity for a good 
damental training in the natural sciences and 
he basic scientific branches of medicine; of the 
rability of more thorough tests of the practical 
iency of candidates for a medical license. Be- 
: closing I would repeat once more that under 
conditions which we would establish, there 
rid be nothing which would interfere with the 
ortunity of the poor though capable boy. 
n the contrary, with opportunities practically 
from expense in our schools and universities 
the boy who has it in him to do large things, 
requirement of higher standards places that 
of necessity, more nearly upon a level with 
e to whom large opportunities have been nat- 
ly open, and gives him a greater chance than 
■ before. 
today we are anxious that the standards of 
^rican medicine should not only be maintained 
raised, it is only because we are impressed 
i the immensity of the duties and responsibili- 
of the physician who penetrates so deeply into 
heart of the public, who should have so pow- 
1 an influence in shaping the bodies and minds 
character of the whole people. It is of vital 
jrtance that the physician should be worthy 
is trust. Sometimes I feel that we, as a body, 
; little realization of the influence which we 
exert in the world. And in closing 
e random reflections, I would say a few 
Is of one whose figure has recently 
; from among us-whose spirit and influence 
in the hearts of thousands of his pupils and 
colleagues and friends throughout the land-one 
who exemplified as have few men in his genera- 
tion, that which the true physician may be. 
But a few weeks ago we were shocked to hear 
of the death of John Musser, Professor of Clinical 
Medicine in the University of Pennsylvania, and 
so lately president of our American Medical Asso- 
ciation. A, country boy, educated in the state nor- 
mal school, Musser graduated from the medical 
department of the University of Pennsylvania in 
1877. Of a fine, strong physique and of an un- 
usually simple and lovable character, he showed 
from the outset, a devotion to that which was best 
and highest in his profession, so single minded 
and so intense that success followed his every 
effort. 
A clinician of marked ability, his various con- 
tributions to literature and his excellent work on 
medical diagnosis made him widely known and 
helped to bring about his well deserved election to 
the presidency of the American Medical Asso- 
ciation. 
A teacher in the University of Pennsylvania for 
over thirty years, his influence upon his students 
was remarkable. No man that I have known has 
done more toward spreading high and clean ideals 
in medicine. Generations of medical students have 
looked on Musser as the incarnation of their 
ideals of a man and a physician. His great 
strength lay in his simplicity, in his singular purity 
of character and in his love of his fellow man, a 
love which had in it something peculiarly broad 
and catholic and fatherly - something which 
brought him very close to those who knew him - 
an indefinable something which was very large. 
He seemed the embodiment of physical power 
and mental equanimity. With his serene, sweet 
smile, he gave to all in full measure from what 
seemed an inexhaustible store of strength and 
sense and wisdom and sanity and courage and 
optimism. 
His capacity for work was amazing. He never 
rested. He never seemed to know what it was to 
be tired - and then in a minute, in the prime of 
his life, he was gone! 
And what remains? 
He has left no monumental or epoch making 
accomplishment. He has written no work which 
will endure long after his generation. There re- 
mains, one might fancy, little beyond the warm 
affection and admiration and love of his friends, 
his students and his patients. 
And yet his loss is something which is not to 
be measured. Something very large has gone- 
but something which is far greater remains. 
John Musser is dead. In a few years, in a very 
few years, we who were his colleague shall be 11 
dead; and in a few more years the students who 
knew him will be dead; and in yet a few more 
years-life is so very short-men may well ask, 
"Who was this man whose name is attached to 
this professorship, who wrote that excellent book, 
so many copies of which are to be found in the 
second hand shops?" And students now and then 
will look up his history and read the story of his 
life before an historical society, as we do now 
with regard to so many a man who in his day 
dominated his little circle. 
And this is fame! And this is immortality! 
Foolish, vain mortals that we are! How often 
do we think such thoughts and say such words 
as these! How often do we regard immortality 
from the standpoint of our own little personal 
happiness in some vague and unimaginable future 
-which is but a foolish and a selfish and a child- 
ish preoccupation; or from that of the mere 
earthly endurance of a name revered for the good 
works with which it has been associated, which, 
in the end, is but pride, pardonable and natural 
and human though it be; or from the standpoint 
of that greater and more enduring influence which 
is a true immortality-the immortality of blood- 
ourselves and our ideals, perhaps our name, car- 
ried on through our worthy descendants to suc- 
ceeding generations. 
But there is an immortality greater than all 
these-an immortality which escapes the circum- 
scribing ties of name or blood or race-the im- 
mortality of a great and noble inspiration which 
has helped to shape and mold the minds and lives 
of hundreds of us living today; which through 
us must spread to countless thousands in the ye 
to come. 
Musser's body may be dust. His name may 
forgotten. New cities may rise upon that wl 
is now his grave. But the great, broad, beaut 
spirit of love and truth and charity and sweetr 
and unselfishness, borne onward and abroad 
the hearts and minds of thousands of those v 
knew him, is immortal. It will live in the m 
perfect and fuller lives of generations yet 
born. What matter if they know not its sour 
That would have meant little to him. It is enoi 
that the spirit and the inspiration will live- 
step in the stairway of human progress. 
Musser's life is a rare and beautiful example 
what the human influence of the physician n 
be-and much of that which he was, many of 
largest qualities he owed to the opportunities : 
experiences of his career as a practitioner ; 
teacher of medicine. 
To every physician it is given to come near 
the hearts of men. Few can leave to their felk 
a legacy like that of Musser-for such men 
very rare. But everywhere among us are th 
who, in a lesser way, are doing a like work, ; 
every one of us knows how much of what g> 
there is in him has come directly from the opf 
tunities and responsibilities of his medical life. 
Is it not, then, natural and right that we sho 
seek to bring it about that our successors sho 
be so prepared that they may meet more f' 
than have we the great duties and privileges 
what may be a noble career? On Some Functions of the 
Free Dispensary 
BY 
W. S. THAYER, M. D., Hon. F.R.C.P.L 
BALTIMORE, MD. 
Reprinted from the Boston Medical and Surgical Journal 
Vol. clxviU, No. 6, pp. 185-188, February 6, 1913 
BOSTON 
W. M. LEONARD 
101 Tremont Street 
1913 ON SOME FUNCTIONS OF THE FREE 
DISPENSARY.* 
Twenty-eight years ago, I came for the first 
time to this city-a rather thoughtless, aimless 
boy-to study with one who is well known to 
most of you here today. After a year under the 
guidance of this man, I left, a serious-minded 
youth with ideals and aspirations and ambitions 
and enthusiasm. 
Anything that I may have accomplished in 
life, anything that I may accomplish in the years 
that remain before me, I owe and I shall owe to 
my dear old master whose wisdom, whose learn- 
ing, whose lively and youthful interest in all 
that is beautiful and good, whose optimism, 
whose charity above all, have been to me a last- 
ing and a guiding inspiration. 
To return to the town so closely associated 
with the memories of this period can but be to 
me a happy event. 
It is also good to visit this institution which 
has, in these years, developed in so creditable 
and distinguished a manner. 
There could be no surer evidence of the wis- 
dom which guides the University than the con- 
struction of a dispensary for out-patients of such 
a character that advice and treatment of the in- 
valid may properly be combined with the study 
and investigation of disease. 
To one, who, for over twenty-five years has 
BY W. S. THAYER, M.D., HON. F.R.C.P.I., BALTIMORE, MD. 
* Address read on the occasion of the laying of the cornerstone 
of the new Medical College Dispensary Building at the University 
of Syracuse, December 14, 1912. 
1 been more or less closely connected with work in 
out-patient departments of large hospitals, it has 
often seemed that the public at large, as well as 
much of the medical public, was strangely ig- 
norant of the possibilities of the free dispensary. 
This is due, in great part, to the existence of so 
many ill-equipped and ill-managed institutions, 
-largely to the fact that even in the best- 
equipped dispensaries the authorities have failed 
to realize the true importance of the opportuni- 
ties and responsibilities which lie before them. 
A few days ago I heard Richard Cabot say 
that the out-patient department is the most im- 
portant part of a hospital. I agree with him 
most sincerely. It is that part of a hospital 
which reaches, or should reach most directly, the 
general public,-in its function of giving advice 
and offering care to the sick, as well as its larger 
function of instructing in methods of life and 
prophylaxis against disease. It is the one part 
of a hospital in which students of medicine are 
able to study those disorders, physical and men- 
tal, with which they are most likely to meet in 
general practice. 
It should be an institution so equipped and 
conducted as to be a central point to which the 
physician practicing among the poor should be 
able to resort for consultation and advice with 
regard to difficult and complicated cases, and it 
should be the especial care of such an institution 
to maintain cordial and intimate relations with 
the physicians in its neighborhood. 
These, I take it, are some of the main func- 
tions of an out-patient department. Now such 
functions as these can only be maintained by a 
dispensary which is in close connection with a 
well equipped institution of learning. It must, 
in the first place, have a considerable staff of sen- 
2 ior and junior physicians; of senior physicians 
of distinction and reliability who, if not regu- 
larly in attendance, should be there at stated in- 
tervals for purposes of consultation and advice; 
and of junior physicians who are active and 
well equipped men, many of whom may be prac- 
ticing physicians. It should further have stu- 
dent assistants for the purpose of history taking 
and record keeping. It should be well equipped 
with modern laboratories, - bacteriological, 
chemical, physical, if one may say so, with appa- 
ratus for x-ray examinations, for recording car- 
diac action and respiration, and with other in- 
struments of precision. It should, if possible, 
have, in addition, a department of physiotherapy 
in which massage, electrical and hydrothera- 
peutical treatments may be given. 
Few dispensaries are equipped with all these 
departments, especially with these latter depart- 
ments, but their desirability, none will, I think, 
deny. 
Now to such dispensaries or to the numerous 
good dispensaries in this country which aim at, 
if they do not reach so great a degree of perfec- 
tion,-to these dispensaries, what manner of peo- 
ple come? To what sort of individual are these 
advantages offered? The answer is simple. 
People come to a dispensary who are ill and in 
trouble, to seek advice and treatment. These 
people are of various classes. In the first place, 
the very poor, who ought not to be expected to 
pay for the services of a physician,-people so 
poor that no physician would wish to take their 
money. This is a large class which often con- 
tains, temporarily, individuals who, from out- 
ward appearances, might seem to be relatively 
well-to-do. We are a rather improvident peo- 
ple, and there are many of us who live very 
3 close to our incomes. We ought not to do this, it is 
true, but we do, and when the unexpected trouble 
comes, the free dispensary, disagreeable though 
it be, is our one resort. The occasional use of dis- 
pensaries by such patients is far more frequent 
than is generally imagined, and the motives 
which induce these individuals to make use of a 
public charity are commonly most creditable. 
Many a man in trouble sends his family, or goes 
himself to the free dispensary, although it may 
be most distasteful to him, rather than seek the 
services of a busy physician for which he knows 
he cannot pay. 
But is such service to be regarded as wholly 
free ? Do these people pay nothing in return for 
the attention which they receive? In some ill- 
conducted out-patient departments where no 
records are kept, where few examinations are 
made, where the patient, after a few questions, 
is handed a prescription and passed on,-the ser- 
vice, such as it is, may truly be regarded as en- 
tirely free. Such dispensaries are not a benefit 
to the community in which they exist. 
In the properly conducted out-patient depart- 
ment, however, the advice and treatment given is 
far from free; the patient pays for the services 
which the dispensary can give him by allowing 
himself to be used as the subject of lectures and 
demonstrations to students and physicians. 
This, one may say, is not much. No, it is not a 
great hardship. But in another sense it means 
a great deal. It is often, indeed, usually, very 
time taking, and there are very few of the poor 
and ignorant who do not prefer to avoid the 
waste of time and the lengthy examination by 
seeking the services of a private physician when 
they can afford it. 
Secondly, there are individuals able and will- 
4 ing to pay a small fee, who yet feel that the 
physicians in the regions in which they live do 
not give them the time, the care or the attention 
that is given them in the dispensary. They be- 
lieve that the services which they obtain at the 
dispensary are more valuable than those for 
which they can afford to pay, and they are will- 
ing to offer themselves as the subjects of study 
or demonstration or lecture, and to sacrifice the 
necessary time for certain advantages which 
they conceive the dispensary offers, advantages 
otherwise out of their reach. 
Thirdly, to the better dispensaries, especially 
to those connected with hospitals or universities, 
where well equipped men are in attendance, or 
where men of real eminence are to be found on 
special days,-it is not uncommon for physicians 
who practice among poor people of moderate 
means to bring their patient for assistance in 
diagnosis. 
During much of the time that Dr. Osler was 
in Baltimore, he gave, three times a week, what 
he called diagnostic clinics before third-year 
students. In a large room, in the middle of the 
dispensary, adjoining the examining rooms, he 
saw several patients each day, before the class. 
Often these patients presented examples of the 
ordinary minor ailments, but if any case of espe- 
cial interest was met with by the physician in 
attendance, it was set aside for Dr. Osler's 
clinic. Moreover, not infrequently, physicians 
practising among people of moderate means 
brought to this clinic cases of an unusual char- 
acter. These patients, by their willingness to of- 
fer themselves as subjects for demonstration, ob- 
tained the advantages of a consultation with Dr. 
Osler which otherwise would have been impos- 
sible. 
5 The opportunity afforded by a dispensary of 
the proper sort for occasional consultations of 
this nature is most valuable to the public, to the 
physician, and to the dispensary itself. 
It is impossible for the busy consultant to see 
the poor in any other way, the advantages, there- 
fore, to these people are obvious. The conscien- 
tious practitioner among the poor, who meets 
in his practice, an unusual instance of disease is 
well aware that a consultation with a colleague 
in the same position as himself, for which the 
patient can afford to pay, the consultation which 
under ordinary circumstances is sufficient, will 
in such a case, be of no real benefit. That under 
such circumstances as these, it is possible to ob- 
tain the advice of men with special experience 
and special clinical advantages, is a great bless- 
ing. The dispensary is equally benefited by the 
opportunity to study unusual and exceptional 
examples of disease. 
The information to be gained from a variety 
of physical, chemical, bacteriological and sero- 
logical methods of investigation of disease has 
become of great importance in late years. The 
methods of examination are, however, so compli- 
cated, so time-taking, and demand apparatus so 
expensive that the ordinary practitioner cannot 
possibly carry them out himself. Private labora- 
tories and special students are required to pur- 
sue this work. But the expense associated with 
such examinations places this assistance beyond 
the reach of a large proportion of the public. 
The establishment of well-equipped laboratories 
in our departments of public health is, it is true, 
offering to the practitioner more and more op- 
portunity to obtain information which is now, 
in many ways, really necessary. 
But there is information which even these 
6 laboratories cannot afford, information which 
can only be obtained for a certain proportion of 
patients, by resorting to private laboratories or 
to a thoroughly equipped institution of learning. 
It is, it seems to me, eminently fitting that a 
dispensary such as this which you are founding 
today should be able to offer such assistance to 
practicing physicians in connection with inter- 
esting and puzzling examples of disease, in re- 
turn for the opportunity of studying and demon- 
strating the case. This, I have long felt to be 
an important function of a dispensary, unrecog- 
nized by many. 
The dangers that the advantages offered by 
such institutions will be abused by individuals 
who are capable of employing their own physi- 
cians, and that real injustice may be done to the 
practitioner who depends for support upon small 
fees, are very slight. Of the properly con- 
ducted dispensary there is exceedingly little 
abuse. Where each patient is studied, where 
thorough examinations are made, where time is 
taken, where instruction is given, the loss of 
time which the dispensary visit involves is so 
great that only those patients come who cannot 
afford to pay for the services of a physician, 
excepting always a few intelligent individuals 
who come because they feel that they cannot 
obtain equally good attention at home. 
Some of these patients there always are,-pa- 
tients who while they can pay the fees demanded 
by the doctors in their neighborhoods, yet feel 
that the services which they obtain from these 
men are inferior in value to those which the 
dispensary offers. 
Is this a dispensary abuse? I think not. It 
is undeniable that in many of our cities, the 
class of individuals who practice among the very 
7 poor is not such as to inspire confidence in the 
intelligent man. Why not say so openly and 
frankly ? We all know it. But this is not always 
so. In the poorer sections of the city there are 
often a certain number of active young men who 
must begin life, at least, in a simple manner. 
Now if these young men are really well fitted, if 
they are earnest students and are able to make 
examinations and employ diagnostic methods 
such as are employed in dispensaries, the public 
in their neighborhood finds it out with astonish- 
ing rapidity and is more than glad to pay for 
their advice and attention, and avoid the neces- 
sity of going to a dispensary. 
And one of the great duties of the dispensary 
is in equipping just such men as these, in offer- 
ing the bright young graduate the opportunity 
to gain experience and training in return for the 
services which he gives as an assistant. 
All large dispensaries need a considerable 
corps of assistants-active, intelligent men- 
many of whom must be young practitioners, and 
if the poor young man at the outset of his prac- 
tice remembers that it is his duty to the public 
as well as to himself to attempt to remain a stu- 
dent as well as a practitioner, if he eagerly seeks 
and takes advantage of the opportunities to as- 
sist or study in properly conducted out-patient 
departments, he will soon find, in the majority of 
instances, that there is little difficulty in build- 
ing up a practice among the poor who recognize 
quickly the man who uses dispensary methods. 
Some years ago, I was appointed chairman of 
a committee to inquire into the question of DisJ 
pensary Abuse in the City of Baltimore. In 
order to obtain some idea as to the feeling of 
the profession on the subject, a number of let- 
ters were sent to men practicing among what 
8 might be called the dispensary class in different 
parts of the city, a few to physicians associated 
directly with large dispensaries, and a few to 
non-medical men known for their general inter- 
est in the subject, asking what, in their opinion, 
constituted the main abuse of dispensaries. The 
answers were most interesting. Scarcely two 
men agreed in their opinion as to what the main 
dispensary abuses were. Many of the answers, 
-I should say, most,-dealt with practices en- 
tirely foreign to any well-conducted university 
dispensary. Upon consideration of all these 
communications, it seemed to me that the abuses 
associated with the dispensaries connected with 
the several honestly conducted institutions of 
learning, were so slight as hardly to be worth 
consideration. 
In one of these letters, an eminent physician 
who has given a great deal of attention to social 
problems, a man who is in the habit of writing 
with considerable vigor, says: ' ' My views on 
dispensary abuse have never been winnowed and 
tried out by careful investigation of the subject, 
but so far I think the chief dispensary abuses 
are: 
(1) The abuse of patients by careless doctors 
and externes. 
(2) The abuse of opportunities by careless 
doctors and externes.. 
That any great harm comes from the free 
treatment of the folk who can pay, I doubt. The 
physicians to whom they would otherwise go are 
usually 'N.G.', and from the point'of view: 
(1) Of health. 
(2) Of character. 
(3) Of instruction in hygiene. 
I believe the patient gets more by coming to 
a free dispensary even when he can pay. I 
9 doubt if his character suffers in the process, and 
as for the loss of money to the doctors, I do not 
regret it. I think it more than made good, from 
the point of view of the public good, which is the 
only point of view that we can take by the physi- 
cal, psychical and educational good done by the 
dispensary, even for rich patients. I do not be- 
lieve you can surely weed out the rich, either, by 
any spotting process." 
I agree largely with the opinions expressed by 
my friend and I am convinced that the blessings 
offered to all branches of a community by a well 
ordered dispensary are enormous, that the 
abuses to which it may be subject, are trivial, 
that there is really no reason to believe that a 
properly conducted out-patient department is 
anything but an assistance to the right-minded 
physician who is practicing among the poor. 
In any dispensary, however, constant care and 
attention is needed as to the personnel of the 
staff and as to the character of the work done. 
Especially important is the establishment of a 
social service department. The physician in pri- 
vate practice or the consultant knows well that 
the patient who demands most attention and who 
requires most time is not he who suffers from a 
grave or fatal disease,-it is the individual with 
complaints often termed trivial which depend 
upon the manner and condition of his life and 
surroundings. By allowing such a patient to tell 
his story, in seeking out the indirect cause of his 
unhappiness, lies the only hope of alleviating 
his suffering. How difficult the discovery often 
is! How simple the remedy! What tragedies 
may result if the conditions remain unchanged! 
And the patients with these secret sorrows, with 
these so-called trivial complaints, come to the 
dispensary and not to the hospital. 
10 It is impossible in many instances, for the 
physician alone to reach the root of the matter. 
This is, however, admirably done by an efficient 
social service department-with visitors to look 
into home conditions,-to acquire the confidence 
of the patient-to complement the work of the 
physician. 
The combination of medical research and in- 
struction with the care of the sick in a free dis- 
pensary is important from many standpoints. 
Its advantages for the student and physician are 
self evident. Its advantages for the patient are, 
however, not always understood by the public. 
They are, nevertheless, very great-as great in 
the out-patient department as in the wards of 
the hospital. The presence of students of medi- 
cine, undergraduates, or post-graduates, is the 
greatest stimulus to the careful investigation of 
the individual case, and to study and research in 
general. The student as an assistant in the 
wards and in the out-patient department of a 
hospital is absolutely invaluable. No hospital 
which closes its w'ards to students can ever hope 
to compete in the quality of its work or in the 
care given to the patients with institutions in 
which ward instruction is given. I have known 
and served in hospitals of both classes, and I 
know whereof I speak. The same is true to even 
a greater extent in out-patient departments. 
There is one point, however, which has not 
sufficiently been emphasized, and that is the 
therapeutic value to the patient himself of medi- 
cal instruction. I rarely make a ward visit with 
the students or give a public clinic without the 
consciousness that what I am saying to the class, 
is of material value to many of the patients. It 
is almost invariably true that advice given in 
public and explained at the same time to the 
11 student has considerably more force than when 
it is given directly to the patient. The suspi- 
cious, nervous invalid rarely doubts the sincerity 
of advice given thus in the presence of others, 
and many a time I have seen the patient induced 
to the urgent operation only after hearing the 
pros and cons considerately discussed before the 
class. 
Especially valuable, often, is the combination 
of instruction with treatment of patients effected 
with various nervous diseases. One of the most 
fascinating and inspiring clinics that I know is 
the out-patient consulting hour of Professor 
Dejerine at the Salpetriere in Paris. Dejerine 
here combines his questions and advice to the pa- 
tient with explanations, confidences and digres- 
sions directed more particularly to his audience, 
in a manner so informal and so sympathetic that 
one feels immediately that the significance of his 
words to the patients is appreciably greater than 
if the advice were given in private. And it is 
interesting to see how true a bond of sympathy' 
is formed between these sufferers and the earn- 
est men in the audience, with whom, perhaps, 
not a word is exchanged. The patient is inter- 
ested in the fact that others are interested in 
her case. She is cheered, not only by the help- 
ful words of the doctor, but by the sympathetic 
glances of the onlookers, and she is reassured by 
the remarks and comments made to this audi- 
ence, in a confidential and intimate manner, in 
the discussion of her case. No one can doubt 
that in such a clinic as this the combination of 
instruction with treatment is beneficial to all 
concerned. 
The prime essentials for an efficient dispen- 
sary are that it be a part of, or intimately asso- 
ciated with, an institution of learning, and that 
12 it should possess a proper equipment for the 
study and treatment of disease. It is with pecu- 
liar satisfaction that I learn that one floor of 
this building, the cornerstone of which has been 
laid today, is to be devoted to laboratories. 
Twenty-five years ago, what laboratory work was 
necessary in a dispensary, could be done by thb 
clinical assistants themselves. Today, the story 
is very different, and it is difficult to imagine a 
dispensary, not associated with an institution of 
learning, which could afford the necessary equip- 
ment or guarantee a staff of a character suitable, 
to carry on the scientific work of the institution. 
What a wonderful field of study it is-the 
study of disease, offering as it does today, prob- 
lems which demand excursions into all of the 
natural sciences, problems which offer to the 
mind of the student the fascination and charm 
which are attached to any scientific investiga- 
tion, quickened by the added consciousness of 
the ends in view, the relief of human suffering, 
the increase of human efficiency, the prolonga- 
tion of human life, the betterment of man! 
Every hospital which opens its doors to the 
student of medicine, every university which 
gives of its resources material and moral, for the 
establishment of institutions such as that of 
which today you are laying the cornerstone, is 
contributing to these great ends. 
Of the specific value of a well equipped uni- 
versity dispensary to the public, to the student, 
to the physician, to the community, I have al- 
ready spoken, and coming from an institution 
which stands sorely in need of a building just 
such as that which you are now erecting, I offer 
you, not without a touch of, may I say, friendly 
envy, my cordial congratulations. 
13 Jamaica Printing Company, 
Jamaica Plain, Boston, Mass. Discussion by 
W. S. Thayer, M.D. 
following the reading of a paper entitled: 
On the Study of Renal Function: The Prognostic Value 
of Studies of Renal Function 
by L. G. Rowntree. 
Congress of Physicians and Surgeons 
Washington, D.C. 
May 6th and 7th, 1913. Discussion by 
W. S. Thayer, M.D., 
following the reading of a paper entitled: 
On the Study of Renal Function: The Prognostic Value 
of Studies of Renal Function 
by L. G. Rowntree. 
Congress of Physicians and Surgeons 
Washington, D.C. 
May 6th and 7th, 1913. 
For the last two years, in association with Dr. 
Rowntree, Dr. Fitz and Dr. Baetjer, have studied the 
renal function of a considerable number of patients 
under my observation, in and out side the wards of the 
Johns Hopkins Hospital. These studies have taken into 
consideration the intake and the output of salt and 
water, the elimination of iodide of potassium and 
lactose after the manner of Schlayer, as well as the 
estimation of the incoagulable nitrogen in the blood 
and the excretion of phenolsulphonephthalein. 
The delicacy of the lactose test, in the absence 
of chronic passive congestion, in revealing early 
disturbance of the vascular apparatus of the kidney, 
especially in association with the manifestation 
termed by Schlayer "vascular hyposthenuria" appears to 
be undoubted. 
I can only emphasize, in my turn, the great im- 
portance, from all standpoints, of the systematic con- 
sideration of the intake and output of chlorides and 
water in renal disease. 
The prognostic value of the estimation of the 
content of the blood in incoagulable nitrogen will 
probably be considerably enhanced through the recent 
introduction by Denis and Folin of simpler and more 
accurate methods of study. 
All observations of the last three years have 
especially convinced us of the real diagnostic and 
prognostic value of the 'phthslein test of ftowntree 
and Geraghty. It is simple and easily carried out, 
and it appears to be a fairly reliable index of the 
renal function at the time of its application. The 
interesting parel]elism between the 'phthalein excre- 
tion and the incoagulable nitrogen content in the 2 
blood, pointed out yesterday at the meeting of 
the American Society for Clinical Investigation, 
by Frothingham, will be remembered by those who 
were present. In Frothingham's experiments the 
increase in the incoagulable nitrogen appears a 
little later than the decrease in the 'phthalein 
output, but follows it very closely. 
The elimination of 'phthalein is materially 
reduced in severe passive congestion of the kid- 
ney; it increases, however, immediately with 
periods of improvement, that which does not occur 
when sufficient damage has been done permanently to 
impair the renal function. 
The detection of a low 'phthalein output, in 
some instances where there is no question of chronic 
passive congestion, may be of great importance from 
a diagnostic and prognostic standpoint. How import- 
ant this may be, may be illustrated by referring 
again to a case mentioned by Dr. Rowntree: The 
patient was a boy, twelve years of age, who was ad- 
mitted to the Johns Hopkins Hospital two and a half 
years ago, complaining of polydipsia and polyuria 
of several years' duration. For two years, the child 
had complained of pain in his legs, rather sharp in 
character end interfering with his walking. When he 
entered he was passing about 2,500 cc. of urine in 
the twenty-four hours, of a specific gravity of about 
1005, without albumen and without formed elements in 
the sediment. The physical examination showed a 
pale boy with rather dry skin and with no demon- 
strable cardiac hypertrophy. His maximum blood 
pressure was ninety-five - the radial arteries were, 
however, palpable, and thicker than one ordinarily 
sees in a small boy. The eye grounds showed no changes. 
The 'phthalein test, a week after entry, showed a 
total excretion in two hours of 7 per cent., and on 
the following day, the excretion was but 3.1 per cent. 
The test enabled us properly to interpret symptoms 
that we might well otherwise have regarded as those 
of diabetes insipidus. Within a day or two, the 
quantity of urine began to diminish, a trace of albu- 
men appeared, and, inside of a week, the boy died in 
uraemic coma. 
At the medical clinic of the Johns Hopkins Uni- 3 
varsity, we have already followed to autopsy probably 
fifty cases in which the 'phthalein test has been 
carefully made. In many instances, our snte-mortem 
opinion as to the extent of renal change, based 
upon the studies previously referred to, has been 
recorded. We are at present tabulating these cases, 
in the hope that conclusions of some value may be 
justified. 
As Dr. Janeway has pointed out, we are con- 
cerned here in the main with chronic progressive 
disease, the aetiology of which is still, in many 
instances, uncertain, with conditions to combat 
which we have, at present, few weapons of decisive 
value. With what means we have now at our command, 
we have considerable power to detect renal disease. 
The most important immediate question which con- 
fronts us in many cases is as to the extent of the 
damage done and what is the outlook for the future. 
Let us not forget that these tests are tests of 
function and not tests of anatomical change. And, 
after all, that which is important for us to know 
is not so much what the kidney looks like, but 
how permanently are its functions impaired, and 
especially, what are the limits of its present 
powers, and how long may they be expected to last - 
when may we look for the onset of fatal decompen- 
sation! Here we must acknowledge still our serious 
limitations, for we can not invariably test the 
limits of functional capacity any more than we can 
test the exact limits of the compensatory power of 
the heart muscle. How far v/e can approach this 
has been brought out by Dr. Rowntree and by Dr. 
Christian. These are, however, questions of special 
importance in slow chronic nephritis. 
When the excretion of lactose is suppressed, 
when the 'phthalein excretion is under 10 per cent, 
in two hours, where a previous persistent vascular 
hyposthenuria has begun to disappear, where the 
urea content of the blood is Uigh, the question is 
simple. But where the polyuria still persists, 
where the blood pressure is high, the lactose ex- 
cretion delayed and the 'phthalein excretion moderate- 
ly reduced, we are often asked: V/hat is the outlook 4 
for life? How near are we to the danger line? 
These questions are not always easy to answer, 
for there are indications that occasionally de- 
compensation may be sudden and unsuspected as it 
may be at times in disease of the heart muscle. 
Nevertheless, such cases are exceptional, and 
I believe that today, thanks to the revival of 
the study of renal function, we are able to dis- 
tinguish early disease of the kidney with greater 
accuracy, to estimate its extent more surely, and 
to prognosticate its future course more safely 
than we were a few years ago. More than this, as 
Dr. Janeway, especially, has pointed out, we have 
learned in some ways to treat our patients better, 
to improve materially their comfort, and to increase 
their chances of survival. 
Of especial importance, it seems to me, from 
the therapeutic standpoint, are the observations 
of Mosenthal and Schlayer, which have been referred 
to by Dr. Janeway, emphasizing as they do and ex- 
plaining the harm that may be done by undue per- 
sistence in the use of diuretics in renal disease. 
In every-day practice we have learned that the 
careless use of diuretics may be injurious, but 
the clear experimental demonstration of the re- 
action of the diseased or fatigued kidney to over- 
stimulation is a suggestive and helpful contribution. "INTEGER VITAE SCLERISQUE PURUS." 
By W. S. Thayer, M.D. 
With the death of Dr. Eugene Fauntleroy Cor- 
dell there is left a gap in the medical life of Mary- 
land which is not likely soon to be filled. And 
what a full and useful career his was! A Vir- 
ginian by birth, educated according to the best 
Virginia traditions in the Episcopal High School 
and the Virginia Military Institute, he was swept 
early in life into the maelstrom of the war, and 
it was only after continuous and creditable serv- 
ice through those terrible four years that he took 
up the study of medicine in Baltimore, which was 
ever after to be his home. 
Dr. Cordell's many activities during the years 
of his life among us it is unnecessary here to enu- 
merate ; they have already been set forth in this 
Journal and elsewhere. Of a scholarly mind, 
Cordell was essentially a student, with a special 
leaning toward matters historical, and his contri- 
butions to the history of medicine in Maryland 
are permanent monuments of his careful, judici- 
ous and painstaking labors. 
But Cordell was not only a student, he was a 
gentleman in the truest and widest sense of the 
word. His never-failing courtesy and considera- 
tion for all,-his dignity and quiet grace of man- 
ner and speech, endeared him to all with whom he 
came into association. Of slender means, living 
in the simplest manner, he was the most charitable 
of men, and the interest which he took in the man- 
agement of the loan fund of the State Faculty 
and in the Home for the Widows and Orphans 
of Physicians is familiar to all. 
I saw him last in the middle of the summer, calling at his house to ask with regard to the avail- 
ability of the loan fund of the faculty for a 
worthy colleague and his family who were in 
trouble. He opened the door himself, and led me 
into his study. How well I remember the earnest, 
grave figure sitting by his desk, on which lay an 
old folio, with the dictionary lying across the 
opened book-the symbol of the great interest of 
his later years. I shall not soon forget the touch- 
ing sympathy with which he listened to my story. 
As I rose to leave he said: "Doctor, you may put 
me down for ." The act was so characteris- 
tic, the spontaneous generosity from him least 
able to give, but always ready to share whatever 
he had with his suffering fellow! 
Cordell's tastes, as has been said, were mainly 
those of a student. His practice could not have 
been large, but his activities were many. This 
modest, sensitive, self-effacing man went his daily 
way so quietly and unobtrusively that few who did 
not know him well realized how full of useful 
work were his three-score years and ten. "In- 
teger vitae s^erisque purus * * ," beset by 
more than the ordinary cares, anxieties and trou- 
bles of existence, with modesty and dignity, he . 
led his busy and useful life, and only now Jie is 
gone do we fully realize how much he achieved 
and how fine was his example. IN MEMORIAM. 
REGINALD HEBER FITZ. 
By W. S. Thayer, M. D., 
Professor of Clinical Medicine, The Johns Hopkins 
University. From The Johns Hopkins Hospital Bulletin, Vol. XXV No. 277 
March. 1914.] 
IN MEMORIAM. 
REGINALD HEBER FITZ.* 
By W. S. Thayer, M. D., 
Professor of Clinical Medicine, The Johns Hopkins 
University. 
It is a sad but grateful opportunity, that of coming home 
today to pay an affectionate tribute to the memory of my dear 
and valued master. 
It is not far from thirty years ago, though it seems but 
yesterday, that we sat in the precipitous amphitheatre of the 
then new school building in Boylston Street, and listened to 
his brilliant talks. No one who heard those remarkable lec- 
tures could have failed to carry away a deep impression of the 
strength, the ability, the learning of the man. They were 
remarkable lectures, remarkable in form and in substance; 
models of clear and precise exposition, admirably delivered 
in language, every facetted word of which seemed to have 
been so chosen that it, and it alone, could fill its place. Stim- 
ulating hours which gave to many of us a lasting realization 
of the importance of precision and accuracy in observation 
and thought and expression. 
Fitz was not an investigator in the sense that he carried 
out or led original, experimental research, but his contribu- 
tions to the science and art of medicine were none the less 
important and valuable. His habits of discriminating pre- 
cision in thought, in observation, in interpretation, in expo- 
sition gave him that penetrating clearness of vision which 
enabled him to extract, as could no one else, from a mass of 
[87] 
* Read at a Memorial Meeting at the Harvard Medical School, 
Boston, Mass., November 17, 1913. 
1 [87] 
apparently unrelated observations, the concise, clear, clinical 
picture, correlated with definite physiological and pathological 
processes and anatomical changes. It is no small achievement 
that this one man should have given to the world the first 
clearly defined description of two such important maladies as 
appendicitis and acute pancreatitis. 
*His communication entitled " Perforating Inflammation of 
the Vermiform Appendix, with Special Reference to its Early 
Diagnosis and Treatment," was delivered in Washington 
before the first meeting of the Association of American Physi- 
cians on the 18th of June, 1886, now more than twenty-seven 
years ago. In this study, the orderly system and simplicity 
of which are so characteristic of the man, he focussed clearly, 
for the first time, the vision of the medical world on the true 
nature of the inflammatory processes occurring so commonly 
in the right lower abdominal quadrant, and showed, convinc- 
ingly, that the seat of primary disturbance, in the great 
majority of instances of this nature, lies in the appendix 
vermiformis. And along with this demonstration, he set forth 
in a masterly manner the clinical manifestations of the disease. 
This publication came at a time when the world was well 
prepared. Everyone recognized that Fitz had, as it were, put 
his finger on the spot. Once set forth, the pathological and 
clinical sequence of events seemed almost obvious-obvious as 
are so many great truths when once they have been clearly 
enunciated. The sharp light thrown by Fitz on this common 
and perilous pathological event brought it about that our 
countrymen were fully ten years in advance of the rest of the 
world in their comprehension of this process, and in their skill 
and efficiency in the care of the patient. 
How many human beings owe their lives to-day, more or less 
directly to Fitz, no one can tell. Surely, it is no small number. 
There has been one curiously paradoxical sequence of this 
great contribution. The word " appendicitis " employed by 
Fitz in the course of this article was immediately seized upon 
by the public and has entered into universal use, but not 
without bitter protest from some who still shudder at its 
etymological hybridism. 
[88] 
2 It is an amusing thought that of all men, Fitz, the most 
careful and accurate, should have been the target of irritated 
critics, because of the introduction into medicine of what 
they regard as an ill-constructed word. 
The practical importance of the facts set forth in this first 
contribution has, it has often seemed to me, somewhat over- 
shadowed the brilliancy of the later work. In his studies on 
the appendix, the truth seemed so nearly ready to emerge of 
itself that the medical public grasped, immediately, the sig- 
nificance of the exposition. The lectures on acute pancreatitis, 
on the other hand, treated of a subject of which little was gen- 
erally known, even anatomically. The analysis of the carefully 
collected pathological material, the discriminating consider- 
ation of the clinical features and the final synthesis of the defi- 
nite, convincing clinical picture of the disease, acute pancrea- 
titis, was truly a great achievement. 
How well I remember the demonstration by Virchow, nearly 
a year after the delivery of the Middleton Goldsmith lectures, 
after I had seen acute pancreatitis recognized clinically and 
confirmed at necropsy-how well I remember the demon- 
stration by Virchow of the organs from a case of disseminated 
fat necrosis with sequestration of the pancreas, accompanied 
by the observation that these instances were pathological 
curiosities. With what pride I sought him out and made him 
familiar with the little pamphlet which set forth so clearly 
and so simply the clinical aspects of the disease ! 
How vivid is the memory of Fitz's recitations and dem- 
onstrations ! What student who attended them can forget 
the charm of that subtle and incisive, but yet humorous and 
not unkindly irony-or rather, perhaps, that ironical face- 
tiousness which so disconcerted some of his pupils and 
colleagues, and so delighted others; which was, I am sure, 
highly beneficial to many who did not fancy it at the moment. 
One did not go to sleep in Fitz's demonstrations ! 
By nature of a careful and judicious temperament, he was 
a strong man, and had the strong man's love for discussion, 
argument, opposition. Just and tenacious of his opinions as 
a strong man should be, his firm mind was not easily shaken. 
But firm though his mind was, it was ever open to recognize 
[88] 
3 [88] 
and welcome and embrace the new truth. This very attitude 
of apparent opposition was one of Fitz's most stimulating 
qualities, inciting his associate, whether student or colleague, 
to keener and more efficient effort. 
At the necropsy table he sought to induce the clinician to 
express a definite opinion as to the nature of the case, and, 
where there proved to have been any failure wholly to appre- 
hend the character or extent of the pathological process, he 
often pointed out the omission in diagnostic procedure or the 
error in reasoning which had been responsible for the incom- 
pleteness of the diagnosis. This most instructive and valuable 
habit was trying to some over-sensitive colleagues. But Fitz 
was consistent; he did not spare himself. While yet pathologist 
at the Massachusetts General Hospital, he used to visit, in the 
surgical wards, patients on whom an abdominal section was to 
be performed, in order that he might compare his bedside 
observations with the results of surgical investigation. His 
opinions he was always willing to express, far more willing, 
sometimes, than those in attendance upon the patient. This 
habit must have been of great assistance to him as a consultant 
in later years; as an example to the house officers it was invalu- 
able. 
Fitz's peculiar keenness of intellect inspired, at first, in 
certain of his students, an admiration and respect not untinc- 
tured with fear-something akin to the Ehrfurcht of our 
Teutonic brethren. But the element of fear dissolved into 
love with the first personal contact. How simple and gracious 
was his reception of the student who, perhaps, with some 
misgiving, sought his counsel in private I His unfailing 
kindness and thoughtfulness, his friendly interest and wise 
advice so freely and generously given, meant more to some of 
us than words can express. 
To not a few of his students, his teaching and example were 
the great inspiration of their school days, and to most of 
these men this inspiration has been a lasting and a growing 
influence. There must be many who owe to him their best 
ideals in medicine, and surely, there are others of his pupils 
who have been, as have I, so jealous of his regard that any con- 
sciousness of lapse or shortcoming has been inevitably asso- 
4 ciated with the sting of the thought that they were unworthy 
the confidence of Fitz. 
It is very strange and sad, the thought that all this wealth 
of wisdom and learning and experience so slowly and pain- 
fully acquired through a long and active life, has vanished 
in a moment. It leaves one with a sense of immense empti- 
ness and vacancy and waste. 
But he has left to mankind a large legacy in his epoch- 
making contributions, 'and with his students and disciples he 
remains ever present, embodied in their highest ideals. If 
these disciples shall succeed in shaping their lives as he 
might have wished, his beneficent influence will long endure. 
[88] 
[891 
5 IN MEMORIAM. 
TWO MEN: 
GEORGE ALEXANDER GIBSON 
HUGH ANGUS STEWART. 
By W. S. Thayer, M. D., 
Professor of Clinical Medicine, The Johns Hopkins 
University. [From The Johns Hopkins Hospital Bulletin, Vol. XXV, No. 277, 
March. 1914.] 
IN MEMORIAM. 
TWO MEN: 
GEORGE ALEXANDER GIBSON 
HUGH ANGUS STEWART.* 
Professor of Clinical Medicine, The Johns Hopkins 
University. 
By W. S. Thayer, M. D., 
Seven years ago, there came to us from Edinburgh, a young 
man who desired to spend a year at work such as might enable 
him to prepare the thesis necessary for the acquisition of his 
doctorate in medicine. This young Scot brought with him 
letters from his former master in Edinburgh, a man distin- 
guished in his profession and very dear to his friends. The 
affection that the pupil always showed toward his master and 
the almost loving interest with which the master inquired for 
his pupil on those too rare occasions when it was my good 
fortune to be thrown with him, have brought it about that 
these two men, in some ways very different, have been closely 
associated in my mind. 
By a strange fate, both of these men, seemingly so full of 
life and strength and vigor, have gone within a few months 
of one another. 
The world was ill able to spare them. 
I cannot refrain from saying, at the outset, a few words of 
the master from whom Hugh Stewart drew much of his inspi- 
ration, the man who gave him that advice which brought him 
to us. 
[89] 
* Remarks made on the occasion of the dedication of a memorial 
tablet to Hugh Angus Stewart, M. D., Columbia University, N. Y., 
November 15, 1913. 
1 [89] 
George Alexander Gibson was born in Perthshire, in 1854, 
and graduated in medicine in Edinburgh in 1876, taking his 
degree of M. D. in 1881. In 1874 he had already obtained 
the degree of B. Sc. at the same university. A fine, spirited, 
able fellow, he soon attained eminence as a practitioner and 
a teacher, and his visits and clinics at the Royal Infirmary 
^ere greatly appreciated by a wide circle of students. He was 
a member of many learned societies and his contributions to 
medical literature were numerous and valuable. Gibson was 
an able clinician and a successful teacher, but above all he 
was a man of unusual personal magnetism. He was not a 
great investigator; he had conducted no notable, original ex- 
perimental work, but he was an excellent observer, a clear, 
forceful teacher, and he had a remarkable power over his 
fellow men, a power always for good; sane, wholesome, stimu- 
lating. Of a large frame, with a ruddy complexion, Gibson's 
clean-cut features might have sprung from some eighteenth 
century portrait, and the fresh glow of his countenance seemed 
to permeate the air about him with a spirit of confidence and 
optimism, an indescribable sense of the joy of life; for Gibson 
had a rare and mellow human charm. The joy of life was ever 
in him-on the golf course; rod in hand by the rushing stream; 
in his library, reading with sympathy the works or the life 
of some master of his art, rejoicing in the wit and wisdom of a 
Holmes, with every incident in whose life he was familiar, 
chuckling over some crystalline epigram of an Anatole France 
whom he loved to quote; in his wards, surrounded by his 
students, or about his more than hospitable board-the joy 
of life was in him and radiated warmth and health and happi- 
ness upon those who surrounded him. Wherever he was, his 
ear was always ready, his eye was ever open to seize some 
unexpectedly humorous aspect of the situation. He was kind- 
liness itself. He loved his fellow man, and his fellows loved 
him. There are many of us here in America who remember 
him with warm admiration and affection. 
Such a man, if he has, as had Gibson, sound training and 
natural clinical ability, cannot fail to be an inspiration to 
his pupils. His great work lies, not so much in his own origi- 
nal contributions to medical science as in the influence which 
2 he has upon those about him-pupils, friends, patients. 
Freed by his nature from the blinders of vanity and pride, 
such a man knows and weighs his own limitations as 
well as those of others, and is often the best and wisest ad- 
viser to the youth who desires to enter upon a more strictly 
scientific career. Such a man George Gibson seemed to me, 
and as such a man Hugh Stewart loved him and looked up 
to him. 
At even so recent a period as seven years ago it was by no 
means customary for a European student to seek, in an Ameri- 
can laboratory or clinic, the opportunity to pursue post-grad- 
uate study. But Gibson realized the importance and the value 
of a cosmopolitan education and experience, and so it was that 
we came to know Hugh Stewart. 
Stewart also was a Highlander, accustomed as a boy to the 
Gaelic tongue-a Scot by birth, by nature, by tradition, by 
education. From a youth passed amid the wild beauty of 
those purple moors and hillsides which for centuries have 
nourished some of the sturdiest of our British stock, he drew 
all the vigor and strength so characteristic of that wonderful 
people-that strain which, springing from a remote corner of a 
little island, is so inseparably bound to all that we most love 
and treasure in history, in romance, in poetry, in art, in 
science, in literature, in statecraft-which has contributed 
so largely to all that makes for the greatness and stability of 
our race. Tall but so well proportioned that he never im- 
pressed one as a strikingly large man, with fine, expressive 
features, Stewart had a quiet, modest, rather diffident manner. 
He was a man of few words, and he never spoke about himself. 
Of his early life, even his best friends knew little, for he rarely 
dwelt upon it. 
At the outbreak of trouble in South Africa, Stewart entered 
the army as a volunteer, and served creditably. He referred, 
occasionally, with some humor, to the circumstance that, for 
a time, his duties put him in charge of a number of army 
mules which had been imported from the United States. I 
regret to say that his opinion of the moral character of those 
mules was such as to inspire a distrust which I was never 
able wholly to shake, as to the business probity of those of 
[89] 
[90] 
3 [90] 
our countrymen who had been instrumental in furnishing 
these important engines of war. 
Quiet and modest as was his demeanor, he was one of the 
strongest and most self-sufficient characters I have ever 
known. His problem once chosen, he went to work with an all- 
absorbing energy and persistency. Remarkably resourceful, 
he rarely asked assistance or advice. He framed his own 
plans, devised his own instruments and pursued his problem 
to its end in an orderly and systematic manner. During his 
first year in Baltimore, he carried out, in Dr. Hirschfelder's 
laboratory, the excellent piece of work on the pulse and blood 
pressure changes in aortic insufficiency, which earned him his 
degree of M. D. and a gold medal. 
After returning to Edinburgh to receive his well-earned 
honors he came again to Baltimore in the fall as my assis- 
tant. His duties in this capacity were numerous and not 
alw'ays easy, but he found time, nevertheless, to carry out 
some exceedingly interesting and ingenious experiments which 
apparently demonstrated that the circular muscle fibres below 
the aortic and pulmonary valves enter into contraction slightly 
later and remain in contraction somewhat longer than the rest 
of the ventricular muscle. In the course of this work, he 
showed remarkable mechanical ingenuity in devising a deli- 
cate instrument for the graphic registration of these muscular 
contractions. Why these experiments were not recorded I 
have never known. Stewart was not one who rushed into 
print and it is probable that he felt that there was still some- 
thing lacking to make the demonstration complete and his 
results unassailable. 
He was an admirable assistant, ready, understanding, far- 
seeing, and he soon showed himself to be a man of excellent 
clinical judgment. His most valuable qualities were, I should 
say, his self-sufficiency and his independence. Deferential, 
never obtruding his opinion, he always knew his own mind, 
and if the opportunity offered, he expressed his views, whether 
or not they agreed with those of his superior officer. He was 
fond of argument, showing, in rather high degree, an in- 
clination to take up opposition to any sharply enounced 
proposition, a tendency which was so striking in an honored 
4 leader of the medical profession in America, whose untimely 
death we have so recently had to mourn-my dear old master 
and friend, Dr. Fitz. But there is no more valuable habit 
of mind than this when it is associated with a fundamentally 
open and judicial temperament; it is an attitude which, as I 
have often said of Fitz, is characteristic of the strong man- 
and Stewart was a strong man. 
I can see him now: We were perhaps discussing some 
question of interest, and, in my enthusiasm, I had expressed 
my views at some length and rather positively. Stewart had 
listened with perfect deference but when I was done, he would 
lower his head a little, as if he were about to charge some 
obstacle, and in a quiet, determined manner, with a slight 
Scotch accent, he would say, " I don't think so "-and he 
was generally able to give good reasons why he did not think 
so. 
After a year's service as Assistant Resident Physician, 
Stewart became Assistant in Pathological Physiology in the 
Johns Hopkins University, and a Fellow of the Rockefeller 
Institute. During this year, he carried out with Dr. King 
some important experiments in which it was shown that the 
toxic element of the bile, that which causes the lowering of the 
blood pressure and the slowing of the heart, lies in the pig- 
ments and not, as is still so commonly asserted, in the salts. 
Following this, Stewart published an interesting note on " The 
Dextrose Consumption by the Isolated Perfused Human 
Heart." 
In 1909, he left Baltimore to become the Associate of Dr. 
MacCallum, as Assistant Professor of Pathological Anatomy 
in Columbia, and it was with most sincere regret that we 
parted with him. That which he accomplished in these last 
four years, I need not tell you. 
Stewart had always desired eventually to enter into clinical 
medicine, and alongside of his experimental study in the 
laboratory and his teaching, he kept in touch with the patient 
at the bedside in St. Luke's Hospital. In medicine his 
especial interest was in the study of the circulatory system, 
an interest stimulated, undoubtedly, by his work with Gibson. 
[90] 
5 [90] 
The list of his valuable contributions shows how consistently 
he pursued the course that he had chosen at the outset. 
To all he seemed a man of exceptional promise, one who 
must surely have made his mark. 
The master, essentially a clinical observer, had impressed 
upon the pupil the desirability, in the new day, of preparing 
himself for a career in medicine by years of fundamental 
study and research, that he might be fitted properly to direct 
the many activities of a modern medical clinic. And there 
were few men in America better fitted for such a career than 
was Stewart at the time of his death. Reserved, undemonstra- 
tive, retiring as he was, it was not difficult to see that Stewart 
was a man of really deep feeling and of rare loyalty. For 
Stewart was a man-a man in the purest and best English 
sense of the word-a man on whom one felt instinctively that 
he could rely in any emergency. And after all, is it not this 
which means most to us in this world ? What skill, what bril- 
liancy, what powers, what accomplishments move us| as do 
those qualities of sturdy and efficient self-reliance and courage, 
and honesty and directness which go to make a man! What 
triumph of genius stirs us as deeply as does the simple story of 
a Scott and an Oates I 
And with all his ability and his talents, it is this inde- 
finable essence of manliness that appeals to us most profoundly, 
as we think of the fine fellow in whose memory we meet today. 
There are few of us who knew him who, in our hearts, have 
not more than once said, " Would that I were a little more 
like Stewart! " 
LIST OF PUBLICATIONS OF HUGH ANGUS STEWART. 
Stewart (H. A.): A Case of Aortic and Pulmonary Incompe- 
tence, Complicated by Pericarditis with Effusion. Edinb. M. J., 
1906, n. s.» XIX, 507-513. 1 pl. 
Stewart (H. A.): Experimental and Clinical Investigation of 
the Pulse in Aortic Insufficiency. Arch. Int. Med., Chicago, 1908, 
I, 102-147. 
King (J. H.) and Stewart (H. A.): Effect of the Injection of 
Bile on the Circulation. J. Exper. M., Lancaster, Pa., and N. Y., 
1909, XI, 673-685; also Tran. Assn. Am. Phys., Phila., 1909, XXIV, 
396-409. 
[91] 
6 Stewart (H. A.): The Dextrose Consumption by the Isolated 
Perfused Human Heart. J. Exper. M., Lancaster, Pa., 1910, XII, 
59-66. 
Stewart (H. A.): The Cause of Cardiac Cohypertrophy. Proc. 
Soc. Exper. Biol, and Med., N. Y., 1910-11, VIII, 13. 
Stewart (H. A.): An Experimental Contribution to the Study 
of Cardiac Hypertrophy. J. Exper. M., Lancaster, Pa., 1911, XIII, 
187-209, 4 pl. 
Stewart (H. A.): The Influence of Salts of Calcium and Potas- 
sium on the Degree of Hypertrophy Produced by Adrenalin In- 
fection in Rabbits. Proc. Soc. Exper. Biol, and Med., N. Y., 1911- 
12, IX, 7. 
Stewart (H. A.) and Harvey (S. C.): Variations in the Re- 
sponse of Different Arteries to Blood Serum and Plasma. Proc. 
Soc. Exper. Biol, and Med., N. Y., 1911-12, IX, 84-87. 
Stewart (H. A.) and Harvey (S. C.): The Vaso Dilator and 
Vaso Contractor Properties of Blood Serum and Plasma. J. Exper. 
M., Lancaster, Pa., 1912, XVI, 103-125. 
Stewart (H. A.): The Mode of Action of Adrenalin in the Pro- 
duction of Cardiac Hypertrophy. J. Path, and Bacteriol., Cam- 
bridge, 1912-13, XVII, 64-81. 2 pl. 
Stewart (H. A.): On certain Relations between Lipoid Sub- 
stances and the Adrenals. To appear in the transactions of the 
XVII International Medical Congress. 
[91] 
7 IN MEMORI AM. 
RUPERT NORTON. 
1867-1914. [From The Johns Hopkins Hospital Bulletin, Vol. XXV, No. 282, 
August, 1914.] 
IN MEMORI AM. 
RUPERT NORTON. 
1867-1914. 
I knew him from the time he was seven years old. Shady 
Hill was the paradise of the boys and girls of Cambridge. 
In front of the old house so dear to generations of Harvard 
students who have received the kindly hospitality of his dis- 
tinguished father-in front of the old house the land fell with 
a gentle inclination toward " Norton's Woods "; and this little 
slope, the nearest approach to a hill in the flatness of Cam- 
bridge, was known to us all as " Norton's Hill "-or " Nor- 
ton's " for short. " Norton's "-what memories of delight 
that name brings! For there, on the winter days, within a 
few steps of the front door, all the boys and girls of Old Cam- 
bridge used to coast. No memory of my youth is more vivid. 
The welcome snow-storm; the laborious watering of the snow 
that the coast might be smooth and hard and icy; the rivalries 
with sled and " double-runner "; the unwelcome thaw. But 
above all, the glories of coasting by night; the beauty of the 
crisp, cold moonlight on the snow; the torches; the big 
double-runners; the older boys and girls, to whom we looked 
up with such awe and admiration-and envy when we, poor 
youngsters, were whisked home at an early hour. It is long 
years ago as I write, but it is still very near in my happy 
dreams. ' . 
At the bottom of the hill began " Norton's Woods," of 
refreshing memory. I wonder how many acres they covered. 
Not so very many, I fancy; and to-day they are in great part 
gone. But the fine old trees, the cool and mysterious shades, 
the rustling of the birds, are as fresh and real to-day as they 
were forty years ago. And so is the old house, with its long 
and leafy avenue, and the kindly face of its master, and the 
charming family circle. 
[242] 
1 [242] 
It is with these scenes and memories that I first associate 
Rupert Norton. His brother Eliot and I used to pore over 
our stamp collections in the spring and fall, and in the winter 
we shared a double-runner. In those days Rupert, barely 
three years younger than we, seemed a little boy. He was then, 
as always, quiet and modest and reserved. Brought up at 
home in an atmosphere of books and art and scholarship, he 
entered college in the sophomore year. His life at Harvard 
was uneventful, his acquaintances not especially numerous 
but well-chosen and devoted to him. At the end of his college 
course he had a severe illness, and it was not until a year after 
his graduation that he began the study of medicine in Ger- 
many. There again our paths crossed, for at this time I also 
was spending a year in the laboratories and hospitals of Berlin. 
Our work was different and we met only occasionally; but 
when I was taken ill with diphtheria, he was at my side in a 
minute and was kindness and consideration itself. Helpful, 
thoughtful, self-effacing, he paid me all those little attentions 
which throughout life he has so unostentatiously showered 
upon his friends, and for which they feel so deep a gratitude. 
After a year in Germany he returned to the Harvard Medical 
School where he finished his course in 1892, taking his degree 
in 1893, as was customary then for those who accepted hospital 
positions. After some months' service in the Children's Hos- 
pital of Boston, he came to The Johns Hopkins Hospital as 
assistant resident physician in the spring of 1893. The staff 
was then small; undergraduate teaching had not yet begun. 
His associates were Hewetson, Smith, Ramsay, Billings, Oppen- 
heimer, Carter, Blumer, Futcher, Atkinson. Careful, faithful, 
thorough in his work, rather diffident in manner, he was not 
quick in making acquaintances; but before he left the hospital 
he was dearly loved by all of his associates. For behind the 
shy, diffident, rather abrupt manner, were hidden most lovable 
and charming qualities of mind and heart: a keen perception; 
a nice sense of humor; a most companionable, lovable, loyal 
nature--kindly and generous, charitable to a fault, intolerant 
only of that which seemed to him soft, unmanly or indirect. 
In April, 1895, he left the hospital and began the practice 
of medicine in Washington-practice which was not rapid in 
2 coming to him; for he was too shy, too retiring, too reserved, 
and his peculiar reticence and even dryness of manner were too 
often interpreted as coldness and lack of interest. But those 
patients who came to know him, and the colleagues who broke 
through the shell of shyness and reserve, found one of the 
warmest, most generous and kindly hearts that ever beat. No 
one who knew Norton failed to love him. 
In the Spanish War he enlisted as an Acting Assistant Sur- 
geon and served throughout the campaign, doing, in the main, 
pathological work in one of the large Southern camps. 
After this, to the disappointment of many of his friends, he 
gave up his Washington practice to become medical-director of 
the Parisian office of a large American life insurance com- 
pany. In his new work he displayed the same care and thor- 
oughness that had been characteristic of all his endeavours. 
While many of us felt that the routine of this position was 
hardly worthy of one of his talent, yet in a way the situation 
had its advantages. The broad literary and artistic oppor- 
tunities of Paris appealed to him deeply, and his life was far 
from empty. Outside of his work and other interests, Norton 
sought for and found opportunities to encourage and help his 
deserving fellow-countrymen of the artistic colony. How wise 
and thoughtful and discriminating his generosity was, few will 
ever realize, for his charity was known only to himself. 
In 1906, the company with which he was associated aban- 
doned its offices in Paris and Norton returned to the United 
States as Acting Superintendent of The Johns Hopkins Hos- 
pital during Dr. Hurd's long vacation. This position he 
filled ably and efficiently ; and, on Dr. Hurd's return, he was 
appointed Assistant Superintendent of the institution. Here 
he soon made himself felt, not only in his administrative 
capacity, but as a valuable helpmate to Dr. Hurd in the literary 
work connected with the position. In recent years he had pub- 
lished several thoughtful communications on subjects pertain- 
ing to hospital management, and his opinion and advice were 
beginning to be more and more widely sought. On Dr. Hurd's 
retirement, the editorship of the Bulletin and the Hospital 
Reports fell on him. His services in this capacity were invalu- 
able. His patience, his conscientiousness, his literary ability, 
[242] 
[243] 
3 his unfailing good taste, were relied upon by all. We had 
looked forward longingly for the day when we might have a 
library worthy of the hospital, in which Norton might find 
his proper position as director of the literary functions of the 
institution. It will not be easy to find his successor. 
And during this time he has grown into our hearts as few 
men could. 
After long years of tried and devoted friendship, Norton was 
married but twelve months ago, to Miss Caecelia Hendrickson, 
of Frederick. No union could have been happier or more com- 
plete. How pitiful was its brevity ! 
How little, sometimes, can we measure a man's work in the 
world by his contemporaneous fame or by the permanent mon- 
uments which bear his name. Norton was not widely known, 
and he published little: but he did a good work, and he leaves 
many friends to whose lives he has added something uplifting 
and enduring. Only now that he has gone, do we who knew 
him begin to realize how large were his generosity and his 
charity, and how deep had been his influence upon us. But 
no one who knew him well, failed to realize at all times the 
unusual quality of his friendship, a friendship which meant 
not only perfect loyalty and devotion but other responsibilities 
not easy to fulfil, to which he was ever true. He who was 
blessed with his friendship never failed to receive, when it 
was needed, the kindly and just and direct word of warning or 
criticism so hard to give but so wisely and simply and consid- 
erately offered. His friends' honour and reputation were as 
dear to him as his own. For these friends, and they were many, 
he has done a noble and a lasting work. His memory will for- 
ever rest in their hearts, and through their better lives his 
influence will long endure. 
When we look back upon his career, we shall remember his 
simplicity, his modesty, his upright, uncompromising honesty 
of purpose and word and practice, his delicate charm of mind, 
his varied attainments and interests and abilities, his faithful 
work in many capacities; but above all we shall remember the 
rare beauty of his friendship. 
[243] 
William S. Thayer. 
4 Dr. Thayer was then asked to speak. 
Dr. Thayer: I well remember the first time that I saw 
Dr. Billings. It must have been something over twenty-five 
years ago when he delivered a series of lectures on the history 
of medicine at the HarvardxMedical School. A valued teacher 
had told us that Dr. Billings was one of the most distinguished 
figures in American medicine, and even then, as a second or 
third year medical student, I had an almost reverent admira- 
tion for him as the editor of the Index Catalogue, and the 
Index Medicus. 
I remember his appearance at that time. His tall, dignified, 
commanding figure, his impressive, forceful manner, his evi- 
dent mastery of his subject left with us an impression which 
few have forgotten. 
And then I remember vividly the first time I had the 
pleasure of meeting him. A few years later, while visiting in 
Washington, a warm-hearted and kindly, but highly eccentric 
lady, the wife of a retired army officer, who had known Bill- 
ings as a young army surgeon, I was invited by my hostess 
at a late hour one evening to pay him a call; and so we set 
forth for Georgetown. It must have been about ten o'clock 
at night when we arrived at the door. No lights were to be 
seen. Evidently all had gone to bed. Undaunted, however, 
my good hostess rang the door bell. There was no answer. 
She rang a second and then a third time. Finally, the 
window over the door was opened, and Dr. Billings appeared 
in his nightgown. " Dr. Billings," said mv comnanion. after 
announcing herself, " I am afraid you have gone to bed." 
" Oh, no," he replied, " not at all, I will come down in a 
minute." " But I am sure you have gone to bed," answered 
the good lady. " Not at all," said he. " If you will wait a 
minute, I will come down at once." But my companion in- 
sisted, and compromised in the end by introducing me from 
the doorstep, in a voice, which I fancy, must have been audible 
for two squares. It was an impressive introduction in which 
the names, character and achievements of my ancestors for 
several generations were carefully recounted. At the conclu- 
sion of the address, it was requested that Dr. Billings name an 
hour on the following morning at which I might present my- 
self at his office in the library. 
The next morning, a shamefaced and embarrassed youth 
appeared at the surgeon-general's library, where he was 
received by Dr. Billings with a simple, kindly courtesy which 
he has never forgotten. In the early years of this hospital, Billings was a frequent 
and welcome visitor, and all were familiar with him at his 
home in the library, that great library which is the Mecca of 
all American physicians. 
What a work it was that he did in the foundation of that 
collection and what an undertaking was the Index Catalogue! 
It is impossible to estimate the debt of American medicine, 
the debt of the whole world to this man. 
It has been said, and I believe justly said, that one of the 
most characteristic features of the scientific work of the Ameri- 
can medical student is the completeness of his bibliography, 
and the familiarity shown by the author with the literature of 
the world relating to his subject. And how many realize that 
this is, after all, due in great part to the circumstance that Dr. 
Billings in that great library which he has built, that library 
which is so freely open to all, has accumulated an unexcelled 
collection of the widely distributed medical literature, and in 
the Index Catalogue and in the Index Medicus has given us a 
ready means of reference to this vast storehouse. 
Twenty years ago, one of my friends, while in Munich, 
called upon his old teacher, Professor von Pettenkofer. En- 
tering his library and turning towards his bookshelves, the 
old professor, with a sweep of his hand towards the Index 
Catalogue said: " That is the greatest work in my collec- 
tion." I recall another incident which illustrates that which 
the Index Catalogue means in all parts of the world. In 1893, 
while looking up some matters in the Bibliotheque de 1'ecole 
medicine, I sent to the desk a slip calling for a number of the 
then new Archives des sciences biologiques de St. Petersburg. 
The attendant handed it to the librarian on duty without com- 
ment. I observed his proceedings from a distant corner of the 
room. He looked at the reference for a minute, seemed 
puzzled, then turned and took from the shelf the last volume of 
the Index Catalogue which contained the title of the first 
volume of the series. Unfamiliar with the journal, his first 
thought was to search for it in our Index Catalogue. 
Such a work as the Index Catalogue could have been accom- 
plished only by a man of immense capacity, of extraordinary 
power of organization. These qualities Dr. Billings had. Whatever he undertook, the perfect implement seemed to 
spring to his hand; wherever he went, as if by magic, the most 
efficient co-workcrs surrounded him so naturally, so simply, 
so inevitably, that one might almost have fancied that it was the 
work' of the hand of chance. But those who knew him saw in 
this grave, strong man, the mind of a master. 
Where shall we look to-day for such breadth of conception, 
such an activating spirit! 
None should revere the memory of Billings more than we, 
for this hospital is his child, and few realize what we owe to his 
wise counsel in the days of its infancy. We, the guardians 
and the offspring of this child of his, must see to it that his 
name is perpetuated among the buildings which he designed, 
by a memorial worthy of the man. Here, of all spots, there 
ought to stand a dignified edifice which should bear the name, 
" The Billings Memorial Museum and Library/' which should 
gather together the scientific collections and the books from 
the hospital and the medical school, which should offer here, 
near the greater foundation in Washington, ample opportunity 
for the study of the history of that art to the service of which 
this great man so nobly devoted the major part of his life. 
Such an institute would be a fitting honor to a noble memory. 
But, alas, it can never give to those who follow us the 
memory of the man which is ours-the dignity of his presence, 
the firmness and gravity of his speech, that rare sense of poise 
and balance and power which he impressed upon all who 
approached him. It was good to have seen and to have felt all 
this. Something, to be sure, is preserved in the beautiful por- 
trait by Cecilia Beaux, but it is a sadly small part of what we 
who have known him could wish to transmit to those who shall 
follow us. A Comparison of the Results of the 
Phenolsulphonep hthalein Test 
of Renal Function 
With the Anatomical Changes Observed in the 
Kidneys at Necropsy 
BY 
WILLIAM S. THAYER, M.D., Hon. F.R.C.P.I. 
BALTIMORE, MARYLAND 
AND 
ROY R. SNOWDEN, M.D. 
PITTSBURGH, PA. 
FROM THE 
AMERICAN JOURNAL OF THE MEDICAL SCIENCES 
December, 1914, No. 6, vol. cxlviii, p. 781 Extracted from the American Journal of the Medical Sciences, 
December, 1914, No. 6, vol. cxlviii, p. 781. 
A COMPARISON OF THE RESULTS OF THE PHENOLSUL- 
PHONEPHTHALEIN TEST OF RENAL FUNCTION WITH 
THE ANATOMICAL CHANGES OBSERVED IN 
THE KIDNEYS AT NECROPSY. 
By 
William S. Thayer, M.D., Hon. F.R.C.P.L, 
BALTIMORE, MARYLAND. 
AND 
Roy R. Snowden, M.D., 
PITTSBURGH, PA. 
Among the most important questions that come before the phy- 
sician are the ever-recurring inquiries: Are the kidneys the seat of 
chronic disease, and, if so, how extensive is the process? What is 
the outlook? 
For the past four years we have used the phenolsulphone- 
phthalein test of Rowntree and Geraghty in a considerable variety of 
conditions in the medical wards of the Johns Hopkins Hospital, and 
as a result of our observations we have come to regard the procedure 
as one of considerable value both in the diagnosis and prognosis of 
renal disease. 
Most of the results which have been reported by those who have 
made use of this method have been based upon clinical observations 
alone. Occasional necropsies have been described, but nowhere, so 
far as we are aware, has there appeared any large series of consecu- 
tive clinical observations followed by necropsy. 
Here and there there are reports, on the one hand, of great varia- 
tions in the test made from time to time in individual cases, and on 
the other hand of instances where an approximately normal or even 
high excretion of 'phthalein has been observed in patients who have 
died shortly and unexpectedly thereafter with all the signs of an 2 
THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
uraemia. In some of these instances, notably the cases reported by 
Foster, necropsy has revealed what was regarded as extensive 
chronic renal change. 
It seemed to us, therefore, that further light might be thrown 
upon the situation by a consideration of those fatal cases occurring in 
the medical service of the Johns Hopkins Hospital in which, after the 
'phthalein test had been made during life, a necropsy with careful 
microscopical study of the kidneys has followed. The fact that 
many of these cases were presented at the Clinical and Patho- 
logical Conference, where a definite opinion was expressed by the 
clinician as to the nature of the case before he was aware of the 
results of the necropsy, has added considerably to the interest of 
the work. 
Dr. Winternitz, who has for some years been engaged in the study 
of the pathological anatomy of nephritis, has been so good as to go 
over all the specimens and to express his conception of the ana- 
tomical nature of the process without previous information con- 
cerning the clinical history of the case. An anatomical classification 
of the material was thus made from a purely objective standpoint. 
The clinical histories of the patients were then thoroughly analyzed 
and the results of our functional tests were considered in their rela- 
tions to the anatomical changes in the kidneys and to the conditions 
existing at the time when the tests were made. 
There were fifty-four cases followed by necropsy in which the 
'phthalein test was made during life. The material was classified 
anatomically as follows: 
Advanced chronic nephritis 20 instances 
Chronic nephritis of moderate extent 6 instances 
Cloudy swelling in association with grave acute infections 6 instances 
Severe acute nephritis 1 instance 
Amyloid kidney 1 instance 
Hypernephroma (unilateral) 1 instance 
Chronic passive congestion (cardiac disease) ... 20 instances 
Advanced Chronic Nephritis. The anatomical changes here 
observed were those of a progressive chronic inflammatory nephritis 
with more or less granular atrophy in gross, and microscopically, 
adhesive glomerulitis, hyaline glomeruli, a greater or less amount 
of interstitial change-infiltration, oedema, scarring. Acute terminal 
changes-haemorrhages, exudate, cellular infiltration, epithelial 
swelling, and degeneration-varied in extent. 
In these 20 patients, as may be seen in the accompanying table 
(Table I), 33 estimates of the 'phthalein output were made, the 
figures varying from 0 to 38 per cent, in two hours. THAYER, SNOWDEN: PHENOLSULPHONEPHTIIALEIN TEST 
3 
Percentage of 
No. of cases. 
Period before death. 
'phthalein in two hours. 
3 
10 days 
7.0 per cent. 
3 
9 days 
3.1 per cent. 
8 . 
. 12 days 
. trace 
11 
5 days 
0 
18 
7 days 
18.0 per cent. 
21 
8 months .... 
24.0 per cent. 
21 
57 days . . : . . 
. 35.0 per cent. 
21 
41 days . . . . . 
36.0 per cent. 
21 
. 23 days 
34.0 per cent. 
21 
18 days 
16.0 per cent. 
23 
4 months .... 
10.0 per cent. 
23 
28 days 
trace 
24 
105 days 
. 20.0 per cent. 
24 
72 days 
. trace 
24 
62 days 
. trace 
27 
6 days 
37.0 per cent. 
29 
14 days 
7.0 per cent. 
31 
. 3 months . . . . 
. 18+ per cent. 
33 
4 days 
0 
38 
3 days 
0 (1 hour) 
39 
3 days 
. 38.0 per cent. 
II 
6 days 
. 15.0 per cent. 
Ill 
5 days 
0 
IV 
. 3 weeks .... 
. 6.9 per cent. 
IV 
13 days 
. 16.6 per cent. 
VI 
23 days 
trace 
VI 
2 days . . . . . 
. 13.0 per cent. 1 hour 
X 
40 days 
26.0 per cent. 
X 
31 days 
. trace 
X 
30 days 
trace 
X 
day of death .... 
. trace 
XV 
4 days 
. slight trace 
XVI 
. . 43 days 
1.5 per cent. 
Table I.-Advanced Chronic Nephritis. 
The test was made within a week before death in 11 cases, the 
excretion in two hours varying from 0 to 38 per cent. The per- 
centage of 'phthalein output was as a rule very low-under 18 per 
cent. The two instances (Cases 27 and 39) with a higher excretion 
were patients who died respectively of a dissecting aneurysm and 
a hemiplegia, accidents coming on in the course of a nephritis 
which had not as yet reached a stage of decompensation. 
The test was made within a month, and over a week before death in 
7 patients. Here the excretion of 'phthalein in two hours varied 
from a trace to 34 per cent. Patient 21, in whom the excretion was 
highest, namely, 34 per cent., twenty-three days before death, was 
an instance of chronic nephritis in a woman of sixty-four with great 
cardiac insufficiency which unquestionably hastened death. Other 
functional tests made in this patient showed, also, more favorable 
results than has been the rule in instances in which the terminal 
stage of the nephritis has been reached without the intervention of 
cardiac failure. The test was made at periods from one to eight 
months before death in 5 patients, the excretion varying from 1.5 per 
cent, to 35 per cent.; it was above 20 per cent, only in Case 21- 
the patient with cardiac insufficiency above referred to. 
Among all these patients records above 36 per cent, were obtained 4 
THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
in but three instances-Cases 21, 27, and 39. Two of these records, 
each in the thirties, were obtained in the patients dying respec- 
tively from a dissecting aneurysm and hemiplegia. The third 
instance was the case of myocardial insufficiency above referred to 
where death was associated with hydrothorax and extensive drop- 
sical manifestations. Here also the excretion of 'phthalein fell to 
16 per cent, eighteen days before death. 
In these patients the renal changes had not presumably reached 
a stage at which decompensation and uraemia were imminent. 
The manner of death in these 20 cases was from uraemia in every 
instance with the exception of Patients 27 and 39-who died sud- 
denly from the rupture of a dissecting aneurysm and hemiplegia 
respectively. In Case XVI there was a terminal meningitis, but 
this had been preceded by unquestionable uraemic manifestations. 
In almost all patients there was cardiac hypertrophy of greater 
or less extent, but in only three was death in any direct sense due to 
cardiac failure (Cases 21, 31, and VI). 
The urine in all of these instances was of low specific gravity, 
and toward the end scanty although there was generally a history of 
preceding polyuria. Albumin was present generally in a moderate 
quantity. In several cases the albumin was abundant at the end in 
association with ischuria and acute terminal changes. The sedi- 
ment was, as a rule, scanty, consisting of hyaline and granular casts 
and occasional red blood corpuscles. In two instances (Cases 23 
and 24) where there was anatomically more epithelial change, epi- 
thelial casts were also found in the urine. In but two instances 
(Case 29, the hemiplegic, and case IV) was the specific gravity at all 
high. Case IV was an instance with rather rapid clinical course 
and a good many acute anatomical changes. Here also there were, 
toward the end, numerous hyaline, epithelial, and blood casts. 
The maximum blood pressure, as shown by the following table, was 
elevated in almost every instance. 
Blood Pressures. 
Case 3 95 
Case 8 235 
Case 11 140 to 175 
Case 18 180 to 205 
Case 21 240 
Case 23 130 to 153 
Case 24 216 
Case 27 170 to 180 
Case 20 130 to 140 
Case 31 225 
Case 33 167 to 138 
Case 38 188 
Case 39 200 to 80 
Case II 226 to 236 
Case III 230 to 80 
Case IV 115 to 175 
Case VI 180 to 260 
Case X 180 to 220 
Case XV 170 to 220 
Case XVI 142 to 160 THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
5 
The one instance (Case 3) in which the blood pressure was low is 
worthy of special note. The patient, a boy of twelve, was admitted 
to the hospital complaining of polydipsia and polyuria of several 
years' duration. For two years he had suffered from pains in his 
legs, rather sharp in character and interfering with his walking; 
probably from his description, muscular cramps. The physical 
examination showed a pale boy with rather dry skin and no demon- 
strable cardiac hypertrophy. The radial arteries were, however, 
palpable; the maximum blood pressure was 95; the eye-grounds 
showed no changes. The urine on entry amounted to about 
2500 c.c. in twenty-four hours; specific gravity, about 1005; no 
albumin; no formed elements in the sediment. The 'phthalein test 
a week after entry, showed a total excretion in two hours of but 
7 per cent., and on the following day but 3.1 per cent. Within 
a day or two the quantity of urine began to diminish, a trace of 
albumin appeared, and occasional hyaline and granular casts were 
found in the sediment. The boy became dull and drowsy and, nine 
days after the last 'phthalein test, died in uraemic coma. 
At necropsy the kidneys were found to be exceedingly small and 
granular, the cortex greatly thinned. On microscopical examination 
there was little cortical substance left, most of the glomeruli being 
completely degenerated and represented by small hyaline masses. 
This is the most striking instance that we have had of the value 
of the 'phthalein test. Without it we might well have failed to 
recognize the nature of the case. 
Further Tests of the Renal Function. In 9 of these in- 
stances further tests of renal function were made. The incoagulable 
N. in the blood was estimated fifteen times in 7 patients. 
In six tests made in five patients within a week before death the 
incoagulable N. was: 
Case 21 0.5 grammes per litre. 
Case 23 1.8 
CaseX 1.876 
Case 23 2.0 
Case 33 2.0 
Case 18 2.1 
In nine tests made in 5 patients at longer periods before death the 
incoagulable N. was: 
Case 21 8 months . . . . 0.4 grammes per litre. 
Case 21 52 days 0.48 
Case 21 40 days 0.43 
Case X 14 months . . . . 0.9 
Case X 31 days 0.84 
Case X 30 days 0.864 " 
Case 31 65 days 1.0 a 
Case 23 28 days 0.88 
Case VI 23 days 0.63 
The two instances (21 and VI) in which rather low figures were 
obtained were both cases in which there were grave cardiac compli- 6 
THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
cations and chronic passive congestion, instances in which, although 
the renal changes were grave, it is yet very possible that they had 
not reached an extent sufficient of itself to have induced uraemia. 
The lactose elimination was suppressed or greatly delayed and 
diminished in all the 9 cases in which it was tested. 
The chlorides were studied in 6 patients. In three (11, 31, and 
VI) the elimination was rapid and complete with polyuria (vascular 
hyposthenuria). The test was made respectively five, sixty-five, 
and twenty-three days before death. 
In 3 cases (18, 27, and XV) one week, seventy-five days, and four 
days respectively before death the chlorides were in part retained. 
In the first case there was tuberculous pleurisy and peritonitis; in the 
second, at the time of the test, there was general anasarca and 
ascites; in the third, an instance of very marked renal change, there 
was slight oedema. 
Iodide of potassium was eliminated in forty-eight hours or less in 
Cases 18 and VI. It was delayed in Cases 11 (seventy-two hours), 
21 (fifty-four hours), 31 (seventy-two hours) and XV (seventy-two 
hours). 
Relation of the Percentage of 'Phthalein Excreted to the 
Length of Survival. The percentage of 'phthalein excreted in 
two hours was 20 or over in 9 tests (6 cases); longest survival, eight 
months. 
The percentage of 'phthalein was from 10 to 20 in six tests (6 
cases); longest survival, four months. 
The percentage of 'phthalein excreted in two hours was under 10 
in sixteen tests (12 cases); longest survival, seventy-two days. 
The percentage of 'phthalein was a trace only in seven tests (4 
cases); longest survival, seventy-two days. 
The 'phthalein was wholly suppressed in four tests (4 cases); 
longest survival, five days. 
These results are quite in accord with those with which we have met 
in this clinic in the past four or five years in cases which have not 
come to necropsy. In no instance of grave chronic nephritis have 
we failed to find a material diminution in the 'phthalein excretion. 
In not a single instance in all the studies made at this clinic by 
Rowntree, Geraghty, Mrs. Winternitz, Fitz, Baetjer, and Snowden 
have we met with an instance such as those reported by Foster, in 
which an excretion approaching normal was found in grave chronic 
nephritis shortly before death. The study of these cases in which 
we have been able to make the anatomical control, tends to support 
our previous impression that the test is one of considerable diag- 
nostic value. This study further reveals in rather a striking manner 
the progressive diminution of the 'phthalein excretion with the 
advance of the disease. This is so definite as to give the test a 
considerable prognostic significance. 
The anatomical observations suggest that in a good many instances THAYER, SNOWDEN'. PHENOLSULPHONEPHTHALEIN TEST 
7 
the terminal event which was almost invariably uraemia, was ushered 
in by acute renal changes which did not manifest themselves by any 
striking alterations in the urine. In many of these instances, a few 
days before death or at the onset of uraemia, the 'phthalein was 
excreted in but a trace. It is not impossible, however, that a month 
previously the percentage might have been considerably higher- 
20 per cent, or even more. Nevertheless, we are considerably 
impressed with the consistency with which a low 'phthalein output 
is found in chronic nephritis of any essential degree, and we feel 
that in the absence of chronic passive congestion the 'phthalein test 
gives us important diagnostic and prognostic help. 
Chronic Nephritis of Moderate Extent. There were 6 cases 
of chronic nephritis of moderate extent. Of these 5 (Cases 4,13, 17, 
20, and XIV) were associated with a high degree of chronic passive 
congestion due to cardiac failure. The other (Case 13) was an 
instance of tuberculous polyserositis with a considerable degree of 
cardiac insufficiency. 
The renal changes in these patients were not extensive, a few 
glomerulo-capsular adhesions, but little scarring, some exudate with 
red blood corpuscles in the glomerular spaces. The kidneys showed 
little gross deformity. In Case XIV, an instance of verrucose endo- 
carditis, the changes were however, more marked and acute than in 
the others. 
The urine in all instances was scanty, the specific gravity, howr- 
ever, tended to be rather below normal, excepting in Case XIV, 
where it ranged from 1020 to 1026. The albumin varied from a 
trace to a considerable amount. In Case 17, an instance of dilated 
heart with grave passive congestion and acute endocarditis, the 
albumin at the end was 0.9 per cent. 
The 'phthalein output in two hours, as shown by Table II, varied 
from 16 to 42 per cent. 
Table II.-Chronic Nephritis of Moderate Extent. 
No of cases. 
Period before death. 
Percentage of. 
'phthalein in two hours. 
4 . . . 
9 days 
39.5 per cent. 
13 . . . 
. . 7 months . 
22.0 per cent. (3 hours) 
13 . . . 
5j months . 
. 32.0 per cent. 
17 . . . 
. . 32 days 
23.0 per cent. 
20 . . . 
12 days 
42.0 per cent. (3 hours) 
IX. . . 
. . 18 months . 
36.0 per cent. 
XIV. . . 
1 day .... 
16.0 per cent. 
The test was made within a week of death in but one instance 
when, on the day before death, it was 16 per cent. 
The test was made between one and two weeks before death in 2 
instances, when it was respectively 39.5 and 42 per cent, in three 
hours. 
In Case 13, an instance of tuberculous polyserositis with cardiac 8 
THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
failure, the output seven months before death was 22 per cent, in 
three hours, and 32 per cent, in two hours one month and a half 
later when the patient was in an improved condition. 
The chlorides at the time of the first test were well excreted; the 
lactose was excreted in twelve hours; urea, 0.6 grammes per litre; 
catalase, from 14.2 to 31. 
In Case 20, twelve days before death, the lactose was excreted 
in eleven hours; K.I. in sixty-two hours, while the incoagulable N. 
was 0.5 per litre of blood. 
In Case IX, eighteen months before death, with a 'phthalein of 
36 per cent., the lactose excretion was much delayed and the urea in 
the blood was 0.8 grammes per litre. 
The blood pressure in this series, as will be seen by the following 
table, was not strikingly high, owing possibly to the condition of the 
heart. 
Blood Pressures. 
Case 4 125 to 160 
Case 13 140 to 210 
Case 17 190 
Case 20 90 to 110 
Case IX 110 to 140 
Case XIV 112 to 130 
On the whole, this group represents older individuals than those 
in whom more advanced nephritis was found, individuals whose 
weakened hearts have been less able to resist the hypertension of a 
developing nephritis. Death, therefore, has occurred from circu- 
latory failure at an earlier period of the renal disease. The analysis 
of the ages of these 6 patients shows that with one exception they 
were all over 40, the average age amounting to 47+, while the 
average age of the 20 patients with advanced chronic nephritis was 
but 38.8, despite the fact that one patient aged 71 is included in 
this list. 
Cloudy Swelling. There were five instances of cloudy swelling 
occurring during severe infections. The nature of the infection was: 
Pneumonia and gangrene Case 1 
Acute endocarditis Case 2 
Osteo-myelitis and abscess of the knee Case 6 
Syphilis, bed-sore, bronchopneumonia and gangrene . . Case 7 
Miliary tuberculosis Case 34 
The microscopical changes in the kidneys were not extensive- 
swelling and granular degeneration of the epithelium, engorgement 
of the capillaries with the occasional escape of a few red blood 
corpuscles into glomerular space or tubules. 
The percentage of 'phthalein excreted in two hours varied, as 
may be seen from Table III, from 20 per cent, on the day of death 
(Case 2) to 50 per cent, forty-five days before death (Case 6). THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
9 
No. of case. 
Period before death. 
Percentage of 'phthalein in two hours 
1 . . . . 
. 9 days .... 
27.0 per cent. 
2 . . . . 
day of death 
20.0 per cent. 
6 . . . . 
. 6 months . 
37.8 per cent. 
6 . . . . 
. 10 days later 
29.7 per cent. 
6 . . . . 
. 45 days .... 
50.0 per cent. 
7 . . . . 
. 20 days .... 
33.0 per cent. (5 hours) 
34 ... . 
9 days .... 
28.0 per cent. 
Table III.-Cloudy Swelling. 
The test was made within two weeks before death in three instances 
(Cases 1, 2, and 34), the 'phthalein excretion varying from 20 to 29 
per cent. In Case 2, in which the output was but 20 per cent, on the 
day of death, the actual renal changes were not more marked than 
in the other instances but there was grave chronic passive congestion. 
In Case 34 the epithelial degeneration was more extensive than in 
any other case in this group and the 'phthalein output nine days 
before death was 28 per cent. 
The test was made at a period from twenty days to several months 
before death in 2 instances, the 'phthalein excretion varying from 33 
per cent, in five hours to 50 per cent. In the former instance, how- 
ever, the test is of little value, owing to the long period of time over 
w'hich it was made and to considerable uncertainty which existed as 
the proper saving of the specimens. The variations in the records 
of Case 6 are interesting. The patient suffering from abscess of the 
knee and osteo-myelitis was febrile at the time of the first two tests 
(37.8 and 29.7 per cent.). At the time of the third test (50 per cent.) 
he was afebrile and in a much better general condition. 
In all of these cases the urine was rather scanty, of normal or 
high specific gravity, the albumin varying from a trace, with a few 
hyaline and granular casts in the sediment, to a large amount with 
hyaline, granular, epithelial, and blood casts (Case 2, acute endo- 
carditis). Excepting in Case 2, where there was grave cardiac 
insufficiency, and in Case 34, acute miliary tuberculosis, anasarca 
was absent or an unimportant factor. 
Our clinical diagnosis as to the renal condition was " cloudy swel- 
ling" in Cases 1, 6, and 7; in Case 2, "chronic nephritis writh an 
acute exacerbation;" while in Case 34 a diagnosis was not recorded 
before the result of the necropsy was known. 
In one instance not included in this list there was widespread 
epithelial necrosis (Case 5). This was a case of syphilis of the 
aorta with valvular insufficiency, extreme cardiac dilatation and 
chronic passive congestion. There was a terminal peritonitis and 
colitis. The 'phthalein test, however, was made nearly a month 
before death and was interesting only for its associatiort with chronic 
passive congestion, in which group the case is classified. 
As we consider these figures then it is clear that a terminal cloudy 
swelling may be associated with considerable diminution in the 
'phthalein output. 10 
THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
Severe Acute Nephritis. There was one instance (Case 10) of 
severe acute nephritis, a man of forty-eight, with ulcerative endo- 
carditis and general septicaemia with a pneumo-streptococcus; 
anaemia; purpura; pulmonary, splenic, and renal infarcts; terminal 
broncho-pneumonia, pleurisy; and death in coma. The blood 
pressure was 135. 
The kidneys were large; the cortex swollen; the parenchyma pale. 
Microscopically there was evidence of a grave acute nephritis with 
much oedema, catarrhal and exudative glomerulitis, and extensive 
epithelial degeneration. 
The 'phthalein excretion four days before death was but a trace 
in four hours and the urea in the blood was 1.2 grammes per litre. 
Amyloid Kidney. There was one instance of pure amyloidosis, a 
woman of thirty-three with an old syphilis, complaining of dyspnoea 
on exertion for five months and swelling of the extremities for a 
month. She was very anaemic. The blood pressure was rather low, 
ranging from 92 to 124. 
The urine was very scanty, showing from 0.4 to 1 per cent, of 
albumin and a specific gravity of from 1012 to 1015, with occasional 
hyaline casts. Two days before death the patient became stuporous 
and comatose. 
Ten days before death the excretion of 'phthalein in two hours was 
but 1.2 per cent.; two days before death but a trace wa$ observed. 
The kidneys at autopsy showed characteristic amyloid disease 
with extensive glomerular change and slight interstitial fibrosis. 
Hypernephroma. In Case 30 a large irregular tumor was pal- 
pable in the right renal region. The ureters were catheterized, and 
from the right side no 'phthalein was obtained; from the left, 17 per 
cent, was excreted in fifteen minutes. The left kidney was found 
to be hypertrophied; the right was almost entirely destroyed, con- 
sisting largely of neoplastic tissue. 
ChroXic Passive Congestion. There were 20 instances in which 
the kidneys anatomically showed changes suggesting only chronic 
passive congestion. Clinically these were all cases of cardiac dilata- 
tion and insufficiency. 
The main lesion in each of these cases was: 
Fibrous myocarditis 8 cases (Cases 9, 12, 16, 22, 32, 36, V, VIII) 
Syphilis of the aorta 7 cases (Cases 5, 10, 14, 25, 26, 37, VII) 
General arterio-sclerosis .... 2 cases (Cases 19, 35) 
Emphysema and pulmonary indura- • 
tion 2 cases (Cases XI, XII) 
Adherent pericardium .... 1 case (Case XIII) 
As may be seen by Table IV, the excretion of 'phthalein in two 
hours varied very greatly according to the degree of cardiac com- 
pensation, ranging from a trace to 71 per cent. THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
11 
No. of case. 
Period before death. 
Percentage of 'phthalein in two hours. 
5 . . . 
29 days .... 
28.2'per cent. 
9 . . . 
6 months . 
25.6 per cent. 
9 . . . 
68 days .... 
58.6 per cent. 
9 . . . 
10 days .... 
. . 59.0 per cent. 
10 . . . 
13 days .... 
. . 30.5 per cent. 
10 . . . 
3 days .... 
. . 25.4 per cent. 
12 (active diuresis) 4 months . 
72.0 per cent. (3 hrs. 50m.) 
14 . . . 
. . 20 weeks 
37.0 per cent. 
14 . . . 
. . 12 weeks 
. . 22.0 per cent. 
16 . . . 
. 40 days .... 
48.0 per cent. (3 hours) 
19 . . . 
93 days .... 
50.0 per cent. 
22 . . . 
14 days .... 
. . 31.0 per cent. 
25 . . . 
11 weeks 
71.0 per cent. 
25 . . . 
3 days .... 
55.0 per cent. 
26 . . . 
. . 4 months . 
24.0 per cent. 
26 . . . 
7 days later 
63.0 per cent. 
32 . . . 
38 days .... 
. 48.0 per cent. 
35 . . . 
3 days .... 
. . 28.3 per cent. 
36 . . . 
35 days .... 
. . trace 
36 . . . 
29 days .... 
. . 38.0 per cent. 
36 . . . 
1 day .... 
trace 
37 . . . 
5 days .... 
69.0 per cent. (21 hours) 
V. . . . 
1 day .... 
. . 16.1 per cent. 
VII. . . 
. . 6 months . 
16.0 per cent. 
VII. . . 
1 week later 
. . 36.0 per cent. 
VII. . . 
. . 1 week later 
45.0 per cent. 
VIII. . . 
1 year .... 
50.0 per cent. 
VIII. . . 
8| months . 
. . 39.0 per cent. 
VIII. . . 
12 days .... 
. . 54.0 per cent. 
XI. . . 
. . 3 days .... 
45.0 per cent. 
XII. . . 
3 months . 
. . 49.0 per cent. 
XIII. . . 
2 months . 
61.0 per cent. 
Table iy.-Chronic Passive Congestion. 
In nine cases the percentage of 'phthalein excreted in two hours 
was under 30 per cent. (Cases 5, 9,10,14, 26, 35, 36, V, VII). In all 
of these instances there w'as grave cardiac decompensation. The 
nature of the change was as follow's: In 4 cases (5, 10, 14, 26) 
syphilis of the aorta with aortic insufficiency and its sequels. 
• In 4 cases (9, 35, 36, VII) fibrous myocarditis with dilatation, 
In 1 case (V) a fibrous myocarditis associated with chronic endo- 
carditis and mitral insufficiency. 
Cases 9, 26,36, and VII are especially interesting as showing what 
remarkable variations may occur in one individual under varying 
circumstances. Thus in Case 9, a colored woman with great car- 
diac dilatation, the output during a period of decompensation six 
months before death was 25.6 per cent. Under rest and diuretics 
there was great improvement, and death came on suddenly while the 
patient was apparently in fair condition. Twice later, when com- 
pensation was reasonably good, sixty-eight and ten days before death 
respectively, the 'phthalein output was 58.6 and 59 per cent. 
In Case 26, a colored man with syphilitic aortitis and aortic insuf- 
fiency, the 'phthalein, during a period of decompensation, was 
24 per cent.; a week later in compensation it was 63 per cent. 12 
THAYER, SNOWDEN; PHENOLSULPHONEPHTIIALEIN TEST 
In Case 36, a colored man with fibrous myocarditis and chronic 
mitral disease while in a condition of grave decompensation five weeks 
before his death, at a time when the urine was very scanty and 
showed a trace of albumin and hyaline and granular casts, the 
'phthalein output was but a trace. A week later the patient was 
much better and, although he was still oedematous, the output of 
urine was above the intake. The 'phthalein excretion was 38 per 
cent. One day before death when the urine again was very scanty 
the output of 'phthalein was but a trace. 
In Case VII, a man of 61 with myocarditis and dilated heart, 
the output of 'phthalein six months before death during a period of 
decompensation wras 16 per cent. A wTeek later, when he was 
improving, it was 36 per cent. Yet a week later it was 48 per cent. 
The urine in these instances of chronic passive congestion was 
scanty, the specific gravity normal or increased. There was a trace 
of albumin and a few casts, excepting in Case 10, w'here toward the 
end, in association with a terminal infection, there wras from 0.6 to 
0.7 per cent, of albumin and numerous hyaline, granular, and epi- 
thelial casts. Anatomically, in this instance, there was extensive 
acute epithelial necrosis, but no 'phthalein test was made at the 
periods when this must have occurred. 
The blood pressure in these patients, most of w^hom showed cardiac 
hypertrophy as well as dilatation, may be seen in the accompanying 
table. 
Case 5 160 to 187 
Case 9 170 to 210 
Case 10 135 
Case 12 100 to 122 
Case 14 120 to 130 
Case 16 82 to 124 
Case 19 200 
Case 22 175 to 210 
Case 25 95 to 124 
Case 26 120 to 160 
Case 32 180 to 182 
Case 35 202 to 242 
Case 36 130 to 175 
Case 37 150 to 175 
Case V 112 to 150 
Case VII 135 to 150 
Case VIII 125 to 190 
Case XI 135 
Case XII 110 
Case XIII 100 to 115 
Blood Pressures. 
The figures for our instances of chronic passive congestion show 
then, in general, a moderate diminution in the amount of 'phthalein 
excreted in two hours, a diminution which, in some cases, may be 
extreme, amounting almost to complete suppression. This is wholly 
in accord with the experiments of Rowntree and Fitz. THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
13 
In 9 cases (14, 16, 19, 22, 25, 26, VII, VIII, XI) other tests of 
renal function were carried out, as may be seen in the following 
table. 
Table V.-Showing Various Tests of Renal Function in Cases of Chronic Passive 
Congestion. 
Grammes of in- 
Grammes 
No. 'phthalein ex- 
of cretion in 
coagulable 
N. per litre 
of urea 
per litre 
cases. two hours. KI. Lactose. Chlorides. 
of blood. 
of blood. 
14 37 per cent. 68 hours. 9 hours. Retained 
16 48 per cent. 72 hours. 19 hours. 
0.49 
19 50 per cent. 56 hours. 10 hours. Retained 
19 A week later, Good 
improved; excretion 
polyurea. 
0.21 
22 35 per cent. 62 hours. 10 hours. .... 
0.4 
22 3 days later. . . .... .... 
0.36 
25 71 per cent. 80 hours. 9 hours. Retained 
0.192 
25 55 per cent. .. 12 + hours. .... 
0.47 
26 24 per cent. 48 hours. Trace only in .... 
1 hour. 
26 63 per cent. .. 4 hours (nor- 
mal amount) 
VII 16 per cent. .. .... Poor 
excretion 
VIII 54 per cent. 48 hours. 50 per cent. Good 
in 3 hours. excretion 
0.33 
VIII Later .. Trace only in Good 
5 hours. excretion 
0.5 
XIII 61 per cent. .. Trace only in .... 
4 hours. 
0.4 
These tests show the variability of the results with iodide of 
potassium, on which we have learned to place little reliance. The 
lactose excretion is profoundly modified in chronic passive conges- 
tion. A striking example of this is to be seen in Case XIII, where 
the lactose is almost suppressed while the 'phthalein excretion is 
fairly good. 
Although the incoagulable N. or urea was estimated nine times in 
7 cases, and during periods of grave decompensation where the 
'phthalein excretion was as low as 24 per cent., in no instance was 
the urea above 0.5 nor the incoagulable N. above 0.49 per litre. 
It is clear then that chronic passive congestion alone may result 
in a very marked reduction in the 'phthalein output in the first two 
hours, a reduction which in extreme instances may amount almost to 
suppression. With the return of compensation, however, the excre- 
tion of 'phthalein rapidly regains the normal precentage. 
The incoagulable N. in the blood has not been high in any of our 
cases even at times when the elimination of 'phthalein has been con- 
siderably interfered with. 
Summary and Conclusions. These obserations show, in severe 
chronic nephritis, a uniformly low 'phthalein output which, as a 
rule, in those instances not interrupted by an acute terminal process, 
decreases steadily up to the onset of uraemia, and is nearly or wholly 14 
THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
suppressed from a day or two to a month before death. Acute 
terminal processes which may be unsuspected clinically, are common, 
and here a sudden diminution in the elimination of 'phthalein may 
come on in cases where the percentage previously excreted is not so 
low as to appear menacing. 
In not a single instance, and indeed not once in all the studies of 
the last five years, have we met with a case of severe chronic 
nephritis1 with a good 'phthalein elimination. 
Chronic passive congestion (cardiac disease) results often in a 
considerable reduction in the two hours' elimination of 'phthalein. 
The results are very variable in individual cases. In marked decom- 
pensation the 'phthalein output may be reduced to but a trace in 
two hours; but the excretion is, as a rule, rapidly restored with the 
reestablishment of circulatory compensation. 
These obserations are in agreement with the experimental studies 
of Rowntree and Fitz. 
In the few instances of chronic nephritis of moderate extent 
w'hich are included among our cases the excretion of 'phthalein was 
uniformly considerably reduced. All of these cases, however, were 
associated with chronic passive congestion of considerable extent, 
but the percentage of 'phthalein was lower than might have been 
expected with an uncomplicated passive congestion. 
In one instance of acute nephritis and in one instance of pure 
amyloid disease the 'phthalein excretion was greatly reduced. 
The cloudy swelling observed in acute infections was in some 
instances, associated with considerable reduction in the 'phthalein 
output. 
These observations then tend to support our previous impression 
that the phenolsulphonephthalein test of Rowntree and Geraghty is a 
procedure of considerable diagnostic and prognostic value, especially 
in the study of chronic nephritis. 
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Austin (J. H.) and Eisenbrey (A. B.). Experimental Acute Nephritis: The 
Elimination of Nitrogen and Chlorides as Compared with that of Phenolsulphone- 
phthalein. Jour. Exper. Med., New York, 1911, xiv, 366-376. 
Baetjer (W. A.). Superpermeability in Nephritis. Arch. Int. Med., 1913, xi, 
593-600. 
Behrenroth (E.) and Frank (L.). Klinische und experimentelle Untersuchungen 
uber die Funktion der Niere mit Hilfe der Phenolsulphonephthaleinprobe. Ztschr. 
f. exp. Pathol, u. Therap., 1913, xiii, 72-83. 
1 As has been pointed out by Pepper and Austin and Baetjer there is a stage or 
form of nephritis in which the excretion of 'phthalein is not interfered with. These 
instances are more or less characteristic in their clinical manifestations and are often 
roughly classed as "chronic parenchymatous nephritis." Their most striking clinical 
features are the elective impermeability of the kidney to salt and the resulting ten- 
dency to hydrops. With regard to most other tests of function the kidneys appear 
to react normally, and beyond the dropsy there are sometimes few disturbing symp- 
toms. These are presumably cases with little glomerular involvement. No such 
instance has come to necropsy in this clinic. THAYER, SNOWDEN: PHENOLSULPHONEPHTHALEIN TEST 
15 
Bonn (H. K.). Phenolsulphonephthalein as Determinate of Kidney Function. 
Jour. Indiana Med. Assoc., 1913, vi, 154-161. 
Boyd (M. L.). Phenolsulphonephthalein and Functional Tests of the Kidneys. 
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Brandeis. Passage de la phenolphthalein dans les urines. Bull, et mem. Soc. 
de med. et chir. de Bordeaux (1911), 1912, 426-428. 
Cooke (C. O.). The Estimation of the Functional Activity of the Kidney by 
Means of Phenolsulphonephthalein. Providence Med. Jour., 1912, xiii, 118-128. 
Dietsch (Carl). Zur funktionellen Nierendiagnostik mittels Phenolsulphonephtha- 
lein. Zeitschr. f. exp. Pathol, u. Therap., 1913, xiv, 512-526. 
Eisenbrey (A. B.). A Study of the Elimination of Phenolsulphonephthalein in 
Various Experimental Lesions of the Kidney. Jour. Exper. Med., New York, 1911, 
xiv, 462-475. 
Erne (F.). Funktionelle Nierenpriifung mittels Phenolsulphophthalein nach 
Rowntree und Geraghty. Munch, med. Woch., 1913, lx, 510-512. 
Fishbein (M.). Functional Test (Phenolsulphonephthalein) of the Kidney in 
Scarlet Fever. Jour. Amer. Med. Assoc., Chicago, 1913, Ixi, 1368-1370. 
Fitz (R.) and Rowntree (L. G.). The Effect of Temporary Occlusion of Renal 
Circulation on Renal Function. Arch. Int. Med., 1913, xii, 24-36. 
Foster (N. B.). Functional Tests of the Kidney in Uremia. Arch. Int. Med., 
1913, xiii, 452-455. 
Fromme (F.) and Riibner (C.). Ueber die Bedeutung der Phenolsulphoneph- 
thaleinprobe zur Priifung der Funktion der Nieren. Berl. klin. Woch., 1912, xlix, 
1889-1891. 
Goldsborough (F. C.) and Ainley (F. C.). The Renal Activity in Pregnant and 
Puerperal Women as Revealed by the Phenolsulphonephthalein Test. Jour. Amer. 
Med. Assoc., Chicago, 1910, Iv, 2058-2060. 
Goodman (C.). Phenolsulphonephthalein in Estimating the Functional Activity 
of the Kidneys. Jour. Amer. Med. Assoc., Chicago, 1913, Ixi, 184-189. 
Keyes (E. L.) and Stevens (A. R.). Intravenous Administration of Phehol- 
sulphonephthalein for Ureter Catheter Study of the Renal Function. New York 
Med. Jour, (etc.), 1912, xcv, 1134-1136. 
Lance (M.). L'examen de la permeabilite renale par la phenolsulfonephthaleine. 
Gaz. d. hop. Paris, 1912, Ixxxv, 32-35. 
Lohnstein (H.). Ueber die Leistungsfaigkeit der Phenolsulphonephthaleinprobe 
zur Bestimmung der Nierenfunktion. Auf Grund fremder und eigener Untersuch- 
ungen. Allg. med. Centr. Ztg., 1913, Ixxxii, 591-593. 
Mouriquand (G.). L'epreuve de la phenolsulfonephtaleine. Lyon med., 1913, 
cxxi, 297-301. 
Pepper (O. H. P.) and Austin (J. H.). Some Interesting Results with the Phenol- 
sulphonephthalein Test. Amer. Jour. Med. Sci., Philadelphia, 1913, cxlv, 254-258. 
Roth (M.). Ueber einige wichtige Fehlerquellen bei der Phenolsulphonephtha- 
leinprobe zur Priifung der Nierenfunktion. Berl. klin. Woch., 1913, 1, 1609-1611. 
Rowntree (L. G.) and Geraghty (T. J.). An Experimental and Clinical Study 
of the Functional Activity of the Kidneys by Means of Phenolsulphonephthalein. 
Jour. Pharmacol, and Exper. Therap., Baltimore, 1910, ii, 579-661. 
Rowntree (L. G.) and Geraghty (T. J.). The 'phthalein Test; an Experimental 
and Clinical Study of Phenolsulphonephthalein in Relation to Renal Function in 
Health and Disease. Arch. Int. Med., 1912, ix, 284-388. 
Rowntree (L. G.) and Fitz (R.). Studies of Renal Function in Renal, Cardiorenal, 
and Cardiac Diseases. Arch. Int. Med., 1913, xi, 258-287. 
Sanford (H. L.). Clinical Study of Elimination of Phenolsulphonephthalein by 
Kidneys, with Report of One Hundred and Fifty Cases. Cleveland Med. Jour., 
1912, xi, 763-791. 
Sehrt (E.). Die Phenolsulfophtalein Methode zur Bestimmung der Nieren- 
funktion. Zentralbl. f. Chir., Leipzig, 1912, xxxix, 1121-1124. THE AMEBIC AIN JOURNAL 
OF THE MEDICAL SCIENCES 
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PHILADELPHIA T 17 A fr WDTO PI) NEW YORK 
706-8-10 Sansom St. 11 El /A Qu J. Tj I> I IT Tj EL 2 West 45th St Remarks by William S. Thayer on the Occasion of the 
Presentation of the Crayon Portrait of 
Sir Wm. Osler by Sargent. 
The precious gift it is my privilege now to offer to the hos- 
pital is but another reminder of him who, though absent in 
person, has been with us and in us and around us in spirit from 
the beginning of this gathering. 
What have been his contributions to medical science, what 
his inspiration and efforts and example have been to this insti- 
tution, are so familiar to us all that it would be impudent to 
mention them. Would that we could put into words the influ- 
ence that the man has had upon our lives I How much of that 
which is best in us is due to him and to his example! In all 
the fifteen years of my close and constant association with him 
1 never knew him to do a hasty or an inconsiderate act, and I 
never heard him speak an unkind word of any man. Of how 
many can one say this? lie is like Maeterlinck's true sage, in 
whose presence discord and strife and misunderstanding are 
impossible. In losing him we felt that we had lost our best 
friend and adviser, but he left us a legacy of tolerance and for- 
bearance and charity that is among the richest of our posses- 
sions. This whole institution is replete with memories of the 
man; and no statue, no tablet, no portrait can bring him more 
■ vividly to our minds. But there will be others who follow after 
to whom our poor words will convey but a faint picture of that 
which is a part of us. And so his old disciples welcome with 
heartfelt gratitude every new image which may help better to 
fix for posterity the presence of our dear chief. 
The value of this new possession is greatly enhanced in that 
it comes to us through the thoughtful generosity of her who 
shares with him our lasting love and affection. Lady Osler 
of her own initiative has induced Mr. Sargent to make this 
replica of the portrait drawn by him for the College of Physi- 
cians in Philadelphia, and has sent it to us to-day. And so 
after all he is with us ! We shall gain new inspiration from his 
counterfeit presence. Let us wait patiently in the hope that, 
four years hence, when the heavy clouds of the hour shall have 
rolled away, we may give him that welcome which our hearts 
hold for him to-day. THE JOHNS HOPKINS HOSPITAL BULLETIN, DECEMBER, 1914. 
PLATE XIV. 
SIR WILLIAM OSLER. 
From Sargent's portrait presented by Lady Osler on the Twenty-fifth Anniversary of the Hospital. Remarks of L. F. Barker and W. S. Thayer on the Dedi- 
cation of the Medallion to the Memory of 
Dr. John Hewetson. 
DR. BARKER. 
To my colleague Dr. Thayer and myself has been assigned 
the honor and the pleasant privilege of saying something about 
our friend and former co-worker, the late Dr. John Hewetson; 
it is to commemorate his life, his work and his personality 
that the beautiful medallion, made by Mr. Brenner, and sub- 
scribed to by a group of those who loved him, is to-day to be 
dedicated. 
Of the group of medical men concerned in the actual work 
of The Johns Hopkins Hospital during its earlier years, all the 
senior members, with the exception of the great Billings, are, 
we are most thankful to say, living and actively engaged; but 
from among the junior members, as the tablet which Dr. Hurd 
has presented indicates, death has already made all too large 
a levy.' We miss all the men who are gone, and we mourn their 
loss to medicine and to society. 
To many of us, Dr. Hewetson's lingering and incapacitating 
illness seemed unusually distressing and tragical. As I re- 
member him in the early " nineties," he seemed full of promise 
for a successful, a useful, and a happy career. Well started in 
Montreal, he came to Baltimore in 1890, and along with 
Lafleur, Thayer, Toulmin, Simon, Frank Smith and Hoch, 
found himself a member of that small group of men who, 
working under the inspiration of a great chief, William Osler, 
set the precedents which have made the medical department 
of this hospital a unique place in which to work. He was 
moderate, capable, industrious, modest, and loyal-qualities 
most desirable for the position which he had to fill. 
At first he devoted himself conscientiously and entirely to 
the performance of the routine duties of the ward service, but 
as soon as the grooves of these had become well oiled, he 
turned to special studies-an analysis of the typhoid statistics 
of the hospital with Dr. Osler, and a study of the malarial 
fevers of Baltimore with Dr. Thayer. He followed with profit 
the courses in pathology and bacteriology given by Drs. Welch 
and Councilman, and in 1894, taking the advice of Dr. Osler 
and Dr. Mall, he went to Germany, where, in the Anatomical 
Institute in Leipsic, he took up the study of the finer structure 
of the nervous system, making excellent serial preparations 
which, after his death, afforded the material for fruitful re- 
search by workers in Mall's laboratory. 
But it was not Hewetson's medical work, good as it was, 
that singled him out as an unusual example among young men. 
That work was interrupted at too early a stage to permit us 
safely to prophesy how distinguishing it might have become. 
Bather than his work, it was the general conduct of his life, his 
forceful, and at the same time lovable personality, which 
distinctively marked him. Behavior, as Bacon aptly described it, is the " garment of 
the mind "; it is the silent and subtle language by which the 
activity, the experience, and the purposes of the spirit are 
revealed to those who can read it; it tells us what a man is, no 
matter what he purports to be. 
When you met Hewetson, and tried to take his measure, you 
soon saw why everybody loved him; you began to do so your- 
self. His frank, open countenance, his cheerful good nature, 
his gentle courtesy, his self-security associated with obvious 
modesty, the evidences of integrity and of sincerity that radi- 
ated from him, and his assumption of well-meaning and of 
generous intention on your part, were excellences that could 
not fail to attract and to endear. There was magic in his eye; 
it beamed kindness; and there was no mud at the bottom of it. 
One felt that in Hewetson's presence and surroundings, high 
standards of conduct must be maintained. He was the kind 
of man whose approval you valued, and whose censure you 
would do your utmost to avoid. In this beautiful work of art, now dedicated to Dr. Hewet- 
son's memory, the sculptor has, I think, depicted some of the 
qualities to which I have referred. It must surely be of benefit 
to all of us at Johns Hopkins, where scholarship is so highly 
revered, to have, also, personality and behavior of the nobler 
sort extolled and commemorated. In days like these, when 
there are convulsive happenings in the world, when men are 
breaking faith with men, when the weak and the defenceless 
are being down-trodden, when not only the living men of many 
nations, but also the great works of man which have endured 
for centuries-pictures, books, cathedrals and universities- 
are being ruthlessly sacrificed, there is danger of our losing- 
confidence in human nature; one begins to wonder if, in 
reality, our much-vaunted civilization is to founder on the 
rocks of hatred, arrogance, and mutual distrust. But we can 
be reasonably sure that it will not be so. Peace and freedom 
will eventually emerge. The spirit of which Dr. Hewetson was 
an exemplar will, we cannot but believe, ultimately triumph; 
and love, humility, and faith will regain their ascendancy in 
a purer, better world. 
At this hospital we shall always cherish Dr. Hewetson's 
memory, and do all we can to foster the ideals of character 
and conduct for which he stood. That this bronze plaque, so 
full of artistic feeling and so sensitively executed, may con- 
tribute toward this end, those who present it, earnestly hope. 
DIL THAYER. 
There is little that one can say after the charming words 
of Dr. Barker. 
I remember well Dr. Hewetson's entrance into the hospital 
family. Bather spare, not very tall but looking taller because 
of his unusually erect carriage and a fashion that he had from 
time to time of squaring his shoulders and throwing out his 
chest-he was a most engaging figure. Uis clean-cut features, 
the face, rather sharp with a peculiarly straight nose and a 
very sensitive upper lip-there was a charm about the man 
which I have rarely seen equalled. His eyes, which Dr. Barker 
has just mentioned and to which Dr. Osler referred yesterday, 
were wonderful clear eyes that looked directly at you and into 
which you looked away back into sparkling and mysterious 
depths. Fascinating eyes, with a gleam and a light in them 
that none of us who knew him can possibly forget! 
He worked hard and faithfully in the hospital, and it was my 
happy lot to be thrown with him constantly. We undertook 
together an analysis of the cases of malaria which had occurred 
up to 1892, a study which we continued until 1894. I shall 
never forget the evenings which we spent about my desk going 
over the histories, writing out the summaries on long sheets 
of paper, and now and then dropping our work to step across 
the hall to chat with Barker. It was in 1891 that Hewetson came to Baltimore. In the 
spring of 1891 he went to Europe to study at Leipsic, but in 
the summer he was called back again by some one of the many 
family misfortunes which one after another followed him. In 
the fall, however, he returned again, this time with Erank 
Smith and me as companions. What a happy trip that was on 
the slow old steamer to London! Soon after we started, our 
party of three received a charming addition in Miss Julia 
Arthur, the distinguished actress. From morning till night 
we four sat upon deck listening to Smith's extraordinary 
stories and songs. I have often wondered if he could do it 
again. Hewetson was the life of the party as he was of every 
company. 
That winter, alas, he was taken ill at Leipsic, and there 
Barker found him and carried him away to a restful spot in the 
mountains where he spent many months. In the following 
summer I visited him in his lovely resting-place above 
Montreux in Switzerland. He looked and seemed so well at 
that time that we were all hopeful that the malady had been 
arrested. 
In 1896, after a trip as ship's surgeon to Australia, he 
joined his family in Biverside, California. But amid lovely 
surroundings cares and sorrows followed him, the illness and 
death of his father and sister and constant anxiety about his . 
brother. 
He was never able to return to work, and gradually and 
slowly, he grew weaker. But throughout it all he was never 
disheartened. There was never a note of discouragement in 
li is correspondence. And how charming were his letters I 
Xo one could write as could Hewetson. 1 fancy that Barker 
and Smith have kept their letters. I know that I have mine, 
and I read them all but a day or two ago. 
In 1905 a great joy came into his life in his marriage to 
Miss Susan Bacon. Nothing could have been more nearly 
perfect than his life during thb few years which followed. The 
devotion of his wife brought to him the peace and the happi- 
ness which he so richly deserved, and his letters during this 
period were a delight. But, alas, this great happiness was but 
for a day, for in 1909 his wife, who had been delicate for 
several years, died. This crowning misfortune Hewetson 
received with the same calm and dignified resignation with 
which he had accepted all his other ills. But it was the end. 
He lingered but a year longer despite loving and devoted care, 
and died in the fall of 1910. 
Through it all, as I have said, he was extraordinarily strong 
and courageous. The charm that we who knew him well had 
always felt, radiated out upon all with whom he came in con- 
tact. As we look back, those of us who were with him in the 
old days, we all feel that he was the finest and biggest and best 
figure of the early group of men who gathered here. He cer- 
tainly was the best-beloved. On the Importance of Fundamental Methods of 
Physical Examination in the Practice 
of Medicine 
By WILLIAM SYDNEY THAYER, M.D., Hon. F. R. C. P. I. 
Baltimore, Maryland 
REPRINT FROM 
THE SOI THEKN MHD1CAJ. JOI'RNU 
Journal of the Southern Medical Association 
Mobile, Alabama. 
Vol. VII. 
December, 1914. 
Pages 933-942. 
No. 12. treatment of disease, of radiography, electro- 
cardiography-all these discoveries and ad- 
vances have transformed that which was once 
described as a "conjectural art" to an edifice 
based upon firm scientific foundations. And 
these solid scientific foundations have given 
to the diagnostic, prognostic and the therapeu- 
tic arts a degree of certainty of which we 
never dreamed but a few years ago. 
To one who can look back over even so short 
a period as a quarter of a century how impres- 
sive is the consideration of the changes in his 
attitude toward many of the common condi- 
tions with which we meet. Let us consider for 
a minute the contrast between some of the 
emergencies of those days and of the present. 
How great used to be our uncertainty and 
anxiety concerning the nature of the severe 
tonsillitis with glandular enlargement suggest- 
ing a possible diphtheria. Today, by means of 
cultures, the nature of the process may be 
determined inside of tweny-four hours. 
Consider again our attitude with regard to 
the diagnosis of various continued fevers^ 
of the hopeless confusion which existed in 
this country and elsewhere as to the use of 
the term "malaria," of the endless discussions 
which used to take place in our medical socie- 
ties with relation to the supposed specificity of 
the fevers in this, that or the other district,, 
perhaps closely contiguous one to another.. 
And then consider how quickly often the vari- 
ous microscopical, bacteriological and serologi- 
cal investigations bring certainty as to diag- 
nosis and point the way to proper and effica- 
cious treatment. 
Consider the feeling of depression that used 
to possess the mind of the physician consulted 
by an individual with rather obstinate sciatica 
or so-called "muscular" pains in his back, with 
regard to the cause of which we were totally 
ignorant. Consider the frequency with which 
some of us used to make the diagnosis of 
"myalgia" or "muscular rheumatism" and the 
infrequency with which we find it in our 
REPRINT FROM 
THE SOI THERN MEDICAL, JOl'RNAL 
Journal of the Southern Medical Association 
Mobile, Alabama. 
Vol. VIL 
DECEMBER, 1914. 
Pages 933-942. 
No. 12 
ON THE IMPORTANCE OF FUNDA- 
MENTAL METHODS OF PHYSICAL 
EXAMINATION IN THE PRAC- 
TICE OF MEDICINE.* 
By William Sydney Thayer, M. D., 
Hon. F. R. C. P. I. 
Baltimore, Md. 
To one who loves to turn his eyes backwards 
and to study the past, the rapidity with which 
our knowledge of pathological processes and 
of the methods of clinical study have come into 
being is very impressive. 
It is less than a century and a half since 
pathological anatomy was founded by Mor- 
gagni and Bichat-since Auenbrugger "in- 
vented" the art of percussion. It is less than 
a century since Laennec devised the stetho- 
scope, the precursor of the many instruments 
of precision on which we now depend for the 
acquisition of information indispensable for 
the intelligent practice of our art. 
In this short scrap of time in the world's 
history, the advances made in our knowledge of 
the natural sciences and their application to the 
study and prevention and treatment of disease, 
the evolution of instruments of precision, the 
stethoscope, the ophthalmoscope, the laryngo- 
scope, the thermometer, the clinical and patho- 
logical application of the microscope, the vari- 
ous instruments for the study of the blood, for 
the graphic registration of cardiac and respira- 
tory action, the development of bacteriologi- 
cal and serological sciences, of the new organic 
chemistry and its application to the study and 
*Oration on Medicine, eighth annual meeting, 
Southern Medical Association, Richmond, Va., Nov. 
9-12, 1914. SOUTHERN MEDICAL JOURNAL 
records today. I was amused to find in my 
consulting room index six diagnoses of myal- 
gia within the last five years and thirty-six 
within the ten years before out of smaller an- 
nual clinical material. To what is this change 
due? It is largely due to the information 
which has been given us by radiography, which 
has enabled us to detect in a considerable pro- 
portion of these patients the organic spinal 
changes which are at the bottom of the condi- 
tion, changes the detection of which often 
gives us the key to proper treatment. Many 
individuals with sciatica who ten years ago one 
could only have condemned to months of rest 
in bed, may now be relieved in a short time by 
simple and proper treatment directed toward 
the spinal changes which are responsible. 
Was there anything twenty-five years ago 
which brought a sadder and more hopeless 
feeling to the mind of the doctor than a visit 
from an individual with a low grade of pro- 
gressive, chronic arthritis? We always, of 
course, realized that occasionally such cases 
were arrested in their course, but in most in- 
stances we could look forward only to a slow, 
steady progress with remissions and exacer- 
bations. Today such patients present to us an 
interesting problem for solution with good 
hope that if we may discover the chronic focus 
of infection which is usually at the bottom of 
the malady its radical treatment will be fol- 
lowed by an arrest, perhaps even a recovery 
from the disease, and the unfortunate patient 
who used to be treated by all sorts of local 
applications to the joints and by all manner 
of dietary proscriptions which sapped his 
strength and added to his suffering, may now 
look forward with good hope to a relief from 
his malady. 
Consider the patient with cardiac disease- 
-with some form of arrhythmia, concerning the 
nature of which but a few years ago we had 
no knowledge whatever. Today by means of 
polygraphic investigation and the electrocard- 
iograph we are beginning to gain some real 
knowledge of the localization of the seat of 
the malady comparable to that which we have 
learned in connection with cerebral localiza- 
tion, and we have already gained most valua- 
ble information of a prognostic and therapeutic 
nature. 
Consider the condition of the individual who 
comes to one today complaining of loss of 
weight, of indefinite febrile symptoms in whom 
perhaps some latent tuberculosis is suspected. 
How early by means of bacteriological meth- 
ods, by skillful application of the tuberculin 
test and by the radiographic examinations- 
how early now can we detect the existence of 
the malady, how much information can we 
gain as to its activity. Or on the other hand, 
what a relief may be the confident assurance 
gained by such methods of precision in diag- 
nosis that these suspicious symptoms are not 
due to tuberculosis. How often in such pa- 
tients is one able by careful search to discover 
the small focus of infection in sinuses, posterior 
nares, tonsils, genito-urinary apparatus per- 
haps, which has been at the bottom of the 
whole trouble, the relief of which may be fol- 
lowed by immediate recovery. 
How little we fancied twenty-five years ago 
that tonsils which externally showed little that 
was strikingly abnormal in appearance might 
be the seat of local foci of infection which so 
depress the vital forces- of the individual and 
produce such manifestations as to give rise to 
the diagnosis of pulmonary tuberculosis. And 
yet, such instances are by no means very rare. 
What a blessing it is that today we are able 
to pick from t'he group of otherwise hopeless 
chronic diarrhoeas those occasional instances 
dependent upon anacidity of the gastric juices 
which may be entirely relieved by treatment, 
or those other cases dependent upon amoebic 
infections which yield so wonderfully to the 
use of ipecac. 
With what certainty does the intelligent use 
of radiography allow us to recognize early 
thoracic aneurysm or mediastinal growths 
under clinical conditions which might not in 
times past have led even to the suspicion of THAYER: FUNDAMENTAL METHODS OF PHYSICAL EXAMINATION. 
their existence? Hlow many otherwise unac- 
countable headaches may today be explained 
by the application of modern physical methods 
of exploration of the sinuses and of the brain? 
Of what incalculable value are the newer 
serological methods for the recognition of 
syphilis ? 
But it would be an endless task to enumerate 
the advances which have within the past 
twenty-five years so brightened the practice of 
medicine. 
The number and delicacy of the different in- 
vestigations which must be made in order to 
reach a definite conclusion as to the cause of 
many common complaints has, however, seri- 
ously complicated practice. Many of these 
investigations can only be carried out in a 
large city and by men who devote themselves 
to special fields of study. And even here the 
expense and the time involved may be trying 
and burdensome to the patient. In many cases 
the proper study cannot be made. 
It is, however, most important to remember 
that the information given by these instru- 
ments and methods of precision has explained 
and clarified many clinical phenomena which 
previously had been incomprehensible to us. 
And much of the information which these 
procedures give us can now be obtained by the 
simplest clinical observation. Nowhere is this 
more striking than in the study of cardiac ir- 
regularities. But a few years ago the causes 
and nature of cardiac arrhythmias was quite 
unknown. The newer anatomical and physio- 
logical studies, the introduction and perfection 
of polygraphic and electrocardiographic meth- 
ods have given us a very considerable amount 
of information, which is not only of diagnostic 
but of great prognostic and therapeutic value. 
We are able to recognize with considerable ac- 
curacy, irregularities due to respiration, extra 
systoles of various sorts, disturbances of con- 
duction (heart block), auricular fibrillation 
with its characteristic pulse phenomena, and in 
some instances auricular flutter as well as al- 
ternating and truly intermitting pulses. But 
comparing the results of these studies with 
that which is to be observed at the bedside, it 
becomes clear that most of these conditions 
may be recognized with a considerable degree 
of accuracy by the simpler methods of in- 
spection, auscultation and percussion. By com- 
bining auscultation with the palpation of the 
carotid pulse and the observation of the ven- 
ous undulations of the neck it is usually pos- 
sible to detect extra-systolic irregularities and 
even with some degree of accuracy to separate 
different kinds. Auricular fibrillation is often 
easy to recognize without instruments and even 
auricular flutter may be suspected. Heart 
block may be recognized in many instances, 
and with intelligent observation the practi- 
tioner armed with nothing but a stethoscope 
may recognize and treat most cardiac irregu- 
larities as well as he who commands a poly- 
graph and electrocardiographic apparatus. 
Consider again the great help given by the 
modern and more accurate methods for meas- 
uring and registering blood pressure by use of 
the sphygmomanometer. But here again the as- 
sistance should be, as it were; retro-active. For 
one who uses the sphygmomanometer to edu- 
cate his own finger may gain considerable skill 
in the estimation of the pressure when the in- 
strument is not at hand. Indeed, the sphy- 
gmomanometer has gone far toward reviving 
the study of the pulse, which had in some 
quarters become seriously neglected with the 
development of the arts of percussion and aus- 
cultation of the heart. It would be difficult for 
me to determine whether the sphygmomano- 
meter had been of greater use to me in the ac- 
curate recording of pressures or as a means of 
educating my own finger. I rarely register 
a blood pressure in my consulting room or in 
the hospital without previously recording my 
own estimate by means of the unaided finger. 
Radiographic examinations have, as has 
been previously said, given us valuable infor- 
mation in many branches of medicine, but the 
comparison of information which we thus gain 
with that which we observe clinically has SOUTHERN MEDICAL JOURNAL 
taught us properly to interpret much which 
the simplest observation may reveal. Thus, 
in lumbago or sciatica the character of the 
limitation of movement, the muscular spasm, 
may often give us in themselves sufficient evi- 
dence to allow us to institute proper treatment, 
to apply the proper corset or bandage or sup- 
port. In disease of the antrum, frontal sin- 
uses and even of the ethmoid, simple trans- 
illumination will often reveal as much or near- 
ly as much as we may make out by the more 
elaborate radiographic methods, and the reali- 
zation of the wide significance of chronic naso- 
pharyngeal infection has emphasized the great 
importance of large glands at the angle of the 
jaw as evidence of persistent infection in ton- 
sils, sinuses or naso-pharynx. 
The microscope has given us proof that true 
malarial infection yields quickly to quinine. 
The various microscopical, bacteriological 
and serological tests have emphasized the truth 
that the common continued fever all over this 
country is typhoid, and have greatly simplified 
the diagnosis even where we cannot avail our- 
selves of the more definite information offered 
by those tests. It is, or it should be true that 
instruments and methods of precision in diag- 
nosis are calculated indirectly to improve the 
diagnostic abilities of him who is yet unable 
to have recourse to the assistance which they 
may give. By the simplest methods of physi- 
cal diagnosis we can determine with a consid- 
erable degree of certainty infinitely more than 
we could a few years ago. The general prac- 
titioner of today ought to be an immensely 
better physical diagnostician than he was thir- 
ty years ago. 
There are other influences which today tend 
greatly to broaden the practitioner of medi- 
cine. I refer to the widespread dissemination 
of good medical literature. The Journal of 
the American Medical Association, especially 
with its excellent reviews of current lierature, 
and its critical editorials, brings to physicians 
all over the country information as to the re- 
cent advances in the medical sciences and as 
to the value of the newer methods of pre- 
cision in diagnosis and in treatment, and the 
work of the Journal of the American Medical 
Association is greatly supplemented by such 
admirable publications as the monthly journal 
of our own society. Thus it has come about 
that the average physician is today a far bet- 
ter informed man than was his predecessor of 
but a few years ago. 
But may it not be perhaps that there is an- 
other side to the picture. May it not be that 
too great a reliance on these various diagnos- 
tic tests or on the information afforded by in- 
struments of precision may sometimes lead us 
to overlook or neglect those simpler methods of 
observation and examination which are of 
prime importance for an appreciation of the 
condition with which we are occupied. I fear 
that with all of us, especially in the cities, this 
is a real danger. It is a danger that has con- 
stantly impressed itself upon me as I associate 
with undergraduate students of medicine and 
with my colleagues. I would not say that the 
art of physical diagnosis has suffered from the 
multiplication of finer diagnostic tests and 
methods, but I do feel very strongly that the 
skill of the average young practitioner of med- 
icine in the art of physical diagnosis in its 
restricted sense has not improved of late years 
as it should have improved with the better 
opportunities for observation and experience 
offered by our schools of medicine. The 
young physician of today may be a man of far 
wider general information than he used to be, 
but too often he is a man of no greater prac- 
tical diagnostic skill. The practice of medi- 
cine is an art which is perfected only by long 
and careful experience and observation at the 
bedside; nothing can take the place of bedside 
study; the diagnostic art cannot possibly be 
acquired from book, lecture or laboratory. 
The foundations once acquired, and they can 
only be acquired by patient practice and obser- 
vation, there is room for the more elaborate 
super-structure, but a super-structure of wide 
general information is of little value to a phy- THAYER: FUNDAMENTAL METHODS OF PHYSICAL EXAMINATION. 
sician who is not skilled in the practical appli- 
cation of the simpler methods of clinical re- 
search which can be carried out by the un- 
aided eye, hand and ear. 
It is impossible for any man to be equally 
perfect in all branches of medicine. That which 
is important for us as practitioners is a solid 
knowledge of the scientific foundations of our 
art and of the fundamental methods of clinical 
investigation which we must use every day- 
a knowledge which can only be gained by long 
practice and experience at the bedside. Be- 
yond this we must have a sufficient acquaint- 
ance with the progress of medicine and of the 
newer methods of laboratory investigation and 
research to enable us to practice such of these 
as we can, to recognize the necessity of having 
others assist us in those which we cannot, and 
to learn to reap from the application of these 
various processes of examination the broader 
conclusions which the results of more elaborate 
and precise methods of study have justified. 
But our knowledge of recent literature, of the 
newer methods of laboratory investigation and 
their significance will be of little value to us 
if we are unable intelligently to apply the sim- 
pler arts of auscultation and percussion. 
The sort of man who is widely read and can 
discuss intelligently the problems of medicine, 
but who is ill at ease at the bedside is familiar 
to most of us. I remember well in my early 
studies in Europe two men who occupied pro- 
fessorial chairs in a celebrated university. Both 
of them were learned men, one a man of spe- 
cial distinction whose name is widely known 
today in medical literature. The other was 
a man who occupied a somewhat less promi- 
nent position, one who during his life wrote 
little and whose name excepting to those who 
studied under him is today by no means so 
widely known. Prof. X gave admirable clinics, 
wrote much and edited large treatises. His 
word was everywhere quoted and he was inter- 
ested in an academic way in the broader ques- 
tions which presented themselves in his service. 
He had an acute and well-trained mind and 
made valuable contributions to medical litera- 
ture, but he was not a good practical physician. 
He was not so much at home with the indi- 
vidual case as he was with the general prob- 
lem. In the pathological laboratory the uncer- 
tainty of his diagnoses was of common report. 
He was a distinguished student and a great 
authority in medicine, but he was not a good 
doctor. He would have made an indifferent 
practitioner of medicine. His colleague, Pro- 
fessor Y, was a man of much less general rep- 
utation who, as I have said, had written little, 
indeed, to the end of his life his contributions 
to medical literature were surprisingly small. 
He, too, was a man of wide reading, but he 
lived in his wards and laboratories and fol- 
lowed every fatal case to the pathological insti- 
tute, where he discussed the problems with his 
students and registered definite diagnoses in 
all instances-diagnoses the accuracy of which 
was proverbial. He'was a great doctor. The 
contrast was striking, the one a learned and 
prolific student but a poor practitioner of his 
art, the other a great physician. As teachers 
of medicine both played important roles, but as 
practitioners there could be no comparison be- 
tween the two. 
That there is a great field for men of both 
of these types in our schools of medicine and 
in our universities is probably true, but among 
practitioners of medicine there is room only 
for the good doctor. 
In these days when the tempter in the shape 
of the avid publisher stands at every corner, 
the ambitious doctor is sometimes too ready 
to rush into print. 'Tis true that by writing 
books to order, as it were, he may gain a cer- 
tain reputation. But no mere writer of treat- 
ises no matter how widely known his name 
may be, can leave the mark on posterity that 
such a man as Schoenlein left in Berlin, or the 
modest Potain in Paris or the elder Janeway 
in New York-all men who wrote little but 
were true clinical students and great physi- 
cians. 
The practice of medicine is not a science; it SOUTHERN MEDICAL JOURNAL 
is an art based upon scientific foundations, and 
unless we are well trained in the practical side 
of our art we shall lack the ability to elicit 
that preliminary information from which our 
scientific training will allow us to draw the 
proper conclusions. The gravest fault in the 
American practitioner of medicine today lies, 
I believe, in the tendency to rely upon various 
diagnostic tests furnished by the laboratory 
and special instruments of precision, while nc 
neglects the invaluable information which he 
can gain from a thoughtful consideration of 
the resuts of the simpler and more easily prac- 
ticed methods of physical diagnosis. 
Let me cite a few examples illustrative of 
the manner in which the diagnostic and thera- 
peutic arts may suffer from a thoughtless re- 
liance upon individual diagnostic tests and the 
neglect of fundamental methods of physical 
examination. Perhaps the commonest and one 
of the most painful instances of the blind re- 
liance upon a diagnostic test is afforded by the 
occasional attitude of some of our colleagues 
toward the result of the examination of the 
sputa for tubercle bacilli. The presence of 
tubercle bacilli in the sputa reveals the exist- 
ence of a so-called "open tuberculosis." But 
is their absence evidence that tuberculosis of 
the lungs does not exist! Of course not. And 
yet, as one of my colleagues especially engaged 
in this branch of practice said to me but yes- 
terday, patients are frequently brought to him 
with advanced tuberculosis who have been con- 
fidently assured by their physicians that they 
were free from the disease because of their in- 
ability to find the positive proof of the exist- 
ence in the shape of tubercle bacilli in the 
sputa. In almost all of these patients a careful 
physical examination would have revealed 
changes in the lungs which a man of experi- 
ence would have recognized as almost inevi- 
tably tuberculous. 
A positive Widal reaction and the cultiva- 
tion of typhoid bacilli from the circulating 
blood afford us strong or positive evidence of 
the existence of typhoid fever, and these diag- 
nostic procedures have proved an enormous 
help to the physician. But it is, alas, all too 
frequent today for one to rely largely upon 
these tests for diagnosis. The cultivation of 
the bacilli from the blood may fail, and the 
Widal reaction may not appear until late in 
the course of the disease, and indeed it may be 
absent throughout the febrile period in in- 
stances in which the skilled clinician could 
scarcely fail to recognize, at least strongly to 
suspect the malady in the absence of any bac- 
teriological or serological tests. 
Now in all such tests there are possibilities 
of error in the laboratory, and especially in 
some large public laboratories under political 
management one should be somewhat guarded 
in placing too much reliance upon the results 
obtained, negative or positive. Blind confidence 
in such tests may lead sometimes to strange 
and pathetic errors of diagnosis. I remember 
very well a few years ago seeing a patient with 
ulcerative endocarditis in which the symptoms 
were in every way characteristic-the anaemia, 
the high intermittent fever, the chills, the leu- 
cocytosis, the evidence of valvular lesion- 
everything was there, but the physician had 
made a diagnosis of typhoid fever because the 
Health Department had reported a positive 
Widal reaction. There was not a point in the 
history of the case, not a symptom, not an 
appearance suggestive of typhoid fever. 
Everything should have led to a correct diag- 
nosis; but the physician had satisfied himself 
by sending a specimen of blood to the Health 
Department and neglecting those other sim- 
pler general methods of examination which 
should have led immediately to a correct con- 
clusion. 
A few moments ago I referred to the diag- 
nostic and prognostic value of the information 
afforded by the sphygmomanometer. The 
ability accurately to measure the blood pres- 
sure is a considerable assistance, but there may 
be, and I fear there are some to whom the in- 
strument has not been an unmixed blessing. 
With a ready means of estimating the blood 
pressure at hand, such individuals may come to 
place their whole reliance upon it and quite to THAYER: FUNDAMENTAL METHODS OF PHYSICAL EXAMINATION. 
forget that nine times out of ten the unaided 
finger may give them the same information. 
Now so long as men have practiced medicine, 
the pulse has been consulted for information 
as to the condition of the patient. The diag- 
nostic significance of high and low pulse ten- 
sion has been well appreciated for years and 
the detection by the finger of the hard pulse of 
high pressure has led many a practitioner to 
the recognition of an early chronic nephritis, 
and has enabled him to point out to the patient 
the desirable precautionary steps in treatment. 
But today the ability to record pressures in 
millimetres of mercury has given the blood 
pressure a position of such importance in the 
minds not only of the laity but of some physi- 
cians that it is only too common to see unneces- 
sary and even dangerous treatment directed 
toward this one symptom without considera- 
tion of what its relation may be to the under- 
lying malady. I am sure that I have seen 
uraemia directly induced by the inconsiderate 
administration of the nitrites in chronic 
nephritis. 
In such circumstances as these it can hardly 
be denied that reliance on a single test has 
tended to obscure rather than to clear the pic- 
ture, to harm rather than to help the patient. 
But this is not a new story-we can find ex- 
amples of the same sort in connection with 
every step forward in the diagnostic art. 
I wonder whether anyone in this audience 
has read William Withering's "Account 
of the Fox Glove," and remembers his inter- 
esting relation of the manner in which he 
learned to use this most valuable drug. Those 
who have read it I am sure were im- 
pressed, as I was, that Withering with 
his extremely limited knowledge of physical 
diagnosis was yet as skillful or even more 
skillful in his method of using digitalis than 
many of us are today. Withering and many 
who followed him administered digitalis be- 
cause of certain general symptoms which the 
patient showed and because of the character 
of his pulse, and from careful clinical obser- 
vation, they learned how to regulate the dose. 
But with the development of the art of auscul- 
tation and percussion, with the acquisition of 
the means of recognizing the different valvular 
diseases of the heart, many physicians have in 
the past neglected greatly the proper consid- 
eration of the character of the pulse and of the 
general condition of the patient-many men 
have come to treat the patient rather according 
to the nature of the valvular lesion in the heart 
than because of the state of the circulation in 
general-to treat the disease rather than the 
patient. William Withering would in all proba- 
bility have been wiser in his treatment of many 
patients than some of us who were taught to 
give digitalis according to book rules based 
upon superficial physiological generalizations, 
rules for instance which forbade the use of 
digitalis in aortic insufficiency. Our ancestors 
used digitalis not according to the nature of the 
cardiac lesion, but as a result of the considera- 
tion of certain gross general symptoms. Many 
of us in like cases have been in the habit of 
exercising our technical abilities in establishing 
a diagnosis, and at this point have practically 
ceased to use our minds, accepting mistaken 
generalizations as to the indications for treat- 
ment, and often I am sure we have been poorer 
doctors than our great grandfathers. 
I have spoken of the danger of placing too 
great a reliance on diagnostic tests and the 
neglect of the practice and consideration of 
the simpler methods of physical diagnosis as a 
widespread danger to all of us in the present 
day. By taking the short cut to a diagnosis, by 
accepting the results of the work of others and 
neglecting the use of our own eyes and ears 
and fingers and minds, we may greatly dimin- 
ish our usefulness as physicians. 
The establishment of a correct diagnosis, the 
first stage in the rational practice of medicine, 
may justly be regarded as the most important 
part of the physician's art. For without a 
diagnosis, or at least without the ability prop- 
erly to consider and to weigh the possibilities 
and probabilities in a given situation, treatment 
of the patient must be unsatisfactory, suitable 
protection of the family and the public difficult, SOUTHERN MEDICAL JOURNAL 
to say the least, and reasonable prognosis im- 
possible. 
The making of a diagnosis requires trained 
powers of observation, skill in the fundamental 
arts of physical examination, inspection and 
auscultation and percussion, as well as a 
knowledge of the use of a large variety of in- 
struments of precision for the investigation of 
individual symptoms. But above all, it re- 
quires a mind which through experience as 
well as training, is capable of weighing and 
appreciating properly, the different manifesta- 
tions of disease and the results afforded by 
various tests of function, so that in the end 
from a multitude of what may apparently be 
contradictory symptoms, the fundamental seat 
and nature of the malady whence all these 
disturbances of function have proceeded, may 
become evident. No book, no lecture, so sim- 
ple demonstration can teach the student the all 
important diagnostic art. With a good com- 
prehension of the physical basis of the methods 
of auscultation and percussion, by the use of 
his eyes and his hands and his ears, he can 
detect many gross physical and some finer 
functional and organic changes. By the micro- 
scope and a variety of relatively simple physi- 
cal and chemical methods he can detect impor- 
tant changes in secreta and excreta. But this 
is but the beginning. Unless upon the basis of 
experience, pathological and clinical, he is able 
properly to correlate his anatomical and func- 
tional observations with known pathological 
conditions and to use his mind intelligently, 
his work will have been for naught. There 
are few diagnostic tests in medicine, and of 
these the physician is not commonly able to 
avail himself. It is not from one or two or 
three points that the diagnosis is generally 
reached, but from the judicious consideration 
of a large amount of information. Much of 
this information-the most important part of 
it-is still to be obtained by the simpler bed- 
side methods, and it is only by the assiduous 
practice of these methods that skill in diagnosis 
may be acquired. 
The part of experience in diagnosis is very 
large and such experience can be acquired by 
all who earnestly seek it, but experience re- 
quires the continuous practice of physical ex- 
aminations and the habit of thoughtful reason- 
ing concerning the results of one's observa- 
tions. 
It is, I believe, very largely the fault of the 
teaching of medicine in our schools that the 
simpler arts of physical diagnosis are not more 
intelligently practiced. In almost all such in- 
stitutions the instruction in physical diagnosis 
in its restricted sense is given over to young 
men-men of limited experience. The full 
professor gives lectures or demonstrations 
upon general or special problems and perhaps 
makes visits in the wards, but he does not-he 
cannot often afford to give his time to the 
teaching of auscultation and percussion and to 
the discussion of the conclusions which may 
reasonably be drawn from the practice of the 
simpler physical methods of examination. 
But, as Friedrich Muller has somewhere 
said, it is just here in the teaching of the fun- 
damental arts of percussion and auscultation 
that the professor, a man of wide experience, 
can do his most important work. The arts of 
auscultation and percussion should be taught 
by the most experienced men available and 
every step should be taken to impress upon 
the student that it is on the practice of these 
methods that he is to place his main reliance in 
the future. My colleague, Prof. Janeway, in- 
tends this year to give a considerable part of 
his time during the third trimester to teaching 
personally the students of the second year class 
the essential principles of physical diagnosis. 
Schools of medicine should moreover offer 
and insist upon a considerable amount of ac- 
tual clinical experience before granting the de- 
gree of Doctor of Medicine. In this respect 
our schools are advancing rapidly, but there 
is still much room for improvement. The nec- 
essity of the so-called clinical year is, however, 
today widely appreciated. 
But it is not only in our schools that steps 
may be taken to improve the practical clinical 
education of the young physician. All states THAYER: FUNDAMENTAL METHODS OF PHYSICAL EXAMINATION. 
should today demand evidence of a sufficient 
clinical experience before granting the license 
to practice. Practical bedside examinations 
should be instituted to test the clinical ability 
of the applicant; and these examinations 
should be conducted by trained clinicians, at 
best teachers of medicine-for after all 'tis the 
teacher of medicine who can best understand 
the young physician and can best judge what 
he ought to know. It would not be a bad idea 
as I have said elsewhere, if these examiners 
were, after the British custom, invited from 
other states-a procedure which would tend to 
obviate mutual suspicions of partiality among 
the graduates of rival institutions. 
But whatever the particulars of the arrange- 
ment, practical tests of the clinical abilities of 
the applicant for a license should be carried 
out throughout America. 
The young practitioner of medicine should 
realize that the most important part of his 
armamentarium on the beginning of practice 
is not so much a varied assortment of instru- 
ments of precision, desirable though they may 
be, as a consulting room in which there is a 
simple couch long enough to allow the patient 
to lie in an attitude of complete relaxation, and 
placed in such relation to a window as to allow 
him to lie in a bright light. This is a most 
vital necessity for any doctor of medicine. No 
man who depends for the examination of his 
patients upon a high combined operating and 
examining table with extension foot pieces, so 
commonly the only couch in the physician's 
office-no man who depends upon such a struc- 
ture alone can succeed in making himself a 
good physical diagnostician. 
And the student should have it well im- 
pressed upon him that he must in his practice 
make physical examinations whenever it is pos- 
sible ; and it is generally possible. It used to 
be said that it was a difficult matter for the 
young physician to examine his patients, that 
such examinations were not allowed excepting 
on the occasion of a formal consultation, but 
these days have passed. For one patient that 
the young man may lose he will gain two if he 
insists on making thorough examinations and 
refuses the easily written prescription until he 
is sure of his ground. 
There is one very important way in which 
the young man may acquire experience and 
that is by seeking service in the ever increasing 
free dispensaries which exist in most of our 
cities. These dispensaries offer invaluable op- 
portunity for the ambitious man. In nearly 
twenty-five years that I have now been in Bal- 
timore it has been a matter of great interest to 
me to see how invariably as a rule the exper- 
ience gained by those men who have been 
assiduous in their dispensary work has been 
appreciated by the public. The poor who come 
to the better dispensaries are examined and 
studied in a fashion far more thorough than 
is practiced as a rule by the physicians who live 
among them, and many individuals seek advice 
at free dispensaries because they appreciate 
this circumstance. They could often afford to 
pay a small fee but they come to the hospital 
because they are not blind to the truth that 
they receive there better attention than they do 
at home. But let the well trained young man 
who has acquired experience by dispensary 
work take up his practice in such a community 
and it will not be long before many learn that 
this doctor examines them and practices those 
methods of study with which they have become 
familiar in the hosiptals, and when they can- 
find such a man they turn to him. And so it is 
in all fields of practice. 
But I have said enough. Some, I fear, may 
feel that I have abused my opportunity by 
repeating old and self-evident truths. They 
are certainly not new, and to some they may 
be self-evident, but they are, I believe, truths, 
and they have their importance-and so let me 
summarize once more the thesis which I would 
emphasize. 
To be a good physician one must be skilled 
in the fundamental arts of diagnosis. To be 
skilled in these arts one must have practice and 
experience. 
It is the duty of our schools of medicine tq SOUTHERN MEDICAL JOURNAL 
see to it that these arts are taught thoroughly 
and by trained and experienced men. More- 
over the student should be offered a considera- 
ble measure of practical experience in wards of 
a hospital before his graduation. 
It is the duty of our states to demand that 
this experience shall have been had, and to 
offer tests under the control of competent men 
which may prove that it has been profited by 
before granting the license to practice. And 
lastly the physician who wishes to become 
proficient in his art should remember that with 
all the information he may gain from diag- 
nostic tests and instruments of precision, it 
is only by continued, daily, clinical observa- 
tion and study by the old familiar bedside 
methods that he can gain that experience 
which will train and ripen his judgment so as 
to make of him a competent and skillful 
clinician. REMARK? ON DR. CHEW, THE PHYSICIAN, 
by 
DR. WM. S. THAYER, 
NOVEMBER 19, 1914.* 
It is a great pleasure and a very great 
honor to be allowed to say a word tonight about 
Dr. Chew as a physician, for all of us who have 
practiced medicine with him in Baltimore feel for 
him a sincere respect and affection. 
The son of a distinguished father who hed 
graduated from Princeton and had been professor of 
practice at the University of Maryland from 1852 
to 1863, Dr. Chew himself received the degree of 
bachelor and master of arte at the femous old 
University and graduated in medicine at the Univer- 
sity of Maryland. Brought up in a scholarly 
atmosphere end endowed with scholarly tastes, Dr. 
Chew entered medicine with an unusual general 
foundation, and no one could better have exempli- 
fied the value of such a foundation. He brought 
with him the traditions of a gentleman and a 
scholar, end throughout his life he has been the 
gentleman and the scholar in medicine. 
Quiet, modest, thorough, unasserting, 
with exceptionally good judgment founded upon his 
natural abilities and training, Dr. Chew soon be- 
came widely known and much esteemed among his 
colleagues as a teacher end as a consultant, and, 
es Dr. Mitchell haw said, he succeeded Dr. 
Richard McSherry in 1886 in the chair which had 
been occupied by his distinguished father and 
by the charming and brilliant William Power, of 
whom some day more should be said at one of 
these meetings. 
As a teacher and as a physician Dr. 
Chew ha4? exerted a very wide influence upon his 
fellowmen. All who have come into connection 
♦Address delivered st the Chew portrait presenta- 
tion • with him have felt that they were dealing with a 
gentleman in the broadest sense of the word. Fie 
traditions of inheritance and education, his natu- 
ral and acquired refinement of mind and character 
have given him a power of understanding which has 
made him an able diagnostician and a remarkably 
good physician, and this same power of understand- 
ing, together with a facility of expression based 
also upon these hatural gifts and acquired 
qualities of heart and mind, hav^ brought him very 
close to his patients, and have enabled him to 
exert an influence for good in this community which 
has been very large. 
I know of no one who is a better exnmnle 
of the type of man to whom the late Professor 
Lemoine of Lille has referred in an interesting 
article upon the value of a general education. T 
quote his words: 
''Indeed, the moral influence which he 
(the physician) is capable of exercising upon the 
patient and which he exercises to an ever-increas- 
ing degree with his intellectual superiority i9 
one of the most important of therapeutic agents. 
One heals by words at 1 east as much as by drugs, 
but one must know how t'o say these words «nd to 
exercise a sufficient moral authority that they 
may bring conviction to the patient and carry the 
full weight of suggestion which is intended. 
Were it but for this reason I shall range myself 
among those who demand the maintenance of exten- 
sive classical studies as a preparation for those of 
medicine, for the best means to uphold the 
prestige of the physician is still to raise him 
as far as possible above his con+empornrdes.H 
How good a picture this gives of the 
position which Dr. Chew occupies in this commu- 
nity*. He has presented andpresents today the 
figure of a truly superior man, p man whose 
intellectual superiority has not only m^de him 
a very wise doctor, but has ^iven him the power 
to use his wisdom and his humanity in such man- 
ner that they may exert their greatest effect , The effection and regard which we, hie 
colleagues, have felt for him is perhaps best 
shown by the circumstance that he is the only man - 
excepting during the period of inactivity of the 
Civil War - who has served two terms as president 
of the Medical and Chirurgical Faculty. Dr. Chew 
was president first during the year 1879-80, but 
nineteen years later, on the occasion o f the 
celebration of the centenial anniversary of the 
foundation of the Faculty, we all felt that he, 
above all others, was the man who stood for that 
which we wished our faculty to represent, and 
accordingly we elected him to the presidency for 
for a second time - a unique and deserved honor. 
It i? pleasant to be able in hi? lifetime 5o 
assure him of our continued love and admiration 
and respect. 
And now it is my happy privilege in 
the name of the committee to present to the 
Medical and Chirurgical Faculty of Maryland Miss 
Kellar's very beautiful portrait of Dr. Chew. REFLECTIONS ON MODERN METHODS OF 
TREATMENT BY SERA AND VACCINES 
W. S. Thayer M. D„ Hon. F R. C. P. I. 
Baltimore, Md. 
Reprinted from The Journal of the Florida Medical Association 
October, 1915, Vol. II, No. 4, pp. 97-111 
Florida Medical Association 
Jacksonville, Fla REFLECTIONS ON MODERN METH- 
ODS OF TREATMENT BY SERA 
AND VACCINES* 
few years ago were dreaded pestilences, 
especially fearful because of our ignorance 
as to their nature and source. 
But during the greater part of the last 
century with all the advances made in our 
knowledge of disease, like progress had not 
been made in its treatment. By observation 
and empirical methods, much had been done 
to alleviate suffering, but it was yet true 
that the specifics remained but two-mer- 
cury and quinine. 
A great advance toward new and specific 
methods of treatment was made in 1880 
with Pasteur's§ classical observation that 
animals when treated systematically by 
doses of pathogenic bacteria of a virulence 
below that necessary to produce a fatal re- 
sult, are rendered, on recovery, more resist- 
ant or truly immune to subsequent infec- 
tions. 
In 1884 Theobald Smith and Salmon^ 
made the remarkable statement that im- 
munity may be produced by introducing 
into the animal body the results of bacterial 
growth in culture fluids. In 1888-90 Roux 
and Yersinlj showed that Bacillus Diphthe- 
riae produced in its growth a soluble toxic 
substance of albuminous nature which, when 
introduced into animals, produced symp- 
toms similar to those following inoculation 
with the organisms themselves,, and in 1890- 
94 Behring, Kitasato, Roux and others dem- 
onstrated in the blood of animals to which 
sublethal doses of diphtheria toxine had 
been administered and of individuals con- 
W. S. Thayer, M. D., Hon. F. R. C. P. I., 
Baltimore, Md. 
When your President so kindly asked me 
to speak before this Society it seemed to 
me that a suitable subject would be a series 
of reflections upon certain prevalent thera- 
peutical methods, for after all there have, in 
the last twenty years, been great changes in 
our methods of the treatment of disease- 
changes which well deserve consideration 
more careful than is sometimes given them. 
The past century has revolutionized the 
practice of medicine. As the speaker ob- 
served ten years ago at St. Louis,f medicine 
has changed in this time from a more or 
less speculative art to an art resting upon 
firm scientific foundations. 
The great features of the last fifty years 
of medical progress have been first, the de- 
velopment of our knowledge of infections, 
and secondly, the advance in our compre- 
hension of chemical and physical processes 
and their application to the study and treat- 
ment of disease. 
The information which we have gained 
as to the cause of many infectious diseases 
and as to the manner in which the infection 
gains entrance, has given us the power to 
control largely many processes which but a 
*Address in Medicine before the South Caro- 
lina Medical Association, Greenwood, S- C., April 
21, 1915. 
Originally published in the Journal of the South 
Carolina Medical Association and reproduced 
with the permission of the editor of that publica- 
tion and the author of the article. 
fThe Problems of Internal Medicine, Science, 
N. Y., N. S., 1904, XX, 706-715. 
§Bull. Acad, de Med., Par., 1880, 2s, IX, 121- 
134; ibid, 390-401; ibid, 527-531; ibid, 1119-1127. 
JProc. Biol. Soc., Wash., 1884-6, III, 29-33. 
y[Ann. de 1'Inst. Pasteur, Par., 1888, II, 629-661 ; 
1889, III, 273-288. 2 
valescent from diphtheria an antitoxic sub- 
stance which, injected into another animal, 
not only acted as a preventive but in 
the actual presence of the disease, by 
neutralizing the poison present in the 
circulation, brought about a rapid disap- 
pearance of the symptoms of the malady. 
Here at last, was a new and truly specific 
treatment discovered, not by accident, but 
by a series of carefully planned and accu- 
rately executed experiments. This was as- 
sociated with the demonstration of the ex- 
istence and value of anti-tetano-toxine. 
Almost at the same time George Murray 
introduced a truly specific method of ther- 
apy of quite another sort in his demonstra- 
tion of the efficacy of the treatment of hy- 
pothyroidism by the administration by the 
mouth of glycerine extracts of the thyroid 
gland. It is, however, especially upon the 
specific treatment of infections that 1 would 
dwell today. 
Time unfortunately has shown that the 
number of pathogenic bacteria, the activity 
of which is due to soluble toxines produced 
by the growth of the organism, toxines to 
which a corresponding protective antitoxine 
is developed in the infected animal, an anti- 
toxine which may be used as a specific rem- 
edy or preventive against the disease, is 
very small and practically restricted to the 
bacteria of diphtheria, tetanus and the un- 
usual disease, botulism. With the greater 
number of pathogenic organisms the poison 
is, for the most part, closely bound up with 
the substance of the bacteria themselves and 
is set free especially on the occasion of the 
death and dissolution of the micro-organ- 
isms. 
But it was discovered that on infection 
with these organisms whose poisonous ef- 
fects are produced in a different manner, as 
well as on the injection of foreign proteid 
substances non-poisonous in themselves, the 
infected animal responds by the production 
of anti-bodies-cytolysins, agglutinins, op- 
sonins, precipitins, whatever they may be 
called-substances the main object of which, 
as pointed out by Zinsser in his recent Har- 
vey Lecture, seems to be the removal or 
destruction of the foreign substance inoc- 
ulated. The presence of these specific 
bodies in the blood and the possibility of 
their demonstration by a variety of physical 
and biological procedures has led to a num- 
ber of valuable methods of diagnosis, such 
as the agglutination tests, the precipitin test 
for human blood, the complement fixation 
tests for various infections, especially for 
syphilis. 
The prophylactic introduction of sera of 
animals immune to infection of this class 
has unfortunately proved of little value, 
and from a therapeutic standpoint also, the 
results following the introduction of such 
immune sera have been disappointing. 
However, in instances where the infec- 
tion is localized, as in cerebro-spinal men- 
ingitis, it has been found possible largely to 
control the infection and to save a consider- 
able portion of individuals who otherwise 
would fall prey to the disease by the use of 
concentrated sera containing the antibodies, 
introduced directly at the seat of infection. 
More than this Cole has recently shown that 
in pneumonia where the strain of pneumo- 
coccus causing the infection is determined 
accurately, the introduction of a large quan- 
tity of a specific anti-serum may exert a 
considerable curative effect. 
It has, however, been determined that a 
considerable degree of immunity may be as- 
sured against a number of diseases, such as 
cholera, plague and especially typhoid fe- 
ver by properly carried out vaccination- with 
increasing doses of dead bacteria. These 
dead organisms set free a certain amount of 
poison and the animal body responds by the 
production of antibodies which, when after 
repeated injections, they have become suf- 
ficiently numerous, form a considerable pro- 
tection against future infections so long as 
they remain present in the blood. 
Yet another interesting attempt to in- 3 
crease the resistance of the infected animal 
is represented by the practice of vaccinating 
the already infected individual with living 
or dead bacilli with the idea of further 
stimulating the production of antibodies. 
This-method we may regard as having first 
been introduced by Koch in the treatment 
with old tuberculin. Old tuberculin, as is 
well known, consists essentially of an ex- 
tract of the substance of tubercle bacilli, 
and the injection of this substance often 
produces remarkable local and general ef- 
fects in the infected individual. It was 
early found, however, that large doses pro- 
ducing sharp reactions diminished rather 
than raised the resistance of the patient, and 
later the treatment by repeated introduction 
of very small quantities of tuberculin, too 
small to produce actual febrile reactions, 
has been practiced widely in different parts 
of the world. Although some have fancied 
that they have seen beneficial effects from 
this treatment, much, however, can not as 
yet be said. 
The work of Wright and his studies on 
the opsonic index have, however, led to 
the widespread practice of vaccination with 
dead cultures of pathogenic micro-organ- 
isms in a large variety of diseases. Wright 
believed that he could show that, as the 
result of vaccination, the phagocytic power 
of the leucocytes could be increased greatly. 
The hypothetical substances which in- 
crease this phagocytic power he called "op- 
sonins." He fancied that he could follow 
in the blood the variations in the phagocytic 
activity of the leucocytes in association with 
the rise and fall of these protective opson- 
ins, and governed his treatment by control 
observations on the blood in the laboratory. 
Studies of the methods of estimating the 
opsonic index in this country have not al- 
together upheld the assertions of Wright. 
His original methods were too crude to jus- 
tify positive, definite conclusions, and in- 
deed even with more careful procedure, 
most observers have felt that it is not easy 
to confirm his results. The practice of vac- 
cination in many classes of infections, with- 
out control by regarding the opsonic index, 
is however widespread in many parts of the 
world, especially in England, and there is 
reason to believe that in some conditions 
good results are to be obtained. 
In connection with our studies of infec- 
tion and the mechanism of defense of the 
animal body, a phenomenon of great prac- 
tical importance was brought to light by the 
observations of Richet, Theobald Smith and 
Arthus. As with so many great discoveries 
the observation was not new; but in the old 
days the significance of the phenomenon 
was not appreciated. Magendie* injected 
into the jugular vein of a dog a considerable 
amount of egg albumen in water without 
much ill effect. Later on attempting to 
repeat the experiment on the same dog 
by way of the cartoid, he was surprised 
to find that the dog died rapidly before he 
had introduced more than a drachm of the 
fluid. Portier and Richet in 1902,f noticed 
that the poison extracted from the tentacles 
of actinia killed rapidly and in much smaller 
doses when introduced into dogs which, two 
or three weeks before, had had a non-mortal 
dose. Arthus$ observed that horse serum 
injected into rabbits in repeated doses at 
intervals of several days produced finally 
grave symptoms both local and general. 
Theobald Smith§ in 1903 made the ex- 
tremely important observation that in guinea 
pigs to which diphtheria antitoxine had 
been administered without demonstrable 
symptoms, a second dose given a week or 
ten days later produced instant death. 
Since then it has been shown that most, if 
not all the foreign albuminous substances 
*Lectures on the Blood, etc., English transla- 
tion, 12.8°, Phila., Haswell, Burroughs & Haswell, 
1839, 247 et seq. 
fCompt. rend. Soc. de Biol., Par., 1902, LV, 
170-172. 
tCompt. rend. Soc. de Biol., Par., 1903, LV, 
817-820. 
§Otto (R.), Gedenkschr. f. d. verbstorb. Gen- 
eralstabsarzt d. Armee **** v. Leuthold, Berl., 
1906, I, 153-172. 4 
when injected into the animal body, give rise 
to a reaction in that organism characterized 
by the production of antibodies designed 
probably as has before been said, to destroy 
the foreign albumen. Now with poisonous 
bacteria these substances act promptly by 
killing the invading organisms. But the 
process of destruction of these invaders by 
the antibody is unfortunately not wholly de- 
void of significance. As von Pirquet has 
pointed out, the period in the course of an 
infection at which these antibodies first ap- 
pear and meet with and attack the poisons 
is associated with phenomena, fever and 
other general symptoms, which form prob- 
ably a part of that which we recognize as 
the symptoms of the specific disease. If at 
a latter period when the protective anti- 
bodies are already present in the animal's 
blood, poisonous bacteria gain entrance, 
they are immediately destroyed before they 
have multiplied sufficiently to form an ac- 
tual quantity of foreign albumen sufficient to 
give rise through their destruction to any 
appreciable symptoms. This von Pirquet has 
illustrated most beautifully in the process 
of ordinary vaccination. There, as we all 
know, in the susceptible individual, a period 
of seven or eight days passes before any- 
thing is observed at the site of vaccination 
and then, suddenly, the characteristic local 
and sometimes general reaction begins. 
During this incubation period the patho- 
genic invaders have been increasing in num- 
ber and the human organism has been pre- 
paring its protective antibodies. When these 
antibodies are set free in large numbers 
and attack and destroy the poisonous in- 
vaders the local and general reaction begins. 
Suppose, however, we vaccinate an indi- 
vidual who has already in his circulation 
the protective substance. What do we no- 
tice? Within 24 hours after the vaccina- 
tion the point upon the arm swells a little, 
begins to itch and looks as if it might be 
beginning to "take," but within a very short 
time this abortive "take" has passed by. 
What has happened? The probability is 
that here the already present antibodies 
have attacked immediately the poisonous 
organisms which have been introduced, and 
destroyed them before they have been able 
to multiply to any considerable extent. The 
result has been that the amount of poison 
set free by the meeting of the antigen, as 
the poisonous organism is called, and the 
antibody has been sufficient only to pro- 
duce a minute local lesion and no general 
effects. 
But with the introduction of a foreign 
albuminous substance the question becomes 
somewhat different. Such a substance may 
be relatively harmless in itself to the organ- 
ism into which it is introduced. It may be 
non-poisonous as in the case of horse se- 
rum, for instance, in ordinary individuals. 
But this non-poisonous substance gives rise 
nevertheless to the development of anti- 
bodies, and when these antibodies have been 
produced, a week or ten days, let us say, 
after the first injection, the re-introduction 
of the foreign substance, if the quantity be 
sufficient, may result in the gravest of 
symptoms, even in the death of the animal. 
It would appear that these grave symptoms 
which develop on the second injection of a 
foreign proteid are directly associated,, as in 
the case of bacteria, with the meeting of the 
antibody and the antigen and the setting 
free of some poison. The severity of the 
reaction varies with the quantity of the for- 
eign substance introduced, and the reason 
that the reaction may be so slight or absent 
in the case of bacteria and so dreadful in 
the case of a foreign albumen is explained 
probably by the small quantities of the 
actual albumen present on the introduction 
of bacteria, and the relatively large amounts 
which are introduced when we inject di- 
rectly a foreign albumen such as horse se- 
rum. 
In other words, it appears that the animal 
body into which foreign bacteria or albu- 
mens are injected becomes "sensitized" to 5 
these substances, that is, it contains anti- 
bodies. This hypersensitiveness to bacteria 
which results in the protection of the ani- 
mal body we call immunity. 
The hypersensitiveness toward non-poi- 
sonous foreign albumens, fundamentally 
similar to that which, in the case of bac- 
teria, constitutes immunity, may be a grave 
danger to the animal organism; the phe- 
nomena by which it becomes manifest on 
the introduction of the antigen we speak of 
as anaphylaxis or better, in the words of 
von Pirquet, allergy. 
I have gone into this matter at consider- 
able length because it has seemed to me 
sometimes that in the use of these new meth- 
ods of prevention and treatment of disease 
which have brought such immense benefit 
and even greater hope into our practice, we 
are sometimes forgetful that we are dealing 
with procedures which may give rise to 
dangerous manifestations, with substances 
which should be used with at least as great 
care as that which we exercise in the use of 
other mineral or organic compounds of the 
pharmacopoeia.* 
Antitoxines. 
Let us now consider certain specific 
methods of treatment, and first, naturally, 
the question of diphtheria. Now the diph- 
theria bacillus as we have said, produces 
in the process of its growth, a soluble toxic 
albuminous substance-the diphtheria tox- 
ine-and the animal into which this diph- 
theria toxine is introduced, provided the 
dose be not lethal, responds by the pro- 
duction of an antitoxine which neutralizes 
the poison and protects the individual. 
There has been no greater blessing con- 
ferred upon the human race in the lifetime 
of most of us here than this great discovery 
which has saved so many thousands of chil- 
dren. How may this antitoxine be pre- 
pared? How is it ordinarily produced? As 
is well known, the method of production of 
the antitoxine used in practice consists in 
the immunization of a horse by progressive- 
ly increasing doses of toxine. When the 
highest degree of immunity is reached the 
horse is bled and the serum obtained and 
standardized in such a manner that the ex- 
act strength may be known. It is measured 
in units, a unit being that amount of anti- 
toxine, 1 c.cm. of which will neutralize one 
hundred times the fatal dose of toxine for 
a guinea pig of 500 grammes. The mix- 
ture of such an antitoxine with a 
bouillon solution of toxine in proper 
quantities will in great part remove its 
toxicity. Furthermore, the injection of a suf- 
ficient quantity of antitoxine into the hu- 
man being will render him immune for a 
certain period of time to infection with 
diphtheria bacilli. And more than this, un- 
less the disease has progressed too far, the 
injection of a certain quantity of antitoxine 
will soon interrupt the course of an already 
acquired infection. 
From a prophylactic standpoint various 
recommendations have been made as to the 
quantity of diphtheria antitoxine which 
should be given, but the careful studies of 
Schick have made it fairly clear that a dose 
of 50 units per kilogramme (2 and 1-5 
pounds) of body weight is sufficient in al- 
most all instances. 
Now in the treatmeint of an actually ex- 
isting diphtheria, the doses of antitoxine 
given have varied very greatly. Because 
of the neutralizing relations of toxine and 
antitoxine, the assumption has been made 
that enormous and repeated doses should 
be given in order to counteract any possible 
subsequent toxine production in the body, 
and huge doses have been administered, not 
only singly but repeatedly with intervals 
*For the history and discussion of the subject 
of allergy and anaphylaxis the reader may con- 
sult the following articles: Anderson (J. F.) 
and Rosenau (M. J.)-Anaphylaxis-Arch. Int. 
Med., Chicago, 1909, III, 519-568, Pirquet (Cl. 
Fr. v.) Allergy, ibid, 1911, VII, 259-288; 383-440, 
Zinsser (H.) Harvey Lecture-To appear shortly 
in Arch. Int. Med. Auer (J.) The functional an- 
alysis of anaphylaxis. Forchheimer's Therapeu- 
sis of Internal Diseases, N. Y. and London, D. 
Appleton & Co., 1914, V, 39-112. 6 
of several days, and often with apparently 
brilliant effect. 
But the use of diphtheria antitoxine is 
unfortunately associated with certain dis- 
tinct inconveniences and indeed with some 
danger, for after all one must remember 
that it is not only the antitoxine that one is 
administering, but antitoxine in solution in 
horse serum, a substance harmless in itself 
on the first dose in the immense majority 
of individuals, but yet capable of causing 
the formation of antibodies in the patient 
to whom it is administered, so that at a 
sufficient period later, reinjection finds the 
patient sensitized with the result that in- 
convenient or grave symptoms may follow. 
And this is sometimes observed in the ad- 
ministration of horse serum to patients. Or- 
dinarily an injection of horse serum con- 
taining antitoxine produces no unpleasant 
immediate results, but not infrequently a 
week or ten days afterwards, there appears 
an annoying urticaria, sometimes patches of 
oedema, sometimes joint pains, together per- 
haps with a little fever. These symptoms are, 
however, usually transient and soon pass 
by. Let us, however, suppose that ten days 
or two weeks after this first injection of 
diphtheria antitoxine in horse serum a sec- 
ond dose is given. Almost immediately 
upon the introduction of this second dose 
symptoms follow which may be all the way 
from merely distressing and inconvenient 
manifestations to grave and even dangerous 
occurrences. The patient may have exten- 
sive oedema at the point of injection, a gen- 
eral urticaria, nausea, vomiting, rapid pulse, 
dyspnoea, perhaps grave asthmatic symp- 
toms, syncope and even death. In the adult 
where the quantities of horse serum intro- 
duced are relatively small compared to the 
size of the individual, the symptoms are 
usually more inconvenient than dangerous; 
nevertheless there are grounds for caution. 
What has happened? In the first in- 
stance, what is commonly called serum dis- 
ease has occurred. The introduction of the 
foreign serum has produced the reaction in 
the body to which we have above referred 
-the production of specific antibodies to 
the horse serum; but these arise so slowly 
that at the time when they are set free the 
amount of foreign serum in the blood is 
slight; indeed, it may be entirely absent. If 
it be present in slight quantities the result 
of the meeting of antigen and antibody is 
evident usually in mild, transient symptoms 
such as those to which we have referred. 
But if a large dose of foreign serum be 
introduced into an animal or human being 
a week or ten days after a previous injection 
of the same serum, i. e., into an organism 
already sensitized and containing a consid- 
erable quantity of specific antibodies, then 
the meeting of antibody and large quantities 
of antigen may set free a large amount of 
poison and grave manifestations of anaphy- 
laxis or allergy occur. 
Now if one remembers the observation of 
Arthus to which I referred to before, name- 
ly: the frequent occurrence of oedema and 
grave symptoms in guinea pigs on repeated 
injection with a foreign serum after some 
days of intermission, one can readily see 
that this is exactly what one might expect 
in human beings. We might well ask our- 
selves whether, with the repetition of doses 
of diphtheria antitoxine after a few days of 
intermission, similar unpleasant symptoms 
might not occasionally occur ; and it is true 
that they sometimes do. 
Fortunately, however, the researches of 
Schick* and others have shown clearly that 
these repeated doses are unnecessary. The 
chief value of antitoxine is in its immuniz- 
ing effects. It has some neutralizing in- 
fluence on a toxine introduced from three 
to six hours before, but only a little. The 
great effect is upon toxines introduced at 
the same time or developing later, and care- 
ful studies have shown that while very 
large doses, perhaps as large as 500 units 
*Schick (B.), Kassowitz (K.), and Busacchi 
(P.) : Ztschr. f. d. ges. exper. Med., 1914, IV, 
83-148. 7 
per kilogramme of body weight, may have 
a maximal effect if there be a large quantity 
of toxine present at the time of introduc- 
tion, yet in all ordinary cases 100 units of 
antitoxine per kilogramme of body weight 
gives the maximal effect. And further- 
more, and this is very important, it is never 
necessary to repeat the dose-a single dose 
is sufficient. 
In a given case of diphtheria then, the 
antitoxine should be given so soon as pos- 
sible, and the proper dose is 100 units to 
the kilogramme of body weight in ordinary 
cases. It should be given by deep intramus- 
cular injection. In the most severe cases 
500 units per kilogramme may be adminis- 
tered. That is, in a child of twenty kilo- 
grammes (44 pounds) 2,000 units will be 
enough in 90 per cent of the cases. In very 
severe instances, however, 10,000 units may 
be given. In an adult weighing 60 kilo- 
grammes (132 pounds) 6,000 units is usual- 
ly sufficient, but in very severe cases 30,000 
units may be given. It is never necessary 
to repeat the dose. In the words of Schick, 
"repeated doses should be abandoned as 
wholly superfluous." 
But when this has been said, we have 
still to bear in mind an extremely important 
circumstance, and that is this-a certain 
small proportion of individuals possess as 
a natural peculiarity an extraordinary hy- 
per-susceptibility toward horse serum, while 
others have become hyper-susceptible as the 
result either of a previous injection of diph- 
theria antitoxine or of horse serum for some 
other purpose. In such individuals the in- 
troduction of any appreciable quantity of 
horse serum may produce symptoms of the 
utmost gravity. These symptoms may be 
rapid, almost immediate, varying from ver- 
tigo, dyspnoea, tachycardia, syncope, ces- 
sation of respiration and death, to the lesser 
symptoms of oedema, urticaria, nausea and 
other symptoms of serum sickness. The se- 
vere and dangerous manifestations of hy- 
persusceptibility are very rare, and yet they 
do occasionally occur. Those individuals 
who are naturally hypersusceptible are com- 
monly sufferers from asthma, hay fever, 
rose colds or subjects of urticaria or ango- 
neurotic oedema. One should always in- 
quire into the history as to these conditions 
before administering antitoxine, and, in an 
asthmatic subject, every precaution should 
be taken. 
To make the point clearer let me mention 
a few specific instances. Seventeen years 
ago while treating some cases of diphtheria 
I took a preventive inoculation of about 
1,000 units of diphtheria antitoxine in per- 
haps 5 c.c. of horse serum. About six 
months later another child with diphtheria 
coughed into my eye. Again I took a pro- 
phylactic dose. Almost immediately, at the 
seat of inoculation, a violent urticaria began. 
This spread over my entire body and was 
associated with nausea, headache and con- 
siderable prostration, which lasted for two 
days-a good example of the ordinary man- 
ifestations of allergy in an adult as the re- 
sult of a previous injection of serum. 
A child, I think under five years of age, 
the daughter of an old friend of mine, an 
assistant in the pathological laboratory in 
Berlin, was given in the early days of the 
treatment, an injection of diphtheria anti- 
toxine and died instantly upon its admin- 
istration. 
Diphtheria developing in a family, the 
Health Warden of the district gave pre- 
ventive doses of antitoxine to all members 
of the household without consulting the 
family physician. One of the children died 
instantly upon receiving the injection. 
A year or two ago diphtheria appeared 
in a well known boys' school in the north. 
A general preventive inoculation was car- 
ried out. One of the boys came in from 
the football field, was given his injection, 
started back toward the field, suddenly felt 
dizzy and faint, had a peculiar suffocating 
sensation and in a few minutes was dead. 
Such instances as these latter are among 8 
the most awful experiences of medical prac- 
tice, and such possibilities, rare though the 
event may be, are quite enough to make one 
hesitate to use such a method of treatment. 
Can we avoid such manifestations? If 
so, how? 
Happily it is perfectly possible to avoid 
them, and no one, in the present state of 
our knowledge, is justified in giving a pro- 
phylactic dose of antitoxine without taking 
certain definite precautionary steps. In the 
first place the studies of Schick of Vienna" 
have given us a most interesting and valu- 
able method of testing the susceptibility of 
an individual to diphtheria infection. It is 
well known that many individuals may be 
exposed to diphtheria without acquiring it, 
and Schick has given us a method of detect- 
ing these individuals who are truly insus- 
ceptible to the disease. It has been shown 
that the introduction of a small quantity of 
diphtheria toxine into the skin produces 
within 24 hours a local reaction similar to 
that occurring in a positive tuberculin test, 
and dependent upon the irritating qualities 
of the toxic substances introduced. Such 
a reaction occurs only in those subject to 
the disease, i. e., individuals who do not 
possess antitoxine in their circulation. 
These interesting observations have been 
confirmed by Park, Zingher and Serota,f 
by Kolmer and Moshage$ and by others. 
Those who fail to show this reaction to 
diphtheria toxine (Schick's test) are im- 
mune, insusceptible to diphtheria and need 
no prophylactic treatment. 
Studies of the susceptibility of individuals 
of different ages carried out by Park, Kol- 
mer and Schick show, if we combine their 
statistics, the following interesting figures: 
Percentage of susceptible individuals. 
Positive Reactions 
Age 
Under one year 13 per cent 
1-5 57.8 per cent 
5-10 50.1 per cent 
*Muenchen. Med. Wchnschr., 1913, LX, 2608- 
2610. 
tJ. Am. M. Ass., Chicago, 1914, LXIII, 859. 
JAm. J. Dis. Child, Chicago, 1915, IX, 190-204. 
10-15 33.3 per cent 
Over 15 26 per cent 
Incidence of diphtheria according to age. 
Age 14,000 cases (Kolmer). 
Under one year 3.2 per cent 
1-5 45.4 per cent 
5-10 32.2 per cent 
10-15 8.1 per cent 
Over 15 11.4 per cent 
This shows that in at least fifty per cent 
of individuals preventive inoculations are 
wholly unnecessary. 
The method of performing the test is 
simple. The amount of toxine to be intro- 
duced should be from one-fortieth to one- 
fiftieth of the minimal dose of diphtheria 
toxine lethal for a guinea pig in four days, 
so diluted (Schick and Park) as to be con- 
tained in from .1 to .3 of a cubic centimetre. 
The toxine unfortunately deteriorates very 
rapidly and must be made fresh, so that the 
test is possible only where one is in touch 
with a reliable laboratory. But if as seems 
certain, the value of the test is upheld, 
health departments local and central, will 
have to make arrangements to supply the 
necessary substance. 
Kolmer's directions for making the test 
are as follows: 
''The injection is made intracutaneously 
by pinching up a fold of skin between the 
index finger and thumb and inserting the 
needle into the epidermis. As the injection 
is made a whitish spot develops and a slight 
stinging pain is felt; if this raised anaemic 
area is not seen the injection is probably too 
deep and unsatisfactory. 
A very fine needle (No. 26) and a per- 
fectly adjusted syringe are necessary. We 
have used with much satisfaction the Ric- 
ord and Fournier's tuberculin syringes. 
Platinum iridium needles are especially 
useful, as they are readily sterilized in a 
flame and are thus adapted for giving a 
large series of injections. 
Injections are readily given in the skin 
of the arm near the insertion of the deltoid 
muscle after cleansing with alcohol and 
drying the skin. 9 
The reaction. This appears in from 
twenty-four to forty-eight hours after in- 
jection and is characterized by an area of 
erythema with a brownish tinge measuring 
from 0.5 to 2 cm. in diameter and accom- 
panied by slight oedematous infiltration of 
the underlying tissues. In colored persons 
the erythema can usually be seen, although 
not always sufficiently well to measure, but 
the oedema is readily palpable. The reac- 
tion usually reaches its height in from forty- 
eight to seventy-two hours and then begins 
to fade within a week or ten days, accom- 
panied by some itchiness and usually fol- 
lowed by a brownish pigmented area of 
some days' or weeks' duration. A slight 
superficial scaling, due to the necrosing ef- 
fect of the toxin on the superficial epithelial 
cells is generally noticed. In the majority 
of instances there is no general reaction." 
Kolmer gives a dose less diluted than do 
Schick and Park, using one-fortieth the 
minimal lethal dose of toxin so diluted with 
sterile salt solution containing 0.25 per cent 
phenol that is contained in 0.05 c.c. He 
feels that with the smaller amount of fluid 
less trauma is produced and less doubt ex- 
ists with regard to the reaction. The full 
details may be found in Kolmer's excellent 
article in the March number of the Ameri- 
can Journal of Diseases of Children. 
The test may be made by means of von 
Pirquet's scarifier, but Kolmer prefers the 
intracutaneous method. 
In such a manner then, we may gain 
rapid information as to the susceptibility to 
diphtheria of any given individual. In a 
large proportion of individuals prophylactic 
treatment is, thus, unnecessary. 
But suppose prophylactic treatment seems 
desirable, what steps should we take to 
avoid a possible allergic reaction ? 
One should always make a preliminary 
injection of one to three drops of antitoxine 
and wait from one-half to two hours to ob- 
serve its effect. If there be no appreciable 
result one may safely administer the de- 
sired dose. If, on the other hand, there be 
a sharp reaction of urticaria or oedema, or 
if, as rarely occurs, there be general symp- 
toms, one must take other steps. If there 
be merely urticaria and oedema at the seat 
of injection, after one-half to two hours or 
less one may give a second dose of one c.c. 
and then, after a second period of two 
hours, the full dose may safely be given, 
for it has been shown that a desensitization 
may be rapidly carried out. 
If graver symptoms, such as vertigo, have 
occurred, it may be safe to give after the 
first dose, several gradually increasing in- 
jections at one or two hour intervals before 
giving the sufficient dose. 
If, however, grave symptoms occur on 
the first introduction of a drop or two, 
vertigo, fainting, dyspnoea, nausea, tachy- 
cardia, oppression, asthma-like manifesta- 
tions, one may consider the advisability of 
omitting further attempts at prophylaxis. 
But if the exposure has been serious it will 
probably be safer to continue with increas- 
ing doses as has just been advised. One 
may adopt, as the first step, the procedure 
advised by Besredka of giving 50 c.c. of 
antitoxine by rectum. 
Suppose, however, that we are in the 
presence of a fairly developed case of diph- 
theria. Should we hesitate to give a full 
dose immediately? We should, I think, al- 
ways try a preliminary injection of a few 
drops of antitoxine and wait one-half to 
one hour. The length of time for desen- 
sitization in such cases is not very great, 
and the risk is too large. 
A most interesting example came to my 
attention but a few days ago. My friend, 
Dr. Thomas F. Branson, of Rosemont, 
Pennsylvania, was called to a neighboring 
college to see a student with diphtheria. As 
soon as the diagnosis was established, to 
use his own words, "Steps were taken to 
give the specific treatment. As has been 
my habit for many years, after the introduc- 
tion of the needle, about 2 to 4 minims of 10 
the antitoxine were injected. I then waited 
for twenty minutes to note untoward ef- 
fects. In the present instance after about 
five minutes there was a sudden blanching 
of the face, pupils were much dilated, lips 
white, pulse which had been about 90, rose 
to 120 and was thready, respirations were 
slow, shallow and sighing. The patient's 
complaint was, 'I cannot breathe.' Con- 
sciousness was not lost. * * * In about 
half an hour all symptoms had passed. A 
few hours later the patient was seen with 
Dr. McCrae in consultation, and it was 
determined to give a few minims as a sec- 
ond dose, in the belief that the factor of 
danger in this case would have been over- 
come by the earlier administration. About 
12 c.c. of serum containing 3,000 units of 
antitoxin were given at this time, the ad- 
ministration consuming a period of about 
one and a half hours. No physical signs 
were present during the second injection. 
Subsequently about 9,000 units were given 
or in all a bulk of perhaps 50 c.c. of serum. 
At none of the subsequent injections was 
there any systemic reaction." It is highly 
probable that in this instance the patient's 
life was saved by the prudence of her ju- 
dicious attendant. 
If by chance we should meet with a pa- 
tient who shows a high degree of hypersen- 
sitiveness to a very small amount of horse 
serum, one may hesitate in attempting fur- 
ther treatment. But just such an experi- 
ence as this would justify one to making the 
attempt if the case were truly urgent. In 
such cases we should proceed with grad- 
ually increasing doses at half hour intervals 
till the full dose be given. Or if it seem 
wise, one may at first try a rectal injection 
of 50 c.c. 
If, then, we bear this possible danger in 
mind, and if we remember that 50 units per 
kilogramme of body weight is a sufficient 
prophylactic dose, and that 100 units per 
kilogramme of body weight is a sufficient 
therapeutic dose in all ordinary cases of 
diphtheria, except in very grave instances 
where 500 units per kilogramme may be 
given, and lastly, if we remember that a 
single dose is quite sufficient and that ad- 
ditional doses are not only unnecessary but 
unwarranted, we shall be in position to ob- 
tain the greatest possible benefit from this 
most valuable and truly specific method of 
treatment. 
A consideration of the phenomena which 
occasionally occur as a result of the admin- 
istration of diphtheria antitoxine should 
impress upon us very strongly the truth 
that the introduction of a foreign serum into 
the human organism is by no means a sim- 
ple procedure or one that is to be entered 
into carelessly. 
The one other malady for which we pos- 
sess a true spicific antitoxine is tetanus, but 
unfortunately the treatment is rarely effi- 
cacious after the symptoms have appeared 
for the reason that the poison has passed 
rapidly upward through the nerves into the 
central nervous system and has attacked the 
ganglion cells of the nervous centres. At 
this period, injection of antitoxine has little 
effect. Von Behring* advises a prophylac- 
tic subcutaneous dose and. if the wound 
continues angry, a local injection at the 
seat of infection. 
Von Behring further advises, if the dis- 
ease has already broken out, a local injec- 
tion at the point of infection as well as an 
injection intravenously. He also advises 
the introduction of antitoxine into the nerve 
trunk leading from the region of the wound. 
But this is not easy to do and recent ob- 
servers have reported remarkably good re- 
sults from the early introduction of anti- 
toxine by lumbar puncture. In this man- 
ner the antitoxine not only rapidly reaches 
the nerve centres but also enters the general 
circulation, while when introduced into the 
general circulation, it does not reach the 
nerve centres in any appreciable quantity. 
*Deutsche Med. Wchnschr., 1914, XL, 1956. 11 
Parkf advises as an immunizing dose the 
immediate injection of 1,000 units of anti- 
toxine and it may be well to follow Von 
Behring's advice and to give a little more 
at the site of the wound. 
In the treatment of an actual case of te- 
tanus Park advises the infraspinous injec- 
tion of 500 to 2,000 units in a child accord- 
ing to its size and 3,000 units in an adult. 
The amount of fluid should be as large as 
may be injected without producing pressure 
symptoms-5 to 20 c.c. In addition to the 
infraspinous injection, Park advises intra- 
venous treatment, the dose amounting to 
2,000 units for ten pounds of body weight. 
These two injections, he says, practically 
suffice for the antitoxine treatment, as the 
blood will remain strongly antitoxic for five 
days. It goes without saying that before 
giving a preventive dose of tetanus antitox- 
ine the same precautions should be taken 
which are taken with administering horse 
serum with diphtheria antitoxine. It is fair 
to say, however, that if we meet with an in- 
stance of already established tetanus there 
is no time to spare and most of us would 
prefer to take the risk in making our in- 
jection immediately. 
Antisera. 
Now let us consider for a minute what 
we may do to combat infections with those 
organisms, the deleterious effect of which 
is not due primarily to soluble toxines. 
Here, as has been said, the infection is nor- 
mally brought to an end by the development 
of antibodies-precipitins, agglutinins, bac- 
teriolysins, opsonins-whatever they be 
called, which tend to favor the destruction 
of the infecting organism. Unfortunately, 
it is apparently true that in order to pro- 
duce any effect sufficient to be of great 
value, the antisera have to be introduced in 
quantities so large as to make effective 
treatment very difficult or impossible. 
Few results worthy of serious considera- 
tion have been obtained in severe general 
infections. In cerebro-spinal meningitis, 
however, where the infection is localized, 
we have a most valuable method of treat- 
ment, which consists in the repeated intro- 
duction of the antiserum directly into the 
cerebro-spinal canal-the seat of infection. 
The antibodies are thus able to reach the 
seat of infection in a degree of concentra- 
tion sufficient in a considerable proportion 
of cases, to bring about a satisfactory re- 
sult. 
Moreover, in bacterial dysentery results 
of some value have been obtained by early, 
large and repeated doses of antiserum, es- 
pecially in small children. The use of anti- 
sera in most other general infections has, 
however, proved disappointing. In cholera, 
in plague, in typhoid fever little has been 
accomplished. Attempts have been made 
to produce antistreptococcus sera, but with- 
out satisfactory results. One reason pos- 
sibly is the circumstance that there are so 
many varieties of streptococci which, with 
our present methods, it is impossible to rec- 
ognize and distinguish. 
Polyvalent sera have had little better re- 
sults ; and I am unaware of any thoroughly 
satisfactory evidence of the essential value 
of any of these antisera. Nevertheless, it is 
conceivable that in streptococcus infections 
if it were possible to identify just the strain 
of organism and to introduce a sufficient 
quantity of an immune serum, some help 
might be obtained. 
In pneumonia, thanks to the researches 
of Cole, Dochez and others^, some progress 
seems to have been made. As you know, 
Cole has distinguished four main types of 
pneumococci which may be distinguished 
by laboratory methods. In two of these 
forms special antisera have produced ap- 
parently an appreciable result, but here at 
fForchheimer's Therapeusis of Internal Dis- 
eases, N. Y. and London, Appleton, 8°, 1914, V, 
469 et seq. 
tDochez (A.R.) and Cole (R.I.) Pneumococ- 
cus Infection: Forchheimer's Thefapeusis of In- 
ternal Disease, 8°, New York and London, D. Ap- 
pleton & Co., 1914, V, 472-508. 12 
present the doses of serum have to be very 
large. The effort is now being made to find 
some methods by which this and other dif- 
ficulties may be obviated. 
In all these maladies again, wherever the 
question of the introduction of a foreign 
serum arises, the same precautions should 
be taken. Where there is a serious ques- 
tion as to whether the introduction of the 
serum is going to be of any value, we should 
be much more careful about taking risks. 
We should always remember the possibility, 
slight though it may be, that one may meet 
with an hypersensitive patient. One should 
never administer a large dose of such se- 
rum to an individual with a history of asth- 
ma ; one should always ask whether there 
has been previous hypodermic treatment 
with horse serum, and if this is the case, 
one should proceed carefully with minute and 
increasing doses at short intervals. 
Vaccines. 
Prophylaxis. But it is not only by the 
production of a passive immunity through 
specific antitoxines and antisera that we 
may seek to combat disease. The oldest 
prophylactic methods have been attempts to 
produce active immunity by means of the 
production of the disease itself under fa- 
vorable conditions, as in the old inoculation 
for smallpox, or by vaccines with attenu- 
ated cultures such as is practically the case 
in cowpox or in the vaccination introduced 
by Pasteur in chicken cholera and in an- 
thrax. In more recent times, following the 
observations of Pfeiffer, attempts have been 
made to produce an active immunity in a 
variety of diseases by the introduction of 
dead cultures of the specific organism in 
increasing doses. Thanks especially to 
Wright, the value of such vaccination 
against typhoid fever has been shown to be 
verv great, the results in the United States 
Army having been especially creditable and 
striking. The same is true to some extent 
in various other diseases; vaccination with 
dead cultures gives a certain degree of im- 
munity against cholera and plague and dys- 
entery, and it is not impossible that im- 
proved technicpie may offer material pro- 
tection against many of the more dangerous 
epidemic fevers. 
In most of these conditions there is no 
material danger in the procedure of vaccina- 
tion provided the quantity of organisms in- 
troduced is not too great, and provided the 
vaccine has been properly prepared. At 
the present moment the gravest danger 
would appear to lie in the rare but occa- 
sional contamination of smallpox vaccine 
with tetanus, and the possibility that the 
vaccine may be, as we have indeed observed 
recently in connection with a certain ty- 
phoid vaccine put forth by a reputable firm, 
quite inert. 
Vaccine Treatment. 
But another question has arisen in recent 
years which is of considerable importance 
in the practice of medicine today, and that 
is the question of the possibility of the use 
of vaccines in the treatment of existing dis- 
eases. The principle on which vaccination 
in the treatment of infectious diseases has 
been introduced is that of stimulating the 
organism to produce protective anti-sub- 
stances quicker and more thoroughly than 
it has been doing, and thus to hasten the end 
of the infection. This is accomplished by 
introducing an additional dose of the poi- 
sonous organisms already present, in sucn 
condition, however, that they are in- 
capable of further propagation. Such treat- 
ment would seem to be especially reasonable 
in localized infections of moderate extent, 
or in infections from which perhaps the 
bacteria enter into the blood only at inter- 
vals. Here an extra impulse to the forma- 
tion of antibodies given by vaccination, 
might reasonably be expected to give addi- 
tional powers of resistance to the organism. 
But if the process be a severe general infec- 
tion where the fight between the invader 
and the host is still undecided, one may well 
ask the question whether the introduction 13 
of an additional quantity of the poisonous 
antigen (in such cases the infecting bac- 
teria) may not be a rash or dangerous pro- 
cedure ; for why should we not, in this 
manner, add strength to the already threat- 
ening intoxication; why might not our 
very interference be that which finally de- 
cides the day in favor of the infectious 
agent ? How can we tell that our small 
contribution may not be just the reinforce- 
ment which is necessary to give the battle to 
the enemy ? 
These are the thoughts which naturally 
come to the mind of the serious man who 
considers the question of vaccination as a 
therapeutic procedure. All of us who lived 
through the excitement associated with the 
production of tuberculin cannot fail to 
have seen the harm which may be done by 
a procedure which is practically a vaccina- 
tion ; and if the possible danger of dimin- 
ishing rather than increasing the resistance 
of the patient, that which according to 
Wright actually occurs during a brief pe- 
riod following vaccination, should be seri- 
ously considered. But with or without con- 
trol by study of the opsonic index, vaccina- 
tion with dead cultures of the infecting 
micro-organism has given apparently en- 
couraging results in a variety of different 
conditions. 
The most satisfactory results, I should 
say, have been in the treatment of local in- 
fections with staphylococci, especially in 
acne, furunculosis and rosacea. Here good 
influences are often obtained by the use of 
vaccines prepared from cultures made from 
the seat of infection, that is so-called 
autogenous vaccines. 
A good deal has been written with regard 
to the treatment of complications of gonor- 
rhoea by autogenous vaccines, but outside of 
infections with staphylococci there are grave 
differences of opinion as to the value of the 
results which have been obtained. 
Tuberculin, of course, has been widely 
used, and there are observers who feel that 
some increase in the resistance of the patient 
may be induced by the very careful admin- 
istration of gradually increasing doses. All 
observers who have studied this matter 
deeply are in agreement, however, that such 
treatment demands very careful oversight by 
a trained observer. 
Vaccination has been practiced in many 
different conditions. Some observers have 
thought that they have had good results in 
the treatment of local colon infections, 
cholecystitis, pyelitis, cystitis; others feel 
that some results have been obtained in the 
treatment of chronic bronchitis. In some in- 
stances the vaccination of typhoid carriers 
has apparently been successful. Few have 
had reliable results from vaccination with 
pneumococci or streptococci, although there 
are those who have fancied that they have 
seen improvement in some instances of 
arthritis supposed to be dependent upon 
local foci of streptococcus, especially 
viridans infection. 
Exactly what we may hope to obtain from 
vaccination as a therapeutic measure has 
been admirably expressed by the greatest 
authority on this subject in America. Theo- 
bald Smith* says: "All parasites tend to 
increase the resistance of the host in which 
they live and multiply. Out of this universal 
fact a number of practical problems arise. 
In any given disease is it worth while to try 
to raise this immunity, and how much energy 
will it cost the patient? If worth while, 
what is the best and most sparing way of 
raising such immunity artificially? In any 
localized infection we must ask: Is this a 
beginning process without attendant im- 
munity, or is it a residual process associated 
with general immunity? If the latter, vac- 
cines may be considered safe. In processes 
associated with fever and bacteriemia, 
science says: Hands off! until we know 
whether we have a progressive disease with 
gradual undermining of the resistance or a 
more localized affection in which the excur- 
*An attempt to interpret the present day uses 
of vaccines. J. Am. M. Ass. Chicago, 1913, LX, 
1591-1599. 14 
sions into the blood are secondary. In any 
case the use of vaccines in these cases must 
be regarded as experimental, and should not 
be undertaken save by one trained in im- 
munologic problems. 
Judged from this point of view, as well as 
from the work of the laboratory as a whole, 
we should say that vaccines applied during 
disease will be rarely, if ever, life saving, but 
they may hurry a stationary or languid 
process which tends towards recovery, by 
bringing into play the unused reserves of 
various tissues." 
It is easy to see from this that vaccination 
may be associated with real danger, and 
alas, I have seen clinical evidence of its ill 
effects more than once. It is of vital impor- 
tance for us to remember that in introducing 
into the human being cultures of poisonous 
micro-organisms we are playing with dan- 
gerous arms; that our first duty is to avoid 
doing harm. We should remember that the 
very first step in the treatment of a given 
case by therapeutical vaccination should be 
the careful bacteriological study of that case, 
and a thorough understanding of the nature 
of the infection; that it is useless and worse 
than useless to vaccinate an individual with 
an organism which is not that causing his 
disease; that only under rare and occasional 
circumstances is it justifiable to vaccinate 
with any but an autogenous vaccine. 
Within a few years, however, certain 
manufacturing houses have placed upon the 
market a number of bacterial vaccines which 
they rashly recommend as efficacious against 
a number of diseases, and notably against 
various forms of arthritis' 
Now what conditions could justify us in 
using a vaccine in the treatment of a case of 
arthritis ? 
First, we should be assured that the 
vaccine is made from the micro-organism 
which is causing the disease; secondly, we 
should be assured that the use of the vaccine 
will not be harmful, and thirdly, we should 
have at least a reasonable assurance that 
there is a likelihood that its use will be 
beneficial. 
But the determination of the exact bacteri- 
ological cause of a given instance of arthritis 
is usually an extremely difficult matter, in- 
volving long and complicated bacteriological 
studies which can be carried out only in as- 
sociation with a good laboratory and a 
trained student, and even then it is usually 
only a matter of inference. Suppose, how- 
ever, we have good reason to believe as a 
result of cultures from the blood or from the 
affected joints or existing local foci, that the 
arthritis is due to some form of streptococ- 
cus or pneumococcus infection; should we 
then be justified in using a stock vaccine? 
Under no circumstances, for we have no 
proof whatever that the organism is of the 
same strain as that from which the stock 
culture is made. 
But suppose we have, after all, produced 
an autogenous vaccine, are we then safe in 
using this? Is there any danger of doing 
harm in the treatment of such a patient? 
The danger of doing harm may be little in 
some instances of chronic afebrile arthritis, 
but when we come to an acute arthritis with 
fever we must bear in mind that some of 
these conditions are also associated with a 
septicaemia and a complicating endocarditis 
in which the balance between attack and 
defense may be very delicate, and in which 
the introduction of an autogenous vaccine 
unless it be very carefully administered, may 
result in diminishing rather than increasing 
the resistance of the individual. I remember 
two cases of slow, chronic vegetative endo- 
carditis due to streptococcus viridans, one 
of them with arthritis, in which the clinical 
course clearly indicated that the sharp reac- 
tions following a vaccination had been the 
definite turning point of the malady towards 
its fatal issue. One can at the most say that 
vaccination in arthritis is in an experimental 
stage, and, although, in some instances, we 
may yet desire to make the experiment, it 
should be undertaken only on consultation 
with, and under the direction of one skilled 15 
and experienced in these methods of treat- 
ment. The use of stock vaccines in the 
present state of our knowledge in any form 
of arthritis is a rash, dangerous and un- 
warrantable procedure, unscientific and un- 
justified from a standpoint of clinical experi- 
ence, despite the assertions of the manufac- 
turing pharmacists. The physician who 
allows himself to be led by the advertise- 
ments of manufacturing pharmacists is not 
a safe practitioner of medicine. 
I speak of these anti-rheumatic vaccines 
only as an example. The same considerations 
apply to the employment of most stock vac- 
cines with the single exception perhaps of 
staphylococcus vaccines as employed in acne 
and furunculosis, where in the absence of 
the possibility of obtaining an autogenous 
vaccine, one would not perhaps condemn 
wholly their careful trial. 
Let us not forget that therapeutical vac- 
cination is still in an experimental stage. As 
Professor Pearce* well puts it: "Prophy- 
lactic vaccination rests on a sound scientific 
basis of experimental study and clinical 
observation. * * * Curative vaccination 
has no sound experimental basis, but the 
application of the general principles of im- 
munity as well as clinical observation offers 
a plausible basis for the treatment of local- 
ized, more or less chronic infections, and of 
'carriers.' On the other hand, no satisfactory 
basis is at hand for curative vaccination in 
the acute, self-limited diseases characterized 
by general dissemination and systemic infec- 
tion. All attempted vaccinations in this 
group must be considered as purely experi- 
mental." 
Therapeutic vaccination is then a method 
of treatment into which the physician is not, 
as a rule, justified in entering without expert 
advice, and this has been well said by 
Wright,f himself, who observes that vaccine 
therapy demands "a man who has spent years 
of study to master the technique, to know how 
to make the vaccines, to know where to look 
for the microbe, to know which are the most 
important microbes, to know how to isolate 
them' and most of all, a man with sufficient 
experience and ability to apply all these 
things." 
But I have allowed myself to ramble too 
far already in these therapeutical reflections. 
What I have desired to do is to point out 
the great steps forward that we have been 
making toward a true, specific therapy of 
many diseases; but I have also wished to 
emphasize the truth that these methods of 
treatment are for the most part delicate, and 
must be applied thoughtfully, carefully and 
with full realization that there are dangers, 
rare though they may be, involved in their 
use, just as there are dangers in the use of 
any drug; and I have wished especially to 
insist that certain other methods of treat- 
ment, especially the therapeutic use of 
vaccines-methods still in an experimental 
stage, and in many instances unquestionably 
of an extremely delicate nature, have un- 
fortunately become prematurely popularized 
and are being practiced today in an unsci- 
entific and dangerous manner-in just such 
manner as tuberculin was used twenty odd 
years ago. While the practice of prophy- 
lactic vaccination has, in some instances, be- 
come a safe, useful and well established 
procedure, vaccination as a therapeutical 
measure is still, with a few exceptions, in an 
experimental stage, and is justified only 
under the direction and with the advice of a 
skilled bacteriologist and serologist; vac- 
cination is not as a rule a method of treat- 
ment which the unaided clinician is justified 
in employing. 
Let us not mar the really great scientific 
progress of the last thirty years-progress 
which has given us so much and from which 
we may expect so much more-let us not 
mar these great gains and endanger further 
advance by rash, hasty and unscientific 
practical generalizations. 
*J. Am. M. Ass., Chicago, 1913, LXI, 2115-2119. 
tQuoted from Pearce, op. cit. ADAMS-STOKES SYNDROME-PERSISTENT 
BRADYCARDIA, INVOLVING BOTH 
AURICLES AND VENTRICLES 
REMARKABLE PROLONGATION OF THE As-Vs INTERVAL 
BY 
W. S. THAYER, M.D. 
BALTIMORE 
From the 
Transactions of the Association of American Physicians 
1915 Reprinted from the Transactions of the Association of American Physicians, 1915 
ADAMS-STOKES SYNDROME-PERSISTENT BRADY- 
CARDIA, INVOLVING BOTH AURICLES AND 
VENTRICLES. REMARKABLE PROLON- 
GATION OF THE As-Vs INTERVAL 
By W. S. THAYER, M.D. 
BALTIMORE 
The patient, Mrs. X., aged about fifty-five years, came under 
my observation on the 27th of April, 1913, in consultation with 
my friend, Dr. Hardin, of Washington. 
At thirteen she had had scarlet fever, and six months later 
diphtheria, followed by more or less extensive paralysis. In other 
respects she had been a healthy woman and had had several chil- 
dren. For ten or twelve years, however, there had been some 
shortness of breath on exertion, and for eight months, frequent 
bleeding from the nose. For two months she had had peculiar 
periods of dizziness in which it had been noticed that her pulse w'as 
slow and irregular. Two weeks before she had had a sudden attack 
characterized by loss of consciousness and repeated slight convulsive 
seizures. Immediately after the attack the pulse was very slow, 
about 18 to the minute, and fairly regular. On the morning pre- 
ceding the attack it had been 44; since the attack it had ranged 
between 28 and 35. 
Examination showed a fairly healthy-looking woman lying on her 
back in bed. The pulse was regular, 36 to the minute. On inspection 
of the neck, by a rather poor light, there was a well-marked impulse 
in the jugular with each beat of the pulse, together with a second 
impulse, occurring at a point about mid-way between each beat. 
xA satisfactory analysis of the jugular undulation was impossible 
because of the dimness of the light. 2 
THAYER: THE ADAMS-STOKES SYNDROME 
The heart was slightly enlarged; the sounds were clear through- 
out. There was heard, however, between each regular beat, a 
slight but yet distinctly audible sound. This occurred constantly 
about mid-way between the regular heart sounds, and had the 
general character of the sound which one commonly hears in 
association with the auricular contraction in heart block. 
We were inclined to regard the condition as one of heart block 
with a 2 : 1 rhythm. Tracings were taken which are reproduced 
in Plates I and II. These tracings show, as may be seen, a brady- 
cardia with an average ventricular rate of 33.7 to the minute. 
There is but one auricular wave to each ventricular beat. That is, 
there is a like slowing of both chambers with a-c periods of unusual 
length. In 23 consecutive beats the a-c period ranges from 0.65 
to 0.82 second in length, averaging, 0.73 second. 
The first, and most natural thought that came to one's mind 
was that this must, after all, be a 2 :1 rhythm, and that, on careful 
examination, an elevation corresponding to a second auricular beat 
might be discovered somewhere on the tracing. And, indeed, 
rough measurements suggested, at first, that the sometimes promi- 
nent notch on the katacrotic limb of the c wave might possibly 
represent the beginning of a second a wave. For the differences 
in the periods separating the obvious a waves from the katacrotic 
notches on the succeeding c waves, and those between the latter 
and the next prominent a waves, were so slight that on first glance 
of the tracings, we were inclined to accept this explanation. 
A more careful study, however, shows that the consecutive a 
waves and the katacrotic notches on the c waves are not equidistant 
one from another, the distance from a given a wave to the suc- 
ceeding notch being almost always slightly greater than that from 
the notch to the following a wave. Moreover, the a wave is a large, 
clearly defined elevation and the wave following the notch but 
slight and sometimes ill-defined. One is therefore obliged to assume 
that the condition is one of bradycardia involving both auricles and 
ventricles; and further, the remarkably constant relation between 
the a and c waves suggests that the chambers respond to a like 
impulse conveyed along the usual paths, with a remarkable delay 
in transmission. The impulse visible in the neck, and the sound Plates I, II and VI were, owing to an unfortunate 
mistake, reinforced by hand over the original tracings 
before reproduction, a circumstance which accounts for 
certain irregularities in the line of the tracing. 
Plate II.-Mrs. X. 27/iv/13. C Pulse, 34. a-c time, 0.74 + sec. 
Plate III,-Mrs. X. 3/vi/13. Lead, I. Pulse, 35.9. P-R period, 0.68+sec. 
Plate IV.-Mrs. X. 3/vi/13. Lead, II. Pulse, 35.4. P-R period, 0.7 sec. 
Plate VI.-Mrs. X 3/vi/13. Pulse rate, 31.3. P-R period, 0.79+. THAYER: THE ADAMS-STOKES SYNDROME 
3 
audible between ventricular contractions were clearly associated 
with auricular systole. 
Five weeks later, on the 3d of June, the patient came to Baltimore 
for further polygraphic and electrocardiographic study. At this 
time she appeared to be in excellent condition. The pulse was 36 
to the minute; the blood-pressure was high, by estimate about 180. 
In the jugular the same slight impulse was visible between arterial 
beats, and with the arterial beat no definite presystolic impulse 
could be seen. The radials were not palpable. The point of maxi- 
mum cardiac impulse was palpable in the fifth space, about 10 cm. 
from the median line, the dulness extending about 3 cm. to the 
right of the sternum. There was no retro-sternal dulness. At the 
apex there was a slight systolic murmur following the first sound 
and between beats a soft, short sound was heard. This was loudest 
at about the juncture of the sixth rib and the sternum on the left, 
but was audible all over the cardiac area. The liver was palpable 
on deep inspiration, descending just below the costal margin. 
Electrocardiographic records were first taken, after which the 
patient who seemed a little tired and short of breath, walked slowly 
up two flights of stairs where further polygraphic tracings were 
made. The electrocardiograms are reproduced in Plates III, IV 
and V. They show a bradycardia involving both auricle and 
ventricle, similar to that recorded in the polygraphic tracing five 
weeks before. 
In lead I (Plate III) the rate of the pulse is 35.9 to the minute, 
and the average P-R interval reaches the remarkable figure of 
0.68 seconds. The beats follow one another at regular intervals, 
and beyond the long P-R periods there is little striking about the 
record. The P waves follow one another at regular periods and there 
is no sign at any point of another P complex interfering with R or 
T elevations. 
In lead II (Plate IV), however, there are several variations from 
the usual relation and character of the P and R complexes. In 
this film the rate of the heart's action is 35.4 to the minute, and the 
average P-R time 0.7+ second. 
The R wave is inverted and has a rather flat summit with a 
notch in the middle. The P wave is large and triangular in form. 4 
THAYER: THE ADAMS-STOKES SYNDROME 
The auricular beats are separated by a period usually varying 
from 1.6 to 1.7 second. At one point (w) after the ninth R wave 
on the record and 1.3+ seconds after the preceding P wave, there 
appears a small inverted deflection which has the general complex 
of a P. This is followed in 0.88+ second at x, by an erect P, some- 
what smaller than the regular auricular complex, and this in turn 
is succeeded after 0.23+ second at y, by an R deflection which 
differs distinctly in form from the ordinary R in the tracing. The 
next P follows at z after a shorter period than usual-1.08+ seconds 
-but occurs but little in advance of the time at which it would 
ordinarily have been due, and has its usual complex. Following 
this slightly precocious P elevation there is an unusually long 
P-R interval-0.88+ second, and the next P complex follows after 
a delay of nearly 0.2 second beyond the ordinary P-P interval. 
The P complexes, excepting the two at the points w and x, are quite 
similar in form. The R complexes occur at practically regular 
intervals throughout and at but one point (y) do they show any 
variation from their usual appearance. 
In lead III (Plate V) in which, unfortunately, but a short film 
was made, the heart's rate was 35.5 per minute and the P-R inter- 
val averages 0.69. There is nothing striking about the appearance 
of this film. The R and T waves are inverted. The P waves are 
smaller than in lead II, of much the same general appearance as 
in lead I. 
The next record was taken with the Mackenzie polygraph (Plate 
VI). The patient seemed a little nervous and tired and had walked 
up two flights of stairs. The pulse rate had become slower-31.3 
to the minute. The average a-c interval was 0.79+ second. The 
general appearance of the tracing was exactly similar to that taken 
on the 23d of April, but at two points slight irregularities were 
noted, associated, I think, with swallowing or some other move- 
ment. At the first of these points (x) regular a and c elevations 
can be made out, although the former is immediately preceded by 
an unaccountable wave. The succeeding a is separated from the 
next c by an unusually long period. At the second point (y) there 
is an elevation preceding the v wave, and the latter is followed 
by that which appears to be an a occurring at a remarkably pre- THAYER: THE ADAMS-STOKES SYNDROME 
5 
cocious period, and separated from the succeeding c by a very long 
space of time. Although no special notes were made upon the trac- 
ings at the time when they were taken, the irregularities at X were, 
I think, dependent upon movements of some sort, for I remember 
distinctly that although the tracings were rather carefully studied, 
no serious irregularity was noticed at the time. It may be that the 
elevation at z represents a precocious auricular systole similar 
to those on lead II of the electrocardiogram but I am disposed to 
regard it as an artefact. Nothing similar was observed on the rest 
of a fairly long tracing. 
Lastly, carotid and jugular tracings were taken with a Verdin 
polygraph (Plate A ll). There was some difficulty in obtaining a 
satisfactory record. The patient became rather nervous and tired. 
The rate of the pulse is here 28.8 to the minute, while the a-c 
interval varies from 0.81 to 0.97 seconds, reaching the remarkable 
average length of 0.886. Excepting for the slower rate of the pulse, 
and the remarkably long A^-IN interval, the tracing differs in no 
essential from those made with the Mackenzie instrument. 
How are we to explain these remarkable records? Are we to 
assume that we are dealing with an instance of complete heart- 
block with idio-ventricular rhythm, or are we to fancy that the 
stimulus for each contraction has developed at the normal point 
and that we have before us an example of simultaneous slowing of 
all chambers of the heart with an auriculo-ventricular conduction 
time amounting in some instances nearly, if not actually, to one 
second, and with a P-R interval which averages between 0.6 and 
and 0.8 second? 
In favor of the former assumption we might regard the rate of 
the heart, 29 to 35 to the minute, almost exactly that of ordinary 
idio-ventricular rhythm, as well as the circumstance that in lead II 
of the electrocardiogram where, at one point, two atypical auricular 
complexes occur, the ventricular rhythm remains essentially un- 
altered. But strongly against such an explanation seems to me the 
circumstance that in a series of tracings taken at an interval of 
five weeks, the relations of auricular and ventricular contractions 
remain almost the same. It is hardly conceivable that at such 
varying periods of time, and in so many tracings, the relation in 6 
THAYER: THE ADAMS-STOKES SYNDROME 
and c waves and the P and R complexes should have been so 
time between the a constant unless auricular and ventricular action 
were controlled by common stimuli. 
Another argument in favor of this assumption would seem to be 
the character of the R wave in the electrocardiogram. This does 
not present the diphasic excursions commonly seen with idio- 
ventricular rhythm, but has rather more the appearance of a com- 
plex dependent upon a stimulus carried from above along the bundle. 
How may one explain the events on lead II of the electrocardio- 
gram? 
The first inverted P complex (w) is probably an auricular extra 
systole. 
How are we to explain the abnormal complexes associated with 
the following P and R elevations? It would not seem probable 
that a P-R interval so short as 0.23 second could represent a true 
conduction time when throughout the rest of the film the P-R 
interval is never shorter than 0.64 second, unless it be that we 
fancy that the P elevation here is an extra systole arising in the node 
or bundle. In extra systoles arising in junctional tissues, the P and 
R elevations are usually, it is true, much more closely associated. 
But might not the delay in this instance reasonably be explained by 
the anomalous conditions which are accountable for the remark- 
able length of the P-R interval during the regular cardiac action? 
The suggestion that the P wave at x is an extra systole is supported 
by the slight variation in its complex, which has already been 
mentioned. 
Following this extra systole, the next regular stimulus, represented 
by the P elevation at z, occurring after a shorter period than usual 
and meeting with an exhausted bundle, is followed by an unusually 
long P-R interval-0.88 seconds. 
The variation in the R complex at y suggests, however, another 
possible explanation. Might it not be that this complex represents 
an idio-ventricular contraction quite unassociated with the impulse 
responsible for the preceding P. The sequence of events then might 
be as follows: A precocious auricular systole at w in a heart in 
which, owing to disease of the bundle, the P-R time is greatly 
delayed, finds the bundle refractory and is blocked. At x there Plate V.-Mrs. X. 3/vi/13. Lead, III. Pulse, 35.5. P-R period, 0.69 sec. 
Plate VII.-Mrs. X. 3/vi/10. Pulse, 28.8. a-c time, 0.886 sec. 
Plate VIII.-S. 22/x/10. Pulse, 31.7. a-c time, 0.21 sec. 
Plate IX.-S. 22/x/13. After exercise. Rate, 43.2. a-c time, 0.19+ sec. 
Plate X.-S. 22/x/10. Continuation of tracing IX after a short pause to read just receiving cup over jugular. Rate, 31.8. a-c time, 0.19+ sec. 
Plate XI.-S. 25/x/10. Exercise. Rate, 49.3. a-c time, 0.2+. 
Plate XIII.-S. 27/x/10. After atropine, 0.002 (gr. 3^). Rate, 57.6. 
Plate XII.-S. 27/x/10. Before administration of atropine. Rate, 39.2. a-c time, 0.19 sec. THAYER: THE ADAMS-STOKES SYNDROME 
7 
occurs a second auricular contraction at a period fully 0.4 second 
later than that at which the regular auricular contraction should 
have occurred. Owing, however, to the long-continued bradycardia 
at a rate close to that of ordinary idio-ventricular rhythm, the heart 
is continually on the threshold, as it were, of idio-ventricular im- 
pulse formation. And indeed, after a delay slightly longer than 
usual such an idio-ventricular contraction occurs at y, at a period 
considerably in advanced of the time when the stimulus responsible 
for the auricular contraction at x might have been expected to call 
forth a ventricular response. 
An exceptionally interesting feature of these tracings is the great 
prolongation of the As-Vs interval in the last tracing in which 
the average a-c period was 0.886. On the whole we see a gradual 
slowing of the pulse from beginning to end of the records taken on 
the 3d of June, a diminution in the rate from 35.9 to the minute 
at the beginning of the electrocardiographic records to 28.8 to the 
minute in the one successful tracing which was obtained with the 
Verdin instrument; this course of events suggests the possibility 
that physical exhaustion may have resulted in slowing of the cardiac 
rhythm and delay in the conduction time. 
I have, unfortunately, been unable to see the patient since June, 1913. 
In July of that year she had two attacks of vertigo with unconsciousness 
and convulsions lasting several minutes. At the time of the attack the 
pulse was slow and irregular; immediately afterward it varied from 
28 to 50. Dr. Hardin writes me: " In June, 1914, she had three more severe 
convulsions; one at three o'clock in the morning, another six hours later 
and another early the following morning. Following these convulsions 
there was continuous and violent vertigo, markedly increased by raising 
her head from the pillow, and lasting for eight days. 
The next and last attack was on the 17th of February, 1915, when she 
fell in her bath-room and was unconscious for some time following. I 
have never seen her in one of these convulsions and have been unable to 
secure any definite data from any of those who have witnessed the attacks. 
Her pulse has varied from 28 to 44, when we have seen her during the past 
winter and she complains almost continually of mild vertigo and a sense of 
confusion and uncertainty in her head." 
We have waited nearly two years before presenting these records 
in the hope that it might be possible to continue our observations. 8 
THAYER: THE ADAMS-STOKES SYNDROME 
Unfortunately, the patient's family have consistently refused to 
allow further polygraphic or electrocardiographic studies. 
It was early felt that it might be well to try the effect of large 
doses of atropine, but unfortunately the patient shows an unusual 
idiosyncrasy toward the drug. Dr. Hardin writes, "The minutest 
dose poisons at once. I have tried it several times when she is 
unsuspecting. I have seen of a grain (0.00013) of atropine 
and also 1 drop of the tincture of belladonna flush her face and 
dilate the pupils so that she cannot see at all, produce great restless- 
ness, insomnia and excitement for hours and hours." 
Clinically, the course of events was typically that of an Adams- 
Stokes syndrome, and it would seem from the history as if at the 
time of the syncopal and convulsive attacks, there may well have 
been long intermissions in the pulse. On the two occasions in which 
we have been able to study the patient, however, there has been no 
actual auriculo-ventricular dissociation, but a slowing of both 
auricles and ventricles to a rate of from 28 to 35, about that of the 
ordinary idio-ventricular rhythm, with a great prolongation of the 
As-Js interval. The remarkable As-Vs interval, as well as the 
rate of the pulse might lead one to suspect a true dissociation, and 
the circumstance that in lead II of the electrocardiogram, despite 
irregular auricular contractions at one point, the ventricle continues 
its regular rate, might support such an hypothesis. 
On the other hand, the constancy of the As and Us relations, 
which remained unchanged for an interval of five weeks, would be 
almost inexplicable unless we assume that the contractions of both 
chambers are governed by a common impulse. Again, the R com- 
plexes are of such a character as to lead one to believe that they are 
dependent on a supra-ventricular stimulus. The one serious objec- 
tion to this assumption, that based upon the regularity of the 
ventricular rate at the time of the auricular extra-systoles in lead 
II of the electrocardiogram, would not seem to be serious if we 
regard the ventricular complex at y as a single idio-ventricular con- 
traction arising, after a very slight delay, in a heart muscle the rate 
of contraction of which has been for a long time so slow that it has 
been continually on the threshold of idio-ventricular stimulus for- 
mation-an hypothesis which is supported by the character of the 
complex. THAYER: THE ADAMS-STOKES SYNDROME 
9 
The unprecedented length of the As-Vs interval-a-c periods 
averaging over 0.7 second and reaching at some points nearly, 
if not quite, one second in duration-P-R intervals often exceed- 
ing 0.7 second-can hardly be used as an argument against 
our interpretation of the manifestations. For although we are 
unaware that As-Vs periods so long as this have previously been 
observed, yet Griffith and Cohn,1 and Peabody and the author2 
have recorded instances in which the a-c interval has amounted to 
from 0.5 to 0.6 second. 
What may be the pathological basis for such remarkable func- 
tional manifestations? From the data at hand, it is obvious that 
one can but speculate. The great lengthening of the As-Vs inter- 
val and the history of the syncopal and eclamptic manifestations 
would suggest disease of the a-v bundle. But how shall we explain 
the slow auricular rate? Despite the general regularity of the auric- 
ular beats and the persistence of the phenomenon, abnormal vagus 
influences cannot wholly be ruled out. One might fancy that there 
were changes which had resulted in a 2 :1 sino-auricular block, but 
with the information at hand this can only be advanced as an 
hypothesis without supporting evidence. 
Instances of permanent slowing of the auricular action to a rate 
below 40 with regularity are by no means common. Such an 
instance the author had the opportunity to study several years ago. 
X, aged thirty years, a civil engineer, consulted me on the 21st of 
October, 1910, complaining of nausea, dizziness and "sinking spells." 
He had been a rather heavy smoker, consuming as many, sometimes, as 
fifteen cigars a day. He had worked very hard at his profession. He 
had been married four years and had two children. 
He had had no serious illnesses in childhood and had never been subject to 
tonsillitis. As a child he had not been allowed to exercise very vigorously 
because, as he said, he had not "grown up to his heart." At college he 
took up rowing, but was generally taken out of the boat for some reason 
or other before the competitions. He had never suffered from palpitation, 
dyspnoea or coughing. 
1 Remarks on the Study of a Case Showing a Greatly Lengthened a-c Interval 
with Attacks of Partial and Complete Heart Block, with an Investigation of the 
Underlying Pathological Conditions, Quart. Jour. Med., Oxford, 1910, iii, 126-151. 
2 A Study of Two Cases of Adams-Stokes Syndrome with Heart Block, Arch. 
Int. Med., Chicago, 1911, vii. 289-347. 10 
THAYER: THE ADAMS-STOKES SYNDROME 
For five years his physician had noticed that his pulse was slow, ranging 
usually between 44 and 52. Early in May, five months before I saw him, 
while under an unusual stress of work, he had an attack of vertigo on the 
golf links which obliged him to lie down upon the ground. After about 
two minutes he was able to arise and finish the game. A week or two 
later while at dinner there was a similar attack in which he fell forward 
onto the table. This was followed by several like attacks at intervals of 
about ten days, and in the first week in July, he had a very severe 
paroxysm in the street car. The vertigo lasted while the car was passing 
about three blocks; he did not fall from his seat. After these attacks 
he was very weak and felt that he must lie down. 
At the time of the attack in the street car he was seen by an excellent 
physician who found a ventricular rate of 32 to the minute, and what 
appeared to be a double venous impulse in the neck, suggesting a heart- 
block with a 2 : 1 rhythm. He then went to the mountains, spending 
some days at rest. At this time his family physician found his pulse 
from 32 to 36. In twenty-four hours the pulse had risen to 42. A few days 
later, on the 15th of July, he had a nervous attack associated with a sense 
of sinking, feeling very weak, as he expressed it, "as if my blood were all 
going out." His physician states that his pulse was again 32. 
Although there was no history or evidence of lues, he was treated with 
mercury and iodide of potassium with apparent improvement until the 
1st of August, when he had another "sinking spell" which w'as repeated 
again two weeks later. At these times the pulse ranged from 28 to 32. 
The patient suffered also from a feeling of nausea in the morning and felt 
rather dizzy, but w'as inclined himself to feel that his dizziness was nervous. 
From the 15th of August he gradually improved and now, October 21, feels 
perfectly well. 
In my consulting room, the patient appeared a healthy man. Nothing 
abnormal beyond the cardiac conditions was found. The pulse was between 
30 and 35, essentially regular. Now and then a beat occurred at a period 
a little earlier than it might have been expected, but was followed by no 
compensatory pause. Inspection of the neck showed a normal venous 
undulation, all three waves being plainly visible. The patient was a well- 
nourished man over six feet tall. The heart was a little large, the impulse 
easily palpable in the fifth space, 11.5 cm. from the median line, slightly 
within the mamillary line; relative cardiac dulness, 3.3. cm. to the right of 
the mid-sternum. The first sound was prolonged and followed by a slight, 
indefinite systolic murmur, heard in the axilla and rather louder over the 
base; the second sounds were clear and of normal relative intensity. The 
murmur was less intense in the erect posture, and barely audible at the 
apex; not heard in the back. The heart was normally mobile; occasionally, 
as the patient was lying on the left side a third sound could be heard. THAYER: THE ADAMS-STOKES SYNDROME 
11 
Polygraphic tracings with the Mackenzie instrument, showed marked 
bradycardia involving both chambers of the heart; no extra auricular 
beats were to be seen; the a-c time was normal. The patient entered the 
hospital for study. A radiographic examination of the chest revealed 
nothing abnormal. 
The urine and blood showed no abnormalities. The Wassermann 
test gave a negative result. ' Radiographic examination of the chest showed 
nothing unusual. 
While lying quietly in bed the pulse varied in rate from 28 to 35. The 
rhythm, though essentially regular, showed, at times, variations consisting 
of occasional precocious beats suggesting sometimes extra systoles. These 
beats were not, however, followed by compensatory pauses (Plate VII) 
and, on the whole, were suggestive of an ordinary sinus arrhythmia. 
Respiration was associated with the normal changes in rate, and exercise 
and emotion accelerated the pulse in the usual manner, but rarely, if 
ever, to a rate above 50 to the minute. The slight irregularities in rhythm 
were somwhat more evident after exercise. It is not impossible, as sug- 
gested by my colleague, Bridgeman, that this exaggerated irregularity is 
associated with respiration. 
Numerous polygraphic tracings showed little beyond the bradycardia. 
The tracing reproduced in Plate VIII, taken when the patient was at 
rest, shows an essentially regular pulse at the rate of 31.7, with a normal 
a-c-v sequence. The a-c interval is a shade long, 0.21 second. In 
the next tracing taken a little later, after exercise (Plate IX), the rate of 
the heart is 43.2. The a-c interval averages 0.19 second. There is an 
interesting alternation in the length of the intersystolic periods. This 
phenomenon was, however, not observed at any other time in our study 
of the patient. In the following tracing (Plate X) taken after a short 
pause to adjust the receiving cup over the jugular, the pulse has already 
fallen to 31.8 and this alternation is no longer evident, while in later records 
(Plate XI) taken after exercise, no such alternation is seen, although the 
rhythm shows considerable irregularity. 
Atropine 0.0011 (gr. -gg) and 0.0016 (gr. 4^) administered subcutan- 
eously, produced little or no effect on the heart's action. After 0.0022 
(gr. 3jy) the pulse rate increased gradually to 60. A polygraphic tracing 
continued for over half an hour after the injection, showed no abnormali- 
ties (Plates XII, XIII). It was, unfortunately, impossible to obtain elec- 
trocardiographic records as the instrument was out of order. 
Since this period the patient has seemed physically well, but the pulse 
has always remained at a rate between 30 and 40 while at rest. I last 
saw the patient about two years ago as he was about to go upon the table 
for an appendectomy. The pulse at this time was 32, and the venous 
undulation in his neck, perfectly normal. He passed through the operation 12 
THAYER: THE ADAMS-STOKES SYNDROME 
without ill effect. His physician, Dr. E. P. Carter, of Cleveland, who 
has studied the patient carefully and confirmed these observations, writes 
(July, 1915): 
" X is very well, active and busy. His pulse . . . when last taken 
by me in May, was 39 to the minute. Polygraphic records have never 
shown any increase in his a-c interval. . . . He has had no attacks 
of dizziness since you saw him." 
Here then we have the history of an individual, the rate of whose 
cardiac action has apparently diminished gradually through a 
period of years, until five years ago, it reached a permanent rate of 
but little over 30 when at rest, a rate which has been maintained 
since that time. 
At one period, five years ago, after excesses in work and tobacco, 
there were several attacks of vertigo and nausea. The pulse, at these 
times, was a little over 30 and regular. With improvement under 
rest, there was, however, no change in the rate of the heart's action, 
and the pulse remains today when the patient appears to be in 
perfect health, at essentially the same rate. In polygraphic tracings 
the a-c interval is normal and beyond slight sinus irregularities 
in rhythm which are increased on exercise, nothing of note is 
revealed. 
What are we to regard as the cause of the bradycardia? 
It is hardly possible to ascribe it to vagus influences, for experi- 
ment shows that the vagus influences are essentially normal. Res- 
piration is followed by the usual variations in rhythm and atropine 
produces its usual effect proportionately, however, to the initial 
cardiac rate. 
One is hardly justified in the present state of our knowledge, in 
assuming the possibility of a persistent sino-auricular block-an 
hypothesis against which one might advance further the essential 
regularity of the pulse through such long periods of time, as well 
as the gradual increase in rate, without irregularity following atro- 
pine. One would fancy that we are here concerned with an essen- 
tially slow stimulus formation, with a so-called sinus-bradycardia, 
a bradycardia depending on chronotropic influences solely. 
But in what do such influences consist? Is the condition to be 
regarded as pathological or only as anomalous? THAYER: THE ADAMS-STOKES SYNDROME 
13 
These are questions which must be answered by time and by 
further study. 
To what were the phenomena of vertigo and nausea due? 
The physician who observed the patient at the time of these 
attacks was at first under the impression that a wave possibly 
indicating an auricular contraction was to be seen in the jugular 
between each regular beat. 
If this observation was correctly interpreted we must assume that, 
at this time, there was a true heart-block-a 2 :1 rhythm. The 
absence of prolongation of the a-c interval is no proof that such a 
condition may not have existed. One would, however, hardly expect 
vertigo with a regular pulse of 30 and above, unless this slow pulse 
followed suddenly on a rate considerably more rapid-unless, say, 
it were a question of a sudden halving of the pulse rate. May 
this have occurred at the time of these attacks? 
Such an hypothesis might be advanced to explain the phenomena 
observed in this patient. The author has seen a similar sequence 
of events in an individual with chronic myocardial disease, whose 
pulse when at rest, was in the sixties. Any effort, such, for instance, 
as sitting up and down several times in bed, was followed by a slight 
increase in the auricular rate with the dropping out of every other 
ventricular contraction. After a few moments' rest the regular 
As-Vs sequence was resumed. At no time was there any prolonga- 
tion of the a-c interval. 
Experimentally, however, in the present case, it was impossible 
to reproduce any such phenomenon by exercise or atropine, and 
even with vigorous exercise the pulse rate was never observed at a 
point above sixty. 
It is a question whether the apparent double auricular impulse 
in the jugular may not, perhaps, have been simulated by the large 
and very evident r wave; indeed, such now is the opinion of his 
physician who has had the patient constantly under observation. 
On the whole the writer is inclined to agree with him and to doubt 
whether any actual auriculo-ventricular dissociation has ever 
occurred in this patient. He is disposed to regard the vertigo and 
nausea as the results of a generally overwrought mental and physical 14 
THAYER: THE ADAMS-STOKES SYNDROME 
state in an individual who might well be predisposed to such symp- 
toms because of his anomalously slow heart action. 
To what this remarkable bradycardia may be ascribed is a 
question which, as has been said, cannot definitely be answered. 
The phenomena observed in this patient are similar to those 
described in Mrs. X., mainly, in that in both there is a striking 
bradycardia involving both chambers of the heart. 
In the former patient (Mrs. X.) both the history and the results 
of physical examination revealed evidences of grave disease of 
the a-v bundle-Adams-Stokes syndrome with extreme slowing 
and irregularity of the pulse; remarkable prolongation of the 
As-Vs period. In the second patient, however, there was no 
lengthening of the As-Vs interval and, despite the history of 
vertigo and nausea, there was no convincing evidence that auriculo- 
ventricular dissociation had ever occurred. Indeed the symptoms 
pointed, rather, to an unexplained sinus-bradycardia. 
Summary. The history is presented of a woman who, for two 
years and a half, has had occasional syncopal and eclamptic attacks 
with extreme bradycardia. 
Between these periods the pulse is regular, averaging (in rate) 
but little over 30 to the minute. 
Polygraphic and electrocardiographic study reveals a syncron- 
ous slowing of both auricles and ventricles with prolongation of 
the As-Vs interval to a period longer than has hitherto been re- 
ported. In polygraphic tracings the a-c interval amounts to from 
0.7 to 1 second; in electrocardiograms the P-R time is often over 
0.7 second. 
The history of syncopal and eclamptic attacks with great slowing 
and irregularity of the pulse, as well as the prolonged As-Vs interval 
observed in our studies, justify a diagnosis of disease of the auriculo- 
ventricular bundle. The cause of the auricular bradycardia which 
would appear to depend on an essential anomaly of impulse for- 
mation, is not clear. 
A second case of apparently essential sinus-bradycardia is 
reported. 
This subject is a seemingly healthy man now thirty-five years of 
of age. The heart rate for at least five years, has been between 30 THAYER: THE ADAMS-STOKES SYNDROME 
15 
and 40 when the patient is at rest. There is no prolongation of the 
As-Vs interval. Exercise, deep breathing, atropine have their 
usual effects on the heart's rhythm and rate, but proportionately to 
the initial cardiac rate. 
Attacks of vertigo and nausea occurred five years ago, but there 
is no evidence that these were associated with auriculo-ventricular 
dissociation. The patient remains in apparently good health despite 
his persistent bradycardia. 
Note.-I am indebted to my friend Dr. Bond, of Indianapolis, 
for the electrocardiograms in Case I. Dr. Thayer : May I first add a word about one phase of 
Dr. Trudeau's activities which has always impressed me deeply ? 
Dr. James has spoken of his diagnostic and prognostic abili- 
ties. These he used for years with wisdom and skill in deter- 
mining just who, among the many patients who presented 
themselves as applicants for admission to the sanitarium, were 
most likely to be benefited by the advantages which it offered. 
As he has said himself, this was not an easy task; it was one in 
the exercise of which he was often criticised; but it was pre- 
cisely those patients in whom the process was at its earliest 
stages, to whom the sanitarium was especially likely to give 
that help which might turn the scale. From this standpoint 
Dr. Trudeau exercised remarkable ability and discrimination. 
But often he went farther and exercised an insight and a 
charity so exquisite that those of us who have experienced it 
can never forget. He knew not only how to choose those whose 
lives were most likely to be saved; he knew how to choose those 
whose lives were most worth saving. 
Some of us have had the experience of sending to him 
patients whose symptoms were not so favorable as, under ordi- 
nary circumstances, to justify admission to the sanitarium, yet 
patients whose character and circumstances were such as to 
appeal to us with peculiar force. We have sent him such 
patients without, perhaps, even a suggestion that they be 
admitted to the sanitarium. How quickly under these circum- 
stances did his clear eye and his generous heart detect the great 
opportunity! 
He who has seen the group of men and women gathered in 
that sanitarium can hardly have failed to realize that this 
was no ordinary collection of individuals, but a body of the 
elect. How many to whom all doors of hope seemed closed are 
now living happy and useful lives, thanks to the skill and 
insight and charity of this great and good man. 
Those who knew Dr. Trudeau in his latter years were more 
and more impressed with the beauty of his face. It was not 
the beauty of line or of color such as one sees in the young, 
but a beauty brought out by crease and furrow and hollow, 
that beauty which character brings to age. Bradford tells of a 
well-known statesman that when spoken to of a certain man, 
he exclaimed: " 1 do not like him. I do not like his face." " That is not his fault," said his friend, " he's not responsible 
for his face." " Yes," he replied, " every man over fifty is 
responsible for his face." I have thought of that remark when 
looking into Dr. Trudeau's face. It was a wonderful face 
with a singular beauty and depth of expression. In the later 
days when sorrow and illness had settled upon him, it seemed 
sometimes as if the body had almost gone, as if nothing re- 
mained but the spirit which glowed in the light that shone 
from his eyes. The body has gone now, but the spirit remains, 
burning in the hearts of thousands of men and women whom he 
has taught to live, animating that fine body of students who are 
carrying on his great work at Saranac and handed on by them 
to us to-night. 
We can hardly express deeply enough our gratitude to Dr. 
James and to Dr. Baldwin and to Dr. Thomas for what they 
have said to us. This is an evening that we shall all remember. [Reprinted from Science, N. S., Vol. XLIIL, No. 
1116, Pages 691-705, May 19, 1916] 
TEACHING AND PRACTICE1 
It would be impossible to address this 
congress without a word of affectionate trib- 
ute to the memory of three great men who 
have presided over these meetings in years 
that have passed, figures, alas, that we shall 
not see again. 
Fitz, the patient, discriminating student, 
the wise, inspiring teacher, whose keen eye 
and orderly mind shed light upon obscure 
corners of the art of medicine; Mitchell, the 
poet, the brilliant physiologist, the acute 
and sympathetic reader of men's minds, the 
great practitioner; Trudeau, the optimist 
who, in his long journey through the 
"valley of the shadow of death," led so 
great an army of sufferers to the land of 
light. 'Tis a heavy loss. But what a varied 
and lasting inspiration the lives of these 
men have left for us and for the world! 
In the last several years, especially 
through the activities of the American Med- 
ical Association, the Carnegie Institution 
and the General Education Board, questions 
relating to medical education have been dis- 
cussed very actively in America, and the 
changes and improvements in our methods 
of teaching and in the character and train- 
ing of those who teach have been greater 
probably than in any other like period in 
the history of American medicine. 
i Address of the president of the Congress of 
American Physicians and Surgeons delivered at 
Washington on May 9. 2 
The relations between teaching and prac- 
tice in hospital and in university have of 
late been the subject of especially vigorous 
controversy in this as in other countries. 
To one who for five and twenty years has 
been engaged with more or less activity in 
the practice as well as in the teaching of 
medicine, who has been associated with two 
universities in which interesting experi- 
ments in medical education are now in prog- 
ress, these discussions have been of absorb- 
ing interest. 
With all the divergences of opinion and 
amid all the heat of' discussion the goal 
aimed at is almost universally the same. It 
is our desire that the hospital, the school of 
medicine and the teaching staff shall be so 
organized that the ultimate service to 
humanity may be the largest; that we may 
gain greater knowledge of disease; that we 
may acquire more efficient means, public 
and private, of recognition, prevention and 
alleviation of the innumerable ills to which 
the human race and its inarticulate com- 
panions and servants are heir: that we may 
become more efficient in the care of our pa- 
tients ; that we may train better physicians. 
These are the main ends of the study of 
medicine. It has seemed to me well to de- 
vote this hour to a discussion of some of the 
phases of the relations between practice and 
teaching. 
In the early days, the study of medicine 
in this country was begun in the office of 
the practising physician. By and by there 
developed schools of medicine in which the 
teachers were successful practitioners. The 
first of these schools were associated with 
hospitals, and although the body of teach- 
ers was not large, yet John Morgan in his 3 
famous address on medical schools, early 
pointed out the necessity that special 
branches of medicine should be taught by 
men who had given their greater attention 
to these branches in practice. The pro- 
fessors of medicine and of surgery who bore 
the brunt of the teaching and directed their 
departments were usually busy men much 
sought for by the public in their commu- 
nity; and the teaching in the old days con- 
sisted largely of didactic lectures, with but 
limited demonstrations. Only thirty years 
ago, at the time when I was a student of 
medicine, the duties of the professor of 
theory and practice consisted solely in the 
delivery of several didactic lectures a week; 
those of the professor of clinical medicine 
consisted in the giving of two demonstrative 
clinics and one clinical conference. An 
assistant professor held one recitation a 
week. An occasional ward visit was given 
in one or another of the large hospitals, but 
these opportunities were improved by but 
a small proportion of the students. Phys- 
ical diagnosis was taught during the second 
year to a class of about ninety by three in- 
structors in several hourly exercises a week 
in sections of 20-30. This constituted the 
work of the department of medicine. 
The direction of such a department was 
properly confided to a distinguished prac- 
titioner, a man of wide experience; and its 
management involved demands upon his 
time no greater than were compatible with 
the suitable performance of his hospital and 
private duties. 
In such a school of medicine the clinical 
instruction of a single medical department 
or unit could be, and often was, carried out 
in a variety of hospitals-those hospitals 4 
with which the professors of medicine had 
the good fortune to be connected. The only- 
association between the university and the 
hospitals was, in many instances, an amica- 
ble agreement on the part of the latter to 
allow instruction in the out-patient de- 
partments, through public clinics in amphi- 
theatre and operating room, and to a cer- 
tain limited extent in the wards. There 
were no university laboratories connected 
with the hospital. University laboratories 
existed at another centre which might or 
might not be near, or at a considerable dis- 
tance from the hospital. These laboratories 
depended in large part upon the hospital 
for their material, but did not often, except- 
ing through the good will of the clinician 
and pathologist, control the supply; and, 
excepting to a very limited extent, the labo- 
ratories at the school rendered no especial 
service to the hospital. 
In such a school of medicine a hospital 
was an accessory, a very close and valuable 
accessory to be sure, but yet an accessory to 
the department of medicine. And in dis- 
cussing matters of medical education the 
hospital and the medical department of the 
university might be considered separately. 
To-day the hospital must be considered 
not as an accessory to the department of 
medicine, but as its vital centre. One can 
scarcely conceive of a school of medicine 
wholly independent of its hospital. The 
laboratories for the study of the chemical 
and anatomical and physiological phenom- 
ena of disease can not well exist at a centre 
removed from the hospital, or under the 
control of individuals other than those di- 
rectly associated with the hospital manage- 
ment. On the other hand, the hospital in 5 
many instances has come to depend largely 
on the cooperation of the university in the 
performing of some of its most essential 
functions. Professors, assistants, under- 
graduate students all go to form a corps of 
hospital servants invaluable to the institu- 
tion. In a word, the relations between hos- 
pital and school of medicine are so close 
and intimate to-day that a discussion of the 
organization of a medical or surgical clinic, 
or of a department of pathological anatomy, 
presupposes the assumption that hospital 
and university be under one management or 
in such close affiliation as to form a single 
working body. For the ends aimed at by 
both hospital and school of medicine are 
closely related. The main, specific purpose 
of the hospital is the care of the sick; that 
of the school is the training of physicians. 
The care of the sick can be carried out best 
through the employment of physicians of 
the highest order, and for these the hospital 
turns to the school. But to offer the stu- 
dent the best possible training the school 
must have opportunities for the study of 
disease and of pathological material, and 
for these opportunities it turns to the hos- 
pital. The delicacy and complication of 
modern methods of chemical and physical 
diagnosis demand laboratories and labo- 
ratory equipment which involve consider- 
able and steadily increasing financial out- 
lay ; they call, moreover, for students of the 
best chemical and physical training to pre- 
side over these laboratories. This has 
brought it about that general hospitals 
which are not integral parts of a univer- 
sity must turn to universities for assistance, 
or spend, for the installation of independent 
laboratories and apparatus and for the em- 6 
ployment of salaried heads of these depart- 
ments, a sum of money which to many insti- 
tutions is almost overwhelming. The uni- 
versity laboratories of bacteriology, serol- 
ogy, physiological chemistry and so forth 
where studies which are, in many instances, 
most practical, are to be made, should be 
in or adjoining a hospital. Thus the econ- 
omy and mutual advantages of cooperation 
are clearly apparent. And more than this, 
in the true university hospital which is cen- 
trally situated, a community of interest is 
constantly drawing together the clinical and 
so-called scientific departments. This is 
particularly true of the departments of 
physiology, physiological chemistry and 
pharmacology-and to the great mutual ad- 
vantage of hospital and of university. 
To-day in the better equipped and organ- 
ized institutions there is in ward and labo- 
ratory, in hospital and school a common 
effort to contribute to the advance of the 
science and art of medicine in its broadest 
sense. Both hospital and school are centres 
of original research. However cordial and 
however free a cooperation there may be 
between the university and hospitals situ- 
ated at a distance from the central plant, 
one must acknowledge the necessity to a 
modern medical school of one central hos- 
pital. And so it has come about that any 
discussion of the organization of a modern 
medical clinic presupposes that which, for 
purposes of illustration, may be called a 
''university hospital" as its centre, and 
calls for a consideration of certain hospital 
arrangements as an integral part of the 
problem. Such a hospital should be organ- 
ized upon a basis entirely different from 
that which used to prevail and still exists in 7 
many institutions. The medical clinic or 
the surgical clinic, if it is to do its full duty 
to the public, to the hospital and to the 
school should be a well-organized unit under 
the control of a single director and a corps 
of associates and assistants. And of this 
corps of associates and assistants, some at 
least, preferably a considerable number, 
should be salaried men, who are required to 
give a large part of their time to their hos- 
pital and university work. All of these 
men should be members of the teaching 
staff of the university. Only in a clinic 
organized on some such permanent plan can 
constructive research be carried out or sys- 
tematic instruction given. The old-fash- 
ioned rotating service is incompatible with 
the ideals of a modern hospital or univer- 
sity. 
According to the size of the institution 
one or more such clinics may exist, and 
there is no reason why, in a large hospital, 
there might not be two or more separate 
clinics, or why in a given university there 
might not be several more or less independ- 
ent professorships of medicine with clinics 
at different hospitals, if the means were 
forthcoming to supply the necessary mate- 
rial for the full organization of such clinics. 
But to return again to the organization 
and constitution of a single department of 
medicine as compared with that of thirty 
years ago. The changes in the method of 
teaching clinical medicine have been great. 
Demonstrative clinical lectures remain an 
important element of medical teaching. 
But the place of the didactic lecture has 
largely been taken by practical instruction 
before small groups at the bedside. This 
involves a considerable increase in the 8 
teaching staff and increases greatly the 
amount of time which the teacher must give 
to his work. Thirty years ago the pro- 
fessor of medicine may have been expected 
to give two or three hours a week to his 
classes. To-day he could hardly be expected 
to devote less than six or eight hours to per- 
sonal teaching. The problems of the teach- 
ing of physical diagnosis in its restricted 
sense are not so different from those of 
thirty years ago; but to-day it is generally 
recognized that the university should offer 
the student far more individual practical 
training than he used to receive. In the old 
days, three men, let us say, were entrusted 
with the teaching of a class of ninety; to- 
day the work would be distributed among 
six or eight at least. 
Thirty years ago there was no such thing 
as a clinical laboratory, and clinical micros- 
copy and chemistry were not taught in the 
medical department. Indeed, there were no 
special medical laboratories. To-day a mod- 
ern medical clinic must, in the first place, 
control a clinical laboratory presided over 
by men who are called upon to give a con- 
siderable portion of their time to the train- 
ing of the student in a large variety of 
methods of examination of secreta, excreta 
and body fluids; and this laboratory should 
also be a centre for scientific research. 
Thirty years ago it was easy for one man to 
preside over the entire department of medi- 
cine and to conduct his practice as well. It 
is extremely difficult, if not impossible, for 
a practitioner to preside over the clinical 
laboratory to-day, and at the same time to 
do justice to his responsibilities as a physi- 
cian. 
Chemistry as related to the practice of 9 
medicine thirty years ago played a rela- 
tively small part in the medical curriculum. 
It was mainly restricted to its application 
to the study of urine, and those studies were 
for the most part of a simple character. 
To-day the chemical problems involved in 
the studies of human metabolism and used 
in the art of diagnosis are numerous and 
complicated, and are steadily increasing. 
No well-equipped medical clinic can exist 
without a department of chemistry, which 
should be presided over by a man of train- 
ing and experience, capable of conducting 
and directing research and of overlooking 
the necessary studies of a variety of prob- 
lems which arise in the wards of the hos- 
pital, for, as has been pointed out, no school 
of medicine can fulfil its mission to-day 
without intimate association with an ade- 
quate hospital. It is not easily conceivable 
that the director of the chemical laboratory 
could find time for medical activities out- 
side the clinic. 
The older methods of physical examina- 
tion, so called, although mastered only by 
practice and experience, were yet mechan- 
ically simple. To-day, however, for the ex- 
ploration of the human body and its activ- 
ities, there are employed physical proce- 
dures which involve the use of instruments 
of great delicacy and demand a highly 
specialized technique. And sub-depart- 
ments of radiology and electrocardiography 
each >with its laboratory and its director, 
are necessary constituents of the modern 
department of medicine. 
The medical clinic should also have a spe- 
cial department of bacteriology and serol- 
ogy, another sub-department the direction 
of which demands much of the time of an 10 
experienced student. Of these laboratories 
also the director should be one who is able 
to organize, conduct and stimulate research. 
Again, there should be in association with 
every medical clinic a department of phys- 
ical therapy for the study and application 
of mechanical, hydro- and electro-thera- 
peutical methods; and especially for the 
teaching of massage and of general physical 
training. Such a department might, it is 
true, be under the combined control of affili- 
ated medical and surgical clinics, but some 
of the responsibility for its organization and 
direction should lie with the chief of the 
medical service. 
It has been said that the directors of these 
sub-departments could hardly be expected 
to give any essential part of their time to 
the practice of medicine. Are they therefore 
wholly to be removed from the care of the 
sick? Is the department of medicine to 
have under its control a number of subde- 
partments presided over by so-called 
"pure" bacteriologists, physiologists, phys- 
icists, chemists-men who are entirely re- 
moved from direct responsibility for the 
care of the sick? Far from it. 
In the ideally arranged department of 
medicine, all of these men should have 
clinical duties and responsibilities-duties 
and responsibilities which, in a hospital, 
may be systematized. And in the properly 
organized department of medicine, although 
many of its members may in a sense be 
specialists, yet none will fail to acquire a 
wide general medical experience. 
Let us now for a minute reconsider the 
problems which confront the director of a 
department of medicine to-day. The 
teacher of thirty years ago followed a rela- 11 
tively simple routine. The chief of a mod- 
ern medical clinic finds himself the head of 
a complicated machine, involving the ap- 
pointment of a large number of salaried as- 
sistants, the manipulation of a consider- 
able budget, which alas! under present cir- 
cumstances, rarely meets the demands of 
the situation, the coordination of a large 
staff of trained workers in clinical, chem- 
ical, physical, bacteriological, serological 
and physiological departments, and the or- 
ganization of a system of group teaching to 
which he must himself devote a very con- 
siderable amount of his time. It is evident 
that the director of such a department 
should be a man who has had a rather 
broad training, who shall have had a basis 
of chemical instruction such as was im- 
possible thirty years ago, and shall have 
spent a sufficient amount of time in work in 
each of the branches represented by the 
sub-departments of his clinic to enable him 
at least to comprehend the significance of 
the work which is there being done, and 
to carry out real supervision. 
Time was when the teaching of medicine 
was, in great extent, a matter of authority. 
The student was led to accept precepts 
enounced ex cathedra. To-day the teaching 
of medicine is largely a matter of demon- 
stration, of example, of practice. The stu- 
dent is inclined rather to distrust precept 
for which proof is not adduced; he is offered 
opportunities to study the symptoms of dis- 
ease and its treatment by the bedside, and 
is instructed in methods by which he may 
control and confirm so far as may be, the 
assertions which he may read in the book or 
hear from the lips of the instructor. The 12 
method of authority has given way to the 
method of observation and inquiry. 
Who should preside over such a clinic as 
this ? Who is the ideal director of the mod- 
ern medical department ? Thirty years ago 
the professor of medicine was properly he 
who had obtained the greatest reputation as 
practitioner or consultant. This reputa- 
tion was often not attained before the age 
of fifty, and was gained through the active 
practice of the art. Such a man, who with 
years, might or might not have attained 
financial ease, might suitably, in these days, 
have been called upon, at a nominal salary, 
to direct a department and to give the two 
or three hours a week which were the sum 
total of the time exacted by the teaching 
duties of the professor. 
But to-day it would be extremely diffi- 
cult, nay, it would be almost impossible, for 
a man with a considerable consulting prac- 
tice to organize and direct a medical clinic, 
such as that which I have outlined, and, in 
addition, to do the amount of personal teach- 
ing which would be necessary. The prac- 
titioner, even if he be purely a consultant, 
is not master of his own time. He may 
limit his consultations to special hours, but 
he can not cut off the increasing calls which 
appeal to his sympathy and come at any 
moment. And even if he see ever so few 
patients, he can not control the complicating 
side-questions to which relations with any 
one ill human being are too apt to give rise. 
With the consultant as with the practi- 
tioner sensu stricto the human influence is 
the most important element in his work. 
The preliminary conferences indispensable 
for the establishment of the necessary rela- 
tions of sympathy between physician and 13 
patient, the interminable confidences of the 
nervous invalid, the unravelling of the 
tangled mental complexes of the psycho- 
neurotic sufferer, the heart to heart talks, 
the breaking of sad news, the straightening 
out of the many complications which so com- 
monly arise in connection with grave ill- 
ness, the letters to physician and family, 
the interviews with friends and relatives 
-these, as the consultant well knows, are 
the duties that consume his time; but they 
are necessary and essential parts of his 
work. It is not the actual time that the 
physician spends in the study of his patient 
■-that is often the smaller part of it. It is 
the accessory duties that render it impossi- 
ble for such a man properly to combine 
active consulting practice with the responsi- 
bilities of the directorship of a large mod- 
ern clinic. 
To accept such a position would necessi- 
tate the abandonment of a large part of that 
physician's practice; this would mean the 
loss of the main source of his income, un- 
less he were a man of independent means. 
If then the professor of medicine in a mod- 
ern university is to be chosen from the ranks 
of those men who have acquired great ex- 
perience through professional success, it 
will be necessary either that the university 
shall pay a very considerable salary, or 
that the professor shall be a man of inde- 
pendent means. Such a salary, unfortu- 
nately, if men of this class are to be ob- 
tained, would have to be quite beyond any- 
thing that is at present possible in most 
universities. The successful consultant is 
usually put to considerable expense for the 
maintenance of the machinery necessary for 
his work, and in many instances comes to 14 
maintain a sort of existence which involves 
large financial responsibilities. However 
much such a man might desire to avail him- 
self of the fascinating opportunities offered 
by the directorship of a large medical clinic, 
it is too commonly the case that, by the time 
he has well entered upon his fifth decade he 
has already assumed responsibilities toward 
others which make it impossible for him 
rightly to abandon the sources of his in- 
come. But this, it seems to me, is not the 
essential feature of the situation. Is the 
physician who through years of practise has 
become the successful consultant, the man 
who is best fitted to direct a large depart- 
ment of medicine or surgery ? By no means 
always. Indeed, in the majority of in- 
stances, it is another course of life which 
should best fit a man for a university pro- 
fessorship. 
There has arisen gradually in this coun- 
try a new class of consulting physician, the 
man who has deliberately planned his career 
from the outset, who has sought through 
long years of study in hospital and in labo- 
ratory, in association with large clinics, to 
gain in a concentrated fashion, as it were, 
that experience which may make his clinical 
opinion, both from a diagnostic and thera- 
peutic standpoint, most valuable. Long- 
continued service in institutions in which 
proper opportunities for study and research 
are offered, is giving to the public to-day a 
number of men who, while thoroughly 
trained and practised in modern methods of 
diagnosis and treatment, have accumulated, 
at a relatively early age, a store of actual 
clinical experience such as is acquired in 
independent practice only after a much 
greater time and, in the majority of cases, 15 
with a loss of touch with some of the more 
recent advances in medical science. These 
men, the products of intelligent methods of 
hospital management and organization, are 
as a rule soon called on by their colleagues 
in more active practice for advice and as- 
sistance as general consultants. Men who 
have pursued such a career, which has in- 
evitably involved at the outset a consider- 
able financial sacrifice, are usually men of 
scholarly tastes who keep in touch with 
laboratories in which they may continue re- 
search and cooperate with their colleagues 
in practice in the study of the nature and 
treatment of diseases. It is from this class 
of men that the professorships of medicine 
are more and more likely to be filled. Such 
a man may well enter upon a professorship 
by the time, or even before, he is forty years 
of age. 
This leads us directly to one of the ques- 
tions which has been most actively discussed 
of recent years: Is a man who has obtained 
his clinical experience largely or purely in 
hospitals properly fittted to teach students 
the essentials of the practice of medicine ? 
A distinguished student of the problems 
of medical education has been quoted as 
saying essentially: "Diseases are the same 
in the rich and in the poor, in human beings 
and in animals. To the clinician the ward 
is his laboratory, and the study of disease 
in the patient in the ward is, in all essen- 
tials, the same as the study of disease 
in the animal in a laboratory. The only 
difference between the study of disease in 
hospital and outside is that in the hospital 
the patient may better be observed. It is a 
mistake to say that it is necessary for a pro- 
fessor of medicine to have had experience 16 
in private practise when the same experi- 
ence may be obtained more intelligently and 
in a much more concentrated form in the 
hospital." 
This conception which has. by some, been 
regarded as characteristic of the point of 
view of those who have favored the estab- 
lishment of professorships of medicine on 
the so-called "full time" basis, has been 
looked upon as fallacious and dangerous by 
many of the opponents of certain modern 
tendencies in medical education. 
"No man," they say, "is fit to teach 
students the art of the practice of medicine 
w'ho has not himself passed through the ex- 
periences of the practitioner. Practice in 
a hospital ward is one thing; practice in the 
home of the patient, another. He who has 
been accustomed to rely on the trained 
nurse and on the many appliances and in- 
struments of precision which a well- 
appointed hospital affords, can have little 
conception of the difficulties which he will 
encounter in private practice. He whose 
only experience has been with the trusting, 
unresisting patient in the general wards, 
will find himself at sea when treating the 
whimsical, critical, prejudiced, opinionated 
invalid in private life. He who has been 
accustomed largely to study serious dis- 
eases in the wards of the hospital will have 
small sympathy with, and little understand- 
ing of the trivial complaints of the super- 
sensitive and nervous members of the more 
well-to-do classes. The conditions that he is 
called upon to treat are to be remedied in 
great part by minor regulations of habits 
and manner of life, of eating and drinking 
and smoking and exercise. His main duties 
consist in ministering to the minds of his 17 
patients-in kindly counsel and encourage- 
ment-in advice tending toward the allevia- 
tion of a thousand petty ills which he who 
knows that they will pass with time, does 
not even consider in himself-which the 
less sensitive patient in the ward barely 
notices. How can one who has never had 
this experience teach students the art of 
practice? Is it not folly to take away the 
teaching of medicine from the experienced 
practitioner and to give it to one who has 
had a training which might almost be called 
academic ? Must we not regard this idea as 
the dream of the layman and of the labo- 
ratory student who, with all his scientific 
attainments, is yet wofully ignorant of the 
conditions of the doctor's life and of his 
duties ? ' ' 
There is much truth in these objections. 
I should have no hesitation in agreeing that 
the medical experience suitable to qualify a 
physician as a consultant or a teacher of 
medicine can not well be obtained wholly 
in the free wards of a hospital. There is a 
great difference between the mental work- 
ings of the patient in the free ward and 
those of the average individual with whom 
one is thrown in private practice. The 
stolid indifference to outside influences 
shown by many patients in the general 
wards renders the study of disease in hos- 
pital not so very different, it is true, from 
the study of disease in the laboratory, but 
so soon as one becomes associated with pa- 
tients of a higher mental order, problems in 
diagnosis and in treatment arise which are 
much more difficult and complicated. It is, 
it seems to me, not easily possible for one 
who wishes to fit himself for practice as a 
consultant or for the teaching of medicine 18 
to gain that experience which he should 
have without a considerable association with 
individuals of more complicated mental con- 
stitution. Moreover, there are certain dis- 
eases which, strangely enough, are rarely 
seen in the free wards, yet are common in 
outside practice, diseases the recognition 
and management of which are of the utmost 
importance. I need refer only to angina 
pectoris. A man who is not familiar with 
the mental attitude of the people among 
whom he or his students are going to be 
thrown, who has not learned by experience 
successfully to navigate his bark through 
the mist of accessory problems which befog 
the antichambers of the sick room, is un- 
able to give to the student much that will be 
of real value in the practice of medicine. 
But fortunately in many hospitals to-day, 
the great development of private wards 
offers abundant opportunity for the acquisi- 
tion of just this experience. The man who 
desires to fit himself for a position as teacher 
of medicine or consultant should spend a 
considerable period of time in practice 
among the class of patients which is to be 
found in the large private departments of 
many of our hospitals. Such an experience 
gained in the hospital will afford him in 
concentrated manner just what he might ob- 
tain otherwise through a much longer pe- 
riod of time in private practice. 
This is the general course of training 
which the aspirant to the professorship of 
medicine is likely in the future to follow. 
His elevation to the directorship of a large 
department of medicine or surgery may be 
directly from the clinic in which he has 
occupied a salaried position and to which 
he has given his entire energies, or it may 19 
come after some years of consulting prac- 
tice during which he has preserved close 
relations with an active clinical department. 
Recognizing the magnitude of the prob- 
lems associated with the organization of a 
large medical clinic, it has been felt that 
such a department could best be presided 
over by men who were able to give their 
whole energies to the university in organi- 
zation, in teaching, in the conduct and di- 
rection of research. And, notably at that 
institution with which I have been con- 
nected for more than twenty-five years, sev- 
eral of the clinical departments have been 
reorganized upon a university plan. 
Through the generosity of the General Edu- 
cation Board, the institution has been en- 
abled to establish a staff of university pro- 
fessors and salaried assistants who take 
charge of these clinics for hospital and uni- 
versity. These men, freed from the calls of 
outside practice, are able to give their entire 
time to the service of the department in the 
care of patients, the promotion and conduct 
of research and in the teaching of medicine. 
And as is well known, the members of this 
staff have agreed to abstain from the prac- 
tice of their profession for their own 
emolument. 
The discussion associated with this ex- 
periment has been very active, centering 
largely upon the last mentioned circum- 
stance-the withdrawal or abstention of the 
university professors and their assistants 
from private practice. Those who have 
objected to this procedure have regarded 
the plan as unwise and even unfair to the 
physician himself, to the hospital, to the 
students and to the public. 
In the first place, with regard to the pro- 20 
fessor himself, it has been pointed out, and 
with justice, that there can be little rela- 
tion between the salary which the university 
could or should pay to the professor of 
surgery or medicine and the gross income 
of the successful surgeon or consultant in 
a large city. It has been asserted that the 
opportunities brought by a considerable 
income for wide association with the world 
at large are broadening to the character of 
the man and are indirectly of value to the 
institution with which he is connected; that 
furthermore it must be a very serious ques- 
tion to the physician himself whether he is 
justified in planning deliberately a man- 
ner of life which can never lead to wealth 
or real financial freedom, when there might 
be open to him an opportunity to give to his 
family and those dependent on him the ad- 
vantages which come with a large income. 
Is he not, it is asked, giving up the "larger 
life" for the smaller, and will not the uni- 
versity in the end suffer by the loss of the 
wide domestic and international relations 
so often established by the professor who 
has the material resources to visit his dis- 
tant colleagues in their clinics and to enter- 
tain them at his home? Will not the hos- 
pital, more directly, lose in the absence of 
those cordial relations which arise to-day 
from the association, as a consultant, be- 
tween the chief of the medical clinic and the 
practising physician? 
Will not the students suffer, it is asked, 
through their association only with men 
who have had a more or less academic train- 
ing in a hospital, who are out of touch with 
the exigencies of actual medical practice? 
Will not practitioner and consultant suffer 21 
seriously in losing their control of the hos- 
pital material which is now to pass wholly 
into the hands of salaried men? And will 
not the public suffer ? May it not indeed be 
regarded as an injustice to the public and 
to the practitioner that they should be 
denied the services of these men especially 
eminent in medicine or surgery, whose opin- 
ions presumably are of special value-these 
men who have been chosen to direct large 
clinics ? 
It can not be denied that these objections 
have a certain force. 
The physician who, starting from modest 
beginnings, has acquired, by hard work, a 
large income can not underestimate the 
blessings and the opportunities that such a 
revenue brings to him and to those who de- 
pend upon him. But such incomes are 
rarely honestly gained without very hard, 
very confining work, and without real intel- 
lectual hardship to the practitioner if he 
be a man of scientific tastes or aspirations. 
To one who has the temperament and ideals 
of the student, the advantages of a univer- 
sity professorship can not fail to appeal 
very strongly. No man who covets a for- 
tune should select a career of a university 
professor. He who enters upon such a life 
knows from the outset what his income is to 
be, and what the outlook for his family. 
He can not expect to be a rich man, and he 
must plan his life accordingly. But the 
compensations are great to one of scholarly 
tastes. The opportunities for study and 
research offered by the university clinics 
and laboratories, limited though they may 
be at certain times by the demands of teach- 
ing, the freedom from the uncertainties, the 
complications, the endless activities of the 22 
life of a busy practitioner or consultant, the 
hours for reflection, for rest, for recreation 
offered by the stated vacations-these, 
wholly apart from the privileges and re- 
sponsibilities of the organization of a large 
department, are advantages so great that 
they will always attract men of the highest 
order. 
"And the larger life?" Who can say 
what "the larger life" is in itself? The 
' ' larger life, ' ' alas, does not always go with 
wealth and that which surrounds it; and 
who shall say that the opportunities which 
come to the university professor of distinc- 
tion and to those about him are more re- 
stricted than those which are open to the 
practitioner and consultant? Certain of 
the luxuries of life the professor may be 
obliged to eschew, but there are other priv- 
ileges which will be his that no money can 
buy. 
It is true that the salary of the university 
professor has not, in general, advanced with 
the incomes of those about him, or with the 
general scale of living; and it is, I believe, 
folly to attempt to put the directorship of 
clinical departments on a university basis at 
salaries such as have been in the past offered 
to the professors in the strictly scientific 
departments. Nevertheless, no one can ex- 
pect such salaries to be large as compared 
with the income of successful men in pri- 
vate practice. It should, moreover, be re- 
membered that with the successful consult- 
ant, for instance, nearly one half of his 
gross income is often absorbed by the legiti- 
mate expenses of his practice. The burden 
of these expenses is lifted from the shoul- 
ders of the university professor whose fixed 23 
income represents a revenue of nearly twice 
that size with the consultant. 
But the salaries of university professors, 
whether in clinical or scientific branches, 
should be materially-very materially- 
larger than they have been in the past, if 
these men are not expected by outside activ- 
ities, to add to their incomes. I can, how- 
ever, see no reason why the salary of a pro- 
fessor of medicine or surgery should be 
larger than that of a professor in a so-called 
scientific branch. In business circles it is 
true that the salary depends purely upon 
the immediate market value, so to speak, of 
the individual; that he who can in the 
world of affairs earn but a modest sum is 
able to demand a far smaller salary than a 
man with larger practical earning capacity. 
The physiologist who devotes himself single- 
heartedly to his teaching and his researches 
might, if thrown on the world to gain his 
living, have but a relatively small earning 
capacity; the clinician, if he have attained 
a popular reputation, may, on the other 
hand, be in a position to make a consider- 
able revenue. 
Universities often obtain the undivided 
services, let us say of the professor of physi- 
ology, for an amount which was once but 
is not to-day a proper living salary for a 
man whose abilities and contributions to sci- 
ence entitle him to a comfortable and prom- 
inent position in the community; that posi- 
tion which it is to the advantage of the uni- 
versity that he should occupy. And such 
professors in many institutions sacrifice 
much to the cause of science. 
This seems to me fundamentally wrong. 
These distinctions must eventually be re- 
moved, unless our universities are to re- 24 
main as short-sighted as our national gov- 
ernment and bring it about that our pro- 
fessorships, like our diplomatic posts, shall 
come to be situations which only men of 
independent means can fill. 
But to return to the question of the pro- 
fessorships in the clinical branches. If the 
salary be adequate, there should always be 
efficient men whose ambition will be to 
occupy chairs of medicine and surgery even 
though they realize fully that the chances 
of the acquisition of a large income are 
small. 
The objection that is so commonly raised 
as to the injustice and unwisdom of any 
understanding or agreement by which the 
directors of the departments of medicine 
and surgery should abstain from private 
consulting practice is one which, as a 
teacher and practitioner, has interested me 
greatly. As has been indicated before, it 
is not easy to see how the director of a mod- 
ern university clinic, or the chief of a serv- 
ice in a large hospital organized on a similar 
basis, can give any essential part of his time 
to outside consultations. According to the 
tastes and character of the man, he will 
probably give more or less of his time to 
private consultations at his clinic. To the 
consultant the puzzling and interesting 
pathological problems brought for his con- 
sideration by patients sent to his consulting 
room by colleagues at home and abroad, 
form the most valuable part of his experi- 
ence. Such patients the professor of medi- 
cine and his associates will doubtless con- 
tinue to see. They should form a great ad- 
dition to the hospital clinic. Some of these 
patients they will desire to admit to the 
hospital for study. But these consultations 25 
the director of a large clinic could hold 
only at stated periods, and to this work he 
could give only a limited amount of time. 
It is difficult to see how it would be possible 
for the director of such a clinic to give the 
proper service to his department, and yet 
conduct anything like an active consulting 
practice outside the institution. Under ex- 
ceptional circumstances, however, the pro- 
fessor will probably accept calls to outside 
consultations, but only under exceptional 
circumstances. The director of a large 
medical department must control his own 
time and his engagements. He who is 
openly occupied in general or in consulting 
practice can never truly be master of his 
time. 
A curiously active discussion has risen 
upon a rather small point in connection 
with the practise of the salaried director 
of a medical clinic. In some clinics, as has 
been said, the understanding exists that the 
professor shall ^contribute whatever fees he 
may collect from private patients to the 
departmental funds. This procedure has 
excited vigorous criticism and opposition; 
it has, indeed, been considered fundamen- 
tally improper, subversive of the higher 
interests and principles of the medical pro- 
fession. 
This is a problem on which I have medi- 
tated seriously, and, look at it as I may, I 
can not but regard it as a rather small and 
relatively unimportant detail of a larger 
general question. The professor should 
naturally demand suitable compensation for 
his services to private patients. But 
whether such compensation should go di- 
rectly to him, or should be turned over by 
him to the budget of his department, seems 26 
to me a matter of detail to be settled be- 
tween him and university or hospital. I 
am at a loss to understand the attitude of 
those who see in this a question of principle. 
Some time before the first experiment of 
a university medical clinic was put into 
practise, a distinguished clinician whose 
services were sought by a-well-known insti- 
tution, offered independently, for the or- 
ganization of his department, a plan which 
is very similar to that which now exists at 
the Johns Hopkins University. This offer 
outlined the establishment of his professor- 
ship upon a purely university basis, with 
the explicit understanding that the income 
from any private consultations into which 
he might see fit to enter, should be added to 
the budget of his department. Such an 
arrangement might be regarded as a dis- 
tinct protection to the professor. For the 
financial questions which relate to practice 
are to some annoying and disturbing. And 
if the salary paid to the university pro- 
fessor be in any way sufficient, I can easily 
fancy that the professor might prefer to 
have it understood that the income from 
any practice which he might care to under- 
take should go into the budget of his depart- 
ment. I can also fancy that others might 
feel differently; that they might prefer a 
complete independence, expressed or im- 
plied, in this respect. I can further fancy 
that the university or hospital might fear 
that if the professor once began to accept 
fees from private patients, he would be in 
danger of being drawn into practice to such 
an extent that it would interfere with his 
university or hospital work. But, as I have 
said, the question of what becomes of the 
professor's fees seems to me of limited im- 27 
portance-a detail in connection with the 
larger problem. I can not see in it a great 
question of principle. 
So far as the student goes, the danger 
that under the direction of a salaried pro- 
fessor, he may be given a training more 
purely academic and insufficiently prac- 
tical seems to me small. In the first place, 
it has already been pointed out that the 
professor of medicine will doubtless be a 
man who has had a considerable clinical 
experience with patients in all classes of 
life, whose training has been by no means 
purely academic, and although some of his 
associates will perhaps be men who have 
not yet acquired the ripened experience 
which should be that of* the head of the 
department, yet no one for a moment fan- 
cies that all the instruction in medicine and 
surgery will be given by the nucleus of 
teachers wholly dependent on their salar- 
ies. In every large clinic, and in every 
large hospital affiliated with a university, 
a considerable part of the instruction in 
general medicine and surgery, as well as in 
specialties, must be entrusted to men with 
or without salaries, who are more or less 
actively engaged in practice. The fancy 
that because the director of such a clinic 
and many of his assistants are no longer at 
the beck and call of the public, the student 
is to be regarded as deprived of the oppor- 
tunities offered by association with men 
who have been or are engaged in active 
practice, is a misconception. 
That which the reorganization of a clinic 
upon a university basis should do, how- 
ever, is to bring it about that the practi- 
tioners who share in the work and advan- 
tages of the hospital and take part in the 28 
instruction may be rather more carefully 
and wisely chosen than they have been in 
the past. Well-digested experience, merit 
and teaching ability should more clearly 
and surely be recognized by a director un- 
trammelled by hospital traditions and bent 
solely on the improvement of his clinic. 
The experienced clinician who is still 
engaged in private or consulting practice, 
if he be a man of high order, is not likely 
to lose his touch with the hospital or with 
the clinic so long as he is able and desirous 
of giving it his services. Indeed, it is prob- 
able that in the future, institutions will re- 
tain a closer connection with some of the 
members of the staff who are engaged in 
private consulting practice by offering 
them the privileges of consulting rooms at 
the hospital. This plan, which has already 
been adopted in some instances, ought to 
be of great mutual advantage to hospital, 
to physician and to patient. To the hos- 
pital because it brings into close connec- 
tion with the clinic those examples of rare 
and unusual disease which are sent to the 
consultant; to the physician because he is 
able to give much more time to his work at 
the hospital; to the patient because if the 
consulting room of the physician be at the 
hospital centre, the many accesory exami- 
nations which so often have to be made, 
can be carried out much more expedi- 
tiously. But if such a physician be en- 
gaged in active consulting practice, he will 
no longer be the director of the clinic, and 
this, as has been pointed out, would seem 
to be desirable from every standpoint. For 
only under exceptional circumstances can 
such a man command the time necessary 
properly to direct a full department. 29 
How much or how little time the head of 
a department of medicine or surgery may 
give to consulting practice is, however, a 
question which in the end, must depend en- 
tirely on the character of the man. He 
may give very little of his time; he may 
give a good deal. But if he be a man 
whose living interest is in his clinic, it 
matters little. For in either instance, 
through the character of the men that he 
associates with him, he will see that his de- 
partment does its best work. 
The objection so often raised that there 
is danger that a professor of medicine or 
surgery who abstains from outside consult- 
ing practice may be removed from touch 
with the profession, is comprehensible but 
not, I think, serious. If the director of 
the department be one who does a consid- 
erable amount of clinical work, he will still 
keep in active touch with the medical pro- 
fession even though his consultations be 
held only at the hospital. In any event, 
the work of the department itself, set forth 
by him and by his associates and assistants 
in public clinics, in medical societies, and 
in journals, should keep him well before 
the eyes of the medical world. 
The tendencies of the hour would seem to 
indicate that a very large nucleus of the 
staff of the medical or surgical clinic will 
in the future consist of salaried men who 
are giving the greater part of their time to 
the activities of the department; and it is 
very interesting that not only in hospitals 
affiliated with university schools of medi- 
cine, but in other independent institutions, 
this idea has already taken root. The ex- 
periment of a generously salaried staff of 
physicians and surgeons who are expected 30 
to give the greater part of their time, if 
not their entire time to the institution, is 
already being made in various hospitals. 
One of the most important functions of 
a modern medical or surgical clinic is that 
it should afford opportunities for the am- 
bitious student with scientific aspirations 
to pursue that course of study and acquire 
that experience which will fit him for a 
university career. Every year there grad- 
uate from our schools of medicine men 
with the ideals, aspirations and abilities of 
the true student, who, because of financial 
disability, are obliged to enter directly into 
active practice. A certain number of these 
men preserve their enthusiasm, make the 
most of their opportunities, and return 
later to the pursuit of those studies which 
have always been the object of their am- 
bitions. Some find unexpected intellectual 
satisfaction in the varied opportunities 
offered by the life of a practitioner. 
Others, dazzled by the financial rewards of 
success, lose their early ideals. Many, 
however, are obliged to sacrifice their am- 
bitions. With the organization of the mod- 
ern medical clinic, there should be a con- 
siderable number of assistantships com- 
manding salaries which should make it 
possible for many of the really good men to 
pursue their chosen career. And it is 
highly desirable that such salaries should 
be sufficient and so graded that these men 
may continue their work through long 
years should they prove themselves of suit- 
able character and ability. 
But-and this is a question very often 
raised-what about the opportunities for 
the development of practitioners or con- 
sultants if every medical or surgical clinic 31 
become a training school for professors of 
medicine ? The answer is simple. The 
training which best fits a man for a pro- 
fessorship differs in no way from that 
which best qualifies him for the career of a 
practitioner or consultant. Some of the 
men who start upon their career in a mod- 
ern department of medicine will remain 
connected with the service in one capacity 
or another for ten or fifteen years or even 
more, until the offer of a position as assist- 
ant or professor or director in anothet 
large clinic comes to them. Many, after 
eight or ten years' experience, will find 
themselves well fitted to enter into the 
practice of medicine or surgery as con- 
sultants. Others after spending a shorter 
period of time will doubtless take up gen- 
eral or special practice. That to which we 
may look forward with reasonable cer- 
tainty, however, is that the reorganization 
of hospital and university clinics accord- 
ing to this general plan, the essential fea- 
ture of which is the establishment of a 
large nucleus of salaried men who give the 
greater part of their time to the activities 
of their service, will provide for univer- 
sity, hospital and public a body of men 
better trained, and with richer experience 
than has been offered in times past. 
There is one point in connection with 
the reorganization of the clinic upon what 
I have called a university basis which 
seems to me of real importance. This has 
been touched upon especially by Dr. 
Meltzer.2 I refer to the desirability of 
ample provision for voluntary assistant- 
ships. This is a matter which touches espe- 
2 Science, 1914, XL., 620-628. 32 
cially hospital organization. The work of 
a modern hospital clinic has changed 
greatly. A well organized medical or surg- 
ical clinic is as truly a scientific department 
as are the university departments of anat- 
omy, physiology and chemistry, and in 
every hospital there is a constant demand 
for more and more students to assist in the 
researches which are being conducted by 
the various sub-departments, and inciden- 
tally in the care of the patients. The great 
advantage to a hospital of the presence of 
students in its wards has often been pointed 
out. Such students form a corps of extra 
assistants who enable us to study and care 
for our patients much more intelligently. 
But where can one find the director of 
a medical clinic who is not longing for the 
services of more young men, recent gradu- 
ates with scientific aspirations, to assist 
him in the study of a variety of different 
problems? As it is to-day, only those men 
who can obtain salaried positions upon the 
staff or are of independent means can af- 
ford to give the time required for such 
studies. But many a student, upon his 
graduation, and during the several years 
that follow, would be more than willing to 
accept a position as voluntary assistant if 
he might be given a room and his lodging 
in the hospital. Every modern medical or 
surgical clinic should have a number of 
these positions open to such men as the pro- 
fessor may see fit to select. There could 
be no better investment for the hospital. 
Research assistants should be considered as 
essential to the welfare of the hospital as 
are the regular internes. 
These are the considerations that I have 33 
wished to bring before you to-day. They 
have to do with matters which are not 
without public significance. 
The relations of the medical sciences to 
the commonwealth are of great intimacy 
and of vital importance. 
Time was when the physician was called 
upon only to minister to his ill or wounded 
fellow. To-day he is something more than 
the healer and the binder of wounds. The 
advice of the medical scientist is sought in 
every sphere of human activity. It is he 
who is called upon to outline and direct 
those measures which protect our homes 
from epidemic, our cities from pestilence. 
It is he who has opened the wealth of the 
tropics to the safe exploitation of man; to 
him we must look for that counsel which 
shall preserve the efficiency of our armies 
in the field and of our cohorts of industry 
at home; which shall lessen the horrors of 
war and the dangers of peace. 
No effort can be too great; no sacrifice 
too costly that may afford to the student of 
the medical sciences the most active stim- 
uli, the best opportunities for training and 
for research. For in the training of the 
student of medicine is involved more closely 
than is generally realized, the prosperity 
and safety of our country. 
406 Cathedral St., 
Baltimore 
William Sydney Thayer Observations on the Teaching of 
Tuberculosis 
By William S. Thayer, M. D. 
Reprinted from the Transactions of the Twelfth Annual Meeting of 
The National Association for the Study and Prevention of Tuberculosis OBSERVATIONS ON THE TEACHING OF 
TUBERCULOSIS 
By William S. Thayer, M.D. 
Baltimore 
No infection brings before the clinician so many and so varied pictures 
as does tuberculosis. There are few conditions in which the early recog- 
nition of the process is so important. There are not many maladies in 
which it may so definitely be given to the clinician to save the life of his 
patient. 
The subject of intensive study for decades, considerable advances have 
been made in diagnosis and in therapy. The establishment of sanatoria 
by municipal, State, and private agencies, the development of special dis- 
pensaries for tuberculosis, with their cooperating forces of district 
nurses, the general education of the public through the agency of local, 
State and national societies have done much to encourage the earlier 
recognition of the disease, and to facilitate better and more intelligent 
treatment. This progress has, however, brought in its train certain 
changes in hospital, in practice and in schools of medicine which have 
not always been for the advantage of public or hospital or student. 
More and more tuberculosis has become to be regarded by the public as 
a disease apart, to be treated by special physicians in special hospitals. 
From the general and private departments of our hospitals pulmonary 
tuberculosis is generally excluded. Special out-patient departments for 
tuberculosis have been started in some hospitals, but wards for the treat- 
ment of pulmonary tuberculosis are very rare. And the public is com- 
ing to feel that when a man attains eminence as a student of tuberculosis, 
he has become a specialist in the strictest sense of the word. This has 
gone on to such an extent that it is dangerous for a clinician to allow him- 
self to become too closely affiliated with a department for the treatment 
of tuberculosis, unless he is prepared to lose much of his general prac- 
tice. In some ways the public suffers from these conditions. 
The course of chronic pulmonary tuberculosis which, as we all know, 
may be compatible with years of useful life, is characterized by all manner 
of intercurrent complications, by exacerbations dependent upon secondary 
infections of the most varied nature which ramify into every region of 
medicine. These exacerbations and intercurrent infections bring before 
the clinician many interesting and difficult diagnostic and therapeutical 
problems on the proper solution of which the life or efficiency of the 
patient often hangs. It is a hardship to the public that such patients 
cannot, as a rule, be admitted to general hospitals. And it is painfully 
true that there are few hospitals to which they can be admitted at all, 2 
OBSERVATIONS ON THE TEACHING OF TUBERCULOSIS 
and fewer of these which afford opportunities for proper study and in- 
vestigation by thoroughly trained men. There is no field in which the 
general hospital can do a greater or more valuable work than in the tem- 
porary care of patients with chronic pulmonary tuberculosis. 
For the student of medicine these tendencies have their advantages 
and their disadvantages. Where tuberculosis dispensaries have arisen 
in connection with teaching hospitals, exceptional advantages may be 
offered for the teaching of physical diagnosis. But, on the other hand, 
the exclusion of pulmonary tuberculosis from the general wards of the 
ordinary hospital, takes from student and interne (and the interne is now 
essentially a fifth year student) a precious opportunity for the study of 
the course of a disease with which it will be vital for them to be familiar 
in their practice. Sanatoria for the treatment of early pulmonary tuber- 
culosis are unquestionably of great value, and hospitals for the treat- 
ment of chronic and more advanced cases are necessary, but in order 
that, in such hospitals, the patients should have the best treatment and 
the students the best opportunity for study, it is desirable that these in- 
stitutions should be departments of, or closely affiliated with, general hos- 
pitals. 
While in tuberculosis, as in any other malady, there will always be 
men, who, as a result of special opportunities and experience, come to be 
regarded - and justly regarded - as authorities, it is highly undesirable 
that pulmonary tuberculosis should become a disease treated wholly in 
special hospitals by men apart from the general profession. The prob- 
lems of chronic pulmonary tuberculosis are problems which affect all 
branches of medical and surgical practise, and the too general segregation 
or removal of patients from active general clinics will be of advantage 
neither to patient, nor student, nor profession. An interesting analogy 
may be drawn between the conditions which are arising with regard to 
pulmonary tuberculosis and those which have existed, and still exist with 
relation to mental disease, the treatment and study of which has for 
years been almost wholly removed from the general medical clinic - and 
not to the advantage of patient or medical science. 
This should not occur with pulmonary tuberculosis. 
The amount of instruction in pulmonary tuberculosis which is now 
offered varies greatly in different schools of medicine. Almost every- 
where in the instruction in physical diagnosis instances of pulmonary 
tuberculosis are brought before the students. In some schools in which 
there are special out-patient departments for tuberculosis, good courses 
of instruction are given in the diagnosis of the early stages of the disease, 
and to a varying extent, on the principles of the treatment of tubercu- 
losis. In a few favored institutions which control wards, or are affili- 
ated with hospitals for the treatment of pulmonary tuberculosis, a real 
opportunity is given for the study of the disease and its complications. 
But in the great majority of our schools to-day the instruction of the 
student in tuberculosis is, to say the least, rather fragmentary. In few 
institutions does the fourth year student in his ward service, if he have WILLIAM S. THAYER, M.D. 
3 
such, or the interne in connection with his year's hospital experience, 
have an opportunity for the study of the course and complications of 
pulmonary tuberculosis. 
This is not as it should be. What should we try to do? 
(1) The establishment of wards for the treatment of tuberculosis in 
all teaching hospitals is the first requisite for proper instruction in the 
care of the disease. Every general hospital should have a ward or wards 
for the temporary treatment of pulmonary tuberculosis. 
This would be of great advantage to the public and to the patient. 
For such a ward will offer to many patients the opportunity to be tided 
over those emergencies which, without the advantage of enlightened care, 
are often immediately dangerous to life. Such wards need not become 
homes for the incurable; and they may serve a very good purpose in the 
temporary care of the chronic tuberculous. Such wards would be of 
immense advantage to the student, because the presence of these patients 
offers to him and to the Staff opportunities for studying a large number 
of conditions and of meeting many problems and emergencies against 
which they are sure to be called upon to contend in their subsequent prac- 
tice. 
(2) The teaching of tuberculosis should be taken up systematically. 
In the older text-books the subject of tuberculosis was rarely treated 
as a whole. The different manifestations of the disease were considered 
according to the location of the process among the diseases of the 
meninges, the diseases of the lungs, the diseases of the genito-urinary 
tract, the diseases of the peritoneum, and so forth as the case might be. 
There was little or no consideration of tuberculosis as an infectious 
process. If, however, we turn to the better modern text-books we shall 
find that here tuberculosis is considered separately as an infectious dis- 
ease, just as we consider typhoid fever or pneumonia or diphtheria. 
When, now, we come to consider the manner in which the study of 
tuberculosis is approached in our schools of medicine we shall find that 
the older method still prevails - that there is little or no consideration of 
tuberculosis as an entity. 
Besides training in the physical diagnosis of early tuberculosis the 
student of medicine should be offered instruction in the common general 
phenomena of tuberculous processes, in the anatomical and clinical char- 
acteristics of the infection, in the general problems of immunity, in the 
conditions which influence susceptibility, in the theory and practice of 
diagnostic tests, in the interpretation of fluoroscopic and radiographic 
observations. This should be done in demonstrative clinics and in prac- 
tice in small groups in the ward. Further opportunities should be given 
for ward work during the fourth year and during interne service for 
observation of the course of pulmonary tuberculosis in the hospital. Thus 
special problems of treatment may be considered and resolved. In short 
we should study tuberculosis not only in its special manifestations, but as 
an individual infectious process, as we study typhoid fever or pneumonia 
or diphtheria. 4 
OBSERVATIONS ON THE TEACHING OF TUBERCULOSIS 
In summary then the two great prerequisites for the proper teaching 
of tuberculosis would seem to be: 
(1) Provision for the care of a certain number of cases of pulmonary 
tuberculosis in our general hospitals. 
(2) The establishment in our schools of systematic instruction in 
tuberculosis as an infectious process, as it is now taken up in the better 
text-books, and not merely as a disease of different systems as it may 
chance to appear. Only thus can we expect the student properly to be 
equipped to meet the emergencies of practice, or to benefit by the special 
advantages which are to be offered by such schools as that which the 
President of this Association, who is the sort of specialist in tuberculosis 
from whom we may all learn, is soon to head. Dr. W. S. Thayer: 'Twas an interesting group of men- 
the 'ittle family that constituted the House Staff of The Johns 
IL pkins Hospital during the years which passed before the 
foundation of the Medical School and before the days when we 
lagan to call on our own graduates to fill the interneships. 
They were gathered from many schools-Lafleur and Hewet- 
son and Barker and Cullen and Futcher and McCrae from 
Canada; Robb and Scott and Toulmin and Ghriskey and Fan 
and Bloodgood and Russell and Clark and Ramsay and Oppen- 
heimer and Edwards from the University of Pennsylvania, 
Brockway and Parker and Lazear from New York; Nuttall 
and Blumer from California; Flexner from Louisville; Young 
and Huger and Block and Hoke from the University of Vir- 
ginia ; Councilman and Abbott and Clark and Reese and Balt- 
zell and Simon and Hoch and Smith and Van Ness and Atkin- 
son and Stokes and Walker from the University of Maryland; 
Phippin and Norton and Cushing from Harvard; Whitman 
from Paris; Broedel and Werckmeister from Germany-to 
mention only a part. 
Few pf us remain to-day to walk the familiar corridors, to 
keep alive the fading traditions and to welcome the old com- 
panions as they return from time to time from all parts of the 
world to edify us with their wisdom and, alas, to surprise us by 
their maturity. But there are some who come back to us often, 
who never change, whose eyes are as clear, whose step is as 
light, whose voices are as fresh as they were 25 years and more 
ago. Brockway and Scott and Reese and Hewetson and 
Livingood and Edwards and Oppenheimer and Ramsay and 
Lazear and Whitman-they can never grow old. 
There is another, peculiarly dear to those of us who remain 
because we have of him a double memory-a memory of his 
youth in which he first left us, and of his prime in which we 
possessed him again. 
Rupert Norton came to us in 1893 as a member of the 
Medical Staff, and remained with us for over two years. His 
1 Johns Hopkins Hospital Historical Club, March 12, 1916. work as a house officer was systematic, painstaking and thor- 
Iough. As one reads to-day the records written in his neat 
and careful hand, the evidence of the character of his work is 
clear. Then came the years of his Washington practice, inter- 
rupted by the Spanish war, when he volunteered immediately 
as an acting assistant surgeon. At the end of the war came 
a period of years during which he was Medical Director of the 
New York Life Insurance Company in Paris, and then, in 
1906, he came back to us again as Acting and Assistant 
Superintendent. From that time to the day of his death he 
devoted all his energies to the interests of the Hospital. 
Among the past members of the staff few have been dearer 
to their associates. Norton was not one of those who made 
friends at first glance. He was so modest, so retiring, so 
diffident that some who met him casually mistook his shyness 
1 for coldness. No one who met him for the first time could 
have fancied the depth of his feeling, the vigor of his enthusi- 
asm, the inflexibility of his determination, the inherent cour- 
age of the man. But wherever Norton was closely thrown with 
anyone he left a friend, and usually a devoted friend. The 
wirmth of friendship that he inspired was but a reflection of 
his own loyalty. He was one on whom his friends could 
depend wholly; and while with regard to himself misunder- 
standing or false report stirred him little, yet nothing was so 
sure to excite in him an immediate and almost fiery resentment 
as a misrepresentation or a slighting statement about a friend. 
He recognized unfailingly and appreciated deeply real merit 
in whatever garb it was clothed, and he was remarkably toler- 
ant of the failings and weaknesses of others. But he had 
little patience with snobbishness or pretence and he was quick 
to detect and resent insincerity or indirectness. 
I have sometimes regretted that one possessed of such admir- 
able qualities of the heart-qualities which so endeared him 
to his friends-should not have given more of his life to a 
practice in which this human influence might have made itself 
more widely felt. To those who knew him well the memory of 
these qualities is a very dear possession. Of his generosity I 
have spoken elsewhere. Not many, even among his closest 
acquaintances, realized the extent of his kindly charity. During his later years in the Hospital his wise advice and 
counsel were much valued by all who surrounded him. 
Few men are quite certain of themselves. However stead- 
fast one may be in his highest aspirations, however deep one's 
devotion to principle, who, at the bottom of his heart, has not 
known a lurking anxiety lest, in the great emergency, his 
action might fall somewhat short of his ideal? He who has 
witnessed the too common frailty of his fellows, how has he 
not meditated on what his impulse might be in the moment 
of supreme temptation or danger? 
But there are some men who inspire their friends with a 
peculiar sense of stability and solidity; some in whom we 
cannot imagine a weak or a mean or a cowardly impulse; some 
men of whom we feel absolutely sure. Such a man was Norton, 
and of his life we may say in the words of the wise old 
philosopher: " ... . meliorem Uli vitam reddidit quam 
accepit: exemplar boni viri posuit; qiuilis quantusque esset 
ostendit: si quid adjecisset, fuisset simile praeterito." (Seneca, 
Epistola 93.) " ... . for he hath returned a better life than 
he received. He hath set downe the patterne of a good man: 
he hath shewed what an one and how great he was: if he had 
added anything, it had beene like unto that which was past." 
(Lodge's translation, London, 1614.) 
It is well that we should seek to perpetuate the memory of 
such men-that we should endeavor in bronze, in marble or 
in color to fix the impalpable and elusive inspiration that 
emanates from their presence. For the face of a good man is 
a benediction. And Norton's presence is with us now. One 
who knew him and loved him well, Victor Brenner, the dis- 
tinguished sculptor, has brought back his calm and dignified 
and thoughtful features. And Mrs. Norton, who has herself 
a double claim to our affection as a graduate of our own train- 
ing school for nurses and as his wife, has asked me to present 
this medallion to the institution to which he gave the best years 
of his life. 
So may his face and figure continue to look out upon those 
who follow us-the face and figure of one whom we who knew 
him, love to recall-as has been set forth upon this plate-as 
physician, counsellor and friend. MEDALLION PORTRAIT OF DR. RUPERT NORTON. 
BY VICTOR D. BRENNER. SCHOLARSHIP IN MEDICINE 
BY 
W. S. THAYER, M.D. 
BALTIMORE, MD. 
REPRINTED FROM 
THE BOSTON MEDICAL AND SURGICAL JOURNAL 
APRIL TWELVE 
1917 [Reprinted from The Boston Medical and Surgical Journal 
Vol. clxxvi, No. 15, pp. 519-524, April 12, 1917.] 
SCHOLARSHIP IN MEDICINE.* 
W. S. Thayer, M.D., Baltimore, Md. 
When Dr. Lewis asked me to speak to you to- 
day, he suggested as a title for my remarks, 
"Scholarship in Medicine," an alluring and 
fascinating subject for reflection for one to 
whom that most blessed privilege is afforded-■ 
the opportunity to reflect. From an experience of 
nearly thirty years, however, I should say with 
confidence that to none do the gods so consist- 
ently deny this privilege as to the physician. 
Indeed, all the progress of mankind seems to 
centre in one great conspiracy to search out the 
secret and silent chambers of the doctor's castle 
and therein to install a telephone. And the 
timid doctor has not, as a rule, the courage of 
one of your eminent instructors who, in the early 
days, when first this scourge of mankind in- 
vaded his laboratory, having endured its inces- 
sant tinkle as long as might have been expected 
of a just and tolerant man, arose with an air of 
determination and demolished the instrument of 
Satan. 
And so, as I write these words, the hour ap- 
proaches at which I have promised to speak to 
you, and the moments for reflection recede 
slowly and surely. 
At a time when honors and awards for excel- 
lence in their school work are being given to 
men who have shown promise, some of them, of 
* Address delivered before the students of the Harvard Medical 
School on the occasion of the award of the John Harvard Scholar- 
ships on Feb. 26, 1917. 
1 becoming what we like to call scholars-at such 
a time, it is not unfitting to reflect on what we 
mean by a scholar, and what one means particu- 
larly by scholarship in medicine. The word 
"scholar" is, after all, one not altogether easy 
of accurate definition, one which has not wholly 
the same meaning to every man. For instance, 
the words "scholar" and "student" are essen- 
tially different in their significance. The great 
mechanician, for example, who by his imagina- 
tion, insight and learning in his special branch, 
has changed the course of human life, is not nec- 
essarily a scholar. He may be an eminent stu- 
dent, but if his attention has been limited to one 
field, if his all-absorbing work has shut him out- 
as with such, men it so often does-from associa- 
tion with fellow students in other branches of 
science and art and history and literature-that 
man is not what one would call a scholar. The 
words "scholar" and "scholarship" bring to us, 
I think, the idea of a certain catholicity of 
knowledge, of a certain breadth of interest and 
association that the brilliant student whose life 
is given entirely to a single branch of learning, 
often fails to attain. 
One of the most important attributes of the 
man that we are fond of calling a scholar, is that 
active, alert interest in all that surrounds him, 
which leads him, despite himself, into sympathy 
and association with men in every sphere of 
human activity. I remember hearing it said of 
a certain distinguished diplomatist that he was 
a dull dinner companion until some word was 
dropped by a neighbor which told of something 
that was new to him. In a minute the whole at- 
titude of the man would change; he would be- 
come alert, animated, full of suggestive ques- 
tions, interested in every word that fell from the 
2 lips of his companion. The sympathies and in- 
terests of such a man soon give him a store of 
general information, an acquaintance and asso- 
ciation , with fellow students, a power to drop 
for a minute the studies to which his special 
energies may be directed and to follow another 
lead with real intelligence and profit-an atti- 
tude which is indicative of that special mental 
superiority which we associate with the scholar. 
Such rare men-for the real scholar is a rare 
man-are not led from the pursuit of their 
main object of study by these surrounding in- 
terests. Rather does the breadth of their sym- 
pathies mature and sharpen their judgment, 
while the increasing refinement of the man's 
character, the resources which his associations 
and learning have brought him, give him a 
great advantage over his fellows in his relations 
with the rest of mankind. 
The foundation for such scholarship is gener- 
ally laid in what we have been pleased to call a 
"liberal education," the common basis for which 
in this country has been the degree of Bachelor 
of Arts. The attempt on the part of the university 
used to be to give the student who attained that 
degree an elementary education in the classics, 
history, philosophy, mathematics and later some 
of the sciences-a basis on which, according to 
the paths which he might follow in his later life, 
he might build the necessary superstructure. 
A hundred years ago the foundations which 
led to a degree of bachelor of arts were relatively 
simple, for our knowledge of the natural sciences 
was still in its infancy. There was time in the 
four years' academic course, which was then 
often finished before the boy was twenty, to give 
him a sufficient knowledge of the ancient lan- 
guages, of philosophy and history and mathe- 
3 matics-of the "humanities" as they were called 
-to make it possible for him in later years to 
take up the trail and follow in whatever direc- 
tion it might lead; and at the same time, through 
his knowledge of Latin, still the universal lan- 
guage of the scholar and the student, to follow 
the progress of science, of the arts and of liter- 
ature in foreign lands. 
But conditions have changed considerably. 
Our knowledge of the natural sciences has de- 
veloped with enormous strides. Latin is no more 
the exclusive language of the scholar. Thou- 
sands of students in special branches of liter- 
ature and art and science are contributing im- 
portant researches in their own tongue. To this 
mass of literature no one language is a key. No 
man who aims to attain to anything deserving the 
name of scholarship, indeed, no man who wishes 
to excel in any one particular branch of science, 
can safely neglect the study of at least 
three modem languages-English, French and 
German. 
At the same time, by the individual who wishes 
properly to fit himself for the study and practice 
of medicine, more and more time must be given 
to the fundamental study of the natural sciences, 
chemistry, physics, and biology in its broadest 
sense; and the course of studies that he must 
pursue both before and after his entrance into 
that which is, strictly speaking, a school of medi- 
cine, is ever lengthening. 
And thus a very old and frequently recurring 
suggestion is again being discussed,-the sugges- 
tion that the man who intends to prepare him- 
self for the study of medicine should devote 
himself almost purely to the study of the natural 
sciences, and should save the time which is be- 
lieved by some to be wasted in the study, in par- 
4 ticular, of the ancient languages. Again, vari- 
ous plans have been adopted in this and in 
other universities which tend to shorten the 
course of studies which lead to the degree 
of bachelor of arts, and to include in the work 
which is counted upon as leading to this degree, 
some of the studies pursued in the school of 
medicine. Much has been written of the wasted 
years of college life, and much has been said of 
the time which is lost in the preparation of a 
student for practice. 
It is, I think, certainly true that there are 
some very paradoxical conditions associated with 
our college education. There is no reason why 
it should not be possible for an intelligent stu- 
dent, with a proper preliminary education, to 
accomplish the studies which bring to him the 
degree of bachelor of arts by the time he is nine- 
teen or twenty years of age. Most boys, if sent 
to good English, French or German prelimin- 
ary schools, could do this easily and without the 
least drain on their physical condition. There 
are serious defects in the management especi- 
ally of our secondary schools. 
If the day ever arrives when the teaching in 
our secondary schools is conducted by men who 
are, for a considerable part, scholars, as is the 
case in the better European schools, this truth 
will, I think, become clearly evident. A large part 
of this instruction, up to the present day, has 
been given by young men teaching up to the 
limits of their knowledge, in the hope of attain- 
ing a competence sufficient to allow them to 
abandon the field of pedagogy for something 
that to them is more profitable. Such men 
teach the classics as if they were dead lan- 
guages. Indeed to them Latin and Greek are 
dead languages. It is useless to try to teach 
5 a dead language. Such men are not likely to 
inspire the youth with a great love of knowledge. 
One trouble with our secondary education is 
that the opportunities in our country are still 
so great that the career of a teacher, with its 
small salary and its restricted opportunities, 
does not appeal to the ablest men. Our boys are 
not so well taught as are English and French 
boys, and they waste several useful years in the 
secondary schools. 
Another rather unfortunate condition exists 
in many of our universities. The old four 
years' academic course, leading to a degree 
of bachelor of arts, has become one of the 
dearest of American traditions. The traditions 
that are associated with this course were found- 
ed upon conditions existing over a hundred 
years ago, at a time when the students were, on 
an average, several years younger than they are 
today, and when the general supervision of the 
college was much more strict and much more 
that of our larger secondary schools. But the 
conditions of life in the academic department of 
the university have changed greatly. With the 
development of the elective system, the students 
were thrown much more on their own responsi- 
bility with regard to their studies, while gradu- 
ally the freedom of life has approached almost 
that of the European university, so much so that 
parents dread to send their sons practically out 
into the world at the age at which they might 
perfectly well be fitted to enter college. Most 
boys, if they had proper educational advantages, 
could finish a half of what they now do in col- 
lege before the time when, in the natural course 
of events, they enter today; and so, in many in- 
stances, now, they are held back. With the 
happy arrangements that have been introduced 
6 at Harvard in connection with the work of the 
freshman year, it should become possible to send 
a boy to the academic department considerably 
earlier than one might otherwise have felt it 
prudent. 
But still there remains the grave question as 
to how to bring it about that the boy with whom 
time seriously counts, may attain the academic 
degree to which his work entitles him, at the age 
at which he might perfectly well accomplish it, 
without sending him to college at fifteen or six- 
teen. It is a serious question, but one which we 
cannot discuss further at this time. 
How do these conditions affect the man who 
seeks to be a scholarly physician? The attri- 
butes which we recognize as those of the scholar 
are the same whatever be the main interests of 
their possessor, whether he be lawyer or physi- 
cian or historian or philologist. It must, of 
course, be acknowledged that the seeds of schol- 
arship lie mainly, not in what a man is taught, 
but in what a man is. I think of one physician 
who may rightly be called a scholar, whose early 
education in the classics, for instance, was lim- 
ited. His sympathies, however, have led him 
into such constant communion with the great 
minds of the past that to read his words one 
would hardly fancy that he had not conversed 
with the old masters in their own tongue. But 
such men are unusual, and I feel very earnestly 
that the surest basis for true scholarship lies 
in a good elementary education,- an educa- 
tion which demands a study of the classics and 
of mathematics at least as extensive as that 
which used to be required in most of our 
universities fifty years ago. A large part of this, 
as I have said before, could be acquired perfectly 
well before the boy enters the college proper; 
7 and under the conditions which exist today this 
should be made possible. 
I know that there are many who disagree with 
me, but I have been greatly interested as the 
years have gone by, to see how strongly some of 
my colleagues, who have devoted themselves to 
the natural sciences, have come to realize the im- 
portance of an old-fashioned basis in the hu- 
manities for the man who wishes to take a really 
scholarly view of his subject. As I said a mo- 
ment ago, I cannot imagine a man expecting to 
attain eminence, certainly not scholarly emi- 
nence in medicine, without an easy reading 
knowledge of French and German. He ought to 
have more; he ought to have a speaking knowl- 
edge. There is nothing that will 'make the ac- 
quisition of such knowledge easier than a fun- 
damental basis of Greek and Latin. To him who 
has been well trained in Latin and French, a 
reading knowledge of the other Latin languages 
-Italian, Spanish, Portuguese and Roumanian 
-comes of itself, if the need be. 
A good fundamental training in mathematics 
is absolutely necessary to him who must be 
familiar with modern physical and chemical 
methods. So far as the question of time alone 
is concerned, there is no reason why a student 
who leaves the academic department of a uni- 
versity at the age of twenty-one should not have, 
besides a sufficient biological, chemical and phys- 
ical training, a good basis in the humanities. 
"But still," some will say, "although the 
study of Latin may be of advantage in acquir- 
ing French or Italian, those languages can per- 
fectly well be learned without it. Is the study 
of Latin and Greek not waste of time for a boy 
who might, by giving them up, save two years of 
his life?" It all depends on what one calls a 
8 waste of time. One might, perhaps, call it a 
waste of time if his chauffeur should seek to 
study Greek and Latin as a preparation for his 
career. A chauffeur may acquire considerable 
mechanical skill in a very short period of time 
by the study of machinery and by working his 
engines. If he be a clever fellow, he may go 
further. But if his aim be to become a chauf- 
feur, and if he must make his living as soon as 
possible, he cannot afford the time for much 
schooling. Yes, if one aims to be a chauffeur 
alone that argument is, I think, good. If the 
individual who starts to study medicine aims 
simply and solely to attain proficiency in one 
particular branch of the art of medicine, it may 
certainly be possible for him to do good work 
without the knowledge of Latin and Greek. 
But I do feel very strongly that the man who, 
from the beginning, seeks to follow only those 
paths which may lead most quickly to the prac- 
tice of the branch which he has selected, or 
which he fancies he is going to follow, is deliber- 
ately building about himself a wall which may 
well hem him into a narrow path for life, and 
shut out from him opportunities for which in 
after years he may long. 
There are relatively few students who, in the 
medical school, are able to tell just what their 
future career is to be. How many men who are 
convinced that their future lies in surgery, find 
themselves, ten years later, in an entirely differ- 
ent branch of work? I fancied that my career 
was to be that of a surgeon. For nearly three 
years I never once doubted it; and then events 
happened which entirely changed my course. If 
I had devoted myself purely and simply to a 
preparation for the life of a surgeon, those op- 
portunities would not have come to me. How 
9 much less common is it for the student who en- 
ters the academic course, to know with certainty 
the path which he is to follow; and when it is a 
matter of a boy of thirteen or fourteen in a sec- 
ondary school it would be a rash father, it seems 
to me, who would deliberately plan to limit the 
boy's training to one special course of work. 
The man who has to cover so much ground as 
he who desires to pursue the study of medicine 
from the point of view of a scholar can hardly 
expect to find himself prepared to enter a school 
of medicine, as they are now constituted, before 
his twenty-first year. By this time, with proper 
schooling, he ought to be able to cover the neces- 
sary ground in ancient and modern languages, 
mathematics and natural sciences. But he can- 
not do it if he prepare in the ordinary secondary 
school along with the other boys of his age. That 
is the grave difficulty. We should have second- 
ary schools in which boys who have passed their 
college examinations at 15 and 16, may still pur- 
sue a year or two of work in the humanities or 
natural sciences-work which will all be val- 
uable to them in their after-career. The diffi- 
culty for the boy who is to study medicine lies 
in his pre-academic years-in the years of his 
secondary schooling, years in which he is too 
often held back. 
I am, then, one of those who believe earnestly 
that a broad, general training, not only in the 
natural sciences, but in ancient, as well as in 
modern languages, and in mathematics, is im- 
portant for him who is to study medicine, if 
he desire to be a broad-minded and scholarly 
man. 
And now a word or two as to the course of the 
student in the school of medicine. In a letter 
written to me a propos of this very talk, the- 
10 writer referred to the discouragement felt by 
some students owing to the extremely crowded 
and dull character of the curriculum. I think I 
understand that to which he referred, although 
I cannot understand how anybody could refer to 
a medical curriculum as dull. When I was a 
student, although I was discouraged enough, 
heaven knows, time and again, there were few 
dull moments in the course. 
But, it may well be asked, how can a man with 
scholarly tastes be happy in a course so crowded 
as is our four years' curriculum, and what can 
one do to make life more endurable for him? 
It ,is undoubtedly true that our American med- 
ical course is extremely crowded. The main 
reason for this is our graded class system, which 
has always seemed to me fundamentally and 
radically wrong. As I have said elsewhere, I 
feel very strongly that by the time a man is 
ready to enter a school of medicine he should 
be of an age and a degree of development at 
which it should be possible for him to select and 
follow his courses as he will, and to present 
himself on his record for examination and for 
acceptance for his degree when he is ready, and 
not before. A graded class system is a make- 
shift rendered necessary in schools because of 
the number of the students and the variation in 
their habits and natural abilities. With children 
a class system is necessary unless the individual 
is led by a private tutor. In our academic de- 
partments the class system also still remains 
and is probably desirable. But when a man 
enters a school of medicine he should be as 
free as he is in a European university, under 
certain general guidance and limits, to pursue 
his studies as deliberately and thoroughly as 
he may choose. I feel strongly that while a 
11 limit should be set as to the rapidity with which 
a student should go through his course in med- 
icine, we ought not to apply methods designed 
for school boys to serious-minded men. There 
are many men in a school of medicine who, by 
spending one or two years more at their work 
than do their fellows, may emerge far maturer 
and better physicians than their more brilliant 
colleagues who go through our present course as 
easily and without effort or strain. I hope I 
may live to see the day when American univer- 
sities may not only afford such opportunities to 
students of medicine, but may also encourage 
their migration from one institution to another; 
when it may be possible for the keen and dis- 
criminating man to accomplish his studies in 
those laboratories and clinics which most appeal 
to him, no matter if his course lead him from 
Boston to San Francisco and back again. It 
is well to remember that in America we are try- 
ing to make a class do together in a given period 
of time, work which, in other countries, many 
of the best students accomplish more deliber- 
ately, according to their own abilities. 
But at the present moment we have, unfortu- 
nately, I think, a graded class system, and each 
man has to follow it alongside of his fellows; 
and, furthermore, the work that this entails takes 
almost all of his time. No one can go through 
this or any other good American school in four 
years and do all his work as he would like to do 
it. Under these conditions it is, I think, impor- 
tant that the student do not attempt to 
specialize too early. You need most of what you 
are obliged to pass through in the high school 
system that is now ours, and as I said a moment 
ago, you cannot tell, no matter how sure you 
may feel today, where you are going to bring up 
12 And then, another bit of advice which may 
seem rather paradoxical. 
I am never tired of emphasizing the difference 
between the modern and the older methods of in- 
struction in medicine. In the older days much 
of that which we were taught was a matter of 
authority. Propositions that we were assured 
were truths were fed to us. Today our effort is 
more to teach you methods by which you may 
control and prove the assertions which are made 
by others. Our desire is rather to make you 
doubt the propounded statement unless a satis- 
factory proof is advanced, or unless you can con- 
firm it by your own methods of control. And 
this should stimulate a love for inquiry and 
investigation which should tend to make of you 
the student that the true physician must remain 
throughout his life. If you are the right sort of 
a man, you are going to find yourself during the 
course of your studies, interested in many ques- 
tions which may lead you into independent in- 
vestigation. But how hard it is to find the time 
for such work in the midst of a prescribed four 
years' course! And when I say that one of the 
most valuable forms of training for the student 
of medicine is a certain amount of original work 
done under proper direction during his course, 
you may find the advice in direct contradiction 
to what I have said before. One of the discour- 
agements that you will meet, it is true, is that 
you will have so little time for such work. But 
some investigation tucked in during the year or 
during the summer vacation can only do you 
good. There are occasions when the student who 
can afford it, pursuing his medical studies under 
the system which I hope will be ours some day, 
might well interrupt his work for six months or 
a year, or even more, to pursue some specially 
13 promising research. I can easily fancy that by 
the advice of an instructor, some students might 
wisely do this under our present system. This 
much I would say: do not let anyone discourage 
you from the desire to investigate; grasp every 
opportunity for research, though they may be 
few, during your school course. Do not, how- 
ever, fancy that because you are interested in 
some promising field of investigation you can 
properly neglect your other work, and expect to 
receive due credit for it. I have had some amus- 
ing experiences of this sort in which brilliant 
men, who might well and profitably have given 
up a year of their medical course to a problem 
of research, have felt injured because the faculty 
would not grant them credit for routine work 
which they had entirely neglected. 
I have referred several times to the necessity 
of a knowledge of modern languages. If you 
have not now an easy reading knowledge of 
French and German, acquire it. You will need 
it every day of your life, and you will never re- 
gret its acquisition. Go to a Berlifiz school; 
learn to talk and not simply to read the lan- 
guage. Buy books on the technical subjects in 
which you are interested and read them. If 
you are not able to go to foreign countries, seek 
opportunities to hear plays in foreign lan- 
guages or go to churches where you can hear 
sermons preached in a different tongue. A 
little sustained effort will give you a reading 
knowledge before very long, and that is really 
most necessary. 
And then when you have finished the course in 
the medical school seek, so far as you can, to 
make the acquaintance of men and methods in 
other parts of your own country and in other 
countries. It is as profitable for a man to "go 
14 to Europe" today as it used to be fifty years 
ago. A period of time spent in a foreign city, 
sufficient to give one an insight into the language 
and habits and ways of the people, and espe- 
cially to give one an acquaintance and associa- 
tion with one's colleagues in a foreign country, 
is of great value. 
Go to large medical meetings in this or in 
other countries whenever you have the opportu- 
nity. Men will often speak to you slightingly of 
the value of such gatherings. They will tell you 
that nothing important is done there, that the 
social functions quite overwhelm any serious 
work, that they are a pure waste of time. Do 
not believe them. There is no more valuable ex- 
perience than that of making the acquaintance 
of the student whose communications you may 
have to read. Such experiences often modify 
greatly our estimate of the importance and 
worth of the man and his publications. 
It is always interesting and surprising to the 
good student to find in his own country, first, 
how much there is that he can learn from the 
methods and practice of colleagues who live but 
a few hundred miles away, and secondly, how 
much he himself can bring to them. Osler's ad- 
vice to all his students used to be to become 
peripatetic doctors, and it is not bad advice. 
Every student who can-after he has finished 
the year's service in a hospital, which all ought to 
seek-should endeavor to spend a year of study 
at some school other than that with which he has 
been familiar as a student or house physician. 
He should seek an opportunity, either in Europe 
or in this country, to put himself under the di- 
rection of some good man associated with active 
university work or with an institute for medical 
research, and if possible undertake a piece of 
15 original work. Such a year cannot fail to be of 
great value to him. It may lead him directly 
into the special branch of study to which in 
after life he is to give his main attention. It 
will certainly expand his horizon considerably. 
And what is sometimes hard for the modest stu- 
dent to realize-if he has done good work in 
the school, in a hospital and then in a new 
clinic or laboratory, his name and his attain- 
ments will soon become reasonably well known 
in American medical circles. Someone said sev- 
eral years ago,-I think it was one of your own 
professors-: ' ' How surprised the students 
would be if they realized how important a part 
they occupy in the conversation of their teach- 
ers ! ' ' 
It is a trite observation, that it is well for the 
professional man to cultivate outside recreative 
interests. Such interests come naturally to one 
with a scholarly mind. It may be the love of 
music or literature or art that leads the student 
of medicine into side paths of study or rest or 
dreams. I know a professor in a large univer- 
sity who, in his summer vacation some 
years ago, uninstructed and unadvised, took 
up the brush, and today is painting 
landscapes of real beauty and merit; this man 
has found not only a recreation but an occu- 
pation which, throughout his life, will push 
backward the limits of age. It may be the col- 
lection of monuments of antiquity, of old books 
or letters, than which nothing is more fascinat- 
ing. Many of us have a deeply implanted love 
for that which is old. Indeed, he who can pick 
up an old book or enter an old house or listen 
to the music of an old opera without seeing 
charming visions with his mind's eye, is deeply 
to be pitied. Who can listen to an opera of the 
16 Second Empire, let us say, without seeing the 
crowded galleries, the dresses and figures and 
faces of those days, the flowers in the hair, the 
waxed moustache, the crinolines, the brilliant 
uniforms, the twinkling lights on the boulevards 
without ? Who can turn the leaves of his incun- 
abula without dreaming of the old eyes that 
have gazed on these pages, of the old fingers that 
have turned them and inscribed their fading 
annotations on the margins ? Who can read the 
old letters without fancying himself in the 
midst of the quaint or stirring scenes evoked 
by the yellow lines; and in free hours, when 
the mind and body demand rest and relaxation, 
what can take us farther away from care and 
anxiety than dreams such as these? 
A distinguished German professor, in the pe- 
riod of his sanity, has advised that every scien- 
tific man might do well at the height of his 
career to change his calling and enter upon 
new paths of activity,-a radical suggestion and 
one possible only to the scholar of catholic in- 
terests. But there are events in the lives of 
many men which make such a change necessary, 
and he who, in the days of activity and success, 
has cultivated broad outside interests as a rec- 
reation, may find in these very interests in the 
hour of illness or misfortune or necessity, the 
means of his re-creation. 
With these few thoughts which have come to 
my mind between telephonic tinklings, I must 
close, for as one of the wisest of Boston doctors* 
has said, "It is a Trespass on the Rules of Pru- 
dence never to know tvhen to have done. Where- 
fore, I have done!" 
* Rev. Cotton Mather: Directions for a Candidate of the 
Ministry, etc., 12°, Boston, 1726. 
17 OBSERVATIONS ON SOME OF 
THE COMMONER DEVIA- 
TIONS FROM THE ORDI- 
NARY MET WITH IN THE 
EXAMINATION OF THE 
HEART OF SUPPOSEDLY 
NORMAL INDIVIDUALS. 
BY 
W. S. THAYER, M.D., F.R.C.P. 
(Ire.), 
BALTIMORE. 
REPRINTED FROM 
THE 
MEDICAL RECORD 
April 14, 1917. 
WILLIAM WOOD & COMPANY 
NEW YORK. OBSERVATIONS ON SOME OF THE COM- 
MONER DEVIATIONS FROM THE ORDI- 
NARY MET WITH IN THE EXAM- 
INATION OF THE HEART OF 
SUPPOSEDLY NORMAL IN- 
DIVIDUALS* 
W. S. THAYER, M.D., E.R.C.P. (Ire.), 
BALTIMORE. 
When Dr. James asked me to speak here to-night, 
it occurred to me that it might be interesting to 
discuss, from the standpoint of the clinician, some 
of those questions which so frequently arise in con- 
nection with the examination of the heart in sup- 
posedly healthy individuals on application for in- 
surance, for entry into the army or navy, in con- 
nection with applications for membership to various 
mutual benefit organizations or with regard to the 
fitness for athletic sports of the growing boy at 
school. These are questions which come before the 
general practitioner as well as the special student 
of cardiovascular phenomena. 
I shall not attempt a systematic review of the 
deviations from the ordinary with which one meets 
*Read at a meeting of the New York Academy of 
Medicine, March 15, 1917. 
Copyright, William Wood & Company. 
1 in individuals with supposedly normal hearts; I 
shall, however, endeavor rather discursively to dis- 
cuss some of the commoner phenomena which give 
rise to discussion in the daily routine of practice. 
Questions as to the Size of the Heart.-It is not 
very infrequent to meet with patients in whom there 
has been some controversy as to the presence or ab- 
sence of evidences of cardiac hypertrophy. This is 
especially common in the growing boy, and I men- 
tion this circumstance only to emphasize the truth 
that in boys from the age of ten to sixteen, during 
a period of active growth, it is not uncommon to find 
a heart of a size apparently disproportionately 
greater than that of the boy. The apex impulse 
perhaps is in the mammillary line, and in the thin 
over-grown youngster, the impulse is peculiarly 
strong and the first sound rather loud and booming. 
But unless there are definite signs of cardiac em- 
barrassment, of hypertension, or unless the cardiac 
measurements are actually greater than they should 
be in the adult, one need not be alarmed by the 
condition. The so-called "hypertrophy of adoles- 
cence" depends, it seems to me, in many instances, 
on a simple disproportion between the size of the 
heart and the size of the physical frame; the chest 
wall is thin and perhaps still rather narrow; the 
apex is very easily accessible. A heart therefore 
which may have reached or nearly reached its full 
development appears large in comparison to the 
boy. The impulse is much more easily palpable. 
The sounds are stronger and nearer the ear. More- 
over, at this age, functional systolic murmurs-to 
which reference will be made later on-are very 
common. On superficial examination then, the im- 
pression may easily be gained that one is in the 
presence of an hypertrophied heart-perhaps with 
2 valvular disease. But in the boy of from twelve 
to eighteen, a heart which does seem dispropor- 
tionately large as compared with the chest, with 
an apex impulse which may be very forcible, and a 
loud booming first sound-in such a boy if the meas- 
urements remain well within the limits of the 
normal for an adult, and there are no other signs 
of cardiac disturbance, there need be no cause for 
anxiety. It means simply that the boy's heart is 
disproportionately larger than his body. It is a 
temporary misfit like the foot of a young mastiff. 
The measurements of the heart in the healthy 
adult vary considerably. In the recumbent posture 
the apex impulse is usually in the fourth space; 
it may be in the fifth. According to the physical 
development of the patient the apex impulse varies 
in its position from 7 to 10 cm. from the median 
line. In some large individuals the normal apex 
impulse may be more than 10 cm. from the median 
line, but rarely. If the impulse be impalpable, care- 
ful percussion gives us an exaggerated idea of the 
size of the heart, the dulness falling about 1 cm. 
farther out. The dulness to the right of the median 
line varies from 2.5 to 4.5 cm. in extent. 
The Movability of the Heart.-The careful ob- 
server is not deceived by the very considerable 
movability of the normal heart, but I have more 
than once seen misconceptions based on a physical 
examination made with the patient lying on the 
left side, with the resulting shifting of the apex 
impulse to a point well outside the usual position. 
The change of position of the normal heart some- 
times amounts to as much as a hand's breadth as 
the patient turns from side to side, a simple and 
obvious phenomenon but one which was never 
pointed out to me during my course as a medical 
3 student. And I remember two physicians who con- 
sulted me with grave anxiety because they had dis- 
covered their apex impulse well out toward the an- 
terior axillary line when lying on the left side in 
bed. In each instance the heart was quite normal 
in size. 
Gallops and Split Sounds.-Considerable confu- 
sion sometimes arises in connection with the in- 
terpretation of split heart sounds or with the pres- 
ence of so-called gallops. And, furthermore, gal- 
lops are often wrongly confused with split heart 
sounds. The commonest form of a split heart sound 
is the slight delay in the pulmonary second sound 
on inspiration heard at the base of the heart, better 
on the left side. In many normal individuals, for a 
few beats during inspiration alone, the second 
sound in the pulmonary area shows a slight split- 
ting, which may perhaps be represented phonetically 
by the sounds "lub-click" instead of "lub-tick." By 
carefully moving the stethoscope from side to side it 
is easy to determine that the sound which is de- 
layed is the pulmonary second, for the reduplication 
is not as a rule heard to the right of the sternum 
and the second part of the sound becomes more 
marked as one passes toward the left from the ster- 
num. It is not heard as a rule at the apex. 
The usual interpretation of the split sound is a 
delay in the pulmonic closure, because with the in- 
creased aspiration of blood into the heart with in- 
spiration, and the slight interference with ventric- 
ular contraction by the inspiratory tug, the weaker 
of the two ventricles is supposed to feel the extra 
strain a little more, and thus in some instances 
there is a slight delay in the pulmonic closure. If 
this were true, one might fancy that a split second 
sound, owing to delay in pulmonic closure, might be 
4 evidence of a weakened heart muscle as a whole and 
might be utilized as an evidence of cardiac fatigue. 
Some observations made by Galli1 on Italian soldiers 
some years ago seem to support this idea. Galli 
found on examining soldiers at the beginning of 
the day, and later on at the end of a long march, 
that there was a distinct increase in the percentage 
of split second sounds at the later period. Again, 
such split second sounds have seemed to me to occur 
rather commonly in the tuberculous and in rather 
debilitated individuals. There is, however, so far 
as I know, no positive evidence to indicate that a 
slight splitting of the second sound during inspira- 
tion alone in the pulmonary area, in the absence 
of other evidences of cardiac disturbance, need be 
regarded as a phenomenon of any special patholog- 
ical significance. 
Splitting of the First Sound.-A splitting of the 
first sound in the sense of a slight flapping charac- 
ter of the sound is rather common in instances of 
cardiac dilatation, and a first sound at the apex of 
a flapping, slightly split character should, it seems 
to me, always awaken one's suspicions. Such a 
sound is not uncommon at the xyphoid cartilage in 
apparently normal individuals and occasionally a 
suggestion of a reduplication may be heard at the 
apex, but very flapping first sounds are rarely unas- 
sociated with other definite evidences of ventricular 
weakness. 
Systolic Click.-There is another rather interest- 
ing variation in the first sound of the heart that I 
have seen in a number of instances; this is a 
peculiar little wooden click occurring immediately 
after the first sound at the apex. In the cases in 
which I have heard it, it has followed a first sound 
of normal character as an after phenomenon. It 
5 is not so loud as a second sound; it is, as it were, 
merely a single click or rattle that is generally 
rather superficial and near the ear and so closely 
associated with the sound as to seem a result of the 
shock. I have heard it in a number of patients and 
have never been able to account for it. Those pa- 
tients in which it has been heard have appeared to 
be in perfectly good health and have shown no other 
unusual signs in connection with heart or circula- 
tion. 
Gallop Rhythm.-The significance of gallops and 
their confusion with split sounds is an interesting 
question. The adventitious sounds which we speak 
of as gallops occur -at two distinct periods in the 
heart cycle. 
Proto-diastolic Gallop-Third Sound.-The first 
and commonest of these sounds is that slight, soft 
sound heard in early diastole about .15 of a second 
after the second sound, which has come to be spoken 
of as the third heart sound. This sound, as has been 
pointed out by a number of observers, is a phenome- 
non present in the majority of young people, if the 
patient be examined on his back or in the left lateral 
posture. The sound is more marked at the begin- 
ning of expiration and may be intensified by condi- 
tions which increase the intra-auricular pressure. It 
has been shown to occur exactly at the end of the 
first period of the long heart pause, the period of 
rapid ventricular filling, which has been called by 
Henderson "diastole" in contra-distinction to "dias- 
tasis," the remainder of the long pause during which 
relatively little blood enters the ventricle. In other 
words, it occurs exactly at that moment when the 
mitral valves should be brought suddenly into a posi- 
tion of tension and approximate closure, and al- 
though the nature of the sound has not definitely 
6 been proved, those observers who have studied it 
are almost unanimous in ascribing it to such a sud- 
den tension of the mitral valves. Bridgman2 has 
reproduced in cardiophonogrammes the vibrations 
associated with this sound and has established its 
time relations. In my studies3 of two hundred and 
thirty-one normal people I found the sound present 
in 58.9 per cent, of individuals over three years of 
age in the first decade, 84.4 per cent, in the second, 
50.9 per cent, in the third, 42.3 per cent, in the 
fourth. A slight proto-diastolic gallop in young 
people in the recumbent and left lateral postures 
may then be regarded as a normal phenomenon. 
Whatever the cause of this sound may be, it tends 
to disappear and become less evident in adult life, 
but with a ventricular dilatation with or without 
associated hypertrophy, the sound is apt to re- 
appear, often with considerably increased intensity; 
it is almost invariable in aortic insufficiency, where 
it initiates the rumble which we speak of as the 
Flint murmur. It is frequently present in old mitral 
disease with dilatation. It is represented by the 
so-called opening snap in mitral stenosis, and es- 
pecially is it striking in old dilatations associated 
with chronic myocardial disease, where not infre- 
quently it is the loudest of the three heart sounds. 
The appearance in an enlarged and a dilated heart 
of a well-marked proto-diastolic gallop is, it seems 
to me, of very considerable prognostic significance. 
A well-marked proto-diastolic gallop is one of the 
gravest indications of severe cardiac dilatation. 
Here then is a sound which at one end of the 
scale, in the young, in association with hearts of 
normal size and of apparently normal functional 
capacity, is of no pathological significance, while at 
the other end of the scale, in the older individual 
7 and in association with dilatation it becomes an 
evidence of grave muscular failure. The presence 
of a third sound in itself, then, tells us little. When 
taken in connection with the associated phenomena 
it may be of considerable prognostic importance. 
In the young, other things being equal, it may be 
regarded as a normal phenomenon. 
Presystolic Gallop.-In the other form of gallop 
the adventitious sound precedes the first sound and 
is associated in time with the auricular contraction. 
It is sometimes audible in young, healthy individ- 
uals, but by no means so frequently as is the third 
sound. Its significance, however, is essentially the 
same in the sense that a very slight suggestion of 
a presystolic sound in an otherwise entirely healthy 
young individual is of no pathological significance. 
When heard, it is only at the limit of audibility. 
Pathologically, however, this* sound becomes accen- 
tuated under definite conditions, namely, in hyper- 
tension and cardiac hypertrophy. So constant is it 
under these circumstances that by many observers, 
especially in France, it has been regarded as a diag- 
nostic sign of slow chronic nephritis, the condition 
par excellence in which hypertension and hyper- 
trophy exist; but it may equally well be present in 
hypertension and hypertrophy without grave renal 
disease, and that such cases occur need not be em- 
phasized here. 
A presystolic gallop, then, if slight and unasso- 
ciated with hypertension or other evidences of car- 
diac disease, need not be regarded as of pathological 
significance. A sound heard at the apex at the 
period of auricular contraction, dull, slight, barely 
within the limits of audibility, is an occasional 
phenomenon in the healthy individual, but its pres- 
ence in association with an unduly forcible apex 
8 impulse or an enlarged heart should lead us to 
suspect what the finger may well have detected be- 
fore-a hypertension. 
Systolic Murmurs.-The phenomena which most 
commonly cause anxiety and doubt in the examina- 
ation of supposedly healthy individuals are the 
cardiac murmurs. Normally it is assumed that the 
heart sounds are clear. But this is by no meaps 
always the case. In a very large proportion of 
young individuals cardiac murmurs are present in 
perfect health. These are almost always systolic in 
time and the commoner forms are represented by 
(1) The basic pulmonary systolic murmurs; (2) 
The apical murmurs, disappearing in the erect pos- 
ture, and (3) The cardio-respiratory murmurs. 
Systolic Murmurs in the Pulmonary Area.-It is 
familiar to those who examine many healthy indi- 
viduals that a fairly loud systolic murmur is often 
heard in the pulmonary area and over the right 
ventricle. Very often the murmur is heard all over 
the cardiac area with the greatest intensity in the 
pulmonary area. Such murmurs are often unasso- 
ciated with anaemia or with any evidence of cardiac 
disease. They are especially common in the first 
and second decade and are generally louder in the 
recumbent posture. They may entirely disappear 
in the erect posture, and are almost always dimin- 
ished greatly in intensity by full inspiration; in a 
large proportion of cases this maneuver results in 
their complete disappearance. Sometimes, as Dr. 
E. G. Janeway4 has pointed out, they may be 
brought out, and always they may be increased by 
forced expiration. They have no pathological sig- 
nificance and need cause no anxiety to the examiner. 
Apical Systolic Murmurs.-Most men are reason- 
ably familiar with the significance of these basic 
9 murmurs, but I have been much impressed with the 
common lack of appreciation of the great frequency 
of like murmurs at the apex. These murmurs are 
usually, but not invariably, associated with basic 
murmurs. The heart sounds themselves are gen- 
erally of a normal character excepting that the first 
sound at the apex is followed by a slight, or fairly 
distinct whiff; this may or may not be transmitted 
toward or even into the axilla; it is often intensified 
in the left lateral posture. During my studies of 
the third heart sound I had occasion to examine 
two hundred and eighteen apparently healthy indi- 
viduals in the first four decades of life. Of these, 
seventy-three, or about one-third, showed systolic 
murmurs at the apex in the recumbent posture. The 
following table illustrates their frequency by 
decades: 
Decades (Over 3 years of age) 12 3 4 
Cases 39 98 55 26 
Murmurs present 22 35 12 5 
56.4% 35.7% 21.8% 19.2% 
The interesting feature in connection with this 
phenomenon is that so soon as the patient stands up 
the murmur disappears at the apex and almost al- 
ways diminishes in intensity or disappears if pres- 
ent before, at the base. This is a very important 
point, for as a rule, in true mitral disease the mur- 
mur if modified becomes a little louder in the 
erect posture. At the same time that I was making 
these studies I examined thirty healthy boys at a 
well-conducted private school just outside of Balti- 
more. All these boys were in the second decade and 
in good physical condition. Eighteen of the thirty 
showed cardiac murmurs of one sort or another. In 
thirteen a soft systolic murmur was heard all over 
the cardiac area in the recumbent or left lateral 
10 posture. Three showed basic systolic murmurs dis- 
appearing on full inspiration. One showed a basic 
systolic murmur, present in the recumbent posture 
alone. One showed a basic systolic murmur with 
no evident change on respiration. There was, how- 
ever, no other suggestion of cardiac involvement 
and it was regarded as probably functional. In 
the thirteen boys who showed a systolic mur- 
mur at the apex as well as the base, the mur- 
mur disappeared invariably in the erect pos- 
ture. Not very infrequently such a systolic murmur 
may be present at the apex without the associated 
basic systolic, but if it disappear in the erect posture 
and there be no other signs of cardiac involvement, 
there is no reason to regard it as of any pathological 
significance. 
To what are these murmurs due? The cause of 
the basic systolic murmur has been much discussed 
and it would be hardly profitable to enter into the 
matter at any great length in a talk such as this. It 
is, however, worth remembering always that consid- 
ering the structure of the aortic and pulmonic rings 
-more or less firm fibrous bands with a distensible 
vessel beyond and a ventricle whose contents varies 
somewhat in amount and whose contraction varies 
probably somewhat in force and rapidity on the 
other side-with these anatomical and physiological 
conditions, it is not remarkable that there should 
be occasional systolic murmurs at aortic and pul- 
monary orifices without structural changes; on the 
other hand it is very remarkable they should not 
always be present. MacCallum and I in our studies 
in dogs,8 were struck with the ease with which one 
might produce a systolic murmur over the conus 
by the very slightest pressure, and I have been in- 
clined to ascribe the frequency of such murmurs 
11 in young individuals in part at least, to the pressure 
of the pulsating conus against the ribs during ex- 
piration, the disappearance of the murmur during 
inspiration being accounted for possibly by the in- 
terposition of a soft cushion of lung. However this 
may be, such murmurs are devoid of pathological 
significance. 
As to the cause of the systolic murmurs at the 
apex one can only speculate. I have been inclined 
to regard such murmurs as due, in some instances, 
to a simple transmission of the basic murmur, in 
some, to a true mitral insufficiency-a mitral insuffi- 
ciency associated with posture. It may, however, 
well be asked, if this is the case, why should the 
frequency of these murmurs diminish with advanc- 
ing years-a question not easy to answer. 
Systolic Apical Murmurs in the Left Lateral Pos- 
ture.-In studying the third sound I have been much 
interested in a phenomenon which I have not seen 
mentioned in medical literature, namely, the intensi- 
fication of an apical systolic murmur when present, 
and its production in some instances where it has 
not been present before, by placing the patient in 
the left lateral posture. This has raised the ques- 
tion which I am not prepared to answer, but put 
forth simply as a possibility, whether the left lateral 
posture may not normally be one in which the heart 
is placed somewhat at a disadvantage and in which 
a functional mitral insufficiency may be favored. 
One is reminded of the rather common assertion by 
patients who are suffering from cardiac diseases 
with insufficient mitral valves, that the left lateral 
posture is peculiarly uncomfortable. Such com- 
plaints, of course, may well be due in some instances 
to the consciousness of the patient of the throbbing 
of his enlarged heart, or, in others, to the presence 
12 of a right hydro-thorax, but I am not sure that yet 
another element may not enter into the condition. 
If it should be true that in normal individuals the 
torsion of the heart in the left lateral posture pro- 
duces a slight functional mitral insufficiency, then 
in the existence of organic disease of the valve, 
one might expect the symptoms to be intensified in 
this decubitus. It is a question worthy of further 
study. 
Cardio-respiratory Murmurs.-Cardio-respiratory 
murmurs are, as a rule, easily recognized by the 
careful student. Nevertheless, they give rise not in- 
frequently to confusion. A murmur present only 
at one phase of respiration, disappearing at other 
times and associated with no other evidence of car- 
diac disease need cause little alarm. Generally if 
the observer listen carefully, he will recognize in 
the sound an intensification of the respiratory mur- 
mur rather than a true endocardial sound. Espe- 
cially common is this of the systolic inspiratory car- 
dio-respiratory murmurs, which are often heard not 
only in the cardiac area, but with considerable in- 
tensity in the back. I have seen several instances 
in which the condition of the heart has been ques- 
tioned in young people seeking entrance into army 
or navy because of a loud systolic murmur heard in 
the back after exercise. This is really very com- 
mon in young people. If the boy be made to run 
about until he become a little short of breath or 
until his pulse rate becomes somewhat accelerated, 
and then, while the heart is still beating rapidly 
and forcibly and the respirations are deep, one listen 
in the back, several beats with each inspiration will 
be found to be associated with that which sounds 
somewhat like a loud systolic souffle. On careful 
observation, however, this will be found to consist 
in a systolic intensification of the inspiratory mur- 
13 mur-a pulmonary and not a cardiac sound. Such 
a phenomenon is obviously of no pathological im- 
portance. 
With regard then to cardiac murmurs, it would 
seem to be important to remember that the basic, 
especially pulmonary-systolic murmurs heard often 
all over the heart, which are loud in the recumbent 
posture, diminished or absent in the erect posture 
and disappear or are greatly reduced with inspira- 
tion, and are unassociated with other evidence of 
cardiac disease-that such murmurs are of no diag- 
nostic significance and may be dismissed from one's 
consideration. Secondly, that systolic murmurs fol- 
lowing an otherwise normal first sound at the apex, 
and usually associated with such basic murmurs are 
very common; that these murmurs, if they disap- 
pear in the erect posture and are unassociated with 
other signs of cardiac involvement may also be dis- 
regarded. Thirdly, that one should be on his guard 
against being misled by cardio-respiratory murmurs, 
which are very common, especially the systolic car- 
dio-inspiratory murmur accentuated after exercise. 
Diastolic functional murmurs, if they exist, are so 
rare that they may be dismissed from consideration. 
An individual with a diastolic murmur is always 
an object of suspicion. One may, however, perhaps 
except those instances in the young, especially in 
children, in which the third sound at the apex is 
peculiarly dull and rather humming. 
Arrhythmias.-Peculiarities of rhythm are par- 
ticularly apt to give rise to controversy. For one 
reason or another it is too often assumed that 
arrhythmia of any sort is evidence of disease of the 
heart muscle, and the rather loosely employed term 
"myocarditis" is applied far too frequently to the 
hearts of individuals whose arrhythmia proves to 
be of little pathological significance. 
14 Respiratory Arrhythmia.-The commonest ar- 
rhythmia is that associated with respiration, which 
in children, in the young, and in the neurotic 
is often rather exaggerated. The ordinary respira- 
tory arrhythmia is, however, of absolutely no path- 
ological import. A heart which beats more rapidly 
at the beginning of inspiration and becomes much 
slower for several beats during expiration, need not 
for that reason be an object of suspicion. If poly- 
graphic or electrocardiographic studies show a nor- 
mal sequence of the contractions of auricle and 
ventricle, there is no cause for anxiety. In some 
children and young people in the bradycardia fol- 
lowing an acute disease this phenomenon is very 
striking and gives rise to unnecessary anxiety. 
Other Sinus Arrhythmias.-Again those other 
sinus arrhythmias not exclusively associated with 
the respiration, instances in which the heart may be 
as irregular as that of a dog, are of real importance. 
An arrhythmia of this sort, if polygraphic and elec- 
trocardiographic studies show no abnormalities in 
the complexes, and a normal sequence of auricular 
and ventricular beats, provided there is no other 
evidence of cardiac disease, is of no special patho- 
logical significance. Such cases are not especially 
frequent, but they are not very uncommon. 
I remember two interesting examples. One a pa- 
tient that I saw during a visit in a distant city, who 
was at the beginning of her first pregnancy. It 
was before the days of regular polygraphic studies. 
Her physician, however, had recognized and appre- 
ciated the condition and asked me to see her merely 
to confirm his assurances that there was no reason 
for interrupting the pregnancy. The patient was 
a young and otherwise healthy woman and had never 
shown symptoms suggesting cardiac impairment. 
So far as could be determined her pulse had always 
15 been irregular. At the time that I saw her there 
was a very marked, unanalyzable irregularity, the 
beats following one another with little order or 
rhythm. But there was no tachycardia, no cardiac 
enlargement, no modification of the heart sounds; 
and in the patient's history there was nothing to 
suggest functional impairment. She was sent away 
to a cooler climate for the summer and there came 
under the care of a conscientious physician who be- 
came greatly alarmed at the condition, frightened 
the family to death and sent them home with direc- 
tions that the pregnancy should be immediately in- 
terrupted-which happily was not done. The pa- 
tient passed through the pregnancy uneventfully 
and has since then had several children. Later on, 
her physician was able to prove by polygraphic 
studies that it was a true sinus arrhythmia. 
I have recently seen a gentleman who had a severe 
aureus infection resulting in abscesses in different 
parts of the body and possibly in an endocarditis. 
He had a very irregular pulse. While on a trip 
away from home he fell into the hands of a physician 
who, on the basis of his irregularity, made an im- 
mediate diagnosis of grave cardiac involvement and 
of probable septic endo- and myocarditis. There 
were no definite signs of endocardial involvement, 
but the irregularity when taken in connection with 
the other symptoms seemed to this observer con- 
clusive. Polygraphic tracings, however, showed a 
perfectly normal auriculo-ventricular sequence; in- 
quiry showed that the pulse had been irregular 
throughout his life, and at the moment the patient 
is apparently recovering without further evidence 
of cardiac involvement. 
Sinus arrhythmia is usually easily recognized 
with a high degree of probability by means of care- 
ful inspection of the cervical veins and by ordinary 
16 polygraphic tracings; with certainty by electro- 
cardiograms. 
Extrasystoles.-That form of arrhythmia, how- 
ever, which gives rise perhaps to the most interest- 
ing questions is that associated with precocious 
systoles. 
Extrasystoles are among the commonest manifes- 
tations met with by the physician and among the 
most difficult, often, to interpret. Must a heart 
showing precocious systoles, ventricular or auricu- 
lar, be regarded as diseased? Must an individual 
with occasional so-called intermissions be refused 
insurance or considered unsuitable for admission to 
army or navy ? This is one of the hardest questions 
for the physician to answer. 
Friedrich Muller, it may be remembered, at a 
Harvey lecture some years ago, expressed the feel- 
ing that extra systoles usually indicated a heart 
which was, as it were, in dis-harmony with its sur- 
roundings, in which there was a lack of relation 
between the power of the heart and the demands 
which were placed upon it. 
Precocious systoles may be produced by electrical 
stimulation of auricle or ventricle or bundle, or may 
arise as the result of focal disease of the muscle. 
They are unquestionably common as early symp- 
toms of hypertension and they are frequently pres- 
ent in the failing heart in grave infections and 
sometimes in valvular or in muscular disease ap- 
proaching decompensation. They are often, then, 
concomitants of true cardiac disease. 
Moreover, in most instances extrasystoles give 
rise to considerable discomfort and mental distress 
in the patient, and, if they are numerous, to some 
real temporary impairment of the cardiac function, 
for a heart the rhythm of which is interrupted by 
frequent precocious contractions is certainly not ac- 
17 complishing its work under the most favorable con- 
ditions. 
Nevertheless, every practitioner of experience 
must acknowledge that precocious systoles are 
common in patients who show no other man- 
ifestations of cardiac disease. They are very 
often met with in individuals who are under serious 
nervous or mental strain. Who has not seen the 
overwrought clergyman who has been distressed and 
alarmed by extrasystoles coming on in the pulpit or 
before the period when he was obliged to appear in 
public? They are frequently seen at the time of 
the menopause. There is abundant clinical evidence 
to prove their relation to certain circulating poisons 
such as tobacco and perhaps to coffee. Again every- 
body is familiar with their frequency in young in- 
dividuals, following an unduly large meal. In some 
of these instances the extrasystoles persist through 
many years without having the least apparent effect 
on the functional capacity of the heart. In other 
instances they disappear entirely on removal of the 
apparent exciting cause. 
I remember well one striking instance of extra 
systolic irregularity at the period of the meno- 
pause-a rather tired, thin, nervous looking woman 
who was greatly distressed by the unpleasant sensa- 
tions and convinced that she had grave cardiac dis- 
ease, of which I could find no evidence whatever. I 
saw her several times and was unable to comfort 
her. Several years later at a theatre a plump and 
pleasing looking person bowed to me from a box. 
I had no idea who she was but afterward discovered 
that she was my late patient. With the comple- 
tion of the menopause her extrasystoles had disap- 
peared, she had gained from fifteen to twenty 
pounds and had grown at least ten years younger. 
How many, I wonder, among those here to-night 
18 who consider themselves in good physical condition 
as to their circulatory apparatus, can remember to 
have suffered from extrasystolic irregularities fol- 
lowing an unusually large dinner. I remember very 
well having earned such a dinner nearly thirty 
years ago on a bet that I could produce the so- 
called intermissions if my friend would foot the 
bill. 
I have known medical students with apparently 
perfectly normal hearts who have already lived 
many years as healthy men, who noticed extra sys- 
toles when in the course of their studies they were 
placed in positions of unusual responsibility. 
The extrasystole, then, may be the evidence of 
a disproportion between the demands upon the 
heart and its power, or of hypertension; it may 
be the result of an abnormal mechanical irritant, 
perhaps of actual myocardial change. On the other 
hand, the abnormal irritant may be of no grave 
pathological significance, such as an over-full 
stomach. Extrasystoles may be evidence of an 
increased irritability of the heart muscle under cer- 
tain general nervous conditions or in the presence 
of circulating poisons such as tobacco. In other 
words, there seems to me to be excellent clinical 
evidence that certain poisons, especially tobacco, 
digitalis, perhaps coffee, mental over-strain, gas- 
tric distention such as one sees after a full meal, 
sexual indulgence, and the conditions associated 
with the menopause in particular, are very com- 
monly associated with transient extrasystolic ir- 
regularities-irregularities which are apparently 
unassociated with organic cardiac disease. 
Extrasystolic irregularity is then a manifesta- 
tion which in itself gives no evidence as to the state 
of the heart muscle or the limits of the cardiac 
power. If a patient show no cardiac hypertrophy, 
19 no evidence of peripheral vascular sclerosis in ap- 
proachable arteries or in the eye-grounds, if the 
heart responds normally to exercise with, as is com- 
monly the case, a temporary disappearance of the 
extrasystoles-under these circumstances one need 
not assume the existence of any serious cardiac de- 
fect. Like so many other questions with regard to 
cardiac diagnosis and prognosis, the interpretation 
of the significance of extrasystoles is one that can 
be decided only in connection with the individual 
case. Polygraphic and electrocardiographic study 
of such cases is distinctly helpful, and electrocar- 
diographic studies in particular should in the future 
bring us valuable information. Lewis,7 as is well 
known, has observed that numerous extrasystoles 
precede sometimes the onset of auricular firbilla- 
tion; numerous auricular extrasystoles, in par- 
ticular, may precede the onset of flutter, and in 
some instances of flutter which has yielded to treat- 
ment, my friend Dr. Bridgman tells me he has ob- 
served the persistence of auricular extrasystoles. 
In a general way the occurrence of auricular 
extrasystoles has seemed to me, although it would 
be difficult positively to justify this impression, a 
rather graver phenomenon than the presence of ven- 
tricular extrasystoles. As I have said, the accumu- 
lation and correlation of large numbers of electro- 
cardiographic records should give us important 
prognostic help, but at the present moment I can- 
not feel that it has added very much which might 
influence one's clinical impressions. 
Those occasional instances of multiple extra- 
systoles with very varied complexes, cases which 
on first examination suggest from the high degree 
of irregularity an auricular fibrillation, such cases, 
though they may yield with extraordinary rapidity 
and for considerable periods of time to rest, can- 
20 not but leave one with a feeling of doubt as to the 
integrity of the cardiac muscle. But in cases where 
the extrasystoles are not very numerous, even 
though they may last over considerable periods of 
time, I am not aware that one is justified in drawing 
any particular conclusions from the complexes 
found in electrocardiographic records. One might 
fancy that extrasystoles showing the same com- 
plex through years might be interpreted as in- 
dicating the existence of a given focal lesion. 
One might fancy that similar extrasystoles show- 
ing entirely different complexes might suggest a 
general hypersensitiveness of the cardiac muscle. 
On the other hand, one might fancy that extrasys- 
toles of extremely varying complexes represented 
multiple organic foci of muscular irritation. These 
are questions which it seems to me cannot as yet be 
answered. 
Clinically I feel strongly that in most instances 
it is impossible positively to determine the condi- 
tions which govern the onset of extrasystoles, and 
I quite agree with Wenckebach8 that we should not 
regard their occurrence as certain evidence of defi- 
nite conditions in the heart. If, however, they are 
present to a moderate extent in an individual in 
early or middle life or during the menopause, espe- 
cially at qight and during periods of strain and 
mental anxiety or after eating a full meal, if there 
be no hypertension, no dyspnea on exertion, or 
no other evidences of cardiac disease, they need 
not be regarded as of any real pathological 
significance. If there be evidence of hypertension 
or of vascular sclerosis or of hypertrophy or dilata- 
tion or of functional cardiac insufficiency, one must 
be much more guarded in his prognosis. This 
much, however, must be remembered: extrasys- 
toles occur very often in apparently normal indivi- 
21 duals, and unless there is some definite reason to 
suspect grave organic disease as a cause we need 
not be unduly alarmed by their presence. 
Let us now summarize the several deviations from 
the ordinary of which I have spoken. 
1. In the first place reference has been made to 
what I believe to be a truth-namely, that in the 
growing boy the heart is often disproportionately 
large as compared with the general physical de- 
velopment. Such a condition is in no sense alarming 
if the boy is about at puberty, unless the heart is 
really larger than it should be in the adult. 
2. The striking movability of the normal heart 
has been mentioned-a circumstance not always ap- 
preciated. 
3. The common reduplication of the second sound 
during inspiration, a reduplication dependent on 
delay in the closure of the pulmonary valves, while 
present in a good many apparently normal indivi- 
duals, may perhaps be regarded as confirmatory 
evidence of muscular weakness, if present through- 
out the cycle or in association with other signs of 
cardiac disease. It is a phenomenon deserving of 
more careful study. 
4. It has been pointed out that a slight proto- 
diastolic gallop-a third sound-is audible in a 
large proportion of young people in the recumbent 
or left lateral posture; that without other evidence 
of cardiac disease this may be regarded as a per- 
fectly normal phenomenon; that in a few young 
people a faint presystolic gallop may be heard; that 
such a sound, if very slight and unassociated with 
other evidence of disease, is also of no pathological 
significance. It has further been observed that a 
protodiastolic gallop of considerable intensity is a 
common association with, and of grave prognostic 
import in, ventricular dilatation; while a presystolic 
22 gallop is the rule in marked hypertrophy with hy- 
pertension. 
5. Reference has been made to the entire lack of 
pathological significance of the common systolic 
murmurs in the pulmonary area, accentuated or 
produced during expiration and disappearing with 
inspiration. 
6. Attention has also been called to the great fre- 
quency of similar murmurs at the apex in the young 
in the recumbent and left lateral posture, and the 
belief has been expressed that when such murmurs 
disappear in the erect posture and are unassociated 
with other evidences of cardiac disease, they are of 
no pathological significance. 
7. The frequency of cardio-respiratory murmurs 
has been emphasized, especially the loud systolic 
inspiratory murmur so commonly heard in the 
young, in the back after exercise, murmurs which 
are not intracardial in origin and are indicative of 
no abnormality. 
8. The complete absence of any pathological sig- 
nificance in respiratory arrhythmia has been re- 
ferred to, as well as the importance of recognizing 
the occasional sinus arrhythmias unassociated with 
but often accentuated by respiration, phenomena 
which are often physiological curiosities rather than 
pathological manifestations. 
9. Finally, the significance of extrasystolic ir- 
regularities has been briefly discussed and the be- 
lief expressed that they are in many instances asso- 
ciated with conditions pointing to an unstable nerv- 
ous system or to other general influences, such for 
example as intoxications-tobacco, digitalis-which 
may hypothetically increase the cardiac irritability 
without the production of true organic lesions. 
Clinically such cases appear to be common. On 
23 the other hand extrasystoles are often associated 
with actual myocardial lesions or with hypertension 
or with mechanical cardiac defects. In smokers, in 
the neurotic, in women at the menopause, in indi- 
viduals who have been subject to special mental 
strain, if there be no other evidence of cardiac in- 
sufficiency or disease, the extrasystole may be re- 
garded as of little importance, but where the heart 
is enlarged, in the presence of obvious vascular 
sclerosis or where, with extrasystoles which have 
not been frequent enough to produce of themselves 
much impairment of function, there is yet evidence 
of diminished cardiac capacity, the extrasystole 
should be regarded as a possible evidence of anatom- 
ical myocardial change. The hope has been ex- 
pressed that electrocardiographic studies may in 
time give us important prognostic help in such in- 
stances. 
1. Galli: Ueber die Leistungsfahigkeit des Herzens, 
Miinchener med. Wochnschr., 1902, Vol. XLIX, pp. 953, 
1005, 1049. 
2. Bridgman: Observations on the Third Heart 
Sound, Heart, London, 1915, Vol. VI, p. 41. 
3. Thayer: Archives of Internal Medicine, Chicago, 
1909, Vol. IV, p. 297. 
4. Janeway: Trans. Assn. Amer. Phys., Philadel- 
phia, 1906. Vol. XXI, p. 61. 
5. MacCallum and Thayer: ibid., p. 52. 
6. Muller: Archives of Internal Medicine, Chicago, 
1908. Vol. I, p. 1. 
7. Lewis: Clinical Disorders of the Heart, London 
and New York, 1914. 
8. Wenckebach: Die unregelmassige Herztatigkeit, 
etc., Leipzig and Berlin, Engelmann, 1914. 
406 Cathedral Street. 
REFERENCES. 
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THE SOUTHERN MEDICAL JOURNAL 
Journal of the Southern Medical Association 
Birmingham, Alabama 
Vol. X 
MAY, 1917 
Pages 367-371 
No. 5 
THE MANAGEMENT OF THE EARLY 
STAGES OF HYPERTENSIVE 
CARDIO-VASCULAR 
DISEASE* 
By W. S. Thayer, M.D., 
Baltimore, Md. 
In that part of this discussion which has 
been allotted to me it has seemed to me 
well to treat of a special class of cases out 
of the very large number of possible con- 
ditions which might be included under the 
heading of "cardio-vascular-renal dis- 
ease,"-essentially the same sort of case 
to which Dr. Barker has referred at the 
opening of the discussion. In a word, I 
shall discuss the management of those 
common instances of hypertensive cardio- 
vascular disease, with or without marked 
renal or arterial change, which so often 
come into the hands of the physician. 
*Read in Section on Medicine, Symposium on 
Cardio-Vascular-Renal Disease, Southern Med- 
ical Association, Tenth Annual Meeting, Atlanta, 
Ga., Nov. 13-16, 1916. 2 
And, moreover, I shall limit myself to the 
management of hypertensives who come 
under our observation at a stage before 
there has been serious cardiac failure- 
The instances of hypertensive cardio- 
vascular disease which consult the physi- 
cian at a time when the heart is still in 
reasonably good functional condition may 
roughly be divided into three classes: 
1. Those patients with little or no evi- 
dence of vascular or renal change who 
show a beginning or well-marked hyper- 
tension. 
2. Those cases that show some albu- 
minuria as well as more or less demon- 
strable changes in the peripheral arteries 
or those of the eye-grounds. 
3. Those instances associated with well- 
marked renal change with impairment of 
function, polyuria, decreased 'phthalein 
output, fixation of the specific gravity. 
Many of the patients belonging to all 
these groups consult the physician because 
during the examination for insurance, or 
for entry into some mutual benefit organi- 
zation, an unsuspected hypertension is de- 
tected. Others may have noticed a throb- 
bing of the vessels, especially at night, or 
a slight vertigo, or headaches, or, perhaps, 
a little dyspnoea on exertion. These men, 
as we all know, are very apt to be persons 
of a nervous temperament who have been 
heavy smokers or eaters or engaged in an 
occupation involving tense mental effort or 3 
physical strain. It is in the stevedore on 
the one hand or in the overwrought stock 
broker on the other hand that such pic- 
tures are especially common. 
With regard to all three classes of pa- 
tients there are certain points of treat- 
ment in this stage of the disease which 
we may consider in common. 
REGULATION OF THE MANNER OF LIFE 
In the first place one can not too strongly 
emphasize the truth that at this time more, 
often, can be accomplished for the patient 
by a deliberate, careful inquiry into the 
habits of life and surroundings and by a 
quiet, earnest exposition of the proper 
course that he should pursue than by any 
medical treatment that can be suggested. 
Time is often the most important service 
that a physician can give such an individ- 
ual. 
At the outset let the patient see to it 
that he begins the day deliberately. Many 
nervous hypertensives start out on their 
daily routine in a rush. One should find 
out the length of time that the patient 
takes to dress and should see to it that he 
gets up early enough in the morning to 
dress without hurry; often it is well 
to advise him to read the newspaper 
while dressing. Many a man can train 
himself into less hasty, more reasonable 
habits and can make his day materially 
more comfortable by getting up a quarter 4 
or a half an hour earlier in order that he 
may dress and prepare for the day delib- 
erately. 
Let him take plenty of time for his 
breakfast and especially see to it that his 
regular morning habits be not interfered 
with by undue hurry. Let him then learn 
to watch himself, to talk to himself, to 
check himself when he finds himself run- 
ning upstairs two steps at a time or walk- 
ing along the street or about the house at 
an unnecessarily rapid pace. Endeavor to 
impress upon him the truth that he can 
save time and a headache by writing de- 
liberately. 
According to the circumstances, it may 
or may not be wise for him to walk to his 
place of business, but let it be clearly un- 
derstood that however much good the ex- 
ercise may do him, anything that starts 
him on a career of hurry is harmful. 
Let him be extremely deliberate in his 
eating. If he take his meals alone, let 
him cultivate the habit of reading a news- 
paper or a book at table if that be neces- 
sary to keep him from habits of bolting 
his food. 
Let him avoid the drinking of an undue 
quantity of fluid at meal times. In gen- 
eral, it is wise to restrict such a patient 
to a half glass of water at meals, however 
much it may be well for him to drink in 
the day. Let him see to it that he take 
at least an hour in the middle of the day for his luncheon or dinner, and that he 
have not less than fifteen minutes' rest 
after he has left the table. 
5 
TOBACCO 
Inquire carefully into his habits as to 
tobacco. There can be little doubt that 
too many strong cigars are very harmful 
to many hypertensives; but the question 
as to whether tobacco shall be forbidden 
or not depends entirely upon the patient. 
To many men who have been habitual 
smokers the complete prohibition of to- 
bacco is an unnecessary hardship. Such 
patients may often be allowed a cigar 
after each meal, but rarely more. 
The way in which a man smokes is also 
extremely important. To many men, the 
smoking of a mild cigar while at rest after 
a meal is a soothing and beneficial pro- 
cedure, while to hurry from the table and 
smoke the cigar while engaged in active 
mental or physical work is exciting and 
harmful. Let the patient understand that 
his cigar, if it be allowed, must be smoked 
during a period of complete relaxation, 
reading or conversation or rest. 
With many individuals it is wise, how- 
ever, to advise abstinence from tobacco. 
This applies especially to those who can 
not smoke at all without smoking to ex- 
cess. It is also true of some patients who 
show annoying and persistent extra sys- 
tolic irregularities or of those who "feel," 
though they may enjoy, even a light cigar. 6 
DIET 
As to diet, much depends upon the indi- 
vidual. It is well to inquire carefully as 
to the habits with regard to tea and coffee 
and as to their effects. The overstimula- 
tion that some nervous men experience 
after strong coffee or tea it is most impor- 
tant to avoid. Sometimes the patient 
recognizes this; sometimes he may not. It 
is generally wise to encourage the taking 
of the morning coffee well diluted with 
boiled milk as cafe au lait, and to allow 
only a small cup after the main meal. 
Those who are conscious of overstimula- 
tion should avoid it altogether or substi- 
tute for it one of the decaffeinized prod- 
ucts. The same considerations apply to 
tea. 
If there be no evidence of essential renal 
involvement, one need impose no special 
restrictions with regard to diet excepting 
moderation in the amount eaten at one 
time and in the quantity of animal food, 
allowing eggs in the morning, at the main 
meal a moderate quantity of meat or fish 
of any sort, while at the third meal as a 
rule no meat should be permitted. With 
such patients it is often well to establish 
the habit of a light breakfast in which the 
only animal food consists of a little bacon, 
and permitting eggs at the third meal, 
luncheon or supper. 
If there be evidence of a decided renal 
involvement or of intestinal putrefaction, 7 
it may be well still further to restrict the 
proteins, allowing animal food at but one 
meal in the day and then in very mod- 
erate quantity, or even restricting this to 
several meals in the week. If the patient 
take a light breakfast, a glass of butter- 
milk in the middle of the morning or an 
early lunch may be wise. 
The amount of fluids that should be 
taken is often an interesting question. As 
a general rule in hypertension it is unwise 
to advise excessive drinking. Often it is 
well to restrict the total fluids to 2,000 
or even 1,200 c. c. in the 24 hours. 
ALCOHOL 
With regard to alcohol, the question is 
an interesting one. There is little to show 
that alcohol is directly responsible for the 
development of hypertension, but there is 
a good deal of reason to believe that that 
which is induced by or associated with an 
immoderate use of alcohol is injurious, 
namely, heavy eating, smoking, exercise, 
excitement, sexual excess. In a young 
man it is always well to advise extreme 
moderation, if not complete abstinence 
from alcohol, for we know how small an 
amount is actually utilized to the benefit 
of the average healthy man. With older 
people, particularly those who have been 
in the habit of drinking moderately, the 
permission of a little light wine with 
meals or a little regular alcohol in the 
shape of whiskey or beer is certainly not 8 
so harmful as to justify interference with 
established habits that mean much to the 
comfort of the patient. 
With many of these patients moderate 
out-of-door exercise is very helpful. The 
man who has been an enthusiastic golfer 
need not be forbidden his exercise because 
of a tendency to hypertension. .If such a 
patient can arrange to get off from his 
business two or three times a week early 
enough to play deliberately a round of 
golf, he may be greatly benefited. Often, 
however, in our cities, the active business 
man has not the opportunity to go out on 
the links. For such a man or for one 
whose symptoms have been so marked that 
even the exercise of moderate golf seems 
too much, hydrotherapy and massage are 
extremely beneficial. Where a well-con- 
ducted hydrotherapeutical establishment is 
at hand, let the patient arrange three times 
a week to leave his office a little early and 
to give an hour or an hour and a half to 
hydrotherapy. A warm salt tub bath, a 
salt rub, an intermittent hot and cold 
douche, a good general massage followed 
by a sufficient period of rest, will in the 
long run give the patient without much 
effort on his part, much of that which a 
game of golf might otherwise have given 
him. 
Riding is a particularly valuable form 
of exercise for these patients. Where it is 
PHYSICAL EXERCISE 9 
possible, a ride on horseback at the end 
of the day is most beneficial. After a ride 
and a bath the strain of the busy hours 
vanishes. Old Cotton Mather wisely said: 
"The saddle is the seat of health." 
AVOIDANCE OF CONSTIPATION 
It is extremely important to establish 
regular habits as to the stools. If there 
be a tendency to constipation the eating of 
fruit, especially citrous fruits at night, 
and of coarse vegetable foods, is very help- 
ful. Such a patient should be carefully 
trained in his habits. He should be taught 
that it is inadvisable to allow himself to 
have a movement of the bowels at any 
other than the regular established time, 
and if assistance be necessary, he should 
restrict himself to the use of non-irritating 
substances such as agar-agar, one or two 
teaspoonsful of the coarse powder three 
times a day with his meals or a tablespoon- 
ful or two of one of the mineral oils at 
night, or in some cases both. It is aston- 
ishing how many people who have re- 
garded it necessary to take a regular lax- 
ative can train themselves into habits of 
perfect regularity by obeying these gen- 
eral rules. If the patient be one who 
travels considerably he should make it a 
rule to carry with him on his trips a bottle 
of glycerine suppositories, one of which, 
if necessary, he may use at the regular 
hour on the railway train. 10 
It is important to search for and to en- 
deavor to remedy any source of local irri- 
tation or strain. It is particularly advis- 
able to be sure that errors of refraction 
are properly rectified. Attention should 
also be directed to focal infection in the 
nasopharynx and accessory sinuses, teeth, 
as well as to digestive disturbances. 
LOCAL FOCI OF IRRITATION 
MEDICAL TREATMENT OF HYPERTENSION 
Medical treatment directed toward mod- 
ifying a hypertension as such is rarely 
necessary and is sometimes harmful. The 
exact physiological significance of hyper- 
tension is by no means clearly understood 
and to give the nitrites at random to 
"knock down the blood pressure" as the 
common phrase runs, is not a rational pro- 
cedure. Hypertension is an indication of 
some functional or anatomical bodily ab- 
normalities, often of the kidneys, some- 
times of the vascular apparatus, but it is 
by no means clear that the hypertension 
itself may not in some instances be a con- 
servative phenomenon. In cases with 
grave renal involvement a fall in blood 
pressure often precedes or ushers in the 
manifestations of uraemia, and a rise is not 
uncommonly seen in connection with con- 
valescence. Some of us have seen in- 
stances in which uraemia has followed so 
immediately upon the artificial reduction 
of blood pressure as to suggest strongly 
that our ill-considered attempts at therapy 11 
may have been responsible for its onset. 
HEADACHE 
Headache is often an annoying, and 
sometimes a baffling symptom. It may be 
due to errors of refraction or to sinus dis- 
ease; it may depend upon constipation or 
other digestive disturbances; it may be an 
evidence of an associated nephritis; it may 
depend upon the high nervous tension of 
the patient; it may perhaps be associated 
with definite changes in the central circu- 
latory apparatus. If, after attention to 
the eyes or to focal disturbances in the 
nasopharynx and sinuses, after suitable 
treatment of constipation or of any disor- 
ders of the digestion, one suspects that 
renal changes are at the bottom of the 
symptoms, it may be wise to put the pa- 
tient for some time upon a diet as low in 
proteins as possible. This in some in- 
stances is followed by excellent results. 
Often obstinate headache, for which no 
cause is apparent beyond the hyperten- 
sion, yields quickly with a vacation or a 
relaxation from the strain of daily life. 
There are some headaches, however, prob- 
ably dependent upon cerebral arterio- 
sclerosis, that persist despite all treatment. 
Here temporary relief may be obtained 
from the nitrites. Sometimes I fancy I 
have seen benefit by the purely empirical 
administration of small doses of iodide of 
potassium, G. 0.2 to 0.25 (grains iii to iv), 
three times a day. Such patients should 12 
be urged to arrange their lives so as to 
have a long summer vacation, a vacation 
of at least a month if possible. And espe- 
cially to the man of forty or over the im- 
portance of occasional short periods of 
rest during his working year should be 
emphasized; it is generally much easier to 
accomplish this than the patient realizes, 
and the doctor should not allow himself to 
be led astray by the common conviction of 
the patient that a change in his manner 
of life is impossible. Many a hypertensive 
leaves for his vacation tense and driven. 
With removal from the scene of his activi- 
ties he forgets his worries, enters into a 
normal out-of-door life, engaging grad- 
ually in sports in the open - long walks, 
golf or even tennis-and after a summer 
of fairly vigorous exercise he returns to 
his work with fresh energy and a mate- 
rially lower blood pressure. 
It is often well to encourage the patient 
while at home to enter upon a regular 
morning and evening course of simple cal- 
isthenic exercises adapted to the physical 
condition of the individual. Good sug- 
gestions may be found in J. P. Mueller's 
"My System." He who has once learned 
to go through systematic daily calisthenic 
movements is not likely willingly to give 
them up, for he soon becomes conscious of 
their stimulating and beneficial effect. 
Especially important is it in talking 
with these patients to emphasize the rela- 13 
tively good prognosis in many instances 
of chronic hypertensive disease; to avoid 
discussing with the patient the figures of 
his blood pressure, a most pernicious and 
dangerous habit; and if the patient be- 
comes much worried about it, to avoid tak- 
ing the pressure more frequently than is 
absolutely necessary. There are few more 
pathetic pictures than the person who, be- 
cause he has heard that his pressure is 
over 200, is beset with the fear that he 
may have but one or two years more to 
live. Two patients consulted me, respec- 
tively, 14 and 13 years ago, for symp- 
toms associated with hypertensive cardio- 
vascular disease. In neither patient have 
I ever seen the pressure below 220. The 
first, a lawyer, was married two and a 
half years ago at the age of 65 and re- 
mains after 14 years, to all intents and 
purposes, a well man; the other died about 
a year ago after an illness of about three 
months. For nearly 12 years, however, 
he was the president of a bank and in 
efficient physical condition. 
CONCLUSION 
To sum up the essential points in the 
treatment of hypertensive cardio-vascular 
disease in its early stage: 
The influences that are likely to aggra- 
vate a hypertension are undue mental or 
physical strain or excitement, heavy smok- 
ing, immoderate eating. These influences 
may best be eliminated by relatively sim- 14 
pie physical and psychical means. Gain 
the patient's confidence, endeavor to en- 
courage him, to relieve his fears and to 
make him appreciate that the essential 
thing in life for him is moderation in all 
things-eating, drinking, tobacco, mental 
or physical effort. Give the patient care- 
ful, detailed advice as to his daily habits. 
Search for and endeavor to remove local 
sources of irritation, errors of refraction, 
sinus disease, gastrointestinal disturb- 
ances. Try to bring it about that he may 
take vacations of sufficient length and may 
learn to seize the opportunity for short in- 
terruptions in his life's routine. Teach 
him to take simple calisthenic exercises 
and encourage outdoor sports when his 
physical condition allows it. If such exer- 
cise be impossible or seem inadvisable, en- 
deavor to arrange for regular massage and 
hydrotherapy. Do not attempt medically 
to treat hypertension in itself. 
Endeavor especially to prevent the pa- 
tient from developing an undue interest in 
his own blood pressure. OSLER, THE TEACHER 
By W. S. Thayer [From The Johns Hopkins Hospital Bulletin, Vol. XXX, No. 341, 
July, 1919] 
OSLER, THE TEACHER 
W. S. Thayer 
Observe, record, tabulate, communicate. 
Use your five senses. The art of the practice of medicine is 
to be learned only by experience; 'tis not an inheritance; it 
cannot be revealed. Learn to see, learn to hear, learn to feel, 
learn to smell, and know that by practice alone can you become 
expert. Medicine is learned by the bedside and not in the class- 
room. Let not your conceptions of the manifestations of 
disease come from words heard in the lecture room or read 
from the book. See, and then reason and compare and control. 
But see first. No two eyes see the same thing. No two mirrors 
give forth the same reflection. Let the word be your slave and 
not your master. 
Live in the ward. Do not waste the hours of daylight in 
listening to that which you may read by night. But when you 
have seen, read. And when you can, read the original descrip- 
tions of the masters who, with crude methods of study, saw 
so clearly. 
Record that which you have seen; make a note at the time; 
do not wait. " The flighty purpose never is o'ertook, unless 
the deed go with it." 
Memory plays strange pranks with facts. The rocks and 
fissures and gullies of the mountain-side melt quickly into the 
smooth, blue outlines of the distant panorama. Viewed 
through the perspective of memory, an unrecorded observation, 
the vital details long since lost, easily changes its countenance 
and sinks obediently into the frame fashioned by the fancy of 
the moment. 
Always note and record the unusual. Keep and compare 
your observations. Communicate or publish short notes on 
anything that is striking or new. Do not waste your time in 
compilations, but when your observations are sufficient, do 
[198] 
[199] 
1 [199] 
not let them die with you. Study them, tabulate them, seek 
the points of contact which may reveal the underlying law. 
Some things can be learned only by statistical comparison. If 
you have the good fortune to command a large clinic, remem- 
ber that one of your chief duties is the tabulation and analysis 
of the carefully recorded experience. 
The collection and study of your own observations is much, 
but he who works in his own small compartment leads, after 
all, a restricted and circumscribed life. Go out among your 
fellows, and learn of them. The good observer is not limited 
to the large hospital. The modest country doctor may furnish 
you the vital link in your chain, and the simple rural prac- 
titioner is often a very wise man. 
Respect your colleagues. Know that there is no more high- 
minded body of men than the medical profession. Do not 
judge your confreres by the reports of patients, well meaning, 
perhaps, but often strangely and sadly misrepresenting. Never 
let your tongue say a slighting word of a colleague. It is not 
for you to judge. Let not your ear hear the sound of your 
voice raised in unkind criticism or ridicule or condemnation 
of a brother physician. If you do, you can never again meet 
that man face to face. Wait. Try to believe the best. Time 
will generally show that the words you might have spoken 
would have been unjust, would have injured a good man, and 
lost you a friend, and then-silence is a powerful weapon. 
When you have made and recorded the unusual or original 
observation, or when you have accomplished a piece of research 
in laboratory or ward, do not be satisfied with a verbal com- 
munication at a medical society. Publish it. Place it on 
permanent record as a short, concise note. Such communica- 
tions are always of value. 
Mix with your colleagues; learn to know them. But in 
your relations with the profession and with the public, in 
everything that pertains to medicine, consider the virtues of 
taciturnity. Look out. Speak only when you have something 
to say. Commit yourself only when you can and must. And 
when you speak, assert only that of which you know. Beware 
of words-they are dangerous things. They change color like 
the chameleon, and they return like a boomerang. Do you 
2 know the story of the young physician, about to enter practice, 
who was sent by his father to his old friend, Sir William 
Stokes, for advice ? A pleasant conversation, and, at the door- 
way, a last word: " Charley, don't say too much." Then, at 
the gate, a voice: " Charley, come back a minute; I'm very 
fond of you, my boy; don't do too much." 
" Don't do too much." Remember how much you do not 
know. Do not pour strange medicines into your patients. 
Our greatest assistance is given by simple physical and mental 
means, and by the careful employment of such drugs as have 
been adequately studied, with regard to the action of which we 
have real information. Do not rashly use every new product of 
which the peripatetic siren sings. Consider what surprising 
reactions may occur in the laboratory from the careless mixing 
of unknown substances. Be as considerate of your patient and 
yourself as you are of the test-tube. 
Familiarize yourself with the work of others and never fail 
to give credit to the precursor. Let every student have full 
recognition for his work. Never hide the work of others under 
your own name. Should your assistant make an important 
observation, let him publish it. Through your students and 
your disciples will come your greatest honor. 
Be prompt at your appointments; that is always possible. 
Many are always late at a consultation; few miss a train. 
There is no excuse for tardiness. 
Live a simple and a temperate life, that you may give all 
your powers to your profession. Medicine is a jealous mis- 
tress ; she will be satisfied with no less. 
Save the fleeting minute; do not stop by the way. Learn 
gracefully to dodge the bore. Strike first and quickly, and 
before he has recovered from the blow, be gone; 'tis the only 
way 
If you can practice consistently all this, .... and then, if 
you can bring into corridor and ward a light, springing step, 
a kindly glance, a bright word to every one you meet, arm 
passed within arm or thrown over the shoulder of the happy 
student or colleague; a quick, droll, epigrammatic question, 
observation or appellation that puts the patient at his ease or 
brings a pleased blush to the face of the nurse; an apprehen- 
[199] 
3 [199] 
sion that grasps in a minute the kernel of the situation, and 
a memory teeming with instances and examples that throw 
light on the question; an unusual power of succinct statement 
and picturesque expression, exercised quietly, modestly and 
wholely without sensation; if you can bring into the lecture 
room an air of perfect simplicity and directness, and, behind 
it all, have an every-ready store of the most apt and sometimes 
surprising interjections that so light up and emphasize that 
which you are setting forth that no one in the room can forget 
it; if you can enter the sick-room with a song and an epigram, 
an air of gaiety, an atmosphere that lifts the invalid instantly 
out of his ills, that produces in the waiting hypochondriac so 
pleasing a confusion of thought that the written list of ques- 
tions and complaints, carefully compiled and treasured for the 
moment of the visit, is almost invariably forgotten; if the joy 
cf your visit can make half a ward forget the symptoms that it 
fancied were important, until you are gone; if you can truly 
love your fellow, and, having said evil of no man, be loved by 
all; if you can select a wife with a heart as big as your own. 
whose generous welcome makes your tea-table a Mecca; . . . . 
if you can do all this, you may begin to be to others the teacher 
that " the chief " is to us ! 
[200] 
An eye whose magic wakes the hidden springs 
Of slumbering fancy in the weary mind, 
A tongue that dances with the ready word 
That like an arrow seeks its chosen goal, 
And piercing all the barriers of care, 
Opens the way to warming rays of hope. 
A presence like the freshening breeze that as 
It passes, sweeps the poisoned cloud aside. 
An ear that 'mid the discords of the day 
Swings to the basic harmonies of life. 
A heart whose alchemy transforms the dross 
Of dull suspicion to the gold of love. 
A spirit like the fragrance of some flower 
That lingers round the spot that this has graced, 
To tell us that although the rose be plucked 
And spread its perfume throughout distant halls, 
The vestige of its sweetness quickens still 
The conscience of the precinct where it bloomed. 
4 Introduction to the Preliminary Course in 
Physical Diagnosis 
By WILLIAM S. THAYER, M.D„ F.R.C.P.I., (Hon.) 
Baltimore, Md. REPRINT FROM 
THE SOUTHERN MEDICAL JOURNAL 
Journal of the Southern Medical Association 
Birmingham, Alabama 
through practice with the more important 
methods of physical examination, you will 
find stimulation in the very difficulties with 
which you meet. You will be an intelli- 
gent practitioner and maybe a contributor 
to the science and art of medicine. Most 
that you are going to learn, from now on, 
you will teach yourself. 'Tis our task to 
try to see that you start in the right way, 
that you make your own discoveries, work 
out your own problems and become in the 
proper sense a student of medicine and 
not a disciple blindly following the pre- 
cepts of a book or a teacher. 
During the past two years you have been 
giving your attention largely to studies in 
the laboratory of anatomy, physiology, 
chemistry, pharmacology and patholog- 
ical anatomy. You are presumably more 
or less familiar with the structure of the 
human body, and with the nature of its 
normal functions, as well as with the gross 
and microscopical changes that occur in 
the commoner diseases. So far, however, 
you have not been called upon to deter- 
mine in the living human bring whether 
the anatomical structure a r d physiolog- 
ical functions correspond with the normal, 
nor have you been confronted with the 
problem of attempting to recognize in the 
living, deviations from the ordinary nor 
abnormalities and processes of disease 
such as you have studied in the patholog- 
ical laboratory. 
In the next three months you are going 
to familiarize yourself with some of the 
simpler methods by which you may recog- 
nize these deviations and abnormalities. 
Next year you will pass on to the applica- 
tion of what you have learned here to the 
diagnosis of disease in the living subject. 
After all, this is but a continuation of 
what you have been doing with Dr. Mall, 
Dr. Howell, Dr. Abel, Dr. Jones, and Dr. 
McCallum. Methods of examination would 
be useless to you had you not had a good 
basis in anatomy, physiology and espe- 
cially pathological anatomy. A familiarity 
with the anatomical changes associated 
with disease is of vital importance. In- 
deed, one may safely say that the most 
important part of physical diagnosis you 
learn in the pathological laboratory. With 
the familiarity with pathological changes 
which you should have gained there, you 
Vol. XII 
July 1919 
Pages 374-381 
No. 7 
INTRODUCTION TO THE PRELIM 
INARY COURSE IN PHYSICAL 
DIAGNOSIS* 
By William S. Thayer, 
M.D., F.R.C.P.I. (Hon.), 
Professor of Medicine, Medical Depart- 
ment, Johns Hopkins University, 
Baltimore, Md. 
In nearly thirty years of teaching in 
this Hospital, the pleasantest and most in- 
teresting, and, I am sure, the most im- 
portant work that I have had to do, has 
been the meeting of the third and second 
year classes at the beginning of their 
study of physical diagnosis. The way in 
which one approaches one's clinical studies 
is a matter of considerable importance. 
"C'est le premier pas qui coute" If the 
first step be a false one, if you begin as 
so many good fellows have begun in the 
past, with the feeling that all you have to 
do is to sit at the feet of a group of pro- 
fessors, whose wise enunciations you are 
to take as gospel, and to learn from books 
descriptions of symptoms, signs and dis- 
eases, and then to go forth and hunt for 
something that matches your mental pic- 
ture, you will be fatally side-tracked. 
You will leave the institution with the feel- 
ing that your medical studies are over, and 
your greatest contribution will be to dis- 
cover that the 'Type" of pneumonia or 
typhoid fever in the region in which you 
live has changed-changed forsooth from 
the mental picture you had carried from 
the class room. Ah, how full medical lit- 
erature is of such communications! 
If, on the other hand, you carry away 
with you a sense of obligation to put to 
proof so far as you can every statement 
with which you meet; if you carry away 
with you a reasonably good knowledge of 
the manifestations of disease based upon 
clinical experience and a familiarity 
*Lecture to the second year class of the Joi ns 
Hopkins University School of Medicine. SOUTHERN MEDICAL JOURNAL 
would very possibly, if left to yourself, 
work out a good many of the procedures 
necessary for the detection of these 
changes in the living. History, indeed, 
shows that methods of physical examina- 
tion were evolved step by step along with 
the advances of our knowledge of patho- 
logical anatomy. In 1760, Morgagni pub- 
lished his famous work on the "Seats and 
Causes of Diseases Investigated by Anat- 
omy." Here for the first time was a sys- 
tematic comparison between the history 
and symptoms of the patient during life 
and the changes observed in the organs at 
necropsy. Morgagni's work marks the 
beginning of pathological anatomy. Pre- 
viously to that time the medical world in 
general had but the rudest conception of 
the changes which disease produced in the 
body, and the methods of examination of 
the patient during life were equally crude, 
but immediately following the work of 
Morgagni, appeared the publication of 
Auenbrugger, in Wien, describing "A New 
Method for the Recognition of the Dis- 
eases of the Interior of the Chest by the 
Percussion of This Cavity," the first de- 
scription of this simple and vital method 
of physical examination, which depends 
upon tapping a structure to determine the 
sound elicited and thereby to gain informa- 
tion as to the physical condition of the 
underlying organs. A simple procedure, 
it seems to us today, yet it was literally 
discovered only about a hundred and fifty 
years ago. When pathological anatomy 
showed that certain symptoms of disease 
were associated with solidification of the 
lungs or accumulation of fluid in the pleu- 
ral cavity, it was not long before acute 
physicians discovered accurate methods for 
detecting the existence of these conditions 
before death. It was not many years before 
a brilliant Frenchman, Laennec, had added 
an immense fund of information as to the 
character and significance of the sounds 
produced in the normal and diseased chest 
by the discovery of auscultation and his 
contribution to normal and pathological 
anhtomy. 
No physician who has not had a good 
experience in the pathological laboratory 
can be, a good diagnostician. The best di- 
agnosticians are those who most frequent 
the necropsy room. 
What you are going to learn now are 
certain principles and methods and pro- 
cedures of observation and examination 
of the living human being. The informa- 
tion which you will acquire from these 
procedures will be of little value, unless 
you have a clear idea of the nature of the 
pathological conditions with which you 
may be concerned. From the employment 
of purely physical procedures you will gain 
purely physical information. In a space 
which should be occupied by an air-con- 
taining body you will discover a solid or 
a collection of fluid. That is as far as yeu 
can go. What that body or what that 
fluid may be, no book can tell you. You 
can arrive at reasonable conclusions only 
by using your own common sense, acting 
upon the basis of the knowledge you have 
gained by your experience in the ward 
and in the pathological laboratory. You 
can not make an intelligent diagnosis of a 
pneumonic solidification of the lung if 
you do not know what a pneumonic solid- 
ification looks like, or the conditions un- 
der which it occurs, or the symptoms to 
which it gives rise. And after all, here 
the application of your common sense to 
medicine only begins. If any of you share 
the common fancy that medicine can be 
practiced by rule, you should rid yourself 
of it forthwith or abandon the idea of be- 
coming a physician. It may be that in 
Heaven all things are regulated by rule, 
including the practice of medicine. Very 
fortunately for us mortals it is different on 
earth. If medicine could be practiced by 
rules; if life could be ordered wholly by 
fixed regulations, the function of the phy- 
sician would be small, and life would be 
insufferably dull. 
You are going to satisfy a competent 
board of examiners that you possess suf- 
ficient knowledge of anatomy, physiology, 
chemistry, pharmacology, as well as the 
methods of physical exploration, and the 
use of surgical instruments to be let loose 
upon the public. From that time on you 
are bound only by the rules of common 
honesty and decency. All that medical 
ethics and etiquette mean is common hon- 
esty and decency and consideration for 
your patient and your fellow practitioner. 
You must practice medicine as you make 
diagnoses by your common sense playing THAYER: PHYSICAL DIAGNOSIS 
upon the basis of your real knowledge. 
He who practices medicine according to 
the directions of X's practice or Y's thera- 
peutics should have been a homeopath: 
he is a puppet. 
Why does a human being consult a doc- 
tor? For various reasons. Firstly, and 
most commonly, because for one reason or 
another he becomes conscious of himself. 
The normal human being does not think 
about himself; he does not know how he 
"feels." He does not attempt to analyze 
the difference between his "feelings" on 
one morning and on another; and even if 
some one were to direct his attention to 
himself and ask him how he "feels" today 
as compared with the ordinary, he would 
probably be unable to answer; he does not 
"feel" at all; of himself and his normal 
functions he is unconscious. When, how- 
ever, for one reason or another, he does 
become conscious of himself and his func- 
tions, sooner or later he becomes interested 
and often concerned, and thence it is but 
a step to the consultation of some one who 
may better be able to interpret the condi- 
tions that puzzle him. The complaints 
which bring the patient to the doctor 
may be simple and easily analyzable, or 
they may be difficult and almost impossi- 
ble to unravel. 'Tis these difficulties and 
puzzles that make the practice of medi- 
cine fascinating to the man who is fit to be 
a doctor. 
Secondly, a man consults a doctor be- 
cause he has come to fear that something 
may be the matter with him, or because 
he wants assurance that he is sound and 
well. It may be that he is a nervously 
constituted individual who has heard 
somebody talk of a malady of some sort, 
the picture of which so obsesses him that 
he wants assurance that he is not a vic- 
tim. It is not uncommon for healthy, vig- 
orous, athletic young men between twenty 
and thirty to ask a physician for a com- 
plete physical examination. This is a 
symptom that is almost pathognomonic of 
a condition which is common, if not mor- 
bid. Nine times out of ten that man is 
contemplating matrimony. 
You have then reached the point where 
you are confronted with the problem of 
the detection and definition of deviations 
from the ordinary or normal in the living 
human being. What are deviations from 
the normal? And how may they show 
themselves? What is the normal? These 
are questions which are often among the 
prettiest problems that a physician may 
meet. To solve them demands careful ob- 
servation, practice and experience. 'Tis 
the only way. In a gross sense deviations 
from the ordinary may be physical (that 
is anomalies or abnormalities in the posi- 
tion or the size or shape of an organ) )r 
functional, in the sense that the action of 
that organ produces different physical or 
chemical manifestations. The detection 
and the interpretation of these physical 
and functional deviations from the ordi- 
nary constitute the fascinating art of di- 
agnosis. 
And do not deceive yourself: diagnosis 
is an art which can be acquired only by 
training, long practice and experience. 
Diagnosis, then, is an art, empirical, if 
you will. The word empirical is used often 
as a reproach in connection with things 
medical. Medicine is "empirical," say the 
critics of the doctor, wishing thereby to 
indicate that the physician deduces his 
conclusions from his own fancies and 
prejudices, or from an experience inter- 
preted by a mind which is not open, with- 
out regard to the teaching of science. 
But science derives its theories and its 
laws only from observation and experi- 
ment and the master whose ingeniously 
designed experiment, whose keen powers 
of reason lead him to formulate the theory 
or detect the law has become a master only 
through long training and study and ex- 
perience. It is no insult to the art of 
medicine to say that it is largely empirical, 
that it is largely based upon the teachings 
of observations and experience. This is 
but to say the truth. The art of medicine 
as it comes more and more to be based 
upon scientifically established conclusions, 
theories and laws, becomes, 'tis true, less 
and less empirical. We are able to recog- 
nize many diseases today with a scientific 
accuracy which was impossible yesterday, 
but still in the interpretations of many of 
the signs of disease, as well as the effects 
of treatment where an exact scientific 
basis for a conclusion is wanting, we must SOUTHERN MEDICAL JOURNAL 
still be empirics in the good sense of the 
word; we must still be guided by experi- 
ment and experience. 
To the physician with a good scientific 
training and an open mind, experience is 
the main teacher and guide which makes 
of him a master in his art. 
To another with an unsound founda- 
tion, experience may be useless. 
To him who is ill-trained and possessed 
of a prejudiced mind (the man to whom 
all experience but tends to bolster a pre- 
conceived idea), to him experience may be 
dangerous. 
What do we mean by physical diagnosis? 
Sometimes the terms "physical" and 
"functional" diagnosis are used as if they 
represented two separate and distinct pro- 
cedures. In recent years, with the great 
increase in instruments of precision and 
the expansion of our knowledge of phys- 
ical and chemical methods of exploration, 
the term "functional" diagnosis, especially, 
has come into common use. This division 
into physical and functional diagnosis is 
comprehensible, but not wholly sound. 
One might truly say that the determina- 
tion of the size or position of the heart 
was a matter of purely physical diagno- 
sis-that the determination of the quan- 
tity and rate of urea output in the urine, 
under fixed conditions of diet and general 
surroundings, was a matter of functional 
investigation. In a general way a division 
between physical and functional diagnosis 
may often be maintained; but in reality, 
physical and functional diagnosis are so 
closely bound together that they can not 
absolutely be separated. For instance, by 
the simple physical methods of explora- 
tion which are included ordinarily under 
the head of physical diagnosis, you can de- 
termine much concerning the normal or 
abnormal functions of the heart and lungs. 
The more complicated questions of func- 
tional diagnosis, as the term is commonly 
used, demand, however, laboratory studies 
and often experiment. In its proper sense 
the term physical diagnosis should be 
used purely with reference to the methods 
of exploration which are employed. This 
is the sense in which it applies to your 
work of this year and next. The methods 
with which you are to work in this course 
are purely physical procedures, which you 
yourself can practice in the consulting 
room and at the bedside of the patient 
with your five senses assisted by the sim- 
pler instruments of precision. 
On your ability to use your five senses 
and properly to interpret the information 
they give you, depends your usefulness or 
your uselessness as a physician. No book 
can teach you physical diagnosis. The 
kernel of all diagnosis is observation; that 
you must make yourself. You can not 
reason safely on the description of an- 
other. The development of well equipped 
laboratories which relieve the physician 
in the city from the necessity of making 
his own examinations of the blood, urine 
and sputa, and the aid that the develop- 
ment of radiography, electrocardiography 
and other methods of physical investiga- 
tion have brought to the physician have 
enabled us to study our patients much 
more accurately than we could thirty 
years ago. 
Radiograms, electrocardiograms, tests 
of renal function, are of great assistance 
in establishing a correct diagnosis and 
prognosis-to the physician who can in- 
terpret them. But' tis well to remember 
that they are but single stones in the ed- 
ifice of a diagnosis. They are of little help 
and may be misleading to one who can 
not interpret them. The man who fails to 
make, or is incapable of making an intel- 
ligent physical examination, is incapable 
of benefiting materially by such assistance. 
The experience of the war has revealed 
a deplorable lack of knowledge of the basic 
principles of physical exploration in the 
medical profession of America. A sur- 
prisingly large number of officers were 
content, without reasoning, to accept a 
laboratory report as the basis for a diag- 
nosis. To take one example, at one time a 
considerable number of soldiers were be- 
ing returned to America with the diag- 
nosis of pulmonary tuberculosis. Investi- 
gation of one hundred of these patients by 
an expert revealed recognizable evidences 
of tuberculosis in only about 30 % 5 the 
other 70 % represented, for the most part, 
convalescents from acute pulmonary in- 
fections. The reason for this was simple. 
Many of the officers dealing with these pa- THAYER: PHYSICAL DIAGNOSIS 
tients had blindly accepted an x-ray diag- 
nosis of pulmonary tuberculosis. But upon 
what was such a diagnosis of tuberculosis 
based? Upon the presence of certain 
shadows which indicated changes in the 
lungs, very possibly in some instances, the 
result of tuberculosis. This is not un- 
usual. Think of necropsies that you have 
seen. How many individuals dying of 
typhoid fever, or cardiac disease, or any- 
thing that you may choose, show in their 
lungs old scars, the evidence of a previous 
tuberculosis - scars often too small to 
recognize by the ordinary methods of clin- 
ical investigation. Many of us in this 
room have such changes in our lungs - 
scars that tell of an old battle fought and 
won by our organism. It is interesting 
and sometimes important to know that a 
man has had such an experience in the 
past. It is interesting to know that he 
has such shadows in his lungs, but from 
the x-ray plate the radiologist can only 
guess at what those shadows represent. 
'Tis for you with your knowledge of the 
symptoms and the physical signs that you 
can make out on examination to deter- 
mine whether such shadows represent the 
evidence of active disease or the inactive 
scar that tells of the dead process. The 
x-ray plate simply gives you another bit of 
purely physical information which can 
properly be interpreted only by careful 
correlation with all the other elements in 
the case. Many of these x-ray records re- 
vealing, 'though they may, our past ex- 
perience, are but post-mortem evidence 
of a process that was, but is no more. 
In other instances, a reasonably intel- 
ligent consideration of the history of the 
patient and the nature of the physical 
signs, should have led the careful exam- 
iner to the conclusion that these shadows 
indicated an unresolved pneumonia or a 
persistent bronchitis with small areas of 
broncho-pneumonia of non-tuberculous or- 
igin. But these officers had come to rely 
so blindly upon the x-ray plate with its 
accompanying and too often unqualified 
statement "pulmonary tuberculosis," that 
they had become incapable of observing 
and properly weighing the physical mani- 
festations which would have justified, in 
most instances, a correct diagnosis. This 
blind reliance upon laboratory tests and 
the associated neglect of the use of one's 
senses and the ordinary methods of phys- 
ical examination is sadly common among 
the profession at large. Not long ago I 
saw, in consultation, a gentleman who 
was said by his physician to be suffering 
from cardiac disease; he feared, angina 
pectoris. I asked him what the symptoms 
of the patient had been. His reply was 
that at first he had thought he had indi- 
gestion, but that Dr. X had found his 
heart enlarged; that Dr. Y had made a 
Wassermann reaction which was nega- 
tive; that Dr. Somebody Else had looked 
into the conditions of the stomach; that 
a differential blood count had been made; 
that the urine showed no abnormalities. 
I asked him if the patient had had pain. 
He had, over the heart. Did it radiate into 
any other part of the body? No. Was it 
associated with exercise? He thought not. 
After a little questioning I realized that 
the doctor had practically no information 
to give me himself as to the symptoms or 
physical signs of the patient. I then saw 
the patient and in a few minutes learned 
that his pains did follow exercise and eat- 
ing; that they did radiate into his arms 
in a characteristic manner; that the his- 
tory alone was such as to justify the di- 
agnosis of angina pectoris. The doctor 
had neglected all ordinary methods of in- 
vestigation and had contented fhimself 
wholly with the reports of laboratories 
and experts on this, that or the other de- 
tail. This is not to practice medicine, nor 
is such an individual qualified safely to 
treat a patient. 
The information which the laboratory 
brings is invaluable to the competent 
physician, but it can be utilized properly 
only when weighed in connection with the 
history and physical examination. The 
fundamental physical examination that 
one makes with his eyes, ears and fingers 
is far more important than any other 
method of study to which you may appeal. 
It is inexcusable that a physician today 
should graduate from a medical school un- 
trained in the basic principles and practice 
of physical examination; but it would sur- 
prise you to know how few officers in the 
Army-and by that I mean the profes- SOUTHERN MEDICAL JOURNAL 
sion at large-are capable of recognizing 
the presence of fluid in the chest in any 
but the simplest cases. 
The art of physical diagnosis depends 
upon observation, experience and judg- 
ment, upon what Corvisart has called 
"Veducation medicate des sens," "the medi- 
cal education of the senses." It cannot be 
learned from books. The only way in 
which you can learn to make a proper 
diagnosis is by making yourself familiar 
with the normal, by learning to detect de- 
viations from the normal, by working out 
yourself the significance of those devia- 
tions from the normal upon the basis of 
what you have learned concerning the ab- 
normal changes associated with disease; 
and this is to be learned only by following 
your patients from ward to necropsy room. 
Deviations from the ordinary or normal 
make themselves apparent in various 
ways: by differences in the size and shape 
of organs, changes which are readily cor- 
related with what you have seen in the 
anatomical and pathological laboratories; 
by difference in the rhythm of action or 
the sounds produced by organs in the per- 
formance of their function; by differences 
in the constitution of body fluids or in the 
various products of secretion or excretion 
of organs; by a multitude of modifications 
of the color, habit, bearing, gait, mentality 
of the sufferer. You must at first become 
familiar with the normal and with the 
manifestations produced by normal organs 
in function. 
In your course on physiology you have 
learned much about the normal function of 
most of the vital organs, but there are 
certain methods of testing and appreciat- 
ing these functions which are rarely taught 
in the course of physiology. The student 
is introduced to these methods ordinarily 
in the presence of patients showing patho- 
logical manifestations. This is, it seems 
to me, undesirable. It is very common for 
the student to pass directly from the study, 
in class room or in laboratory, on lower 
animals, of the normal anatomy and phys- 
iology of the lungs and heart, to the study 
in the living human being of the symptoms 
and signs of disease. He is introduced to 
the various instruments of precision com- 
monly in use, only or almost only, in con- 
nection with their application to the detec- 
tion of disease. A far more rational pro- 
cedure would be to allow a student, while 
he is engaged in his physiological studies, 
to become familiar with the use of methods 
and instruments of precision as applied to 
the normal individual, to become familiar, 
for example, with the movements of the 
normal chest, with the sensations con- 
veyed by palpitation under normal condi- 
tions, with the sounds to be elicited by 
percussion of the lungs and the abdominal 
viscera, with the methods of outlining the 
position and size of the organs, as well as 
with the sounds which are to be heard on 
listening to the normal respiration or to 
the heart's beat. He should become famil- 
iar with the phenomena associated with 
the normal function of heart and lungs as 
revealed by physical examination, but espe- 
cially should he be familiar with the physi- 
cal explanations of these phenomena. If, 
for instance, you are familiar with the 
sound of respiration over a normal lung 
and appreciate the reasons for the exist- 
ence of such a sound, you will then quickly 
note any changes from this normal with 
which you may meet, and you should be 
able to make rational deductions as to the 
disturbances of function which may have 
caused them. 
Next year you must be lead through a 
series of the commoner deviations from 
the ordinary or normal. If you become 
familiar with the manifestations of the 
normal heart in function, if you become 
familiar with the character of the sounds 
produced by the normal heart, and with 
the accepted physical explanations of their 
cause; and if, later, you come across an 
individual, in whom, let us say, the second 
sound of the heart shows peculiar modifi- 
cations, you will be face to face with an 
interesting problem concerning which you 
should be in a position to reason intelli- 
gently. The normal second sound is due 
to certain physical conditions. Here it is 
modified, perhaps replaced by a new and 
unusual sound. You will naturally assume 
that there has been some interference with 
the normal processes to which the second 
sound is due, with the closure of certain 
valves. You will notice on careful exam- 
ination that this modification of the sec- THAYER: PHYSICAL DIAGNOSIS 
ond sound is heard in certain areas only 
and, by further consideration, you deter- 
mine its distribution in relation to the 
direction of the blood current and the 
anatomical disposition of tne cavities of 
the heart. And then you will consider the 
associated modifications of the outline and 
size of the heart, and of other sounds, 
which may indicate that the pressure is 
raised in cavities behind the valve at which 
this unusual sound is produced. Further 
you may find evidences of the engorge- 
ment of the venous circulation as shown 
by the veins of the neck, or enlargement of 
the liver. There may be modifications in 
the character of the radial pulse. In the 
end, by a process of deliberate reasoning, 
you will arrive at the conclusion that you 
are perhaps dealing with an insufficiency 
of a valve, the closure of which is normally 
associated with the production of this 
sound, the insufficiency of which might ac- 
count for the whole train of manifesta- 
tions that you have observed. Now, when 
you have once worked out correctly a 
problem of this sort, as most of us will, if 
you go into the subject as you should, you 
will have taken a long step forward, and 
you will have gained confidence in your 
own powers of reasoning which will have 
been used exactly as you will have to use 
them throughout your life as a practi- 
tioner of medicine. 
I greatly hope that before many years 
much of the work you are now beginning 
may be undertaken in connection with the 
courses of anatomy and physiology, so that 
at the same time the student may familiar- 
ize himself with the form and functions of 
the organs in the laboratory and in the 
living human being. 
In the third year, as I have said, you will 
study selected patients exemplifying 
changes occurring in the heart and lungs 
and abdominal viscera. We shall try to 
give you an opportunity to do this in small 
groups and in such manner that you may 
learn to work out your own diagnoses. 
To most of the sounds elicited by percus- 
sion of normal or diseased organs, to some 
of the normal sounds or modifications of 
these sounds arising in heart or lung, in 
health or in disease, there are applied spe- 
cific terms, terms introduced for brevity 
and convenience. Often unfortunately the 
terms employed to describe a given sound 
vary somewhat according to the author. 
He who starts the study of physical diag- 
nosis by reading books on auscultation and 
percussion finds himself sadly confused 
when he is confronted by the patient. A 
safe way, indeed, to confound yourself and 
to delay your proper development as an 
individual capable of detecting disease, is 
to begin the study of physical diagnosis 
by reading books, to form pictures in your 
mind of what these various sounds and 
manifestations may be and of what they 
indicate. Such a course places a student 
at the outset at a disadvantage. It is in- 
conceivable that he should form a correct 
idea of what he is to hear in the chest from 
the description that he reads in a book. 
Fancy that you have never seen or heard 
a violin, how near do you think you could 
come to a conception of the sound of a 
violin from a description read in a book? 
The parallel is exact. If you begin by 
reading a book on physical diagnosis you 
start with a preconceived idea as to the 
character of the sounds and manifestions 
with which you are going to meet. This 
idea cannot be wholly right, and it may be 
very difficult to rid yourself of it. You will 
start with a preconceived conception as to 
the significance of the sound which you 
have come to associate with the term, 
which may interfere gravely with the 
proper use of your reason. You may, be- 
fore you know it, find yourself reduced to 
a condition alas, far too common in medi- 
cine, that of seeking to make a diagnosis 
by the matching of a mental picture gained 
from a description with that which you 
find before you. The individual to whom 
diagnosis means matching pictures is lost! 
The bane of physical diagnosis, indeed, 
of medicine in general, is the terminology. 
Words! Beware of the careless use of 
words! A word or a term means to many 
who hear it an instant mental picture. 
And too often to that mental conception 
we are forever enslaved. Most of the 
troubles of mankind are due to the tyranny 
of words. It is a dangerous thing, thought- 
lessly to coin a new word or a new term. 
Think, only, of the tragic confusion in the SOUTHERN MEDICAL JOURNAL 
minds of men today arising from the term 
a "League of Nations!" 
Of one thing you may be sure: the pic- 
ture that a given term suggests to another 
will never be the same as that which it sug- 
gests to you. For heaven's sake remember 
that terms are made for convenience. To 
paraphrase Seneca, "The term, if thou 
knowest how to use it, is thy handmaiden, 
if thou knowest not, 'tis thy master." Let 
the term be your handmaiden and not your 
master. Remember that it is used merely 
as a convenience; that it is not the essence. 
Don't allow yourself to think of the mani- 
festations of disease in the sense of a word 
or a term. Don't let the term itself usurp 
in your mind the picture that for simplic- 
ity's sake it is used to evoke. The reverent 
attitude of some physicians toward terms 
comes dangerously near putting them in 
the category of the good woman who, filled 
with wonder at the discoveries of the as- 
tronomer, begged him to tell her how he 
had accomplished that which seemed to her 
the most remarkable of all, the discovery 
of the names of the stars! 
During the next year you should en- 
deavor especially to learn to describe the 
manifestations of disease in the simplest 
possible manner, and to use as few unnec- 
3ssary terms as possible. Be simple and 
clear in your language and descriptions. 
If you use a term to describe a sound, for 
instance, about which there can be doubt 
in anyone's mind, you are not simplifying, 
you are confusing; rather describe the 
sound. And I beg of you, never invent a 
new term unless it is absolutely necessary. 
The safest way to avoid pitfalls is at the 
beginning to read nothing about physical 
diagnosis beyond that to which we refer 
you here. You need no book on physical 
diagnosis this year. You must work out 
your own salvation. Nobody can do it for 
you. Books won't do it for you. Prayer 
won't bring it to you. On your technical 
skill and your ability to reason without 
preconceived ideas, from the information 
that your senses bring you, on the basis of 
your physiological, anatomical and patho- 
logical learning, depends your success as a 
physician. If you proceed without books 
and work out your diagnoses gradually 
and step-wise through the use of your own 
gray cortex, you will be following the 
course that you must pursue during life in 
dealing with any new or unusual feature 
of disease. You will not be unduly dis- 
turbed by preconceived ideas, and you will 
not readily forget the explanation or sig- 
nificance of changes which have been de- 
tected by your own powers of reasoning. 
This year the work will be restricted to 
the study of the normal individual. But as 
we study the procedures for the detection 
of the position of normal organs, the 
methods of controlling their normal func- 
tions ; as you study in the healthy individ- 
ual the movements and sounds to which 
the normal organs of the chest give rise in 
the performance of their functions, you 
will readily appreciate most of the modifi- 
cations which gross physical changes in 
those organs should produce, and you will 
be able to detect and interpret the mani- 
festations of the diseases with which you 
will meet next year far more quickly than 
you imagine. 
After all, the summary and description 
of the methods of examining a patient 
which is to be found in the w'orks of a 
recent author by the name of Hippocrates, 
are perhaps as clear and sound as any that 
have been set forth: "At the outset deter- 
mine the similarities to, and deviations 
from, the normal, the most severe, the 
easiest to recognize, those recognizable in 
any manner whatever. Look for that 
which may be seen, felt, heard, which may 
be appreciated by sight, by touch, by hear- 
ing, by the nose, by the tongue and by the 
powers of reason; in a word all that can 
be discovered by such powers of apprecia- 
tion as we possess." Reprinted from The Canadian Medical Association Journal, 
September, 1919 
LAENNEC-ONE HUNDRED YEARS AFTER 
ADDRESS IN MEDICINE 
William S. Thayer, M.D. 
Baltimore 
AT the outset, let me tell you how deeply I appreciate the honour 
that you have done me in inviting me to address you-with 
what happiness and satisfaction 1 appear before an audience of 
Canadians. That broader sense of patriotism which links us all 
to the Mother Country which is as much mine as yours, has suffered 
much in the five years that have passed. But despite the noisy 
discord of ephemeral politics, that which has happened has, I think, 
drawn closer about us the bonds of a common ideal and a common 
inheritance which we cannot and would not escape; and the aureole 
that to-day surrounds Canada in the eyes of every American who 
deserves the name, can never fade. 
piya 6e p.£po$ r^suac rvjs t£xvv]$ Uvat to SvvaffQat axpititv" 
" The power to explore is to my mind a great part of the art." 
-Hippocr. epid. III. 
These words appear on the title page of Laennec's "Traite 
d'auscultation mediate," which appeared just an hundred years ago. 
It is fitting for more reasons than one that we pause on this notable 
anniversary and consider, for a moment, the man and his work, 
for there are lessons therein which we may well take to heart. 
Rene-Theophile-Hyacinthe Laennec was born on the 17th of February, 
1781, in a stone house which fronted on the charming quai that 
Delivered before the Canadian Medical Association, Quebec, June 26th, 1919. 2 
THE CANADIAN MEDICAL 
borders the little port of Quimper in the Department of Finisterre 
in Bretagne. 
His father, Theophile-Marie Laennec, was a light and airy 
personage-a lawyer by profession, a courtier by nature, a furious 
framer of mediocre verse, through which he curried favour with 
the great and the fair, an indefatigable office-seeker, a prolific pro- 
fessor of lofty and exemplary sentiments and advice of which he 
himself was a sufficiently poor exemplar; a futile but withal an 
entertaining person-a singularly anomalous and ill-chosen father, 
however, for a serious and distinguished son. 
Laennec had two uncles, one, Michel, a prelate, who died an 
emigr£; the other, Guillaume-Francois Laennec de la Renardais, 
a physician of Nantes, to whom Laennec owed much. His mother, 
Michelle Gabrielle Felicity Guesdon, of Quimper, of whom little is 
known, was an Angevine by descent, and came from a family of 
some literary distinction; she died five years after his birth. 
After his mother's death, Theophile was sent with his brother 
by his happy-go-lucky father first to his uncle Michel at Elliant, 
and a year later, on the latter's removal to Treguier, to his uncle 
Guillaume at Nantes. Guillaume Laennec was a fine and sturdy 
character, a graduate in medicine at Montpellier, who had studied 
previously in Paris, and with John Hunter in London. He was at 
this time rector of the University of Nantes. The two boys were 
taken into his house and cared for as members of his own family. 
For Theophile especially his uncle grew to have a deep and lasting 
affection, which was manifested throughout his life. Laennec's 
early instruction was gained at VInstitut Tardivel and the College 
de VOratoire, which, for the year '91-'92, was under the vigorous 
direction of no less a personage than le P. Fouche de Rougerolles, 
then on the threshold of his eventful career. In August, '92, he 
gained the accessits of two prizes of honour, and a first prize in 
composition-French translation. 
At this time, to the dismay of his uncle, Theophile was already 
writing verse. In these days when the air is rent with protests at 
the burden and the waste of time involved in the acquisition of a 
smattering of Latin by our boys who are to pursue a career requiring 
knowledge of the natural sciences, it is not uninteresting to read 
(Rouxeau) a charming metrical translation of the first eclogue of 
Virgil, written by a boy under twelve years of age. 
But rhyming was not his only distraction; he appears to have 
been a boy in every sense. 
The Revolution followed its course. The guillotine was set ASSOCIATION JOURNAL 
3 
up in the square under the Laennecs' very windows. Uncle Guill- 
aume became a surgeon in the army. But Theophile tranquilly 
pursued his studies, and graduated in 1795. At about this time, 
his father married for a second time, Genevieve-Alice-Julie Urvoy 
de St. Bedan, the widow of an emigre. Renouncing the temptation 
to which he almost surrendered, to join the engineers, Theophile 
began the study of medicine at L'Hotel Dieu of Nantes. 
Here, actively engaged in the lesser duties of military surgery, 
he became deeply interested in natural history in all forms, roam:ng 
about the country and devoting himself to his collections. He had 
also developed an enthusiasm for Greek, to which he gave special 
attention. Alert, active, ambitious, he was filled with the desire 
to perfect himself in various arts and graces, such as riding, dancing, 
music-studies, the pursuit of which was difficult with the scant 
means afforded by his scatter-brained parent. 
In 1798, he passed through a severe illness, which may well 
have been a typhoid fever. 
In the insurrection of 1800, Theophile took part in the military 
expedition of General Grigny in le Morbihan. While stationed at 
Vannes and at Redon, he composed a long poem, humorously de- 
scribing the expedition. This was supposed to be the product of 
an ancient Celtic bard, Cardoe, translated after years of effort, by 
its discoverer, Cenneal (Laennec), and was entitled "La Guerre des 
Venetes." On his return, Laennec entered the military hospital 
as an army surgeon of the third class. 
At this time his uncle had long been struggling to induce the 
recalcitrant father to supply the funds necessary to enable the boy 
to pursue his studies in Paris, but it was not until April, 1801, that 
Theophile joined his brother "Michaud" at 947 rue St. Dominique 
d'Enfer, and entered the Ecole speciale de Sante, as the Ecole de 
Mededne was then known. The two main schools of clinical medi- 
cine in those days were that of Corvisart at the Unite (Charite) 
and that of Pinel at the Salpetriere. Under Corvisart, Laennec 
began his studies. It was a fortunate choice. Corvisart had a 
well-organized clinic where (Rouxeau) "each morning in groups 
the students were trained in the examination of patients, while the 
observation was completed wherever it was possible, by those 
careful and methodical necroscopical examinations, the taste for 
which Corvisart contributed so much toward spreading in France." 
Here Theophile found himself thrown with Bayle, for whom he 
developed early a warm attachment. 
From the outset, Laennec was a marked student, and was soon 4 
THE CANADIAN MEDICAL 
made a member of the Societe d'instruction medicate. At twenty 
he was an accomplished student of English, German, Latin and 
Greek, and beside following the clinic at the Charite, and the last 
inspiring course of Bichat, on pathological anatomy, he found time 
to attempt to perfect his Greek at the Ecole Centrale des Quatre 
Nations. In 1801, he was also admitted to the Ecole pratique, 
where he studied under Dum£ril, Chaussier, Fourcroy, Deyeux, 
Hall6, Pinel, Bourdier, Peyrilhe, Richard, LeClerc, and Cabanis. 
He also worked with Dupuytren, in his studies in pathological 
anatomy. 
From the outset Laennec kept careful and detailed notes of 
all his observations and lessons, and among his papers is an in- 
teresting shorthand record of the celebrated debate in connection 
with Bayle's inaugural thesis. 
His first medical communication was published in the Journal 
de medecine de chirurgie et de pharmacologic" for June, 1802, entitled, 
"Observation sur une maladie du coeur, ossification de la valvule 
mitrale, dilatation du ventricule droit, avec affection de la poumon et 
du plevre gauche." N month or two later, Laennec published an 
analysis of Bell's work on gonorrhoea and venereal disease, and in 
the same year, an account of a group of cases of peritonitis. This 
last publication marks an epoch in medical history, setting forth 
clearly and sharply the clinical and anatomical features of the 
disease touched upon by Bichat, but as yet unrecognized clinically. 
This remarkable work was the beginning of a series of contributions, 
anatomical and clinical, which have been equalled by few men in 
the annals of medicine. 
At the time his labours were especially devoted to the study 
of normal and pathological anatomy. In association with Bayle, 
he began to work with Dupuytren on his treatise of pathological 
anatomy-work which was soon to be broken off, owing to mis- 
understandings with the former. From this time on his publications 
were frequent and important. In February, 1903, there appeared 
a "Note sur une capsule synoviale situee entre Vapophyse acromion 
et Vhum&rus", the discovery and accurate description of the sub- 
deltoid bursa, the surgical importance of which has been recognized 
in such recent days. 
A little after this he described the fibrous capsule of various 
abdominal organs, especially that of the liver, which was as yet 
unknown as distinct from the peritoneum. In the distribution of 
prizes to the "Ecoles speciales de Paris," in September, 1803, Laennec 
obtained the first prize in surgery, and shared the first prize in ASSOCIATION JOURNAL 
5 
medicine with Billerey. Later, at the Concours of the Ecole pra- 
tique, the announcement of his candidacy had so disturbing an 
effect in preventing others from coming forward, that at the special 
request of his instructors, he withdrew his name, and took a position 
"hors de concours". Already his success was so great that he 
started a small course in pathological anatomy on his own account, 
and determined to write a treatise upon the subject. 
A member, at its inception, of the Societe anatomique, he was 
a constant contributor, his most important communication being 
his " M emoire sur les vers vesiculaires," etc. 
As ever, the careless father was negligent in providing for the 
industrious son, and Laennec's work was associated with constant 
worry as to matters of finance. But finally, in 1804, he was able 
to pass his examinations and present his thesis, which was entitled, 
"Propositions sur la doctrine d'Hippocrate relativement a la medecine 
pratique." In this interesting document, Laennec showed his 
familiarity with the Hippocratic writings, which, happy man, he 
read more or less fluently in the original. The thesis is replete with 
wise observations. He begins with the quotation: " Medicine is 
not a new science. For a long time its principles have been estab- 
lished and its path traced. By following these through long years, 
many valuable and useful discoveries have been made, and every 
one who, endowed with the necessary qualities, knowing that which 
has been done before him, starts from this point and follows the 
same route, will make new contributions. But he who rejects the 
work of his predecessors and disdaining all, pursues his studies by 
another route, and with another point of view, and thinks he has 
found something, he deceives himself and deceives others." 
He points out the necessity of the proper classification of 
disease on a basis of pathological anatomy, of the vital importance 
of the study of diagnosis by careful observation and correlation, 
not only of the general symptoms on which prognosis depends, but 
of the special symptoms associated with each disease process. 
"The only method by which one can acquire solid knowledge in 
medicine depends on avoiding the adoption of any principle which 
is not proven by many individual facts, by studying with care the 
characters and the course of diseases, and by treating them accord- 
ing to the indications drawn from the observation of that which 
has succeeded in like cases. This is the method which Hippocrates 
asserts to have been known long before him, which he regards as 
the only way by which one may make real discoveries." 
He ends with the words of Klein (Interpres Clinicus): "I 6 
THE CANADIAN MEDICAL 
assert that medicine is free. I place myself neither with the ancients 
nor the moderns, and I follow the one (party) as well as the other 
when they cultivate the truth; yet more often, I repeat, myself, 
their observations." Wise advice for the day in which it was 
written, wise, if not taken too literally, for all time. 
Theophile Laennec had already wron the recognition of his 
masters and associates. He was made a member of the Sociite de 
Vicole de medicine and became an editor of the Journal de medecine, 
etc. He took up the torch from the hands of the dying Bichat, 
and his studies of pathological anatomy were worthy of his great 
predecessor. The work on peritonitis was a classic both anatomi- 
cally and clinically. In 1805 he published a note on pathological 
anatomy in which he sought to set forth a system of classification 
of organic changes-an interesting and valuable communication 
which led to a long dispute with Dupuytren. At about this time 
he came chiefly interested in the study of the Celtic dialect of lower 
Brittany, of which eventually he acquired a considerable knowledge. 
He published frequent critical reviews and an annual summary of 
the diseases prevailing in Paris-a duty which brought him into 
close touch with the Hotel-Dieu and the St. Louis, as well as the 
Charite. But already his hard work had told upon him seriously. 
That which he called his "asthma" disturbed him greatly, and the 
rest he needed he could not take. A happy vacation of several 
weeks in 1805 with his cousin, Madame de Pompery, at Courcelles, 
near Soissons, did much to freshen and strengthen him. Rouxeau 
publishes a number of amusing verses and extracts from plays 
which Theophile seems to have written during this short vacation 
with surprising facility and spontaneity. 
In 1808, Laennec retired from the Journal de medicine. He was 
beginning to acquire a practice of his own. 
In 1809, the Ecole de sante de Paris became the Faculte de 
medecine; Laennec was a doctor of the new school. 
In 1812, he was named Alternate Physician "medecin sup- 
pieant ") at the Beaujon. 
In 1814, be was at the Salpetriere, where his knowledge of 
Gaelic was of the greatest help to him in caring for and consoling 
the young Breton conscripts, who, unable to make themselves, 
understood, were distressingly homesick. 
He had become the great authority on pathological anatomy, 
and in the Dictionnaire des sciences medicales, he wrote on "Anatomic 
'pathologiqve, Ascarides, Cartilages accidrntels, Crinon, Cucurbitains, 
Degeneration, Degenerescence, Disorganization, Ditrachysiros ou 7 
ASSOCIATION JOURNAL 
bichorne rudy, Encephaldide, Fibreux, Fibro-cartilayes acddentels, 
Filaire, Furie infernale." 
In 1816, Laennec was appointed Chief of Service at the Neckar, 
where he gathered about the bed-side a group of devoted students. 
It was here at the Neckar that his great discovery was made. 
Every one knows the story; how one day in 1816 he noticed boys 
at play in a court of the Louvre who, with the ear applied at the 
extremities of long pieces of wood, listened to the transmission of the 
sound of a pin scratch at the opposite end, how, on the following 
day, he rolled a notebook tightly, and placing one end against the 
chest of a patient, was delighted to find that he could hear the 
heart beats more clearly and distinctly than he had been able to 
hear them with the naked ear. Soon he devised his simple wooden 
cylinder and began his researches. It was, after all, a natural step. 
Up to the time of Bichat and Laennec, despite the work of Morgagni, 
little had been known of the pathological changes in organs. Laen- 
nec, a great observer, inbued with his new knowledge of pathological 
anatomy, had his eyes wide open for something more than that 
which percussion and inspection and mensuration could give; and 
the acute mind found the way. 
What Laennec did with his discovery is a model for all time. 
In the three years that followed, he had brought before the world 
the characters of normal respiration and voice sounds, and their 
variations, with different physical changes in the constitution of 
the lungs as clearly as they may be taught to-day. But more than 
this, he had described anatomically and clinically the various forms 
of bronchiectasis, emphysema, pulmonary oedema and pulmonary 
apoplexy. 
The description of pneumonia from an anatomical standpoint 
is almost as admirable as the demonstration of the method by which 
its presence could be determined clinically. Again, his description 
of the different forms of pulmonary tuberculosis, in ward and 
laboratory, the recognition of the possibility and manner of arrest 
of the disease, are models of acute observation and understanding. 
His contributions to the diagnosis of diseases of the heart are not 
upon the same plane, owing, doubtless, as Saintignon points out, 
to the circumstance that the physiological explanation of the heart 
sounds and their significance was at that time unknown. Starting 
with the false hypothesis that the second sound was auricular in 
origin, he never found his way out of the jungle. 
This was a wonderful work for one man. How was it done? 
Laennec tells in his own words in the preface to his book: "When 8 
THE CANADIAN MEDICAL 
a patient enters the hospital, a student is given the task of collecting 
from him what anamnestic information he can give as to his disease 
and of following its course. As I examine the patient myself, I 
dictate the principal symptoms that I observe, those, especially, 
which may go to establish the diagnosis or the indications as to 
treatment, and I give my conclusions, subject to amendment, if it 
be necessary, by later observations. This dictation, which is made 
in I atin for obvious reasons, is taken down by the pupil in charge 
of the patient, and, at the same time, on a separate notebook, which 
I call the "diagnostic sheet, which it is the special duty of another 
pupil to keep in order that he may hold and read it to me, if neces- 
sary, at each visit. When any new sign appears, such as may 
modify the first diagnosis, I add it also. If the patient dies, the 
protocol of the necropsy is taken by the pupil in charge of the 
observation. I re-read these observations before all those present 
at the necropsy, and if there be occasion to make any correction, 
I do it on the spot, and after having taken their counsel." 
Laennec's visits, according to one of his pupils, Toulmouche, 
lasted from an hour to an hour and a half. He invited his colleagues 
and friends to interesting necropsies, and he always committed 
himself before the necropsy in the presence of all as to the changes 
which he expected to find. There could be no better model for 
study and instruction. 
In May, 1818, Laennec spoke before the Societe de V ecole on 
auscultation, and finally, in August, 1819, just a hundred years 
ago, the famous "Traite d auscultation mediate" appeared. It 
made a great impression, and although seriously criticized by some, 
it was soon taken up by the world. 
I aennec was small and delicate of frame. "Little Laennec," 
"the little Professor," his fiery adversary, Broussais, called him. 
But he was spirited and devoted to outdoor sports, especially to 
hunting, for which some of his rich patients gave him opportunities 
on their estates. During the winter he practiced in his apartment 
with an air-gun. Frail as he was, he was especially proud of his 
prowess in athletics of all sorts. "He was but a breath of air," says 
Pariset, "and he thought himself a Hercules." He was musical, 
and played the flute. He drew fairly well, and amused himself at 
other times at the turner's table. But the scant recreation that he 
snatched from his work was of little benefit. He burned the candle 
at both ends, and it is probable that he was already suffering from 
the malady that had carried away his master, Bichat, and his com- 
panion, Bayle. He had wounded himself during a necropsy and ASSOCIATION JOURNAL 
9 
developed an anatomical tubercle on his finger, which persisted, 
Finally, in 1820, worn out, he retired definitely, he fancied, to his 
beloved Kerlouarnec, in Brittany, There with his faithful com- 
panion and housekeeper, afterwards to become his wife, he lived for 
two years by the sea. The blessed solace of solitude, the joys of 
hunting and roaming about his lovely native fields, the opportuni- 
ties of leisure to renew his studies of the classics and of the dialect 
of his people, rest and peace, gradually brought new strength, and 
after two years, duty called him again to Paris. 
On his return, he found new and wearying tasks thrust upon 
him in the shape of an appointment as physician to Her Royal 
Highness, the Duchess de Berry, and shortly afterwards as pro- 
fessor of the Faculte. 
At this time, Broussais, with his so-called physiological doctrine, 
held considerable sway-that strange doctrine which ascribed all 
the vital processes to that which he called "irritation", and all 
diseases to its excess or deficiency-the excess meaning inflammation, 
the default, debility. For him there was no essential difference 
between diseases, which are distinguished only by the degree of 
irritation and the particular sympathy of one organ for another. 
The physician must occupy himself only with the organ primarily 
affected, which was, in most instances, the gastro-intestinal tract. 
The terms " gastro-enterite" and " gastrite" played a large part in 
the "physiological doctrine" with which Broussais believed he bad 
revolutionized medicine. All that had gone before could be thrown 
aside, and treatment was reduced to the simplest terms. It was 
another system like that of Hahnnemann or Brown or Gall-words 
-championed by a convinced, fiery, spirited, vain, intolerant 
advocate. 
In his opening lecture at the College de France, Laennec warned 
against the fallacies of the new "doctrine" in a clever parable of 
the life and work of Paracelsus. And from this time on there was 
war between the clinic of Vai de Grace and that of the Charite, to 
which Laennec had moved with his new chair-war in which the 
acute and well-considered criticism of Laennec easily triumphed 
over the fiery diatribes of the modern Paracelsus. His clinic was 
soon sought by physicians from all countries, eager to learn his 
methods. In 1823 he was made a member of the Academy of 
Medicine. 
In 1824, he married his companion, Madame Guichard-Guegen, 
veuve Argou. In the same year he was made a Knight of the 
Legion of Honour. 10 
THE CANADIAN MEDICAL 
From 1824, when the first edition of his treatise was exh austed 
he had been working assiduously, in addition to all his other duties, 
on a second edition, the form of which he had entirely changed, 
making the work in reality a treatise on the diseases of the heart 
and lungs. This was completed and published in May, 1826. 
It was his last effort. The strength that he had gained in his 
long rest in Brittany bad soon given out. His cough had increased. 
In April he developed fever and dyspnoea and, soon, a persistent 
diarrhoea. His voice grew hoarse; he became profoundly emaciated, 
and in June, himself unconscious of that which all others could see, 
he left for Kerlouarnec, where he died on August 13th. Two 
hours before his death, he removed his rings and laid them on the 
table by his bed. To the queries of his wife, he replied; " Some one 
else will soon have to do this for me; I would save him the trouble." 
He was forty-five years old. 
In the ten years that had passed since his discovery of aus- 
cultation, he had brought the art of physical diagnosis of diseases 
of the lungs from a state of the utmost crudity almost to the point 
at which it remains to-day. He had done this not only through 
the introduction of his new method, but through the study and 
analysis of the Changes in the organs themselves, and through the 
careful application to diagnosis, not only of auscultation but of all 
other methods then known, and by a conscientious objectivity 
which is a model. In his opening lecture at the College de France, 
he says that, if he presents hypotheses, "I hope to present them in 
such manner that one cannot attach more importance to them than 
do I myself, and I hope that I shall never give that which I think, 
that which I suppose, my point of view, my theory, in a word, for 
that which constitutes the true science, for that which one knows." 
That which Laennec had done for the lungs was later extended 
to the heart with the growth of our knowledge of physiology of the 
circulation, by Bouillaud, Hope, Stokes, Corrigan, Graves, Flint 
and others. 
It is just one hundred years since the appearance of Laennec's 
book. Since then great things have happened in medicine. The 
advances in our knowledge of the natural sciences, the associations 
which attach med'cine to a firm scientific basis, have increased 
rapidly. The developments in the domain of pathological anatomy, 
of bacteriology, of chemistry, of physics-to mention only the 
applications of electricity in exploration, and of the x-rays, have ASSOCIATION JOURNAL 
11 
given us a deeper insight into the nature of the processes of life and 
of disease, and have augmented our powers of control and recog- 
nition and prevention, and, happily, in some instances, our powers 
of relief and conquest of disease. 
The refinements of diagnosis and the possibilities of treatment 
demand to-day an increasing mass of knowledge and experience 
which we struggle, often in vain, especially in the United States, 
to crowd into an insufficient period in our universities and schools 
of medicine. All the new methods of research, however clean-cut 
and valuable their results may be, are of use only if they are exer- 
cised by one who has mastered them by practice and experience. 
A new instrument of precision, a new method of surgical procedure, 
in the hands of the inaccurate or the inexperienced, is of no ad- 
vantage ; it may be misleading and harmful. Refinements of method 
must themselves be studied and practiced carefully. But even 
then they are in themselves rarely final; they are but additions to 
our basic armamentarium, new bricks for the edifice of diagnosis 
and treatment, useless if the foundation be deficient-nay, more 
than useless-dangerous. In the domain of diagnosis, the simple 
procedures of Auenbrugger and Laennec remain the basic essentials 
of the art. No man is fit to profit by modern refinements of diag- 
nosis who is not experienced in the study of pathological anatomy, 
familiar with the changes in organs, and well trained in the funda- 
mental methods of physical exploration, who has not gained through 
practice at the bed-side a skill and experience in the art of ausculta- 
tion and percussion which has made him familiar with the physical 
manifestations of the activities of heart and lungs in health and in 
disease. How variable these manifestations may be in the normal 
subject should be known by all physicians. 
"The power to explore is to my mind a great part of the art." 
This familiarity, this training, this power, is to be gained only 
in the necropsy room and in the ward. Books cannot teach it; it 
cannot be learned in the lecture-room; no magic power of inherit- 
ance can transmit it. "There are," says Laennec, "some things 
which one can transmit well only by experience and practice; . . . 
however, it is precisely in these points that I count on training the 
students at the clinic; such are the distinctions of the various 
nuances of crepitant, dry and moist rales, the (distinction of) deep 
and superficial phenomena, ... of the manner in which, in the 
most difficult and uncertain cases, in pericarditis, for example, one 
arrives at a definite diagnosis through comparison of the signs and 
by a process of exclusion." 12 
THE CANADIAN MEDICAL 
The experiences of the last few years have made it painfully 
clear that a very large proportion of our American physicians, and 
I understand that, to a certain extent, the same is true in this 
country, are sadly lacking in the essential foundations of a training 
in diagnostic methods. In the army there is apparent a wide- 
spread tendency to reason and act precipitately and without con- 
trol on information furnished by the laboratory. Physicians forget 
that laboratory reports are in few instances final, that their value 
depends in great measure on their relation to the clinical aspects 
of the situation-that at every point the human element comes into 
play, that a laboratory report from an unreliable source is worse 
than worthless. 
It is becoming easier and easier for the physician to obtain 
x-ray plates or fluoroscopic examinations of his patients, examina- 
tions of sputa and excreta, cultures, agglutination and complement 
deviation tests, which come ba<*k to him as short and definite re- 
ports. Too often the x-ray report especially, is written so as to 
convey to the practitioner a sense of finality which is generally un- 
justified. To the physician who is not wholly familiar with the 
clinical aspects of the case, this is a danger-a trap into which he 
falls in too many instances. To him who is incapable of controlling 
it, an x-ray report is often a liability rather than a help. In the 
army in France the greater part of the unjustifiable diagnoses of 
pulmonary tuberculosis were dependent upon the blind acceptance 
of an x-ray report. The same is true in connection with many 
laboratory tests. I have seen the most obvious ulcerative endo- 
carditis regarded and treated as typhoid fever because of the 
report from a health department of a positive typhoid agglutina- 
tion test. 
It is, alas, too common in private practice to meet with men 
who have almost abandoned the examination of the patient, and 
depend on the reports of consulting specialists and on laboratory 
tests. Not long ago, as I told my students this spring, I saw in 
consultation, a gentleman who was said by his physician to be 
suffering from cardiac disease; he feared, angina pectoris. I asked 
the physician what the symptoms had been. His reply was that 
at first he had thought that the patient had indigestion, but that 
Dr. X. had found his heart enlarged, that Dr. Y. had made a 
Wassermann reaction which was negative, that Dr. Somebody 
Else had looked into the conditions of the stomach and given the 
patient a test breakfast without notable result, that a differential 
blood-count had been made; that the urine showed no abnormalities. 
T asked if the patient had had pain. He had, over the heart. Did ASSOCIATION JOURNAL 
13 
it radiate into any other part of the body? No. Was it associated 
with exercise? He thought not. After a little questioning, 1 
realized that the doctor had practically no information to give me 
as to the symptoms or physical signs manifested by the patient. 
1 then spoke with the patient, and in a few minutes learned that his 
pains did follow exercise and eating; that they did radiate into his 
arms in a characteristic manner; that the history alone was such as 
to justify a diagnosis of angina pectoris The doctor had neglected 
all ordinary methods of investigation and had contented himself 
wholly with the reports of laboratories and experts on this, that, and 
the other detail. This is not to practice medicine. But, though 
a rather exaggerated picture, it is an example of what one met too 
often among younger as well as older officers in our hastily gathered 
together medical corps. 
In one ward of one of our army hospitals in America during 
an epidemic of pneumonia, the Chief of Service discovered thirteen 
unrecognized empyemas among thirty-two patients. One hundred 
years after the publication of Laennec's book, the commonest event 
of my visits to camp hospitals in France was the discovery of un- 
recognized pleural effusion, pleurisy regarded as unresolved pneu- 
monia. 
Who is to blame for such conditions as this? Is it that the 
men who enter medicine to-day are incapable of acquiring the foun- 
dations of the art? 1 think not. On the contrary, in those hospitals 
in the United States Army where courses of instruction were insti- 
tuted, it was surprising to find the avidity with which medical 
officers, young and old, grasped the opportunities offered, and how 
quickly some acquired proficiency in methods of physical examina- 
tion, which, in the medical school, they had not properly been 
taught. 
The fault lies in our methods of medical instruction, and here 
again 1 fancy that you, in Canada, have been less at fault than we. 
Nevertheless, I am disposed to believe that the general interest in 
bacteriological, serological, chemical, and the newer physical 
methods of exploration have in many schools led us to forget the 
necessity of prolonged and systematic training in laboratory, ward, 
and out-patient department, in pathological anatomy and in physical 
diagnosis in its more restricted sense, in auscultation and percussion. 
Training in diagnostic methods is useless if it be not preceded and 
accompanied by experience in the dead house. The student must 
be familiar with the anatomical changes in organs which he seeks 
to recognize in the living subject. He must follow the patient from 
the ward to the necropsy table. More than this, proper instruction 14 
THE CANADIAN MEDICAL ASSOCIATION JOURNAL 
in auscultation and percussion demands careful supervision of the 
student-instruction in small groups. The student must be led to 
make his own discoveries, to solve his own problems-he must be 
directed to a proper course of reasoning. Physical diagnosis can 
be taught only by the bedside. Again, this early instruction in 
physical diagnosis should not be relegated wholly to the young 
instructors. One of the most important duties of the professor of 
medicine is to give his personal attention to the students who are 
for the first time approaching the patient. It is at this point in 
the career of the student that the wise and experienced clinician 
can exercise his most important and lasting influence. It is, I 
believe, the attempt to teach the diagnostic art didactically that is 
at the root of the inefficiency of so many practitioners to-day If, 
at the outset, the student be encouraged to read books or to listen 
to discourses on diagnostic methods, he starts with a handicap of 
preconceived ideas which he may never overcome. Again, the 
necessity of familiarity with the normal is too often overlooked. 
No student should leave the medical school without appreciating 
the frequency, position and character of the sounds heard so com- 
monly on the expansion of atelectatic borders of lungs. 
No man should be allowed to enter the practice of medicine 
who has not, by experience, made himself familiar with the ausculta- 
tion of the normal heart and with those murmurs which are the rule, 
rather than the exception, in young individuals, especially cardio- 
respiratory murmurs. If he be not familiar with the normal, he 
will be a poor judge of the significance of deviations from the 
ordinary. 
"The power to explore is to my mind a great part of the art." 
In epitomizing the life of a great physician, I have desired to 
emphasize the thought that the kernel of the art of medicine lies 
in the power to explore. This power is gained only by experience 
and by practice. 
The last century has perfected the art of diagnosis in many 
ways. But proficiency in the basic methods of exploration which 
we owe to Auenbrugger and to Laennec is as vital to-day as it was 
an hundred years ago. 
In those parts of this paper which deal with the life of Laennec, 
the author has drawn largely on the works of Saintignon (Saintignon, 
Dr. Henri: "Laennec: Sa Vie et Son (Euvre," Paris, J. B. Bailliere 
et Fils, 19, rue Hautefeuille, 1904), and Rouxeau (Rouxeau, Alfred: 
"Laennec avant 1806," Paris, 1912). Nursing and the Art 
of Medicine 
By W. S. Thayer, M. D„ Hon. F.R.C.P.L 
Late Brigadier General, M.C., U. S. A. Reprinted from the 
American Journal of Nursing NURSING AND THE ART OF MEDICINE1 
By W. S. Thayer, M.D., Hon. F.R.C.P.I. 
Late Brigadier General, M.C., U. S. A. 
It is not as one filled with affectionate remembrance and stirred 
by the inspiration of direct association with a large figure in the med- 
ical world, that I am here this evening. It was not my good fortune 
to work personally with Miss Delano. Indeed, we met but once, and 
then quite incidentally, at a gathering of the Committee of the Council 
of National Defense, but the memory of a fine, strong, earnest face 
remains. 
It is rather as a sincere witness to the value of that which she 
represented,-of that to which she gave her life; of the influence which 
the nurse, as exemplified by Miss Delano, exercises on the practice of 
medicine and on the public; of what the nurses whom she and her 
friends helped to select, have done in this war, that I am now before 
you. 
Miss Delano's life was given largely to the education of the 
trained nurse. She and the colleagues with whom she so wisely sur- 
rounded herself during the last several years of her life, represented 
a group of women who are to-day the right arm of the medical pro- 
fession, that branch of the medical profession (and I use the word 
advisedly, for a trained nurse is a member of the medical profession 
in its broadest sense),-on which depends the practice of some of the 
most vital parts of our art. 
From all time woman has stood by the bedside of the sick and 
the wounded. Why? Because her sphere has been at home while man 
has been called to the strife and the driving activities of life abroad? 
In part, perhaps, but that is not all. The prime reason has been that 
woman has done this task better. She has always done it better and, 
I venture to say, she will always do it better. 
The discoveries which are giving to the practice of medicine a 
surer scientific basis, are teaching us at the same time how essential 
is that which we call the "nursing" of the patient. The perfection of 
our methods of nursing has been one of the greatest advances of the 
last hundred years of medicine. The surgeon must still bandage and 
dress his wounds, and the physician should still be able to bathe and 
dress, to massage, manipulate and care personally for his patient, but 
much of this he can never do so well as does an experienced woman. 
Moreover, in daily life his functions carry him from house to house, 
1 Read at a meeting in memory of Jane A. Delano, in Philadelphia, May 
7, 1919. and limit the moments he can spend at the bedside. The patient, if 
he is to receive the attention that he requires, must be watched and 
cared for by one who is efficient and experienced, understanding and 
cooperative. True efficiency in the care of the patient at the bed- 
side is to be learned only by experience and by practice. Love alone 
cannot supply it; gold alone cannot buy it. 
Understanding can be acquired only by instruction, study and 
well directed observation; cooperation, only through a thorough 
realization that the practice of nursing is an integral part of the prac- 
tice of medicine, as inseparable from the art of practice as are diag- 
nosis and prognosis and advice. Generally it is the most important 
element of treatment. 
Medical practice becomes daily more complicated, for disorders 
of the human mind and body are not simple things, and as we know 
more we are finding ever more ways in which we may be of service. 
Our methods of diagnosis are more numerous and more time- 
taking; and the gain may not always be apparent; but we cannot 
neglect them for we know how many lives are saved by the early 
detection of disease and the initiation of proper prophylactic meas- 
ures. And then the details of the care of patients are much more 
complicated than they were, for we have come to know that by these 
procedures we save life and invalidism and mental and physical 
anguish. 
Beyond a few specific measures, such as the employment of the 
antitoxin for diphtheria, the treatment of myxoedema, and prophylactic 
vaccination against typhoid fever, the greatest advance in the prac- 
tice of medicine in the past century has been the development and 
standardization of the art of nursing, toward which such noble work 
has been done by the group of women among whom Miss Delano was 
a leader. 
The contribution of the trained nurse to the art of medicine is 
difficult to overestimate. The sympathetic touch, the dexterous hand, 
the gentle presence of woman, that is much, yet that is not new. But 
to have always in the sick-room, one taught to observe and record 
accurately; one educated and practised in the methods of antisepsis 
and asepsis; one who has, through supervised practice, proved her- 
self an adept in the art of attending to the wants and comforts of the 
invalid, with the least disturbance and inconvenience, and the least 
exhaustion to him; one who is familiar with all ordinary medical and 
surgical appliances and procedures and mechanical methods of 
treatment; one who has, as a result of years of experience in a well 
planned course, acquired a real knowledge of the significance of 
symptoms; one on whose moral character and influence one may depend as surely as is possible in the case of the woman who passed 
under the supervision of the leaders of nursing in this country,- 
these are incalculable gains. The physician or the surgeon who knows 
what the trained nurse means to the practice of medicine feels help- 
less without her. Her functions are wholly complementary to his. 
Without the nurse, the proper practice of the art of therapy is incon- 
ceivable. 
The profession of nursing is laborious and wearing. It demands 
health and youth and strength. The years of practical activity of a 
nurse are relatively few. But to be a trained nurse demands more than 
mere bodily strength. It demands intelligence and education well 
above the ordinary, and stability and strength of character. Rela- 
tively few women are adapted to the career of a trained nurse. 
The relations between nurse and patient are such as often to be 
fraught with obvious danger. It is the inestimable contribution of 
that fine body of women who, in England and America especially, 
constitute and have constituted the superintendents of our well organ- 
ized training schools, to have demonstrated that, under women of 
character and ideals, the selection and education of nurses may be so 
organized, so standardized, that these dangers are reduced to an 
almost negligible minimum. 
Only tried women are suitable to go out into nursing and espe- 
cially into army nursing. No better proof of this can be found than 
the prejudice which existed in 1898 among many excellent medical 
officers of the army, against the introduction of the trained nurse 
regularly into the army service. These officers could not conceive the 
presence of attractive young women among the somewhat rough boys 
of the army without complications and scandal. This prejudice still 
persisted among some army officers after twenty years. No more bril- 
liant vindication of the character of the trained nurse could be imag- 
ined than the universal chorus of tribute of to-day, tribute not only 
to the courage, the loyalty, the efficiency of the work of the army 
nurse in America and France, but to the uplifting, stimulating, re- 
fining influence that these women exercised upon officers and men. 
Silly, idle, unhealthy-minded, careless-tongued busybodies will 
start gossip which readily spreads, and such rumors have been spread 
about the nurses in France, among others. Let me beg of you one 
thing,-if any such rumors reach you, and you desire an answer, ask 
the "doughboy" who has passed weary hours in an army hospital, but 
unless you wish to stage a tragedy, don't tell him who told you! 
I remember well the conditions of the Spanish War. I remember 
the fine work done by nurses; but I remember also the difficulties, the 
anxieties and the obstacles in the way of those who endeavored to maintain the standards of the service, and to show to the medicai 
corps what nursing in the army might and should be. 
Twenty years later, in considerable measure through the efforts 
of Miss Delano, the beginning of the present war found an army nurs- 
ing corps well established, and a Red Cross Reserve, gathered under 
her supervision, to which fell the main burden of the nursing in 
France and in America. Thirty-five thousand nurses were enrolled 
in the Red Cross. Nearly eleven thousand regular and reserve nurses 
served in France alone. The anxieties and the danger of the voyage 
these women bore as calmly, and often more so, than the men. To 
their work in France I can testify as one who was among them. I saw 
them under all conditions. In the hurriedly improvised camp hospital 
of the crowded base port, and in isolated points in the base sections; 
in spots removed from all that was interesting and stimulating, where, 
at times, refined women had to sleep crowded together, twenty or 
thirty in a rough, open ward, without privacy, with the crudest and 
most insufficient sanitary arrangements, exposed continually in damp, 
rainy weather, with mud so deep that one could navigate only in rub- 
ber boots. I saw them in half-finished base hospitals in the Vosges, 
under like conditions, in the bitter northern winter, where with 
fingers and toes numb and blanched with cold, one nurse had almost 
to care for a whole ill-heated ward. I saw them work day in and d?' 
out without rest, without recreation, in the darkened wards by night, 
and the fog and rain by day, and bear the strain every bit as well as 
men. I saw them in field hospitals behind the lines, in areas not in- 
frequently bombed at night and sometimes by day. I saw them go to 
the front for service in evacuation or field hospitals, as members of 
teams formed for the care of the wounded suffering from shock, at 
points shelled by day and bombed by night; in dugouts when off duty 
but exposed to all the dangers of war when at work. They served 
without fear, without flinching, without complaint. But one murmur 
did I hear, and this a murmur and not a complaint, a regret that it 
might not be given to them to share more fully the duties and the 
responsibilities at the points of greatest danger. Wherever they went 
they brought order and cleanliness, and system and contentment and 
peace. Ask the "doughboy" what it meant to him to find himself at 
last in a ward presided over by a nurse. Try to say a light word about 
a nurse to a "doughboy" who has been under her care! 
Several instances may illustrate the influence and efficiency of 
the nursing service in France. Not infrequently it fell to me to visit 
a certain field hospital, temporarily immobilized, about eight miles 
behind the lines, in a region not infrequently bombed by aviators. It 
was a sorry looking place. In old, dingy barracks, with little iron French cots, and a sadly insufficient personnel-for it was never pos- 
sible for the medical corps to obtain its full equipment-lay boys with 
coughs and colds, and bronchitis, and pneumonia, and occasionally 
the gassed; and in other wards were cases of meningitis and diph- 
theria, with only untrained orderlies to look after them. Alas, order 
and cleanliness were impossible to obtain with all the struggles of the 
medical officers. Then one day, on another visit, I stepped into the 
same wards to find everything changed, the floors clean, the bed 
clothes in order, the patients looking rested and happy,-it was almost 
a miracle. A few army nurses had arrived upon the scene and 
straighway everything was transformed. 
Some weeks later, the division surgeon, a fine medical officer of the 
old order, said to me: "Colonel Thayer, all my life I have opposed the 
introduction of nurses into the army, but I want to tell you that my 
experience of the last few weeks has entirely changed my opinion, and 
if I can succeed in arranging it, I propose never to be without them 
again." A few days after that, I met the surgeon of the division 
which was moving into that sector, and asked him as I left the office 
if there were any way in which I could assist him. He replied im- 
mediately: "Indeed you can, if your influence is of any value in 
keeping the nurses in field hospital No. X. Col. Y. tells me that he is 
going to take them with him, and unless I can get a new group it will 
be simply impossible properly to carry on the work." 
What the nurse was to the wounded and ill officers and men in- 
dividually, it would be difficult to express. This was shown in their 
letters to those at home. It fell to the officers to censor the letters of 
the patients; and with unfailing regularity, by the time the second 
or third letter home was written, there were expressions of touching 
and undying gratitude to the nurses. For these nurses and for the 
other American women working with the Red Cross and like societies, 
there was nothing that the convalescent soldier would not do. 
One more touching incident,-one of my friends stopped one day 
by the bedside of a severely wounded man who was just beginning to 
turn the scale toward recovery. As the patient looked up at the sur- 
geon he said: "You know, Colonel, the first thing I knew, the first 
thing I saw when I opened my eyes, was a nurse in a white apron 
bending over the bed; and then, you know, I just knew it was all right, 
and I shut my eyes again and went to sleep." He "just knew it was 
all right"-and so it was, wherever they were, God bless them I 
To the cause of the sound education of the nurse, and the exten- 
sion of her sphere of activity in relation not only to hospitals and to 
private practice, but to the broader fields of public hygiene and sani- 
tary instruction, Miss Delano gave much of her life. She lived to see nursing generally recognized as an indispensible 
complement to the practice of medicine, as it must one day be recog- 
nized as an integral part of the art of therapy; she lived to see the 
trained nurse universally regarded and employed as a vital agent in 
measures of public sanitation throughout the civilized world. 
To the affiliation and coordination of the important nursing 
agencies of the country, to the end that under the American Red Cross 
there might be established a force of nurses properly selected and 
organized, adequate not only for the demands of peace, but for the 
emergencies of war, she gave the latter years of her life. It was work 
well done. 
She lived to see the standards of nursing for which she stood, 
recognized by the government. She lived to see the nursing agencies 
of America united and cooperating with the Army and the Red Cross. 
She lived to know that the Red Cross was ready, and to realize that 
it had given to the army a contingent second to none in the service, in 
character, in morale, in organization, and in efficiency. She lived to 
see that the American Army Nurse had stood the test. She gave her 
life freely and unreservedly to a noble service. She accomplished that 
which she undertook. She died at the height of her powers, at work. 
She was a fine figure, the figure of an American Nurse. The Medical Aspects of Reconstruction 
BY 
W. S. THAYER, M.D., Hon. F.R.C.P.I. 
LATE BRIGADIER-GENERAL, M. C., U. S. A., BALTIMORE, MARYLAND 
FROM THE 
AMERICAN JOURNAL OF THE MEDICAL SCIENCES 
December, 1919, No 6, vol. clviii, p. 765 Extracted from the American Journal of the Medical Sciences, 
December, 1919, No. 6, vol. clviii, p. 765. 
THE MEDICAL ASPECTS OF RECONSTRUCTION. 
By W. S. Thayer, M.D, Hon. F.R.C.P.I, 
LATE BRIG.-GEn'l, M. C., U. S. A., BALTIMORE, MARYLAND. 
In the ordinary practice of medicine, apart from the fundamental 
question of diagnosis, the doctor finds himself mainly concerned 
with the closely interwoven problems of the prophylaxis and treat- 
ment of disease. The war has emphasized the importance of that 
other duty of the physician which is so difficult often to fulfil, 
namely, the care of convalescence-that part of medicine which 
may more properly be regarded as "reconstruction." 
When the acute symptoms of a disease have passed, when con- 
valescence is well established, the activities of the physician too often 
come to an end. In private practice the doctor, sensitive lest he 
may seem unnecessarily to obtrude his services on the patient, who 
no longer needs immediate supervision because of the emergencies 
of the disease, makes his adieu with an earnest recommendation that 
the invalid take a suitable vacation, advice which the latter rarely 
feels justified in following. 
In hospitals the demand for space requires that the patient be 
discharged so soon as he is comfortably on his feet. A few fortunate 
institutions are able to offer to a limited number of patients the 
advantages of a "convalescent home," which affords rest and good 
food for perhaps two weeks. In general, however, with the dis- 
charge of the doctor in private practice, or of the patient in hospital, 
the duties and responsibilities of the physician as regards that par- 
ticular individual are considered to be at an end. The conduct of 
his convalescence is left to the patient, who is now his own master. 
In war, conditions are different. The patient is not his own 
master; he is the servant of his country and his master needs his 
services as quickly as they may be available. These services are, 
however, useful only when the subject is restored to complete 
efficiency and able to perform his duties to the full. The conditions 
of service in France were such that every man who could be returned 
to the line and every man who could be useful at the base was 
needed at the earliest moment; on the other hand, it was equally 
desirable that every man who was not fit for service be returned to 2 
THAYER: MEDICAL ASPECTS OF RECONSTRUCTION 
America with the least possible delay. Thus it was that the exig- 
encies of war soon brought it about that the study and care of con- 
valescence became one of the most vital and important of medical 
questions. 
In other words, in war time in France the value of the care of 
convalescence, of medical reconstruction in its narrow sense, came 
to take its proper place in the practice of medicine. 
It is not alone to the period after discharge of the patient from 
the hospital that the term "reconstruction" may be applied. To 
think of reconstruction as applicable alone to the treatment of those 
convalescent from a grave wound or malady is an idea as mistaken 
as to think of prophylaxis as associated only with measures of general 
sanitary preparation, such as one may adopt before the occupation of 
a camp site, or to think of treatment as of necessity associated with 
the wards of a general hospital. In reality the problems of recon- 
struction are so closely interwoven with questions of prophylaxis 
and of treatment, that in private practice, as well as in war time, 
they form an indivisible trinity. 
The individuals with whose rapid and efficient rehabilitation we 
were concerned may briefly be classified as follows: 
1. Those numerous instances of exhaustion, concussion, and 
especially of fear, anxiety neuroses and psychoneuroses of all sorts, 
which, if not arrested at an early period, so easily pass down the line 
of communications and under the influence of the surroundings of a 
general hospital become "fixed." 
2. The mildly gassed, who are especially liable, if not properly 
cared for, to present annoying psychoneurotic phenomena. 
3. Those psychoneuroses of a more serious character which need 
longer treatment and care at a base hospital. 
4. Convalescents from all types of non-disabling wounds, gas 
intoxication, operations and disease. 
5. Patients suffering from that complex of symptoms known in 
the A. E. F. as an "effort syndrome," a group which includes many 
of the convalescent gassed. 
6. The tuberculous. 
It was soon found that in the confusion of battle and the necessity 
of rapid evacuation a large number of men suffering from simple 
exhaustion, fear, concussion and a variety of lesser functional 
nervous phenomena, and often incorrectly classed among the gassed, 
passed back into base hospitals, far distant from their original 
station. The same was true of many of the mildly gassed. Some 
of these men recovered quickly after a few days' rest. Many were 
clamorous to return to the front. Some were quite ignorant as to 
why they had been sent back. These men, who before returning 
to their organizations were obliged to go to a depot division, were 
permanently separated from their original assignments. Lying 
about hospitals they rapidly lost morale, discipline and physical 
vigor, and on their arrival at a depot division were soft in every 
way. In others of a more impressionable character, ill-judged THAYER: MEDICAL ASPECTS OF RECONSTRUCTION 
3 
treatment in a general hospital resulted in the fixing of psycho- 
neuroses which, once established, were difficult to overcome. It 
became clear early that measures must be taken to hold these 
men so near the front as possible at some point where they might 
be given rest, suitable treatment and study. This was the main 
problem of reconstruction at the front. 
At the base the problems were almost equally urgent. The 
ordinary disability board in the crowded hospital, obliged to pass 
upon the soldier as he is hurriedly evacuated, can make but an 
imperfect and superficial prognosis as to the future capabilities of 
the given individual, an estimate often changed over and over again 
as the convalescent passes from hospital to hospital on his way 
toward the rear. During the often long periods of physical inactiv- 
ity the patient's muscles become relaxed and his morale depressed, 
and soldiers frequently required considerable periods of retraining 
before they were able to take up their functions. With others it was 
only through the discovery by actual test at the front and failure 
satisfactorily to perform the duty assigned to them that men found 
gradually their proper level. This meant a material loss of time. 
It became evident that those men who, on discharge from the hos- 
pital of the first instance, were regarded as fit for some duty in 
France must be sent directly to some spot where they might receive 
such treatment and training as would prepare them at the earliest 
possible moment for the special functions which they might have to 
fulfil. This was the main problem of rehabilitation as it related 
to the base. 
1. Problems of Reconstruction in Divisional, Corps and 
Army Areas. The first desideratum, as has been said, W'as that 
instances of exhaustion, fear, the mildly gassed and psychoneuroses 
be held for a few days at field hospitals or at divisional or corps rest 
or retraining camps. That a proper selection of suitable cases be 
made demands the presence of well-trained medical officers at the 
"triages"-advanced field hospitals-that which, unfortunately, 
was not always possible in the organization that we possessed in 
France. Excellent results, however, followed the stationing at 
these points, at the suggestion of Col. Salmon, of trained neuro- 
psychiatrists. Here many instances of simple exhaustion or fear or 
concussion, which previously had been sent to the rear, perhaps as 
gassed, were held, suitably treated and returned to their organiza- 
tions after two or three days' rest. Under favorable circumstances 
it was found that as many as 80 per cent, were returned to their 
divisions-the average during the Argonne offensive was 65 per cent. 
But in times of special stress such measures were not possible 
at crowded field hospitals in corps and divisional areas. The wise 
measure was accordingly adopted of establishing in the army area 
special so-called neurological hospitals and special gas hospitals. 
The neurological hospitals were under the general supervision of 
Col. T. W. Salmon, senior consultant in neuropsychiatry, the army 
psychiatrist and a carefully selected staff. To Col. Salmon's fore- 4 
THAYER: MEDICAL ASPECTS OF RECONSTRUCTION 
sight, good judgment and efficiency as director and senior consultant 
in neuropsychiatry our army owes much. 
In the Argonne the gas hospitals were placed temporarily under 
the professional supervision of Lieut.-Col. Richard Dexter, senior 
consultant in medicine for gas. Between these two groups of hos- 
pitals the mildly gassed and the instances of exhaustion, fear and 
other lesser psychoneuroses were differentiated, and suitable treat- 
ment, mental and physical, was afforded to all. 
From the neurological hospitals an average of 58 to 60 per cent, 
were returned to the front. From the gas hospitals many of the 
simply exhausted were also sent directly to such corps as had 
established a rest camp or replacement depot, and thereby saved 
to their original organization; others passed to the rear and were 
distributed in various base hospitals. The early and proper treat- 
ment of the gassed resulted in a material shortening of the period 
in hospital, and hastened their return to active service. 
While the desirability of the designation of special base centres 
or hospitals for the care of the gassed was recognized, the difficulties 
of evacuation were such that their establishment had not become 
possible at the time of the armistice. 
2. Problems of Reconstruction at the Base. In base areas 
there were established certain institutions which were in a stricter 
sense reconstruction centres. 
(a) The Neurological Base Hospital (117) at Lafauche. Thus, 
at Lafauche, not more than fifty miles from the front, there was a 
special neurological hospital (117), to which were sent those cases 
returned from the like hospitals in the army area. Here and in a 
small adjacent convalescent camp, under the care of a selected 
staff, over 93 per cent, of these cases wTere returned to duty-20 
per cent, to field duty. Only 7 per cent, of those sent from the front 
to Base Hospital 117 were returned to America. 
The nature and value of this institution, Col. Salmon has dis- 
cussed elsewhere. To this hospital, which, in extent, was far from 
adequate to the demands made upon it, psychoneuroses arising 
elsewhere in the A. E. F. were also sent so far as possible. 
(6) The Orthopaedic Retraining Centre. The earliest of the special 
reconstruction centres was the Orthopaedic Retraining Camp estab- 
lished by Dr. Goldthwaite, first in the Vosges and afterward at St. 
Aignan in Touraine. Here excellent work was done in rehabili- 
tating officers and men whose disabilities were found to depend on 
various remediable surgical defects, especially on bad shoeing. 
(c) The Convalescent Camps. To meet the demand for a more 
rapid and efficient rehabilitation of all convalescents there was 
planned near each group of base hospitals, a special camp, in which 
it was hoped that convalescents might receive carefully devised 
physical and mental training, associated with skilled supervision, 
which, on the one hand, might be directed toward the rapid rehabili- 
tation of the patient and on the other toward the earliest possible 
recognition of the moment at which he was fit to return to duty. THAYER: MEDICAL ASPECTS OF RECONSTRUCTION 
5 
Into the history of these institutions it is impossible to enter 
at length. Already at the time of the inception of our hospital 
system the convalescent camp in the British service had reached 
a high degree of efficiency. The British experiences and the results 
which they had achieved were of the greatest value to us. It was, 
after all, on the British model that we had hoped to build. Suffice 
it to say that at the outset, designed as an overflow, to relieve the 
crowded base hospital so soon as might be, they were regarded as 
commands suitable for older or less capable officers. Soon, however, 
the value and importance of the work of retraining, the complexity 
and delicacy of the problems involved, the necessity that the director 
of such a camp should be possessed of signal tact and judgment and 
savoir fair e, brought it about that in the British service the position 
of commanding officer of a convalescent camp came to be one for 
which officers of the very highest qualifications were sought. 
100 
RECEIVED AT 
TRIAGES 
05 
TO DUTY 
20 
TO DUTY 
DIVISION 
35 
TO ARMY < 
NEUROLOGICAL 
HOSPITALS 
14 
TO DUTY 
A 3 
B 6 
C 5 
15 
TO BASE 
HOSPITAL 
117 
ARMY 
s.o.s. 
1 
TO U.S. 
A - Front Duty 
B - Temporary Base Duty 
C - Permanent Base Duty 
Outcome of concussion and nervous cases arising in battle. (Salmon.) 
Our camps were under canvas, and it was desirable that the con- 
ditions under which the men should live might be so nearly as 
possible those which they might expect under favorable conditions 
while on active duty. The camp was under the charge of a medical 
officer. It was not, however, a hospital but a retraining centre. 
The object to be attained was the most rapid possible preparation 
of the individual for his return to duty. To accomplish this it was 
necessary to consider both the mental and the physical aspects of 
the case. The soldier must be given graded physical training, care- 
fully adapted to his powers; these powers must be tested at frequent 
intervals. As the individual proved himself able to return to duty 
he must be sent to the depot camp or reclassified and assigned to 
that duty for which he was fitted. To accomplish this with the 
greatest efficiency a carefully designed schedule of work, play and 
amusement must be arranged. Th^ soldier must, in the first place, 
be always under military discipline. He must be on a duty status. 
This he should never be allowed to forget. Periods of drill, setting- 6 
THAYER: MEDICAL ASPECTS OF RECONSTRUCTION 
up exercises and inarches, should be carefully interlarded with other 
periods of rest, recreation and amusement. The amusements and 
periods of rest should be so planned that the patient's mind should, 
so far as possible, always be healthfully occupied. It is often true 
that men who tire soon at drill, enter enthusiastically into games 
through which valuable physical training is acquired. Relaxation 
in the shape of music and theatrical performances, in which the 
patients take part, shoidd be provided. The programme of the day 
should be so ordered that the soldier has no idle time, and the 
schedule of work and play should be one calculated to improve the 
morale of the camp as a whole. For neurotic individuals, especially 
those with effort syndrome, the moral aspects of treatment are 
especially important. With many such the work should be so 
arranged that at the outset, although under military discipline, the 
men may not feel themselves driven-that the primary physical 
demands may not be too great. Such men, started aright, soon 
find themselves carried along in the general stream, and freed from 
anxiety and apprehension, they gain with surprising rapidity. The 
soldier should be observed by medical officers at the end of drills, 
marches or exercises. So soon as he becomes able without effort 
to perform the work and play of a given class, he should be passed 
on to the class above in which the physical demands are greater. 
The demands for graduation from the last class should be equal to 
those to which the soldier is subjected on a duty status. 
Such, roughly, was our ideal of the convalescent camp. To each 
of our institutions an officer was assigned who had had special 
training in cardio-vascular disease and had passed several months 
at Colchester with Dr. Thomas Lewis-officers carefully selected 
and supervised by Lieut.-Col. Alfred E. Cohn, senior consultant 
in cardio-vascular disease, whose excellent conception of the con- 
valescent camp was set forth in lectures before the Army Sanitary 
School. 
To these camps convalescents of all sorts were sent so soon as 
they might be discharged from hospital. Although, at the period of 
the armistice, most of our camps were in a crude and undeveloped 
state, several had demonstrated their value. It had been hoped 
that a special central laboratory and camp for the study and treat- 
ment of effort syndrome might be established at Pougues les eaux, 
but it was considered better to send the ordinary run of cases of 
effort syndrome to these camps, and the results, so far as we could 
judge, were good. 
(d) Measures with Regard to Tuberculosis. In the early spring 
of 1918 Col. Bushnell, impressed by the considerable number of 
instances of so-called pulmonary tuberculosis returning from France, 
detailed Major, now Lieut.-Col. Webb, to investigate the matter. 
Col. Webb found that out of one hundred cases arriving at an 
American port with the diagnosis of tuberculosis, only about 30 
per cent, presented manifestations justifying the diagnosis. On 
arriving in France and studying the conditions at a base port where THAYER: MEDICAL ASPECTS OF RECONSTRUCTION 
7 
patients were being gathered for deportation, similar conditions 
were found. This was due largely to (a) a lack of proper knowledge 
of physical diagnosis or a lack of attention on the part of the officers 
in charge, or (b) to the habit of accepting the interpretation of a 
Roentgen-ray plate by a radiologist as evidence of active tubercu- 
losis. Systematic instruction in the diagnosis of tuberculosis was 
given by Lieut.-Col. Webb in many of the base hospitals; further- 
more, arrangements were made by which all cases in which tuber- 
culosis was suspected without the demonstration of bacilli in the 
sputa were referred to special collecting centres in which arrange- 
ments for their proper study were afforded. In two of these centres 
near base ports special arrangements for the detention and care of 
the tuberculous who needed rehabilitation before deportation were 
provided. 
These in a general way were the measures of medical reconstruc- 
tion adopted in France. 
The experience gained in the British convalescent camps and in 
one of our incomplete and mushroom-like organizations has given 
us some results on which it is worth dwelling. At one of the earliest 
of these formations, convalescent camp No. 2 at Lifol le Grand, 
Capt. Bridgman was able to make some interesting observations. 
Here careful physical examinations of the patients were made by 
competent officers on entrance and before discharge, and a " follow- 
up" system was established which was designed to obtain replies 
from battalion medical officers two months after the return of the 
soldier to his organization and again in six months. Out of the first 
5000 cases replies after two months were received in 2000, from 
which it became apparent that outside of the killed and wounded, 
over 99 per cent, of those returned to duty as Class A men were 
performing their normal functions-a significant evidence of the 
value of a well-ordered convalescent camp. 
It was further possible, with a considerable group of these cases, 
to study the period between the admission to hospital, the onset 
of disease or operation and the moment at which the subject had 
proved himself fit for full duty. 
In other words, these convalescent camps in war offered for the 
first time, so far as I am aware, an opportunity to obtain information 
as to the average duration of convalescence from ordinary medical 
and surgical conditions in the normal young adult. The figures pub- 
lished in the article soon to appear by Captain Bridgman and 
shown on the chart are suggestive. They emphasize the point 
with which I began, namely, that in medical practice the question 
of convalescence is sadly neglected. 
When we consider, as Bridgman has pointed out, that it takes a 
robust young soldier thirty-four days to pass through and recover 
from the effects of an acute tonsillitis, fifty-eight days from a pneu- 
monia, seven weeks from a herniotomy, five weeks from a tonsillec- 
tomy, with all the advantages offered by a, convalescent hospital, 
we may well pause and reflect. 8 
THAYER: MEDICAL ASPECTS OF RECONSTRUCTION 
TABLE SHOWING THE AVERAGE TOTAL PERIOD IN HOSPITAL AND 
CONVALESCENT CAMP OF MEN DISCHARGED TO DUTY. 
(MODIFIED FROM BRIDGMAN.) 
Average total 
Diagnosis. 
No. of 
stay in hospital 
cases. 
and camp. 
Influenza 
. . . . 828 
31 
Pneumonia 
. ... 170 
58 
Acute bronchitis 
. . . . 233 
36 
Mumps 
. . . . 53 
39 
Measles 
. . . . 18 
27 
Scarlet fever 
. . . . 7 
77 
Catarrhal jaundice .... 
. . . . 7 
38 
Diphtheria 
. . . . 5 
57 
Tonsillitis and sinusitis . 
. . . . 90 
34 
Medical Conditions. 
Hemorrhoidectomy .... 
. . . . 25 
45 
Herniotomy 
. . . . 41 
50 
Hydrocelotomy 
. . . . 7 
54 
Tonsillectomy 
. . . . 8 
37 
Surgical Conditions. 
Gas 
1195 
37 
Enteritis 
512 
30 
Concussion 
192 
45 
Exhaustion 
80 
40 
War Casualties. 
The grave sequels of so many acute infections, especially the 
psychoneurotic phenomena following operations and many of the 
continued fevers, might well be in part avoided if we possessed in 
civil life opportunities to offer that which we were beginning to 
provide for the care of our troops in France-adequate care of con- 
valescence. It is easy to see what an immense advantage such 
institutions for the care of convalescents would be to large industrial 
institutions. It is equally easy to comprehend the grave difficulties 
which would attend the conducting of such an institution in civil 
life. Nevertheless, it is clear that convalescent departments are 
needed and should be started in connection with our large hospitals; 
not convalescent homes, but institutions under the charge of active 
and specially trained physicians; institutions in which every arrange- 
ment for the well considered rehabilitation, mental and physical, 
of the convalescent may be carried out. Here in America the 
admirable work of General Hospital No. 9, at Lakewood, has shown 
what symptomatic, physical and mental training may do for the 
large body of slightly subnormal individuals from whose ranks a 
considerable percentage of the effort syndrome were derived. The 
treatment of these cases differs in no essential from that which should 
be afforded to convalescents in civil life. 
If our experience in this war shall help to awaken a new interest 
in the care of convalescence and shall convince the medical profes- 
sion and the general public of the importance of suitable physical 
training in the rehabilitation of the inefficient, a beneficent advance 
will be made in the art of medicine. THE AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 
George Morris Piersol, M.D., Editor. 
John H. Musser, Jr., M.D., Assistant Editor. 
Monthly. Illustrated. 1920 pages yearly. Price, $5.00 per annum. 
rpHE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, founded in 1820, has 
I long been recognized as the leading medical journal of the English-speaking race. From 
the first it sought the epoch-making papers, and becoming recognized as their medium, 
it has, in turn, been sought by those who have had discoveries or real advances in the 
art and science of medicine to announce in its Department of Original Articles. During 
1919 The American Journal will still further develop a feature that has proved most 
useful and popular, namely, a series of Special Articles, written by prearrangement with 
men of the highest authority, and covering present-day topics of the greatest importance 
and interest. These articles are designed to be clinical and practical, and to present 
important advances and the latest knowledge clearly and concisely, with particular reference 
to application in daily work. The Department of Book Reviews will continue to comprise 
critical and discriminating estimates of important new books, as well as briefer notices of 
books of less importance and of new editions. The Department of Progress of Medical Science, 
under the charge of recognized specialists, will continue to summarize the actual advances in 
the art and science of medicine appearing in the leading medical periodicals of the world. 
PROGRESSIVE MEDICINE 
A QUARTERLY DIGEST OF ADVANCES, DISCOVERIES AND IMPROVE- 
MENTS IN THE MEDICAL AND SURGICAL SCIENCES, COVERING THE 
ENTIRE DOMAIN OF MEDICINE. Edited by Hobart Amory Hare, M.D., 
Professor of Therapeutics, Materia Medica and Diagnosis in Jefferson Medical College, 
Philadelphia, etc. Assisted by Leighton F. Appleman, M.D., Instructor in Thera- 
peutics, Jefferson Medical College, Philadelphia. In four octavo volumes, containing 
1200 pages, amply illustrated. Annual subscription price, in heavy paper covers, $6.00, 
net; in cloth binding, $9.00, net. Carriage paid to any address. 
PROGRESSIVE MEDICINE is the story of the progress, discoveries and improvements 
I in the various branches of the medical and surgical sciences, and is published four times 
a year, in March, June, September and December. The matter presented is the digested 
essence of the entire medical literature of the world published during the previous twelve 
months, modified, explained and criticised in the light of the personal experience of the con- 
tributor. By this method useless information is discarded and only that which is valuable 
and really helpful to the practitioner is retained. Practicality and thoroughness are the con- 
trolling features. The contributors are authorities in their respective lines, and their 
experience in private and hospital practice enables them to choose unerringly that which 
their brother workers require. Every article is original, the veritable product of the author 
whose name it bears. The style is narrative in form, hence easy to read. The interpre- 
tation of the facts stated is given and their bearing upon the whole subject under 
consideration is clearly and simply indicated. 
COMBINATION RATES 
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Progressive Medicine (paper covers) and the American Journal " 10 00 
LEA & EEBIGER OSLER 
By William S. Thayer OSLER 
By William S. Thayer [From The Nation, issue of January 24, 1920.] 
OSLER 
William S. Thayer 
AS the accumulating tragedies of the aftermath of war 
gather fatally one on another, a puzzle and a mystery 
to the thoughtless masses whose imperfect eyes seek in vain 
for the cause, the old dead ache that we have borne for these 
last interminable years, the old dead ache that it is our 
dream to outlive breaks out now and again in new and cruel 
crises. Such a crisis was the death of Sir William Osler, 
as much a tragedy of the war as if he had fallen by the 
side of his boy, "forward as fits a man." 
Son of a canon of the Church of England, bom in 
Bond Head, Ontario, in 1849, he was at the outset destined 
for the clergy, but his inclination carried him toward 
medicine, and after four years in Toronto and Montreal he 
graduated at McGill University in 1872. For the two years 
following he studied in London, Berlin, and Vienna, and 
in 1874 he returned as lecturer and later as professor of 
the Institutes of Medicine at McGill University. In 1884 
he was called to the University of Pennsylvania as Pro- 
fessor of Clinical Medicine, and in 1889 to the Johns Hop- 
kins University as Professor of Medicine and Physician 
in Chief to the Johns Hopkins Hospital. In 1905 he left 
America to become Regius Professor of Medicine and Stu- 
dent of Christ Church at Oxford. Such is a brief outline 
of his academic career. He held honorary degrees from a 
large number of American and foreign universities, 
was a Fellow of the Royal Society. 
In the two years spent in Europe he made important 
original studies on the blood. Wherever he went his de- 
votion to work, his remarkable power of observation-for 
throughout his life he was an observer rather than an ex- 
perimenter-his extraordinarily quick grasp of the signifi- 
cance of that which he saw or read, his clear vision and 
sound, sane judgment, his simplicity and sincerity and hon- 
3 esty impressed his colleagues and the public, and he came 
to be much sought for as a consultant. 
In 1892, after a year of intensive work, he published his 
treatise on "The Practice of Medicine," which, largely be- 
cause of its rare personal quality, because it represented 
the fruits of actual observation and experience, has been 
for so many years the standard text book of medicine in 
America. He delivered many lectures before learned socie- 
ties, the Goulstonian lectures in 1885, the Cartwright 
lectures in 1886, the Harveian lecture in 1906. He pub- 
lished a number of short volumes on different medical sub- 
jects-chorea, cancer of the stomach, angina pectoris-and 
a very large number of notes on a great variety of patho- 
logical conditions observed in his constant clinical activi- 
ties. He delivered many addresses and was the author of a 
considerable number of charming and valuable historical 
and biographical essays. 
His work in the organization of the new medical clinic at 
the Johns Hopkins Hospital in 1889, his insistence that, for 
the proper care of the patient as well as for the improve- 
ment of the teaching of medicine, the student should be 
used, as in England and France, as an assistant in the 
wards, and his practical abandonment of-the barren didactic 
methods were steps of great importance in the advance- 
ment of medical instruction and in the improvement of 
hospitals in America. These were notable achievements; 
they have been abundantly recounted in the last few weeks. 
But if one turn to the notes of those who knew him and 
were close to him, such as the tributes by eighteen of his 
associates in the Johns Hopkins Hospital Bulletin for July, 
1919, he may perhaps be struck by the lack of stress laid 
on the scientific and material aspects of his work; for it 
was in the human side of this man that lay his true great- 
ness. It is probable that there has, in America, been no 
medical man so universally revered, no man whose power, 
whose inspiration has reached so many, no man so loved. 
Wherein lay the secret of this power? What was the man- 
ner of the man? 
His father was Cornish, and Osler was a true Celt. A 
Celt in appearance, not large, of a very dark, almost olive 
complexion, with a rather long, drooping black mustache- 
a Celt in his charming vivacity and brilliancy and in his 
sparkling wit. Not large, but well built, with a wiry, ath- 
4 letic figure, a long, swinging, active gait, a peculiarly mo- 
bile face, serious and almost stern when at rest, with deep, 
dark brown eyes with an irresistible humorous twinkle; 
deep clear eyes, so clear that although they might some- 
times seem unfathomable, they told at a glance of a pure, 
kindly, loyal spirit behind. As a teacher he was wholly 
simple and devoid of circumstance or of the least attempt 
at studied eloquence or theatrical effect. He taught mainly 
by the bedside. His alert eye missed little. His few, 
kindly, often droll words gained the early confidence of the 
patient, and kept the student on his tiptoes. His talks in 
the wards were replete with epigrams. The right adjec- 
tive, often quaint and unusual, was always on the tip of his 
tongue, and to a rare degree he possessed the power to in- 
spire in the patient confidence, courage, and hope; in the 
student, enthusiasm. 
The equanimity that he preached he likewise exemplified. 
"Let not the Crooked Things that can't be made streight 
encumber you," said Cotton Mather.* Few followed this 
wise maxim as did Osler. Of the hopeless and irritating 
dilemma he always saw the humorous aspect and 'twas dis- 
missed in the twinkling of an eye, with the one word that 
might almost-indeed sometimes did-accomplish the seem- 
ingly impossible. These "Oslerisms," as his disciples 
called them, were a delight to his pupils. Indeed, at one 
time two had almost published a collection. 
Plus je songe a la vie humaine, plus je crois qu'il faut lui donner 
pour temoins et pour juges 1'Ironie et la Pitie, comme les Egyp- 
tiens appelaient sur leurs morts la deesse Isis et la deesse 
Nephtys. L'lronie et la Pitie sont deux bonnes conseillieres; 
1'une, en souriant, nous rend la vie aimable; l'autre, qui pleure, 
nous la rend sacree. L'lronie que j'invoque n'est point cruelle. 
Elle ne raille pas ni l'amour ni la beaute. Elle est douce et 
bienveillante. Son rire calme la colere, et c'est elle qui nous en- 
seigne a nous moquer des mechants et des sots, que nous pouvions, 
sans elle, avoir la faiblesse de hair.f 
This gentle "Ironie" for which we have no word in Eng- 
lish, this gentle "Ironie" which neither wounds nor embit- 
ters-how well he understood it! In nearly thirty years of 
friendship, in fifteen years of daily association with Osler, 
I never heard from his lips an unkind word about a brother 
*Manuductio ad miniaterium, etc. 12°. Boston, Hancock, 1726, p. 147. 
tAnatole France: Le Jardin d'Epicure, p. 121. 
5 practitioner. He saw and he appealed to the best in every 
man. More than this, no one could speak ill of his neighbor 
in his presence. He who forgot himself once never did so 
again. One evening among the group of students who gath- 
ered about his table on Saturdays, an old college mate began 
to ridicule a colleague. In a moment Osler turned, and 
pointing to the photograph over his fireplace, said: "Do you 
not think that Innsbruck statue of King Arthur a fine 
figure?" The colleague flushed, the students shivered, the 
subject changed. And it was ever so. 
He loved his fellow men and they loved him. His table 
was always filled with passing guests: colleagues from a 
distant point, the country doctor, the student who, coming 
to visit the clinic, was stunned to find himself carried away 
to luncheon with the great man that he had expected only 
to listen to from afar. "The master word in medicine," he 
said in one of his most beautiful addresses, "is work." But 
efficient work, he says in another, means inevitably system. 
He knew not idleness, and he put into his life and main- 
tained in a manner which can only be described as master- 
ful, a remarkable system. 
At seven he rose; breakfast before eight. At a few 
minutes before nine he entered the hospital door. After 
a morning greeting to the superintendent, humming gaily, 
with arm passed through that of his assistant, he started 
with brisk, springing step down the corridor towards the 
wards. The other arm, if not waving gay or humorous 
greetings to nurses or students as they passed, was thrown 
around the neck or passed through the arm of another col- 
league or assistant, and by the time the ward was reached, 
the little group had generally grown like a small avalanche. 
The visit over, to the private ward. For the many con- 
valescents, or the nervous invalid whose mind needed di- 
version from self, some lively, droll greeting or absurd 
remark or preposterous and puzzling invention, and away to 
the next in an explosion of merriment, often amid the 
laughing but vain appeals of the patient for an opportunity 
to retaliate. For those who were gravely ill, few words, but 
a charming and reassuring manner. Then, running the 
gauntlet of a group of friends or colleagues or students or 
assistants, all with problems to discuss, he escaped. How? 
Heaven only knows! 
A cold luncheon, always ready, shortly after one. Twenty 
6 minutes rest in his room; then his afternoon hours. At 
half past four, in the parlor opposite his consulting room, 
the clans began to gather, graciously received by dear 
"Mrs. Chief," as Lady Osler was affectionately known. 
Soon the "Chief" entered with a familiar greeting for all. 
It was an anxious moment for those who had been waiting 
long for the word that they had been seeking with him. 
After five or ten minutes he would rise, and perhaps beckon 
to the lucky man to follow him to his study. More often he 
slipped quietly from the room and in a minute reappeared at 
the door in his overcoat, hat in hand. A gay wave of the 
hand, "Goodby " and he was off to his consultations. 
Dinner at seven, to which, impartially and often, his as- 
sistants were invited. In the evening he did no set work, 
and retired early to his study where, his wife by the fire, 
he signed letters and cleared up the affairs of the day. Be- 
tween ten and eleven o'clock, to bed. Such were his days. 
Three mornings in the week he took at home for study; 
He utilized every minute of his time. Much of his summer 
vacation went to his studies. On railway, in cab, on his way 
-to and from consultations, in tramway, and in the old "bob- 
tailed" car that used to carry us to the hospital, book and 
pencil were ever in his hand, and wherever he was, the, 
{happy thought was caught on the wing and noted down. 
His ability at a glance to grasp and to remember the gist of 
-the article that he read was extraordinary. 
His power to hold the mastery of his time was remark- 
able. .He escaped as by magic, but so graciously, so engag- 
ingly that, despair though one might, he could hardly be 
irritated. No one could speak consecutively to Osler against 
his will. How did he do it? I know not.^ 
His humor was irrepressible. It cropped out in every-< 
thing. Now it was in medical articles, published under an, 
amusing pseudonym, which were excruciatingly funny- 
reports of amazing cases, subjects which could lead no man 
astray, but have been seriously and solemnly quoted. Now 
it was a sly thrust at a colleague in the absurd title of a 
medical paper which mysteriously found its way into the 
program of a society meeting. Now it was the elaborately 
prepared counterfeit of a new journal, presented at a din- 
ner, with a whole table of contents which brought horror 
to the hearts of the victims-and the rest a blank. His as- 
sistants had always to be on their guard. The genial 
7 practical jokes played on his friends were endless, and so 
notorious that, alas, they have grown sadly with repetition. 
In a tight place he would pass under his nom de plume, un- 
known to the puzzled bore who had sought to nail him down. 
His generosity to his assistants was unending, and almost 
every gift, every act of kindness was accompanied by some 
droll and often really humorous mystification. 
Wherever Osler went the charm of his personality 
brought men together; for the good in all men he saw, and 
as friends of Osler all men met in peace. Under his in- 
spiration the Medical and Chirurgical Faculty of Maryland 
took on a new life, and a new harmony reigned among all 
about him. 
Throughout all his life Osler was a student of the lives 
of those who had gone before. Biography was to him of 
compelling interest, and in his numerous biographical es- 
says, some of which have been collected in "An Alabama 
Student," he stimulated in his students a reverence for the 
great names of medicine, and an interest, sometimes as 
deep as his own, in the search for the recondite in the his- 
tory of our art. 
But above all this Osler was a scholar. In early life he 
had given little time to the classics. But few men have 
lived more completely in the atmosphere of the great minds 
of the past. An insatiate reader, his memory was re- 
markable, and the timely and happy quotation was always 
on his lips. Nightly, for half an hour, he communed with 
that which was best in literature. He loved books, and 
early laid the foundations of the great collection which 
was his at the time of his death-a collection, at the out- 
set, of the first editions and early publications of the mas- 
ters of medicine and later of like treasures in all branches 
of science and the humanities. At the time of his death 
he had accomplished the impossible-Osler, doctor of medi- 
cine and practitioner of his art, was president of the British 
Classical Association. 
His occasional addresses, collected in part in "^Equani- 
mitas and Other Addresses," were the mirror of his own 
ideals and his own character. Written in an engaging and 
forceful style, they contain much that is beautiful. But 
that which is more beautiful and more impressive than 
the words is the thought that Osler lived and practiced to 
the letter the precepts that he preached. He rarely'spoke 
8 of himself, but at the great farewell dinner in New York 
he talked briefly and touchingly of his ideals. These ideals 
he realized. 
Some have criticized Osler for his reluctance to enter into 
combat against that of which, in his heart, he disapproved; 
some were inclined to regard him as one who shunned dis- 
agreeable complications rather than facing them. Osler 
did hate and shun useless strife, but when the time came- 
and he was a very wise judge of the proper moment-no 
one was more fearless or more outspoken than he, as more 
than one of his colleagues may remember. When the word 
must be spoken, he was ready to speak it regardless of 
what it might mean for himself. 
His home life could scarcely have been more beautiful, 
and Lady Osler was no less dear than he to the im- 
mense circle that came to call them their friends. In 
Britain as in America, Osler's charm and brilliancy, his 
learning and his skill brought him the same universal 
affection and respect. He was made a baronet, a deserved 
honor. His house at Oxford became the Mecca of Ameri- 
cans. His hospitality knew no bounds. Sometimes forty or 
fifty guests would gather for afternoon tea. 
There was but one child, Edward Revere Osler, a lad of 
but ten when they left America. In this boy Osler's life was 
centred. Always attractive and fond of outdoor life, he 
developed into a singularly charming character, with an in- 
terest in and an understanding of that which is beautiful 
in art and literature rare in one of his age. He began to 
collect books and to collect them intelligently. To his 
father this development was an inexpressible joy. 
Surrounded by honors and love abroad, and with perfect 
happiness at home, a figure of growing significance among 
his colleagues of the old university, active in his profession 
and in the gathering and cataloguing of his wonderful 
library, the sky was clear-and the war came. 
Whole-heartedly and without a bitter word, he gave him- 
self as ever to the duties of the hour. In the medical de- 
partment of the army his advice was sought on all manner 
of questions. He was consultant to a number of hospitals 
and in our hours of hesitation and delay he was active 
in stimulating his old students to come to the aid of those 
who were fighting our battles. Lady Osler was no less ac- 
9 tive than he. The boy first worked at a hospital in France, 
then entered the Training Corps, joined the artillery, and 
left for the front. It was a strange picture, this man who 
all his life had been the apostle of "Unity, Peace and Con- 
cord" ("^Equanimitas and Other Addresses," p. 447) flung 
suddenly with all that was nearest and dearest into the 
vortex of war. True to his own precepts he consumed his 
own smoke; there was never a lament or a complaint. But 
in his letters to those near to him the ever present anxiety 
for his boy was manifested by the inevitable reference made 
in brave, cheerful words to the sword that hung over their 
heads. 
In August, 1917, cruelly wounded, Revere died, cared for, 
mercifully, by dear friends who chanced to be at his side. 
The blow Osler bore with calm dignity and beauty. The old 
life continued; his house, as ever, was open to all. In the 
last year of his life over sixteen hundred guests sat at his 
hospitable board. But it was a crushing blow from which 
he never recovered, and it killed that exuberant vitality 
which had promised so many long and fertile years. 
With the same old cordiality he greeted his friends, with 
the same outward air of enthusiasm he went about his 
many activities. His address as president of the Classical 
Association was a contribution in which those who strive 
for the maintenance of high standards of scholarship in 
medicine will long take comfort. 
The twelfth of July was his seventieth birthday. Two 
volumes of contributions to the medical sciences prepared 
in his honor by pupils and friends were presented to him 
by his colleague Sir Clifford Allbutt. His old students and 
companions in Baltimore united in dedicating their affec- 
tionate tributes to the beloved master. Testimonials of 
gratitude and affection poured in upon him from all sides. 
On few in their lifetime has such honor and love been 
showered. He was deeply moved. But his heart was 
broken. And when the test came, the old bodily vigor and 
resistance were gone. 
In his last days he remembered as ever his associates 
of former years. Week by week he dictated or wrote let- 
ters from his sickbed first to one and then to another of his 
old friends. And when he could no longer write he asked 
those by him to write in his stead. 
He was a keen observer, a brilliant clinician. His con- 
10 tributions to medicine and medical education were im- 
portant. He was a great teacher. But his main strength 
lay in the singular and unique charm of his presence, in 
the sparkling brilliancy of his mind, in the rare beauty of 
his character and of his life, and in the example that he set 
to his fellows and to his students. He was a quickening 
spirit. 
At the meeting following his death, the Medical and 
Chirurgical Faculty of Maryland adopted this minute: 
Died 
on 29 December, 1919, at Oxford, 
WILLIAM OSLER, Baronet. 
Physician, teacher, guide, lover of his fellow man. 
Noble exemplar of charity and tolerance and temperance and 
work and love; 
Untiring stimulator and generous benefactor of this Society; 
Whose sparkling wit and genial, subtle humor smoothed the 
rough way of life for so many weary spirits; 
Whose presence banished discord and suspicion. 
The gap which his absence leaves among us will forever be 
warmed by the glow of that all-embracing love which radiated 
from his presence like a halo of light, and brought to all about 
him something of the peace that now is his. 
11 INTRODUCTION 
by 
WILLIAM SYDNEY THAYER 
MWe are in the midst of a groat reform in 
medicine. In our day for the first time, the full 
domain of this so comprehensive field of learning 
has been laid open to scientific research. Doc- ■ 
trines that belong to the oldest traditions of man- 
kind are put to the test not only of experience but 
of investigation. For experience proofs are de- 
manded, for research accurate methods. 
"Everywhere inquiry presses on into the 
most intricate circumstances appreciable by the 
human intellect; knowledge embraces in its expansion 
countless diverse details which disturb the concep- 
tion of the simplicity of human life and to many seem 
more appropriate as adornments of learning than as 
implements of action. 
"Especially does this embarass the practi- 
tioner of medicine. He to whom the exercise of his 
profession allows hardly the necessary time for 
reading, who but too often lacks sufficient literary 
resources as well as a comprehension of the newer 
experiences, finds himself in a dizzy chaos in which 
the ruins of the old are inextricably entangled with 
the building stones of the new." * 
So wrote Virchow, nearly sixty years ago; 
and the "great reform", which was not altogether new 
in his day, continues; and to-day, as then, there 
are those who cry aloud that the details into which 
scientific research lead us are but adornments of 
learning rather than implements of action. The 
$usy practitioner still laments his lack of oppor- 
tunity to read, and is still distracted in his 
effort to distinguish among the ruins of the old 
the building stones of the new. 
The "great reform" of which we have all 
been so conscious for more than a century, has, 'tis 
true, gathered impulse and momentum with the years; 
* Virchow: Die cellular Pathologie, etc., Ed. 3, 
Berlin, A. Hirschwald, 1. and exact scientific methods of research have 
found their way into all branches of medicine and , 
surgery. And here and there those apparently de- 
tached and unrelated details which have seemed to the 
Philistines but adornments of learning, have found 
their application, and, now and again, have become 
implements of action of incalculable value. Exact 
scientific methods have brought us a considerable 
volume of knowledge in these last sixty years, 
knowledge that has given us much power for good. 
*Tis the scientific experimental method that has 
brought us much of the information that we now 
posess concerning infections, information, in so many 
processes, as to the infectious agnets and the manner 
of their entry or transmission, knowledge which forth- 
with cleared the way for measures of public prophy- 
laxis that have taken away much of the terror of some 
of the greatest plagues of mankind. 'Tis exact 
scientific methods that have given us information as 
to the manner of action of many of these infectious 
agents and the reactions to which they give rise in 
the human and animal organism, information which has 
led, through the discovery of specific agglutinins 
and precipitins and of the Bordet phenomenon of com- 
plement deviation, to the establishment of diagnos- 
tic procedures of the greatest value; more than this, 
it is these methods of research that have given us in 
some instances specific curative antitoxins as in 
diphtheria and in tetanus, and in others, antibodies 
of material curative value, as in dysentery, cerebro- 
spinal meningitis and pneumonia; or of more or less 
preventive efficacy, as in typhoid fever, cholera, 
dysentery and plague. 
It is to these methods of scientific re- 
search that we owe antiseptic surgery. 
Again they have given us a conception of 
the manner of action of certain drugs and have enabled 
us, through purposeful experimentation, to produce 
new chemical substances of important therapeutic value. 
Accurate quantitative physical and chemical methods 
are yearly teaching us more of the intricate and here- 
tofore hidden processes of nutrition and tissue change 
in health, and of their pathological perversions - 
knowledge which has already given us powers that ere really life-saving in such a disease as diabates. 
They are opening to us an insight into the physiol- 
ogy of the circulation and respiration as well as 
into the hitherto unknown functions of organs of 
internal secretion, and have enabled us, in some 
instances, to compensate for a lifetime deficiencies, 
that in the past were disabling or fatal. 
The "great reform" of medical progress has 
brought changes to the life of the physician. So 
much new knowledge, so many new methods of explora- 
tion to be employed in the detection of processes of 
disease at stages so early that in the past their 
very existence might not have been suspected - the 
only stage, perhaps, at which one may hope to arrest 
the malady -- exact scientific methods demanding 
training and experience in so many different branches 
of the medical sciences And then so many compli- 
cated and elaborate necessities of technique for' the 
treatment of disease, especially for the surgeon. 
The surgeon daily performs operations of which one 
would hardly have dreamed sixty years ego, and with 
such assurance that he is unusually distressed if he 
f ee? s with regard to any procedure the anxiety that, 
forty years aro, he felt with regard to every opera- 
tion to which the word "major" was applied. But the 
acquisition of this assurance, this perfection, in 
the surgical art has required a training and an ex- 
perience, an equipment and opportunities for work 
which have left little time for attention to other 
phases of the science and art of medicine. He who 
desires to practice with the p-reatest efficiency the 
surgical art must devote all his energies to his 
special task, and even in surgery i+self perfection 
of the art has demanded further specialization. 
And so it is. in all branches of the medical sciences. 
Where the opportunity has offered men have riven 
years or a lifetime to the study of special problems, 
to the elucidation of special obscurities, to the 
perfecting of special methods of exploration or treat- 
ment of disease, and have thereby become the recog- 
nized authorities and advisers of their colleagues on 
special points in the art of medicine. The recognition of the simple truth that 
medical knowledge can be rained only through the 
study of disease, that the sick-bed is one of the 
most vital laboratories for medical research, that 
treatment is of the best only where the patient is 
most carefully and efficiently observed, has opened 
more generally the wards of hospitals to the student, 
and has brought the investigator and the practitioner 
into closer communion. Specialization, emulation in 
the study of disease, its causes, its prevention and 
its treatment, have increased the interdependence of 
medical men, and have brought the physician closer to 
his fellow the world over. The multitude of labora- 
tories that welcome the investigator, the associations 
and congresses, general and special, local, national, 
international, the common interest of the world in 
medical research, not only bring the physician into 
closer contact with other members of his profession, 
but are placing the doctor, his problems, his ideals, 
his accomplishments more and more prominently before 
the public eye. The physician has become less 
isolated, his horizon has been broadened, and the 
learned world, somewhat doubtfully and fearfully, has 
been obliged more generally to receive the student 
of medical science into the fellowship of scholars. 
But with all the improved modern diagnostic 
and therapeutic methods, the qualities and traininr 
which go to make up the wise practitioner remain 
essentially the same. The greatest work of the 
physician is still accomplished through his personal 
influence on his patient, an influence that depends 
upon his common sense, his human experience and sym- 
pathy, his temperament and his character. And care- 
ful bed-side observation and experience form still 
the main basis of efficiency in practice. In his 
daily work, however, the doctor of medicine must 
anneal repeatedly to histological, bacteriological, 
physical and chemical assistance. To comprehend 
and understandingly to employ these procedures the 
physician must have a knowledge of chemistry, of 
physics, of mathematics, indeed, considerably be- 
yond that which was demanded or nossible in days not 
long past. This is so true that it is our greatest 
concern at the present moment to provide means for 
-the suitable early training of the student of medi- 
cine in these vital foundations. The volume of our knowledge and the 
diversity of the fields of study demanded in the 
different branches of medicine have made it more and 
more impossible for the individual, in literature as 
in practice, adequately to cover ground that used, in 
older days, to belong to one man, and along with the 
development of specialism in practice, there has 
grown up a considerable forest of medical publica- 
tions on special subjects. Relatively few of these, 
alas, are of any great value. A variety of unfortu- 
nate influences have resulted in the flooding of the 
world with a mass of inferior medical literature. 
The physician feels that he must write to make him- 
self known, and yields too readily to the temptation 
of the opportunities offered by the publisher who, 
no4 unnaturally, is often interested mainly in the 
financial returns. There is but one excuse for 
writing on a scientific subject: namely, that one 
has a real message to give. Modern medical litera- 
ture in comparison with its volume, contains few such 
messages. The value of a medical publication de- 
pends mainly on the experience and authority with 
which the author writes. It is difficult, nay im- 
possible, in these days, for one man to write a 
textbook of medicine that is not, in considerable 
part, a compilation. Compilations are generally 
poor food for the reader, be he student or practi- 
tioner, and medical literature in the last thirty 
years has produced much serious mental indigestion. 
Indeed Virchow's words describe but too vividly the 
position of the practitioner to-day when with 
anguish he contemplates the dizzy chaos of modern 
medical literature in sn hopeless effort to dis- 
criminate between the ruins of the old and the 
building stones of the new. Simplicity in exposi- 
tion can come only from one who is a master of his 
subj ect. 
Dictionaries and encyclopaedias of medi- 
cine, designed to meet these difficulties, were not 
new even in Virchow's day. Some of Laennec's most 
interesting contributions were to the Dictionnaire 
des sciences medicales. Virchow himself was the 
editor of a system of no mean merit, and since that 
time many a system has come and gone. But sys- 
tems that deal with a subject to which so many ad- 
ditions are being made as to medicine, soon become old, end systems ore revised much less easily 
than textbooks. The effort, introduced by 
the editor of this publication to produce a 
treatise on the practice of medicine in which each 
section, edited by one who is a recognized 
authority in his special branch, may set forth 
concisely and with authority the subject of which 
it treats, is not new; but the arrangement by 
which, through the loose-leaf system, revisions 
and additions may be accomplished from time to time 
without complete re-edition, would seem to be a 
plan of real promise which may well tend toward 
simplicity and efficiency. 
It is pleasant to see that the editor has 
succeeded in bringing together aurhors from so many 
different parts of the world. The interests of 
science know no political boundaries. The 
relations between European and American medicine 
are sure to become closer as time goes on, and 
•tis the hope of many that the day may come when 
not only in their later years but in their under- 
graduate lives, students may wander more freely 
from clinic to clinic seeking the stimulus that 
comes from fresh associations and new points of 
view. 
If the publication of this system 
may help to overcome medical Chauvinism, if it 
may help to bring together more closely students 
of medicine throughout the world, it will have 
done a good work. ON SOME UNPUBLISHED LETTERS OF LAENNEC 
By W. S. Thayer [From The Johns Hopkins Hospital Bulletin, Vol. XXXI, No. 358, 
December, 1920] 
OX SOME UNPUBLISHED LETTERS OF LAENNEC* 
W. S'. Thayer 
One hundred years ago, on or about the 15th of August, 1819, 
there appeared a book which marked the beginning of an epoch 
in medical history. One hundred years ago to-day the author 
was a tired, ill man, seeking a little rest and recreation in his 
beloved Kerlouarnec near Douarnenez on the coast of Brittany, 
endeavouring to stay the inroads of a disease which had carried 
away already -his friends Bichat and Bayle, that malady to 
which he had devoted such brilliant and fertile studies only to 
fall in the end its victim. 
The last two years have brought to me several opportunities 
to visit some of the scenes of Laennec's boyhood, and through 
the great kindness of his biographer;, Professor Rouxeau and 
Dr. Cornillot, librarian of the Bibliotheque de VEcole de mede- 
cine in Paris, I have had the opportunity to examine the relics 
preserved at the museum of the Ecole de medecine at Nantes, 
and to study some of his precious manuscripts. 
A few days before my return from Paris last September it 
was my good fortune to come into possession of the three 
letters which I take pleasure in showing you. 
A word to begin with on the circumstances of his life. 
Rene Theophile Hyacinthe Laennec was born at Quimper, in 
Brittany, on the 17th of February, 1781. 'Tis a charming 
little town, Quimper, situated at the junction of the rivers 
Steir and Odet. The town, flanked by a high hill, lies along 
the banks of the Odet with its rushing tide. The house in 
which Laennec was born stood on the quay itself. His father, 
Theophile Marie Laennec, was a notary, a native of Quimper. 
His mother was an Angevine of noble extraction. The name,1 
[425] 
* Read before The Johns Hopkins Hospital Medical Society on 
March 29, 1920. 
1 Saintignon, Dr. Henri: Laennec: Sa vie et son oeuvre, 12°. 
Paris, J. B. Bailli&re et fils, 1904. 
1 [425] 
Celtic in origin, comes probably from the word " Lenn " 
which signifies study or reading; it might properly be trans- 
lated " reader " or " man of study." It is pronounced as if it 
were spelled "Lennec"; that is, it should so be pronounced. 
Oddly enough, even in France, it is commonly mispronounced 
" Laennec." This is wrong, the diaeresis having been added 
only in recent years by one of his biographers, Theophile 
Ambroise. None of his family use the diaeresis in the spell- 
ing of their name, and his collateral descendants pronounce 
their name " Lennec." 
Five years after his birth his mother died, probably of 
tuberculosis, and Theophile and his younger brother 
" Michaud " were placed under the care of their uncle, the 
Cure of Elliant. On the removal of the uncle two years later, 
the two boys were sent to Nantes, where they were put under 
the care of another uncle, Dr. Guillaume Francois Laennec, 
who, at this time, was rector of the local university. 
Laennec's early education was gained at the Institut 
Tardivel and the College de I'oratoire, which in the school 
year '91-'92, w'hen Theophile entered, was under the direction 
of no less a personage than the celebrated Fouche, then a 
priest. In his uncle William, who was a physician of no 
mean ability, who had studied with John Hunter in London, 
Laennec found a devoted friend and adviser, a father indeed, 
far more of a father than his own brilliant but vain and 
scatter-brained parent. Some of the talents and tendencies of 
this parent he inherited and manifested early in his career, 
to the considerable discomfiture of his uncle; such for instance 
as a remarkable facility in versification. 
In 1795 he began to study medicine at the Hotel-Dieu de 
Nantes. At the same time he was an ardent student of the 
classics. At the age of 11 he translated the first eclogue of 
Virgil into excellent French verse. He was especially inter- 
ested in Greek. While devoted to out-door sports and to 
natural history, the boy, rather early, became impressed with 
the desirability of perfecting himself in a variety of arts and 
graces which might fit him better to commune with the great 
world. He desired earnestly to take lessons in dancing. He 
felt that he should learn how to play some musical instrument 
[426] 
2 and, indeed, became a flute player. He could not help playing 
the flute. No one with an upper lip like his could fail to play 
the flute. 
In 1798 a severe continued fever, probably typhoid, nearly 
cut short his career. 
In 1800 he accompanied the forces of General Grigny as an 
army surgeon during the campaign in le Morbihan, passing 
his time principally at Vannes and Redon. During this 
campaign he wrote an amusing poem entitled " La guerre des 
Venetes" which purported to be a translation of the wrork of 
an old Celtic bard, Cardoe, by a Breton of the name of " Cen- 
neal "-obviously his own name reversed. The manuscript 
of this interesting production which his father had, or sought 
to have done into Celtic, was lost for a number of years. It 
has recently been found and is now in the possession of Pro- 
fessor Rouxeau. 
For several years it looked as if the improvident parent 
might fail to produce the wherewithal to send his brilliant son 
to Paris, but finally, in 1801 Laennec entered the College 
special de sante. There he devoted himself especially to study 
in the clinic of Corvisart at the Charite, then known as the 
Unite. He became a companion of the brilliant Bayle, with 
whom he began important anatomical and pathological studies 
under Dupuytren. This early anatomical work, normal and 
pathological, was notable. He was the first to describe the sub- 
deltoid bursa, as well as the fibrous capsule of the liver. At the 
age of 21, in a remarkable communication, the result of the 
analysis of six cases with necropsies, he set forth the first clear 
clinical and anatomical picture of peritonitis. For general 
peritonitis Laennec did that which, some 80 odd years later, 
Fitz did for appendicitis. 
At the same time his brother Michaud, who was preparing 
for the law, was gaining new laurels. In 1802 this brilliant 
boy entered three contests at the Ecole des quatre nations, 
taking the first prize in all-French, Latin literature and 
general grammar. In the following year Theophile, in the 
Concours des Ecoles speciales de Paris, took the first prize in 
medicine and surgery. He was bitterly disappointed in 
missing like honours in chemistry and anatomy. The reputa- 
[426] 
3 [426] 
tion of the brothers had, however, become so formidable that 
when at the next concours of the Ecole pratique, his name was 
entered, there were no contestants, and at the request of his 
instructors, he withdrew from the contest. 
In 1804 Laennec published a remarkable article on " Vers 
vesiculairesP Some of his original drawings for this publica- 
tion I saw last summer at Nantes. He cannot be said to have 
been an artist, but the work was carefully and well done. 
In the same year he published his thesis, " Propositions sur 
la doctrine d'Hippocrate relativement a la medecine." The 
thesis contains much that is interesting and sound. Here is a 
paragraph: 
The only method by which one can acquire solid knowledge in 
medicine depends on avoiding the adoption of any principle which 
is not proven by many individual facts; by studying with care the 
character and course of diseases and by treating them according 
to the indications drawn from the observation of that which has 
succeeded in like cases. This is the method which Hippocrates 
asserts to have been known long before him, which he presents as 
the only way by which one may make real discoveries. 
In the same year he became a member of the Societe de 
VEcole de medecine, the precursor of the Academic de mede- 
cine. He was likewise made an editor of the Journal de 
medecine. 
In 1805 he published a valuable article on the classification 
of organic changes; this led to a distressing quarrel with 
Dupuytren, which lasted for several years. He was feverishly 
active, working day and night. Delicate, rather frail physi- 
cally, he wras very fond of out-door sport for which, alas, he 
had small opportunity, and his uninterrupted studies told 
upon his health. The happy presence of a cousin, Madame de 
Pompery, at the Chateau de Couvrelles, near Soissons, afforded 
him the opportunity for a much needed vacation. Rouxeau, in 
his biography,2 gives a charming account of his visit, during 
which he met the young woman who was later to be his wife. 
This account bears interesting testimony to his social charms 
and to the ease with which he wrote really rather clever verse. 
2 Rouxeau, Alfred: Laennec avant 1806, 8°. Paris, Bailli^re 
et fils, 1912. 
4 In 1812 lie was made medecin suppieant at the Beaujon. In 
1814 he was attending physician at the Salpetriere which was 
then a military hospital. In 1805 he had taken up the study 
of the native tongue of his people and had acquired a reading 
and speaking knowledge of the Celtic dialect of lower Brittany. 
In 1814 there were, in the Salpetriere, many young Breton 
conscripts, wholly unable to speak French and wretchedly 
home-sick. To these poor fellows Laennec was a God-send. 
" More than one," says Rouxeau,3 . doubtless owed his 
recovery to the joy of finding in Paris a compatriot who knew 
so well how to comfort them in their maternal tongue." 
In 1816 he became chief of service in the Hopital Necker. 
It was in this year that he made his famous discovery of the 
stethoscope. The story has been told so often that one need 
not repeat it here. With the introduction of the stethoscope 
and the irevelations following its use, he began immediately 
to accumulate the material which later formed his book. 
Under the strain of his increasing practice and his constant 
and engrossing studies, his health began seriously to give way, 
and in August, 1818, he took a vacation of several months in 
Brittany, whence he returned on the 1st of November. While 
correcting the proof of his book, he was at the same time busy 
with the manufacture of his stethoscopes. Professor Rouxeau 
tells me that it is probably true that all the stethoscopes 
in existence at the time of his death were macle by Laennec 
himself. Working with a lathe in his own room, he sought 
to prepare enough instruments so that whosoever bought the 
book might have a suitable implement with which to pursue 
his studies. 
In these days of prolific terminology, when so many of us 
coin with delight strange, new, and often barbarous words to 
express simple things, it is interesting to know that Laennec, 
who wrote and spoke clearly and simply himself, resisted the 
introduction of any term for the instrument beyond the 
simple word " cylinder." Others, however, sought to name 
the implement for him, and in the end, somewhat reluctantly, 
he gave way, modifying the term " thoraciscope," suggested 
[426] 
[427] 
3 Op. cit. 
5 [427] 
by his uncle Guillaume Laennec, by substituting the other 
Greek root.4 
About August 15 the book finally appeared, marking, as 
Rist5 has well pointed out, the beginning of modern clinical 
medicine. 
But in its precious folds were imprisoned the heart's blood 
of its author, and on the 16th of August he writes to his 
colleague Perusel of his suffering, his "hypochondrie, goutte, 
asthme " and says: " I am determined to abandon medicine 
and Paris and retire to Brittany, where few patients, I hope, 
will be tempted to seek me." At the end of the year, exhausted 
and suffering from that " asthma " which but too clearly 
must have been the beginning of his fatal illness, he retired to 
Kerlouarnec where he spent two years in rest and recuperation. 
But he could not resist the call of life and activity in the 
capital. Health, or the semblance of health returned, and 
early in 1882, he reappeared in Paris to find himself appointed 
physician to the Duchesse de Berri, an honorable post but not 
a sinecure. He was soon made professor of medicine at the 
College de France. His practice became arduous. His lec- 
tures at the university were carefully prepared and revised, as 
is testified to by the notes which remain. The first of these, 
delivered on the 22d of August, 1822, forms the introduction 
to the Archives generales de medecine. 
At that time Broussais, with his doctrine of irritation, held 
full sway. With him the clear-seeing Laennec could not fail 
to clash. Impetuous, ardent, dogmatic, eloquent, Broussais 
had a large and enthusiastic following, and the controversy 
between the two professors was celebrated. It is interesting 
to-day to read the fine, impassive, logical comments of Laennec 
upon the views of his fantastic adversary. While Broussais 
captured the popular imagination and had a large following, 
the real ability of Laennec soon made itself felt among the 
more thoughtful students. His clinic grew in popularity; his 
name became more widely known, but his health could not 
long stand the strain. 
4 Rouxeau: Paris m6d., 1919, XX, No. 44, III. 
5 Rist, E.: Presse m6d., Par., 1913, XXI, 357. 
6 [427] 
In 1824 he married Madame Guichard-Gueguen, veuve 
Argou, his devoted companion and house-keeper for many 
years. He was made a Knight of the Legion of Honour. 
Already in 1824 the first edition of his book had given out. 
With the new material that he had collected, Laennec had been 
busily engaged on a second edition in which the original book 
was almost rewritten. By May of 1826 the revision was 
finished, but its preparation had exhausted the physical 
capital of its author. At the end of June, he gave up his work 
in Paris and returned to Kerlouarnec, where he died on 
August 14 at the age of 45. 
It was a life of great achievement. He had made im- 
portant contributions to anatomy; he had taken his place 
among the great pathological anatomists. He had been the 
first, anatomically and clinically, to describe peritonitis, bron- 
chitis, emphysema, pulmonary oedema, pulmonary apoplexy. 
He was the first accurately to describe the character of the 
sputa in pneumonia, and his pictures, anatomical and clinical, 
of pneumonia and of pulmonary tuberculosis will always re- 
main classics. His methods of clinical study have never been 
surpassed, and stand a model for the clinician of to-day. He 
might almost be called the father of modern clinical medicine. 
For with all the work of Auenbrugger and Corvisart, the art of 
physical diagnosis hardly existed before Laennec. 
Personally he was a small, rather delicate looking man, 
with curly chestnut hair. The face was rather thin and oval 
with a particularly long, typically Celtic upper lip, which is 
striking in the bust of Toulmouche at Nantes. Last summer, 
through the courtesy of Professor Rouxeau, I had the happy 
chance of seeing not only this bust, but also the one good 
portrait of Laennec which exists. This portrait, painted by 
Dubois in 1812, is owned by his great-nephew M. Robert 
Laennec, who most graciously received us at his charming 
place in the suburbs of Nantes. The picture is life-like; 
one feels that it must have been a good portrait. The face 
and figure are most interesting. The expression, somewhat 
narquois, is attractive-a fine, witty, rather whimsical look. 
Although the man seems small and thin and delicate, yet 
the long, pointed, typically Irish upper lip and something 
7 [427] 
about the mouth give a strong suggestion of vigour and spirit 
and humour. One can well fancy his physical energy. 'Tis a 
striking painting of an engaging figure. 
The three letters which follow were written to an old school 
mate, Dr. Courbon Perusel, of Carhaix, in Finisterre, who has 
[428] 
Bust of Laennec by Toulmouche (1844), taken 
from Paris medical, November, 1919. 
consulted him because of a " dartre," a term which, in those 
days, evidently covered a large variety of cutaneous manifesta- 
tions from simple seborrhoea and senile keratosis to graver 
affections. 'Tis clear from the context that the good fellow's 
annoyance was based largely on moral compunctions as to the 
justification of his contemplated matrimony. Laennec en- 
deavours to reassure him, and upbraids him for what he con- 
8 siders purely hypochondriacal fancies. But it is three years 
before Perusel is convinced; and before he can persuade him- 
self that he is justified in taking the momentous step, he has 
consulted the fashionable dermatologist of the day, Jean Louis 
Alibert, with regard to whose methods Laennec expresses him- 
self with some severity. 
The first letter was begun on the 22d of April, 1817, and the 
first folio, in which Laennec gives so vivid a description of 
his busy life, is written evidently at one sitting, one might 
fancy before going to bed. The next four pages are written 
on separate sheets. The fourth page ends with the words: 
" Je croix quen-" The fifth page continues the sentence, 
" somme, on ne doit" etc., but is written with another pen 
and in a somewhat different form, clearly at another time. The 
sentence is finished, however, before the confession which 
follows in two lines, in the shape of a new date "29 Avril" 
and an acknowledgment that there has been a week's interrup- 
tion in the letter. How many of us have done the same! 
The second letter in which he speaks of his intention to 
retire to Brittany, is written on the 16th of August, 1819, the 
very day after the publication of his book. The third, fourth, 
fifth, sixth and seventh lines are in great part erased, 
" scratched out," the erasures apparently made by his own 
pen. By careful study with a lens it has, however, been 
possible to discover the original text. The same is true of his 
later reference to Alibert. The several words erased in the 
thirteenth line of the second letter I have not been able to read. 
[428] 
9 [428] 
* The letters are reduced to one-half their original size. 
10 [428] 
11 [429] 
12 [429] 
13 [429] 
14 [429] 
15 [430] 
16 [430] 
17 [430] 
18 [431] 
By means of the lens it has been possible to decipher the third, fourth, fifth, 
sixth and seventh lines which have been in great part erased, as well as the 
reference to Alibert in the seventh line from the bottom of the page. These 
lines should read as follows: 
" pour moi, je me bornerais volontiers & n'en pas avoir d'autres. il est vrai 
que j'en ai tout autant que vous, ou peu s'en faut, et de plus, de 1'hypochondrie, 
de la goutte, de l'asthme; tant y-a-t'il que je suis d6termine a abandonner la 
medecine = " 
The seventh line from the bottom of the page should read: " comme il est 
toujours aussi 16ger que vous l'avez connu," 
19 [431] 
20 [431] 
[432] 
21 [432] 
First letter written to, 
M. Courbon PSrusel, 
Doctor of Medicine at, 
Carhaix, Finisterre, 
Paris, 22 April, 1817. 
I beg a thousand pardons, my dear PSrusel, for having so long 
delayed in answering your letter of the 28th of February, which I 
received on the 8th of March. Ever since that day not one has 
passed without my having intended to write to you on the follow- 
ing day. I owe you full and entire apologies, for I am ashamed to 
have been so often in arrears to you, and consequently I am going 
to explain to you in detail how it comes about that with the 
greatest desire to learn all the news of my friends and even to 
write to them, I end almost always by writing to them only in 
the case of the most urgent necessity. In order to do this I must 
explain to you my manner of life. I rise at half past seven or 
even at eight o'clock, for I need much sleep. I dress myself, 
generally, while giving consultations. I make my hospital visit 
(at Vhdpital Nicker) and then a bit of clinic to the students who 
follow me. This brings me to half past ten, and already time 
presses me to such an extent that generally I cannot return to my 
house for luncheon. Then I begin a round of visits which ends 
only at about half past five. After dinner, that is to say at about 
half past six, I begin another round which lasts till ten o'clock. 
There then remains for me one hour until eleven when I go to 
bed, plus several minutes from time to time before breakfast and 
dinner to keep up-to-date my correspondence of all sorts, to cor- 
rect and put in order the observations gathered by the students 
in my hospital, to arrange my little affairs, and so forth. This 
picture gives you but a feeble idea of that which, for a man who 
is rather busy, is this whirlwind of relations of all sorts in which 
one finds himself carried away in Paris, however hard one tries 
to simplify them. I have often been astonished that you and some 
others of our confreres should have retired to very small towns. 
To-day I applaud you and approve very strongly. For myself 
I think very seriously Centre nous) of arranging my affairs so 
as to be able, in a very few years, to retire to lower Brittany. 
Had I that which was due me here it would probably be to-day. 
I come to the question on which you have consulted me. I can 
not see how you can push your delicacy to such an extremity. 
The contagious nature of dartres in the gravest cases is certainly 
very obscure. I know not if the immediate and continued applica- 
tion during a period of time of a phagedenic dartre in full sup- 
puration could produce an effect other than that of a rubefacient, 
but I know a good number of husbands who have exudative 
dartres on the scrotum without having communicated anything 
to their wives, and vice versa. As for furfuracious dartres like 
22 yours, a good third of the human race is attacked at one period 
or another of their lives, and after 60 years there are no indi- 
viduals on whom one may not find them if one search well. The 
slight sensitiveness of the skin at this age brings it about that 
people have them generally without suspecting it. 
If one were to turn to the opinion of the greater part of the men 
and especially the women affected with dartres they would have it 
that they had all contracted the affection by contagion, but on 
observing with a little care, one sees, 1°, that considering the 
essential nature of the affection dartres approach by insensible 
nuances other cutaneous diseases of which we have never thought 
of suspecting the contagiousness, and particularly certain 
varieties of erysipelas of a chronic course. 2°, that from an 
setiological standpoint, for one case in which one might suspect 
contagion one sees thousands which prove the contrary; that in 
a great number of individuals dartres are the product of a bad 
regime and particularly of want, of uncleanliness, of too habitual 
loss of sleep, of excesses in study, of excesses of the table, of 
habitual exposure to cold or humidity (in certain workmen) and, 
in general, of all those causes which disturb the insensible 
perspiration. But the diseases really et absque dubio contagious, 
e. g., plague, smallpox, contagious itch, syphilis, do not arise from 
transgressions of regime. One should not call contagious, but 
epidemic and endemic those diseases due to analogous errors 
which spread most rapidly, such as typhus of camps and hospitals; 
for whatever has been said to establish the existence of contagion 
in these cases, it has been proved only that a reunion of too many 
healthy or diseased men in too restricted an area gives rise to a 
centre of infection which one may not frequent or sometimes even 
approach, without contracting there a grave fever for which one 
has vainly sought specific characteristics, for they vary in each 
epidemic. Separate the patients, give each one of them space and 
attention as to cleanliness, and the supposed contagion ceases. 
Who would dare to propose a like remedy against plague and 
smallpox? 
To return to dartres, it seems to me that the facts show that 
almost all men are more or less subject to them; that many chil- 
dren born of non-dartrous parents are affected with them in their 
early age (the same is true of scrofula); that others contract them 
at various periods of their life as the result of hygienic errors, and 
that old age, the age least susceptible to contagious diseases, 
brings them to many people who never have had them. I think 
that when they are of moderate degree and not due to accidental 
causes, one should regard them as simple incommodities, the result 
of a loss of equilibrium in a constitution in other respects very 
[432] 
23 good. I should compare them from this point of view to scrofula, 
which when it exists to a slight degree in a subject in other re- 
spects healthy and robust, is really not more than the excess of a 
constitution which is indeed the best of all, the lymphatico- 
sanguine temperament, and is recognized only by the physician. 
Dartres arise as does scrofula in infants born of parents free from 
these affections. But both of these diseases are communicated 
sometimes by generation as is the very constitution of the parent, 
their physiognomy and the sound of their voice. I think that' 
on the whole one should not regard them as a disease to treat 
excepting when they are very severe. 29 April-I had dated my 
letter the 22d current hoping to have finished it on that day. 
Here we are at the end of the month and I have not yet been able 
to finish this letter written, as is everything that I do, in broken 
periods. You must not, however, wait for it longer. The affair, 
indeed, is not worth the trouble, and I am going to finish by saying 
two words to you concerning that which has given me the greatest 
success from a point of view of treatment. 
I have never accomplished any appreciable effect with seabiosa. 
with fumaria. with the root of wild pansies (which I have em- 
ployed but little), with preparations of antimony. Anti-scorbutics 
have seemed to me to have some value in scrofulous dartres. 
sublimate in cases in which one may fancy a syphilitic base. 
I have had remarkable success with bitter almond in two or three 
cases of scaly dartres of great intensity: but in a multitude of 
other cases, I have obtained no results, although pushed gradually 
to a dose of 3 to 4 ounces for three glasses of decoction, which the 
patient took each day and continued during eighteen months and 
more thereafter. At a dose so large as this and sometimes even of 
two ounces I have seen it produce in some individuals a tonic 
spasm of one side of the face, with distortion of the mouth and 
embarrassment of speech, which at first glance might have been 
taken for a sign of hemiplegia. This accident ceases in three 
or four days on interrupting the remedy. 
Of all the depuratives that which has given me the best results 
is the use of sulphuric baths prepared with three ounces of solid 
sulphate of potassium for a bath, to which is added besides, a half 
glass of vinegar or four drachms of sulphuric acid. In your case 
I should content myself with taking twenty of these baths in the 
month of May, as many in September, and this for several years 
if it should be necessary. And I should take in addition for a 
longer time, that is say 3 or 4 months, a glass of sulphurous water 
[432] 
[433] 
6 Here ends the fourth page of the manuscript. The continuation 
on a new sheet is written with a different pen and clearly at a 
later date. 
24 a quarter of an hour before each repast according to the following 
formula: 
[433] 
5 Solid sublimated sulphur 3i 
Sugar Jiv 
Dissolve in hot water 0 ii 
Put in bottle, cork and allow to cool. 
I freed myself ten years ago of two furfuracious, scaly dartres 
by bitter almond in large doses continued eight months and the 
use of the above sulphurous fluid. But from the successes and the 
non-successes, if indeed I have had these, which I have obtained 
since then, I should prefer the baths. 
If a dartre should exist in a region where it were well to remove 
it so soon as possible, on the face or at the corner of the mouth, 
etc., I should advise you to touch it lightly with nitrate of silver; 
this procedure which, at the bottom, but changes the nature of the 
inflammation is without inconvenience. I have used it upon 
myself. I have seen here a patient of 80 who was cured at 56 of 
extensive dartres by the use of deliquesced oil of tartar (" par de- 
faillance") which was painted upon the eruption with a brush. 
It was first diluted with three-fourths water and in the end em- 
ployed pure. The internal treatment employed at the same time 
was of no significance. I wish I had the time to go into the matter 
more extensively, but intelligenti pauca. 
I have taken some steps recently to assist (?) your brother. But 
I had occasion to observe that attachment to " principes "T was 
not a title of recommendation with many people and nothing has 
yet changed here in this respect. 
I was much vexed not to have three or four days to myself 
when I was in Quimper in 1814. I propose to go there on a trip 
the coming year and I hope sincerely that this time I may arrange 
to be able to visit you. I embrace you with all my heart. 
Your confrere and friend, 
R. T. H. Laennec, D. M. 
Second letter, written to, 
M. Courbon Perusel, 
Doctor of Medicine at, 
Carhaix, Finisterre, 
Pakis, 16 August, 1819. 
I can not conceive, my dear Perusel, your anxieties as to the 
essence and the circumstances of the very trivial inconveniences 
from which you are suffering. (So far as I go I should be well 
content to have nothing more. It is true that I have fully as many 
7 Underscored in the original. Are we, perhaps, to accept the 
word in its Latin sense? 
25 as you, or approximately, and in addition hypochondriasis, gout, 
asthma, and so forth; so much, indeed that I am determined to 
abandon medicine)8 and Paris and to retire to Brittany where 
few patients I hope, will be tempted to seek me out. I am leaving 
on about the 16th of September and probably I shall have the 
pleasure of seeing you in October, for a small affair will bring 
me to Morlaix and I shall certainly pass through Carhaix in going 
or returning. We can then speak at leisure.9 
In your place I should restrict myself to taking yearly thirty 
sulphurous baths in the springtime and as many in the autumn to 
attenuate the dartres, and I should not endeavour to free myself 
entirely for fear of making things worse. As to the fear of 
contagion I am really scandalized (medically speaking) that such 
an idea still runs in your head. On my conscience, if I had a 
daughter or a sister to marry, your condition would hinder me in 
no way from giving her to you. Dartres, scrofula, phthisis, and 
many other diseases are suspected of being contagious only 
because they are very common, and a careful examination of the 
facts destroys this suspicion very easily. 
I have communicated your memorandum to Alibert. (As he is 
always as frivolous as you have found him)10 I told him that it 
was the question of a colleague in order better to fix his attention, 
and as a result I am sending you your prescription. You will see 
that my precautions have not been of great service: for he has 
given you, as he would to another, a common formula of consulta- 
tion, where you will find that which you know as well as he and 
not an idea from which you may profit. You will see that he 
talks to you as if one could not take sulphurous baths excepting 
in Paris, forgetting in this that he is writing to a physician. 
Certainly it would not be more difficult at Carhaix than in the 
Rue St. Lazare to put into a bucket 4 ounces of sulphur and 
one-half ounce of sulphuric acid, and if one wishes to prepare 
douches for spraying, it is not difficult to have made a tube of white 
metal and to fit upon one end a spray to convey the water from 
the first storey to the ground floor. His article 4° there are indeed 
other early procedures, etc., signifies this: "If the patient were 
under my observation I should apply to his dartres different mild 
caustics and repercussives." He has adopted this practice and 
makes use especially of nitrate of silver, and indeed in his position 
it is desirable to cure dartres promptly even if it were only for a 
time. This gives him the vogue especially with the ladies, and as 
he sees only strangers who come to Paris to be treated, he never 
[433] 
8 These lines are erased by heavy marks of his pen. 
9 Here several words are crossed out so successfully that one 
is unable to read them. 
10 Erased but deciphered with the lens. 
26 sees that which follows. One must acknowledge, however, that 
the use of these caustics rarely has grave inconveniences. But 
certainly you are not such a child as to desire that your skin be 
clean at whatever price as do the greater part of the patients of 
Alibert. 
Your ever devoted confrere and friend, 
R. T. H. Laennec, D. M. 
Third letter. 
Kerlouarnec par Douarnenez, 18 January, 1820. 
In its time, my dear PSrusel, I received your letter of last 
month, to which the wandering life that I am leading here, while 
they are almost completely rebuilding my hermitage, has hindered 
me from answering earlier. 
I had learned through Toulgoet of your marriage, and I con- 
gratulate you, all the more sincerely in that I know that you are 
a man who can appreciate all things at their true value, that which 
one cannot say of all people who marry. There is one thing, 
however, to which in my opinion you ascribe far too much 
importance: namely, the question of medicine of which you speak 
to me. I cannot blame you for having followed the advice of 
Alibert, although (between us) you may be sure that he gave 
it to you as frivolously as almost all that which he gives to the 
public: But I think that you would do well to stop there for the 
moment, and especially to be guarded in the use of mineral depura- 
tives-you know as do I that the long use of sulphur sometimes 
brings about blood spitting, and you know equally well the incon- 
veniences of another sort of the preparations of mercury. 
Optima interdum medicina, medicinam non agere. For my own 
account and for that of others (when I find the people intelligent 
enough) I follow this maxim of Celsus, in all the little ills which 
are much more difficult to cure than to endure, and I advise you 
as a friend to do the same. 
I am going to lecture you, however, on this subject, as I 
promised, and I hope that this will be in the course of the spring. 
In the mean time accept the assurance of the sincere attachment 
of your devoted confrere and friend 
R. H. T. Laennec, D. M. 
There is much in these brief lines on which one might com- 
ment or moralize. Especially interesting is the reference in 
the second letter to the non-contagiousness of phthisis. 
Laennec is very careful in his statements as to the con- 
tagiousness of tubercle. In the manuscript notes for his 
twentieth lecture at the College de France, which I was able to 
examine last summer through the great kindness of Dr. Cor- 
[433] 
[434] 
27 [434] 
nillot, I find the following entry: " Tuberc. sont il contag.? 
Contag. des sarophules et des tuberc. crus dans bp de pays, 
mesures administr. Faits pour et bp plus contre. Observ. de 
tub au doigt par inocul. ne pas trop s'y fier: mais certes pas 
facilement contag. en nos climats: " 
But later there is added with another pen: " Toutes les 
malad. contag. peuvent I'etre plus ou moins. petite verole, 
syphilis, peste elle meme, moins vers la fin d'epid, mais contag. 
n'est pas moins certaine." 
This might be translated " Are tubercles contagious ? The 
contagiousness of scrophulosis and of tubercles, believed in 
many countries. Administrative measures. Facts for and 
many more against. Observation of tuberculosis on the finger 
by inoculation. Don't rely on it too much: but certainly not 
easily contagious in our climate all contagious diseases 
may be so more or less-small-pox, syphilis, plague itself, less 
toward the end of epidemics, but contagious none the less 
certainly." 
In the second edition of his book he discusses the question 
in much the same way. " Tuberculous phthisis," says he,11 " has 
long been considered contagious and is now so regarded in the 
popular mind, and in the opinion of magistrates and of some 
physicians in certain countries, and especially in the southern 
parts of Europe. In France at least, it does not seem to be. 
One sees often among people of moderate circumstances, a 
large family sleeping in the same room with a phthisical 
patient, a husband sharing to the last moment the bed of his 
phthisical wife without contracting the disease. The woolen 
clothes and mattresses of the phthisical, which in certain 
countries are burned and which in France, as a rule, one does 
not even wash, have never seemed to me to convey the disease 
to anyone. However, prudence and cleanliness would demand 
more precautions than are usually taken in this respect. Many 
circumstances, however, prove that a disease which is not 
habitually contagious may become so under certain circum- 
stances." He then goes on to ask whether a direct inocula- 
tion may produce the disease at least locally, and describes an 
11 Traite de 1'auscultation mediate, 2me edition, Paris, ChaudS, 
1826, I, 649 et seq. 
28 instance in which he infected himself at a necropsy with the 
subsequent development of an anatomical tubercle. Later he 
says: " If the question of contagion may be regarded as in 
doubt with relation to tuberculosis, there is no doubt as to 
hereditary predisposition." 
It is interesting and remarkable that, with his clear recog- 
nition of the manner of spread of chronic tuberculosis in the 
lungs, the repeated fresh outbreaks following so often the 
softening of caseating areas, the idea of direct inoculation 
should not have imposed itself upon him more forcibly. 
The reference in his fir^t letter to the development of facial 
spasm following the prolonged used of oil of bitter almond is 
also interesting. Laennec was so careful an observer that any 
such statement deserves consideration. I have, however, found 
no support for the assertion in the literature. 
The same might be said of his statement with regard to the 
influence of sulphur in inducing haemoptysis. 
The notes of his lectures at the College de France, half of 
which are in the possession of the Ecole de medecine, half 
owned by his great nephew in Nantes, are written on small 
quarto sheets, 12 cm. square. Each page is divided into two 
columns, the division apparently made by folding rather than 
by ruled lines. The main substance of the lecture is in the 
right-hand column; the space on the left is reserved for notes 
entered in a small, close hand. The lectures are not written in 
full. They are rather in the nature of carefully prepared 
memoranda. Laennec wrote a sort of personal short hand. 
Many words are abbreviated. Much is in Latin, which is also 
abbreviated. Some of his abbreviations are interesting. In 
the termination " ation " the " ti " is often omitted, as in old 
Latin texts, and written " aon," " dans " is written " ds," 
" beaucoup " is written " bp," " qudquefois " is almost always 
written " qqfois." Capitalization is often omitted, and punc- 
tuation is very crude. The latter peculiarities may, indeed, be 
noted in the letters which have been reproduced above. In 
the main his notes are not hard to read while he writes in 
French. His short-hand Latin is not so easy. 
Some of his entries are interestingly epigrammatic. In his 
opening lecture are notes like this: " Science, ce que I'on 
[434] 
29 [434] 
sait." " Science, that which we know." "theorie, maniere 
de voir, on ne voir [sic] tout et swtout tout d la fois. Done, 
indispensable, mais pas oublier qu echaffaudage, s'en servir 
comme d'un instrum, pret d le rejeter et changer des quun fait 
resisted " Theory, way of looking (at things). We do not 
see all and especially all at one time. Therefore, indispens- 
able. But not to be forgotten that, scaffolding, one must 
make use of, as of an instrument ready to throw it aside and 
change it so soon as a fact holds its own." 
The notes of his twentieth lecture, that on tuberculosis, are 
deeply interesting. The kernel of the description of pul- 
monary tuberculosis in the second edition of his book is clearh 
discernible. 
As one glances over the notes of his lectures he is impressed 
with the clearness of view, the remarkable objectivity and the 
sane and accurate ratiocination. The more one considers 
Laennec's career the more deeply is he impressed by the 
greatness of the man and the magnitude of his work. And in 
thought, in methods, in expression he had that clearness and 
simplicity that marks the truly great. Here are the closing 
words of his introductory lecture taken down from the notes 
in his own hand: 
" As for me, I shall not quit the path traced by the medical 
observers who have successively increased the treasure of 
science from Hippocrates to our day. If I diverge from some 
of them I do not fear to say that 'tis from a leaning toward 
simple observation-even though 1 may be accused of em- 
piricism. Corvisart was my master, and 'tis perhaps to him 
that I am indebted for a certain distaste for explanations and 
theories. I shall make every endeavour to present the facts 
alone and connected by their most striking analogies, and if 
sometimes 1 am obliged in their exposition, to have recourse to 
some theoretical, hypothetical views, I trust that it may be 
evident that 1 am not insisting upon them, and that I may 
never put forward my individual opinion for science-that is 
to say, that which we know." 
[435] 
Preceding the presentation of the above paper at the meeting 
of the Laennec Society on March 29th, 1920, in commemora- 
30 tion of the one hundredth anniversary of the publication of 
Laennec's book on Auscultation, Dr. Henry Barton Jacobs 
brought before the Society a complete series of the editions of 
this book with the possible exception of one or two English 
translations. Dr. Jacobs is preparing a bibliography of these 
editions with reproductions of title pages, etc., which will be 
published later. 
[435] 
31