VOL. XXI.

No. 11.

cations.

CHAIRMAN'S ADDRESS BEFORE THE INDIANAPOLIS MEETING OF THE MIDDLE SECTION OF THE AMERICAN LARYNGOLOGICAL, RHINOLOGICAL AND OTOLOGICAL SOCIETY, APRIL 8, 1903.

BY L. C. CLINE, M. D., INDIANAPOLIS, Professor of Rhinology, Laryngology and Otology in the Medical College of Indiana.

GENTLEMEN:-It affords me great pleasure to welcome you to this, our "no mean city" situated as it is at the center of our nation's population. The time that is consumed in coming together, presenting and discussing subjects pertaining to our field of work is of as great value to us and to those we serve as are the great commercial and industrial conventions to their followers.

Our best work does not emanate from our own efforts in our daily routine, but comes through mingling with our fellowworkers, exchanging views, giving and receiving kind but firm criticism of our theories, modes of operation and inventions. When we look over a period of two decades we marvel at the great strides and changes that have occurred in the pursuit and practice in all branches of our profession, and especially in our own.

It has been said that the American doctor with all his energy and push is too prone to take up and adopt all the new fads and theories of practice without first giving the subject due consideration. While this in many instances is true we are just as eager to correct our mistakes and set up a signal of warning as we were to adopt them. For example we have seen the arrival and departure of the sulphuretted hydrogen gas bag which was reported

the air passages and alimentary tract. We have witnessed the craze to remove ovaries by our friends in the abdominal field, come and go. We have seen the great wave of treatment which expresses itself in the indiscriminate use of the saw and cautery sweep the country. I am sorry to say it still holds with some superficial and indiscreet manipulators, whose sole object is to open the breath-way quickly regardless of consequences.

The physiological functions of the turbinates and nasal mucosa have been partly or wholly destroyed in many noses by the indiscriminate use of the cautery or cutting instruments for the relief of existing disturbances, whereas if the cases had been more carefully studied and the treatment directed toward the true cause the nasal membranes could have remained intact, and after the relief of the congestion the patient left with a normal nose capable of performing its physiological functions. I do not mean to decry the use of the cautery, the scissors and saw, but their indiscriminate use in non-selected cases.

We have been passing through an age of fads and the departments of medicine and surgery have contributed a good share to their support. In our zeal to push forward and present something new we are too prone to act upon suggestions without due consideration of the surrounding influences that may have a bearing on the subject. We need to lay more stress on the etiology and pathology of diseases.

The importance and rapid development of appliances and methods of treatment of the upper air passages and the commercial shrewdness of apparatus and instrument makers have been the cause of thou-sands of doctors equipping themselves with cautery-batteries and other apparatus without preparation or special knowledge

of the normal and abnormal structures with which they were to deal, attempting to cure all the disturbed conditions of the air passages with the liberal use of cocaine and the cautery-knife, snare or scissors. Time and disappointment have about corrected those erroneous notions and the cautery has taken its place, with those that are informed, and is only occasionally used in selected cases. Specialism is looked upon by many of those older in the profession who have not had the advantages of medern teaching, as minimizing and in a narrowing or contracting sense, while quite the contrary is true with those that are up in the work. The specialist should not only have a thorough knowledge of his subject but he should possess a working knowledge of general medicine. Some claim that the specialist exceeds his rights when he looks beyond the local lesion and should refer his patient back to general medicine for further treatment. But as a matter of fact a large per cent. of the local lesions are due to systemic conditions.

A specialist should be able to analyze and group his cases and determine which are due to local lesions and what local lesions are due to systemic conditions. The specialist that does not take into account systemic conditions is not worthy of the name of specialist.

In anticipating what I would say in addressing you on this occasion nothing has appealed to me more than to call brief attention to some aetiological factors and the results obtained by the different methods of treatment of the great majority of patients that apply to us for relief. It is quite noticeable that during the last few years more and more attention is being paid to the study of general conditions with local manifestations.

It is important that we should possess an intimate knowledge of all adjacent and associated structures together with their physiological relations to each other as well as the general system. It is becoming necessary to devote more time and attention to the chemistry of the fluids of the body and their influence as manifested in local disturbances. More attention is being paid to the nutritive and eliminating functions of the body. We are all more or less familiar with cases of infil

trated and irritable mucous membranes following influenza or grippe, and know that some of these cases resist all local measures of treatment until the general system is taken into account and the secretive, eliminative and nutritive functions. are re-established. It is altogether likely that changes take place in the blood through the influence of the toxins, and that these new compounds are deposited in the tissues. In many cases treatment will bear out this view as hygienic and alterative measures produce the best results. We are all more or less acquainted with the increased congestion and glandular activity in the upper air tracts in diseases of the heart, the kidneys, liver and the gastro-intestinal tract.

When we look at the local lesions from a broad or general medical standpoint, excluding congenital or acquired deformities, we are surprised at the great number of cases that have some systemic factor in their etiology.

The condition to which I wish to direct my remarks, more particularly, is that designated by the terms lithæmia, the urie acid or gouty diathesis. To my mind it is questionable as to whether there is a hereditary tendency to lithæmia or gout. but whether the fault is not in our method of living and the large consumption of meat. There is never an excess of nitrogen in a meatless diet, but with a diet largely of flesh there is an excess of nitrogen and this introduced into the system, goes on accumulating in uric acid compounds until its presence in the blood causes a high blood pressure and its deposition in the tissues and joints.

Faulty digestion does not necessarily mean an increase of uric acid, but it does mean other toxic conditions; the influence of which is often manifested in inflammatory attacks of the membranes of the upper air passages or some weakened part of the mucous tracts. Hence it follows that exposure to inclement weather, fatigue or mental worry; dietetic, sexual or alcoholic excesses will suffice to precipitate a catarrhal attack by impairing digestion and favoring toxic infection. Were it not for these conditions the system would be able to withstand the attacks of most germs that are awaiting their opportunity to get into the tissues and the circulation.

My observations have led me to believe that one of the most common predisposing causes of a large per cent. of the diseases that are met with in the nose and throat is associated with if not largely due to uric acid or other toxic influences from faulty digestion.

We should classify our cases and study more carefully the influences that lead up to the various local lesions with which we have to deal, typical examples of which are found in naso-pharyngeal obstructions, causing impairment of the voice, sense of smell and hearing. The systemic condition should receive at least an equal if not the greater share of our attention. should not content ourselves with the relief of the local conditions only, but measures that are far reaching in their effects must be studied and judiciously applied.

We

While we feel assured that we possess a correct knowledge of the local lesion in a given case, still it is necessary to investigate every factor that may have contributed to the local disturbance. A patient's surrounding, his business and social relations, his mode of exercise and recreation, his habits of dress and care of the skin, and more than all else, his diet and manner of eating should receive our careful attention. I am fully convinced that more of the ordinary ills of our American people can be laid at the door of our dietetic follies than to any other cause.

We consume too much nitrogenous food, we eat too much meat, the auto-toxæmic state that follows is quite sufficient to precipitate catarrhal attacks of the mucosa and glandular structures of the upper air tracts. Many of the incipient cases that apply to us for treatment would get well without drugs or surgical interference with a rigid correction of diet, exercise and hygienic influences. I might cite many cases illustrative of the curative influence of first directing attention to the toxic and lithæmic conditions, but will not presume upon your intelligence and further consume your time. I hope that these few remarks may not be in vain, but may stimulate your renewed interest in investigation and practice along these lines which will, if carried out, in many instances obviate the necessity of the more radical use of caustics, the cautery and cutting instruments in the large group of

cases with such systemic causative factors as have been indicated in this paper.

Willoughby Building, 224 N. Meridian

street.

VACCINATION RECORD OF ONE HUNDRED AND THIRTY-EIGHT STUDENTS OF THE INDIANA MEDICAL COLLEGE Who Visited the Indianapolis Smallpox Wards and Each Observed from Forty to One Hundred Cases of Smallpox Under Direction of Clinical Teachers, During the Late Indianapolis Epidemic of Virulent Smallpox (Dec. 1, 1902 to April 1, 1903) in which there were Over 700 Cases with a Mortality of Sixteen and Twothirds Per Cent.

BY DRS. A. W. BRAYTON AND CHARLES E. FERGUSON, Teachers of Clinical Medicine in the Medical College of Indiana and Consultants to the City Hospital.

At the time of holding these clinics in late February and early March of 1903, a severe epidemic of virulent smallpox was at its acme and on its decline in Indianapolis. A state of alarm existed in the city; trade and travel were becoming demoralized; outside towns were threatening and advising quarantine; the legislature was in session, and one of its members, Senator Gibson, had died of "black smallpox, variola purpurosa," and the disease had been carried to his home with the result that his six children had the disease, two dying, as did also his brother who nursed the stricken family. Free vacci

nation stations had been established, 120 in number, and 25,000 people vaccinated at the public expense, four-fifths of the vaccinations having been done by the Senior and Junior students of the Medical College of Indiana, who devoted the evenings of an entire week to the work in the various drug stores and fire stations of the city. The present writers had been special students and diagnosticians of smallpox for some ten years, for the city, county and State health board authorities, and because of their observation of the lack of practical knowledge of smallpox on the part of most of the physicians of the State, thought the present an excellent opportunity to teach the clinical features of the disease in all of its stages to the Senior and Junior students of the college, the greater portion of whom will locate in Indiana towns and hamlets within the coming and present year. This clinical knowl